HomeMy WebLinkAboutMiscellaneous - 208 Main Streeter
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Date. / � ....�.'.......... .
� TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..��.�.1�'�............................
has permission for gas in :
installation ... t: `.'.' . `. ............. .
in the buildings of .....R.: 1: t, -.K ............................ .
at ... ............. North Andover, Mass.
Fee....�.. Lic. No.. `:..:... .. ... :.: s%� ....... .
GAS INSPECTOR
Check #
%�5�9
JG
MASSACHUSETTS UNIFORM APPLICATIONO E O
2 F PERMIT T DO GASFITTING
(Print or Type)
,14 1L � `Mass. Date
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p Permit # q L S
Building Location DOwner's Name
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Type of Occupancy__
New [] Renovation ❑ Replacement [� Plans Submitted: Yes❑ No ❑
Installing Company Name rfiLLA /7i¢r(1 Check one: Certificate #
Address_. q / % c7/tr� SE A:J- Corporation Z1111 (f
- 1= -i!-/L SS
P 9:>a 1/1W 51-3 3 ❑ Firm/Co.
IP
Business Telephone'�
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes El— No ❑
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A Itabllfty Insurance policy D'�— 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:
Signalure of Owner or Owner's Agent Owner -E] Agent ❑
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 installallons performed under the permit Issued for t Is application will be In mpliance with Ali
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of lh General La
� T e of Ucense:
Plumber
Title — asfittor gnalu "o c nse um er or Gas rtler
City/Town aster cense Number
IU 1'il(�/F n--� C Journeyman
21413 FLOOR
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Installing Company Name rfiLLA /7i¢r(1 Check one: Certificate #
Address_. q / % c7/tr� SE A:J- Corporation Z1111 (f
- 1= -i!-/L SS
P 9:>a 1/1W 51-3 3 ❑ Firm/Co.
IP
Business Telephone'�
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes El— No ❑
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A Itabllfty Insurance policy D'�— 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:
Signalure of Owner or Owner's Agent Owner -E] Agent ❑
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 installallons performed under the permit Issued for t Is application will be In mpliance with Ali
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of lh General La
� T e of Ucense:
Plumber
Title — asfittor gnalu "o c nse um er or Gas rtler
City/Town aster cense Number
IU 1'il(�/F n--� C Journeyman
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NORTH
TOWN OF NORTH ANDOVER
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Certificate of Occupancy
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