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HomeMy WebLinkAboutMiscellaneous - 160 WATER STREET 4/30/2018A'SBA NIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER, , Mass. Date 19 q U Building permit # `�3 l Location d A-4- v, S �' � V �Avl coo - Owner's z "QK. Er--*- - t2 tj J°��eiS New C1 Renovation ❑ Replacement Q Plans Submitted: Yes ❑ No p� 4Chheck one: Ceritlicate Inslalling Company Name l4-Mvlc4-q �- (2 c �� o or Address S Ei Partnership i✓� ❑ Firm/Co. Business Telephone' ry �rSZ G Name of Ucensed plumber or Das Fitter �i / /� •tau%( �il�it/iV4-,-j INSURANCE COVERAGE: Check one I have a current liability Insurance policy or its substantial equivalent. Yes a No ❑ K y®u have checked ye, please Indl to the type coverage by checking the appropriate box. A liability Insurance policy � . Other e .. type of Indemnity ❑ Bond O 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: S4gnature of Owner or Owner's Vgent Owner 11 Agent ❑ I nereoy canary that an or the details and Information I have submitted (or entered) In above application are true and accurate to the best of my knoa9edgo and that all plumbing work and Installations performed under the permit Issued for this application will be M compliance with all pertinent provisions of the Massachusetts Stele Gas Mode and Chapter 142 of the General La- -r--ye aws Type of License: �S "�' Plumber na ur of n um er or Gas Filter s Iter / Master license Number Journeyman A "10VED (OFFICE USE ONLY) AC NNW mono WIN mom 4Chheck one: Ceritlicate Inslalling Company Name l4-Mvlc4-q �- (2 c �� o or Address S Ei Partnership i✓� ❑ Firm/Co. Business Telephone' ry �rSZ G Name of Ucensed plumber or Das Fitter �i / /� •tau%( �il�it/iV4-,-j INSURANCE COVERAGE: Check one I have a current liability Insurance policy or its substantial equivalent. Yes a No ❑ K y®u have checked ye, please Indl to the type coverage by checking the appropriate box. A liability Insurance policy � . Other e .. type of Indemnity ❑ Bond O 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: S4gnature of Owner or Owner's Vgent Owner 11 Agent ❑ I nereoy canary that an or the details and Information I have submitted (or entered) In above application are true and accurate to the best of my knoa9edgo and that all plumbing work and Installations performed under the permit Issued for this application will be M compliance with all pertinent provisions of the Massachusetts Stele Gas Mode and Chapter 142 of the General La- -r--ye aws Type of License: �S "�' Plumber na ur of n um er or Gas Filter s Iter / Master license Number Journeyman A "10VED (OFFICE USE ONLY) Date ... NORTH TOWN. OF NORTH ANDOVER - �� PERMIT FOR GAS INSTALLATION �9SSACEHUSEt This certifies that has permission for gas installation in the buildings of . +�:'"r��. .. '% ?. % '"... . ........... . at North Andover, Mass. Fee!" . - Lic. No.. GAS INSPECTOR WHITE: Applicant CANARY: Building Dept., PINK: Treasurer GOLD: Flle