HomeMy WebLinkAboutMiscellaneous - 29 Coventry Lane (2)MASSACHU's%TTS UNIFORM APPLICATIO
nint of Type) N FOR PERMIT TO DO GASFITTINQ
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Name evm�-es
New Renovation C1 ReplacemerA [I Plans SubmKted:. Yes 0 No El
Ins.talling Company
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8usInessT
Name of Licensed Plumber or Gas Fitter
Check one:
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Corp.
Ej Partnership
-t4:ftm/co.
/ AO
INSURANCE COVERAGE: ; Check one
I have a current liability Insurance policy 'or its substantial equivalent. ' Yes No 0
It you have checked "e , please Indicate the type coverage by checking the appropriate box.
A IlabIfty Insurance policy Other type of indemnity 13 Bond 0
Certificate
OWNER'S INSURANCE WAIVER: I am aware that the licenses does not bays 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:
%nature of Owner or Owner*s Agent owner 11 Agent 11
I = certify that all of the details and Information I have submitted (or entered) In abo - pl-rallon are true and accurate to the best of my
It go and that all umbing work and Installations performed under the fm ed for a application will bo -In compliance with all
pwUnent provisions of t�a Massachusetts State Gas Oode and apter 142
Twe.ettkensa: r
Title tomumber Signatuve—of Wensed PlUmber 0 tier
Ga3twer I 01%�-
aster License Number �P/11101
IA1JV
Cfty/Town :? Journeyman
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Ins.talling Company
/1,
8usInessT
Name of Licensed Plumber or Gas Fitter
Check one:
e
Corp.
Ej Partnership
-t4:ftm/co.
/ AO
INSURANCE COVERAGE: ; Check one
I have a current liability Insurance policy 'or its substantial equivalent. ' Yes No 0
It you have checked "e , please Indicate the type coverage by checking the appropriate box.
A IlabIfty Insurance policy Other type of indemnity 13 Bond 0
Certificate
OWNER'S INSURANCE WAIVER: I am aware that the licenses does not bays 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:
%nature of Owner or Owner*s Agent owner 11 Agent 11
I = certify that all of the details and Information I have submitted (or entered) In abo - pl-rallon are true and accurate to the best of my
It go and that all umbing work and Installations performed under the fm ed for a application will bo -In compliance with all
pwUnent provisions of t�a Massachusetts State Gas Oode and apter 142
Twe.ettkensa: r
Title tomumber Signatuve—of Wensed PlUmber 0 tier
Ga3twer I 01%�-
aster License Number �P/11101
IA1JV
Cfty/Town :? Journeyman
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Date ... /�?'.h ./-/./ .....
TOWN OF NORTH ANDOVER
0 PERMIT FOR GAS INSTALLATION
x
SS'C US
This certifies that../4. ..................
has permissio4c,torj gas insta6ilg6gpp .......
in the buildings of ..............
at ... North Andover, Mass.
Fee2.�..—.'.'/ . Lic. No./ ............ .............
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File