HomeMy WebLinkAboutMiscellaneous - 107 SUMMER STREET 4/30/2018 (2) 107 SUMMER STREET
210/038.0-0252-0000.0
1
i
Date.... .. .
40RTH
o� TOWN OF NORTH ANDOVER
'• PERMIT FOR GAS INSTALLATION
SSACNUSE�
This certifies that . .��
has permission for gas ins/t�allation--��'-���.-�:� �f . . . . . . . .
in the buildings of) . . . . . . . . . . . . . . . . . . . . . . . .
at . ��? // Y .�t -'' . . . . ., North Andover, Mass.
Fee-- . . .L Lic. N6'���� d. . . . . .. . ..... . . . . . . . . .
GAS INS ECTOR
Check# �
7134
MASSACHUSETTS UNIFORM APPLICATI ,1V FOR PERMIT TO DO GAS FITTING
'7
City/Town: � �` '_—_ MA Date:j9_-.9 Permit# /I--------
Building Location: _ _ _ • Owners Name:
Q�_
Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional ❑ Residential(Id
New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑
FIXTURES
to to
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SUB BSMT.
BASEMENT
1 FLOOR...
2 Nu FLOOR
3 FLOOR
4 FLOOR
5 FLOOR
6'H FLOOR _
h
7'"FLOOR
8 FLOOR
l,`�(^ (� Check ne Only Certificate#
Installing Company Name:���` � —T- Q� --- 1'1 ---
orporation
Address:aT-V -e-r7YQ-f 6 (City/Town: 1.0,jState:
❑ Partnership —___—_--___-
Business Tel:� � c _ "77J Fax:---------------------- ❑Firm/Company _—___________
Name of Licensed Plumber/Gas Fitter: a
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL'.Ch. 142 Yes No El
If you have checked Yes,please indi a the type of coverage by checking the appropriate box below.
A 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent —
By checking this box❑;I hereby certify that all of the details and information 1 have submitted(or entered)regarding this 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 beJ6
compliance with all Pertinent provision of:the.Massachusetts State Plumbing.Code and Chapter 142 of the General Laws. .
Type of License:
By------------- ---- - „E],Plumber
. "E]Gas Fitter � ---------=----- -..
Si nat a of LiceAed Plumber/Gas Fitter
Title-----------------
�El/rr�City/Town___________ _ ; eyman Lic Number: LI�10APPROVED OFFICE USE ONLY staller