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HomeMy WebLinkAboutMiscellaneous - 12 Johnson Street �� Jv �� .. Date:Ze/o....... 1 J5 .`J0 aFNcprh�� TOWN OF NORTH ANDOVER 03?•1 `` •• 00� PERMIT FOR PLUMBING „+ gsgCMUS� This certifies that.... .�.`......�..........J...�............ ....�.......�.....�.......t.-..-. ..................... ..................... has permission to perform.......°�.........G`...a�......z........�....T�'..S.......................... ........ plumbing in the buildings of.... d""10" 'l'i r�/ ................................................................. at.... ,e�........w/.L� ? d^!.... � North Andover Mass. Fee k...`....Lic. No.2o(n(P(o / ' ................................................................................ PLUMBING INSPECTOR Check# 33 0 r f � c E l � ` v I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK rt f CITY MA DATE tLL ( PERMIT# JOBSITE ADDRESS J 2 J OWNER'S NAME L� Il __ ,�r�► POWNER ADDRESS i TELp�-711FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL '' PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES® 'NOD FIXTURES"I FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I 1' ! Q f ii _ _I _I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM ! ( __ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f I _ ! _� — ► 1 I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN --jr—JE 1 (_-_____I FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) I i _.__..._! KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK ( - TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER L 1 .I .._ _I I ___-_ f _. INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESF]11 NO D- ' IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY BOND D OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are anq accurate he best of,my kn ledge and that all plumbing work and installations performed under the permit issued for this application will be inliance with all rtinent ion o e Massachusetts State Plumbing Code and Ch pter 142 of the General Laws. PLUMBER'S NAME LK �1IILICENSE SIGNATURE MP 0I JP®� CORPORATION ..J#=PARTNERSHIP 0# i LLC j COMPANY-NAME CXA--1 ADDRESS CITY LZLSTATE ZIP �® -- ___J TEL FAX CELL��EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i t ., The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Cl,✓i ° Address: / City/State/Zip: 6Aoj�q�, J �L4( Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction er�loyees(full and/or part-time).* have hired the sub-contractors 2.[�am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. F1We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.OTTumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.[i Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they ECre doing all work and then.hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ° Insurance Company Name:. {y Policy#or Self-ins.Lie.#: /� n (� ( U S �� Expiration Date: 2 h.3 201 Job Site Address: J C" , C*4[tet C',4,. 3rEity/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certo"der the pains d penalties of per'ury that the information provided above is true and correct. Signature: M Date: © � Phone#: 7 �- 3 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be fillgd out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Gon->4 onwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Stxoot Boston}MA.02111 Tei,#617-727-4900 ext 406 or 1-877TMASSA.F.B Revised 5-26-05 Fax#617-727-7749 _ www.�ass,gov�dia owlaZOMMONWEALTH OF MASSA HUSETTS; B,.4ARD:b PLUMBERS'>AFb GASF>IT .>wRS ` C S:SU:ES,:..:'THE F0LL0WfNG' L I:Cf#JS�D AS A. JOUR:tEYMAN P UL MB ERcc J t R11 MtJ N D C H E C K.-.... yt^ N uj 9 B I RCHW00D TERR. :.:.... ;: ;;:MA 018 -1.60> G;F�OVE LAN:Q> <::::>::. 34 :. 7 I • ; � Location No. � 1� Date MaRTM TOWN OF NORTH ANDOVER F R 9 t � � • i ; , Certificate of Occupancy $ 01 S / } Building/Frame Permit Fee $ 3 `/ s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 07 6 15876 Building Inspector .a TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER A.5 DATE ISSUED: � CC SIGNATURE: � Building Commissioner/In for of Buildings Date Z SECTION i-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /J Jp fi'.0 Sa.