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HomeMy WebLinkAboutMiscellaneous - 88 ELM STREET 4/30/2018N pO_ A w co N m O � O O O � m m om --1 o � o f Date .. 4�/Z......... r-5 ,vae OL TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................ . has permission for gasinstallation in the buildings of ...7/7/ at .. .. 6!m . ST... . Fee.. . Lic. No..'V�6.. . Check # YO ?-�'3 8123 iN7rth�,' doves, ass. ....... .......... GAS INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) G 0 «/ C NORTd AMPOJEL , Mass. Date 0 012 Permit # Building Location_IR59 S� Owner's Name C biJ IKAr1Lf S1 m � n f Oth d A N10Q2(2, . MA Type of Occupancy 3 IFS IL� New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑ ✓ftp Installing Company Name COLUMBIA CIAS GF MASSACHUSETTS Check one: Certificate # Address 55 MARSTON STREET X7 Corporation 1862 LAWRENCE, MA 01841-2312- ❑ Partnership Business Telephone 9 7 8' 69) " 640 6 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have aYes Srrenntest liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. No 0 If you have checked Vis, please indicate the type coverage by checking the appropriate box. A liability insurance policy K 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: 'i Signature of Owner or Owner's Agent , Owner❑ Agent El 1 hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accurte to the best of my knowledge and that all plumbing work and installations performed under the permit a-= liance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of tVhe Ge By T e of License: Plumber Signature of Licensed Plumber or Gas axy- Title Gasfitter Master license Number 374-5 City/Town Journeyman APPROVED OFFICE SE ONLY 1 w • • • moon ISO Installing Company Name COLUMBIA CIAS GF MASSACHUSETTS Check one: Certificate # Address 55 MARSTON STREET X7 Corporation 1862 LAWRENCE, MA 01841-2312- ❑ Partnership Business Telephone 9 7 8' 69) " 640 6 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have aYes Srrenntest liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. No 0 If you have checked Vis, please indicate the type coverage by checking the appropriate box. A liability insurance policy K 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: 'i Signature of Owner or Owner's Agent , Owner❑ Agent El 1 hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accurte to the best of my knowledge and that all plumbing work and installations performed under the permit a-= liance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of tVhe Ge By T e of License: Plumber Signature of Licensed Plumber or Gas axy- Title Gasfitter Master license Number 374-5 City/Town Journeyman APPROVED OFFICE SE ONLY v a 0 0 .. a m N N ' z v -a o . z D n In m m D a• v � m 0 ,n G7 C r o z Q A m D m -� r 0 z m 9{ O O m a v Z o � A -4 c O N o Z • •z Q v a 0 0 .. a m N N ' z v -a o . z Date 8923 CN This certifies that has permission to perform A. .................. 7 /7 . ................ plumbing ' in the buildings of at. . r7w .............. No h Ando a SS. FeeO ..... Lic. No.. J0.S0 PLUMBING INSPECTOR Check TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING . o44r- CN This certifies that has permission to perform A. .................. 7 /7 . ................ plumbing ' in the buildings of at. . r7w .............. No h Ando a SS. FeeO ..... Lic. No.. J0.S0 PLUMBING INSPECTOR Check MX MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print Type) Mass: DateAk Permit # Bugding Location 0 �o G / f'I S Owner's Name �r/4/J k)j �///f /�/,� Type of Occupancy. mss% D FA)// X 2 - New 0 Renovation ❑ Replacement Pians Submitted: Yes ❑ No FIXTURES Instaigng Company Name BRADFORD PLUMBING & Check one: Adilress HEATING MECHANICAL INC. Lic. #12580 Tel. #(978) 521-0262 )gf-Corporation P.O. Box 5269 ❑ Partttersf>i Business Telephone BRADFORD, MA 01835 0269 P - - - - - ❑ FtmVCo. Name of Licensed Plumber lf�i !//rs Z) A( I /-/? Certificate INSURANCE COVERAGE: I have a cu erg liabilityns ra ce mercy or Its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked res, please indicate the type coverage by, checking the appropriate box A liability insurance policy. 