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HomeMy WebLinkAboutMiscellaneous - 215 GRANVILLE LANE 4/30/2018May 12, 2015 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, N A 01923 Tel: (800)566-0323 Re: Property Address: 215 Granville Ln, North Andover, Ma 01845 Policy Number: H3221813690421 Underwriting Company: Liberty Mutual Fire Insurance Company Claim Number: 031692436-0001 Date of Loss: 3/9/2015 Attn: Town/City Official Pursuant to M.G.L. c. 139, § 313, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, 5 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, X99, if you intend to initiate proceedings designed to perfect a lien pursuant to Mass. General Laws, Ch. 139, § 3A & B, or Mass. General Laws, Ch. 143, � 9, or Mass. General Laws, Ch. 111, § 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 P 11.7, —,N 0 Date ..... ..... 03... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... ....... C - 4P has permission to perform .... .. .. ... ....................... wiring in the building of ... 0 ............................................... at ...... ..... ............. . North� Andover, Mass. Fee ..... ..... Lic. No. ....... ELEcrRicAL bigP'ECTOR Check # I o -� -) THEC0Mff0NWEALTH0FM4SS4CHUSE77S Office Use only DEPAI�VTOFPUX1CSAFETY VPermit No. -:� 77 BOARDOFFIREPREVE MONR0l0 EGULMONSM7CM12C ._ Occupancy &Fees Checked 4� APPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) ItC G Qmyti; `(E Date " Ll--o3 To _ Inspector of WireE Owner or Tenant Jhr1 -t en� ` nOG v,� Owner's Address CQ Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building QQ5 �CeA Utility Authorization No. _ Existing Service Amps / 7`lo Volts Overhead ® Underground No. of Meters New Service Amps / Volts Overhead M Underground M No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work oJ+' �e,� JV%Ae No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures/© Swimming Pool Above Below Generators KVA round ground No. of Receptacle Outlets / '�7 1 (� No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW 1 No. of Self Contained [ Detection/Sounding Devices Local Municipal r ---J Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER _,140/J/ `�a t`'>( c v It Jnsutai=Cbvng_- Ptas=ttDthemgmmrWofMwmdxmMG=iWIaws IhaveaarrerI abtlif kis=oeR y=bcragComplete Coweageoritsakstarti equivalat YES NO Ihavestlbrmtledvabdploofofsalneloftoffm YES � lfyoubaved�edodYES ple mdcaihetypeofcovwageby dxWdarlgthe box INSURANCE BOND HRMNAME 17 OII-IIR �i-3a-e3 htspec1JmDaeRet*d c_- ftax SpX4) EVirafionl)* ElinatedvalueofEbCtricalWotk$ voo,a Rough Final LketlseNo. LicetmeAloWe i sigira �;l%ll 1=wNo VJ_D C_ Business Tel. NO. 3(Do-* �YJ"L t" Ar1r6Pcc (G/ W U D +'GC ( �j� 'lam cM /► Q/ e1y_ l Alt Tel No. �i- 1- /1 Pi OWNER' S INSURANCE WAIVER;Iamawn that ftIioalsedo r"bavedr- ina anxoow georAsabsWntkdequvalatasmWiedbyMassacIusarsGalaalLaws !1 and datmysgnah=ondmpmmapphcationwaivesthiswgwF rlem (Please check one) Owner � Agent M Telephone No. PERMIT FEE $ � J signature o , wner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02919 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: Cites Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: - Address City- Phone #: Insurance. Co. Policv # Company name: Address City Phone #: Insurance Co Pollcy # Failure to secure coverage as required -under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonments welLas_civil_penaltiesin-theinrm-d-a ;TOP WORK ORDERand_a.fine_af_($11)0.00)-atlayagainsstme 1 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 under the pains and penalties of perjury that the information provided above is irw and correct. Signature LldtC Print name Phone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept []Check if immediate response is required 0 Licensing Board E] Selectman's Office