HomeMy WebLinkAboutMiscellaneous - 72 MARBLEHEAD STREET 4/30/2018rv1ASsnGitu'sc f-i•s u1,111 -011M 013W,-AT16(=011 PEWIT TO DO GASFITTf G
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11
� n d.: 'CAldlnU Locillo5!P Owner's NamcV14HIf"t
at vs Type of Occupancy
New p Renovation ❑ Replacement ❑ Plans Submitted: Yost] No 91
Installing Comniny Name /I%fIFFCLz A6(r y
Address
Business Tcicphone
Name of Licensed Plumber or Gas Filter
-9
Check one:
❑ Corporation
❑ Paltnershlp
WFlrm/Co.
Certificate
INSURANCE COVERAGE:
I have a curren liability Insurance policy or Its substantial equivalent which meets the requlrements.of MGL Ch. 142.
Yes No ❑
If you have checked yes. please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy X Olitcr We of Indemnity ❑ pond ❑
OWNER'S INSURANCE WAIVER: Lam aware "that the licensee docs -tot Lave the Insurance coverage rc(Iulred by
Chapter 142 of the Mass. General Laws, and .that my slunaturc on this permit application waives this reciulreti;ent.
Check one:
gnalure of C�wnor or CMmm s Agonl Owner❑ Agent ❑
hereby cotilfy 11, 1a.Lakof.Ahe-dotalls-and Inlonnal on I1'havc submillod (or entered) In above application ate true and accutale to the bast of my
knowiodgo andithit all=12,-
ur a iln ovk awed lUtallallo,� ;)ortotmod under the ponnll Issued for this application will be In compliance With all
poltinonl ptovislldl f e _,-ln3 _iuiotti Sulo G` 41�f is and Chapter 142 of the�onls( lfor t3.
Dy_ )) ..1 r of Uconso:� ) AOulnoynian
16mTillo DEC 1 6 1- gor Iso um or t s d oT r
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Installing Comniny Name /I%fIFFCLz A6(r y
Address
Business Tcicphone
Name of Licensed Plumber or Gas Filter
-9
Check one:
❑ Corporation
❑ Paltnershlp
WFlrm/Co.
Certificate
INSURANCE COVERAGE:
I have a curren liability Insurance policy or Its substantial equivalent which meets the requlrements.of MGL Ch. 142.
Yes No ❑
If you have checked yes. please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy X Olitcr We of Indemnity ❑ pond ❑
OWNER'S INSURANCE WAIVER: Lam aware "that the licensee docs -tot Lave the Insurance coverage rc(Iulred by
Chapter 142 of the Mass. General Laws, and .that my slunaturc on this permit application waives this reciulreti;ent.
Check one:
gnalure of C�wnor or CMmm s Agonl Owner❑ Agent ❑
hereby cotilfy 11, 1a.Lakof.Ahe-dotalls-and Inlonnal on I1'havc submillod (or entered) In above application ate true and accutale to the bast of my
knowiodgo andithit all=12,-
ur a iln ovk awed lUtallallo,� ;)ortotmod under the ponnll Issued for this application will be In compliance With all
poltinonl ptovislldl f e _,-ln3 _iuiotti Sulo G` 41�f is and Chapter 142 of the�onls( lfor t3.
Dy_ )) ..1 r of Uconso:� ) AOulnoynian
16mTillo DEC 1 6 1- gor Iso um or t s d oT r
as.fillo(„ .
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` Date.. ;.. �.�...t ...
NORTH ° TOWN OF NORTH .ANDOVER
of qti S
F� hts E° oA PERMIT FOR GAS INSTALLATION
This certifies that .../ ,...! ....}'...�.. ...� .'.7.. t .... ...
has permission for-gasinstallation --` % {: !�. !
in the buildings of.
at fl.. ,f .:`{ ...` ; North Andover, Mass.
Fee.. !y,J ic. No../.(.'
o../.!. ......
GAS..INSP...EC...R........... .
�f1 TO
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File