HomeMy WebLinkAboutMiscellaneous - Exception (538)Date...... .........
�� .oto ,e 'ryO -
3? �a� TOWN OF NORTH ANDOVER
o s PERMIT FOR GAS INSTALLATION
This certifies that .,lf.(�.� Viz. S .%.. 4. �� ............... .
has permission for gas installation ....1). � .....................
in the buildings of .../� / f� .� . c /A. � ........................ .
at .................................. . North Andover, Mass.
Fee ... tf ... Lic. No.. ! ....... ..... 't, ..... .
GAS INSPECTOR
Check # / t,, >' 1
4413
N,&r vu -r Ri iN o i Yo—r X31 ��
MASSACHUSETTS UNIFORM APPLICATON FOR�P TO DO GAS I+MING
(Type or print) Date -,? -3, 0
NORTH ANDOVER, MASSACHUSETTS
Building Locations
#`i �-7
A;/ 0 c r @ 9230 /-S Z/41/ -r- / / Permit # 'Y((0
&f Amount $ Vy "iz
Z-L"Igni &Z:Z Owner's Name �� 3
New F Renovation Replacement Plans Submitted
(Print or type)' / / p C® one: Certificate Installing Company
Name ✓ � (tet A6 ! Sq 1,VAA _ .lav C . Corp
Address 1 _/ -Z -S7G AJ` T -,P'��cle- L I I ElPartner.
Business Telephone 9 ;7,F_ ?3 F- a o _3 y 1:1 Fim/Co_
Name of Licensed Plumber or Gas Fitter
R
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 Noo
Ifyou 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 0 Agent 0
t nerevy cernty that an of the aetans ana tntormanon t nave suvmIrtea (or entema) m 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 Massachusetts Staj�';as CoemqVhapter 142 ofthe General Laws.
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;OVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber
® Gas Fitter License Nlumber
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Journeyman
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