HomeMy WebLinkAboutMiscellaneous - 5 COLBY COURT 4/30/2018 \_�_-
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Dat4 �:....................
OF p10RTly,�
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
I SSACHUS�
This certifies that
............................................ ......... ....................................................
has permission for gas installat'on ...........21.', -.........................................
in the buildin s of.....( ✓d�.... ,. .............. .............................
at................ .. ..... ................................................. ..., No Andover, Mass.
Fee•. 6............ Lic. No. ..........................
... ... . . ....................................
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING'WORK
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CRY ,� , MA DATE - PERMIT# _
JOBSITEADi)RESS ? v v_C 0 NE S NAfi,�E
OWNER ADDRESSYPE OR TEL,� gFAX��..-- -�I
TPR.INT OCCUPANCYTYPE COMMERCIAL[] EDUCATIONAL RESIDENTIAL EO
CLEARLY NEWT] RENOVATION:[T REPLACEMENT: PLANS SUBMITTED: YES[j NO
APPLIANCES 7 FLOORS-4 BSM 1 2 3 1 4
__.. _.._.f( I - I :8 S I 10 I I 11 I1_2§
BOILER � y
i3 14
BOOSTER
J
CONVERSION BURNER _ ___---I(� .! !-- = ---�=,L---. _ _1 �__ __f
COOK STOKE `� F- J-1-1 �I(.� I ._ I (�.YJ( Pe 1 �IDIRECT VENT HEATER
DRYERH�,
.� J
FIREPLACE
FURNACE
! 1 __
GENERATOR --- ---
GRILLE ( # 4_ ___. I _► w
INFRARED HEATER
LABORATORY COCKS
1.-,__. ! -_ _j ___._i___j (�.v _)i_,__I .. ai
MAKEUP AIR UNIT
J l_. rI ,_T.Ar.-_
OVEN
POOL HEATERS [ ► _.�s _ ___( . =.a
'
ROOM/SPACE HEATER I
ROOF TOP UNIT I !
t.
_ J ^I 1
TEST
UNIT HEATER
0NV NNTED ROOM HEATER ! 4 _(( y_I i i( (! ► ,.. ►I C I
WATER HEATERl__._i`_ .I :i _ __ ._I{. ,_({__ . _►r i �1 _ I .1 3
.. Tr _Jf I( i
INSURANCE COVERAGE
I have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESj NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY :7 BOND 01
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. I
CHECK ONE ONLY: OWNED 0 AGENT F.11
SIGNATURE OF OWNER OR AGENT
i 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 perforated under the permit Issued for this application Wil be In compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# M SIGNATURE
NIP _..:- MGF�_ JP �, j G LPGI Q CORPORATION{ # PARTNERSHIP #[ u� LLC
COMPANY NAME:L ma ADDRESS
CITYSTATE �--
]
_ IP TEL
FAX=– LL�s – qIL
a
41. 5 Date... fJ� .. ..
4.�
NORTH TOWN OF NORTH ANDOVER
3r as a PERMIT FOR GAS INSTALLATION
O F
7SSACHUSE�
i
This certifies that . . . .`. .`. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .
,Oas permission for gas installation . ..._: .. :. . . r-:.- '-. . . . .
in the buildings of / . . . . . . . . . . . . . . . . . . . . . . . .
at.
... . . . ! ' . . . ?�!. . . . . , North Andover, Mass.
Fee.,6 . . . . Lic°.No Z z Z% . .
GAS INSPECTOR
WHITE:
HI
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�- WHI :Applicant CANARY:Building Dept. PINK:Treasurer
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MASSACHUSETTS UMFORM APPLICATON FOR PERMIT TO DO GAS FITTING
Type or print) Date =
NORTH ANDOVER, MASSACHUSETTS '
i
Building Locations Permit#
Am unt S 1,5��
Owner's Name !��
s
New❑ Renovation ❑ Replacement Plans Submitted ❑
I L n v ` z n
Z G n
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z C m r - z z C z
Gn L n z :r C
:.j L z _ Z d C: > en :t
e.ri z -t m =r. :� n z C <n
SUB -8ASENI ENT
` BASE ,vt ENT
IST. FLOG R j
2 D . FLO U R
3RD . FLOOR
x.:
1'r it . FLOG R
5'r if . FLO G R
6T It . F L O O R
7TII . FLOOR
A ST Ii . FLOOR
(Print or type ri Ir (� J Check one: Certificate Installing Company
Name VV Corp.
Addr s ❑ Partner.
Business Telephone 7 �, ❑ F1 Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
j
If you have checked yes,pieasimdicate the type coverage by checking the appropriate bo. .
-' Liability insurance policy LZU 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:
Sienature of Owner or Owner's Agent Owner ❑ A2ent ❑
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 pe rmed u er Permit Issued For this application will be in
^_- compliance with all pertinent provisions of the Massachusetts State a ter 112 oral Laws.
{
By: ignature of Licensed Plumber Or Gas Fitter
Title Plumber 1 I
CitviTown Gas Fitter License (Numoer '
Master
Journeyman
APPROVED(01''FICF.USE ONLY) �