HomeMy WebLinkAboutMiscellaneous - 11 West Woodbridge j „ r✓ ����h as� BUILDING
FILE-
Date. ./.` .7. ... . ...
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Of HQ DTH ,ry
TOWN OF NORTH ANDOVER
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• PERMIT FOR GAS INSTALLATION
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SSACNUSE
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This certifies that . . . . .S.1,4 N. _. . . . . . . . . . . . . . . . . . . .
has permission for gas installation .. . . . . . . . . . . . .
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in the buildings of .. . . . . . . . . . . . . . . . . . . . . . . . . .
at . . . .1.l. . . o. . . . . °°.�� �'.'`�5 .`" .., North Andover, Mass.
Fee. . . . . . Lic. No..� o �. . . . . t-}. *. . . . . .
GAS INSPECTOR
Check# 3 Yz y
5900
MASSACHUSETTS UNIFORM APPUCATON FOR PERMI T TO DO GAS FITTING
(Type or print) Date � Q-7
NORTH ANDOVER,MASSACHUSETTS
Building Locations � �U Ci /O �-, 1 IJ 2--0— Permit# �4 G
Amount$
Owner's Name S U / ''��v(�
New Renovation Replacement Plans Submitted 0
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SU B-BASEM ENT
® BASEMENT
IST. FLOOR
F 2ND . FLOOR
• 3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6 T H . F L O O R
7TH . FLOOR
8TH . FLOOR
Name or type) �lie ! � /4 �2� /�� `� Ch k one: Certificate Installing Company
/ /' � � Corp.
Address 1
Partner.
KJ-�-Vofvu 4-XL
Business a ep one _ j Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No�
If you have checked Les,please indicate the type coverage by checking the appropriate box.
Liability insurance policy D/ Other type of indemnity D Bond 13
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.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent
I hereby certify 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 installatio performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusett to G Code andC ter 142 of a Gener� aws.
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7
L,
By: Signature of Licensed Plumber Or Gas Fitter
Title Plumber
City/Town [:] Gas Fitter Icense um er
10—Master
APPROVED(OFFICE USE ONLY) [3 Journeyman