HomeMy WebLinkAboutMiscellaneous - 37 FIRST STREET 4/30/2018J L, ; Date.:`... ................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that.. .!?.: .....
has permission for gas installation .. H.i ....-. A. !'. :.... .
in the buildings of ....`.."..... {
at ......... `.....'..................... North Andover, Mass.
Fee......... Lic. No, .......... ' ............... .
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) _ Cj
MA Date 2000 Receipt# Permit# J ? J `
Building Location ` �3 � ' W Owner's Name f'Z:l CQ, t
Map: Lot: Zone: Type of Occupancy
New 91 Renovation ❑
,7o --
Replacement ❑ Plans Submitted: Yes ❑ No ❑
Installing Company Name EASTERN PROPANE & OIL, INC.
Address 131 WATER ST DANVERS MA 01923
Estimate Value of
Business Telephone
800-322-6628
Name of Licensed Plumber or Gas Fitter
Checkone: Certificate
XCorporation
❑ Partnership
❑ Firm / Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No ❑
If you have checked des, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S 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.
Checkone:
Owner ❑ Agent ❑
Signature of Owner or Owner's 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 underthe permit issued for this application will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen rraal.L,a�ws.
By Type of License: `W �"
Plumber Signature of Licensed Plumber or Gas Fitter
Title Gasfitter
Master License Number
City /Town RJoumeyman
APPROVED (OFFICE USE ONLY)
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Revised 05/17/00
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Installing Company Name EASTERN PROPANE & OIL, INC.
Address 131 WATER ST DANVERS MA 01923
Estimate Value of
Business Telephone
800-322-6628
Name of Licensed Plumber or Gas Fitter
Checkone: Certificate
XCorporation
❑ Partnership
❑ Firm / Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No ❑
If you have checked des, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S 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.
Checkone:
Owner ❑ Agent ❑
Signature of Owner or Owner's 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 underthe permit issued for this application will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen rraal.L,a�ws.
By Type of License: `W �"
Plumber Signature of Licensed Plumber or Gas Fitter
Title Gasfitter
Master License Number
City /Town RJoumeyman
APPROVED (OFFICE USE ONLY)
r
Revised 05/17/00
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