HomeMy WebLinkAboutMiscellaneous - 862 SALEM STREET 4/30/2018 (2)Date. � -/V ...
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .. � . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . . /-7 ................
in the buildings of k.........................
at 6re ..... North Andover, Mass.
'7-
Fee, -2 �� ..... Lic.
Check # 4 1 z i- GAS INSP'ECTOF4y"�
1 ••
MASSACHUSMS
(Type or print)
NORTH ANDOVER, AAASVA..11
TO DO GAS FfrMG
Date ? - 31- Q
Building Locations / ( 57 Permit # -Z o
Amount $ 1i7
Owner's Name
New ❑ Renovation ❑ Replacement �' Plans Submitted
(Print or type) r,r. Checkone: Certificate Installing Company
Name �� G U / ! /s s�L C/
Corp.
Address q W a 0 X El Partner.
7wr iv 5 /6 4; /f
Business Telephone 11 Firm/Co.
Name of Licensed Plumber or Gas Fitter e Q
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ED— No�
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ED- Other type of indemnity 0 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 13 Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are we and accurate to. the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 1,4; of the General Laws.
by:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber / J`—el P--�
Gas Fitter =Se Numoer
Master
Journeyman
IST. FLOOR
ITH. FLOOR
(Print or type) r,r. Checkone: Certificate Installing Company
Name �� G U / ! /s s�L C/
Corp.
Address q W a 0 X El Partner.
7wr iv 5 /6 4; /f
Business Telephone 11 Firm/Co.
Name of Licensed Plumber or Gas Fitter e Q
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ED— No�
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ED- Other type of indemnity 0 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 13 Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are we and accurate to. the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 1,4; of the General Laws.
by:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber / J`—el P--�
Gas Fitter =Se Numoer
Master
Journeyman