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HomeMy WebLinkAboutMiscellaneous - 19 EMERSON COURT 4/30/2018 -�� M ti _ .� 3327 Date% ... ."R.. .-. ........ NpRTM TOWN OF NORTH ANDOVER pE tee° ,a'6 O PERMIT FOR GAS INSTALLATION F �� A ��SSACHUSES = 1 This certifies that ::-^. . . . . � . . . . . .r� . _,� . .!�!. . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . in the buildings of -`!U': � � ?.. . . . . . . . . . . . . . . . G' at / . . . . . . .:`:. . .`. . :: . . . . . . . . . . . . .. North Andover, Mass. Iry ; - Fee. '. . . Lic. No. . :. . . . . . . . . . . . / GASAWS ECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer 1 t > MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING �tType or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations/ �rn �Sl U" � Permit# Amount S `Z,d � Owner's Name G New❑ Renovation ❑ Replacement Plans S mitted ❑ n N j - z C w Z C z 1 Z SUS -BASENI ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLUOR J'ril . F L 0 0 R 5T If . F L U O R 6T if FLUOR 7T 11 . FLUOR 8 T 11 . F L O O R (Printr ') Check one: Certificate Installing Company Name ' I vwL��4 ' Corp. Address V- ❑ Partner. 3 Business Telephone 7 ZL— f' ❑ Fi /Co. Name of Licensed Plumber or Gas Fitter . k �v 7 INSURANCE COVERAGE Checklorwl. I have a current liability Insurance policy or it's substantial equivalent. YesNo❑ If you have checked yes,pleas in 'cate the type coverage by checking the appropriate bo. . Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waive/I I aaware 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 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 ins taIla tio erto under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts St Ga >apter I _o the Genera Laws. Bv: Signatur of Licensed Plumber Or Gas Fitter Title Plumber Z Z Citv/Town ❑ Gas Fitter dense i umoer' Nlasier kPPRO`v'ED(UFFICF.USE ONLY) ❑ Journeyman