HomeMy WebLinkAboutMiscellaneous - 4 ELLIS COURT 4/30/2018 (2)`
�, _'�.
'.�.
r
H
/�
6 U 2 4 Date/�',?/`*�/�Z'�?-�p -
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ........ ...........
has permission'for gas installation ................ �V-
in the buildings of ........................
at ....... I North Andover, Mass.
Fee.).)./.� ... Lic. No..�'��.� .. ..........................
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING
or print) Date 2 y 19
twtcfH ANDOVER, MASS/ACHUSETTS
Building Locations �/ ( r
New ❑ Renovation ❑
Permit 9
Amount $
Owner's Name (�
Replacement M Plans Submitted ❑
(Print or
Name
Check one: Certificate Installing Company
❑ Corp.
Address ❑ Partner.
Business Telephone „ — _ 13 Firm/Co.
Name of Licensed Plumber or Gas
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked ves, please indicate the type coverage by checking the appropriate box.
Liability insurance policy (% Other type of indemnity ❑ Bond ❑
4
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Vtass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent ------- — Owner ❑ AgS.-,❑
i hereby certify that all of the details and information ave submitted (or entered) in abov a licati are true and accurate to the
best of my knowledge and that all plumbing work d insta11 tto. s perfo d and etm sued r this application will be in
compliance with all pertinent provisions of the VI ssac� tate Ga ode d hapt I ' : the General Laws.
By:
Title
City/Town
APPROVED wFFicF USF ONLY)
Signature ' icensed Plumber Or Gas Fitter
Plumb
❑ Gas i er)L censeNumoer
Master
❑ Journeyman
j�
(Print or
Name
Check one: Certificate Installing Company
❑ Corp.
Address ❑ Partner.
Business Telephone „ — _ 13 Firm/Co.
Name of Licensed Plumber or Gas
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked ves, please indicate the type coverage by checking the appropriate box.
Liability insurance policy (% Other type of indemnity ❑ Bond ❑
4
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Vtass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent ------- — Owner ❑ AgS.-,❑
i hereby certify that all of the details and information ave submitted (or entered) in abov a licati are true and accurate to the
best of my knowledge and that all plumbing work d insta11 tto. s perfo d and etm sued r this application will be in
compliance with all pertinent provisions of the VI ssac� tate Ga ode d hapt I ' : the General Laws.
By:
Title
City/Town
APPROVED wFFicF USF ONLY)
Signature ' icensed Plumber Or Gas Fitter
Plumb
❑ Gas i er)L censeNumoer
Master
❑ Journeyman