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HomeMy WebLinkAboutMiscellaneous - 141 CORTLAND DRIVE 4/30/2018 141 Cortland Drive:Unit #10 BU FILE i �I I i I l t 9 9 1 8 } NORTM TOWN OF NORTH ANDOVER owePERMIT FOR WIRING This certifies that ... v, ... ... ...Q..t??.�.r..t ........... .......................... has permission to perform ......... � ../........... ............`�``�.. wiring in the building of..../.,��/.. ....( :..-................... ..... ................... .North Andover,Mass. Fee./4.. ...'. Lic.No...!. ............................. ELECTRICAL INSPECTOR Check # Commonwealth of Massachusetts Official Use only •�✓ - ^� Department of Fire Services Permit No. 9� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. I/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL ®RKAll work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPEALL INFO RW City or Town of: TIONS Date: Z 1 ) I I By thus application the undersi ed gives no ' e of his or her in entio�o pTo the erform the electrical ctor wor des: belo Location(Street chi Number) � ' � r. � �� Owner or Tenant DO b Owner's Address Telephone No.�l7 Is this permit in conjunction with a building permit? 'Slee Purpose of Building f 1 ►� �jk� © NO BLDG PERMIT# S66 - dot I f � h� Utility Authorization No. Existing Service C w Amps �w / Volts --�� Overhead El Undgrd© No.of Meters f ' New Service Amps / _Volts Overhead r] Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrfcal Work: � (VIhP flz PV+V) 0-Fvr. ,I �fiis R-r� P SVM PVMP Com letion of the following table maybe waived by the Ins ector o(Wires. No.of Recessed Luminaires (Z No.of Ceil:Sus . No.of p (Paddle)Fans TransfoTotal' I No.of Luminaire Outlets �. No.of Hot TubsrmersA Generators KVA No. of Luminaires ( � Swimming pool g nd e ❑ rnd. ❑ 0.0 mergency Ig ting i t No. of Receptacle Outlets Q No.of Oil Burners Batte Units FIRE ALARMS No.of Zones No. of Switches 10 No.of Gas Burners No.of D electron and No. of RangesInitiatin Devices i No.of Air Cond. Total eat Pum Tons No.of Alerting Devices c No.of Waste Disposers p Number..Tons KVV No.Of Self-Contained Totals: .......w.............. No. of Dishwashers Detection/Alertin Devices Space/Area Heating IOW Local❑ Municipal ! No, of D ere Connection ❑ Other rY Heating Appliances Se . KW curxty Systems.* No. of Water No.of No.of Devices or E uivalent Ballasts Heaters IOW al Data Wiring: Si s Bas No.Hydromassage BathtubsNo.of Devices or E uivalent No.of Motors Total HP or Wiring: 1 OTHER. No.of Devices or Equivalent Estimated Value of Electrical Work. 3 S�O o Attach additional detail if desired, or as required by the Inspector of Noires. Work to Start: (When required by municipal policy.) Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner, the licensee provides proof no permit for the performance of electrical work may issue unless undersigned certifies that such liability insurance including"completed operation"coverage or its substantial equivalent. The 11 h coverage is in force,and has exhibited proof of same to the permit issuing office. f CHECK ONE: INSURANCE N BOND ❑ OTHER ❑ (Specify:) I I cert,render the pains and penalties o f perjury,that the information on this application is true and compkte: FIRM NAME Licensee: ]S 5 1^M e r LIC.NO.: 2 7 7 1 R, Signature LTC.NO.: 1 (Ifapplicable,enter ex pt�n the license number line.) 1 Address: �S — 1� G o ► r� G N )?��, I Bus.Tel.No.:6;o d *Per M.G.L c.147,s ;7 61,security work requires Department of Public Safety S Licen Alt.LIC.NO.: I O'9V1�TER'S INSURANCE WAIVER; I am aware that the Licensee does not have the liability insurance coverage norm required by law. By my signature below,I hereby waive this requirement. I am the(check on []owner ❑owner's normally g I Signature Telephone No.' — PERMIT FEE: $ D i ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH INS -ECTION: Passed—[ Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date z 2.FINAL INSPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—[ j Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: P ssed—[ ] Failed—[ ] Re-inspection required($50.00)- [ ] Ii spectors' comments: (Inspectors'Signature-no initials) Date I 5.