HomeMy WebLinkAboutMiscellaneous - 1875 Salem Streets
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NpRTTOWN OF NORTH ANDOVER
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PERMIT FOR GAS INSTALLATION
9
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This certifies that
has permission for gas installation
in the buildings of..`��7'.�:�............................
at ............. North Andover, Mass.
Fee .. Lic. No..� ........
GAS INSPECTOR`
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
a
instailir.g
Mass. Date C-(1c�� Pe.^'^it � �� ( ��n r
Eu/ilbirg Location Cwner's Name
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mp-:ry Name tpr"'-y ie. - e ZP
Eusiress Te!ephcneIF %y—�Cj 3
Name of Lce.1 1 fur,;bel or Cas rr'er �' �It k
Check one:
C Cor;:craticn
r Farnersi;ip
Certi nate
INSURANCE COVERAGE:
I have a curent liability insurance polio;( cr its substantial equivaier� which meets the re:,uire^eats of MGL Ch. 142.
Yes ❑ No 17
If you have checked yes, please irdicate the type coverage by checking the appropriate box.
A liability insurance policy Q Cther type of indemnity ❑ Eer,d C3
OWNER'S INSURANCE WAIVER: I am aware that the licensee rices nct have the insurance cover -ace 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 Cwner's Agent Owner❑ Agent ❑
hereby cer',i;y that all of the details and information I have submitted (or entered) in above app!icaticn are true and accurate to the best of my
krcwledg3 and that ail plumbirg ',York and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen I Laws.
Tme of License:
Title Plumber Signature of Licensed P umber 45r Gas Fitter
Gasfitter r
Cityrcwn Master License Number
O r! U c ONLY Journeyman
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Eusiress Te!ephcneIF %y—�Cj 3
Name of Lce.1 1 fur,;bel or Cas rr'er �' �It k
Check one:
C Cor;:craticn
r Farnersi;ip
Certi nate
INSURANCE COVERAGE:
I have a curent liability insurance polio;( cr its substantial equivaier� which meets the re:,uire^eats of MGL Ch. 142.
Yes ❑ No 17
If you have checked yes, please irdicate the type coverage by checking the appropriate box.
A liability insurance policy Q Cther type of indemnity ❑ Eer,d C3
OWNER'S INSURANCE WAIVER: I am aware that the licensee rices nct have the insurance cover -ace 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 Cwner's Agent Owner❑ Agent ❑
hereby cer',i;y that all of the details and information I have submitted (or entered) in above app!icaticn are true and accurate to the best of my
krcwledg3 and that ail plumbirg ',York and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen I Laws.
Tme of License:
Title Plumber Signature of Licensed P umber 45r Gas Fitter
Gasfitter r
Cityrcwn Master License Number
O r! U c ONLY Journeyman