� s 7ckee t / 3 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Required Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Intion: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record 0 Dims A.) 5712 e4 Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable Licensed+Construction Supervisor: O License Number Address '� Expiration Date ic Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name Registration Number r Address _o Expiration Date /z Signature Telephone V/ SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check au a licable New Construction ❑ Existing Building ❑ Repair(s) >l Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: _ �/ 1 �4c P iU o d, cy./ 1.2,v c-Ir A/_'e rT 1'ti/� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant I. Building �° (a) Building Permit Fee rad s, O O Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e) X (b) �© 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Coz: as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief } M / CP/4 ,e C Qrr�oyA11 Print N� L 6N-Cs�JZtr'�3 6<l0/(J�1 Signature of Owner/Agent Date 1 Elm RIMINI NO. OF STORIES SIZE r BASEMENT OR SLAB SIZE OF FLOOR TIMBERS IST 2 NO 3RD L SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIIv1ENSIONS OF GIRDERS -HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT fil i c A /4 e �' DDAu p�A,-) PHONE 0r 7 F - C J0 9-4 2,'O LOCATION: Assessor's Map Number PARCELO SUBDIVISION LOT(S) STREET Ia ✓O //w S eJ Sf2� ST. NUMBER ************************************OFFICIAL USE ONLY*********************************** REC MENDATIONS 9,F TOWN AGENTS: CONSERVATION ADMINIS ATOR DATE APPROVED O O-L DATE REJECTED COMMENTS doff. 4o - sec Lt (A t kite f TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed fof in: -4 (Location of Facility) r Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector • �` E'j �r iUN PLANMORTGAG - ---- �-A.Q.- HERN ASSOCIATES, INC. 342 N.MAIN STREET ANDOVER MA 01810 TEL: (978) 474-4410 FAX. (978) 474-5067 MORTGAGOR: M1rHAEL[. At-+n, t nutsE A mr, l4 vAty DEED REF: 3g1y3 PG: U4 LOCATION: Ja Nov son/ ST PLAN REF: CITY,STATE: A4 A N nOVER MA JOB#: 41816&5-0 DATE: q- ly-q l SCALE: 1=201 1 dD sa.2c' 1 w M Z s �Y Woo p S � c 3i P4RCfi JokwSON sTMET CERTIFIED T0: gAK gp�TDN tvA NOTEi This mortgage inspection was prepared This mortgage Ins ectloll was p prepared In accordance specifically be for mortgage purposes only and with t11e Technical Standards for Mortgage Loan is not to be relied upon as a lend ep property H OF Inspections as adopted by the Hassachusetts Board of Registratlino survey, used for recording, preparing deed �` descriptions, or construction. Ho corners were y��P S.r_ Surveyors 25 of Professional Engineers and Lend ''9� Surveyors 250 CHR 605. set. Building location and offsets are o CARMEN yG I further state that In m professional opinion that approximately located on the ground and J t11e structures shown conform with the local zoning horizontal are shown re not be for zoning determination A. dimensional setback requirements at the time of construction only and are not to be used re establish property A`- are exempt under provisions of M.C.L. CH. 10-A Sec. 7. lines. The matters shown hereon are based on client-furnished information and may be subject .9 to further out-sales, takings, easements and rights Gr q O i �1.Property/house is not 1n a Flood hazard. of way, and other matters of record and prescriptive �!' FCI$T J`� Q2.Property/ilouse is in a Flood hazard Area. or other rights. Northern Associates, Inc. assumes no 0 SJQ C33.Information is insufficient to determine responsibility herein to the land owner or occupant, NA( LAND Flood Hazard. accepts no responsibility for damages resulting from said /� oQ Flood Hazard determined f�o,p �pjest ej al Flood reliance by anyone other than the said mortgagee and Its assigns /� I(I `V Insurance ij Map Panel�( f�( C. in connection with its proposed mortgage financingto said mortgagor. Date �[_[_f 2one — Pd Town of North Andover Building B+epartmenP 27 Charles Street North Andover, NIA. 0 U. Robert Nicetta 1845 * 4 a .Building Commissioner � g tcfru5 titi . (978) 688-9545 978 688-9542 Fax HOMEOWNER LICENSE �E,�pT,ON Please print DATE 108 LOCATION Number Street Address Map/lot 10MEOWNER Name Home Phone WCWk Phone ESENT MAILING ADDRESS City Town i State Zip Code The current exemption for"homec)"ers"was or less and to allow su of two unextended to include mer its ch homegwners engage -c=ped dwofings not possess a license, provided that the owner acts as an individuates hue who does penrisor DEFINITION OF HOMEWOWNER: (State Buodng Code Section 1118 3.5.1) Person(s)who owns a parcel of la there is, nd on which he/she resides or intends or is intended to be, a one or two farrWY reside on which cessory to such use and/or farm s esding.attached or detached sues�- two-year period shalt not berAnsidered a ho4u?owner ►►I' personv►fio ore'tir orie in a The undersigned 'homeowner"assumes res Applicable �3ula�onsonsble codes, by-faves, rules and regPOnulations, ilrty for�mpl.e with the State Building Code and other The undersigned "homeowner"certifiesthat helshe Building Depaftent minimum inspection understands the Town of No.Andover �Om 'with said procedures and requirementslures and requirements and that he/she will ' IOMEOWNER'S SIGNATURE 'PROVAL OF BUILDING OFFICIAL I NORTH Town ofE Andover No. o - 'A ' ■ dower, Mass., GOCHC I �,p A°RATED CJ S H E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System ' BUILDING INSPECTOR THIS CERTIFIES THAT..... � A. ..........n. .N.m..vA. ....................................... Foundation ...................... has permission to erect.... r.�la..� ....... buildings on ...l Ck TO IV ,SON %4L• .................................................. ......................... . Rough to be occupied as.......Fronj..f......irov.*r!.e�.....APPI..�......bfJ*...�.....�. ............... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By- ws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 9199a �f aO IMEND PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR C Rough . .......................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. Date.. . f.... .. tL \ f N°RTM 1 ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION h �9SSACMUSES4 This certifies that . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . has permission for gas installation in the buildings of /. �! .�. . . . . . . . . . . . . . . . . . . . . . at .(. .. tb*L . . . . . . . . . .. North Andover, Mass. Fee. -j�: . Lic. No. ,�7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / `` GAS INSPECTOR ~, Check# /3 `''11 A813 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) y J 30 _ WK71-1 Mass. Date I q Permit# � �J Building Location_.. 12 JO H Q SO►J S I Owner's Name NI I C HA E1-- 044f6VA 0 E`10tT H A 0 00v C PL � Type of Occupant-e n l New ❑ Renovation ❑ Replace4ent/W Plans Submitted: Yes[] Nocc ❑ Y W N N (A V Z CC z N a of rt O to W W W 0 V W t S A tl J z O W �. Q X z = O }. Cr a m N h W W O O 4. r- (1) h tl W a = �. U3 o > w N ¢ W Z V W N Z W a CC a N.cc W tl 0 > u !- WJ W Z a W Q tl h y- W CQ Z o Z a 0 X a W > a W M Z. < CC Q a '.s O tl 2: U. a tl J V y Q a M- O SUB-8SMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET X7 Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone .687-1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: II have acu renntt liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked ye, 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. Check one: Signature of Owner or Owner's Agent , Owner[] Agent[I hereby certify that all of the details and information I have submitted(or entered)in4e . cation are true and acacu to to the best of my knowledge and that all plumbing work and Installations performed under the permit is application wil n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the GeiT of License: Plumber Signase Plumber or Gas Title Gasfitter 3-145 .l 4 5 Master License Number City/Town Journeyman . O IC S_ONLY I. BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE N0. APPLICATION FOR PERMIT TO ADO GASFITTING NAME TYPE OF BUILDING J ' ;' '• LOCATION OF BUILDING I • i PLUMBER OR GASFITTER LIG NO. I PERMIT GRANTED DATE _,19 I GAS INSPECTOR