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HomeMy WebLinkAboutBuilding Permit #599 - 393 MAIN STREET 4/8/2010 BUILDING PERMIT of N°oTH qti TOWN OF NORTH ANDOVER 3�° , r- *° APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received �SSACHUS�� Date Issued: y C� IMP RANT: Applicant must complete all items on this page LOCATIONfC/ Pnnt -PROPERTY OWNER Print MAP 210 PARCEL: � ' ZONING DISTRICT: Historic District yes no Machine.Shop Village 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 _ 'Septic Well Floodplain Wetlands Watershed District :Water/Sewer PESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Phone: Address: .57 CONTRACTOR Name: Address: d 'r c, Supervisor's Construction License; / Exp. Date: ��h ... . Home Improvement..License: e�CP���lL Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ GO FEE: $���— Check No.: /D 2OCI' Receipt No.: 22 A0 f I NOTE: Persons contracting with un register contractor do not have access to the guaranty fund 0- 9. signature of Agent/Ovvner ignature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools ±r Well Tobacco Sales Food Packaging/Salesy 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 HEALTH Reviewed on Signature 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 -Tem,p Dumpster-on site, yes no Located-at 124 NlaiwStreet Fire Department signature/date COMMENTS 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 3 ❑ Notified for pickup - Date _......__._.......---..............._........_........_....._..................._._._._.......................................................--................................._..._.....__......................_............................._..._...._..._........................................._.........._.........._............................_.............._........................._..............................._. Doc.Building Permit Revised 2010 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 r 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 ❑ Flbor/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) ❑ 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) ❑ 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:Building Permit Revised 2008 Location No. Date �� NORTH TOWN OF NORTH ANDOVER N F Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #Inv?- 22909 V Building Inspector oz�,� RTH own of 4 ®ver . isA K E dover, Mass.,_Y_4&�49 coCHICME".C. e 79 ADRATED P`Qa\ �CC7 `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System / �� BUILDING INSPECTOR THISCERTIFIES THAT............................. ....... .......��....' ..........g./.Y..................................................................................... Foundation has permission to erect........................................ buildings on .,3,x .......... ...4..{.�y....-� ..................................... Rough to be occupied as................. ,S' .... ..... Z2tGl../...............:........................................................ Chimney provided that the person accepting this permit shall in every respect 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 CONSTRUCTI0 STARTS Rough ..................... ................. ............................. Service B G 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. L<:> 00 CERTIFICATE OF LIABILITY INSURANCE OP'II Bw EDATE(MM/DDIYYYY) Q NN 1 02/17/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Francis Provencher Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 530 Rogers Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lowell MA 01852 Phone: 978-459-8681 Fax:978-454-9343 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Penn-America INSURER B: 86ninn's Construction INSURER C: 8 Mammoth Rd. INSURER D: Dracut MA 01826 INSURER E: COVERAGES 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 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER EFFECTIVE PO PI T N DATE MMIDO/YYYY DATE MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000000 A X COMMERCIAL GENERAL LIABILITY PAC6862247 01/13/10 01/13/11 PREMISES(Ea occurrence) $ 50000 CLAIMS MADE a OCCUR MED EXP(Any one person) $ 5000 PERSONAL&ADV INJURY $1000000 GENERAL AGGREGATE $2000000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 POLICJECT Y PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN _ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—I CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION .ITA AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVFMu E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) EL.DISEASE-EA EMPLOYE $ If yes',describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRE T1VE ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachuseus Department of Industrial Accidents Office of,investigations 600 Washington Street Boston, MA 0211, www•massgorldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lem bl Name (Business/Organization/Individual): Address: City/State/Zip: f Phone#: T71an employer?Check the appropriate box; m a emplo with � 4. ❑ I am a general contractor and IType of project(required): ployee (full d/or part-time).* have hired the sub-contractors6. ❑New construction a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers' COMP.insurance. 8 ❑Demolition P [No workers' comp. insurance 5, We are a corporation and its 9, El Building addition ❑ required] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. C. 152,§1(4),and we have no insurance required.] t employees. [No workers' 12-El Roof repairs POMP.insurance required.] 13.7 Other n3'a"i3licant that ch=ks bora#I must a?so fill o,t these_ below shoe _ _ I3omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractor;that check this box m--attached an additional sheet showing the name of the sub-contractors and their workers'comp policy information. I am an employer that is providing workers'compensation insurance for information. my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lie. Y Expiration Date: Job Site Address: L 2 Attach a copy of the workers'come p nsat►on policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imrrisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this Investigations of the DIA for insurance coverage verification. statement maybe forwarded to the Office of I do hereby certify the pains and penalties of perjury that the information provided above true d correct Signature: Date:_ Phone#: Offecial use only. Do not write in this area, to be completed by city or town offciaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6. Other Contact Person: Phone#: i Information an d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of suchemployment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.', Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,no?the.Department.of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/lieense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, i, please do not hesitate to give us a call The Department's address,telephone and:fax.number:... . The Con monweal& of Massachusetts. Department of Industrial Accidents Office of lnvestibaiions 600 Washington Street Boston,MA 0.21.11. Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax #617-72.7-7749 )xrvrw.mass._o ov/dia. Ate eo Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite S 170 Boston, Massachusetts 02116 Home Improvement CAactor Registration == M -• Registration: 121604 t Type: Individual 'isM Expiration: 5/24/2012 Tr# 293905 QUINN'S CONSTRUCTION J 4v THOMAS QUINN ' 868 MAMMOTH RD. . DRACUT, MA 01826 's M f Update Address and return card.Mark reason for change. Address Renewal - ❑ � � Employment � Lost Card DPS-CAI ca SOM-04/04-G101216pp ✓fie i�orrvyrcaauaea�i o�✓�cu.�uoelZa Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Office of Consumer Affairs and Businessla ion u R g a Registratioq -X21604 ti 10 Park Plaza-Suite 5170 Expiratjon X5/24/2012 Tr# 293905 Boston MA 02116 Type' , Indiv�duai QUINN'S CONSTRUCTION THOMAS QUINN 868 MAMMOTH RRD DRACUT,MA 01826 - "!��"��� Undersecretary Not valid without signature M tssxchusetts - Department of Public SafeIN Restricted to: 00 Board of 136ildin'- Regulations and Standards ConstrucfionSupervisor License 00- Unrestricted License: CS 39732 1G-1 2 Family Homes I Resfricted to: 00 �' ' I THOMAS X QUINN z}; x ! 868 MAMMOTH RD ' Failure to possess a current edition of the DRACUT. MA.01.8.26 Massachusetts State Building Code is cause for revocation of this license. Expiration: 3/25/2012 Refer to: WWW.Mass.Gov/DPS (unimisioner Tr#: 18330 �ontraEt Tom Quinn Employer ID # (978) 265.2390. QUINN'S CONSTRUCTION ' ,. ✓1 '868 Mammoth Road • Dracut, Massachusetts 01826 Date Street Address(Not Post Office Box) Job Name d / City/Town, State&Zipcode Job Location - Daytime Phone: Evening Phone: Job Phone Mailing address(if different,from above) Salesperson(s): ( j Contractor Registration#: ':_;'e�3 Exp. Date: We hereby submit specifications and estimates for: rf��r+ 4A � L•��i !! -..` ./ 4'G i`r� ���" �; /cs' -.. / f � / � "A//L/O �/A//C.d r 0 / The following scheduled will be adhered to unless circumstances beyond the contractor's control arise: Work scheduled to begin: //_OT ' Expected Date of Completion: 9 IM—JO` (Date Contractor Will Be Contracted Work) (Date When Contracted Work Will Be Sustantially Complete TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE THE CONTRACTOR AGREES TOERFORM THE.WORK, FURNISH THE MATERIALAND LABOR SPECIFIED ABOVE FOR THE SUM OF: $ y` 0 includes all finance charges in this amount" Pa me .s will be made accordin to the following SCHEDULE: $i upon signiN contr ct 'Not to exceed. 1 3 of the total contract price OR the cost of special order items, whichever is greater*). $ By _/ /_or upon completion of $ By / /_or upon completion of __-----—--------------------------------------------- ------ ----------------------------------------_------------------------ $ 13 (jj upon completion of the contract(*Law forbids demanding full payment until contract is completed to both parties'satisfaction In order to meet the completion schedule,the following material/equipment must be special ordered before the contracted work begins.('Law requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contractor price or(b) the actual cost of any special equipment or custom made material which must be ordered in advance to meet the completion schedule'): $ to be paid for DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies of the cont�_q_ iId go to the homeowner and the c ntractor Home Owners Signature: �' Date: Contractors Signature: b Date: �� ` You may cancel this agreement if it has been signed by a party thereto at a-place other than an address of the seller,which may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted,'by telegram sent or by delivery, not later than midnight of the third business day following the signing of the agreement. Date......41- ...... ........-...'.1 j0RT" TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SS CHUS This certifies that ..... . ......... has permission to perform .... .................................................. ..... wiring in the building of....T.".1-0 .................................... at...".....i�.... .......... ......-,,'4orth Andover,.,Mass. Fees.. Lic.No?94�Z�12.......... ... . .... ........ .. .... ELECTRICAL INSPE R Check # 8 7 U` 7 Commonwealth of Massachusetts Official Use Only 0. Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co (MEC) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: A wy?u A, U q City or Town of: NORTH ANDOVER. To the Ins ector of Wi es: By this application the undersigned givv>:iotice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building per{ #? Yes No El (Check Appropriate Box) Purpose of Building f ( Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followingt¢ble may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones r No.of Switches No.of Gas Burners No.of Detection and TotInitiatin Devices No.of Ranges No.of Air Cond. Tons No. of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal El ❑ Other Connection No.of Dryers Heating Appliances KW Security o SysteDevims:* or Equivalent 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 Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of le trical Work: (When required by municipal policy.) Work to Start: W141A Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabili insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove age is in force,and has exhibited proof of sam,1 tole pe "t issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) � �/ I certify,under the pains and pena ' s o erjury, tat th!e-Wormation on this h�Splacatton t ue and complete. FIRM NAME: v Cf iv LIC.NO.: Licensee: sw'el•t 114 � �b,A Signature LIC.NO.: (If applicable, enter `exempt"in file license number e.) 6 / us.Tel.No.: Address: / ��(( 416ACL� �l Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security woFK requires Department of Public Safety"S"License: Lic.No. WJ 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 Signature Telephone No. PERMIT FEE: a