HomeMy WebLinkAboutMiscellaneous - 75 MILLPOND 4/30/2018Tv
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Date .....................
r. - - � ��'
TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
This certifies that ........ r'� ...................
has permission for gas installation . ....`...... `..... .. ."
in the buildings of,.-. `... .."C/ ....................... .
at '.::. ' '...�.......... North Andover, Mass.
Fee`........ Lic. No.�w ..
GAS INSPECTOR/
Check # %
61
3:'73
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) _
t NORTH ANDOVER Mass. Date 3
Building Location j 1]pn2j Permit #
Owners Name-
? :Y New _ Renovation II ReplacementPlans Submitted D
FIXTUR=c
(Print or Type) f�
Installing Company Named/
1 Address �� �I�r)r�2 ;,.z,
ar��
Business Telephone: /c�/y-%9
Name of Licensed Plumber or Gas Fitter
U 1 Check one: Certificate
rye. G"► 1�9Ijr� Q Corp.
Partner.
Firm/Co.
Q44
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy E] Other type of indemnity Q Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
I
A Signature of owner/agent of property Owner 17 Agent
I hereby certify slut all of the details and information I hay submitted (or entered) in above application are true and accurate to the bat of my
knowledge and that aLL plumbing work and Installations performed under Permit issued fo: this application will -be in compliance with, dl pertinent
provisions of the Massachusetts State Gas Code and Chapta 14: of the General Laws.
By TYPE LICENSE:
Plumber
Title PlumGasfber
Signature of Licensed
Plumber or Gasfitter
City/Town: Master
Journeyman ]aqua
APPROVED (OFFICE USE ONLY) License Dumber
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BASEMEMT
I ST FLOOR
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2ND FLOOR
3110 FLOOR
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f
4TH FLOOR
5TH FLOOR
6THFLOOR
7TH FLOOR
STH FLOOR
(Print or Type) f�
Installing Company Named/
1 Address �� �I�r)r�2 ;,.z,
ar��
Business Telephone: /c�/y-%9
Name of Licensed Plumber or Gas Fitter
U 1 Check one: Certificate
rye. G"► 1�9Ijr� Q Corp.
Partner.
Firm/Co.
Q44
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy E] Other type of indemnity Q Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
I
A Signature of owner/agent of property Owner 17 Agent
I hereby certify slut all of the details and information I hay submitted (or entered) in above application are true and accurate to the bat of my
knowledge and that aLL plumbing work and Installations performed under Permit issued fo: this application will -be in compliance with, dl pertinent
provisions of the Massachusetts State Gas Code and Chapta 14: of the General Laws.
By TYPE LICENSE:
Plumber
Title PlumGasfber
Signature of Licensed
Plumber or Gasfitter
City/Town: Master
Journeyman ]aqua
APPROVED (OFFICE USE ONLY) License Dumber