HomeMy WebLinkAboutMiscellaneous - 96 LOST POND LANE 4/30/2018 (3)7,
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Dat .- ..............
%` TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ......0-. f....��. ���'.... .
has permission for gas installation ...v P. N ..................
in the buildings of .: `.............................. .
at .......ti..1. ................... North.Andover, Mass.
Fee.. Lic. No..I.G5 S.....`)�`/. "1 ....
GAS INSPECTOR
Check # I L(
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MASSACHUSETTS UNIFORM APPLICATON FOR PERK Ur TO DO GAS FITTING
(Type or print) Date 1-31--07
NORTH ANDOVER, MASSACHUSET S /
Building Locations LO s% d �► /�' Permit # ��
AmoAnt $ ��"--
Owner's Name
New Renovation D Replacement oz:
Plans Submitted
(Print or type) r- 4' r' -
Address
us
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
11 Corp.
Partner.
E]Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ Noo
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ Other type of indemnity 0 Bond D
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 D Agent
I ncicuy ccnuy unat au of me uetans ana mrormatton i nave 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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusettsf91atipC is Code aj!A Chap¢ IA2 of the General Laws.
By:
Title
City/Town
(OFFICE USE ONLY)
Signature of Licensed Plu er Or as Fitter
Plumber z/ q
DGas Fitter License Number
Master
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SU B -BA SEM ENT
B A S E M E N T
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4 T H. F L O O R
5 T H. F L O O R
6 T H. F L O O R
7 T H. F L O O R
8TH. FLOOR
(Print or type) r- 4' r' -
Address
us
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
11 Corp.
Partner.
E]Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ Noo
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ Other type of indemnity 0 Bond D
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 D Agent
I ncicuy ccnuy unat au of me uetans ana mrormatton i nave 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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusettsf91atipC is Code aj!A Chap¢ IA2 of the General Laws.
By:
Title
City/Town
(OFFICE USE ONLY)
Signature of Licensed Plu er Or as Fitter
Plumber z/ q
DGas Fitter License Number
Master
fri--kUrneyman