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HomeMy WebLinkAboutMiscellaneous - 12 STACY DRIVE 4/30/2018 U STACY DRIVE 2101081.0-0056-0000.0 Date.�//� /.�� . ....... . NORTH pF �.a o ,,,,'ti'O a� °` TOWN OF NORTHAAN VER O � D • PERMIT FOR GAS INSTALLATION �,SSACHUSEt This certifies that . .� '�� ? . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . �!� `? `'.r in the buildings of . . . . . . . .. .-.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . ?. . 5ell.,. `. ? . . . . . . . . . . . . . . . . .. North Andover, Mass. �1 r Fee. Lic. No.�.�. ?. �.r. . . `�. . v!`';!1.. . . . . . . . . . GASINSPECTOR Check# Z yz v� 63U4 MASSACHUSETTS UNIFORM APPUCAT DN FOR PERMIT'PO DO GAS FfMNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building �— Building Locations /� J / 'Lli/ )�j(J/� Permit# Owner's Name C���—N Amount$ 6 New D Renovation D Replacement Plans Submitted � a w rA w o ° H x � ' ' w w p O p z F w w m z u w �' z F a a > w H z F e x w a w w 0 Z Z , d w < a F. F z O z p x �d x o x fz 3 0 a o xo > a a H o SUB -BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 1� 3RD . FLOOR [7T TH . FLOOR TH . FLOOR TH . FLOOR H . FLOOR 8TH . FLOOR (Print or type/), J Check one: Certificajns aliing Company Name c��LL } C l c Corp. Address to X-;I- J El P &2, Partner. Business a ep one Firm/Co. Name of Licensed Plumber or Gas Fitter 'u-iffF14LITlulck— INSURANCE COVERAGE Check one: 1 have a current liability Insurance,policy or it's substantial equivalent. Yes ❑�' No ❑ If you have checked yes,please in ' to the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 13 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. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 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 installations perfo. ed er Permit sued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas od d Ch r 2 he General Laws. By: Signature of ic(�Wa Plumbe Or G Fitter Title ©')slumber lT l City/Town, 0 Gas Fitter LICallse INUMDer 13--master APPROVED(OFFICE USE ONLY) ❑ Journeyman — MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date �� 19�( Permit# °�a � !31 A,�� Building Location 12 S'r4_y C., Owner's Name 61 Type of Occupancy New ❑ Renovation ❑ Replacement 51-" Plans Submitted Yes ❑ No Cf— U) W Q) U) U) Cc¢ ¢ cc Q O U) = (W.7 U) W �O U m f= S U)Z D: Na > Z 0 6- W ¢ m W Q w W O co o. w Q w ¢ cn c7 v W = v) w ~ a:ui 0O o W rn (7 F- Z -� F- Z W W 0 LL W U J Q Z Q W J Q Q I`- t- } W m Z O 1.- W O Cn _ � = O cal MW LL 5 3 o cal OU M > o Oa H O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 13TH FLOOR 7TH FLOOR 8TH FLOOR / Installing CompanyyrName f � �s eLt�5__P/11 ,S.� Check one: Certificate Address 171/_ eyt� /V C:1 Corporation is O`�? f I Partnership Business Telephone_ so ���,jjjs�o 14-Firm/Co. Name of Licensed Plumber or Gas Fitter yI�OL:!q �✓L'GLs INSURANCE COVERAGE: I have a current li ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes J�No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy 14f Other type of indemnity ❑ Bond U OWNERS 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. Check one: I n r r or r' A ant ` -- O� _ 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 Installations performed under the permit Issued for this application wlll-�, be In compliance with all pertinent provisions of the Massachusetts State plumb in ode and Chapter 1 of the General Laws. By Type of License Title L9�Plumber ❑� Gagg�fitter Signature of Licensed Plu er or as Fitter Cit lTown 1]�-I aster nne)VE Of l , _ .,- tt Y3 ❑ Journeyman License Number M�//z�_� BELOW FOR OFFICE USE ONLY I FEE NO: APPLICATION FOR PERMIT TO DO GASFITTING OWNER: NAME & TYPE OF BUILDING LOCATION OF BUILDING: PLUMBER OR GASFITTER: LICENSE NO: PERMIT GRANTED DATE: 19 GAS INSPECTOR rT —ir 2249 Date...7. .' 7%...... 3 NORM TOWN OF NORTH ANDOVER pf ti�ao ,e 1'40 ? ��, PERMIT FOR GAS INSTALLATION SSgCHUSE ..a EE This certifies that . . . ... . . . ..... z has permission for gas i stallation ! ' %" 1 •. . .' �. 1�.. . . in the buildings of . 4.1 ... . . . . . . . . . . . . . . at .l¢?. .,,�c ! . . . . . . . . .. North Andover, MaS o ; Fee./5! . Lic. No..-//. -0 . . . . . . . . . . . . . . . . . . . . . . . . � �• GAS INSPECTOR ro WHITE:App1tZ;7g CANARY:Building Dept. PINK:Treasurer GOLD:F9 j