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Home My WebLink AboutBuilding Permit #390 - 21 DUDLEY STREET 11/2/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: j Date Received Date Issued: f �/ IMPORTANT:Applicant must complete all items on this page LOCATION - M-eqd rq-bt &Ac ut4l Print PROPERTY OWNER ( Q(/1 v Q 8- Unit# Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other glSep�tic, D Welll q FloodplaLu; ❑Wetlands; 0 WatersfiedlDastnt, O;Water/Seweri DESCRIPTION OF WORK TO BE PERFORMED: - YL, a, J dentification Please T pe or 'nt Clearl OWNER: Name: t ��(,q Ck— Phone: Address: j CONTRACTOR Name: (c, Cb �j Phone: g qoL Address: -7 Rcchav'i-Say) SAN f ey I' Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $�5�� Com' FEE: $ Check No.: I Q 2^ Receipt No.: Tv� NOTE: Persons contracting 't Sh unregistered contractors do not have access to the guaranty fund ignatureof Agent/Owner� Slgnatureoflcontractor, Location 22 ) S No. ' Date MORTh TOWN OF NORTH ANDOVER O 9 + s }�o Certificate of Occupancy $ CHO<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ //�� TOTAL $ Check #• (� v 2`t/ G 3 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ i Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ � Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS M HEALTH Reviewed on Signature I COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS L Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi J Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) a Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi AORTiy TONM of .rAndover, 0 -XV No. dover, Mass., o LAKE COCMICMEWICK %ps RATED p'PI 1 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT............... ..............pel. '.o1!r ............................. ...................... Foundation has permission to erect........................................ buildings on ......lkal......D4 d. .................... Rough .......;tw..... . ........®................ himney to be occupied as..... . �provided that the person epting s permit shall in every spect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR • UNLESS CONSTRU TS Rough - ......... ...... ............... ................................. ................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE,DEPARTMENT, Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. f AIC D® CERTIFICATE OF LIABILITY INSURANCE 09/2112011 THIS CERTIFICA'T'E IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETMJEEN THE ISSUING'INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poiicy(ies)must be endorsed if SUBROGAlON IS WAIVED,subject to the terms and conditions of the policy,cettain policies may require an endorsement. A statement on this certificate clues not confer ruts to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME RIONPrescott&Son Insurance Agency, Inc. WC.No E ; FAC.No 963 Eastern Avenue woo I Malden,MA 02148 AFFORDING COVERAGENUC r INSURER A. Savers Pcopet(y&CaSt a Irlsura me 6 31771 INSURED INSURER B: Dempsey, Eric INSURER C.- 7 Richardson Sreet Ngo: Billerica,MA 01821 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABO:/E FOR THE POLICY PERIOD INDICATED. NOTMATHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IiUIIH RESPECT TO M RICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SVBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOUYN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. @NSR TYPE OFl11StPPtIINCEADM SUrEIR POLICY EBF7PEMNAL&ADVFNJUW LTR iWVD POLICY NUMBER LIMITS GEINERALLN6LITY EACHOCCMRBCE S LWAPARE 10EEN LD fxYMM.E d"QALGENERALUAZLITY FREASES Eacawrrmye g Q A M& ❑ HEAP(ATrp me; ) S GENERAL AGGRE,3ATE S GEN'L AGGREGASTE U- 14 f A PPU ES PER FROWLYS-COM-10P AGG IS riF.UCY I PR(R i LOC s AUTOMOENLE LIA�nY (E am SDRC I-LliF;1 S fit(ALgo BOULY IT4JJRy('P.perms) S AOS LLOW NEA t SCtESL� 8ODLY FNJJRY tP'r�5jMQ S ROS 01F JE6 zPROPERTY DAMJr�ES s%RED AUTOS AUTOS iT UMBRELLA LOADOCO R EACIIOCCUMBICE S EXCESS LIAR HC11Vh1S-MA0E1AGC4ZEGATE T DED I I RE—WRMONSS WORKERS COMPENSATION d'atCSLAT9J- � OTl3 AND EMPLOYERS*LIABILITYT . ANY FRCM,�ELOR21FARAE YIN E-L.E�AOZIM4 S 100.00 OFGICERWBABM EXCL UDEED? r---IN(A' AR0426077 0991612011 09/16!2012 Pkvvdal-y in N" E.L-13SEOSE-EAiMPLOYEE S 100,000 DBS OPE O ttPTIOeIOL�I a P SCR;pBE.L..