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Home My WebLink AboutBuilding Permit #358 - 453 STEVENS STREET 11/6/2007 i BUILDING PERMIT "°Rr" q TOWN OF NORTH ANDOVER c APPLICATION FOR PLAN EXAMINATION � o Permit N0: r' Date Received ��SSACHUS�� Date Issued: II IMPORTANT:Applicant must complete all items on this page OGATION x k P `"fit{l3. l '.:,: Y �'" 4 � T7,�eSR r §.•wP' ,.Mk x y r r Y � ; 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 epticr "Ille11 °} ' loodplarr " We#lends V1latershed`l3�str�ct r r - Water/Sewer �� DESCRIPTION OF WORK TO BE PREFORMED: ✓ e-JD c:,�M_e17t t,J;,7dQCA4 5 Identification Please Type or Print Clearly) OWNER: Name: 11'1�'C�ia� TcVP 4 ci r;i,) Phone(&j7),!�/.2 'at-`1.S.S Address: S veL- ,,v T ,3, �w CONT# GTOR �- x Y F 1 4 L ? Address ?.- Supervisor's Concense Fore lrrtproerrretat License_ } ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 4770,00 FEE: $ � Check No.: �'J' Receipt No.: �=_26 774 NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/C±wrier ' y Sign, -e... f contractor - Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools 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 DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nection/Sianature & Date Driveway Permit Located at 384 Osgood Street ,.a :FIRE:DEPARTMENT -Tem Dum ster on site . es P P Y no Located at 124 Main Street Fire Department';signature�date 4 _ COMMENTS x 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 2007 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o 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 o Workers Comp Affidavit o 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 o 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 NpRTfy 0 0 _ Andover 0 oy� dover, Mass., o COC HIC ME WICK V AERATED C7 `s BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D 9 1 BUILDING INSPECTOR THIS CERTIFIES THAT ' _ F ...................... .. ............................................................................... ... ....................... Foundation has permission to erect........................................ buildings on ... ........ Rough to be occupied as............... ... l. 4( U4/�l'.... Chimney . . . .................................................................... provided that the person accepting his 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 CONSTRUCTION TARTS 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. 0oWt Bu, Regula. ,ons and tan�tart 5 One AshNti -PI - Room 0oston. Mka hu t> setts 02 1,08 Reon: 146964 TXpe: Ltd Liability Partne cu _ €xpiraiion: 62/2009 Tr# 133222 t14RC4N 'we LLMC. PAUL C®ut 41 N. l *00-14.D'EI RY, NH 03053 v Update Address and-return card.Marls reason for change. Address Renewal Employment Ej Lost Gard DPS-CAI 0 50M-05/0& 80 PC84 A& . Board of B4Hding•Regulations and Standards License or registration valid for individul use only Ht3MO iM OYt ME"T GONTRNICTOR before the expiration date. If found return to: +atr�..1 69ft Board-of Building Regulations and Standards Re. st 09` Tr# 133222 One Ashburton Plate km 1301 — Boston,Ma.02108 _ = ability'Partrie MORGAN PAUL CQUTIJ 8 430", PID"dtUt Not valid without sagua, LONf] ND� RY,Nht '3i)53 Adainistca#or fxt jd s + it h z { �:o.u� ... �.,4r_.Nx;<.,3,is.:+tkdMaw.4uxsaY9�r�Gk,rtnv..eew:,tnxua vcs..Ya.e,:u%..t.na,.;...s>+.ti,.,may.....n..:...v....�.1'i.xr.:awwuuaua,<rts�cwed'v�hm:aidw:esiYlah#nciGyr.3:a t�,'ua'qac.�k/r.,r..i,:8�ti6�x.'Wi�u..3�S;x4'SaG;+'Gr�iiN�Os�3�'�i��*�3::G.i.,,arM4.:�- -.Yi6tit.Ys�+rb'x`Hh�fa`urs•�iv ;;. BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 092035 Birthdate: 03/27/1973 i Expires:03/27/2009 Tr.no: 92035 Restricted: 00 PAUL COUTURE JR 4 ORCHARD ST RAYMOND, NH 03077 _0,� i Commissioner BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR r r, Number CS 092194 Birthdate: 07/17/108c s Expires:07/17/2009 Tr,no: 9.'