HomeMy WebLinkAboutMiscellaneous - 30 GIBSON COURT 4/30/2018Date ..........................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .................... ....... ; .............
/ " 1" 6"
has permission for gas installation - -e -,( -' w - ---
...............
'in the buildingsof .........................
at ......... North Andover, Mass.
Fee. Lic. No..-��2 ...............
GA&INSPECTOR
1. 4
Check #
4 -' 3
MASSACHUSETIS UNIFORM APPLICATON FORPERAUr TO DO GAS FnTING
(Type or print) Date S1 02 -
NORTH ANDOVER, MASSACHUSE
Building Locations Nxd �2j J, "10
Permit #
Amount $
Ownees NameA..,W0:jfP nLes t
New Renovation Replacement/Q Plans Submitted
(Print or
2 1:()
W 0 1 � V1 vvlth4
Name officensed Pluniber or Gas Fitter
A,
C,hcQk one: Certificate Installing Company
Corp.
Partner.
E] Firm/Co.
INSURANCE COVERAGE Ch--'- one:
I have a current liability Insurance policy or it's substantial equivalent yes Noo
If you have checked r 1pleM�Acate the type coverage by checking the appropriate..
Liability insurance F licy Other type of indemnity Bond 0
"oncy
Ownees Insurance Waiver� Wlam aware that the licensee does no have the Insurance coverage required by Chapter 142 ofthe
Mass. General Laws, and that my signature on this permit application waives this requirement
Check one.
Signature of Owner or Owner's Agent Owner 0 Agent 0
1 hereby certify that all ofthe details and infommfion I have submitted (or entered) in above application am true and accurate to the
best of my knowledge and that all plumbing work and installations der Permit Issued for this application will be in
compliance with all pertinent provisions ofthe Massachusetts Statelz= 142 ofthe Gen&al Laws.
(OFFICE USE ONLY)
Aftnature of Licensed Plumber Or Gas Fitter
Plumber 17---r- L9
Gas Fitter License Nuinbef/I
Master
Journeyman
111111111111
.1
till
ryyywl�.,
Rip I'm 1�
(Print or
2 1:()
W 0 1 � V1 vvlth4
Name officensed Pluniber or Gas Fitter
A,
C,hcQk one: Certificate Installing Company
Corp.
Partner.
E] Firm/Co.
INSURANCE COVERAGE Ch--'- one:
I have a current liability Insurance policy or it's substantial equivalent yes Noo
If you have checked r 1pleM�Acate the type coverage by checking the appropriate..
Liability insurance F licy Other type of indemnity Bond 0
"oncy
Ownees Insurance Waiver� Wlam aware that the licensee does no have the Insurance coverage required by Chapter 142 ofthe
Mass. General Laws, and that my signature on this permit application waives this requirement
Check one.
Signature of Owner or Owner's Agent Owner 0 Agent 0
1 hereby certify that all ofthe details and infommfion I have submitted (or entered) in above application am true and accurate to the
best of my knowledge and that all plumbing work and installations der Permit Issued for this application will be in
compliance with all pertinent provisions ofthe Massachusetts Statelz= 142 ofthe Gen&al Laws.
(OFFICE USE ONLY)
Aftnature of Licensed Plumber Or Gas Fitter
Plumber 17---r- L9
Gas Fitter License Nuinbef/I
Master
Journeyman