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Home My WebLink AboutMiscellaneous - 40 UPLAND STREET 4/30/2018.................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that... . . ............. GYV�5 .has permission for gas installation ...... V\ik.z ...... !� �......... ..... ......... in the buildings of ...........6.�, low. -0 .............. I ................................................................................. at .......... ............... ........v1. PANorth Andover, Mass. Fee 1, �� .. 0 ........... ) . ..... Fee..(..PO.`..'...... Lic. No. .... ..M GASINSPECTOR Check # -521 bi 09878 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK __. CITY - tJoRT �•32/a NL�o MA JOBSITE ADDRESS 4 UPLA4 D Sr OWNER'S NAME <T OWNER ADDRESS TE FAC� TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: Q RENOVATION: [l REPLACEMENT:'' PLANS SUBMITTED: YES ® NO FLOORS- BSM 1 2 _ _-3n Jf 4 5 6 7 8 9 10 11 12 13 14 APPLIANCES Z BOILER BOOSTER - CONVERSION BURNER .COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE�— FRYOLATOR FURNACET _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN _ POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST _ UNIT HEATER UNVEMTED ROOM HEATER WATER HEATER —Ke --dT—HE—R -rem 1twe 6 j , INSURANCE COVERAGE I have a current liabilify insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND r OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. - CHECK ONE ONLY: OWNER El AGE T 0 SIGNATURE OF OWNER OR AGENT ' hereby certify that all of the details and information I have submitted or entered regarding this application are true and aogyrate to th t of nowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp all P pro 'si of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. y _. J PLUMBER-GASFITTER NAME �aw�t5 ) (�.G.GFi£GC� LICENSE# 15-(.qg Si URE MP [3'MGF � JP ® JGF QI LPGI ® CORPORATION [af PARTNERSHIP ®# LLC -- COMPANY NAME: ee _ Bra g ADDRESS CITY STATE'/1'I 12 TEL FAX CELL s��d6-IgQ`1 EMAIL le�r�e 6�a :,_ .s .� "Ati) NIFORM APPLICATIOPI FOR PERMIT TO DO- (GASFITTING Print of Type) NORTH ANDOVER, , Maas. Date �g (J Building PermitLocation Owner's Installing Coi New Renovation ❑ Name Replacement ❑ Plans Submitted: Yes ❑ No p r5; Check one: Corp. Partnership ❑ Firm/Co. Business Telephone --a_(' Name of Licensed Plumber or Gas Fltter v INSURANCE COVERAGE: Check one 1 have a current liability Insurance policy or Its substantial equivalent. ;Yes No ❑ '{If`you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy [J Other type of indemnity D Bond ❑ Certificate OWNER'S INSURANCE WAIVER: I am aware that the Ilcensee does not have the Insurance coverage required by Chapter 112 of the Mass, General Lawn, and that my signature on this permit application waives this tequiremeat. Check one: Signature of Owner or Owners hgent Owner ❑ Agent ❑ I hereby certlPy that all of the details and Information I have submitted (or entered) In above application are true and accurate to the best of my ;. `knoaAedge and that ellplumbing work and installations performed under the permit sued for this application will be In compliance with all pertinent provisions of the Massachusetts State Oas a - and Ch t IA2 of THIS CltylTown NTrUYED (OFFICE USE ONLY) ap er the of LawsQu -�T of nae: ,umber urs o m et or Of Qasplter Master nse Number L} Q Journeyman mom Noon NNINNIN 0.000 0 on 0000A INOUNNION NOUN �C:No 0 000C:C::C10:w C:NJ ::C':': r5; Check one: Corp. Partnership ❑ Firm/Co. Business Telephone --a_(' Name of Licensed Plumber or Gas Fltter v INSURANCE COVERAGE: Check one 1 have a current liability Insurance policy or Its substantial equivalent. ;Yes No ❑ '{If`you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy [J Other type of indemnity D Bond ❑ Certificate OWNER'S INSURANCE WAIVER: I am aware that the Ilcensee does not have the Insurance coverage required by Chapter 112 of the Mass, General Lawn, and that my signature on this permit application waives this tequiremeat. Check one: Signature of Owner or Owners hgent Owner ❑ Agent ❑ I hereby certlPy that all of the details and Information I have submitted (or entered) In above application are true and accurate to the best of my ;. `knoaAedge and that ellplumbing work and installations performed under the permit sued for this application will be In compliance with all pertinent provisions of the Massachusetts State Oas a - and Ch t IA2 of THIS CltylTown NTrUYED (OFFICE USE ONLY) ap er the of LawsQu -�T of nae: ,umber urs o m et or Of Qasplter Master nse Number L} Q Journeyman -. ti.T ►r}r'.!��^ate-• -� .. � •^ ^- _. .-- .... Date ... . ....Ll ..... . 0 OE NORTH - TOWN OF NORTH ANDOVER 1N E° rdE '°� PERMIT FOR GAS INSTALLATION A 9�ACaMUSEt fThis certifies that ......... .. .I—— pi ' .... ........ . ��,,'� has permission for.gas nstallatiori .7(...- Z........ in the buildings of 1 ... /.1'.�f%`f. �......... . at ...`'F.. �L'!�i.:... North Andover, Mass.. Fee ,:% Lic. No �_` .�'� sasr'-y'' • -c ... ...... ` ` GAS INSPECTOR WHITE: Applicant CANARY: -Building Dept. PINK: Treasurer GOLD: File