HomeMy WebLinkAboutBuilding Permit # 12/6/2002 f.v
MASSACHUSETTS UNWORM APPUCATON FOR PERMYr TO DO GAS FiTHNG
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
Building Locations ' {✓ �� 5-r Permit# 3
Amount$ 3 p
Owner's Name ✓o,V& N /New Renovation❑ Renovation "' Replacement ❑ Plans Submitted
w , 0
SUB-BASEM ENT
BASEMENT
'ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4'T H. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH . FLOOR
8TH. FLOOR
(Print or type) n Ch one: Certificate Installing Company
Name, /"/� /"%Tim e 1L Corp
Address y d C/-/ ®e Ra ���-�c, � Partner.
Business Telephone 1/ 7 7 �" 'Ci Finn/Co.
Name of Licensed Plumber or Gas Fitter e;4�1046_1
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes [3' No o
If you have checked M please indicate the type coverage by checking the appropriate box,
Liability insurance policy 0` Other type of indemnity ❑ Bond 0
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 [3 Agent ❑
1 hereby certify that all of the 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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By: Signature of Licensed Plumber Or Gas Fitter
Title ❑ Plumber 4 �,_f14,A
City/Town ❑ Gas Fitter License Number
Master
APPROVED(OFFICE USE ONLY) E Journeyman