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ) Inspectors' comments: (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. i I I I The Commonwealth ofHassachuseas Department oflndustrial,Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass:govldia Workers' Compensation Insurance Affidavit: 13-ailders/Contractors/JEleetxicians)plurnbers Apulicanf Xn£ormation Please Print Les=ibly NaMQ(B.usiuess/Organization/Individual): Address: �C �d City/State/Zip: J rl0�-F IV 4 0 3' 6 ) Phone#: 6 0 / 3 [Axan employer?Check the appropriate box: Type ofproject(required): i a employer with 4. ❑ I am a general contractor and Iloyees(M-aad/orpart time).* have hired the sub-contractors6 ❑New construction a sole proprietor orpartner listed on the attached sheet.x 7. ❑Remodeling . and have no employees These sub-contractors have 8. ❑Demolition king for me in any capacity. workers'comp.insurance. g. ❑Building addition workers comp,insurance 5. ❑ We are a corporation and itsired.] officers have exercised their 10.®Electrical repairs or additions a homeowner doing all work right o£exemption per MGL 11.[]Plumbing repairs or additions elf.(No workers'comp. c.152,§1(4),and we have no 12.[]Roofrepairs ance required.]i employees.[No workers' 13.❑Other comp.insurance required.] !`Any applicant that checks box#1.must also JMI outthe section below showing their workers'compensation policy information. 7 Homeoviners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. )Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: I"-LAY' V'1 1'�l G.S i, 1` l to SV 1r e,ye e Policy#or Self-ins.Lie.#: Expiration Date: l 6 Yob Site Address: G Y��w h �+�d U City/State/Zip No d I k 4Mee— M A 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 flue of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify under the pains andpenaldes ofperjuiy that the information provided above is true and correct. Signature• �1.i2/J/� �—• Date: _ T Phone#: I I Official use only. Do not write in this area,to be completed by city or town official. i Ci or Town: City Permit/License# I Issuing Authority(circle one): I x.hoard of$ealth 2.Building Department 3.CitylTown Clerk 4.Electrical inspector S.Plumbing Inspector , G Other I Contact Person• Phone#: I • I • I Date $ sic • 3?�. "ISO- �oo� TOWN OF NORTH ANDOVER PERMIT FOR PLdMBING SSACNus� This certifies that .rg� 1-Irp. �l.k .t . . . .� . . . . . . . . . . . . . . . has permission to perform . . . . . M-A/.*. . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . at . . ./. �f . .C.C. L � x.1 .4.-.�. . . . . . . ... . . . .. North Andover, Mass. Fee L/� .Lic. `No. 2.`/,.., ?. . �.. . . -� Z. . . . . . . . . . . PLUMBING INSPECTOR Check p 7 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS / I Date � l�! Building Location � � �Qo^ �r Owners Name & Rw Permit# dtmxl� Type of Occupancy /nV Amount � New Renovation Replacement Plans Submitted Yes ❑ No ❑ FIXTURES I C w x H vx, 0 G Z G U A 3 z w r7 Rel A SUBB9VI)r i —MR" � aix>f 5M It" � 6M HIM I 7II3 I�OQR ; s>li lum i (Print or type) Check one: Certificate Installing Company Name /?l�P /�e �0�' Corp. Address Partner. I Business Telephone s���7 t/ EjFirm/Co. Name of Licensed Plumber: j,�/� Insurance Coverage: Indicate the type of insurance coverage by checking the�opriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature 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 instottto s perfo u er P tmit Issued for this application will be in compliance with all pertinent provisions of the Masch tate Plu o and r2-of the-General Laws. Y' Ign a or MensprPJAWBEF7 pe of Plumbing License Title City/Town icense E um er Master Journeyman 11i PROVED(OFFICE USE ONLY u 04 vto T" TOWN OF NORTH ANDOVER 0 0 PERMIT FOR WIRING AL 'S CHUS This certifies that ...... ..................................................... ................................ has permission to perform--........ ............................................. wiring in the building .......;5A -!:-"................. at.ZY1....... ..................................p.......`-­;'--2/-N/*�*`}..... North Andover,Mass. Fet-3' .... Lic.No ELECTRICAL�SPECTO Check # 8394 Commonwealth of Massachusetts Official Use Only l Department of Fire Services Permit No. ?3 ,9`1 Uy BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checke&5744�,/ [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -I �0 p 1 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant ,,`— l 4, fcx-� t _ p til „� �� . Telephone No. �l Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building !2 ��c .'� .t_ j Utility Authorization No. � Z Existing Service Amps / Volts Overhead ❑ Und rd No. g � of Meters 1 New Service '10n Amps (_ / `L>JL-Volts Overhead❑ Undgrd No.of Meters ( 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Lv t<,t- Completion t-Com letion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed LuminairesNo.of Ceil:Susp.