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WORTh TOWN OF NORTH ANDOVER
c= PERMIT FOR GAS INSTALLATION
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This certifies that ... .. . . . ..
has permission for gas installation . . . . . . . . . . . . . . . . . .. .. . . . . . . .
in the buildings of . . .= - .. .'.': . `'
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at ! ,' .:(' .�. .. . .:. .:- /. ., North Andover, Mass.
Fee. �7. . . . Lic. No.. �".1. :.: .a !.. . .. . . .
GASINSPECTOR
WHITE:Applicant CANARY:Building Dept. PINK:Treasurer
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT T GAS FITTING
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Type or print) Date 2 9 I2. 'V e
NORTH ANDOVER, MASSACHUSETTS
Building Locations 1-2L6 A-P P I e f o li S+ Permit 9
,,I Amount S
1�0. Q(1C,O(l C'I— ?'tit a( Owner's Name Co�Wfl!"�L �'t"Qh 60 eu t
New Renovation ❑ Replacement ❑ Plans Submitted ❑
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2,N D . FLOUR
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(Print or type) Check one: Certificate Installing Company
Jame W6 to !Zoete P/ernbino �i �leof�n� Gore � Corp. /6aQC
Addressx 7 2 ❑ partner.
Mr" h Hndo ✓ems, �ti►, d
Business Telephone q 7A '775 4Z (?? ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter R d b e r^ - 3.
INSURANCE COVERAGE Chec, one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked ves_please indicate the type coverage by checking the appropriate box.
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:
Siznature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby ceriifv that all of the details and intormanon I have submitted for entered)in above application are true and accurate to the
best ofmv knowledge and that all plumbing work and installations performed under Permit l ued forth's application will be in
compliance with all pertinent provisions of the Massachu its State Gas Code nd Chapter I ' oftGeneraf Laws.
Bv: Signature of Licensed Plumber Or Gas Fitter
Title ❑ Plumber 8.51;7
CitviTown ❑ Gas Fitter !cense wumoer
�i�iaster
APPRO'vED orrici.USE-)NI.Y) ❑ Journeyman