HomeMy WebLinkAboutMiscellaneous - 177 HIGH STREET 4/30/2018N
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Date ..� .��L.:?... .
°' TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION/
This certifies that ... ........
t
has permission for gas installation ... ....................
in the buildings of ............................
at .......#.......... North Andover, Mass.
Fee.. .U.... Lic. No.. ... ..........�V
GAS INSPECTOR
Check # C7 / )
r
6136
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
MO P�_TN A i3DN C. T2, , Mass. Date l Permit # b
Building Location 7% N 1& H ST Owner's Name J O) J C0LL ltJ_S
MOCTH AMOOVC rc-, Type of Occupancy RLS 1 D E 0T) A L —S) N6LC
G
New ❑ Renovation ❑ Replacemen X Pians Submitted: Yes[] No ❑
Installing Company Name BAY STATE GAS COMPANY Check one: Certificate #
Address 55 MARSTON STREET XJ Corporation 1862
LAWRENCE, MA 01840 ❑ Partnership
Business Telephone 7!B-68.7-1105 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
INSURANCE COVERAGE:
I have acu renntt liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy JK . 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:
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 abo plication are true and accu�te to the best of my
knowledge and that all plumbing work and Installations performed under the permit iss f r this application will n mpliance with all"
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S.
(/ i
T e of License:
Plumber Signature of this
Plumber or Gas
Title Gasfitter
Master License Number 374'5
City/Town Journeyman
APPROVED O IC SE O
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Installing Company Name BAY STATE GAS COMPANY Check one: Certificate #
Address 55 MARSTON STREET XJ Corporation 1862
LAWRENCE, MA 01840 ❑ Partnership
Business Telephone 7!B-68.7-1105 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
INSURANCE COVERAGE:
I have acu renntt liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy JK . 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:
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 abo plication are true and accu�te to the best of my
knowledge and that all plumbing work and Installations performed under the permit iss f r this application will n mpliance with all"
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S.
(/ i
T e of License:
Plumber Signature of this
Plumber or Gas
Title Gasfitter
Master License Number 374'5
City/Town Journeyman
APPROVED O IC SE O
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