HomeMy WebLinkAboutMiscellaneous - 15 Holly Ridge i
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTI '
(Print or Type)
NORTH ANDOVER Mass. Date c
s ` kuilding Location r,5 /IOZ4y A r dp Permit #
• Owners Name -&/ower
• P New renovation D Replacement Plans Submitted
FIXTURES
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1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
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(Print or Type) Check one: Certificate
Installing Company Name�fiWdtT "-.-- pj"es }(��7`� �] Corp.
Address �yy�� 1"Ld,- 03o3f1 Partner.
[Z��/Co.
Business Telephone:CL0 ) yam— 2 T�//
Name of Licensed Plumber or Gas Fitter sor -a-
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy6]--`6`i`her type of indemnity 0 Bond
Insurance Waiver: 1 , the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 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 iueed for this application will-be-in compliance with all pertlnent
provisions of tho Massachusetts State Gas Code and Chapter 142 of tho General Laws. -.
By TYPE LICENSE:
Plumber
Title Gasfitter Signature. of Licensed
Cit /Town' Ma er P1 ber r Gasfitter
Y Q,)
carne man
Y
2
APPROVED (OFFICE USE ONLY) --License Number .
Date. . . . . . . .. ...'!. .
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NpRTM TOWN OF NORTH ANDOVER
pF .ao 1tip
F? PERMIT FORitP&NSTALLATION
�9SSACHUSESt
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This certifies that . . . .
/ J y
has permission for gas installatfion`���.!,,/.r.:. t:'. .: . ... . . . . . . .
in the buildings of . .
at /x.1.14 . .e. . . .t:,. : , North Andover, Mass.
Fee. x ✓v Lic No >. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .
(3 j/ 4 1`- � � GAS INSPECTOR
WHITE:ApplicantjC' GAW*RY-9uilding Dept. PINK:Treasurer GOLD: File