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HomeMy WebLinkAboutMiscellaneous - 24 RUSSETT LANE 4/30/2018N -4. Date./ '? .......... ,ORTN 11 TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION This certifies that Z ...... has permission for gas installation .. ........... in the buildings of ../. �z. Z ........................... 0 at r. ez .... N rth Andover, Mass. Fee..,?. Lic. ��.-;, ......... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer �0 7rp ACI� I APP7CATON FOR PERMIT TO DO GAS G t) PARCEL Date 1:)e G 19 �► twit I H All U" Building Locations 3 V SSS -4 ( A Permit 9 3 Y112 y— Amount S w �O v ejZ Owner's Name O R VU ,} New© Renovation 1:1 1:1 ❑ ' Plans Submitted ❑ (Print or type)` y Check one: Name C Mn.1 t. ✓N O� 0 A\ I W1 t )-- ED �� C. f7/�j Corp. 2 Certificate Installing Company Address 3 �� ©t -IP-) S IM)2� 1 NJ ty \ YJ ❑ Partner. Business Telephone 2151— (3 Lf 4— ( 0 rZ ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter p Lj Ga- ev t INSURANCE COVERAGE Check one: 1 have a current liability insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes, please indicate 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 vlas eneraI L�s, and tsignature on this permit application waives this requirement. ( CrZ n Check one: Sisnature of Owner or Owner's Agent Owner ❑ Agent i hereby certify that all of the details and information I have submitted (or entered) in above application are true ana 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 of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Bv: Signature of Licensed Plumber Or Gas Fitter Tide ❑ Plumber I O Z l `I CityiTown © Gas Fitter Liconse iNumoer ❑ Master PPP,0VED (0FF10E (AE ONLY) � ❑ loumeyman .. is (Print or type)` y Check one: Name C Mn.1 t. ✓N O� 0 A\ I W1 t )-- ED �� C. f7/�j Corp. 2 Certificate Installing Company Address 3 �� ©t -IP-) S IM)2� 1 NJ ty \ YJ ❑ Partner. Business Telephone 2151— (3 Lf 4— ( 0 rZ ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter p Lj Ga- ev t INSURANCE COVERAGE Check one: 1 have a current liability insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes, please indicate 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 vlas eneraI L�s, and tsignature on this permit application waives this requirement. ( CrZ n Check one: Sisnature of Owner or Owner's Agent Owner ❑ Agent i hereby certify that all of the details and information I have submitted (or entered) in above application are true ana 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 of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Bv: Signature of Licensed Plumber Or Gas Fitter Tide ❑ Plumber I O Z l `I CityiTown © Gas Fitter Liconse iNumoer ❑ Master PPP,0VED (0FF10E (AE ONLY) � ❑ loumeyman