HomeMy WebLinkAboutMiscellaneous - 35 EQUESTRIAN DRIVE 4/30/2018 (2)N
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Date� y/G. ' .....
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` TOWN OF NORTH ANDOV, R
PERMIT FOR GAS INSTALLATION
This certifies that ...14.,...�c . �. ..........................
has permission for gas installation ... ..................
in the buildings of .....o ...........................
at -P. A, North Andover, Mass.
Fee.2-�f.... Lic. No.. d ?... .....
GASINSPECTOR
Check #
6570
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/rown:l , f l/, O . Date: U/ Permit#
Building Locad Owners Name:yc'
Type of Occupancy: CommercialQ EducationalQ Industrial Institutional„, Residential f/.
New:0 Alteration:[ --I Renovation Replacement: Plans Submitted: Yes } No.
CIYTI IQCC
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yesl.... `No .
If you have checked Ylp, please Indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of Indemnity E] Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
__.9
Signature of Owner or Owners Aflent Owner ! Agent
accurate to the best of my Knowledge and that all plumbing work and Installations pert under the
compliance with all Pertinent provision of tit Massachusetts State Plumbing Cod*,pWCh&0W 142 of t
Type of Ucense:
Byi Plumber
Titiel� Gas Fstor , Signatu o censed P umber as FMaI
Journeyman
Cityrrownl License Number:
APPROVED (OFFICE USE ONLY) I LP Installer
this application are true and
for this application will be in
Check One Only Certificate #..
Corporation_
Partnership
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yesl.... `No .
If you have checked Ylp, please Indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of Indemnity E] Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
__.9
Signature of Owner or Owners Aflent Owner ! Agent
accurate to the best of my Knowledge and that all plumbing work and Installations pert under the
compliance with all Pertinent provision of tit Massachusetts State Plumbing Cod*,pWCh&0W 142 of t
Type of Ucense:
Byi Plumber
Titiel� Gas Fstor , Signatu o censed P umber as FMaI
Journeyman
Cityrrownl License Number:
APPROVED (OFFICE USE ONLY) I LP Installer
this application are true and
for this application will be in
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