HomeMy WebLinkAboutMiscellaneous - 174 Foxwood Lot 32y" U1711IruriNi APPLICATION FOR PERMIT TO DO GASFITTING
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,Maas. Date 1 19
Suliding
Locations —� `7 Permit
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Owner's
Name`J�-'
New Renovation ❑ Replacemerrt ❑ Plans Submftted: Yes No
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SASIEMENT
IST FLOOR �
21413. FLOOR I
3R5 FLOOR
4TH FLOOR
!TH FLOOR
4TH FLOOR r
7TH FLOOR t
0TH FLOOR
Check one:
Certificate
installing Company Name Vli. ` r. h S Q •
Address � • o . 3 zy— [ iU>r
d Partnership
IM IA 7) i We 3 f
i ❑ Firm/Co.
Business Telephone
Name of Ucensed Plumber or Gas Fitter s> >_ v-9-
'INSURANCE COVERAGE: Check on
I have a current liability, Insurance policy or its substantial equivalent. Yes t No ❑
If you have checked Yes, please Indicate the type coverage by checking the appropriate box
'A Ilablifty Insurance policy Other type of Indemnity O Bond ❑
'.OWNER'S INSURANCE WAIVER: IL am aware that the Ilcensee does not have the Insurance coverage 'requlred by
(Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
%natura of Owner or Owner's Agulit Owner ❑ Agent ❑
I hereby cartify that ati of the details and Information 1 have submitted (or entered) In above application are true and accurate to the best of my
'knowledge and that all plumbing work and Instailatlons performed under the permit Issued for this application will be In compliance with all
p*M"nl provisions of the Massachusetts State Gas Gbde and Chaplet 142 Of aha GWPW La
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nse:
Title na urs o nae um er or as er
IN
Ctty/Tovm license Number
Master
G
K. TTIOWD (OFFICE USE ONLY)
3 TD2304 Date ......
NORTH 1TOWN OF NORTH ANDOVER
pF i��ao ,"tiO
PERMIT FOR GAS INSTALLATION
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This certifies that ..6.?A./1.n. fk �.f
has permission for gas installation ....!
in the buildings of ...% . ! . r ....................... A
y �-Y,� c ~
at . %. �. .. F ......... ........... N�Andover, Masi
Fee. .7 ' . Lic. No./ b 3.
AS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File