HomeMy WebLinkAboutMiscellaneous - 52 Kingston Street 52 KINGSTON STREET
210/023.0-0006-0052.S
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
'. (Print or Type)
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NORTH ANDOVER.L__, Maas. Date
Building Permit
Location S;2—,fl �H f
Owner's }+
Name �� �rrr eG,.Z,1
New ❑ Renovation ❑ Replacement Pians Submitted:. Yes ❑ No [!"r'
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tAtEMENT 3 i
IST FLOOR
IND.FLOOR I
SRD FLOOR
4TH FLOOR
STH FLOOR }
tTH FLOOR
7THFLOoR t
0TH FLOOR '
/ , Check one: CertificateInstalling Company Name l/ � l , .�' � �,�orp
Address d Partnership
'2 Ule`h ❑ Firm/Co.
Business Telephone
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE: Check one
I have a current liability Insurance policy or Its substantial equivalent. Yes R, No ❑
If you have checked_yes, pleaseIndicatethe type coverage by checking the appropriate box.
A IlablI ty Insurance policy Other type of IndemnRy ❑ gond ❑
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:
%nature of Owner or Owner's ant Owner 0—' Agent ❑
I hereby certify that all of the details and Information I have submitted(or entered)M above application are true and accurate to the best
knowledge and that an plumbing work and Installations performed under the permR Issued this application will be In compliance with oellfmy
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the ws.
Tof License:
Plumber
Title oastitter SignaluWal Licensedum er or as er
FMaster Ucense Number � 67�--
Ctty/'T0'^m ❑Journeyman
AptTio,vED(OFFICE USE ONLY)
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2349 Date...1.r.....`.?U.
pA ,ORT N 1 TOWN OF NORTH ANDOVER
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0 � `p PERMIT FOR GAS INSTALLATION
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.�, . . . . .�:�. . . . . . . . . .
This certifies that . ..
has permission for gas ' stallation 1 . . . . �.�
in the buildings of
at .' ' ),RNorth Andover, Mass.
Fee. . . .A Lic. No.. .�?, . . .
GASINSPECTOR
WHITE:Applicant CANA Y: Building Dept. PINK:Treasurer GOLD: F4*tb