HomeMy WebLinkAboutMiscellaneous - 10 UNION STREET 4/30/2018Date........ . �� .
A/°" °" TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION'
9SSACHUS*' /
This certifies that ..: . . . ...... !.. . . . .. I ........ .
has permission for gas installation .... L -t.. /Y .................
in the buildings of ..........................................
at ...�? iLt A-...... , North Andover, Mass.
Fee. 30 .... Lic. No.. I -N........
(3AS INSPECTOFf
Check #
66:'0
MASSACHUSETTS UNN ORM APPLUCATON FOR PERMIT TO DO GAS FMING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS date
Building Logations�-
Owner's Name
New ❑ Renovation Replacement ❑ Plans Submitted ❑
Permit # eq U
Amount $ 3 �.
(Print or type)
Address =,
Name of Licensed Plumber'or Gas Fitter
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
❑ Firm/Co.
INSURANCE COVERAGE
1 have a current liability Insurance, policy or it's substantial equivalent. Check one:
If you have checked yes, please indicate the type coverage by checking the appropriate box.No❑
Yes
Liability insurance policy Other type of indemnity ❑
Bond ❑
Owner's Insurance Waiver. 1 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:
I hereby certify that all of the details and information IOhave submitted (or entered) rn 1 application gent13 a and accurate t
the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Smote Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town,
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber j y�'
❑ Gas Fitter L Icense um er
❑ Master
rti&—.a man