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 requlremeni Check one: Senxturo ni lla.or nr ll.,..nr'. Msw* - Owner •O Agent ❑ I nereoy cerury mat all 01 me detals 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 Plumbing Cod and Chapter 142 of the General Laws. BY &gn re of U used Plumber Title Type of Ucense: MasterV Journeyman YAPPFiWED (OFF{CE USE ONLYI license Number = a z N ar 6A J ._ fA O 2 F it, cr! W Y j fA �- H := a W ui s . IA T C W fA d_ QW C z Q •W C Uj < W p < dl °' S O 1L W Z F ( W C p .� J to C d J p < p AL C .s z p -+ oo vs < x r'c z W a tW. s 0 o. x v W x i Y m c o 3 e- w e. o a< 3¢ m o sue—esMT. BASEMENT 1ST FLOOR 214D FLOOR I 3RD FLOOR -4TH'FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Instaigng Company Name BRADFORD PLUMBING & Check one: Adilress HEATING MECHANICAL INC. Lic. #12580 Tel. #(978) 521-0262 )gf-Corporation P.O. Box 5269 ❑ Partttersf>i Business Telephone BRADFORD, MA 01835 0269 P - - - - - ❑ FtmVCo. Name of Licensed Plumber lf�i !//rs Z) A( I /-/? Certificate INSURANCE COVERAGE: I have a cu erg liabilityns ra ce mercy or Its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked res, please indicate the type coverage by, checking the appropriate box A liability insurance policy. 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 requlremeni Check one: Senxturo ni lla.or nr ll.,..nr'. Msw* - Owner •O Agent ❑ I nereoy cerury mat all 01 me detals 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 Plumbing Cod and Chapter 142 of the General Laws. BY &gn re of U used Plumber Title Type of Ucense: MasterV Journeyman YAPPFiWED (OFF{CE USE ONLYI license Number w a . Z N N - ul Q O - cc 1 c CL Ti d - r 04/13/2011 13:30 19785212751 ANTHONY&MALCOLM INS PAGE 02/03 �-W CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DaNyyy) PRODUCER (978)3F3 -S623 FAX 04/13/2011 (978) 521-27$1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ANTHONY & MALCOLM INSURANCE AGCY-. INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3 SO. CENTRAL ST. PO BOX 5128 HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR BRADFORD, MA 01835 ALTER THE COVERAGE AFFORet=n tav rue enr'rwr�.. INSURERS AFFORDING COVERAGE NAIL # BRADFORD PLUMBING &HEATING MECHANICAL, INC. INSURER A: Hanover Insurance PO BOX 5269 BRADFORD, MA 01835 INSURERS: Travelers INSURER C: -"sURER D; ��—I INSURER E; THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE: POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSfONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR DD' iTPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION GENERAL UA COMMERCIAL OWN614942410 06/01/2010 06/01/2011 EACH OCCURRENCE LIMITS COMMERCIALGENC;RALLIASIITTY S 2,000,001 CLAIMS MADE,DAMAGE TOREN ED X OCCUR 'An S A MED 300, 001 EXP 'An Town of No. Andover Inspectional Services 1600 Osgood St. No. Andover, MA 01845 wVRY 'Co (ZVU1/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIE3 BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 GAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTR 04 REPRESENTATIVES. At1THQRIZE0 REPRESENTATIVE Frederick Malcolm Jr./JA I*ACORD CORPORATION 1988 _ Y one Person) E 1S PERSONAL 8 AOV INJURY S 2 000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE a 4,000 POLICY jECT LOC PRODUCTS - COMPIOP AGO S 4,000 AUTOM091L.EUABILRY ANY ADN803637704 06/19/2010 06 19 2021 / / AUTO COMBINED SINGLE LIMIT OTHER THAN EA ACC ALL OWNED AUTOS ) 4 A X SCHEGULEDAUT'OS BODILY INJURY S X MIRED AUTOS IPerpernen) S SOO i X NON -OWNED AUTOS BODILY INJURY 1 00( A (Per m alllent) S S 1 OO( Soo. Town of No. Andover Inspectional Services 1600 Osgood St. No. Andover, MA 01845 wVRY 'Co (ZVU1/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIE3 BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 GAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTR 04 REPRESENTATIVES. At1THQRIZE0 REPRESENTATIVE Frederick Malcolm Jr./JA I*ACORD CORPORATION 1988 PROPERTY DAMAGE GARAGE LIABILITY (Per accltlent) S 