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3531
Date. �! . �� �" ` . ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies thatrte.... • • • • • • • .
has permission for gas installation( --e......... • • • • • • .
in the buildings of �-0-' ..................
t � e
at North Andover, Mass,
Fee%..:.... Lic. No.f-�. 3.... / � ............
/{ `��� GAS INSPECTOR
tt WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
1U j !z- 7 4 A tvm t-rc Mass. Date__L_j2_2_19 Permit #
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instilling Company Name : i (-'A g T A .:� A(n mA T r'1 X20 Check one:
Add'ress7 oA H /vt A.
❑ Corporation
M E 7 H U e rJ 01 rl 0 1 ❑ Partnership
Business Telephone 49 92 -5 9 -7
2--Firm/Co.
Name of Licensed Plumber or Gas f=itter "i O (AE P T A • 5A M M tjTr_jr
Building Location
a' L I vii : nJ
AV'Q-- Owner's Name fU oe-
S �-4 k To,2[JA ,n �
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MA 01 N,� Type of Occupancy�i
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New ❑ Renovation ❑ Replacement fes" -10' Plans Submitted: Yes ❑ No ❑
Certificate
INSURANCE COVERAGE:
I have a current Babillty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Ga' No ❑
If you have checked yes, 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 El
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 ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws.
T of License:
I�lumbw n ure o cen u or Fitter
Title tter
er License Number �f 333
Ro'Nn Journeyman
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Certificate
INSURANCE COVERAGE:
I have a current Babillty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Ga' No ❑
If you have checked yes, 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 El
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 ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws.
T of License:
I�lumbw n ure o cen u or Fitter
Title tter
er License Number �f 333
Ro'Nn Journeyman
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3533 Date Z ... `..... ...... .
TOWN OF NORTH ANDOVER
A PERMIT FOR GAS INSTALLATION
r,
This certifies that .................
has permission for g_ -ass installation '---"�_A ...................
in the buildings oftl�................... .
at . �GZ .::- ........ �-'.... /? � ,North Andover,
Mass.
Fee.1--'r .. Lic. No.T..... C , .... h A.............
G TOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
v\
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
1yoltltl kz pp Mass. Date i 2) Permit #
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Building Location
r-'06IJ Ave-
Owner's Name]OV 3"OiEp#-Mg
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P D0
V e e_E OA VA U t$ J
Type of Occupanry
l 7�• N T 1 r�
New ❑ Renovation ❑ Replacement 2- Plans Submitted: Yes❑ No ❑
Installing Company Name�i_r;e e TQ.` A( Al A T 0 r 0 Check one: Certificate
Address_ 13nAH 1v%,a r J ( ❑ Corporation
M- 7 N U e rJ ►11 rl 0 I kq y ❑ Partnership
Busine .Telephone/0 92 — q 9 -7 I 2--firm/Co.
Name of Licensed Plumber or Gas Fitter ' r) (AE ieT A - f)a M M ►9 7A & �
INSURANCE COVERAGE:
I have a current 1' biltty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 2 No ❑
If you have checked yes, 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 C3
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 ed for this application be in compliance with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws.
T%:er
f License:VA
mber n ure of Licensedu or Fitter
Title Plumber
Lioense Number 8333urneyman
I
Y
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Installing Company Name�i_r;e e TQ.` A( Al A T 0 r 0 Check one: Certificate
Address_ 13nAH 1v%,a r J ( ❑ Corporation
M- 7 N U e rJ ►11 rl 0 I kq y ❑ Partnership
Busine .Telephone/0 92 — q 9 -7 I 2--firm/Co.
Name of Licensed Plumber or Gas Fitter ' r) (AE ieT A - f)a M M ►9 7A & �
INSURANCE COVERAGE:
I have a current 1' biltty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 2 No ❑
If you have checked yes, 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 C3
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 ed for this application be in compliance with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws.
T%:er
f License:VA
mber n ure of Licensedu or Fitter
Title Plumber
Lioense Number 8333urneyman
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