HomeMy WebLinkAboutMiscellaneous - 215 RALEIGH TAVERN LANE 4/30/2018TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...........
has permission for gas installation .....
in the buildings of
........................
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at North Andover, Mass.
Feez� . . . Lic. No. . .
...........
S�P TO�
Check 3,2
MASSACHUSi+H'I'S UNIFORM AFFUCATON FOR PERTVHr TO DO GAS FHT NG
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations 215 Raleinh Tavarn I ;;nP Permit#
Amount $
Owner's Name Jof h Pembl e
New Renovation Replacement P'latts
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SUB-BASEM ENT
BASEMENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. `FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type)
Name
Address
ec one: Certificate Installing Company
Corp. -
0 Partner.
Firm/Co.
,Name of Licensed Plumber or Gas Fitter,,w49�- Ato .
INSURANCE COVERAGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Yes, please tpdicate the type coverage by checking the appropriate box.
Liability insurance policy 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:
Signature of Owner or Owner's Agent Owner ❑ Agent
I herebv certifv that all of the details and information I have submitted (or entered) in above aoolication are true and accurate to the
best of my knowledge and that all plumbing work and installations
compliance with all pertinent provisions of the Massachusetts Stat(
(OFFICE USE ONLY)
.,,Signature of,!
Plumber
Gas Fitter
master
® Journeyman
armed under Permit Issued for this application will be in
Code and ChaoteL142*flhe-General Laws.
sed Plumber Orra . Gas Fitter
51
License Number
ate.............
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... e5-1-1026--.,�� /,/ .............
has permission to ........
plumbing in the -buildings of
at ...... 7JN,-0-r-t,—xndover, Mass.
.........
F63-0 ... Lic. No.. .. .......
P LU M B I Rel N'SOPECTOR
Check
de
FAM001
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location 215 Ral ei gb Tavern I anipwnersName John Pembl a Permit#
Amount
Type of Occupancy Residential
New 0 Renovation Replacement [Ef Plans Submitted Yes ❑ No
1 00'
(Print or type)
Installing Company Name Andover Plumbing R Heating C-nTnr
Chec one: Certificate
Corp. 2122
Address 20 Aegean Dr. Unit #10 ®partner.
Business Te ep one(g��tiQ@_Q�Qa Firm/Co.
�t
Name of Licensed Plumber. George Lar o
Insurance Coverage: Indicate th of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature 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 installatio performed under Permit Issued f this application will be in
compliance with all pertinent provisions of the Massach set to Plumbing d of the Gegeral Laws.
By: igna ure o ce um
Type of Plumbing License
Title 9 983
City/Town cense Numner Master Journeyman ❑
APPROVED (OFFICE USE ONLY