HomeMy WebLinkAboutMiscellaneous - 16 VILLAGE GREEN DRIVE 4/30/2018Date.(:-. . . . . 21
TOWN OF NORTH/ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... e.�
. 11 � "�
--.A ......................
has permission for gas installation
in the buildings of
atNorth Andover, Mass,
............
.........
Fee.-Ilq ... Lic. /.
/ .
GAS INS P96TO'R .
Check #
6148
MASSACHUSETTS UNIFORM APPLICATON FOR PERMrr TO DO GAS FITTING
(Type or print) Date 9 7, d7 p�
NORTH ANDOVER, MASSACHUSETTS 19 y�
Building Locations v ' % c C 6'e e `` (✓ `'� �on� o 11 Permit #
1 /
jC Owner's Name Amount S
New D Renovation
Replacement Plans Submitted D
w
09
w a
W v�
z u w x
., Q �, �'
z
W
Fdd a c
OG W F
`�
A
>
w
Z d W
o
d F. F. 5.
3 a
vl
z C
0
a
F,
W
A
.a W
SUB -BASEMENT
.da
>
a F O
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
1",TH.
3RD. FLOOR
P
4TH. FLOOR
FLOOR
6TH. FLOOR
A
7TH. FLOOR
18TH.
FLOOR
(Print or type) fC
Name y/
//
Check one:
Corp.
Certificate Installing Company
LLIS
Address
Partner.
cT
G ��
Business a ep onea 7X
S �"
Firm/Co.
Name of Licensed Plumber or Gas Fitter
4, � /C
INSURANCE COVERAGE
Check one:
I have a current liability Insurance• policy or it's substantial equivalent.
If have
Yes 13
NoO
you checked ves, please indic to the type coverage by checking the appropriate
box.
Liability insurance policy
Other type of indemnity D
Bond
13
Owner's Insurance Waiver: l 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 r" Agent r"
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 installatio
compliance with all pertinent provisions of the Massach se p as Code aormed nd Chapter er t142 of the GeneralLaws.Issued for this n will be in
91
Title
City/Town
VED (OFFICE USE ONLY)
gnature of Licensed Plumber Or Gas Fitter
ET'PI'lumber rj �� G
Gas Fitter "
(cense um er
Master
13 Journeyman