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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 CASFITCI'
MG
(Print or Type) _ t
,c NORTH ANDOVER Mass. Date/ 9
building Location 7 16 Permit # �J `v
R Owners Name,7, A,
YV
New 77 Renovations Replacement Plans Submitted
FIXTUP=,-Z
(Print or Type) Check one: Certificate
Installing Company Name Q Corp.
Address"/s is - Partner.
"""'Firm/Co.
Firm/Co.
Business Telephone: sl--%ep�5—c3yf
Name of Licensed Plumber or Gas Fitter
Insurance Coverage. Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy 611 Other type of indemnity u Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee or
this application does not have any one of the above three insurance coverages.
ignature of owner/agent of property Owner Ll Agent E
I hereby certify that all of the devils and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowicdge and tI at sU plumbing .pori; and InstAUvions petfornted under Permit iuued to. this apptication will be in compliance with all pertinent
provisions of tho Massachusetts State Cas Codc and Chapter 142 of the General Laws.
By
T-:tl.e
City/Town:
APPROVED (OFFICE USE 0NLY1
TYPE LICENSE:
1110,
Plumber
Gas fitter signature of Licensed
Master Plumber or Gasfitter
Jcurnevman
License /Number
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2ND FLOOR
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5TH FLOOR
6TH FLOOR
7TK FLOOR
8TH FLOOR
(Print or Type) Check one: Certificate
Installing Company Name Q Corp.
Address"/s is - Partner.
"""'Firm/Co.
Firm/Co.
Business Telephone: sl--%ep�5—c3yf
Name of Licensed Plumber or Gas Fitter
Insurance Coverage. Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy 611 Other type of indemnity u Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee or
this application does not have any one of the above three insurance coverages.
ignature of owner/agent of property Owner Ll Agent E
I hereby certify that all of the devils and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowicdge and tI at sU plumbing .pori; and InstAUvions petfornted under Permit iuued to. this apptication will be in compliance with all pertinent
provisions of tho Massachusetts State Cas Codc and Chapter 142 of the General Laws.
By
T-:tl.e
City/Town:
APPROVED (OFFICE USE 0NLY1
TYPE LICENSE:
1110,
Plumber
Gas fitter signature of Licensed
Master Plumber or Gasfitter
Jcurnevman
License /Number
Date..'.!......... �....
TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
A
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. ti.0� I
This certifies that ................ :...[.. .. ....
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has permission for gas installation,!:::. r...... .... r . .... .
in the buildings of ='% .'�- — �: '`Y . .................
frat ......J!'.North Andover, Mass.
Fee.,.-? ).. „,:. Lic. No– ......................... .
�'r L O�JL�9`4 0,9:13 25, WPAID GAS INSPECTOR
WHITE: Applicant l CANARY: Building Dept. PINK: Treasurer GOLD: File
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AunuSt 113
(Print or Type)
NORTH ANDOVER,—, Mass,
Building
Location W /2l t. �X4
ATION FOR PERMITTODO PLUMUINU C/
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Parma #
Owner's
Name ,I OLIN
New ❑ Renovation -421' Replacement ❑ Plans Submitted: Yes ❑
PIXTURE$ .
yQY1*
Installing Company
I/
Check one:
❑ Corp.
Address�o��iY,;/r� ,5,T t ❑ Partnership
Firm/Co.
Business Teleahone
Name of Licensed Plumber
INSURANCE COVERAGE:ec one
I have a current liability Insurance policy or Its substantial equivalent Yes ❑ No ❑
If you have checked y", please Indicate the type coverage by checking the appropriate box.
Certificate
A Ilabilly Insurance pollct:* , Other type of indemnity ❑ Bond ❑
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:
Owner ❑ Agent ❑
a cera o et a Owner's en
I hereby cartiy that all of the details and InfamaiM I have submitted (or entered) In alvf6tlon are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permM 1 lila appl{catlon be in compliance with all
ped1nenl provisions of the Massachusetts Slate Plumbing Code and Chapter 112 of as
APffWff) (OFFICE USE ONLY)
celeMEW—
License Number , 210 S— I'
Type of Plumbing License: Master ❑
Jouineyman
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INDFLOOR
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ATH FLOOR
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Installing Company
I/
Check one:
❑ Corp.
Address�o��iY,;/r� ,5,T t ❑ Partnership
Firm/Co.
Business Teleahone
Name of Licensed Plumber
INSURANCE COVERAGE:ec one
I have a current liability Insurance policy or Its substantial equivalent Yes ❑ No ❑
If you have checked y", please Indicate the type coverage by checking the appropriate box.
Certificate
A Ilabilly Insurance pollct:* , Other type of indemnity ❑ Bond ❑
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:
Owner ❑ Agent ❑
a cera o et a Owner's en
I hereby cartiy that all of the details and InfamaiM I have submitted (or entered) In alvf6tlon are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permM 1 lila appl{catlon be in compliance with all
ped1nenl provisions of the Massachusetts Slate Plumbing Code and Chapter 112 of as
APffWff) (OFFICE USE ONLY)
celeMEW—
License Number , 210 S— I'
Type of Plumbing License: Master ❑
Jouineyman
DIVISION OF REdISTR'ATION
efCENSED AS A JOURNEYMAN PLUM R
IN PLUMBERS AND._GASFI.TIER
ISSUES THIS. LICENSE TO
Gr.CG E BELLEVILLE 0
,6.7 ADDISON AVE
' 'r3
LYNN MA 01902-00 }�
'-20J58 05/01/94 65999
1
DIVISION OF REdISTR'ATION
efCENSED AS A JOURNEYMAN PLUM R
IN PLUMBERS AND._GASFI.TIER
ISSUES THIS. LICENSE TO
Gr.CG E BELLEVILLE 0
,6.7 ADDISON AVE
' 'r3
LYNN MA 01902-00 }�
'-20J58 05/01/94 65999