HomeMy WebLinkAboutBuilding Permit # 12/28/2005 A/WSSACHUSMS UNNORM APPUCATON FOR P TO DO GAS WrING
(Type or print) Date ZIA Jy ...
NORTH ANDOVER, MASSACHUSETTS
A�!'). ' ,�d / r%a ,.Permit#
Building Locations Amount$ L
Yx
Ower's Name
a
Replacement�`�< ���°"'� Plans Submitted
New Renovation ® P
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El
H z H ® ® E� UU O vFi
SUB -BASEM ENT
BASEMENT
1ST . FLOOR
2ND . FLOOR
3RD . F L O O R
4TH . FLOOR
5 T H . F L O O R
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
Check one: Certificate Installing Company
(Print Or type)
Name /; " ✓ ti fir' rg Corp.f�
Address
o , 4r a, El Partner.
Business Te ep one , , .`"m
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent.
Yes No
If you have checked yes,please indicate the type coverage by checking the appropriate box. Bond
Liability insurance policy10
Other type of indemnity
Owner's Insurance Waiver: I am aware that the licensee does nal 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 13 Agent
i 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.
Signature of Licensed Plumber Or Gas Fitter
BY: Plumber V,.—Y.3
Title Gas Fitter icense Number
City/Town Master
Journeyman
APPROVED(OFFICE USE ONLY)
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