HomeMy WebLinkAboutMiscellaneous - 85 MARTIN AVENUE 4/30/2018 (8)MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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I )nE'L A &O oV(—X , Mass. Permit # U ( O
Building Location ?6 MA R11 /V A VE Owner's Name P IC NA PO � l\i /l_J / CkC pc
Type of Occupancy CC SI[/z-�)ijPL
New ❑ Renovation ❑ Replacements` Plans Submitted: Yes[] No ❑
Installing Company Name BAY' STATE GAS COMPANY
Addriss 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone q 7 b- 6 8,7= 110 5
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one:
X❑ Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
INSURANCE COVERAGE:
I 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 Vis, 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:
Owner[] Agent ❑
Signature of Owner or Owners Agent
hereby certify that all -of the details and information I have submitted (or entered) in abo plication are true and accu�te 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.
By Te of License:
Plumber Signature of UcenssedP,umber or Gas
Title Gasfitter
Master License Number 374"5
Cit /Town Journeyman
AP O IC S _ O
CM
RAME
Installing Company Name BAY' STATE GAS COMPANY
Addriss 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone q 7 b- 6 8,7= 110 5
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one:
X❑ Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
INSURANCE COVERAGE:
I 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 Vis, 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:
Owner[] Agent ❑
Signature of Owner or Owners Agent
hereby certify that all -of the details and information I have submitted (or entered) in abo plication are true and accu�te 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.
By Te of License:
Plumber Signature of UcenssedP,umber or Gas
Title Gasfitter
Master License Number 374"5
Cit /Town Journeyman
AP O IC S _ O
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