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337 �l:..:�,,c�....
,�ORTM TOWN OF NORTH ANDOVER
Qy`,tD •!16 0
PERMIT FOR GAS INSTALLATION
This certifies that .......................
has permission for gas installation ........................... .
in the buildings of ..`'.�:.� .`. ! �` ` - ...................... .
at .. ........ , North Andover, Mass.
Fee.. � - :.. Lic. No..5 ..... ............
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
V
2ASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS
or print)
iwrcIH ANDOVER, MASSACHUSETTS
Building Locations
Owner's Name
New ❑ Renovation ❑ Replacement 0� -
Date / �� -17-190(9
Permit # 3 J / 7
Amount S
Plans Submitted
(Print or asp �` J Check one: Certificate Installing Company
Name ❑ Corp.
t
Address �'—'��✓ ❑ Partner.
Business Telephone S TFICo.
Name of Licensed Plumber or Gas Fitter -21,, d r% p
INSURANCE COVERAGE Check o :
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked yes, plea e i icate the type coverage by checking the appropriate bo. .
Liability insurance policy Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiv 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
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 all plumbing work and installations p o d u der Permit Issued for this application will be in
compliance with all pertinent provisions of the'vlassachusetts State ter 14aws.
By:
Title
City/Town
APPROVED (UFF1Cii USE ONLY)
' ignature of'Licensed Plumber Or GF* er
L
Plumber z Lz 9
Gas Fitter
Lic,,Inse Numoer
Master
loumeyman
i�
I
(Print or asp �` J Check one: Certificate Installing Company
Name ❑ Corp.
t
Address �'—'��✓ ❑ Partner.
Business Telephone S TFICo.
Name of Licensed Plumber or Gas Fitter -21,, d r% p
INSURANCE COVERAGE Check o :
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked yes, plea e i icate the type coverage by checking the appropriate bo. .
Liability insurance policy Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiv 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
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 all plumbing work and installations p o d u der Permit Issued for this application will be in
compliance with all pertinent provisions of the'vlassachusetts State ter 14aws.
By:
Title
City/Town
APPROVED (UFF1Cii USE ONLY)
' ignature of'Licensed Plumber Or GF* er
L
Plumber z Lz 9
Gas Fitter
Lic,,Inse Numoer
Master
loumeyman