HomeMy WebLinkAboutMiscellaneous - 50 Kingston Street - 50 KINGSTON STREET
_ 210/023.0-0006-0050.R
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'v"QHkr+UbtI IS UNIFORM APPLICATION FOR PERMIT TO DO OASFITTING
(Print or Type)
NORTH ANDOVER
_ , Mass. Date Ig
i Building
Locallon �- s'p o �,,�,� f Permit # 6by
LOOU
Owner's
Name —I �LGv Crit , �✓
New ❑ Renovation ❑ Replacement Plans Submitted:. Yes ❑ No
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SUIR—esMT.
11111AIEMENT
IST FLOOR
1N0.FLOOR I
3RO FLOOR
4TH FLOOR
4THFLOOR' !
GTH FLOOR i
7THFLoOR t
aTH rL00LEHIIEEB- -11RI 1. 1 .R
Installing Company Name Check one: Certificate
cy� the� � r•,-`-�rp
Address � � o
d Partnership
QUsPt /Yl ❑ Firm/Co.
Business Telephone 570? 37V V503
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE: Check qne
1 have a current liability Insurance policy or its substantial equivalent. Yea Q No ❑
It you have checked res, Please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy tJ Other type of Irxfemnity ❑ 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.
Ch one:
nature of Owner or Owner's Agent 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 the permit Is this appllcatlon will be M mpllance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the ai
� T of License:
Titlel3asnlIN
signature° nae um er or as er
Master Lkense Number
Cl-ty/To` n D Joumeyman
APFIJOVED (OFFICE USE ONLY)
ate 2352Dateo �; .........
Nor+TM TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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A9SSACHUSEt
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11. 1
This certifies that . . . . v�. .
has permission for gas nst llation . . ,GSA.
in the buildings of .
at a. .. .. . . . . . . rth�Andover, Mass:
Fee.�.U.' Lci.
. No.. . . . . . . . . . . . . . . . . . . . . . . . . .
C GAS INSPECTOR '
r�L�+A,..�J• r�
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:Fill