HomeMy WebLinkAboutMiscellaneous - 276 RALEIGH TAVERN LANE 4/30/2018//
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Date. . 9'.7:/P�.-. e ......
2,291
,AORTH TOWN OF NORTH ANDOVER
6
0 PERMIT FOR GAS INSTALLATION
49
This certifies that .............. ........
has permission for gas installation ... LL -.H ...................
in the buildings of .............................
at Z . e6qte f.12. OP, North Andover, Mass.
Y;s .
Fee—Q,.77.. Lic. No.!��,7�Z
09/17/% 14:2� ��RCTA
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
MASSACHUSETTS UNIFORM APPUCATION
(Print or Type)
/V Mass. Dat 14
Budding Locationt:2a,
FOR PERMIT TO'DO GASF177ING
19 Permit# 22-5't
Owners Narr�&,--
TYPeofOccupancy RE5lDCNTirqL-
New C] Renovation 0 Replacement R""' Plans Submitted: Yeso No C]
Installing Company Name T :'-AM AIA T 14 �Q Check one: Certificate
Address 30 0oA(H1Y%f4tj i -NI C3 Corporation.
n] E TH Ue tj t1i ri C) 0 Partnership
Business Telephone /,,�p -9 1 - 17 (7 -7 1 g-,hrm/Co.
Name of Ucensed Plumber or Gas Fitter --Rj)jBF-e-T A- -5AmMj4-FfjjeCD
INSURANCE COVERAGE:
I have a currepbilfty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. . 142.
Yes No 1-1
If you have checked ves, please Indicate the type coverage by checking the appropriate box
A liability Insurance policy Other type of Indemnity 0 . Bond 0
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:
OwnerO Agent 0
Signature of Owner or Owner's 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 and installations performed under the pern for this applicat' be in compliance with all
of tj s.
perfinent provisions of the Massachusetts State Gas Code and Chapter 142 �"�'�-Vaw
., ;�_ �j I
BY. Tjkoff, Uucense: 1-43,
Plumber �-WhAture of Ucbnsed Plum M
Title tter
ter Ucense Number
m,
City/Town Journeyman
APPR0VEffT6FRUEUSrZWL-'?1-
0
SEEMS
Installing Company Name T :'-AM AIA T 14 �Q Check one: Certificate
Address 30 0oA(H1Y%f4tj i -NI C3 Corporation.
n] E TH Ue tj t1i ri C) 0 Partnership
Business Telephone /,,�p -9 1 - 17 (7 -7 1 g-,hrm/Co.
Name of Ucensed Plumber or Gas Fitter --Rj)jBF-e-T A- -5AmMj4-FfjjeCD
INSURANCE COVERAGE:
I have a currepbilfty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. . 142.
Yes No 1-1
If you have checked ves, please Indicate the type coverage by checking the appropriate box
A liability Insurance policy Other type of Indemnity 0 . Bond 0
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:
OwnerO Agent 0
Signature of Owner or Owner's 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 and installations performed under the pern for this applicat' be in compliance with all
of tj s.
perfinent provisions of the Massachusetts State Gas Code and Chapter 142 �"�'�-Vaw
., ;�_ �j I
BY. Tjkoff, Uucense: 1-43,
Plumber �-WhAture of Ucbnsed Plum M
Title tter
ter Ucense Number
m,
City/Town Journeyman
APPR0VEffT6FRUEUSrZWL-'?1-
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