Contact person: Phone #: E] Health Departmeni 0 Other Location 1(-/ No. Date SOR-I �Th TOWN OF NORTH ANDOVER U Check # - / -'(,- '166 1 1 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING -'7 v,m BUII,DING PERMIT NUMBER: �/� DATE ISSUED: SIGNATURE: Building Commissioner/I t r of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: l O 6 � Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide RegWred Provided ReqWred Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Infortnation- 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record J��(iU d—�J�,�1JiFr�2 f/z9ULl/��/►� � lS� Cs�iV!/I�C.L ,r�'D. Name (Print) Address for Service: 1 Sign.Tre Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ f ��EA) y. J)f a7Z </2.� L% .cnsed Construction Supervisor: * O eCP&ZS LAIr PR—/Ud 030(o. License Number Address Id/3103, lema9� &63 .0-70 00 Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ p, 12-7 6 Z / Company Name Registration Number &/4j���aes �ivr- p��-H�rl yI"f O�t� 7 �. Address h1 1 'iL 6 70 LnoM Expiration Date Signvature Telephone Ma rn X ic Z O NOR �) W SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 & 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... 0 SECTION 5 Descri tion of Proposed Work check all applicable) New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ JAddition Accessory Bldg. ❑ Demolition. Other ❑ Specify Brief Description of Proposed Work: C�9M7cc /001 t7or) ofF l( 167e-iq��J Auo /JT_;C,.ov? 07 - SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OM, CIAL USE ONLV `; ' t 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel X (b) ` 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Herebv authorize to act on My behalf, in all matters relative to work authorized by this building permit application. -Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I> as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si ature of Owner/ ent Date NO. OF STORIES 2 SIZE BASEMENT OR SLAB�r�-. SIZE OF FLOOR TIMBERS iSTZ o 2 ND2X10. 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Ma"064wd IL PROFESSIONAL, STRUCTURAL ENGINEERING P.Q. BQx es9 GIA\ DESIGN SERVICES E. HAMPSTEAD. NM 03M Clow AX (GM RESIDENTIAL • COMMERCI 39>I� ��� ���%► -7 P ? la5la5 TITLEur EST •fit NO . JOB r,a�D J SUBJECT Vt .RIL L,,x►+ -eeg f=, _ SHEET N0. DESIGNED BY— DATECAECYED BY DATE _ 2*p ki.coQ,1JCaEL, 11a0o,u%-- 20 A'FrSLT �£T Al L. - FL S-t2.%IL-TU mo— S-timt- e6Am W ►Zx4j5 5fl�.�v 2-2x2. �t�c.K�1�Gh �015T S P.O. BOX E. HAMPS (603)329- FAX 603)329•FAX (603) TITLE SUBJECT � 11 _,` �:.Yy T-LAn rL- &AI n If ; DESIGNED BY ^,DATE. CHECKED BY PROFESSIONAL STRUCTURAL ENGINEERING DESIGN SERVICES J U t3 J SHEET lU N 0 . w.;.Z._�l O NO. bS DATE '_k i L :`a v -T � FILA L) SAuv W ►cR, R ctxo STI FSG,-�` . EZ� i�laaiL��dl -P°s C.QQSS SOL II?'UCrINC P.O. box 958 IE. MAMI MA0, NH 03826 (603) SW5540 FAX (603) 329-6406 RESIDENTIAL • PROFESSIONAL b Sl RUCTURAL ENGINEERING DESIGN SERVICES TITLE �1�V 1, ?t.1 I Eu (J EST .) NO • 47.rtQ38 JOB SUBJECT T�C� $En ravP�'eRT D�TA1 _� SHEET NO. -•ab DESIGNED BY&6-HOLES DATE CHECKED BY DATE 9/ FOR 1/2" P BOLTS— PAGGERED FOR TOP IQE OF 5TEEL PWE NAILER 2x6 (TYPICAL) /� TOP OF FOUNDATI OR PAD STRUQTURAL STEEL SUPPORT BEAM � (E 4" 0 SCHED. 40 K� STEEL POST (TYP) DETAIL -A (l -PLACE .). . N 0 SCALE CAP PLATE It 1 /2••X5"x5'• t11„ Z I �t'A�� �ASCS. p PR�u.1 Nc, vt iG 1/2"x5"x5" �t,.�aCKntL'�tLi cH1�.�Il1�ticLaaA�? BAIL I'�ATt i .. e FAX (00 329-6406 M PROFESSIONAL STRUCTURAL ENGINEERING DESIGN SERVICES TITLE u V ESTJOB • NO, Gy-„y03c SUBJECT S” :S0?F44TL-T _ SHEET NO. DESIGNED BY DATE ,.1�-8L*6.,.CHECKED BY DATES.._.... 9 I" HOLES FOR 1/2- 0 BOLTS 0 O.C. STAGGERED FOR TOP PLJ�Tr' NAILER 2x G (TYPICAL) TOP- OF ---, FOUNDATION OR PAD W N? --x 45 PORT BEAM �j .i i I! tL 4" 0 SCHED. 