HomeMy WebLinkAboutMiscellaneous - 6 Fernview Avenue U-11 6 FERNVIEW AVENUE U-11 1
�' 210/464.7-0006-0011.0
3 51 41 Date . . .. .... �......
NORTH , TOWN OF NORTH ANDOVER
10 _.oto ,0 ti0 1
O PERMIT FOR GAS INSTALLATION {
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,SSACHUSEt
This certifies that .,�-. • • • • • • • • • •
has permission for ganstallation ; . . . . . . . . . . . . . . . .
in the buildings of .--�-.... .! . • • • • • • • • • • • • • • • • •
at . . � r ''`'�• (`'` • • • • • •, North Andover, Mass.
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Fee � . . . Lic. No..'. .`... . . . . ,z ll*,J � . . . . . . . . .
`GAS IN
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WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
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MASSA 1 APP CATON FOR PFRIVIIT DO GAS P1F1 NG
Y
'Type or print) -FARM Date , 19
NORTH AND//O �J
Building Locations LY `/? //�f�C - / Permit 9
Amount S la, 6 V
Owner's Name & _ rl
New❑ Renovation ❑ Replacement �� Plans Submitted ❑
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Sl1B -BASEM ENT
BASE ,M ENT
IS"r. FLOOR
2N D . FLOG R
3RD . FLOOR
J'r I1 . FLOOR
s'r 11 . FLO G R
6T 11 . FLOG R
7•r U . F L O O R
F1, n O R
(Print,-pr type) Check one: Certificate Installing Company
Nam( — 0 �<% ❑ Corp.
Addr fss ❑ Partner.
Business Telephone Firm/Co.
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 ves,please indicate the type coverage by checking the appropriate box.
Liability insurance policy El Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver. I am aware that the licensee does not 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:
Sienature of Owner or Owner's Agent Owner ❑ Agent ❑
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 install ns performed under Permit.Issued For this application will be in
compliance with all pertinent provisions of the vlassachu s e GasC e Chapt I.32 of th enera aws.
By: se
ignature of Licensed Plumber Or Gas Fitter
Title ❑ Plumber
CirviTuwn ❑ Gas Fitter License umoer
I taster
Journeyman
APPROVED(UFFiCF us,-ONLY) ❑