HomeMy WebLinkAboutMiscellaneous - 52 PROSPECT STREET 4/30/2018 52 PROSPECT STREET
210/080.0-0023-0000.0 j
I
7 5t ti; Date. .
HORTh
�-
3? TOWN OF NORTH ANDOVER
p A
• - PERMIT FOR GAS INSTALLATION
SACH USEtA
,
This certifies that . . . . . � . . . . . . . . P/ . . .
has permission for gas installation . . . . .i9 . . . . . . . . . . .
in the buildings of . . . . . . . . ... . .C;GqP'i. . ?. . . . . . . . . . . . . . . . . . . . .
at . . . . . . . . .. . . . . . ! �. J?f � : +� , North Andover,_Mass.
y
Feec1.�U . . Lic. No.. . . . . . . .
GASINSPECTOR j
Check# j`>
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
Cit /Town: 1' I °1 ' o2C�(� a//
y , MA. Date: � z Permit#
,a0Building Location: J r-is � �'f` � `�
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Ff Plans Submitted: Yes❑ No❑
FIXTURES
LU
Z w � _
m = O W w v U) O x W w
O -Jo Z Z p W W W W O Q :)
Lug Ca a.
Cl)> LU v Z y 0 o W 0 a W x LL
W W F 0
LLI
� W W Z O J H P O Z J U' LL x W I-- W W
O W- W j Q W W W m > O ZZ O y Z > Z Q x
U a a LL 0 0 x x g O a a W H > > > � O
SUB BSMT.
BASEMENT /
1 FLOOR
2 Nu FLOOR
3 FLOOR
4 IH FLOOR
5 FLOOR
6 FLOOR
7 FLOOR
0 FLOOR
Installing Company Name: Check One Only Certificate#
❑Corporation
Address: City/Town: State:
❑Partnership
Business Tel: Fax: &" G�-9-Y 3G d
�--1 \
Firm/Company
Nam ..-.
Name of Licensed Plumber/Gas Fitter: �
INSURANCE COVERAGE:
1 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.
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 1:1Agent E]
By checking this box❑;I hereby certify that all of the de ails and information I h ve sub ' ed(or entered a rding this application are true and
accurate to the best of my Knowledge and that all plumb ng work and installation perfor d under the �ra
d for this application will be in
compliance with all Pertinent provision of the Massachu etts State Plumbing Cod and p 2 of t e e Laws.
Ty f License -,, - C
By Plumber
Title L1Gas_Fitter Signature o Licensed umber/Gas Fitter
aster
City/Town Journeyman License tuber: 16361
APPROVED OFFICE USE ONLY ❑ LP Installer