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Date. .,.k ..C'.`/......
TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
This certifies that �1,4114,
has permission for gas installation
in the buildings of ..............
at Cf. . .... ......AA.., North Andover, Mass.
Y
Fee. F. " ... Lic. �No..`!' :..... .
GAS INSPE TOC R
Check # / C C / c
46U3
MASSACHUSETTS UNIFORM APPLICATON FOR PERN& TO DO GAS G
(Type or print) Date % 3
NORTH ANDOVER, MASSACHUSETTS
Building Locations r ii— S U�%ice / / ( /� l� Permit # L(� 6
pt hPi N & S %/Tri o N Owner's Name
New [ Renovation ❑ Replacement ❑
Amount $ I- r
%
Plans Submitted ❑
NNatmme or 84 QA 1'lAu A L
Check one: Certificate Ipst�ing Company
0 ""rp. (p
❑ Partner.
❑ Finn/Co.
Name of Licensed Plumber or Gas Fitter 0-D E CA.L LA I&A. -I
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes [3-- No❑
Ifyou have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑- - 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.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
i nereby cermy that all of the details and mtormation 1 have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this ap lication will be in
compliance with all pertinent provisions ofthe Massachu�s State Gas Code and QLpter 142 ofthe era Laws. r�
VED (OFFICE USE ONLY)
Signature of Licensed/Plumber Or Gas Fitter
Plumber /
[as Fitter License NumBer
0-MIaster
❑ Journeyman
•
•
NNatmme or 84 QA 1'lAu A L
Check one: Certificate Ipst�ing Company
0 ""rp. (p
❑ Partner.
❑ Finn/Co.
Name of Licensed Plumber or Gas Fitter 0-D E CA.L LA I&A. -I
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes [3-- No❑
Ifyou have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑- - 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.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
i nereby cermy that all of the details and mtormation 1 have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this ap lication will be in
compliance with all pertinent provisions ofthe Massachu�s State Gas Code and QLpter 142 ofthe era Laws. r�
VED (OFFICE USE ONLY)
Signature of Licensed/Plumber Or Gas Fitter
Plumber /
[as Fitter License NumBer
0-MIaster
❑ Journeyman