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HomeMy WebLinkAboutMiscellaneous - 0 SHARPNERS POND ROAD 4/30/2018 (4)1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING —� (Print or Type) Mass. Date %J 19� Permit #_ Building Location Wwner's Name Type of Occupancy New Renovation ❑ Replacement ❑ Plans Submitted:\es❑ No ` ■■■■■■■■■■■■■■■ ,\,NOON �� ■�■■■■■■■■■■ ■■ Installing Company Name yankpp r;aG & n; 1 Check one: Certificate T# Address 140 SO. Main Street CR Corporation 103c Middleton Ma. 01949 ❑ Partnership Business Telephone_ 5(18-774=27Fi0 O Firm/Co. Name of Licensed Plumber or Gas Fitter �Wi I I iam R Harris _ INSURANCE COVERAGE: I have a current liability Insurance policy or Its substantial- equivalent which meets the requirements of MGL Ch. 142. Yes 12 No ❑ If you have chtcked,yes, please Indicate the type coverage by checking the appropriate box. A ilabllfty Insurance policy ® Other type of Indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does riot have the Insurance coverage requlred by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: owner[) Agent ❑ Signature of Owner or Owner's 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 installations performed under thepermit Issued for this ap kation will ,cornpllanco with all pertinent provisions of the Massachusetts Slate Gas Code and Chapter 142 of tho Go I Laws. By T o of llconse: ��"� _.. Title ti L 1995 Plumber Signatu^ re Lc_ens© u_m e�Gas fitter Master Licens'o Number 3785 Cil /Towntter Journeyman A! C 0 MOM�� .. mom ■mom ■NOON ■■■■■Nsor.� �m • • ■■■■■■■■■■■■■ NOON■ ■ ... ■■■■■■■■■■■■ NOON■ ■ ■r .. ■NON NO■ ■■ ■ ■N■ ■ ■ ■ • • NOON ■■NNE■ r_ _ _ _ t ■ Installing Company Name yankpp r;aG & n; 1 Check one: Certificate T# Address 140 SO. Main Street CR Corporation 103c Middleton Ma. 01949 ❑ Partnership Business Telephone_ 5(18-774=27Fi0 O Firm/Co. Name of Licensed Plumber or Gas Fitter �Wi I I iam R Harris _ INSURANCE COVERAGE: I have a current liability Insurance policy or Its substantial- equivalent which meets the requirements of MGL Ch. 142. Yes 12 No ❑ If you have chtcked,yes, please Indicate the type coverage by checking the appropriate box. A ilabllfty Insurance policy ® Other type of Indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does riot have the Insurance coverage requlred by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: owner[) Agent ❑ Signature of Owner or Owner's 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 installations performed under thepermit Issued for this ap kation will ,cornpllanco with all pertinent provisions of the Massachusetts Slate Gas Code and Chapter 142 of tho Go I Laws. By T o of llconse: ��"� _.. Title ti L 1995 Plumber Signatu^ re Lc_ens© u_m e�Gas fitter Master Licens'o Number 3785 Cil /Towntter Journeyman A! C 0 iS 14 Date ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... ......... has permission for/gas installa I'll ;�— J. in the b '9ju ings ofj471-. . . . . . . . . at ................ North Andover, Ma9f. Fee. Lic. No ............. GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File