HomeMy WebLinkAboutMiscellaneous - 96 SECOND STREET 4/30/2018Date .... l i.?. . d .Z, . .
TOWN OF NORTH ANDOVER
s
PERMIT FOR GAS INSTALLATION
This certifies that
q has permission for gas installation .......... .
in the buildings of ...To 6,e� „ J4
at ...� ... Jam. P� d'� S t .... ,-,North A dover, Mass.
Fee. .a.S.. Lic. No. 13�uS `S:. �ozZi WA
GASINSPE TOR
Check #5/, =)=3
41 40
MASSACHUSETTS UNIFORM APPUCATON FOR PERAUr TO DO GAS Fr.rr] ATG
(Type or print) Date' L'j Z,
NORTH ANDQVER, MASSACHUSETTS
Building Locations `y 'E (7 /� A,/It A Permit #
_ Amount $
Owner's Name ,h i � � h�0
New []I/ Renovation 0 Replacement 0 Plans Submitted a
(Plim
0
Name of Licensed Plumber or Gas Fitter -`P 4,L,4, C --
INSURANCE
ffone:• Certificate Installing Company
Corp.
Partner.
O. FE- Co.
Check one:
I have a current liability Ins�uancePolicy or it's substantial equivaleaL Yes E3 NoO
If you have checked M please the type C0 VMage. by checking the appropriate box
Liability insurance policy ErOther 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 haws, and that my signature on this permit application waives this requirement
ofOwner or
Check one:
Owner
I herety certify that all ofthe 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 P9{ ' Issued for this application will be in
comphimce with all pertinent provisions of the Massachusetts to Cede and C&er 142 of the General Laws.
/ r
City/Town
(OFFICE USE ONLY)
Signature of Licensed Plumber Or Q6 Fitter
Plumber a—/ T—
M—Ehm Fitter License Number
Master
M,Iexrneyman