HomeMy WebLinkAboutMiscellaneous - 79 MARBLEHEAD STREET 4/30/2018Date .. �a/... .
y
/.,o TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that z �: ... .
..
has permission for gas installation ...�� n'. !... .
in the buildings of .:�yc� -cry ....................
at ...:............... .t..A!�9.. , North Andover, Mass.
Fee.' ? `..... Lic. No......... ..-�........... .
GAS�SG GIOR
Check #. l� / -�17
36: 3
MASSACHUSE,TTc,UN11-UHM AIrNUCATION FOR PERMIT TO DO GASFITTING .
(Print or T )
Q/�P� Mass. Date 1!A v0 Permit # tleO3
Bulding Location Owner's Name
Type of OccupanZ-w
ry
G
t
i
New ❑ Renovation ❑ Replacement 21 Plans Submitted: YYes:p No ❑
Installing Company Name �t i �, AE (Z T A . `Am M A Tri r2 L' Check one: Certificate
Address 3C-) 00t4 C H rh A- ry i- KJ . ❑ Corporation
ME T N U E tj 01 r1 U 1 y ❑ Partnership
Business Telephone r/o 12 - 9 (7 -7 f 2-'Firm/Co.
Name of Licensed Plumber or Gas Fitter "f O A E f° T A - 58 M m H zit L-)
NSURANCE COVERAGE:
have a current pf bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Q' No ❑
Id you have checkedrtes, please Indicate the type coverage by checking the appropriate box
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 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 C1
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the pe i ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws.
BY T of license: C�
Plumber t.WhAture of Licensed PlumlWor Q,
as rtter
Title tter 8333
er License Number
City/Town N Journeyman
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ARE
SOMEONE
Installing Company Name �t i �, AE (Z T A . `Am M A Tri r2 L' Check one: Certificate
Address 3C-) 00t4 C H rh A- ry i- KJ . ❑ Corporation
ME T N U E tj 01 r1 U 1 y ❑ Partnership
Business Telephone r/o 12 - 9 (7 -7 f 2-'Firm/Co.
Name of Licensed Plumber or Gas Fitter "f O A E f° T A - 58 M m H zit L-)
NSURANCE COVERAGE:
have a current pf bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Q' No ❑
Id you have checkedrtes, please Indicate the type coverage by checking the appropriate box
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 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 C1
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the pe i ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws.
BY T of license: C�
Plumber t.WhAture of Licensed PlumlWor Q,
as rtter
Title tter 8333
er License Number
City/Town N Journeyman
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