HomeMy WebLinkAboutMiscellaneous - 21A BALDWIN STREET 4/30/2018Date ......
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TOWN OF NORTH ANDOOZVER
GAS INSTALLATION
PERMIT FOR
AC H
This certifies that . . /?Av./. . r.-�6�A ... . ...........
has permission for gas installation
in the buildings of . .�k
at f3Pe 1----�-North Andover, Mass.
Fee.
S* 'IN* S'PECTOR;p
Lic. No.7.?Y.).-. .
Check # 313.(/
6224
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
JJOR7 H A Q 00VE IZ , Mass. Date / 8Z 7 Permit # 2 2
Building Location % d/f!, 23g --3Q t34LW11 Si Owner's NameMW) Atj)90\je L NSC /UTfl.
Type of Occupancy If FSIQQJTI�I
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone q 7 !B-6 8,7—'l 10 5
Name of Licensed Plumber or Gas Fitter - Francis X. Corkery
Check one:
XJ Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
INSURANCE COVERAGE:
I have a�ceusrrenntt liability insuranceEl policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
No
If you have_checkedYe, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy X( . 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 Owner❑ Agent ❑ s Agent ,
I hereby certify that all of the details and. information I have submitted (or entered) in abo plication are true and accur to to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mplianoe with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene (j
ey T e of license:
Plumber Signature of cen Plumber or Gas
Title Gasfitter
Master License Number 3%4"Jr
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SUB—BSMT.
BASEMENT
-I
1 ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
I—dl
7TH FLOOR
STH FLOOR
H
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone q 7 !B-6 8,7—'l 10 5
Name of Licensed Plumber or Gas Fitter - Francis X. Corkery
Check one:
XJ Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
INSURANCE COVERAGE:
I have a�ceusrrenntt liability insuranceEl policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
No
If you have_checkedYe, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy X( . 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 Owner❑ Agent ❑ s Agent ,
I hereby certify that all of the details and. information I have submitted (or entered) in abo plication are true and accur to to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mplianoe with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene (j
ey T e of license:
Plumber Signature of cen Plumber or Gas
Title Gasfitter
Master License Number 3%4"Jr
City/Town Journeyman
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