HomeMy WebLinkAboutMiscellaneous - 1 HIGH WOOD WAY 4/30/2018 (2)N
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Date. . 3 o
...................
,AORTH
Of Ail
6.
6
A,
0 TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies'that S. .47� ...................
has permission for gas installation.. . � ....................
in the buildings of ..... k A ..........................
at .............. North -Andover, Mass.
Fee.'.'�7 Lic. No. ... ....
J&AS INSPECTOR
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5217
t�I�tSSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
y�' -:D 1(ii�filftUr. iJ;ass.. Gate !9 Permit # 1
B611dir4gLocation ujppj,
I Owner's Name_- 0> ®10 ool� ....
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Type of Occupancy I`iSlkillx
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New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No
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i Address
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D Check one:
CerYt
cate
coWration
/A^ bk❑. Partnership
Firm/Co;
'Gas Filter�NameofUcensedFMumber or
_
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i
FA
E COVERAGE:
;.irent iabllfty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch: 142
i No O, I
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c ecedyes, please indlccate the type coverage by checking the appropriate box.surance pc
licl
z IAIVI Other type of indemnity, ❑ Bond ❑
OWNER'S INSURANCEER: I am aware that the licensee does not have the insurance coverage required b 4 tw
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Chapter 142 of the Mass. General Laws, and that my signature on this g y
: t permit application waives this requirement.
n Check one:
ry>�, Owner❑ Agent ❑
Sgnature of Owner or Owner;'s Agent
qs S
a Hereby oarlify that all of the details and information I 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 the permit issued for this application will be in compliance w
pertinent provisions^qt the Massachusetts State.Gas Code and C. apter 142 of ith all
the er I laws.
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lrk� �1 T of License:
' irk Plumber Signature of Licensed lumber or Gas itler
s „irk Gasfitter
City/town s j bumyman
e License Number
� �1
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BASEMENT
ISTFLOOR
17
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLyOOR
7TH FLOOR
STH FLOOR
' C tY1l s.
Bhussianm re, lns1fls..'fCeolempphaony._ samep'19_�
B' ItSLilIIfy�srA�1/ZLY.irr"J 3LLL��
i Address
-�s8�wajs�s�.'►+
D Check one:
CerYt
cate
coWration
/A^ bk❑. Partnership
Firm/Co;
'Gas Filter�NameofUcensedFMumber or
_
r
t'
i
FA
E COVERAGE:
;.irent iabllfty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch: 142
i No O, I
jt r
c ecedyes, please indlccate the type coverage by checking the appropriate box.surance pc
licl
z IAIVI Other type of indemnity, ❑ Bond ❑
OWNER'S INSURANCEER: I am aware that the licensee does not have the insurance coverage required b 4 tw
+ i
Chapter 142 of the Mass. General Laws, and that my signature on this g y
: t permit application waives this requirement.
n Check one:
ry>�, Owner❑ Agent ❑
Sgnature of Owner or Owner;'s Agent
qs S
a Hereby oarlify that all of the details and information I 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 the permit issued for this application will be in compliance w
pertinent provisions^qt the Massachusetts State.Gas Code and C. apter 142 of ith all
the er I laws.
r .
lrk� �1 T of License:
' irk Plumber Signature of Licensed lumber or Gas itler
s „irk Gasfitter
City/town s j bumyman
e License Number
� �1