HomeMy WebLinkAboutMiscellaneous - 13 ALCOTT WAY 4/30/2018 (2) 13 ALCOTT WAY
210/025.0-0016-0013.0
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304 1 Date. Z J.
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f TM , TOWN OF NORTH ANDOVER
3?p' Ito e.4,
o p PERMIT FOR GAS INSTALLATION
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This certifies that .. . ..: . <::. . . . . . . : . . . .. . .. . . .
has permission for gas installation . . . . .. . .;< :. . ... .. . ... ... .. .
in the buildings of .. . .. '... . .. .. . . . . . . . ... .. . . .. . .. . ..
at ... . . �� l.. .` • . .. .`. ... ... . .. . .. . .. North Andover, Mass.
Fee...°.?.. . . . Lic. No.:.. . .. :: . . . . . . ... . .. . .. . .. . .. . .. . ..
GASINSPECTOR
WHITE:Applicant CANARY:Building Dept. PINK:Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TOD GASFi17ING
(Print at Type
A /1 '� , Mass. Date --igpermit # �a
Building Location /f / /t� d�i�'7 Owner's Name
" Type of Occupancy��
New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No C1
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SUB-aSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR I I
4TH FLOOR
STH FLOOR
6TH FLOOR I
7TH FLOOR
STH FLOOR
Installing Company Name Check one: Certlflcate
Address ® Corporation
s AZI ❑ Partnership
Business Telephone ��j��� Fir /Ca
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
!shave a curregnt I illy insurance policy or its substantial equivalent which meets the requirements of MGI_Ch. 142
Yes L9' No ❑ '
If you have checked yes, please
indicate the type coverage by checking the appropriate box.
A liability insurance policy 9;,' 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 C]
I hereby certify that all of the details and information I have submitted(or entered)in a ove application are true and accurate to the best of my
knowledge and fhat all plumbing work and installations performed under the permit I ed for this application be In compl with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the eral Laws.
By Type of Ucense:
ber natur a cense um er or Gas Ater
Till@ startj
r
aster License Number
Myr Journeyman
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