HomeMy WebLinkAboutMiscellaneous - 84 COTUIT STREET 4/30/20182;
Date. C ...........
o� TOWN OF NORTH ANDOVER
�' PERMIT FOR GAS INSTALLATION
This certifies that .. �� ... .! ..`.:..... �:`..` .1 ............... .
has permission for gas installation .... . .................... .
in the buildings of .....J. .. c ......................... .
at . n. ` :. ..:.... / .................... North Andover, Mass.
Fee......... Lic. No..!........
Check # 1
;JS/
............... ..........
GAS INSPECTOR
MASSACHUSETTS UNIFMM APPLICATIONfOR PERMIT TOM10-GASP ING
(Print or Type)
Mass. Date 2QPermit # 332
Buildinglocation � � �"I �1 Owner's Name �f�,i{1� M22Er
V
Type of 0=vancy
G
New ❑ Renovation ❑ Replacement 2-�-' --Pians -Submitted: Yes❑ No_❑
Installing Company
Business T
Name of Licensed. Plumber or Gas fuer
Cho& one:
❑ Corporation
❑ Partnership
P Firm/Co.
Ceruriate
INSURANCE VOVERAGE:
I have a curr liability Insurance policy -or Its sululardiai equivalent which -meets the requirements of MGL Ch. 142_
Yes No ❑
If you have checked y, please .indlede.the type coverage by checkingAhe appropriate boot.
A liability insurance.policy)( Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware,VW-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:
Owner❑ Agent .❑
Signature of Owner or Owner's Agent
I hereby certify that all -of the details and information I have submitted (or entered) in aboveapplication are true and accurate to the best of my
knowledge and that all plumbing worts and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Law
BY
Tvna of License:
Plumber WnUaffiWEIM m or
Title Gasfitter
Master License Number3100.
City/Towm Journeyman
N
■ENEEMENSEEN
EMEMEN
oil
E-E1
Installing Company
Business T
Name of Licensed. Plumber or Gas fuer
Cho& one:
❑ Corporation
❑ Partnership
P Firm/Co.
Ceruriate
INSURANCE VOVERAGE:
I have a curr liability Insurance policy -or Its sululardiai equivalent which -meets the requirements of MGL Ch. 142_
Yes No ❑
If you have checked y, please .indlede.the type coverage by checkingAhe appropriate boot.
A liability insurance.policy)( Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware,VW-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:
Owner❑ Agent .❑
Signature of Owner or Owner's Agent
I hereby certify that all -of the details and information I have submitted (or entered) in aboveapplication are true and accurate to the best of my
knowledge and that all plumbing worts and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Law
BY
Tvna of License:
Plumber WnUaffiWEIM m or
Title Gasfitter
Master License Number3100.
City/Towm Journeyman
N
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