HomeMy WebLinkAboutMiscellaneous - 74 MILLPOND 4/30/2018N
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Date .. � .` jl.!. `..'...... .
5250
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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.� SACH SE�4
This certifies that..
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..... ............ .
has permission for gas installation ..............
in the buildings
.................
at ............, North Andover, Mass.
Fee. Lic. No.?.�>.�.�.:'..-
9-1:��S-
INSPECTOR
Check #
5250
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MAS,SACHUSEYI'S UNIFORM APPUCATON FOR PERMiT TO DO GAS FTITING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Date ���
Owner's Name
Permit #
Amount $ 3 0
Newo
Renovation Replacement Plans Submitted
Name of Licensed Plumber or Gas Fitter 1�'3 A ) 11
heecc one: Certificate Installing Company
vl -7 Corp..
�❑ Partner.
❑ Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insur nce policy or it's substantial equivalent. Yes ❑ No ❑
If you have checkedLes> plea dicate the type coverage by checking the appropriate box. ❑
Liability insurance policy Other type of indemnity 13Bond
Owner's Insurance Waiver: I a 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:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
t hereby certify that all of the details ano iniormauon 1 uavn buuuuuGu wi ---/ .a. - .f y,, »-. •• » -_ -..- ________ __
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with ail pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. 44 -pe
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OVER (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber a b ) ? 9
❑ Gas Fitter License lNumber
�`❑ Master
.,❑ Journeyman