HomeMy WebLinkAboutMiscellaneous - 25A BAY STATE ROAD 4/30/2018Date.....................
HOFTM
01 14,
TOWN OF NORTH ANDOVER
PERMIT FOR GAUNSTALLATION
SACHUS
This certifies that ..................................
has permission for gas installation .......
in the buildings of .... �S .....................................
at ........ . North Andover, Mass.
Fedi .F-. Lic.
.. ...........
Check# J5/ Cep
6596
_SSICHUSi=T3t t tuna
N- .ew
9T-H.F1
Installing Company.
-
Check one. CerliHattr
l° Corporation
�y® Partnership
Business Telephone ` P$ ❑ FtrrrtlGo
Name of Licensed Plumber or Gas Fitter ^j:
INSURANCE COY AGE
1 have a current 114blitly insurance policy or its substantial` equivalent which meets the requirements of
Yes CY No ❑
It you have checked es, tease Indicate the ;
Y_ P type eoverage by checking the apompriate box:
A itablifty Insurance policy ❑ Other type of. indemnity ❑ Bond
OWNER'S INSURANCE WAIVER: I em aware that the licensee doges not have - the Insurance coverage required by
Chapter 142 of the Mass. General taws, and that my signature on'this permit. application waives this requirement.
Check one:
OwnerO Agent ❑
Signature of Owner or Ownei s Agent
I hereby cedfly that ati of .the details and Inforirtation t have submitted for entered) -in above appficatlon are bus and accurate to the best of my
knordedge and that all plumbing work and Installations performed under the ertnIt issued I thif application will be in compElance with afs
pertinent provisions of the Massachusetts State Gas Code: and Chaplet 142 o General s.
TF `... r
nse:Title r. ignature o cense . um er o Gas itterr q f�
aster t kense Humber
Cily/Town Journeyrttan.
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