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HomeMy WebLinkAboutMiscellaneous - Exception (761)r� 3 4 v it Date.... . .............``.. gORTM TOWN OF NORTH ANDOVER Oy tao ,s,tiOL p PERMIT FOR GAS INSTALLATION This certifies that ..!.....` .`.,:'./'� ` ...... . has permission for gas installation . ... `... .` ............ . in the buildings of ..... " '.................. at :............ .. ......:...... , North Andover, Mass. Fee::... �... Lic. No..:`...% GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 1 ; MASSACHUSETTS Ui`t`IFORM APPLICATON FOR PERMIT TO DO GAS FITTING ype or print) ate �� I �/ NORTH ANDOVER, MASSACHUSETTS BuildingLocations �� eyd X10 t-- t �� P topermit 9 un t S c��' -� Owner's Name �✓� ,,,,, ,- New F7Renovation ❑ Replacement Plans Submitted ' '� (Print or D Nam. _y7W—tA9,qC0o4tL�y Business Telephone Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. ❑ Partner. INSURANCE COVERAGE CheckriijnV I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ I f you have checked ves, plea e i dicate the type coverage by checking the appropriate box Liability insurance policy Other type of indemnity❑ Bond ❑ Owner's Insurance Waive . I am aware that the licensee does not have the Insurance coverage required by Chapter I I? of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's A_ent herebv cerrifv that all of the details and intbrmation I have subm best of my knowledge and that all plumbing work and installation compliance with all pertinent provisions ofthe :Massachusetts Sti By: Title Ciry/Town .APPR01vED ioFi--v: USE `)NLY1 Check one: Owner ❑ Aeent ❑ (or entered) in above application are true and accurate to the 497171r/d under Permit Issued Fore -LL �lication will be in e and Navter� the General Laws. Signatur/of Licensed Plumber Or Gas F'rter Plumber Gas Fitter ice. se iNumoer i�laste- Journeyman .r (Print or D Nam. _y7W—tA9,qC0o4tL�y Business Telephone Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. ❑ Partner. INSURANCE COVERAGE CheckriijnV I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ I f you have checked ves, plea e i dicate the type coverage by checking the appropriate box Liability insurance policy Other type of indemnity❑ Bond ❑ Owner's Insurance Waive . I am aware that the licensee does not have the Insurance coverage required by Chapter I I? of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's A_ent herebv cerrifv that all of the details and intbrmation I have subm best of my knowledge and that all plumbing work and installation compliance with all pertinent provisions ofthe :Massachusetts Sti By: Title Ciry/Town .APPR01vED ioFi--v: USE `)NLY1 Check one: Owner ❑ Aeent ❑ (or entered) in above application are true and accurate to the 497171r/d under Permit Issued Fore -LL �lication will be in e and Navter� the General Laws. Signatur/of Licensed Plumber Or Gas F'rter Plumber Gas Fitter ice. se iNumoer i�laste- Journeyman