HomeMy WebLinkAboutMiscellaneous - 80 Kingston Street3325 Date...%� ..'.'....... .
NORTN TOWN OF NORTH ANDOVER
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PERMIT FOR GAS INSTALLATION
9
This certifies that ... x � ....`'..:..... f�i . f.. .
has permission for gas installation ... .............
in the buildings of .... ( .............. ........ .
at ...."P.Z. / �( '/x-* s s /L N. . . . . ..... , North Andover, Mass.
Fee. Lic. No... �S .`;,3. . ..........................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
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MASSACHUSETTS UNI FORM APPLICATON FOR PERMIT TO DO GAS FITTING
-Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations L' C� L".-"�
New ❑ Renovation ❑
/ / /Z 1 19 �, C�
Permit 9 313 2J
Amount S 111) �11i
Owner's Name �t_G 2-c(C ic-e
Replacement 0-- Plans Su miffed ❑
to
(Print or rypc)./I
\lame
Address
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
Business Telephone ��� .- ZrJ 'Firm/Co.
Name of Licensed Plumber or Gas Fitter Lc)
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes � No ❑
If you have checked ves,please :nd' ate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ Bond ❑
Owners 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 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 M- assachus tts ..tate G•_ Code and C pter 142 the Gena�Laws.
By:
Title
City/Town
IAPPRO` ED wi,i--icF. [ISE ONLY)
V71
Signature of Licens Plumber Or Gas Fitter
lumber AU 5 C—
❑ Gas Fittericensei oer
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❑1 Journeyman