HomeMy WebLinkAboutMiscellaneous - 76 MOODY STREET 4/30/20184w Date. .
41
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A TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..... 7!.44
. ...........................
(1k,
has permission for gas installation ..... P'no.
in the buildings of ..... 26 ..... . :-_5�': ...........
at ff 4A V ./40. ............. North Andover, Mass.
Fee. A�
GAS INSPECTOR
Check#
6040
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MASSACHUSETTS UNIFORM APPUCATON FORS TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations /�� /� i�J� Permit # O
Amount $
Owner's Name
New Renovation D Replacement Plans Submitted D
(Print or
Name_
Name of Licensed Plumber or Gas Fitter
Che k one: Certificate Installing Company
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes �� NoO
If you have checkedrimes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy C-3 Other type of indemnity 13 Bond 13
Owner's Insurance Waiver: 1 am 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 13 Agent 0
1 herebv certifv that Al nfthP APta;IC and ;.,f:,—.,*;.... i 1.-.,-.
i ill auuvc appucation are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas CAeknd Chapter 142 of the General Laws.
A A
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Sign ure of Licensed Plumber Or Gas Fitter
er ^� 8
Gas Fitter (cense Number
Master
Journeyman
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SU B -BASEM ENT
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BASEM ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or
Name_
Name of Licensed Plumber or Gas Fitter
Che k one: Certificate Installing Company
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes �� NoO
If you have checkedrimes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy C-3 Other type of indemnity 13 Bond 13
Owner's Insurance Waiver: 1 am 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 13 Agent 0
1 herebv certifv that Al nfthP APta;IC and ;.,f:,—.,*;.... i 1.-.,-.
i ill auuvc appucation are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas CAeknd Chapter 142 of the General Laws.
A A
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Sign ure of Licensed Plumber Or Gas Fitter
er ^� 8
Gas Fitter (cense Number
Master
Journeyman