HomeMy WebLinkAboutMiscellaneous - 28 Forest Street/ -fj- ; /-,
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .............. S . . .". ./ - I
.......................
has permission for gas installation .................. : ...........
in the buildings of .......................................
*at .1 .......
.................... North Andover, Mass.
Fee .......... Lic. No��O/. ......... .........
GASINSPECTOR
Check #
MASSACHUsETTS UNIFORM APPLICATION FOR PERMIT TO Do GASFITTING
(Print or Type)
A,,e-,OL- MA Date 20 0/ Receipt# permilit*
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12j? A-4.,-5 0— OwneesNam
Building Location
--i i ffF Lot: Zone: Type of O�cupz
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New a---- Renovation 13 Replacement Q Plans Submitted: Yes Q No 0
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SUB-RAMT.
BASEMENT
LO -
1 S T FLOOR
2 N D FLOOR
3 R D FLOOR
4TH F L 0 0 R
STH FLOOR
67H FLOOR
-77-
7TH FLOOR
17H F L 0 0 R
Installing Company Name EASTERN PROPANE & OIL, INC. Checkone: Certificate
Address 1 131 WATER ST DA-NVERS INIA 01923 Corporation
Q Partnership
Estimate Valueof Work:
Business Telephone 800-322-6628 C3 Firm / Co.
Nameof Licensed Plumber orGas Fitter -
INSURANCE COVERAGE:
I have a current liability insurance policy or its subsLantial equivalent which meets -the requirements of MGL Ch. 142.
Yes 9--- No Cl
If you have checked ves, please indicate the type coverage by checking the appropriate box.
A liability insurance policya----- other type of indemnity M
Bond C3
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
ChaDter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Checkone:
Owner 0 Agent Cl
Signature of Owner or Ownefs 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 ' oerf ormed under the permit issued for this application will be in compliance with
all per'd . nent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By I y e of License:
Plumber Signature of Licensed Plumber or G s Fitter
Gas�fitter
I ide Master
City/Town ONLY) rJoumeyman
,APPROVED (OFFICE US[: tLy��
License Number—L!�69 -/&"
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