HomeMy WebLinkAboutMiscellaneous - 12 WILLIAM STREET 4/30/2018 (2)N
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Forest St.
'Mic,11ton, NIA 01949 RP\N
508) 774-2772 p . v C�
gEQ SER
FORM 4 - SYSTEM PLA PNG RECORD
Commonwealth of Massachusetts
Massachusetts
System Pumning Record
l� stem
ov--bac.
C .bO(A-- p, FC 6 + 0,+
Nate of Pumping: �- 31 —
Quantit)Pumped: Qallons
C"'1ioo1 No ❑ Yes ❑ Septic Tank: No ❑
Yes
��`stem Pumped by: CU��(`e-�
Contents transferred to: &) License #:.:
Inspector
0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0
Date.. ��/. �/- /15! .....
Z TOWN OF NORTH ANDOVER
o PERMIT FOR GAS INSTALLATION
This certifies that .... 7& . .� 7 % j.r ... �`-/..s........
has permission for gas installation ..."..............
in the buildings of ... ? f.? .....................
at .fl ,? .. ! . (l R' .......... , North Andover, Mass.
Fee.).) ..... Lic. No..� � .'!.'. �. �.� * n, ........
/ GAS INSPECTOR
Check #
%►86
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASP; TING
G
(Print � or Type)
Ndt
R.TH Mass. Date 5 Z016l Permit #
Building Location !Z WIGL/AMS S`/'. Owner's Name irtANCI)IS 09PRXAk-
W k-rg A M 66V6& , tiA Type of Occupancy ��SlDEI�TI AL - S/ F
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01841-2312
Business Telephone q (B— 6 8 7-110 5 exr *3010
Check one: Certificate #
�1 Corporation 1862
❑ Partnership
❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
INSURANCE COVERAGE:
I have a current liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy 1K 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:
Signature of Owner or Owner's Agent . Owner❑ Agent El
I hereby certify that all of the details and information I have submitted (or entered) in above pplication are true and accute to the best of my
knowledge and that all plumbing work and installations performed under the permit issu f r thZ.=
liance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s.
By T e of License:
Plumber Signature of Licensed Plumber or Gas
Title .4Gasfitter
Master License Number 374-5
City/Town Journeyman
APPROVED OFFICE USE ONLY)
MEN'
KNEE
MIR
ME
iue
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01841-2312
Business Telephone q (B— 6 8 7-110 5 exr *3010
Check one: Certificate #
�1 Corporation 1862
❑ Partnership
❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
INSURANCE COVERAGE:
I have a current liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy 1K 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:
Signature of Owner or Owner's Agent . Owner❑ Agent El
I hereby certify that all of the details and information I have submitted (or entered) in above pplication are true and accute to the best of my
knowledge and that all plumbing work and installations performed under the permit issu f r thZ.=
liance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s.
By T e of License:
Plumber Signature of Licensed Plumber or Gas
Title .4Gasfitter
Master License Number 374-5
City/Town Journeyman
APPROVED OFFICE USE ONLY)
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