HomeMy WebLinkAboutMiscellaneous - 12 VILLAGE GREEN DRIVE 4/30/20182
Date. ,l -./7. c . -:� ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .....................
has permission for gas installation ..... -`............
in the buildings of ....c u
at ..... ./1.f. 7 North Andover, Mass.
Fee..): .. Lic. No..':�:;.3.? �..
-9GAS INSPECTOR
Check # /
4247
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type
_jV, ove, i Mass. Date Lre,2_ C�� Permit* <
Building' Location/ a U" l hlzve— CJelaew A} wnler•s Name Z% Pnow
A�q 2
.;� ! 4 141.? Type of Occu4 _ is ESi Fi N T i
New ❑ Renovation ❑ Replacement jgo'Plans Submitted: Yesp No ❑
-G.
1
Installing Company Name:jr",i;egTA . �-1m MA TO r 01 Check one: Certificate
Address 30. CraA [ H 1h A: ry - `-Kf . ❑ Corporation
1111= T H U S n) 01 rl D l k ❑ Partnership
Business Telephone 1 — 9 9 "7 1 g-'Firm/Co.
Name of Licensed Plumber or Gas Fitter _ --RQ j3 E P.T A - 5A Mr31 d -FA r )
INSURANCE COVERAGE:
1 have a current f bility Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked Ye. please indicate the type coverage by checking the appropriate box
A liability insurance policy 0-*" Other type of Indemnity ❑ 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.
Check one:
Signature of Owner or Owner's Agent Owner[] Agent [3
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 pe i ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofAmer Laws.
BY T of License:
Plumber n ure of cen u _ or Gas rtter
Title tter
y� Joum License Number Va-
O IC L�
II
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Installing Company Name:jr",i;egTA . �-1m MA TO r 01 Check one: Certificate
Address 30. CraA [ H 1h A: ry - `-Kf . ❑ Corporation
1111= T H U S n) 01 rl D l k ❑ Partnership
Business Telephone 1 — 9 9 "7 1 g-'Firm/Co.
Name of Licensed Plumber or Gas Fitter _ --RQ j3 E P.T A - 5A Mr31 d -FA r )
INSURANCE COVERAGE:
1 have a current f bility Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked Ye. please indicate the type coverage by checking the appropriate box
A liability insurance policy 0-*" Other type of Indemnity ❑ 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.
Check one:
Signature of Owner or Owner's Agent Owner[] Agent [3
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 pe i ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofAmer Laws.
BY T of License:
Plumber n ure of cen u _ or Gas rtter
Title tter
y� Joum License Number Va-
O IC L�
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