HomeMy WebLinkAboutMiscellaneous - 257 MIDDLESEX STREET 4/30/2018V
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3513
Date /�'-) :J�?. ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .... F -a ..............
has permission for gas installation .... ...................
in the buildings of ..: .... -.` ............................
C/
at.,1. ....................�: , North Andover, Mass.
FeeP....... Lic. No-23,3i....�.......
-GAS'INSPECTOA�V
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print a Type)
G
k e Ve4l-. Mass. te�C'6-� 19 P Permit #
Building Location Owners Name • �D �� C� G
/v ` (6" //L Type of Occupancy_
New p Renovation p Replacement Plans Su rfiitted: Yes p No p
Installing Company Name T MA T r1 r2t' Check one: Certificate
,-
Address_ ?i i? Corporation
M E T H UE rJ 01 ra U Partnership
Business Telephone_ 6 ,1�Z - 9 9 "7 f @-,Rrm/Co.
Name of Licensed Plumber or Gas Fitter --R o (AE P T A - 5 A M M 1q Z -A 0
INSURANCE COVERAGE:
I have a current f biltty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ _
If you have checked Yes, please indicate the type coverage by checking the appropriate box
A liability insurance policy '
riY � 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 [3--
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 installations performed under the pe i ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofTlaws.
BY T of License: G�
Plumber n ure o cen u _, or atter
Title - tter
or
- License Number
ou
meyrnan
I
Y
•
•
Y
Installing Company Name T MA T r1 r2t' Check one: Certificate
,-
Address_ ?i i? Corporation
M E T H UE rJ 01 ra U Partnership
Business Telephone_ 6 ,1�Z - 9 9 "7 f @-,Rrm/Co.
Name of Licensed Plumber or Gas Fitter --R o (AE P T A - 5 A M M 1q Z -A 0
INSURANCE COVERAGE:
I have a current f biltty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ _
If you have checked Yes, please indicate the type coverage by checking the appropriate box
A liability insurance policy '
riY � 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 [3--
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 installations performed under the pe i ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofTlaws.
BY T of License: G�
Plumber n ure o cen u _, or atter
Title - tter
or
- License Number
ou
meyrnan
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