HomeMy WebLinkAboutMiscellaneous - 5 STACY DRIVE 4/30/2018 5 STACY DRIVE
210/091.0-0034-0000.0
7 8 ° 4 Date.. .�.�.
NOR7M
o= �' TOWN OF NORTH ANDOVER
- PERMIT FOR GAS INSTALLATION
• � a
•' h
SACHUSEtt
This certifies that .1<. . !. . . .5.!�4r4v..�. .0
has permission for gas installation
in the buildings of iL.?.y 1.1 ( �. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at .,5� . . S.�✓�. t f. . �-- . . . . . . . . North A over, ass.
Fee. Lic. No..
GAS INSPECTOR
Check# /0 �'y
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: C h U -C 2 MA. Date: 'Z-L << Permit#
Building Location: C Owners Name: W / 6le
Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ No❑
9
FIXTURES
W F- U =
z
Q F-
m = O of W 0 co H 0 = co W
z I— Z W j lz O 0 F
O W rn F- W O Q H
W N V W W W Z 0 = N 0 W W ❑ = LL
ZW
Z W >- W 0 J F- P 0 z -j 0 LL H = W H W W
0 ❑ ❑ 1=i 0 C7 W W m > O z 0 W Q —
g 0 a > >z z W I> 0
SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 THFLOOR
5. FLOOR
6 TH FLOOR
7 FLOOR
8 TH FLOOR
Installing Company Name:
Check One Only Certificate#
]� y�� �f;�- �pvttis2c t � � C�
El Corporation
Address:_Q /91 Ytd 2J City/Town—_'L, ',//c[.t— State: k4l�"
❑Partnership
Business Tel:g 7� �D ��� ZU Fax: S��'e-
[a'Firm/Company
Name of Licensed Plumber/Gas Fitter: .,c.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No 1-1
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
❑
Signature of Owner or Owner's Agent Owner E] Agent
By checking this box❑;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 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 t General Laws.
By Type f License:
lumber
Title ❑Gas Fitter Sig ature of Licen d PlumbeNGas Fitter
[�-Master
City[Town ❑Journeyman �h /
APPROVED OFFICE USE ONLY El LP Installer License Number:_ C1 U ?) (1