HomeMy WebLinkAboutMiscellaneous - 72 BLUE RIDGE ROAD 4/30/2018wt
Date....�'l ..14- r!w... .
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TOWN OF NO yddarl ANDOVER
;. -Y 1*1 PERMIT FOR GAS INSTALLATION
This certifies that .... '. :-... .,..t .... ..' . r
has permission for gas installatio .! - �.t :............... .
in the buildings of .. , �- .:.. n : .: n.. ...................
at......
North Andover, Mass.
Fee.?.:....... Lic. No...?G`�.�' �. �,.... �. -,ter.:......... .
/ GAS INSPECTOR
Check 76 d
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5755
MASSACHUSETTS UNIFORM APPLICATIGN FOR PERMIT TO DO GASFITTING
(Print or Type)
i1tp�,pXj� �4rv►�w✓_� , Mass. Date JD 20 Permit #����
Building Location 72 i3%iii !L,!l Owner's Name�%e� LI�✓�[vc,
Telephone yi 2�-3 Type of Occupancy
New ❑ Renovation ® Replacement El Plans Submitted: Yes E] No[]
Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate
Address 100 Myles Standish Blvd., Suite 101 X❑ Corporation 132 C
Taunton, MA 02780 Partnership
Business Telephone (800) 822-1300 Manager -Bob Olander X8055 Firm/Co.
Name of Licensed Plumber or Gasfitter William Kent Corson (800) 822-1300 X8051 Cell (508) 294-6660
INSURANCE COVERAGE: EnergyUSA Propanes Inc:
has a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142.
Yes D No ri
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
liability insurance policy X❑ Other type of indemnity Bond
NNER'S INSURANCE WAIVER: I am aware that thelicerisee does not have the insurance coverage required by
iapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner F-1 Agent
of Owner or Owner's
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and
accurate to the best of my knowledge and that all plumbing -work and installations performed under the permit
issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Code
and Chapter 142 of the General Laws.
-Type of License:
By a.Plumber
Title Gasfitter
City/Town X❑ Master
APPROVED (OFFICE USE ONLY) r1journ,eyman
Signature of Licensed Plumber or Gasfitter
License Number 3707
ONEOMM
MM .. -
■■■■■■®■■■■■■■■■■■■■■■■■■■
mm .. -
■■■■■■■■■■■■■■■■■■■■■■■■■■
Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate
Address 100 Myles Standish Blvd., Suite 101 X❑ Corporation 132 C
Taunton, MA 02780 Partnership
Business Telephone (800) 822-1300 Manager -Bob Olander X8055 Firm/Co.
Name of Licensed Plumber or Gasfitter William Kent Corson (800) 822-1300 X8051 Cell (508) 294-6660
INSURANCE COVERAGE: EnergyUSA Propanes Inc:
has a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142.
Yes D No ri
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
liability insurance policy X❑ Other type of indemnity Bond
NNER'S INSURANCE WAIVER: I am aware that thelicerisee does not have the insurance coverage required by
iapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner F-1 Agent
of Owner or Owner's
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and
accurate to the best of my knowledge and that all plumbing -work and installations performed under the permit
issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Code
and Chapter 142 of the General Laws.
-Type of License:
By a.Plumber
Title Gasfitter
City/Town X❑ Master
APPROVED (OFFICE USE ONLY) r1journ,eyman
Signature of Licensed Plumber or Gasfitter
License Number 3707
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