HomeMy WebLinkAboutMiscellaneous - 121 Foxwood Lot 23 .,4 a3
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Ur WUH+M APPLICATION FOR PERMIT TO DO GASHTTING
(Print or Type)
NORTH ANDOVER , Maas. Date �-� lg46
Building
Location — 2 3 Permit # ok
Location �L I
Owner's
Name
New Renovation ❑ Replacement0 Pians Submitted:. Yes '
❑ No ❑
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BASEMENT
1!T FLOOR4.1
IND FLOOR i
X110 FLOOR
4TH FLoon
ATH:FLOOR
4THFLOOR
ZTH FLOOR t
!TH FLOOR
f 1 Check one: Certificate
Installing Company Namefc
Addresso�� -L 0 6
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. d Partnership
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❑ Firm/Co.
Business Telephone Y-3
Name of Ucensed Plumber or Gas Fftter -S—J >= C-4P G L f -
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INSURANCE COVERAGE: Check any
I have a current liability Insurance policy or Rs substantial equivalent. Yes L� No ❑
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
ilablI ty Insurance poitcy Other type of Indemnfty ❑
A Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 cf the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's eat.
Owner ❑ Agent ❑
1 hereby certify that aq of the details and Information I have submitted(or entered)In above application are true and accurate to the best o1 my
knowledge and that all piumbinq work and Inatallatlons performed under the permK Issued far this appikatlon will be In compile
nce with all
pertinent provisions of thha Massachusetts State Gas Dade and Chapter 142 01 the al La
ey TCumber
nse:
na urs o cense um of or as eli�r
Title ler
Master license Number. 1;_znL
Ctty/Town Journeyman
APP9 NE0 (OFFICE USE ONLY)
2312 Date.,l/. - �,/
NORTH1TOWN OF NORTH ANDOVER
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PERMIT FOR GAS INSTALLATION 'a
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�9SSACHUSE�t� p
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This certifies that . P.<./A* f.lT �!. . .?. . . . . . . . . . . . . . . . .
has permission for gas installation . . . .. . . . . .
in the buildings of . . . .?� f�.' . . . . . . . . . . . . . . . . . . . . . . . . .
at . . . . . . . . . . . . , N h Andover, MaN.
'
Fee. . °. Lic. No../()
GAS INSPECTO
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