HomeMy WebLinkAboutMiscellaneous - 244 MAIN STREET 4/30/20183? ! v Date.. e.
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„ORTM TOWN OF NORTH ANDOVER
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PERMIT FOR GAS INSTALLATIQF
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This certifies that ... e .... ..... !............ .
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has permission for gas install, tion ... -V .?-'.. • • • • •
in the buildings of .
at .:�:f. `�.. • �. • • `.-� "<• '�r , North Andover, 11ss.
Fee.-?�:. "�.. Lic. No........... :... .
GAS INSPECT
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MAP 41
✓IASSACHUSE FORM APPLICAT N FOR PERMIT TO DO GAS FITTING
O
or print) f Date 19 .
1vuxTH ANDOVER, MASSACHUSETTS
Building Locations . 6 I/��—�'�% S Permit #
Amount S pmt/
Owner's Name ,(fes
New ❑ Renovation ❑ Replacement Plans Submitted ❑
(Print or typ T j J Check one: Certificate Installing Company
La.-(rName J� r7' Corp.
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Addres A 151 pU t✓ I%(j /Z— 5 -JL b e %7/J !!� Partner.
Business Te
Name of Licensed Plumber or Gas Fitter
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2 Firm/Co
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑
If you have checked yes, please indicate the lupe coverage by checking the appropriate box.
Liability insurance policv 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 ❑
11CICUy cen,iy inai all or me aetaus ana information 1 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 of the il,lassachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed
Plumber
/❑ Gas Fitter 7(
❑ Master
I -'—L. Joumevman
Cl�
17T If. FLO OR
(Print or typ T j J Check one: Certificate Installing Company
La.-(rName J� r7' Corp.
r
Addres A 151 pU t✓ I%(j /Z— 5 -JL b e %7/J !!� Partner.
Business Te
Name of Licensed Plumber or Gas Fitter
V
G
2 Firm/Co
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑
If you have checked yes, please indicate the lupe coverage by checking the appropriate box.
Liability insurance policv 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 ❑
11CICUy cen,iy inai all or me aetaus ana information 1 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 of the il,lassachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed
Plumber
/❑ Gas Fitter 7(
❑ Master
I -'—L. Joumevman
Cl�
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tit
COMPLAINT NUMBER DATE:
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COMPLAINTANT: CLOSE DATE:
ADDRESS: PHONE:
OWNER: Y1� G 'P I�A-JL PHONE #:
ADDRESS: n, i i , -\ -
INSPECTION DATE:, ORDER L DATE -
COMPLAINT:.
C6 -LL h�
ACTION: „
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