40 STEEL POST (TYP) MELD CAP Pt AIE R_ 1 /2"x5"x5" x5"x5* 'IV R 1 /2"x6"x6" W/WELDED -0 EMBEDMENT STRAPS Q (TYPICAL.) ( PLACES) BAR 1 /2'x 12" (TYP 4_��j 4 PER PLATE top DETA I L- Al (1^ PLACE) N 0 SCALE 6 P.O. BOX 958 E. HAMPSTEAD, NH 03826 (603) 329-5540 FAX (603) 329-6406 RESIDENTIAL • PROFESSIONAL STRUCTURAL ENGINEERING DESIGN SERVICES TITLE ��y��Nl=�1.1 gipc- y-1 Cg EST .� JOB 3 SUBJECT —T AA el cT�i L� lc:. SHEET DESIGNED BY DATE h-11121 CHECKED BY DATE Soli 1 S .Y�t']' 1111, - �I.ySYI ��C�1Y►1 P.O. SOX 958 E. HAMPSTEAD, NH 03826 (603) 329-5540 FAX (603) 329-6406 RESIDENTIAL • COMMERCIj TITLE t�1.x.,1 �\Q �t \r,'E,1,ic.`g„ SUBJECT Wll -%\Z)k �ONr a, lA€ ELr,'\L0'r PROFESSIONAL STRUCTURAL ENGINEERING DESIGN SERVICES EST -� NO JOB S SHEET NO. DESIGNED BY �1iv� DATE 2 CHECKED BY DATE to_r !AfLL,l\,\D 10Ck LL P - �aow not = I b-1 C)PLr Sx w 158,1 i In,) iZ,xyb Ll) 4 641�ics � a Ic. P.O. BOX 958 E. HAMPSTEAD, NH 03826 (603) 329-5540 FAX (603) 329-6406 RESIDENTIAL • COMMEF PROFESSIONAL STRUCTURAL ENGINEERING DESIGN SERVICES EST • N0.�. JOB SUBJECT �.i.TECt.' �JCt. �'l c� ��" SHEET NO . DESIGNED BY AT£L,S.3L=LCHECKED BY DATE DSS i G O IJ .'-V' D, p� S cA&.,p 4-� sNv Seri vux ?S sT s- r�'L_\a a gal �€.�r� ; � � '� .��� �. 22-t- `,A Z: -a' ENERGY CONSERVATION APPLICATION FORM FOR LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS 780 CMR Appendix J (effective 3/1198) Applicant Name: J r=tdkiFE 12. � ) OI-t(i Ota UE. I Nt ^N Applicant Address: Z I'S G-ra,0w-N U 1 tri 1t. -a h► . Or N Dov my-- Applicant Phone: Compliance Path (check one): Site Address: ZIS 6-aP m U IU-#— Roa,P City/Town: N d R-1-1.4 A N 0 cy e�- Use Group:�- Date of Application: Applicant Signature: 0 PresCAPtive Package (Urnited to I. or 2 -Family wood frame buildings heated with fossil fuels only) Package (A through Kit from 'fable J52.1 b): _- Heating Degree Days (FODa5) from Tebte J5.21a:_ (For Items d. through i, fib in all values that apply from Table J52tb:) a. Gross Wal Area sqA f. VlFatl R -Value R- b. Glazing Areal. sgtt. g. FIoDiI' R -value R- a a Glazing % (1W x b T a) % It Basement wall R- d. Glazing U -value tl= i. SW PerlineW R- et. e. Cei ing R,vahn R- I. Heating AFUE 0 Component Performance: "Manual Trade -Off" (Limited to wood or metal famed buildings only) Climate Zone (from Figure J6.2.2) 0 Zone 12 0 Zone 13 0 Zone 14 Attach Trade -Off Worksheat from Appendix J, [and HVAC Trade -Off Worksheet if applicable) 0 MAScheek Software Attach Compliance Report and Inspection Checklist printouts. 0 System Analysis OR 0 Renewable Energy Sources Attach Mass Registered Architect or Engineer Analysis ALTERNATIVE FOR ADDITIONS ONLY: a Gmw Wali + Cding Area Z 13 sq.fL b. dazing Area' 2'l 60L c. Glazing % (too z b + a) 15 �h )( ADDITION with Glsaug % (c.) up to 40% cwy use 786 CMR Table J1.1.2.3.1 below: MAXIMUM it -value MINIMUM R -Values Fenestration Celling I Wail Floor Basement Wall I Slab Perimeter. Depth 0.39 R=37 R 13 R-19 R-10 I R-10. 4 It 0 "SUNR00111" addition (greater than 40°A glazing4o-wall and ceiling gross area) Attach `Consulner Information Form' from 780 CMR Appendix B. Official's Name: Official's Signature: Application. Approved 0 Denied 0 Date of Approval/Denial: Reason(s) for Denial: (provide additional details as needed on back side) 'Glazing Area nW be either Ralgh Opening or U+4t dmenslooe BeRRs 08/12/98 t ✓fie �amvino�zt�/P,a%� �'✓,��,�oac�utel�i I BOARD OF BUILDING REGULATIONS r License: CONSTRUCTION SUPERVISOR Number• CS 072425 Birthdate 1 011 311 964 Expires .1 0,./_l_3_/2003 Tr. no: 16618_ Restricted ,1 G_ -- STEVEN P JACKSON _ `30 KOPERS LANE* PELHAM, NH 03076 Administrator ` CONTRA CTO of $u� ldg R�g�itations and 5tan�tards MENI' i �CTOR j HOiIIE IMPF�QVE ! I JACKSON VEEN 30 K6PEI P.ELHAM, Nr+'Wv— I B NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: �1 (Location of Facility) Si tore