HomeMy WebLinkAboutMiscellaneous - 15 WOODCHUCK LANE 4/30/2018 (3)Date ...7.:. 3 &- c Z ... .
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3� - TOWN OF NORTH ANDOVER
O D
("� ;. a PERMIT FOR GAS INSTALLATION
This certifies that A", W. ...L�'.{ <.l.'j. r ...................
has permission for gas installation .....�.Eq L .I. ..............
in the buildings of .../0'.T.T ..........................
at ...... North Andover, Mass.
Fee.}. ?.. Lic. No.,.`l ?... ..
GAS INSPECTOR
Check #
4091
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTIlVG
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations �,j��:�J6 o eL S L 20
a%y�liSeia�Y WAAA0 7_i Owner's Name
New ❑ Renovation ® Replacement ❑ Plans Submitted ❑
Permit #
Amount $
(Print or type >> C one: Certificate Installing Company
Name 1 i� / 'f i /` � Corp.
Address /J� 2' 11,e_ El Partner.
Business Telephone %W — ;// 7f1 %/ Firm/CO.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a currant liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Ml 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. Laws, anth y signature on this permit application waives this requirement.
Check one. ❑
Signature of Owner or Owner's Agent Owner ❑ Agent
i hereby certify that all of the details and information 1 have sutmuttea (or enrereal in aoove appucanon are uue anu auutat ►c to uic
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St Code and Chapter 1F of the General Laws.
City/Town
VED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
. Plumber a, 4 J 7
❑ Gas Fitter License Number
Master
❑ Journeyman
1ST. FLOOR
:2ND. FLOOA
FLOOR
(Print or type >> C one: Certificate Installing Company
Name 1 i� / 'f i /` � Corp.
Address /J� 2' 11,e_ El Partner.
Business Telephone %W — ;// 7f1 %/ Firm/CO.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a currant liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Ml 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. Laws, anth y signature on this permit application waives this requirement.
Check one. ❑
Signature of Owner or Owner's Agent Owner ❑ Agent
i hereby certify that all of the details and information 1 have sutmuttea (or enrereal in aoove appucanon are uue anu auutat ►c to uic
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St Code and Chapter 1F of the General Laws.
City/Town
VED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
. Plumber a, 4 J 7
❑ Gas Fitter License Number
Master
❑ Journeyman