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01 �kORTN .4 TOWN OF NORTH ANDOVER
PERM11"FOR GAS INSTALLATION
This certifies that .................. I ........... I ... i .............
has permission for gas installation ........................
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in the buildings of ......................... t' �;-� ............
at ........ ........... I North Andover, Mass,
Fee ......... Lic. No.,�', ...... ........... ..............
GAS INSPECTOR
I
WHITE: Applicant— CANARY: Building Dept. PINK: Treasurer GOLD: File
-jrASSACNUSETTS UNIFORM APPLICATION FOR PERMIT TO UO GASFITTIN(3
(Print or Type)
l NORTH ANDOVER Mass. Date W, 01�-1"-%y
f �uilding Location.,,o xk ( ite&sS %?� Ud 141'.9oa,AZ Permit # —A-9/
Owners Name/?'
• �' _ New Renovation I] Replacement Plans Submitted ❑
FIXTIIR! c
(Print or
Type)
Check one: Certificate
Installing
Company Name
Corp.
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Firm/Co.
Business
Telephone: 6,-) 3-
Name of
Licensed Plumber
or Gas Fitter
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SUR—RSIMT.
BASEMENT
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f
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6THFLOOR
TTI( FLOOR
STH FLOOR
(Print or
Type)
Check one: Certificate
Installing
Company Name
Corp.
Address�v
max
P rtner.
S/f�.�'r✓t
��
Firm/Co.
Business
Telephone: 6,-) 3-
Name of
Licensed Plumber
or Gas Fitter
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy 0 Other type of indemnity [—] 13ond 17]
Insurance Waiver: Waiver: 1, the undersigned, have been made aware that the licensee of
Chis application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 1-1 Agent 0
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 aU plumbing work and InsbsUations performed under rermit itsecd fo. this application wW be in compliance with in pertinent
provisions or tho Matsachutetts Slate Gas Code and chapter 142 of the Genual Laws.
M
Title
City/Town:
APPROVED (OFFICE USE ONLY)
PE LICENSE:
Plumber
slitter Signature oi Licensed
Master Plumber or Gasfitter
Journeyman _ � `�
License !lumber