(Paddle)Fans No,of Total Transformers KVA 41 i No.of Luminaire Outlets No.of Hot Tubs Generators KVA l No.of Luminaires Swimming Pool Above ❑ in- ❑ o.o mergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones I No.of Switches No.of.Gas Burners No.of Detection and InitiatingDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices r No.of Waste Disposers H�Totals Number Tons KW No.of Self-Contained Detection/Alertin Devices . No.of Dishwashers Space/Area HeatingKW Municipal Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water KW No.of Devices or E uivalent No.of No.of Heaters Si s Ballasts Data Wiring: No.of Devices or,E uivalent No.Hydromassage Bathtubs No.of Motors TotalHP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. , Estimated Value of Ele trical Work: apt c'b(7 0' (When required by municipal policy.) Work to Start: Z p Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: 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 I undersigned certifies ertifies that suchcove ge is m force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (BOND ❑ OTHER ❑ (Specify.) I certify, under thepains andpenalties of perjury,that the information on this application is true and complete. FIRM NAME: C1 IJ LIC.NO.: ?R1$c Licensee: Signature LIC.NO. 'Z (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:Address: S . �•-� % t.? (�—�..�.1�� .vc.� Alt *Per M.G. c. 147,s. 57-61,s unty work requires 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 Signature Telephone No. PERMIT FEE. $,, / °� r r 64 JAZ k The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lee!bly Name (Business/Organization/Individual): Address: City/State/Zip: ,u u 7au - Phone #: Are y an employer? Check the appropriate JYox: .t 1. I am a employer with 4. Type of project(required): �_ ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. 9• ❑ Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.E] 1 am a homeowner doing all work right of exemption per'MGL 11.❑ 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' comp. insurance required.] 13.[:] Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation Policy t information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such. Contractors 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:_ Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: I ( . , City/State/Zip: 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 on 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 1 -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. 1 110 hereby ce under thepains andpenalties ofperjury that the information provided above is true and correct Si ature: Q Date: (a Phone#:_J2 Official use only. Do not write in this area,to be completed by city or town official 1 City or Town: Permit/License# j Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other i Contact Person: Phone#• l NOIRIf � a I CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER I Permit# 240(Qct 3,2007) Date: Lune 22. 2009 THIS CERTIFIES THAT I THE BUILDING LOCATED ON 141 Colydand Drive I MAY BE OCCUPIED AS Single Family Resident ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. II Certificate Issued to: Meetinghouse Commons LLC 115 Carter Field Rd I North Andover MA 018!!45 i Building Inspector +� I I iI i I r i NORTH Town o _ _ Andover On.� war+' .K4• '�'. •.t. o '� dover Mass. 1 . > > 0 1, COCMICMEWICK V A�RATEO S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System A BUILDING.INSPECTOR THIS CERTIFIES THAT W-.eieX'z.'!'.... .... ��F �!� ��ur 17,1..........................................,.................................... F a •on has permission to erect........................................ buildings on ��`� .......d ° - (// a &� tobe occupied as............................... 1 .E.... .1.. .,.................................................................................... Chimney provided that the person accepting this permit shall in every res7iect conform to the terms of the application on file in nal this office, and to the provisions of the Codes and, By-Laws relating to the Inspection, Alteration and Construction of 4 Buildings in the Town of North Andover. WUMBING INSPECTOR—', VIOLATION of the Zoning or Building Regulations Voids this Permit. Rous %°�� ?