HomeMy WebLinkAboutMiscellaneous - 18 SAUNDERS STREET 4/30/20181�
MASSACHUSETTS LNIF'ORM APPLICATON FOR PERMIT TO DO GAS FITTING
Type or print)
NORTH ANDOVER, MASSACHUSETTS
Buildine Locations
V
2.//7 19 & d
S _ Permit 9 2`'1`l --L'
Amount S e....
Owner's dame --Ili t` //le!2
New ❑ Renovation ❑ Replacement D -l" Plans Submitted ❑
(Print or type)+� � f �� j� � � � /J CheckCneCertiricate Installing Company
Ni am e— I
Address J V )V X Fd�LJ ❑ Partner.
`vt 0 v�-
�Business Telephone 191 Firm/Co.
'dame of Licensed Plumber or Gas Fitter / S /) I/� J/`� l�Yl -e-1- •-e-
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ED- No❑
Ifvou have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ — Other [vpe of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter I42 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent ❑
I herebv certify that all of the details and information I have submitted (or entered) in above apphcanon are true ana accurate to me
best of my knowledge and that all plumbing work and installations pertbrr ed un ' r Permit Issued for this ap * -ation will be in
compliance with all pertinent provisions ofthe Massachusetts Stare _'Gude aprer 1 of the Genen P aws.
By:
Title
CirytTown
A-PPROVED IUFI ICc USE')NI.Y)
Pignature of Licensed Plumber Or Gas Fitter
lumber
�.3
❑ Gas Fitter )cense Ivumoer
Master
❑ Journeyman
:r
i'
(Print or type)+� � f �� j� � � � /J CheckCneCertiricate Installing Company
Ni am e— I
Address J V )V X Fd�LJ ❑ Partner.
`vt 0 v�-
�Business Telephone 191 Firm/Co.
'dame of Licensed Plumber or Gas Fitter / S /) I/� J/`� l�Yl -e-1- •-e-
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ED- No❑
Ifvou have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ — Other [vpe of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter I42 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent ❑
I herebv certify that all of the details and information I have submitted (or entered) in above apphcanon are true ana accurate to me
best of my knowledge and that all plumbing work and installations pertbrr ed un ' r Permit Issued for this ap * -ation will be in
compliance with all pertinent provisions ofthe Massachusetts Stare _'Gude aprer 1 of the Genen P aws.
By:
Title
CirytTown
A-PPROVED IUFI ICc USE')NI.Y)
Pignature of Licensed Plumber Or Gas Fitter
lumber
�.3
❑ Gas Fitter )cense Ivumoer
Master
❑ Journeyman