HomeMy WebLinkAboutMiscellaneous - 75 Bonney LaneMASSACHUSETTS UN FORM APPUCATON FOR PERNIN TO DO GAS FITTING
(Type or print) Date Z(�
NORTH ANDOVER, MASSACHUSETTS
Building Locations
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Owner's Name
Permit #
Amount $
I Renovation Replacement Plans Submitted
:
1r
7—ND. FLOOR
(Print or type)( `� /J C e one: Certificate Installing Company
Name_ /a%' J J 14 /���1 �•?it�_ / � Corp.
Address , y � n F6 2 ' l❑ Partner.
BusinessTelephone ® 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 0-1*' No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box. 13Liability insurance policy �' Other type of indemnity 13Bond
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:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information t nave suom ttea kor entereu) in aoove appncanon are true auu at wrau: to utc
best of my knowledge and that all plumbing work and i Ilations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mass h ettsS to Gas Code,4nd ChapteY42 of th neral Laws.
By:
Title
City/Town
OVED (OFFICE USE ONLY)
S>'gnature of Licedssed Plumber Or Gas Fitter
P.a 1lumber 90 3
❑ Gas Fitter License um er
aster
Journeyman