/G fir,` Ficial `� :1 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECT R. UNLESS CONSTRUCTIONST TS ----, .._............................. Service BUILDING INSPECTOR d Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final Uc''� j.t G� - -� No Lathing or Dry Wall To BeDone FIRE DEP TMENT Until Inspected and Approved by the Building Inspector. Burner , N Street No. f / Smoke Det. SEE REVERSE SIDE �} d� NORTH Of I 40 1 n r �A4To0 APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Building Permit# 2-40 ADDRESS/LOCATION OF PROPERTY : /y J Co d/,*d-Qn"g- (jZvj7 loll Map /1) q G Parcel Lot Number � n . i 1 I SUBDIVISION movi DATE REQUESTED FILED/READY FOR INSPECTION I M ,Q� S CLOSING DATE ON PROPERTY: FIVE(5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS$20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. Permit Issued to: W hTLLC Address ,� r r2( M✓� � SIGNED RO TIN NoN�-5UR1SaalowAL CONSERVATION 0 Njj\ - c04o8 PLANNING ' DPW-WATER METER (e It g10 I SEWERIWATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMI AL OF THE OCCUPANCY/INSPECTION REQUEST DPW c �� Signature File: Application for OC form revised Jan 2007 +� I I � Dae. `NORT: do TOWN /NORTH ANDOVER PERMIT FOR PLUMBING • s : i s o s • ,SgACNUSE� This certifies that . . ./. .'l. C�. . . . . . . .! . . . J ( . . . . . . . . has permission to perform . . . .E�r. `''. . . fir" i. . . . 1 . . . . . . .plumbing in the buildings of f. . . . ... . . .:?:=? . . ; . . . . . . ... . . . . . at . . . I. . . . ' . . . . . . . . . . . . . . . . . . . . . . ., North Andover, Mass. Fee/>o. . . . .Lic. No..�. �.'� ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # 7920 i I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location /� 1 ty Owners Name Date Permit Type of Occupancy Amount .� 1 New Renovation Replacement 'rl Plans Submitted Yes No ❑ ❑ I FIXTUI2Es C LOD ..� Lo • w E.+ U KaR 02 &�SF1NIIVI' � M ELOCR 3t HLOQZ I 4IHHlJCR SIH Fl" j 6MFLOCR i H R S1EIKJOCR (Print or type) Check one: Installing Company Name Certificate Corp. Address ❑ G � � Partner. usmess elephone rl Firm/Co. Name of Licensed Plumber: Insurance Coveras?e• Indicate the me,ofinsurance coverage by checking a appropriate box: Liability insurance policy u Other type of indemnity Bond Insurance Waiver. I, the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature 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 perforiped under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus�tt, e and Ch 4 e General Laws. By. ignawre oumer Tide Type of Plumbing License City/Town S%S~ License um er Master 1�i Journeyman ❑ APPROVED lo�cs USE ONLYfJ I y Date.. /,/ /�.7 A, ... H°RTH °F o? �' TOWN 0 NO H ANDOVER . � • PERMIT FO GAS INSTALLATION SAC HU This certifies that . . . . c.`/ . . . . . . . . . . .. . . . . . . . . . . . . . has permission for gas installation . . . . x . . . . . . . . . . . . . . in the buildings of . . . . � . �!. . . . . . . . . . at lqx . . . �!. . . , North Andover, Mass. Fee./O.0'. `. Lic. No.. .15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C GAS INSPECTOR Check# 6616 i i i j MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS Ff rMG (Type or print) NORTH ANDOVER, MASSACHUSETTS date 6.. — Building Logations Permit# , Owner's Name Amount New❑ Renovation D Replacement D Plans Submi d I � a zw w a rn c4 O O Z m x a W rQ W p O = O Z I C7� U W �' Z dF O �" > W ed� H z (�. m W OC W F Ca F x a x x Cz a d C C O W W F w 3 o c� ,� `� SU B•-BASEMENT U C > D off. F p v— BASEMENT 1ST. FLOOR i 2ND . FLOOR 3RD . FLOOR 4TH , FLOOR 5TH . FLOOR 6TH . FLOOR 7T0 . .FL00R. 8TH .' FLOOR (Print or type) Name Check one: Certificate Installing Company D Corp. Address W Partner. usmess' a ep one <_ D Firm/Co. Name ofLicensed Plumber�or Gas Fitter i INSURANCE COVERAGE I have a current liability Insurance,policy or it's substantial equivalent. Check one- If ne: I Yes ff� Ifyou have checked es please indic a the type coverage by checking theappropriate bo . No� Liability insurance oticI P Y � Other type of indemnity 13 Bond I D 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 thisermit p ,application waives this requirement. � Signature of Owner or Owner's Agent Check one: Owner D Agent hereby certify that all of the details and information I have submitted(or entered) in above application are true and accurate to the 13 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 Massachusetts State Gas ode and Cha ter 2 o i P General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title Plumber l "� City/Town, t as Fitter License Number UMaster _ APPROVED(OFFiCE USE ONLY) D Journeyman 4