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Date.;�/.. . �. .. . .1.. ... .
Of 40RTH
TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
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y This certifies that . . . . . . . .�,. . . . ..�. . . . . . . . . . . . .
has permission for gas installation . . . . f � ��� . . ... . . . . . . . . . . .
in the buildings of . . .f�.f.;. c� .��.-.f. . '. . . . . . . . . . . . . . . . . . . . . . . .
at . . . A . . . . : . . , North Andover, Mass.
Fee. .2..(�. . . . Lic. No.`'j V. . . . . . .. . . . . . . . .
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GAS INSPECTOR
Check# i
4185
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MASSACHUSETTS UNIFORM APPUCATtON FOR PERMIT TO_DO GASFI
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Mass. Dater _C, I'ermIt
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Willing Location lint G� /Owreet'a Name
C.9:/P� �4=✓ ��i Type of Occupancy
~r ~ New p Renovation p Replacement Plans Submftted:` Yesp 1 No
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1ST FLOOR �.
214D FLOOR
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Installing Company.Name DEMERS FLAG & lit g. ' i ne. ;: Chectc one: Cettlilcae$ #
Address P.0 BOX JAI Corporation
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V I �� S p Partnership
Business Telephone_ �"' � �• O Firm/Co. 4:"i
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Name-of Licensed Plumber or Gas Fitter DONALD DEMERS
INSURAN.CE'COVERAGE:
1 have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Clu:142
Yes XQ . : No O r
Y04-have checked yes;please Indicate the:type coverage by checking the appropriate box.'
A.Ilabdtty Insurance policy Other type of Indemnify O Bond.C7
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: y
OwnerO ' Agent O.
Signature of Owner or Owner's Agent
I hersby tartly that all of the details and(nlormalion I have submitted(or entered)In above applicallon are bus and actuate to the best of my
'= knowledge and Thal all pplumbing work and Installations performed under the permit Issued lot cation will be In comptlance with aG
perllninl provisions of the Massachusetts Stale Gas Code and Chapter 142 o1 th
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T e o1Ucense:
umbo gna ure o cense um t or as ret aAll
slitter Maslcr �Ucense Number � � 9442
n Jotuneyman f a;
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l�W Northern Utilities
c'lylE3aySta a-Gas n�n Natural Gas WARNING NOTICE — AVISQ CUSTOMER COPY
J A NiSoume Company A NiSource Company
STREET / �v 4C � .��� '/�CIUDAD P OPIETARIO TELEFONOTY OWNER E
CALLE
CUSTOMER SUITE TELEPHONE ADDRESS
CLIENTE APARTAMENT TTELEFONO DIRECCION
AIR SUPPLY
THE FOLLOWING PROBLEM MUST BE CORRECTED IMMEDIATELY: ❑ PIPING ❑TUBERIAS SUMINISTROS DE AIRE
LOS SIGUIENTES PROBLEMAS DEBEN SER CORREGIDOS IMMEDIATAMENTE: APPLIANCE VENTING
i //� J�/' /' � ARTEFACTO DE GASP ❑ C� TOS D�NTILACI��'
EXPLAIN: C6CIC L H!�I C7 41 A/ �� d � JJJ /,
EXPLAIN: L 1
YOU MUST CONTACT A QUALIFIED CONTRACTOR FOR REPAIR:
CO/MUNIQUESE CON UN CONTRATISTA ESPECIALIZADO PARA EFECTOS DE LA REPARACION:
J PLUMBERElELECTRICIAN ❑ CHIMNEY CLEANER ❑ OTHER:
/BCCI PLOMERO ELECTRICISTA PERSONA QUE LIMPIA EL CANON
O HUMERO DE CHIMENEA OTRO:
THIS WARNING NOTICE IS FOR YOUR SAFETY AND PROTECTION. AFTER ESTE AVISO ES PARA SU SEGURIDAD Y PROTECCION. PARA LA RE-
REPAIRS ARE MADE CONTACT BAY STATE GAS/NORTHERN UTILITIES FOR STAURACION DEL SERVICIO COMUNIQUESE CON BAY STATE GAS/NOR-
THERN UTILITIES DESPUES DE QUE LAS REPARACIONES HAYAN SIDO
RESTORATION OF SERVICE. HECHAS.
GAS LEFT ❑ ON-CONECTADO METER LOCKED ❑YES-SI
CONTADOR APPLIANCE LOCKED ❑ YES-SI
EL GAS SE CERRADO ARTEFACTO CERRADO {
ENCUENTRA FF-DESCONECTADO CON LLAVE NO-No DE GAS CON LLAVE ❑ NO-NO
CUSTOMER SIGNATURE: TENANT OWNER
FIRMA DEL CLIENTE: ❑ INQUILINO ❑ PROPIETARIO
DEATE TIME CHA 2/ a(.r HPRA , EMPLOYEE 0:/7 74
� EMPLEADO
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