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HomeMy WebLinkAboutMiscellaneous - 21 STACY DRIVE 4/30/201875/6 Date. r) l ........ i I TOWN OF NORTH ANDOVER 10 • PERMIT FOR GAS INSTALLATIQN CMU�4't This certifies that .../. ... l?`� <<<!!' %� ................. . has permission for gas il�tallation ..... /Y ................ . in the buildings of ...CT . : ........................... at... .�.... F9.�. !....D.0......, No Andover, Mass. Fee. 3 t..� .. Lic. No.. ?. ..�...%..� ... f . % . ..... ASINSPECTOR Check # / D y V MASSACHUSEnSUNIFORMAPPLICATONFOR PERM TTO DO GAS FMING (Type or print) Date p? NORTH ANDOVER, MASSACHUSETTS Building Locations c2 % s ��' /7- Permit # n a Amount $ X� A' Q r �' / (� U�� Owner's Name New Q Renovation 0 Replacement © Plans Submitted (Print or type) T 114 G L O r!q r/ �� �/CjLe-*one: Certificate Installing Company Name Corp. Address /'- d . 13 O X S -/,R, LJ Partner. � w�tervice 144 -lIle vz Business Telephone 7-71 6 bis' q S'o y Firm/Co. Name of Licensed Plumber or Gas Fitter %Xwn'q,s k94 //y /?,q -a INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes E] No o Ifyou have checked yes, please indicate the type coverage by checking the appropriate boat Liability insurance policy El Other type ofindemnity 0 - Bond 0 Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. . Check one: Signature of Owner or Owner's Agent Owner I hereby certify that all ofthe 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusetts State Gas Code and Chapter 142 ofthe General Laws. (OFFICE USE ONLY) Signature ofLicensed Plumber Or Gas Fitter ® Plumber a Vf 33 D Gas Fitter License Number ❑ Master Journeyman