of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector S. P. Jackson Building and Remodeling L.L.C. 7/28/2003 Page 5 9th Payment due upon installation of tile floor $4,500.00. Final payment due upon completion of work for $2,549.00 I, (we), the undersigned, understand and accept the above contract. Per Massachusetts Building Code, homeowner has 3 days after signing to cancel contract. o° LLJ 0 amz U 0 a3� o U `fw o a w p . Iwo) O y w O ° w° N a cn A Gq 0 -o w° x o a4 v 0 U G w a o w a w W x o w °i w O o a: ° i r: 1 co o cn o cn o° LLJ 0 amz z 0w w P-4 AQ P O p c CO3 CD y .O 'E. m m CL t O � �3 -v a� OQ CL i O O a. CL CMCX CA C Cc O C O C Z O 0 CL V y � C C CO2 0 w Cc w U) 0 a3� o `fw o . Iwo) O y V V �C : ea L: w O _ as ma 1 S' m�0 2 :- o a S p c w CM m c S v:mm Cy a c m m v ;D i • y C 41` O y �ECD .9 a8 m 4! _ o cm �o c o a m 0cm C II1 •-.03 Q Cp d0 c = m IDo O. W H C* o y m N m r m m w yr C OC O �. N CL ;M; �E w :Z;a .y Z o LLA a mo- 5 COO CO2 .0 zip co CD ZZa2m� z 0w w P-4 AQ P O p c CO3 CD y .O 'E. m m CL t O � �3 -v a� OQ CL i O O a. CL CMCX CA C Cc O C O C Z O 0 CL V y � C C CO2 0 w Cc w U) I 4W -7 _� - Date. . ...... IN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... has permission for gas installation in the buildings of .......... .......................... at ................................ �=, North Andover, Mass. Fee. . . . -.N.... Lic. Check # n .............. WCTOR GASJNS V . MASSACHUSETTS UNIFORM APPLICATON FOR PERMPT TO DO GAS FMING (Type or print) Date TU I / a NORTH ANDOVER, MASSACHUSETTS Building Locations lJ�org V t) I e LKn e Permit # Amount $ Owner's Name ~�-e ' I hC, t7 � h New Renovation ❑ Replacement ® Plans Submitted ❑ (Print or type) pp �� Ali C� one: Certificate Installing Company Name rltn�yemAS {I�/iCklK Corp. Address —.30 Ct k `r ,r C. ❑ Partner. mc/('1 ry) ric Y*OA D Irr6o Business Telephone o f '78j- 3116-006L/ ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Th. WiF95 %V1 rk-4r INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes, please indicate the type coverage by checking the appropriate box Liability insurance policy ❑ 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. C'.hee* one' Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby cermy that all of the details and mioTmation 1 have submitted (or entered) m above application are true 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 Massachusetts State Code and Chapter 143 ofthe General Laws. riD. _ _ 11k,,,I-- . VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber :' S � %O ❑ Gas Fitter T-lcense Number ❑ Master journeyman 'LOW Date.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING. This certifies that ... ................ .. ..... ......... h�s permission to perform /* plumbing in the buildings of . . .......... .................... ail. .......... North Andover, Mass. Fee.-"�). Lie. No;7;..t,5.,. . ...... �. . �� %4 .... ....... --,,PLUM BAASPECTOR Check # 5 6 7 4 0 t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTSaa, d 3 rj— .� I Date L'y Building Location �l S 6 CA,V r � Ir eft v Owners Name n?e,, ai `� �0� �l na n Permit # ��S •.�� Amount of Occupancy tr e New El Renovation Er Replacement Plans Submitted Yes 0 No El FIXTURES (Print'or type)�/'Cu's n1 Check one: Certificate Installing Company Name IY ` Lu e, �� Corp. Address J O Q/C �� r e Partner. VIM r re7)m y4 0 It -60 Business Telephoneq w- 3 y t U p q ® Firm/Co. Name of Licensed Plumber: ren r '-i 71. '' rpt y� .S / t/ ' f Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate 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 F1 Agent n 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing C and hapter 142 of the General Laws. YK ell, r,� tti! _ ,D (OFFICE USE ONLY Type of Plumbing License ea 5'l-70 icense lNumver Master Journeyman t6,6-2)