HomeMy WebLinkAboutMiscellaneous - 1265 SALEM STREET 4/30/2018 1265 SALEM STREET
210/106-A-01 34-0000-0
i
Date. ..... .
H°RTH
Of „ao ,ti0
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? '` TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
SACHUSEtSh -
This certifies that . . .��ti.�'.�: . .- . . . ��. ��. . . . . . . . . . . .. . . . . .
has permission for gas installation . . . P. I.i1k
in the buildings of . , . 1.tk'�pr.li.e. . . . . . . . . . . . . . . . . . . . . . . . . . .
at . ?.0.: . . S !- : .. . .`';-. . . . . . . ., North Andover, Mass.
Fee.). , . . . . . Lic. No..`~� .. . . . . . . . .
GAS INSPECTOR
Check# ?
�' 3
MASSACHUSETTS UNIFORMAPPUCATONFOR PII2MITTODO GAS FITTING
(Type or print) Date 3
NORTH ANDOVER,MA('SSACHUSEETTS?
Building Locations / J/ /F IY/. � F7— Permit#
`, hh Amount$
Owner's Name V T16y t
New❑ Renovation F1 Replacement Plans Submitted
x F
z a H o z z F a
C7 W x W F" A > w
z a W F F
z � w a F ° z o z W o '
o w a a U oa > a ° F o
SUB -BASEM ENT
L BASEMENT
1ST. FLOOR
2ND . FLOOR
3RD . F L O O R
+ 4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
(Print or type) ,//77 // Check one: Certificate Installing Company
Name f/�1/ 11 V F,P ��f lr. N l��r -17�.�� � Corp.
Address d ,�h/I/ hA zj Al; % 114 14 Partner.
7,F o 3--3-5'St'-3
Business Te ephone- E] FimVCo.
Name of Licensed Plumber or Gas Fitter
r
INSURANCE COVERAGE Check on .
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Les,please i icate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ 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 13 Agent 13
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 u r Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code , d Chapter 142 of the eral Laws.
BY: 5i, nature of Licens lumber Or Gas Fitter
Title Plumber �z 9L4
City/Town n Cjas Fitter License Number
Master
APPROVED(OFFICE USE ONLY) � Journeyman