HomeMy WebLinkAboutMiscellaneous - 24 CARLTON LANE 4/30/2018N_
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Date. . . '3/ 3 /P�1 - - --,
opo ry� TOWN OF NORTH ANr%dVER
0441 PERMIT FOR GA $ IN;ALLATIO
LI -X
This certifies that ... C!? ..................
has permission for gas installation .... � ................
in the buildings of .................
at North Andover, Mass.
Fee.. .... Lic. No.. .42:7
..... ...... �--
GiSINSPECG
Check# Py C7
67*t 0
MASSACHUSETTS; UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING 0�1
iprint or ypel
Mass_ Date 20permit i ? d
Building ocatf n owner a % (y�I
Type of occupancy
Newo Renovation 0 Replacementz Plans submitted: Yes 0 No 0
INSURANCE COVERAGE:
I have a currents bility insurance policy or its substantial equivalent, Which meets the requirements of MGL Chi 142,
Yes No 0
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability Insurance policy II/ other type of indemnity 0 Bond 0
OWNER'S INSURNACE 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 permits lication valves this requirement
signature o owner or owner's Agent
Check one: -
Owner 0 Agent 0
1 Hereby certify that all of the details and Information i`have submitted tar enteredl In above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed under theper tied for this applicatio 11 be in complia ce with
ail pertinent provisions of the Massachusetts 5 tate Gas Code and Chapter 142 of the G ne I L
Type o'r License:
By 0 Plumber re of Licensed fltftber or Gas Fitter
Title 0 G ',_ter
1 Ciryfrown #er License dumber q43 L
APPROVED (OFFICE USE ONLY) � p Jourr eyman
s
a
FARM We
INSURANCE COVERAGE:
I have a currents bility insurance policy or its substantial equivalent, Which meets the requirements of MGL Chi 142,
Yes No 0
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability Insurance policy II/ other type of indemnity 0 Bond 0
OWNER'S INSURNACE 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 permits lication valves this requirement
signature o owner or owner's Agent
Check one: -
Owner 0 Agent 0
1 Hereby certify that all of the details and Information i`have submitted tar enteredl In above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed under theper tied for this applicatio 11 be in complia ce with
ail pertinent provisions of the Massachusetts 5 tate Gas Code and Chapter 142 of the G ne I L
Type o'r License:
By 0 Plumber re of Licensed fltftber or Gas Fitter
Title 0 G ',_ter
1 Ciryfrown #er License dumber q43 L
APPROVED (OFFICE USE ONLY) � p Jourr eyman