HomeMy WebLinkAboutMiscellaneous - 22 BOXFORD STREET 4/30/20187 5 66 Date. . /////. X� ........
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TOWN OF NORTH'ANDOVER
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PERMIT FOR GAS INSTALLATION
CHU
This certifies that .... .......
has permission for gas installation . .#. /7 ....................
in the buildings of' ............................
at ............ Noqh-,Andover, Mass.
Fee.3!�. Lic. No.J. c .. .....
G4S WSPECTOR
Check # / ,� / -? �
k
MASSACHUSEM UNIFORMAPPUCATONFOR PERMPT TO DO GAS FITTING /
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations• Permit #
A ount $
A��= Owner's Name /� /,�
New ❑ Renovation ❑ Replacement Plans Submitted
(Print or type) A Chc Ce: Certiiistalling Company
Name N�l / �rp
Address `'� w v ❑ Partner.
Business Telephone 6f 7 MAI Q ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes D No ❑
If you have checked yes, please ' dicate 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 hereby certify that all of the details and mtormation i nave suormueu for emereu) M auvvu dFFM auv,J air uuc ailu accuiaic to ure
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 of the Massachusetts `tate Gas Coderd apte 42 oft General Laws.
ICity/Town
i
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber
Gas Fitter Icense Number
Master
Journeyman
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(Print or type) A Chc Ce: Certiiistalling Company
Name N�l / �rp
Address `'� w v ❑ Partner.
Business Telephone 6f 7 MAI Q ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes D No ❑
If you have checked yes, please ' dicate 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 hereby certify that all of the details and mtormation i nave suormueu for emereu) M auvvu dFFM auv,J air uuc ailu accuiaic to ure
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 of the Massachusetts `tate Gas Coderd apte 42 oft General Laws.
ICity/Town
i
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber
Gas Fitter Icense Number
Master
Journeyman
Location , ,-/,
No. I , 1-Y 1-3 Date —//� / ,
4
570�
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit F , e
Sewer Co nection Fee $
Water Connettiorf4lFe
', e $
Up
TOTAL
4 , 9
Building Inspector
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