251 ANY AUTO AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC S EXCESSIUMIMLLA UABILTTYOH X N614942410 06/01/2010 06/10/2011 AUTO ONLY: ASG S OCCUR CLAIMS MADE Q EACH OCCURRENCE d 1 00( A AGGREGATE S 1 OO( DEDUCTIBLE f RETENTION SWORKE S COMPENSATION AND EMPLOYERS' EMPLOYER$' LIABILITY 7P]UB81OK648010 08/10/2010 08/10/2011 WC STATU- B ANY PROPRIETOVARTNER/EXECUTlVE 0TH• OFFICER/MEMBER aXCLUOE09 dwC SPECIALPROVISIDNS EyCIAneRO-ISIO E.L. EACH ACCIDENTg, E.L. DISEASE S 500 bNew -EA EMPLOYE t SOO OTHER E.L. DISEASE. -POLICY LIMrr S 5OO DEBCRIPTfON OP QpEgAT10NIS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSF,MENT J SPECIAL PROVISIONS plumbing & Heating C Town of No. Andover Inspectional Services 1600 Osgood St. No. Andover, MA 01845 wVRY 'Co (ZVU1/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIE3 BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 GAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTR 04 REPRESENTATIVES. At1THQRIZE0 REPRESENTATIVE Frederick Malcolm Jr./JA I*ACORD CORPORATION 1988 375 6 U Date ..?.. :... C :! ....... / pORTN1 TOWN OF NORTH ANDOVER "'&o '& o '6'6 e OpL PERMIT FOR GAS INSTALLATION P a This certifies that ., !../.. E..:.:.....,'.. r:!r. �:'...... . has permission for gas installation .. ! ....... ................... in the buildings of ...... ................................... at .......: ... r. '.:.:.....`........... , North Andover, Mass. Fee......... Lic. No........... ............ :......... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer a.::- t,...: -r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) J ��� �,f /& ���ivvY`�Mass. Date / t �`� 19 Permit # G W • Building Location 79' loo- Owner's Name Type of O panty New C3 Renovation E]ReplacemeT C3 Plans Submitted: Yes❑ No Installing Company Name wc- Check one: Certificate Address A /1- 1 ❑ Corporation „!�� �: ❑ . Partnership Business Telephone �o �(����% _ ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability insurance icy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes L1 No If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy ❑ 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 th ass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ $TaMITTre of Own Owner's Agent 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 wi a in compliance with all rtinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General T)s�e of License: Plumber Signa re of Licensed Plumber or Gas Fitter Title City/Town APPROVED (OFFICE USE ONLY) Gasfi r er license Number umeyman N N ¢ W N Y 2 ¢ N N W ¢ WN. N ¢ ¢ O O V m N t 2 h S n O J ¢ Uj i.- <f } z z O F' u¢r z o W < W ¢ W ¢. O O d ¢ < N tL N O V W = N W < O O _ W WW W z a = ¢ S V ¢ O W > U. W 4- V J y 1.. ¢ W z 4 Z. O O W W O al ' F- 4 W > W Z BASEMENT 1ST FLOOR I 2ND FLOOR 3RD FLOOR I I 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR I+ 1 STH FLOOR Installing Company Name wc- Check one: Certificate Address A /1- 1 ❑ Corporation „!�� �: ❑ . Partnership Business Telephone �o �(����% _ ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability insurance icy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes L1 No If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy ❑ 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 th ass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ $TaMITTre of Own Owner's Agent 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 wi a in compliance with all rtinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General T)s�e of License: Plumber Signa re of Licensed Plumber or Gas Fitter Title City/Town APPROVED (OFFICE USE ONLY) Gasfi r er license Number umeyman N2 4710 Date ............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that �`�. (. � .� �'.� `-:... .............. has permission to perform ...... r ...................... plumbing in the buildings of ... L .............. . .r at ...cT s. . r.oj...... ............. , North Andover, Mass. Fee. ..... Lic. No.. ... ........ .. ' ..... ...... . PLUMBING INSPECTOR Check # f WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Ld MASSACHUSETTS UNIFORM APPLICATION FOR RMI TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS p Date Building Location 00 O e% 5T Owners Name Agi�l%l 5�9�'%�Sd ° Permit # Amount tIA1,'�e' Jr- Type of Occupancy Owe New Renovation Replacement ® Plans Submitted Yes No FIXTURES (Print or type) Check one: Certificate Installing Company Name //*//0/1 Corp. Address 0. 13 o X 5"7Z- Partner. L�w�tt�« err¢ Old yL- Business Telephone 9/f Firm/Co. Name of Licensed Plumber % s4 -c W14 /lo 1? /fy Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box Liability insurance policy [a Other type of indemnity 11 11 ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature . Owner Agent 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stat]>mbing Code and Chapter 142 of the General Laws. Type of Plumbing License aY933 icense Number-- Master F1 Journeyman M VED (OFFICE USE ONLY • (Print or type) Check one: Certificate Installing Company Name //*//0/1 Corp. Address 0. 13 o X 5"7Z- Partner. L�w�tt�« err¢ Old yL- Business Telephone 9/f Firm/Co. Name of Licensed Plumber % s4 -c W14 /lo 1? /fy Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box Liability insurance policy [a Other type of indemnity 11 11 ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature . Owner Agent 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stat]>mbing Code and Chapter 142 of the General Laws. Type of Plumbing License aY933 icense Number-- Master F1 Journeyman M VED (OFFICE USE ONLY 5, 3476 Date .. ,1. ?. r . c . /.... . ,HORTM TOWN OF NORTH ANDOVER py`40 ,e,tiOL p PERMIT FOR GAS INSTALLATION This certifies that .... . has permission for gas installation ....... Cit . .............. . in the buildings of ...fl : .......................... at .... ......`.............. North Andover, Mass, Fee.. /.)..... Lic. No.. ?..'...... .......... r ........---t ..... . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer k MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS ffrMG (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 8 t 57- Uti?T I#- /Dy'/� p SLJH'IPSaw Owner's Name New ❑ Renovation ❑ Replacement Date / h 3 - Plans Submitted ❑ Permit Permit # y Amount S Ir— Plans r- (Print or type) Check one: Certificate Installing Company Name A%/10 R.f r✓ &41 ❑ Corp. Address 1�6 do �r -672- ❑ Partner. -ow,fray/e_ elf Old Y2 _ Business Telephone - ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 7 tw INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ED If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy © Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 1=12 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agenr Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true ana accurare Lo tut: best of my knowledge and that all plumbing work and installations performed under Permit Issued For this application will be in compliance with all pertinent provisions ofthe Massachusetts State Gas Code and Chapter 112 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber a elX33 Cirv/Town ❑ Gas Fitter icense iNumoer ❑ Maszer APPROVED (OFFICE USE M.v) � Journeyman ONLY) r� R F L 0 0 R (Print or type) Check one: Certificate Installing Company Name A%/10 R.f r✓ &41 ❑ Corp. Address 1�6 do �r -672- ❑ Partner. -ow,fray/e_ elf Old Y2 _ Business Telephone - ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 7 tw INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ED If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy © Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 1=12 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agenr Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true ana accurare Lo tut: best of my knowledge and that all plumbing work and installations performed under Permit Issued For this application will be in compliance with all pertinent provisions ofthe Massachusetts State Gas Code and Chapter 112 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber a elX33 Cirv/Town ❑ Gas Fitter icense iNumoer ❑ Maszer APPROVED (OFFICE USE M.v) � Journeyman ONLY)