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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTIr
(Print or Type)
NORTH ANDOVER Mass. Date s Q
building Location Permit #
Owners Name
Y
• - New Renovation D Replacement E3 Plans Submitted D,
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(Print or Type)
Installing Company Name
Address �/-(J
Business Telephone:
Name of Licensed Plumber or Gas Fitter
Insurance Coverage:
appropriate box:
Check
one: Certificate
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Corp.
Partner.
Firm/Co-
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(Print or Type)
Installing Company Name
Address �/-(J
Business Telephone:
Name of Licensed Plumber or Gas Fitter
Insurance Coverage:
appropriate box:
Check
one: Certificate
Q
Corp.
Partner.
Firm/Co-
Indicate the type of insurance coverage by checking the
Liability insurance policy �21 Other
Insurance Waiver: I, the undersigned
this application does not have any one
Signature of owner/agent of property
type of indemnity Q Bond Ej
have been made aware that the licensee of
of the above three insurance coverages.
Owner ❑ Agent 0
I hereby certify that all of the dcuils and information 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 pctfomied under Permit isseed to: this application will_be in compliance with all pertinent
provisions of tho iltasuchusetts State Cas Code and Chapter 142 of tho Central I.Aws.
TYPE LICENSE:
Plumber
Gasfitter Sign ure of Licensed
Master Plumber or Gasfitter
Journeyman License
License Ilumber
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
-, Date .....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ............. )......... ! ....................
has permission for gas installation ...I. ....................
in the buildings of .................. I ............
at .. L.' '...... ... �...... �,r. LS.�,, North Andover, Mass.
Fee.:,:��.... Lic. No.........:. ..........................
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File