HomeMy WebLinkAboutMiscellaneous - 38 HAROLD STREET 4/30/2018r
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o= ° TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
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This certifies that r? ...................
has permission for gas installation ...%14f '�... Ile. C «A�4.?. :
in the buildings of ..
at ........... North Andover, Mass.
Fee. Lic. No...) ?...�...
/GAS INSPE..CT00' }
Check #
6778
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO n- OrrTING
(Print or Type)
A) C) ELI A►JDOVEIZ ,Mass. Date z Permit (�Q 9 Peit # � ? 7
Building Location__ 2 8 4,40 dA2 OL)^ �) Owner's NameDA► j 0' f t.I E �)
/V OR Ll A IADDkk 14A Type of Occupancy k'�SlD��1/Az �FA/'7/Ly
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New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑
Installing Company Name BAY STATE GAS COMPANY Check one: Certificate #
Address 55 MARSTON STREET X7 Corporation 1862
LAWRENCE, MA 01841-2312
❑ Partnership
Business Telephone q 7 $ — 6 8,7-110 5 Exr *306 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
INSURANCE COVERAGE:
I have s current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes R( No O
If you have checked • yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy K 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 ❑
1 hereby certify that all of the details and information I have submitted (or entered) in abo
plication are true te to the best of
knowledge and that all plumbing work and Installations performed under the permit iss f r this application will and a n��mpl ance with alimy
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S.
T e of License:
FTitle Plumber Signature of 'cense Plumber or GasGasfitterTown Master License Number
APP O IC SE O Journeyman —
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Installing Company Name BAY STATE GAS COMPANY Check one: Certificate #
Address 55 MARSTON STREET X7 Corporation 1862
LAWRENCE, MA 01841-2312
❑ Partnership
Business Telephone q 7 $ — 6 8,7-110 5 Exr *306 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
INSURANCE COVERAGE:
I have s current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes R( No O
If you have checked • yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy K 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 ❑
1 hereby certify that all of the details and information I have submitted (or entered) in abo
plication are true te to the best of
knowledge and that all plumbing work and Installations performed under the permit iss f r this application will and a n��mpl ance with alimy
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S.
T e of License:
FTitle Plumber Signature of 'cense Plumber or GasGasfitterTown Master License Number
APP O IC SE O Journeyman —
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