HomeMy WebLinkAboutMiscellaneous - 16 DEVON COURT 4/30/2018 M
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3 3 n 8 Date. . .. .... ..........
MpRTM , TOWN OF NORTH ANDOVER
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o A. A PERMIT FOR GAS INSTALLATION
SACNUSEt
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This certifies that `. . .f. . .. . . .. . . . . .r ; . . . . . . . . .. . . . . . . . . . . . .
has permission for gas installation- � ?y . . . . . . . . . . . . . . . .
in the buildings of �: . . . . . . . . . . . . . . . . . . . . . .
at . .. . . . :.t:�`:` .- . . . . . . . . . . .� . ., North Andover, Mass.
i f•GAS INSPECTOR
WHITE:Applicant CANARY:Building Dept. PINK:Treasurer
E
Y MASSACHUSETTS iJNIFORM APPLICATON FOR PERMIT TO DO GAS G
��Type or print) Date �j� I
NORTH ANDOVER, MASSACHUSETTS /,
Building Locations L�' 'boI/ 0v0� Permit# a
Amount S �
Jwner's Name � y
New❑ Renovation ❑ Replacement Plans Submitted Ef
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Z C } Z z C Z :c]
Z " - C
f. z
SLI 6 -BASENI ENT
BASE .vl ENT
IST. FLOOR
2ND . FLOOR
3RD . FLOOR
Tr if . F L O O R
5TIt . FLOOR
6T Ii . FLOOR
7T 11 . FL0012
3T 11 . F1, 00 R
( toPrint r e) f ��vf ����\ Check one: Certificate Installing Company
amt 1J' V� ❑ Corp
Address ❑ Partner.
< sv7
Business Telephone — irm/Co.
Name of Licensed Plumber or Gas Fitter
v
INSURANCE COVERAGE &Z Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked yes,please i icate the lupe coverage by checkin<g the appropriate box
Liability insurance policy 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
i`1ass.General Laws,and that my 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 I have submitted(or en ered) in above application are true and accurate to the
best of my knowledge and that all plumbing work arid installat' e d under P it is or this app Ica ill_be
compliance with all pertinent provisions of the Massachusetts to C Chapt r 42 of the General Laws.
Bv: ignat e of Licensed Plumber Or Gas F•tter
Title Plumber
CitvrTown Gas Fitter 717en—se 7 umner
Master
APPROVED(UFPICF:USE ONLY) Journeyman