�sEASE-POI cyLJMT S 500,000 LOPERATIONSWow DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach ACORD 101.Addiftnal Remarks Schedule.ffmore space isreyuLredl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATWE ------------ e 198&2010 A +J`f�' 'i"Its reserved. re registered marks of ACORD 1. ,�omN , o�✓uaaaar/aavPld g Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registratioo, 0272 Expiration;=:`3/21/2012 Tr# 292627lu ---F- , Type''- -IfidWidual;;_ -, DEMPSEY C0NST=;&f2QQFfJG;, ERIC DEMPSEY , 7 RICHARDSON BILLERICA,MA 011321 ti 5 Undersecretary '- i♦9assachusetts= Department of Public Safety Board of Buildin- Re.-ulations and Standards Ccuastruction Supervisor Specialty.License c License: CS SL 99681 Restricted to: RF,WS,DM ERIC DEMPSEY 7 RICHARDSON STREET BILLERICA, MA 01821 Expiration: 5/23/2012 �'numis�i,uur Tr#: 99681 Dempsey Construction & Roofing Specialists Proposal 7 Richardson Street Billerica,Ma 01821 978-670-8904 ,proposal -- Customer Name Gail Apkarian FRep 3f41 i0 ... . Address 23 Dudley Street -. . 10/27111 City North Andover State Ma ZiP 0184Phone 978-807-3229 _. . _. qty Price for left side Unit Price TOTAL. Strip existing 2 layers down to roof deck and re-Trail where necessary. Any broken or rotten plywoodfroof boards will be replaced at a cost of time and material. Install V of ice&water shield undedayment along all eves&valleys. Install 15LB felt paper on remainder_ Install 8"aluminum drip edge around entire pelimeter(white,mill or brown:finish). Install 30 yr;3 tab,or architect roofing shingles(color and style chosen by homeowner) Counter flash and tar chimney where necessary. Install 1 new 2"pipe flanges,left side&1-3"right. Install two new roof vents on left side_ Remove all roofing debris. Thisis a labor,material,dump and permit proposal. proposal price is valid for 30 days from above date_ Five year warrantee on all workmanship Payment Details 0 Check Q Payable to Eric bempseY TOTAL $2,000.00 dowry for materials _ remainder clue upon completion Office Use only Signature of acceptancef;-r AC4C> CERTIFICATE O F L DATE,MMIDDIYYYY) �-- LIABILITY INSURANCE 9/6/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE C :RTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFF ORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(les)must be endorsed. If SUBROGA'T'ION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate!:does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER CONTACT Commercial Lines NAME: Prescott and Son Insurance Agency,Inc. PHONE (781)322-2350 FAX A1C.No.ExtL 963 Eastern Avenue E-MAIL JAIC,No ADDRESS: PRODUCERcusTomrglp#00037175 Malden MA 02148 INSURERS AFFORDING COVERAGE I INSURED NAIC# INSURERA:USF Insurance Co ` INSURER B: Dempsey Construction Roofing Specialists ' INSURER C 7 Richardson St INSURER D: f INSURER E: Billerica MA 01821 i INSURER F COVERAGES CERTIFICATE NUMBER:CL10121709362 REVISION MjMBER: THIS IS TO CERTIFY THAT 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS E..OBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD L SUBR LTR TYPE OF INSURANCE I POLICY EFF POLICY EXP INR WVD POLICY NUMBER MMIDDIYYYY MMIDDIYY LIMITS GENERAL LIABILITY I - EACH OCCURRENCE i S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Eao:currencel 5 100,000 A I CLAIMS-MADE a OCCUR IP127114 9/3/2011 9/3/2012 t MED EXP(Any on=person) �S 55,000 PERSONAL&AE`/INJURY IS 1,000,000 GENERALAGGFI=GATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY nRLOC PRODUCTS-CCl/P/OP AGG IS 1,OOO,O Q QO- n 5 AUTOMOBILE LIABILITYCOMBINED SING_E LIMIT ANY AUTO l{ { (Ea accident) {S ALL OWNED AUTOS I I BODILY INJURY_3er person) S k ! BODILY INJURY;'ar accident)I S SCHEDULED AUTOS I! 1 PROPERTY DAN/ I HIRED AUTOS i I(Per accident) t 5 NON-OWNED AUTOS f 5 + UMBRELLA LIABI OCCUR I I EACH OCCURREJ,ICE i S EXCESS LIAB CLAIMS-MADE AGGREGATE E S DEDUCTIBLE I I S RETENTION S I l+ !S --- WORKERS COMPENSATION I WE STATU- 5T—H-7' — AND - EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN IER - OFFICER/MEMBEREXCLUDED? NIA E.L.EACH ACC Ih=NT ande It yes,describe under(Mandatory in E.L.E. DISEASE-EA EMPLOYEE S DESCRIPTION OF OPERATIONS below EL DISEASE-F OLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Agach ACORD'101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTIC:° WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE J S Scholnick/CAH t 10565 Date....�. .. .... .. ...... f N�oTM r '•�_'"�� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,T— U S� This certifies that L�LTGG ....�................ ......................... has permission to perform wiring in the building of...... ............ .L-40 .5................................. .........;�U..�.�:�-: ..........5..�....�;T�rthAndover,Mass. Fee.6-��' .... Lic.No. 0...� ......:......... . ...... . . ELECTRICAL INSPECTOR Y Check # Commonwealth of Massachusetts Official Use Only Permit No. /0363 )6 3 Department of Fire Services Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME ),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: A / // City or Town of: NORTH ANDOVER To the Inspo6torlof Wires: By this application the undersigned gives notice of his or her inten o to perfoim the electrical work described below. Location(Street&Number) CAS� Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building ��yy,� Utility uthorization No. /! 2 M 4 Existing Service C.(/(/ Amps `2 l 70 Volts Overhead WUndgrd❑ No.of Meters 2— New Service Amps / Volts Overhead ElUndgrd F-1No.of Meters Number of Feeders and.Ampacity Location'and Nature of Proposed Electrical Work: JUP 2dA-2 9J! e i Completion of thefolloxdng table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:SNo.of Totalusp.(Paddle}Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting nd. rnd. Batter Units Receptacle Outlets No.of Oil Burners FURME AL,&_tMS No.of Zones No.of Switches No.of Gas Burners No..of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: - Detection/Alerting Devices Space/Area Heating KW Local❑ Municipal [:1 Other No.of Dishwashers 5 p g Connection No.of Dryers Heating Appliances KW Security Systems:* rY No.of Devices or E uivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts. No.of Devices or Equivalent } No.Hydromassage Bathtubs No.of Motors Total HP Te1No.ecoofDe�es.pr Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of 4lectribal Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEG Rule 10,and upon completion. INSURANCE C E: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such c�kverage is in force,and has exhibited proof of e o the rmit iss2i o ce. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) �/ f I certify,under the pains d enaltte(�of p ry,that e ' mation on this application is true nd mplet FIRM NAME: V T/��/ IC LIC.NO. Licensee: p �Gl Signature LIC.NO.: (If applicable,ent mpt"iJ�tllt lice number line.) Bus.Tel.No.: Address: — 1 L c� Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work req ices Department of Public Safety"S"License: Lic.No.. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE:$ Signature Telephone No. G 7461-:j Date..� . . �f ....... Of MONTH '14, TOWN OF NORTH ANDOVER ♦ f FwMwF t PERMIT FOR GAS INSTALLATION h �'IS SACHUSEI This certifies that . .51:� L. . . .C. �. /? �`�. G. . . . . . . . . . . . . . has permission for gas installation . f!.�..3. . . . . . . . . . . . . . . . . . . . in the buildings of . ��!�! . �'. �h.`.... . . . . . . . . . . . . . . . . . . . . at . .�.�:.?.�. . .D4.C�.� �.:% . . . f'. . . ., North Andover, Mass. Fee. . 3v. ... Lic. No..r< 7C `: . . . . . . . . . . . . . . LINSPECTOR Check# / L L i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING ur� City/Town: A/C? 114/AyL,,e9. , MA. Date:_ //— IC-10 Permit# Building Location:_ /Q-9/ D(/d I•p y s( Owners Name:_�A/�P A L..IAZU Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ ResidentialI New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ] Plans Submitted: Yes ❑ No❑ FIXTURES W F- Y Ui= (n U m = O W W tU U) O = W W Z H 9 Z O W W W W O � M NW W W m 00 Q a I— O w X W I Z w W z 9 = Lu o Lu a 1 _ LL > U W Z O J H H O Z -j U' ur = W W W W Z } W N Q Q m W O Z O N > Z x V o o LL W C9 C7 = _ -j O a. W H > > > O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5TH FLOOR 6 FLOOR 7 FLOOR 8 FLOOR n Installing Company Name: 041 (f,,UA-o R—A �2 Check One Only Certificate# � ❑Corporation Address:iL d JU X�a6 City/Town: l Z-777Vv---.. State: �y El Partnership Business Tel: Fax: imt/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Ye—s* No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy a 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner El Agent By checking this box❑;1 hereby certify that all of the details and information I have submitted(or entered)regarding this 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ❑ Plumber Title ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter a Master APPROVED OFFICE USE ONLY El LP Installer an Licese Number: �3� ��