HomeMy WebLinkAboutMiscellaneous - 8 BRIARWOOD COURT 4/30/2018J
Of "0 TPI
0 0 TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
SSA US
This certifies that ..... . M.. l i� ........ .
has permission for gas installation,U<�/,.,t, .
in the buildings of .. ....
--
at
Fee, -<1.—'.,.... Lic. No......
Check # Z�
5*136
—.., ..............
oeth Andover; Mass
INSPECTOR
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t
4
MASSACHUSEI IS UNIFORM
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
New ❑ Renovation ❑
7 :C N FOR PERMPrTO DO GAS FITTING
Date � - 3 ®T
K Permit # 3/
Amount $ .
pr's Name > Vl
❑ Plans Submitted 13
(Print or
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
❑ Corp.
11 Partner.
�irm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 13No ❑
If you have checked Les, please i dicate the type coverage by checking the appropriate box.
Liability insurance policy Z- 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 ❑
i hereby certify that all of the details and information 1 have sunrmttea (or
best of my knowledge and that all plumbing work and installations perforr
compliance with all pertinent provisions.of the Massachusetts State Gas C1
By:
Title
City/Town
APPROVED (OFFICE USE orn.Y)
aoove appucauon are aue na accurate to me
Issued or this a cation will be in
er 142 e Laws.
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber 2: 3J3
❑ Gas FittertL cue Number
❑ Master
0 Journeyman
SUB-BASEM ENT
Paco
FLOOR
14TH.
(Print or
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
❑ Corp.
11 Partner.
�irm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 13No ❑
If you have checked Les, please i dicate the type coverage by checking the appropriate box.
Liability insurance policy Z- 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 ❑
i hereby certify that all of the details and information 1 have sunrmttea (or
best of my knowledge and that all plumbing work and installations perforr
compliance with all pertinent provisions.of the Massachusetts State Gas C1
By:
Title
City/Town
APPROVED (OFFICE USE orn.Y)
aoove appucauon are aue na accurate to me
Issued or this a cation will be in
er 142 e Laws.
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber 2: 3J3
❑ Gas FittertL cue Number
❑ Master
0 Journeyman