HomeMy WebLinkAboutGas Fitting Work MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY North Andover MA DATE 6/2/2014 PERMIT# �
JOBSITE ADDRESS 325 Abbott St OWNER'S NAME Bob Corcoran
OWNER ADDRESS 9 Whitney Rd N Andover TEL 617-512-3967 1 FAX 0
OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL ]
TYPE OR
PRINT NEW: ® RENOVATION:® REPLACEMENT: ® PLANS SUBMITTED: YES E] N0=
' CLEARLY
APPLIANCES -a FLOORS — BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
-
COOK TOP
DIRECT VENT HEATER
DRYER
FIRE PLACE
FRYOLATER
FURNACE
GENERATOR
GRILL
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT FT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
Ti.ST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
GAS PIPING FOR 500 GAL UG LP TANK x _.. �
INSURANCE COVERAGE -SEI
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES XQ NO
IF YOU HAVE CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X❑ OTHER TYPE INDEMNITY [] BONDEJ
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the ;
Massachusetts General Laws and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ® AGENT ❑ -M
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true andLa rate to*e best my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in ce with all Perti rovision of the
Massachusetts State Plumbing Code and Chatper 142 of the General Laws
PLUMBER-GASFITTER NAME I Timothy Surdam LIC #. 0 -J SIGNATURE
MP ® MGF❑ JP[—] JGFX❑ LPG]❑ CORPORATION X❑# 164 PARTNERSHIP ❑#OLLC ®#
COMPANY NAME: Lorden Oil Co Inc ADDRESS: F777 69 Fitchburg Rd,PO Box 669
CITY: Ayer STATE: ® ZIP 1432 TEL: I 978-772- 000
FAX: 978-772-5956 CELL: EMAIL:
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