HomeMy WebLinkAboutMiscellaneous - 175 CANDLESTICK ROAD 4/30/2018 (2)Date.:% /c..........
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•° 1- TOWN OF NORTH AN VER
• PERMIT FOR GAS IN ALLATION
9
This certifies that .'GQIQ`.lfi�s
has permission for gas installation ... y ...................
in the buildings of .. L.L
at .. .... s' ,(4 :.`<<. ...... , North Andover, Mass.
Fee. Lic. No. .........,. L...........
GAS INSPECTOR
Check #
753
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS
(Type or print) Date ho
NORTH ANDOVER, MASSACHUSETTS
Building Locations / G Permit #_
Amount $
Owner's Name 1�� S%LsU�-u5 62d,/47—
New
,.2 I,/4%New ❑ Renovation ❑ Replacement Plans Submitted
(Print or type)
Name C
Address
Name of Licensed Plumber or Gas Fitter . I 1 -::T -
Check one: Certificate Installing Company
❑ Corp.;S( Lf6
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No 13
If you have checked ves' please indicate the type coverage by checking the appropriate box.
Liability insurance policy 0" 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. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent 0
I hereby certify that all of the details and information I have submitted entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations ed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State ��' Cod�hapter`142 of the General Laws.
own
VED (OFFICE USE ONLY)
Signatyfe bf[Lieensed Plumber Or Gas Fitter
Plumber I j� I d_
Gas Fitter License Number
Journeyman
-
-
SUR-BASEM ENT
'BA9'EM ENT
��2ND.
���t•�v�������������
FLO
17TH. FLOOR
STH. FLOOR
(Print or type)
Name C
Address
Name of Licensed Plumber or Gas Fitter . I 1 -::T -
Check one: Certificate Installing Company
❑ Corp.;S( Lf6
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No 13
If you have checked ves' please indicate the type coverage by checking the appropriate box.
Liability insurance policy 0" 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. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent 0
I hereby certify that all of the details and information I have submitted entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations ed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State ��' Cod�hapter`142 of the General Laws.
own
VED (OFFICE USE ONLY)
Signatyfe bf[Lieensed Plumber Or Gas Fitter
Plumber I j� I d_
Gas Fitter License Number
Journeyman