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NORTH
TOWN OF NORTH ANDOVER
40
PERMIT FOR GAS INSTALLATION
S 9SSNCHUSEt
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This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . . . �J�.X. . . . . . . . . . . . . . .
in the buildings of . . .F L �/ �. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . . f. . ./;z:, ? ��. `. .�?� . . . . .. North Andover, Mass.
Fee. .2.1.. . . Lic. No.j . '. . . . . . . .
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Check# J /J t !
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5926
MASSACHUSETTS UNIFORM APPUCATON FOR PERMrr TO DO GAS FITTING
(Type or print) Date 3/ 13�o -7
NORTH ANDOVER, MASSACHUSETTS
Building Locations *'J//
41--( Permit# t 'C
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Owner's Name �//Vmount$ 1w
New D Renovation Replacement n/, Plans Submitted
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z d w ¢ E F. v� m ZO z W O vFi x
x o x 3 a a u a > A a F O
SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
STH . FLOOR
(Penne or type) n L T( /�i IV4- Che k one: Certificate Installing Company
/C �--� / Corp.
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Address �� �y1— d
Partner.
Business a ep one ` ��,� Firm/Co.
p
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE b Check one-
I have a current liability Insurance policy or it's substantial equivalent. Yes Noo
If you have checked yes,please indicate the type coverage by checking the appropriate box.
Liability insurance policy 0--- Other type of indemnity ED Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent 13
hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and insta io s performed under Permit Issued r this appy ation will be in
compliance with all pertinent provisions of the Massach efts tate G ode and Chap 14�oe Gene Laws.
By: Signature of Licensed Plum er Or Gas Fitter
Title lumber 4) Z
City/Town 13 Gas Fitter Icense Num e
Master
APPROVED(OFFICE USE ONLY) [3 Journeyman