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Home My WebLink AboutBuilding Permit #008-2011 - 62 ADAMS AVENUE 7/1/2010 BUILDING PERMIT of tkORTi 7D TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 0 Permit NO: '2011 Date Received y' C"-1- Date Issued: 7 / oSSAC is LWORTANT:Applicant must complete all items on this page PARCEL ' tid.V4 n 0 R4 TYPE OF IMPROVEMENT PROPOSED USE ResidNon- Residential New Building e Afami Industrial I Addition Two or more family Industrial AlteratioP'--------.' No. of units: Commercial Repair, &placemW Assessory Bldg Others: Demolition Other 71 nds a' w5tbh/ DESCRIPTION OF1WORK TO BE PREFORMED" J__rllcl f7 Y= Identification Please Type or Print Clearly) OWNER: Name: _T c S if Iz /4 n Li f g*rq Phone- Address: Iq T? A vn rAr. A /V T)Q 1/11 1Z P"a- 6. 7 C E)N TM RA T. W Name •Q,Na-M"• 4'1 A n -7 7 i Ad Kms!'' 44 X_dress; J, ;�'1'z-1 ' 0'1 7'Au.- 7 �f ARCHITECT/ENGINEER Phone: Address: —Reg. No. FEE SCHEDULE:BULDINGPERMIT.MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /A, a FEE: Check No.: Receipt No.: ;25 0 V7 NOTE: Persons contracting with unregistered contractors do not have as to the guaranty fund 7� I Location -2 // f S� No. Date �a^T� TOWN OF NORTH ANDOVER Of t�•o ,•1ti� + _ Certificate of Occupancy $ sACHUSE�� Building/Frame Permit Fee $ �� 1 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #2300 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBodyArt 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlreceipt 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 l 24 Main Steet ; Fire�Departments�gnature/date _?.'. `.r _ x - _ 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) I f ❑ Notified for pickup - Date i 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 Pp 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 i 'Addition Or Decks ❑ Building Permit Application j ❑ 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) ❑ 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 N OTE: 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 ORTH TOI%M of Andover No. . ....... 0 LAKJo over, Mass.,7// COCHICHEWICK 0'r? TED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT..............I r, 14rc BUILDING INSPECTOR ...... .............................I...................................................................................................... Foundation has permission to erect........................................ buildings on ...6�. 1-4 'oe-el'_-Jr .......*****"**... Rough /- /?,-- /�Oo' **"' *... *... tobe occupied as......................................................................................................................................................................... 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 UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough .......................................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place an 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. i I Massachusetts- Deltartntent of Public Safet. Board of Building Re1� littions aril Standards Construction Supervisor License License: cs 40329 _ Restricted to: 00 CHARLES S -MIERS 21 W SHORE RD (3�1 WINDHAM, NH 03087 Expiration: 12/3/2010 (l min issiuncr - Tr#: 9627 _ p i ✓fie Consumer & osiness Regulation Office of Consumer Affairs&Bdsiness Regulation qHOME IMPROVEMENT CONTRACTOR Registration: _,,4150258 Type: Expiration: -V7720.12 Ltd Liability Corpt Ci.r.&Son ALL Charles Miers 21 W.Shore Rd. Windham, NH 03087 Undersecretary 9: FROM CTHU)JUN 3 2010 10:66/57, 10:66/No,0000000164 P 7 ACORV _ CERTIFICATE OF LIABILITY INSURANCE DA/3/too01 6/3/2 0 0 PRODUCER (603)673-1201 FAX: (603)673-4828 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Holt Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 319 Nashua, Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Sox 9 Milford NH 03055-0009 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERa:LIBERTY MUTUAL FIRE INS CO TRINITY STEEL LLC INSIJRER B: 490 Amherst Streeti JSURERC IN'•3URER D: Manchester NH 03104I INSURERE COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTAN DING ANY REQUIREMENT•TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT'WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR 1MAY OERTAIN THE INSURANCE AFFOR DEC BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OFSUCH POLICIES..CGGREGATE LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INR�TADD'LPOLICY EFFECTIVE POLICY EXPIRATION LTR }_ POLICY NUMBER DATE M.TD 1YYYY DAT MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COdM`rtCV r-EalE='u_LABILITY FREid,SES.Ea ccctlrrence $ i _.ANI MADE LJ OCCUIR MED E<P'An y one aer;on Is '_�cRSCNAL 3 ADV iNJJRY GENERAL AGGREGATE - Fnl'I_A;ch?EGATELIti+I?q=°LI=SRER � PRCDLCTS_(CN,1WODAGG $ FOL!