.194 Restricted: 00 MARC W COUTURE 114 i-ANGFORD RD P-. YMOivD, NH 03077 Canmisaoner Inc k.ornmunweucen UJ lrlu��uena�eu� Department of Industrial Accidents Office of Investigations 600 Washington Street b Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orpa nation/Individual): M p t2�Ci 7 JL67�e_rt-c2 ' Address: / 3 0 j2 oc1*1?4,hQ,*" /C� City/State/Zip:i.9��lo�,c�er yl! o3o S.5; Phone#: (60 3 �- Are you an employer? Check the-appropriate box: Type of project(required): 1191 am a employer with 4. ❑ I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors ❑ 2.El am a sole proprietor or partner- listed on the attached sheet. t Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.. g• M.Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11 E3 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] . *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must 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 my employees. Below is the policy and job site information. / Insurance Company Name: L/6eH-�,r bt uk/q l Policy#or Self-ins.Lie.#: Lt/C S 3/5 3S q,1?500 l 7 Expiration Date:&&0 d Job Site Address: t153 5/r_, uak7,5 City/State/Zip:-U, /�hc(cove,v, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, 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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains an penalties of perjury that the information provided above is true and correct Si ature: Dater 1116lo7 Phone#:t&0.2) 9015 O•fj`ceial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit%License# Issuing Authority(circle one): 1.Board of Health. 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• C 58 Route 27 Morgan Exteriors LLC 5 Pine St. Ext. Raymond, NH 03077 Nashua, NH 03060 603-895-2092 HOME IMPROVEMENT CONTRACT 603-791-4425 THIS AGREEMENT,made and entered into between,Morgan Exteriors,58 Route 27, Raymond, NH 03077 hereinafter referred to as Contractor '� ' AND YC.e��, ` _O�'(1C!► IQ�gnnl _ STREET 5 S�cv Si' CIN �'� STATE �_ ZIP ISHS Home#: (1-512"14-55 Work#:Mr./Mrs. . hereafter referred to as OWNER. CONTRACTOR hereby agrees that it will furnish all labor and materials necessary to install the following described work at premises located at the above address.CONTRACTOR agrees to start described work on/or about 6 to 8 weeks after issuance of building permit,and to complete described work in about ZZ to working days.Time not being of the essence.If required,building permit is the responsibility of the said Contractor. CONTRACTOR shall not be held liable or delays due to causes beyond control. Brand Name PbirK (A�ctV�. Color �/ Special Instructions Model �V `�n •' " ra'd % yj J,(1 a 0 W0 DoubleHung............................................. Two Lite Slider.......................................... Three Lite Slider........................................ Picture Window......................................... V� :V5•C'(� � . Casement(1-L)(2-L)(3-L)(4-L) .................. Bow(3-L)(4-L)(5-L)................................... N Bay ........................................................... Garden...................................................... D Work not to be done by MORGAN EXTERIORS Basement Hopper............................. Awnings.................................................... h 6 Super Peak Glass..................................... 3 Half Screens............................................. O Customer Initials Full Screens............................................. Grid systems........................................... All Checks Payable to MORGAN EXTERIORS Alum.Exterior Trim................................... ,■, Inside Wood Stops.................................... VV TOTAL INVESTMENT$ 11,70 DEPOSIT$ 442. Inside Casings.......................................... p� DUE AT REMEASURE$ "T,17- Inside Stools............................................. Other......................................................... S BALANCE due upon completion$ u 2-5 THE OWNER SHALL PAY FOR THE WORK: ❑ In Cash or check Upon Completion ❑ Owner will make Bank Arrangements You may cancel this agreement if it has been signed by a party thereto at a place other than the address of the seller,which may be his main office or branch'thereto,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 this agreement