HomeMy WebLinkAboutMiscellaneous - 36 ALCOTT WAY 4/30/2018 (2)Date...
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3� TOWN OF NO ANDOVER
-PERMIT FOR GAS INSTALLATION
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�9SSACHUSEI
This certifies that..... ' ............................ .
has permission for gas installation=:.....-`. ` . .. :... .
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in the buildings of ...
North Andover, Mass.
F63,4; .... Lic. No::�f.'a a'. 11 ...........
GAS INS
Check #,-
7065
,
7065
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFiTTING d
(Print or Type)
Mass. Date 20L -LZ Permit#
Building Location Owner's Name A"
�+ 15 ' Type of Occupancy
New ❑ Renovation ❑ Replacement Plans Submitted Yes ❑ No ❑
Installing Company Name %,�� ! I ,
Address
,+
Business
7Xy� wison L(_
A y���J 0,
179—
Name of Licensed Plumber or Gas Fitter �j
Check one:
❑ Corporation
❑ Partnership
irm/co.
Certificate
INSURANCE COVERAGE:
1 have a curre lability insurance policy or its substantial equivalent which meets the requirements of. MGL Ch 142.
Yes No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
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 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 permit issued for this application will
be in compliance with .all pertinent provisions of the Massachusetts Szaz
d er of the General Laws.
BY Type of License
Title ❑ PI ber
❑ sfitter Signature of Licensed lumber or Gas Fitter
aster // 1 �.Z
C,%� own ❑ Journeyman License Number
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IBASEMENT
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is :::
Installing Company Name %,�� ! I ,
Address
,+
Business
7Xy� wison L(_
A y���J 0,
179—
Name of Licensed Plumber or Gas Fitter �j
Check one:
❑ Corporation
❑ Partnership
irm/co.
Certificate
INSURANCE COVERAGE:
1 have a curre lability insurance policy or its substantial equivalent which meets the requirements of. MGL Ch 142.
Yes No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
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 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 permit issued for this application will
be in compliance with .all pertinent provisions of the Massachusetts Szaz
d er of the General Laws.
BY Type of License
Title ❑ PI ber
❑ sfitter Signature of Licensed lumber or Gas Fitter
aster // 1 �.Z
C,%� own ❑ Journeyman License Number
e PRnvCn n==1r1c I icm nui 1