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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION¢
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This certifies that`.::: - '.. ... �' .......... �.
has permission of gas inst lation :.
in the buildings of .:......... ............
at ... �.....�...... ........ North Andover, Mass.
Fee.,?..,-.... Lic. No....... .... ..........................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
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MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations 25- G ��" wOoc� Sf
Permit # 6,/
Owner's Name Amount $ e �.=
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New ❑ Renovation ❑ Replacement ❑ Plans Submitted
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(Print or type)
Name %fie
i
Address - CO NC S -f , Ln -,d -r m c4,, o, �i►�y
Business Ielephone
Name of Licensed Plumber or Gas Fitter I ec 0,0n P o-V/1A Gt, d
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Check one: Certificate Installing Company
❑ Corp.
❑ P ner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance icy or it's substantial equivalent. Yes 13If you have checked es ple dicate the type coverage by checking the appropriate box.
No
Liability insurance policy10 Other type of indemnity 13 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.
Signature of Owner or Owner's Agent Check one:
Owner 13 Agent 13I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurato
best of my knowledge and that all plumbing work and installations performed under Po the
ermit Issued for this application will te to
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Lawc_
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
.3 Plumber 3O Z3 � • 7 -
Gas Fitter icenseum er
n (aster
LL=:JJ�Journeyman
NORTH ANDOVER HEALTH DEPARTMENT
120 Main Street • North Andover, MA 01845
Telephone (508) 682-6483, Ext. 32
Housing Inspection Report
COMPLAINT #_
COMPLAINANT
ADDRESS OF PREMISES ;Act 02• -ee—A Ly40O A
OCCUPANT
OWNER
OWNER'S ADDRESS 23 6e-4� ✓
DATE OF INSPECTION HOUR
ROOMS/VIOLATION:
Form #NIR -1 Actlon Press 885.7000
NORTH ANDOVER HEALTH DEPARTMENT
120 Main Street • North Andover, MA 01845
Telephone (508) 682-6483, Ext. 32
Housing Inspection Report
COMPLAINT #_
COMPLAINANT
ADDRESS OF PREMISES _ AZ GAO &2 00 <
OCCUPANT J1,9629 Q 7" --
OWNER 4L.,rJ1163' 0077"K
OWNER'S ADDRESS a6 Z3
DATE OF INSPECTION /11/9 99 HOUR 94'00 AR
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INSPECTOR
Form MR -1 Actlon Press 885.7000
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
l NORTH ANDOVER Mass. Date
E wilding Location C2 --Z � Permit
• Owners Name
• New 77 Renovation D Replacement Plans S mitted D
FIXTU?'=5
C!'
(Print or Type) Check one: Certificate
Installing Company Name ` 6 Y\/ Corp.
Address Partner.
iR:f- ZZ(f e- �IAS' - Firm/Co.
Business Telephone:0--5- b
Name of Licensed Plumber or Gas Fitter �j
Insurance Coverage: Indicate the type o 71surance cove/rage by checking the
appropriate box:
Liability insurance policy Q�other type of indemnity Q Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
ignature of owner/agent of property Owner Agent
I hereby certify that all of the details and information i have submitted (or entered) in above application are true and accurate to the belt of my
knowledge and tlut all plumbing work and installations petfomted under Permit iueed for this application will -be in compliance with ail pertinent
provisions of tho Massachusetts Slate Gas Code and Chapter 14I of tho Genual Inws.
By
Title
City/Town:
APPROVED (OFFICE use ONLY)
TYPE LICENSE:
Plumber
Gasfitter Signature of Licen ed
Master Plumber orasfi.tter
Journeyman
License Number
V
•
■oenn�o�n��s����os���i�
(Print or Type) Check one: Certificate
Installing Company Name ` 6 Y\/ Corp.
Address Partner.
iR:f- ZZ(f e- �IAS' - Firm/Co.
Business Telephone:0--5- b
Name of Licensed Plumber or Gas Fitter �j
Insurance Coverage: Indicate the type o 71surance cove/rage by checking the
appropriate box:
Liability insurance policy Q�other type of indemnity Q Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
ignature of owner/agent of property Owner Agent
I hereby certify that all of the details and information i have submitted (or entered) in above application are true and accurate to the belt of my
knowledge and tlut all plumbing work and installations petfomted under Permit iueed for this application will -be in compliance with ail pertinent
provisions of tho Massachusetts Slate Gas Code and Chapter 14I of tho Genual Inws.
By
Title
City/Town:
APPROVED (OFFICE use ONLY)
TYPE LICENSE:
Plumber
Gasfitter Signature of Licen ed
Master Plumber orasfi.tter
Journeyman
License Number
Date //!V r!�G' - ? ......
A TOWN OF NORTH ANDOVER
PERMIT FOR 4S INSTALLATION
This certifies that . <'.�- !.h.... ' Gi cc <:. ............
has permission for gas installation .....f! A .�7 ...............
in the buildings of ..13
-.°..� ............................. .
at .. .? .. C-. l r N. .4. ° .� ........... , North*
orth Andover, Mass.
Fee. 3 ° ?"' . Lic. No.3 .... y.. .. ��- � .....
,GAS INSPECTOR '
Check #
6175