HomeMy WebLinkAboutMiscellaneous - 1 ALCOTT WAY 4/30/2018 (2)N
'J � 5 S Date:. !:9'? :.. (':?� .......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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This certifies that ........ .:-.`-:
has permission for gas installation ......
in the buildings of ................ • • .
at :. J . , North Andover, Mass.
F ee v Li No... ... ,.,•
rGAS INSP,5CTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
"Iii �•• _T. ,� �jCC jj��W i , Mass. Date ifl 2600 Perm i t #
e.
Building Locational cutt%VFiU Owner's Name f '_,�r _
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Type of Occu cyI��� t I Gc
New ❑ Renovation ❑ Replacement lel Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name CLIMATE BESIGN
Address 7 Street
Haverhill, MA 01830
(M) 312-9999
Business Telephone Lic. Plumber: Michael H HoNse
Name of Licensed Plumber or Gas Fitter
Check one: Certificate
'!<orporation / q Y3c
- Partnership
- Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of ,v[GL Ch. 142.
Yes C--` No C
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy CC/ Other type of indemnity G Bond G
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.
Signature of Owner or Owner's Agent
Check one:
Owner - Agent C
I hereby certify that all of the details and information I have submitted (or entered) in the above application
are true and accurate to the best of my knowledge and thatall plumbing work
and installations performed under the permit issued for this application will be
in compliance with all peninent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By
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C Gasfiner
Title
•!./,Master
Signature of Lic used Plumber or � s trn
`'/,
Ciry/Town
Journeyman
7
License Number
APPROVED (OFFICE USE ONLY)
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OEM
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Installing Company Name CLIMATE BESIGN
Address 7 Street
Haverhill, MA 01830
(M) 312-9999
Business Telephone Lic. Plumber: Michael H HoNse
Name of Licensed Plumber or Gas Fitter
Check one: Certificate
'!<orporation / q Y3c
- Partnership
- Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of ,v[GL Ch. 142.
Yes C--` No C
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy CC/ Other type of indemnity G Bond G
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.
Signature of Owner or Owner's Agent
Check one:
Owner - Agent C
I hereby certify that all of the details and information I have submitted (or entered) in the above application
are true and accurate to the best of my knowledge and thatall plumbing work
and installations performed under the permit issued for this application will be
in compliance with all peninent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By
Type of License:
'Wlumher
C Gasfiner
Title
•!./,Master
Signature of Lic used Plumber or � s trn
`'/,
Ciry/Town
Journeyman
7
License Number
APPROVED (OFFICE USE ONLY)
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