If the Owner refuses to permit Contractor to proceed with the work herein,or in the event of any breach by the Owner of this agreement'for any reason whatsoever shall cause the owner to pay Contractor a sum of money equal to thirty-three and one-third percent of the price agreed to be paid,as fired liquidated and ascertained damages,and not as a penalty,without further proof of loss or damage. Contractor shall not be held liable in damages for delays in the performance of this contract due to causes beyond its reasonable control Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on behalf of the owner to enter into this agreement This Contract represents the entire agreement between the Owner and Contractor and no representative or warranty shall be binding upon either party,unless included herein.An interest charge of 1.50%per month(18%per year)will be added to any amount unpaid after 30 days from invoice date.In the event of default in payment of this order or any part thereof and the account is referred to an attorney for collection,the purchaser agrees to pay reasonable attorney fees.AM material is guaranteed to be as specified All work to be completed in a workmanlike manner according to standard practices.Any alterations or as a deviation from above specifications involving extra costs will be executed only upon written orders and.will become an extra charge over and above the estimate. The contractor represents that all our workers are fully covered by Workmen's Compensation Insurance. b ? Date ojAcceptance O Signature Signatur (owner) Offorntractor) Signature Date (owner) �� Location / / S� -Sye rem S No. Date 0/ 40R, TOWN OF NORTH ANDOVER Certificate of Occupancy $ ,SSAC14USEt Building/Frame Permit Fee $ r 5 y Foundation Permit Fee $ Other Permit Fee $ TOTAL $ c{s Check # "i 6 9 Building Inspector s TON" OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 7777.77 Soc Nx BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date G 0& / SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 1�� _�r V� Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record _ P19i'l R Name(Print) Address for Service r Signature Telephone (� 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed nstruction Supervisor: Not Applicable 11 j Ch&*sv� lyd Licensed Constrruction Supervisor: ^ 3�- / /IA/Co/�}/ `jfL e �j/`` License Number Address Expiration Date ic Sign r Telephone 3.2 Registered Home Im rovement Contractor Not Applicable 0 &-- � c PZ Company Name / �(� (j /,/, , / (�/' /�� S�/ ��v��2 J/�� Registration Nu ber Address `'V J { l Expiratio Date Si natur Tele hone 1 1 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR ' Number.. CS 055823 Birthdate: 06/07/1947 Expires:06/07/2002 Tr.no: 24942 Restricted To: 00 t JOHN CONSTANTINO 226 LINCOLN AVE HAVERHILL, MA 01830 Administrator The Commonwealth of Massachusetts Department of Industrial Accidents • Office of Investigations �F Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # ?Pop 3 ?�G/�7 I am a homeowner performing all work myself. a I am a sole proprietor and have no one working in any capacity a I �U I am an employer providing workers'compensation for my employees working on this job. Ea Company name: Address l �f 5 CS / /�G !� �✓ S 7 / Phone#: / lO? Insurance Co.. _CUC._�. -` y Policv# A . i Company.name: Address k� CU: Phone#: Insurance Co. : Policy# �i Failure to secure coverage as required under Section 25A or MGL 152 can lead fo the imposition of cnm'inal penalties ofd Pirie up to$1,500:00 and/or one years'imprisonment as welt-as_civil penalttesinihe1nrmnf-aS-TQP-_-ORK_OR )ER.arid.a fine_of�$1DO flq)-asiay.againstme. I understand that a copy of this statement may be forwarded to the office of Investigations of the DIA for coverage verification. I do hereby certify and r e p ' s an=altie erjuryth he information provided above is true and correct. � Gam_ _ Signature Date Print name 2,-/:o Phone.