HomeMy WebLinkAboutMiscellaneous - 27 Buckingham Roadcc
Date. 0 i ........
TOWN OF NORTH ANDOVER
P ERMIT FOR GAS INSTALLATION
This certifies that ...............
has permission for gas installation .... /. .. ...
in the buildings of ... 53� ..,. 1'. .
at �2 4 .6 xi—,. . . P . k.*.*.*.,.*,* Nor*th' Andover*,' Mass*.
Fee. Lic. No. /A
GAS INSPECT(A
Check# Jf-� C
4833
MASSACHUSEnS
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
s Name
New Renovation El Replacement
FORPE&JITTO DO GAS FfnING
Date
Permit# - UY 7-7
Amount $ .76
C117
Plans Submitted 11
(Print or type
Name W/1�
Address
Name of Licensed Plumber or Gas Fitter
C-�he�c one: Certificate Installing Company
Lj-Corp. . e90237C
13 Partner.
E] Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0-- NoO
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 13 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 14� of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
SiRnature of Owner or Owner's Aizent
Owner L_j Agent
I fir-YOVY CURIly LIM d1l U1 L11C UMUIS allU 11110rMaLlon i nave suonuttea (or enterea) in aDove application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed u;nd P mi sued for this application will be in
er);#�X142 of the General Laws.
compliance with all pertinent provisions of the Massach�s�tt§,,Statp,164g,-egOW;� Map
Licensed Plumber Or Gas Fitter
Plumber 1,V10
Gas Fitter License Number
Raster
OVED (OFFICE USE ONLY)
INEME
M
1ST. FLOOR
Pais 11M
,5TH. FLOOR
(Print or type
Name W/1�
Address
Name of Licensed Plumber or Gas Fitter
C-�he�c one: Certificate Installing Company
Lj-Corp. . e90237C
13 Partner.
E] Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0-- NoO
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 13 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 14� of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
SiRnature of Owner or Owner's Aizent
Owner L_j Agent
I fir-YOVY CURIly LIM d1l U1 L11C UMUIS allU 11110rMaLlon i nave suonuttea (or enterea) in aDove application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed u;nd P mi sued for this application will be in
er);#�X142 of the General Laws.
compliance with all pertinent provisions of the Massach�s�tt§,,Statp,164g,-egOW;� Map
Licensed Plumber Or Gas Fitter
Plumber 1,V10
Gas Fitter License Number
Raster
OVED (OFFICE USE ONLY)