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(Print Ult-UNtvt APPLICATION FOR PERMIT TO DO GASFITTINQ
NORTH ANDOVER , Mass. Date- -2-f ,gQ6
Building
Looatlon �! ,�j� � 13 6� Permtt #—_ p
Owner's t/ j
Name � � •
New ®'� 'Renovation ❑ Replacement ❑ Plans Submltted:. Yes
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2110 FLOOR I
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4TH FLOOR
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~ Check one: Certificate
installing Company .Name 0a '. S Q• �� I u c .
�orp _L S 0 C6
'Address �-O ::�k
d Partnership
(2 3 / ❑ Firm/Co.
Business Telephone
Name of Licensed Plumber or Das Filter i _e .: -►-v�,
'INSURANCE COVERAGE: Check on
I have a current Ilabllfty Insurance polcy or its substantial equivalent. Yea COY No ❑
If you have checked yes, please Indicate the type coverage by checking the aupproprlate box.
A liablifty insurance polcy 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 appllcaHon waives this requirement.
Check one:
SIgnature of Owner or Owner's Agellt Owner ❑ Agent ❑
Thereby certify that an 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 rformed under the permit Issued for this appikatIon will be In compliance with all .
pertinent provisions of the Massachusetts Stale GasCode and Chapter 142 of the al 1AT nse:
MIS umbeerr na urs o nse um of
or as IT or
Master _.-cense Number > 7
ty/Town L,Joumeyman
4"f'ODWo (OFFICE USE ONLY)
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'. Date.
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NpRTM TOWN OF NORTH ANDOVER
0 �� PERMIT FOR GAS INSTALLATION
�9SSAC HUSES�h �.
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This certifies that . . �! �l�!s.��,Y. . . �.� ��. . . . .. . . . . .
has permission for gas installation . . . f. -'-/,r. . . . . . .
in the buildings of . . /' . . . . . . . . . . . . . . . . . . . . . . . .
at . . .U.-. . ° . . . . . ., North kndover, MasX
Fee.7. ( :.:. Lic. No.. 1.U.?`� �j '�.�. . . . .
GAS INSPECTO!k
1
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