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3385
Date.. . ... ..... .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation . �Z l/, h N ; t C. c
in the buildings of C. w H A'.? .
at `:. ` .. !..'.. ` ..... . , North Andover, Mass.
Fee.. i.... Lic. No... ud .... ... C L ............
V6AS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
i.
M SSACHUSETTS UNIFORM APP�ICATIO PERMIT TO DO GASFITTING
(Print or Type) �l7 041
nn
�`Cti��y t= r ,M� Date 3 d a Receipt# Permit#
ACI -o Ss r-orn LkM N lou+S
Building Location � / Owner'sName Ckcx
Map: Lot: Zone: Type of Occupancy -
New ❑ Renovation ❑ Replacement ❑ 1 Pla Submitted:i Yes ❑ No ❑
Installing Company Name.�,i.tnrr_:oc�n Cirri E ire_
Address 131- lis c ket-i- 3 -Da n v f_.t- a cj E C1 3 '�
EstimateValueof Work:
Business Telephone I -i nt, -6:4;1 -
Name of Licensed Plumber or Gas Fitter'�—
Checkone: Certificate
M Corporation
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 11f No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy IS 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.
Checkone:
Owner ❑ Agent'O
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above a7;Law.
a true and accurate to the best of
my knowledge and that all plumbing work and installations performed under the permit issu
lication will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge ra�l
By Type of License:cS f` "
Plumber Signature of Licensed Plumber or Gas Fitter
Title Gasfitter
Master License Number •C. `T
City /Town Journeyman
APPROVED (OFFICE USE ONLY)
ON
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Installing Company Name.�,i.tnrr_:oc�n Cirri E ire_
Address 131- lis c ket-i- 3 -Da n v f_.t- a cj E C1 3 '�
EstimateValueof Work:
Business Telephone I -i nt, -6:4;1 -
Name of Licensed Plumber or Gas Fitter'�—
Checkone: Certificate
M Corporation
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 11f No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy IS 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.
Checkone:
Owner ❑ Agent'O
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above a7;Law.
a true and accurate to the best of
my knowledge and that all plumbing work and installations performed under the permit issu
lication will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge ra�l
By Type of License:cS f` "
Plumber Signature of Licensed Plumber or Gas Fitter
Title Gasfitter
Master License Number •C. `T
City /Town Journeyman
APPROVED (OFFICE USE ONLY)
i of 4;'
.1WINI Ig
Date ............
q4s-_ OR
TOWN OF NORTHAND, GVER
PERMIT FOR PLUMBING
This certifies that ........ ................
has permission to perform ........
plumbing in the buildings Of ...... ............
at ................................. North
h Andover, Mass.
Fee. Lic. No.. 3 q .3
PLUMBIN/G 1,NSPECTOR
Check #
77'10
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
��n o Date ' �� 'C'
Building Location iS � f R L o- .51 Owners Name �' �" rs l ��»L Permit # 7iv
Amount
Type of Occupancy
New 0 Renovation M Replacement Plans Submitted Yes
No ❑.
FTYTT T7? tic
(Print or type)
Installing Company Name
Address
Check one: Certificate
Corp.
i
Partner.
Business 1 elephone l % .. A' Firm/Co.
Name of Licensed Plumber: 0 6VIr \ ��
Insurance Coverage Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this applicatio
nc n does not have any one of the above
e •
lure
Owner 1:1 Agent
Tereby 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 perform under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St ao and Chapter 142 of the General Laws.
City/Town
APPROVED (OFFICE USE ONLY
Type of Plumbing License
301 q.3
Ocense 114uin0er Master ❑ Journeyman j7-1--