HomeMy WebLinkAboutMiscellaneous - 69 ELM STREET 4/30/2018 -69 ELM STREET
210/055.9-0007"0000.0 r
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HORT1y
Of .ao ,ti0
o? °� TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
SACHUSES
This certifies that . . . . . 5. . .
has permission for gas installation
in the buildings of . . .SC rvevl�/''
at . . .�� /. .-
. . . . . . . . . . . . , ,ort An ver, Mass.
Fee Lic. No.
GAS INSPECTOR
Check# O 7✓
01 5 4 ,,M-
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF;TTING
(Print or Type)
Mass. Date Permit #
Building Location (09-7� ELYI ST. Owner's Name_GWzCy6 $CH2L(EA rim,
" WMA ANONC , HA Type of Occupancy FAHI
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑
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SUB-8SMT.
BASEMENT
I ST FLOOR
2ND FLOOR
3RD FLOOR _
4TH FLOOR
ON STH FLOOR
M
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name_COLUMBIA G&S GF MASSACHU561Ts Check one: Certificate #
Address 55 MARSTON STREET XJ Corporation 1862
LAWRENCE, MA 01841 - 231Z ❑ Partnership
Business Telephone 9 7 8-691- 640 6 - ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
INSURANCE COVERAGE:
I have a current liability insurance❑ policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No
If you have checked Vis, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy P< 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 pplication are true and accur4te 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. (/
T e of License:
Plumber Signature of Licensed Plumber or Gas
Title Gasfitter
Master License Number 374 5
City/Town Journeyman
APPROVED (OFFICE USE ONLY