HomeMy WebLinkAboutMiscellaneous - 26 RICHARDSON AVENUE 4/30/2018a
Date. ......
f
NORTH
TO N OF NORTH ANDOVER
• PERMI AS INSTALLATION
This certifies that ..... /? ..I, .. i .,..`............ .
has permission for gas installation x / i . ....... .
in the buildings of...1).t,.5.!................................
at ............ . North Andover, Mass.
Fee.... l.... Lic. No.. J, A?.G.. .. -... ....... .
/GASINSPECTOR'
Check # / 3 ell -
5997
/l -
5997
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS Z Z 7
Building Locations
Permit # S%Y
Amount $
Owner's Name 1:9 C I
New Renovation Replacement Plans Submitted
(Print or type) (' %%
Name. VF/ / /5�lilillBiu °-e-- !i V--- /�
Address5'0 /3 Z)/ Fe -
7
j 77777
Name of Licensed Plumber or Gas Fitter 01
C k one: Certificate Installing Company
Corp.
Partner.
From/Co.
INSURANCE COVERAGE Check one:
1 have a current liability Insurance policy or it's substantial equivalent. Yes 0— NoM
If you have checked vs, please indicate the type coverage by checking the appropriate box. D
Liability insurance policy [Y Other type of indemnity 13 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
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 apd ins Ilations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mass efts to Gas Code and Ch er 142 o the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
['Plumber
Gas Fitter License Nuinfiber
Master
Journeyman
i
2ND. FL
7TH. FLOOR
(Print or type) (' %%
Name. VF/ / /5�lilillBiu °-e-- !i V--- /�
Address5'0 /3 Z)/ Fe -
7
j 77777
Name of Licensed Plumber or Gas Fitter 01
C k one: Certificate Installing Company
Corp.
Partner.
From/Co.
INSURANCE COVERAGE Check one:
1 have a current liability Insurance policy or it's substantial equivalent. Yes 0— NoM
If you have checked vs, please indicate the type coverage by checking the appropriate box. D
Liability insurance policy [Y Other type of indemnity 13 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
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 apd ins Ilations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mass efts to Gas Code and Ch er 142 o the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
['Plumber
Gas Fitter License Nuinfiber
Master
Journeyman