HomeMy WebLinkAboutMiscellaneous - 4 KINGSTON STREET 4/30/2018Date.k�.
35 14 ... . ..... .. .
Of &ORTN TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that t� ................
has permission for gas installation -0 ................
in the buildings of ............................
at North Andover, Mass.
... d1c. No .........
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
t -� - 12- o
iIAS.SA �LAPPCATON FOR PERMIT TO DO GAS FITTING
or print) -PARCEL Date D,,y(6 19 9?
Ivry rH ANDo
Building Locations ' �Permit # C- Rj-1y
Owner's Name
New Renovation ❑ Replacement
M
Amount S
' ��
Plans Submitted
(Print or Check one: Certificate Installing Company
Name Corp.
b
Addressr6-ocl k07 a',f
Partner.
Business Telephone /o 5?!% Firm/Co.
Name of Licensed Plumber or Gas Fitter
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 E] Bond
1:1
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.
Signature of Owner or Owner's Agent
Check one:
Owner 13Agent ❑
hereby certify that all of the details and information I have submitted (or entered) in above application are true ana accurate to me
best of my knowledge and that all plumbing work and install ns performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachu mitts tw Gas C Chapte,�?,42 of the G ral haws. -1
By:
Title
CityiTown
APPROVED WhricF use ONLY)
v Signature of Licensed Plumber Or Gas Fitter
Plumber , 7�5,
❑ Gas Fitter 77cense iNumoer
❑Master
r7 Joumeyman
r'
(Print or Check one: Certificate Installing Company
Name Corp.
b
Addressr6-ocl k07 a',f
Partner.
Business Telephone /o 5?!% Firm/Co.
Name of Licensed Plumber or Gas Fitter
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 E] Bond
1:1
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.
Signature of Owner or Owner's Agent
Check one:
Owner 13Agent ❑
hereby certify that all of the details and information I have submitted (or entered) in above application are true ana accurate to me
best of my knowledge and that all plumbing work and install ns performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachu mitts tw Gas C Chapte,�?,42 of the G ral haws. -1
By:
Title
CityiTown
APPROVED WhricF use ONLY)
v Signature of Licensed Plumber Or Gas Fitter
Plumber , 7�5,
❑ Gas Fitter 77cense iNumoer
❑Master
r7 Joumeyman