HomeMy WebLinkAboutMiscellaneous - 613 Forest Street _ `
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HORTIy
Of�...o ,°6
b or TOWN OF NORTH ANDOVER
• - PERMIT FOR GAS INSTALLATION
�,SSACMUSE�
This certifies that . . °`.`. . . . . . .`.. . . . . . . '��.��"
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has permission for gas installation .":!^. c�'.�0� �11 . . . . . �--
in the buildings of . . . . . . . . . . . . . . . . . . . . . . . .
at �. . . !' .`. . . . . . . . . . ., North Andover, Mass.
Fee.3. . . . . . Lic. No../.? � � . . . . . . . .Q _. .. . . . . .
/GAS INSPECTOR
Check#
4537
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINO �)c
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Building Location ��7 ko('o J—,, Owner's Name T
Type of Occupancy
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New Renovation [) �Replalement ❑ Plans Submitted: Yes❑ No
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2ND FLOOR
3R0 FLOOF. I I I I I I I I I ! I
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4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
lns' ling Company Name TOWNSEND PROPANE SERVICES Check one: Certificate
Address 75 WEST MAIN STREET C C Corporation
GEORGETOWN, MA 01833 ❑ Partnership
Business Telephone 987 3528711 ❑ Firm/Co.
Name of Licensed Plumber or.Gas Fitter � Id LA t 224
INSURANCE COVERAGE:
I have a current liability insurance p_clicy or its subs`,antia! equivalent which meets the requir emier,ts of MGL Ch. 142.
Yes [X No ❑
If you have checke-� yes, pease !ndic�te the type coverage by checking t~e appreprzte Mx
SiG;y insurance policy CIX Other typ? of in-de;,niity ❑ 8or,d iF'
OWNER'S INSURANCE WAIVER: I aim awzre t at the licensee does not have the Insurance coverage req!ire-t by
Chapter 142 of the Mass. Genera! La r,s, and that my signature on this p_rmi� application waves this requirement.
Check one:
Owner❑ A^ye,�t ❑ -
&grature of Ager,,
I hereby oer'i fy that ail of the dela,5 and infor ,aticn I have submitted (cr entered)in above aDplica;ion are true and a`curate to the test c` my
;;nowiedge and U a;a.`! plumbing work and insta'la.cns p?ro�ed under b`,e pemit iss4:ed for b5is app n wiG be in oomplia:noe ;h a'!
A
pertinent pror'sicns of the Massa�us?t'�State Gas Cede and Chaoter 142 of the General Laws.
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EY � T _ o! License:
Plumber Signature of Lice -&cumber or Gas Fitter
TiLte slitter �7
Master License Number�..T' I z Q
CityROwn Journeyman
(Or IC USS Or.'l�-