HomeMy WebLinkAboutMiscellaneous - 294 PLEASANT STREET 4/30/2018I
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Date. .2. ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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This certifies that ./ ...... ..... ". Z/
has permission for gas installation ....................
in the buildings of .... ,/ ..............................
at ....... ........... North Andover, Mass.
Fee. .... Lic. .................... .........
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GASINSPECTOR
Check #
MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO GASFITTING
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A7;1,21,413 Mass. Date-- TW AI A� .,2Q2L,2—. Permit
Building Location I:VW/7� /--,—Owners Name,&,L, laa 7),-z6l
Typeofoccupancy RE5l-T-)CivrirqL—
New E] Renovation E] Replacement 2�� Plans Submitted: Yeso No C]
Installing Company Name 'Arji;e(e T �7-AM MA T v.) �0 Check one: Certificate
Address 00 4 C H /Y% f -A 6J i -N1, 0 Corporation
E TH Ue r -J 01 rl - 0 1 0 Partnership
Business Telephone lo 92- -17 -7 -7 2--Firm/CO.
Name of Licensed Plumber or Gas Fitter 1- 0 T A-'5AmMjq7-AP(')
INSURANCE COVERAGE:
I have a current Obility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Fk?' No 13
If you have checked Yes, please Indicate the type coverage by checking the appropriate box
A liability insurance policy Other type of indemnity 0 Bond F-1
OWNER'S INSURANCE WAIVER: I am aware that the licenseedoes 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 OwnerO Agent 0
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 ed for this application i be in ompliance with all,
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 0 her 'aws.
By Tjjoff, UUcense: u of c u or I 6.,e:
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Plumber 'Zin re eni tcter
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Title tter
or Ucense Number Va-�)
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City/Town eyman
APPROVEOWFZCEUS��
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Installing Company Name 'Arji;e(e T �7-AM MA T v.) �0 Check one: Certificate
Address 00 4 C H /Y% f -A 6J i -N1, 0 Corporation
E TH Ue r -J 01 rl - 0 1 0 Partnership
Business Telephone lo 92- -17 -7 -7 2--Firm/CO.
Name of Licensed Plumber or Gas Fitter 1- 0 T A-'5AmMjq7-AP(')
INSURANCE COVERAGE:
I have a current Obility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Fk?' No 13
If you have checked Yes, please Indicate the type coverage by checking the appropriate box
A liability insurance policy Other type of indemnity 0 Bond F-1
OWNER'S INSURANCE WAIVER: I am aware that the licenseedoes 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 OwnerO Agent 0
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 ed for this application i be in ompliance with all,
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 0 her 'aws.
By Tjjoff, UUcense: u of c u or I 6.,e:
t
Plumber 'Zin re eni tcter
t
Title tter
or Ucense Number Va-�)
ou
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m,
City/Town eyman
APPROVEOWFZCEUS��
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