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2781 Dat6�F ... /I
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATIOW
CHU
This certifies that —.. .-- �--- �7� .....
has permission for gas installation—
in the buildings of . ............ .........
at ..................... North Andover, Mai6.
Fee!;��.'.... Lie. No..� ....... ..........................
GASINSPECTOR
9ATt: Applic nt CANARY: Building Dept. PINK: Treasurer
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MASSACHUSETTS UNIFORM. APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Ty
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_ 0? Mass. Date �' 19 r0 Permit#
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Building Location �� I�i�, i 1\.G t lc ner' Name C -UC (�
Map: Lot: Zone:' Type afOccupancy)�� tRX
New :1 Renovation
Fee:
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Replacement ❑
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Installing Company Name 131 WAIER STREET
Address P.0 BOX 6666
Estimate Value of Work: DANVERS, MA 01 923
t° %.&
Business Telephone 6 X41 1 D
Name of Licensed Plumber or Gas Fitter
Plans Submitted: Yes ❑ No ❑
Check one:
^Corporation
❑ Partnership
❑ Firm / Co.
Certificate
INSURANCE COVERAGE:
I have a current 'gbility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ZI
If you have m cked yes, please indicate the type coverage by checking the appropriate box.
A liability. insurance policy 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.
1 Check one:
Owner O Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License: ,� t
Plumber Signature of Licensed Plumber or Gas Fitter
Title Gasfitter 9Master License Number
City / Town Journeyman
APPROVED (OFFICE USE ONLY)
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I..r1V r L.r rl� 1 1 lyl I-lrv4. �wr �y,
Installing Company Name 131 WAIER STREET
Address P.0 BOX 6666
Estimate Value of Work: DANVERS, MA 01 923
t° %.&
Business Telephone 6 X41 1 D
Name of Licensed Plumber or Gas Fitter
Plans Submitted: Yes ❑ No ❑
Check one:
^Corporation
❑ Partnership
❑ Firm / Co.
Certificate
INSURANCE COVERAGE:
I have a current 'gbility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ZI
If you have m cked yes, please indicate the type coverage by checking the appropriate box.
A liability. insurance policy 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.
1 Check one:
Owner O Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License: ,� t
Plumber Signature of Licensed Plumber or Gas Fitter
Title Gasfitter 9Master License Number
City / Town Journeyman
APPROVED (OFFICE USE ONLY)
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