HomeMy WebLinkAboutMiscellaneous - 33 ALCOTT WAY 4/30/2018i
Date/ . - / ......
TOWN OF NORTH ANDOVER
10$ - *09 PERMIT FOR GAS INSTALLATION
S.4c
AC U
This certifies that ................. "'o ........
has permission for gas -installation
in the buildings of ......................
at 21
(�
............... ........ North Andover, Mass.
,
Fee,?�...K. Lic'. N o r 't ............
GAS INSPECTOR
Check#
7061
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
�'� • ANw VOR , Mass. Date 70 Permit# 7L -
Building Location c.% /4d7�' �� Owner's Name JA'rJC� /%14g`Ca—H
` /�j • Type of Occupancy
New ❑ Renovation ❑ Replacement � Plans Submitted Yes ❑ No ❑
Installing Company Name ��1 f � AA Check one:
Address 6 13o>,,--, Loc.J®® 1 ❑ Corporation
�u ' ���`��
C1 Partnership
Business Telephone 9157- 9 )1-Y irm/Co.
Name of Licensed Plumber or Gas Fitter
Certificate
INSURANCE COV RAGE:
1 have a curren ability insurance policy or its substantial equivalent which meets the requirements of. MGL Ch 142.
Yes V No ❑
If you have checked yes, please i icate the type of coverage by checking the appropriate box.
A liability insurance policy OthertYP a of indemnity❑ Bond C1
OWNERS 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:
Owner ❑ Agent ❑
I nereoy certify that all of the details and information I have submitted (or entered) in above application are true and accurate to
the bestof my knowledge and that all plumbing work and installations performed under the permit issued for this application will
be in compliance with .all pertinent provisions of the Massachusetts State Plumbing Code and C - er 1 of the General Laws.
BY T pe of License I
Title Plumber
O_Gasfitter Signature of Licensed PI tuber or Gas Fitter
Master / 3
Ci on% ❑ Journeyman License Number /!
e �onvGn ncrir`r � icr n�ii v�
■
■
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ON MIN
ON
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MIN
EMONEENEENNEEMENNON
MIN
• • -
■■.■■■■■■■■■■■■.■■�■■.■■■■-
Installing Company Name ��1 f � AA Check one:
Address 6 13o>,,--, Loc.J®® 1 ❑ Corporation
�u ' ���`��
C1 Partnership
Business Telephone 9157- 9 )1-Y irm/Co.
Name of Licensed Plumber or Gas Fitter
Certificate
INSURANCE COV RAGE:
1 have a curren ability insurance policy or its substantial equivalent which meets the requirements of. MGL Ch 142.
Yes V No ❑
If you have checked yes, please i icate the type of coverage by checking the appropriate box.
A liability insurance policy OthertYP a of indemnity❑ Bond C1
OWNERS 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:
Owner ❑ Agent ❑
I nereoy certify that all of the details and information I have submitted (or entered) in above application are true and accurate to
the bestof my knowledge and that all plumbing work and installations performed under the permit issued for this application will
be in compliance with .all pertinent provisions of the Massachusetts State Plumbing Code and C - er 1 of the General Laws.
BY T pe of License I
Title Plumber
O_Gasfitter Signature of Licensed PI tuber or Gas Fitter
Master / 3
Ci on% ❑ Journeyman License Number /!
e �onvGn ncrir`r � icr n�ii v