HomeMy WebLinkAboutMiscellaneous - 8 DEVON COURT 4/30/2018m
A
a
Date..�n.
° TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ............... •.�..... .................. .
r �
has permission for gas installation .. '. `....... ...�.f . � .. .
j ,. ...
in the buildings of ...'. r: !:. �'--?:.. `.:J.. - .........
at ..11f.. . '...- t ............ . North Andover, Mass.
Fee:.. `�.. Lic. No.1`--Pd,.. .:.-� r �1......... .
GAS INSPECTOR
Check #-
3 6 7
367 -
CAN"N
6
MASSACHUSETTS UNIFORM APPLICATON FORP TO DO GAS FITTING
�e or print) Date 9
NORTH ANDOVER, MASSACHUSETTS
Building Locations `�"L ° OdA ` 4t Permit # 2& v
Owner's Name
New ❑ Renovation ❑ Replacement P
Amount
e �V-1-� S
Plans Submitted
(Printor e)
Name IN (J
Address
— (-, Kf- 59y.5
Name of Licensed Plumber or Gas Fitter -/T/L Vt d'9 ( ,0 L
k one: Certificate Installing Company
U Corp.
El
El
)0
Partner.
INSURANCE COVERAGE Check onp.
I have a current liability Insurance policy or it's substantial equivalent. Yes FM No[:] ;
If you have checked Yes, please i icate the type coverage by checking the appropriate bo
Liability insurance policyOther type of indemnity ❑ Bond 13Owner'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 El
i hereby certify that all of the details and information I have si
best of my knowledge and that all plumbing work and install
compliance with all pertinent provisions of the Massachusetts
(Title
OVER (OFFICE USE ONLY)
(or entered) in above application are true and accurate to the
d under Permit Issued for this application will be in
and -C -alter 142 of the General Laws.
Signature of Licensed Plumber Or Gas Fitter
Plumber
Gas Fitter =Number
Master
Journeyman
�5TH. FLOOR
(Printor e)
Name IN (J
Address
— (-, Kf- 59y.5
Name of Licensed Plumber or Gas Fitter -/T/L Vt d'9 ( ,0 L
k one: Certificate Installing Company
U Corp.
El
El
)0
Partner.
INSURANCE COVERAGE Check onp.
I have a current liability Insurance policy or it's substantial equivalent. Yes FM No[:] ;
If you have checked Yes, please i icate the type coverage by checking the appropriate bo
Liability insurance policyOther type of indemnity ❑ Bond 13Owner'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 El
i hereby certify that all of the details and information I have si
best of my knowledge and that all plumbing work and install
compliance with all pertinent provisions of the Massachusetts
(Title
OVER (OFFICE USE ONLY)
(or entered) in above application are true and accurate to the
d under Permit Issued for this application will be in
and -C -alter 142 of the General Laws.
Signature of Licensed Plumber Or Gas Fitter
Plumber
Gas Fitter =Number
Master
Journeyman