HomeMy WebLinkAboutMiscellaneous - 483 JOHNSON STREET 4/30/2018 (2) 483 JOHNSON STREET
210/098.A-001 B-0000.0
f. Date.. .. ....... .
NORTH
16
o? TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
�,SSAC NUSEt�h �'
This certifies that . . `.� . . . . . . . . ./. . . . .J!e
has permission for gas installation . &. . . �fr . .t . p��e .�
in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . .X. . .Y�.�'��c°'t. . 5 � : . . North Andover, Mass.
Fee l,. T ? Lic. No..£���.37 . . . . . . .
GAS INSPECTOFf
Check# /u�v
8082
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I ilorih Wow 1 MA. DATE PERMIT#
JOBSITE ADDRESSr�T,5;TohOWNER'S NAME
GOWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[�
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: [g PLANS SUBMITTED: YES❑ NO❑
FIXUTRES Z FLOOR- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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 YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY (K OTHER TYPE INDEMNITY ❑ BOND ❑
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 ❑ AGENT ❑
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 accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. c�
i t
l �
PLUMBER/GASFITTER NAME: o -' LICENSE# SIGNATURE
COMPANY NAME: r ADDRESS:
CITY: STATE: - ZIP: �� FAX
TEL: CELL: EMAIL: t
MASTER + JdURNEYMAN❑ LP INSTALLER❑ CORPORATION # 0 3 PARTNERSHIP❑ LLC❑#0