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HomeMy WebLinkAboutMiscellaneous - 38 WAVERLY ROAD 4/30/2018Date ... II a 5 '03'.... �.ao ,eye O TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...� ?.r"?.s�:�w 5�-k. L .............. has permission for gas installation ...�. n �. �'-........... . in the buildings of .� S �t ^' S at ...? .. A . ��....... , North dover, Mass. Fee..` .. Lic. No. S05 :.17tt�Z't �&UC--- _ 0 GAS INSPECTOR Check # ( "Q 4541 �t MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING It (Type or print) Date J /� NORTH ANDOVER, MASSACHUSETTS I �! �( ✓ / Building Locations � � � -�''� �� `� L—y !� G' � b �'� Permit # Amount $ ��-- i9 vl.' �v ✓ t Owner's Name ,jj s l(f ftJ� New ❑ Renovation ❑ Replacement �'"* Plans Submitted ❑ (Printor type) _ `2� / C eck one: Certificate Installing Company Name �/�% � � - L � S Li Corp. Address __ 3 ❑Partner, // 19`Firm/Co. Name of Licensed Plumber or Gas Fitter ,2 rq, J; z r4 b INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked M, please indicate the type coverage by checking the appropriate box. 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. Check one: ❑ Signature of Owner or Owner's Agent 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State" G'asode and Qq pter 142 of the General Laws. City/Town OVER (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber /Lro ® Gas Fitter License Number ❑ Master ❑,dburneyman - . - �7TH. FLOOR (Printor type) _ `2� / C eck one: Certificate Installing Company Name �/�% � � - L � S Li Corp. Address __ 3 ❑Partner, // 19`Firm/Co. Name of Licensed Plumber or Gas Fitter ,2 rq, J; z r4 b INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked M, please indicate the type coverage by checking the appropriate box. 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. Check one: ❑ Signature of Owner or Owner's Agent 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State" G'asode and Qq pter 142 of the General Laws. City/Town OVER (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber /Lro ® Gas Fitter License Number ❑ Master ❑,dburneyman