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HomeMy WebLinkAboutMiscellaneous - 1060 OSGOOD STREET 4/30/2018 (13) ` � ���5 � � ��10� / Date. .O.. . ... .. NORTH Of TOWN OF N TH ANDOVER O 9 • PERMIT FOR GAS INSTALLATION 9 - SSACMUSE This certifies that /VX /11 fc I . . .P x4. . . . . . . . . . . . . . . . . . has permission for gas installation . . Y r..!1.zt:/-I/. :� . . . . . . . . . . . in the buildings of . Ax.1. � . . . . . at 0 6.ev. . .(?s.s . . . . . . . . . . . . .. North Andover, Mass. Fee. .a.a . . Lic. No..c- .,,P.E.X.. . . . . . . . . . . . . . 'GAS INSPECTOR Check# - gq 5859 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING �j (Print or Type) 5- ? - -ob �`�c•������c\c�y�1. Mass. Date 19 Permit # � Building Location 1(2�CCc—) �S�©c�S�Owner's Name Type of Occupancy_ 0 M - New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No N Q N W N Y = 6 N N H v a N S ►- N Q N O W ¢ 0 O V m _ Z O F x o W < ¢ =. O O t- < W to F- ;y W O N tL = I O < ti z Ir-N Orr V W N W C< ¢W H W O F' S W w Y rr: h GC W Yt J ` W W Q O > W r V J �. W r Z < W W O Z. < CC < i O O W a O fit F- a 2 O C Y G a 1- O SUS—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RDFLOOR _ P 4TH FLOOR STHFLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name MILNE PLBC.R HTmG heck one: Certificate Address PO BOX 603 Corporation ❑. Partnership Business Telephone �.y1� D Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COV RAGE: I have a current 4fabildy insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 19 No ❑ If you have checkedrtes. please Indicate the type coverage by checking the appropriate box. A liability insurance policy D� Other type of indemnity O 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. OwnerCh k one: Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details 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 performed under the permit issued for this application ill be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the GTAM�"al BY TiMausr'neyman license: mber Si ature of Licensed Plumber or Gas Fitter Title sfitter erLicense Number Qty/Town APPROVED( 1 NL t NORTH O iteo 1/.O F y 9 i NORTH ANDOVER BUILDING DEPARTMENT 4 4„v• � 400 Osgood Street SwCHU`+ Tel: 978-688-9545 Fax: 978-688-9542 BUSEVESS FORM FOR TOWN CLERK DATE: )141 NAME: I'1 C� ADDRESS: ZONING DISTRICT: l �— TYPE OF BUSINESS: BUILDING LAYOUT PROVIDED: YES O AVAILABLE PARKING SPACES: l ZONING BY LAW USAGE: YES NO ✓A BUIL/DI�NG INSPECTOR SIGNATURE Revised 11.5.04 BUSINESS FORM FOR•DOWN CLERK