# Official use only do not write in this area to be completed by city or town official' M City or Town a Permit/Licensinq E] Building Dept ❑Check if immediate response is required C] licensing Board p Selectman's Office _ Contact person: Phone#: F1 Health Department Ei Other NORTH E Town of Andover dover, Mass., oRATED BOARD OF HEALTH PERMIT T D . Food/Kitchen Septic System THIS CERTIFIES THAT........ SAO BUILDING INSPECTOR �00.1VJ4............... ..ov-1 ..... ,. .................................................. Foundation has permission to erect......... � g ........ Rough to be occupied as...... ...... VAheaoov`..�'`1L........moi/ti vGtr._............................ 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 qb �8 4( ys • VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS,CONSTRUCTION STARZt....'. ELECTRICAL INSPECTOR Rough ............. ...1.f................................................................................... 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. MASSACHUSETTS UW1 ORM APPLICATON FOR PERMIT TO DO GAS; G Type or print) Date. ,. 19 NORTH ANDOVER, MASSACHUSETTS ,. 3uildine Locations 4 3 S-L8U P1Ii-- P 1'^�L# AitrQunt S Owner's Name { ' �Cw Renovation ❑ Replacement Plans Submitted ❑' '� 2 :! z r Z Z G 13 - B .-k SEM ENT ; EM ENT is r . F' LOO R FLOUR T 11 F L U O R7,777 A S r II FLUO K •" :� 6T11 . FLU0 R } ;t•: ;T II . FLUOR ,. 8T H . F1. O0 R �«� asF r�_ �� Lc one: Certificate Installing Company 3 5 1 4 Date.. . .... ... ... 1 Corp. U Partner. NORTH 1 TOWN OF NORTH ANDOVER �'FimVCo. F? �p PERMIT FOR GAS INSTALLATION �, o••''�t No 9SSACMUSE �� . . . . . . . . . . Bond ❑ This certifies that(It" . . . . . . . . . . . a, ge requited by Chapter 142 of the has permission for gas installation . . . . . . . . . . . . � in the buildings of,,, • • • • • • " " " " rc. 'GGv rwl. . ., North Andover, Mass. Agent ❑;'• at .!�`5-�-•— 11pplication: n accurate to the Fee!�. . . Lic. No.T..�`-f• • • • 44 ' ' ' ' ' ' ' ' sued for tbis.a ��cati .. . on will be in GAS IN 3 of the Goner laws. WHITE:Applicant CANARY: Building Dept. PINK:Treasurer 3 lgnature of Cicensed Plumber Or Gas Fitter <'` Tille ❑ Plumber 9983 Cirv;Town ❑ Gas Fitter License I umoer ❑ Masfer -•�PPRO'v'ED t()FFicF USE I)NI.Y) ❑ Journeyman Dat . N2 452 HORT: o TOWN OF NORTH ANDOVER j• .�? ,e -. •• OL PERMIT FOR PLUMBING s o� •'a ,SSAC04USE� i This certifies that has permission to perform .. . . . .. . . . . . . . . . . . plumbing in the,buildings of ?. . eflo . . . . . . .; North Andover, Mass. Fe-eZ7 . . . . . . . �;' � {� jUg� �` PLUpA iEIG INSPECTOR Check # aRv ` WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORMAPPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) , Mass. Date 19 Permit* 2� Building Location 453 St�� s O is Name Pa J a_ ype of Occupancy New ❑ Renovation ❑ Replacement 0' Plans Submitted: Yes ❑ No ❑ B • P •# SEWER# FLXTURES SEPTICm 2 N y I— 07 H N O Z W Y -! N �' V Q N W 41 O y Z N Q < S f. 7 _O N J H W N F- W N H V @ N < y U. 4. Qj K - Vf S @ W y Y _a U Z O @ H W @ d y z D 4 N O s d < O Gz+ W 2 ¢ J U. W < Y 3 ° Z x J N ° U. Sa v y o = z H Y °. O _z _z d W �c .� y < Q. Q = N N a Q o z o o s w o t!J D D J Z N N U. C7 O d 3 C @ SUB—BS T. BASEMENT — IST FLOOR 2ND-FLOOR Lt 1 I 3RD FLOOR 4TH FLOOR I STH FLOOR I 6TH FLOOR I 7TH FLOOR 8TH FLOOR Installing.Company Name Adover Plbq. & Htq. Co., Inc. heck one: Certificate 1 ,address_ an Dr Unit-10 L/ Corporation ~ 2122 • hMathuPn Ma 01844 ElPartnership ^ _ Business Telephone (978) 685-8383 ❑ Firm/Co Name O F Licensed Plumber George LaRoSe INSURANCE COVERAGE: I have a current lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No C3 - If you have checked yes; please indicate the type coverage by checking the appropriate box A liability Insurance policy 2/ 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: 'ignature of Owner or Owner'sAlgent Owner C3Agent C3 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 =errtinentprovisions e and ofltheuMaassachusetwork ts State Pliutions mb ng Code and Chapterformed under r Permit2 of the G neral L awspfication will be in compliance with all �v rtle Signature of licensed Plumber :dy/Town Type of License:Master❑ Journeyman ❑ a� PP8CVM OFFI US ONLY) License Number__()98