HomeMy WebLinkAboutMiscellaneous - Exception (528)MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print r Type)
` Mass. Date - zt ri--Permit oZ .6 4
Building Locatlon Owner's Name
Type of Occupancy y
New ❑ Renovation Q Replacement Mel Plans Submitted: Yesp ' No p
Installing Company Name OW _H L e PLUM8IN Check one: Certificate #
Address BALEY_ 1r.H. Itlenm rj ' D Corporation r
❑ Partnership .
Business Telephone d I Ur' Firm CO.
Name of Ucensed Plumber or Gas Fitter D E
INSURANCE COVE AGE:
I have a curve fly Insurance policy or its substantial -equivalent which meets the requirements of MGL Cit. 14Z
Yes No El g i..5,
11 you have checked yM. p::7.
cele the type coverage by checking the appropriate box `
A liability Insurance dl Other t e o . e P cYtype t Ind mnity D Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance cover'age.requlred by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement
Check one:
Owner[ Agent ❑
Signature al Owner or Owners Agent
I hereby certly that an of the details and Infermallon I have subm.IIted (or entered) In above application are true and accurals to the best of my
knowledge and that an plumbing work and Installations performed under the permit Issued for this application will be In compliance with aq
Pertinent provisions of the MSSsachU80113 Slate Gas Code and Chapter 142 of the Ge 1 Laws.
T e of License:
Alt-
Plumberna urs o ce Plumber or as Filter
Tills Gasfillor
-ilyy/Town aster License Number
v't'IMT.-IfTaiilZ , Journeyman
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Srre--113MT.,
BASEMENT
1ST FLOOR
J
2110 FLOOR
SRO FLOOR
4TH FLOOR
`
ST11 FLOOR
eTH FLOOR
TTN FLOOR
j
6TH FLOOR
Installing Company Name OW _H L e PLUM8IN Check one: Certificate #
Address BALEY_ 1r.H. Itlenm rj ' D Corporation r
❑ Partnership .
Business Telephone d I Ur' Firm CO.
Name of Ucensed Plumber or Gas Fitter D E
INSURANCE COVE AGE:
I have a curve fly Insurance policy or its substantial -equivalent which meets the requirements of MGL Cit. 14Z
Yes No El g i..5,
11 you have checked yM. p::7.
cele the type coverage by checking the appropriate box `
A liability Insurance dl Other t e o . e P cYtype t Ind mnity D Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance cover'age.requlred by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement
Check one:
Owner[ Agent ❑
Signature al Owner or Owners Agent
I hereby certly that an of the details and Infermallon I have subm.IIted (or entered) In above application are true and accurals to the best of my
knowledge and that an plumbing work and Installations performed under the permit Issued for this application will be In compliance with aq
Pertinent provisions of the MSSsachU80113 Slate Gas Code and Chapter 142 of the Ge 1 Laws.
T e of License:
Alt-
Plumberna urs o ce Plumber or as Filter
Tills Gasfillor
-ilyy/Town aster License Number
v't'IMT.-IfTaiilZ , Journeyman
f
V
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2526 Date . S� /�7.7... .. .
NpRTM
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
p
This certifies that . C/..'. D. ....... ...........
has permission for gas installation ... P !q i g .............
in the buildings of ..J ) P." -i ............. .
f ig
at ............. North Andover, Masse
Fee. SRAl Lic. No. 141". . ............. .............
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File