HomeMy WebLinkAboutMiscellaneous - 137 Foxwood Lot 25 v
I
i
I
j
it
I�
I
(Print or Type) 1 - urAli-UHtvt APPLICATION FOR PERMIT TO DO OAS;PiTTING
, .
NORTH ANDOVER , Maas. Data _i g c?6
�1- j Location t Z
Permit #�3
Owner's n
Name
New_. .[��. Flenovatlon Q Replacement ❑ Pians Submitted:. Yes Q No Q
X ' r.
e v K h a
z C }-
4 N h p 0 z ic
1K fm 4 W
C Y h
W Id 49
1 Z .h �Zi1 J
t 3 }t ` H
a S ti 4 s a ap. �M.
SA IRMENT
114T FLOOR
ityo FLOOR t
9RDFLOOR
4THFLOOR
STH FLOOR
iTH FL00A
t.
7TH FLOOR 1
4T FLOOR
y.
Check one: Certificate
InMaliing Company:Name �� r. S Q• 1\&c
Address Pdorp.
Cl Partnership
1/Vt LA, n LR 3 / ❑ Firm/Co.
Business Telephone
Name of Licensed Plumber or Gas Fitter Wit•t-.P— Q e,t
tMSURANCE COVERAGE: Check on
,I have a current Ilabllity Insurance policy Or Its substantial equivalent. Yes LST" No ❑
If you have checked es, please Indicate the type coverage by checking the appropriate box.
AalatrAlty Insurance "Icy Other type of Indemnity ❑ Bond ❑
QWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by'^
'Chapter 142 of the Mass. General Lawn, and that my signature on this permit application waives this requirement.
Check one:
S�gnatura of Owner or.Owner•s ant
Owner ❑ Agent Cl
IfI hereby certify that art of the details and Informatlon I have submHted (or entered)in above appllcallon are true a
knowledge and that alt plurnbtng work and Installations dom"d under the rmfl Issued for this nd accurate to the:best of my
the pe pe app will be In compliance with all
pertinent provisions of i e Massachusetts State Gas Code and Chapter 142 Ot the aJLA .
�' T nse:
Title umber na ure oae um er or as er
ler
MastertJcense Mrmber�L'e
'Ctiy/Town ❑Journeyman
I'AP T)OVt_D (OFFICE.USE ONLY)
� l
I
2 3 3
Date.lt`?.�G; �. .....
NpRT� TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
3 �
�9SSACHUSEt�
This certifies that . z?A . . . . . . . . . . . . . . . .
has permission for gas installation . . .P.< . . ?: . . . . . .`
in the buildings of . . .f.0 P
. . . . . . . . .
at . . .1 7. . f�x.`1. °.° . . . . . No . . .Andover, Mass.
Fee. .7t�..� . Lic. No.J.t??.`x.67 . . . . S . .
J AI . . . . .
R"
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File