�t .I f.T L0� AUTOMOBILE LIABILITY CONSBINED SINGLE LIMIT $ j ! A,"rAJT!) (Ee.accident) ALL Se.71.ED ATOS I ECDILY INJJRY $ SCHEDULED AU-OS (Perpemon) i1RED.4UT05 �-- ECDILY NJIIR4 I10NC:"aNSDI+.J7J3 (Per-�Itlen) � FCFER1YDAMAGE-- --- (Peracc:&nt) GARAGE LIABILITY NU70 ON=)-EA ACGUENT $ JYSJro EI.ACC $ OTHER THAN AiTC ONLY AGG $ EXCSSSI UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE P.CGFEGATE $ I $ F a.EDUC-IE'-E $ PE-FN710P. $ $ A WORKERSCO,'APENSATION 05/01/2C10 05/01/2011 Tn 'ATIrIG OTH- AND EMPLOYERS'LIABILITY r' EIR ANY F=�iFF'iEnOF.!?HRTNErTIt,1,ECUT`',E YJN Q PENDING El EP+:.HAGGIDEIJT $ 100,000 OFFCERiMEMBER E{CLUDFC9 (Mandatory In NH) Cffioer: Exleluded EL.CISEASE-EAEMPLOYEE $ 1001C00 tf'..e",de;rr�be.mear EPECIAI-PG04'I�ICI.S:elcw E.L.DISEA$E-POLICY LIVIT $ 500,C00 OTHER I I I DESCR-'PTION OF OPERATIONS t LOCATIONS IVEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS IRON 6 STEELWORK - DECORATIVE. Plass job CERTIFICATE HOLDER CANCELLATION (603)490-3214 SHOULD ANY OF THE ABOVE DESCRIBEDPOLICIES OFCANCELLED BEFORE THE EXPIRA7ION C.J. Miers COnatzuction DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRrrTEN 21 'West Shore Road NOTICET07HE CERTIFICATE H.C1-DERNAMED TOTHE LEFT.BUT FAILURETO DO SO SHALL Windham, NX 03087 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED F EPRESE14TATIVE Lisa Ikerd/IKERD ACORD 25(2009101) (V1968-2009 ACORD CORPORATION. All rig hts reserved. INS025(2ooGo, The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts I Department of rndustrial.Accidents Office of inVest�e ations 600 Washin,on Street Boston, MA 02111 Workers' Compensation Insurance Affidavit Bind s/Contract A licant Information ors/Electricians/Plumbers Please Print Legibly Name,(Business/Organiza6m/Individual): ' So Al L a' Address:—d l City/State/Zip: 4 r�;�o� hone#: G 03 Fps' c7 /7 Are you an employer?Check the appropriate,h(°x: 1•❑ I am a employer with 4. L'J i am a o 7=od oject(required): employees(full and/or part-time).* have hirederie contractor and I construction the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t odeling ship and have no employees These sub—contractors have working for me in any capacity. workers comp. ' olition [No workers' comp.insurance 5, P insurance. ing addition❑ We are a corporation anditsre4uired.] officers hake exercised their rical r3.❑ I am a homeowner doing all work rift of ex ��addrhonsm self p emption Per MGL bing repairs or additionsmsurance�required.]st com . c. 152,§I(4):and e have no 1_ employees. [No workers' [?1,00f repairs *A-ay=nnt t that check4_box e, comp.it s ancc required.] 13-11 Other f�'^ ,. must? 2211(,.r1'L'nC ee�rn,'n'`"OP.'9.^.CA�..r Homeowners who submit this affidavit indicating the,a,p icm n,- _ ' workers'coM"a"°"'^".,,.t:c. fc—=alio- doing av inr and t m hire outside contxacto s 16u,'.submit a new affidavit indicating such. 'Contractors that check ta;is box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.poiicy information. I am an employer that is providing workerscompensation insurance for my employees. Below is the pole ,and'ob ' information. cJ ! �e Insurance Company Name: POlicy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Attach a copy of the workers'compensation policy declaration pa- City/State/Zip: Failure to secure coverage as required under Section 2CTL p be(showing the policy number and expiration date). c. 152 imposition of ' fine up to$1,500.00 and/or one-year imprisonment,ass well as Civil penalties elead�o e of STOP WORK pRDER and of a of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office a a fine Investigations of the DIA for insurance coverage verification I do hereby c fj en under the pains andpalties -b of�per,jury that the informadom provided above is true and correct Signature: _.. Date:.... Phone#: 7 Official use only. Do not write in this area, to be completed by city or townL City or Town: Permit/License Issuing Authority(circle one):1.Board of Health 2.Building Department 3. City/Town Clerk 4.Elector 5.Piumbia�6. Other Inspector Contact Person: Phone C. J. MIERS & SON, Inc. Established 1857 ROOFING CONTRACTORS Above All A Good Roof 21 West Shore Road,Windham, New Hampshire 03087 c C. J. MIERS & SON, Inc. Established 1857 ROOFING CONTRACTORS Above All A Good Roof 21 West Shore Road,Windham, New Hampshire 03087 /4i�e �• 763A � S p G a Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"a ; Massachusetts consumer guide to home improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1488-283-3757. Homeowner Information Contractor Information Name Company Name f ioll C.Y -4 1, l., e Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name e PA m S S T'f' (' City/Town State Zip Code usiness Address(must include a street address) 1./onv A, *1 4d0sr'.sN0xC ai) Daytime Phone Evening Phone .ityrrown State Zip Code 7 �� tS!�'D W A-I O DS '7 Mailing Address(lt different from above) Business Phone ederal Employer M or S.S.Number law requires that mon home ba- a venppl rGGG�nnnatraetor Reg.Ntanber lixphm n due pmvra.eot eontracton have a I - d .��//v aad mgistration namlax ��•'+++aTs^s .a o,� The Contractor agrees to do the following work for the Homeo ner: `l! M diffil we worK to completed,specifMg me type,nrana, n o De usect, AMM Required.Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will he excluded from.the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) ,0—Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perforin the work,furnish the material and labor specified above for the total sum of: Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 of the`total contract price or the cost of special order items,whichever is greater) $44(2 0 by /�/� or upon completion of (l„ ISI Vic—, i,=' s ro r A E/47 $ by /_/_ or upon completion of $ 9) upon completion of the contract. (Law forbids demanding full payment until contract is completed to both patty's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order S to be paid for to meet the completion schedule.(**) NOTES:(')Including all finance charges(**)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 contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? Yes (all terms of the warranty must be attached to the contract) Subcontractors-Thevontractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract * Don't be pressured into signing the contract Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Itnprovement Contractor Registration. You may inquire about contractor registration by:writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 1-800-223-0933. * Does the contractor have insurance? Check to see that your contractor is properly insured. * Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's.normal place of business,provided you notify the contractor in writing at his/her main office or branch office 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 See the attached notice of cancellation form for an explanation of[Iris right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two identicat copies of the contract must be completed and signed One copy should go to the homeowner. The other copy should be kept by the contractor. Homeowner's Signature tractor's Si nature -1471lld Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an . alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws,chapter MA. Homeowner's Signature Contracto Signature�` NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. 'Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific regal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about Your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplica and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner"and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work., Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or tf you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law,"contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation. 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787'or 1-(888)2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specificall about the contractor registration component of the Home Improvement Contractor Law,contact: y Director of Home improvement.Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 (617)727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register ferinal complaints against a business, call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 .. t Date. NORTIy �ON`.�ao ,e,tiO 3 O TOWN OF NORTH ANDOVER � 9 " PERMIT FOR GAS INSTALLATION y9SSACHUSEt This certifies that It y . . ., has permission for gas installation in the buildings of . ? *, �r..... . . . .! . . . . . . . . . . . . . . . . .. . . . . at . /0!--:� . . . . . . . . . .. North Andover, Mass. Fee.—1n, .a` Lic. No..e.'.r: h. . ��c < / v GAS INSCfoR Check# 6727 MASSACHUSETTS UNIFORM APPLICATON FOR PFRMTT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Loqations Permit# �� Owner's N e ' Amount New $ � Renovation Replacement Plans Submitted ❑ t � a ' ww W MW x M 2 O 0 = H x F yy Z G C IW, F �+ z �" C z z p F Z Q w Z F F W O 0 W O C Z O F w W S O 0 rZ SU B-BASEM ENT $ j pC > p F FO BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . .FLOOR 8TH . FLOOR (Print or type) r NameJ- 1%L[ Check one: Certificate Installing Company Address /—f � k d Corp. -TV --)A 0. � �J 0 U � Partner. Business a ep one ,� S- amu ' Y ¢�`L` � 13 Firm/Co. Name of Licensed Plumber'or Gas Fitter f$✓ , FINSURRANCECOVERAGE liability Insurance•policy or it's substantial equivalent. Check one:Yes cked yes.please iodic a the type coverage by checking the appropriate box No[] nce policy 1 Other type of indemnity D Bond Owner's Insurance Waiver. I am aware that the licensee doesnot $ e the Insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: t hereby certify that all of the detailsOwner ED Agent and information I have submitted(or entered)in application s a 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 Massachus S G Cod d Chap r 142 of4Ub General Laws. By: S ature of Licensed Plumber Or Gas Fitter Title Plumber City/T°wn, Gas Fitter c um er Master APPROVED(OFFICE USE ONLY) [3 Journeyman ��r! ., il