HomeMy WebLinkAboutMiscellaneous - 18 NORMAN ROAD 4/30/2018f
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation . W l�: ?- n
in the buildings of ..K to !v f :........................ .
at o. A- 3l.#q...... .1..., North Andover, Mass.
FeeP.-(?. v J Lic. NoID.. I3I. ..... Axi— .. ..... .
GASINSPECTOR
Check # / n -2- Z
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MYTI IRRC
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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City/Town: h c �/f/cl 00,e MA. Date: Z 1 // Permit#
Building Location: 009, PC4 Owners Name: A2 e dt1
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [�]�
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: [- Plans Submitted: Yes ❑ No ❑
MYTI IRRC
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yesto ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 0r 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
_Signature of Owner or Owner's Agent Owner El Agent El
By checking this box ❑, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
_ •- -••_ -- ...y ani L—L — piumuujy wurK anu mstanations perrormeo unser the permit issued for this aoolication will he in
—1. acIuucm piuvision ur me iviassacnusetts Mate F lUrnbi"de any, Chapter 142 of the Geperal Laws
Type License:
By lumber
Title
El Gas Fitter Signature of Licensbd Plumber/Gas Fitter
Duster
City/Town ❑Journeyman License Number: 3
APPROVED OFFICE USE ONLY ❑ LP Installer
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SUB BSMT.
BASEMENT
1 FLOOR
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3 FLOOR
4 FLOOR
sTH FLOOR
6 FLOOR
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Installing Company
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Name: _ J c
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Check One Only Certificate #
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Address: uol !7 (Z dk �! City/Town: '7-1- V-
ElCorporation
Business Tel:
Fax:
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❑ Partnership
Irm/Company
Name of Licensed Plumber/Gas Fitter:-
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yesto ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 0r 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
_Signature of Owner or Owner's Agent Owner El Agent El
By checking this box ❑, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
_ •- -••_ -- ...y ani L—L — piumuujy wurK anu mstanations perrormeo unser the permit issued for this aoolication will he in
—1. acIuucm piuvision ur me iviassacnusetts Mate F lUrnbi"de any, Chapter 142 of the Geperal Laws
Type License:
By lumber
Title
El Gas Fitter Signature of Licensbd Plumber/Gas Fitter
Duster
City/Town ❑Journeyman License Number: 3
APPROVED OFFICE USE ONLY ❑ LP Installer
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