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BUILDING FILE
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS ffrnNG
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS '
Building Locations ? '-� ,-%V lr e,y 1~
Permit#
Owner's Name Amountbl!V j A, Zr Ck t9 I
$
New Renovation D Replacement ❑ Plans Submitted D
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W 0 9 a
a o o x F
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O F z @.. � W � W � � F a F
D z 'a < e 0 00 W O � m
SUB -BASEM ENT
BASEMENT-- �`
1ST. FLOOR
2ND . FLOOR r
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . .FLOOR.
8TH .' FLOOR
(Print or type) r
Name f VI �' —h Check one: Certificate Installing Company s e Corp.
r
Addrvs iJ V0
1\1 n. 777"q6� Partner.
use e s 'e ep one R479
irm/Co.
Nome of.Licensed Plumber'or Gas Fitter Cl7 I/tf ret (`u�
INSURANCE COVERAGE
I ave a current liability insurance,policy or it's substantial equivalent. Check one:
If you have checked es,please indicate the a cove Yes L.Y No1
type rage by checking the appropriate box.
Liability insurance policy Q-- Other type of indemnity D
Bond 13
Owners 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.
Signature of Owner or Owner's Agent Check one:
t hereby certify that all of the details and information I have submitted(or enOte ed in Move Aer 13 gent 13
true and accurate t
best of my knowledge and that all plumbing work and installations performed under Permit Issued o�roth srapplication will be in the
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter.142 of the General Laws.
By: ignature of Licensed Plumber Or Gas Fitter
Title Plumber L/ • / +
City/Town, Gas Fitter - !9r` R-1, h 22 I
License � —I er
Master
APPROVED(OFFICE USE ONLY) urneyman
- `fes d'1
Date.. ..J��.. ....C>
°f
TOWN OF NORTH ANDOVER
F p
PERMIT FOR GAS INSTALLATION
y9SSACH
This certifies that . . ... . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation
in the buildings if . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . . .?. . . . . . . . . . . . ... . . . . . . .: , North Andover, Mass.
Fee,-56. ... . . Lic No.. . . . .CP
. .... . . . . . . . . . . . . . . . . .
GAS INS U R
Check#
6764