HomeMy WebLinkAboutMiscellaneous - 416 WAVERLY ROAD 4/30/2018Date. :31�4.d ....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation < .......................
in the buildings of .......................
at ...... North Andover, Mass.
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IN
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6348
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 2/
(Print or Type) ��))
?JCSkT A fJD6Z 6Z , Mass. Date
Permit # (o
Building Location U16" WAUCRLY KD Owner's Name_ KIMV 8 GnP�6>zi OF A►�l� r.
"" .. °•f NOLL Aon nycz M�1 Type of Occupancy_ XC- 51df-0 M'L- -5/ LtGE
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑
..
Installing Company Name BAY STATE GAS COMPANY Check one:
Addr6ss 55 MARSTON STREET X7 Corporation
LAWRENCE, MA .01840 ❑ Partnership
Business Telephone q 71B-68,7-'1105 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Certificate #
1862
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked Ye, 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'sAgent owner[] Agent ❑
I hereby certify that all of the details and information 1 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 mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene i
T e of License:
Plumber Signature of Licensed Plumber or Gas
Title Gasfitter
City/Town Master License Number
Journeyman
AP O IC SE O
MEN
Ron
100100100100101010
SEEN
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MEN
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son
Installing Company Name BAY STATE GAS COMPANY Check one:
Addr6ss 55 MARSTON STREET X7 Corporation
LAWRENCE, MA .01840 ❑ Partnership
Business Telephone q 71B-68,7-'1105 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Certificate #
1862
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked Ye, 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'sAgent owner[] Agent ❑
I hereby certify that all of the details and information 1 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 mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene i
T e of License:
Plumber Signature of Licensed Plumber or Gas
Title Gasfitter
City/Town Master License Number
Journeyman
AP O IC SE O
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