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Home My WebLink AboutMiscellaneous - 445 JOHNSON STREET 4/30/2018 (2) 445 JOHNSON STREET 210/098.A-0034-0000.0 �t Location '7 b / �� No. _ Date 6 ,7Y ?-� d NORTN TOWN OF NORTH ANDOVER C? •. Ow r ' Certificate of Occupancy $ sACMUs�t� Building/Frame Permit Fee $ r5 Foundation Permit Fee $ Other Permit Fee $ i TOTAL $ `� Check # /.��_' Building Inspee"for 1 i r� TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED: �3X� 0-4 �• - ad E SIGNATURE: 1AL& twZ��— ldin Commissioner/I t of Buildings Date Z SECTION I-If INFORMATION 0 1.1 PropeR ddress: 1.2 Assessors Map and Parcel Number: hMap Number Parcel Number thi � . 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 Reqtiired Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of ecord r S'Q.yy, e 1 Name(Print) Address for Service: Signature Telephone V 2.2 Owner of Record: Y Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed onstruction Supervisor: Not Applicable ❑ fill Licensed Construction Supervisor: 2 3 jI j jx n)' License Number mns 11- -92 Expiration Date ignature Telephone r 3.2 Register7 Home Improvement Contractor Not Applicable 0 0 fSD Company Name 16 L -1 M J-31 S n J l 4 E� �„� r Registration Number r rM A� 5:L56 ' 9 6 zo Expiration Date ^� Signature Telephone G) 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.......❑ SECTION 5 Description of Proposed Work check all applicable New Construction ❑ 4Y E ' ting Btplding ❑ Repair(s) ❑ Alteration s ) ,;E]+ ;., Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work:' f e I in SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be C;MCIAL.USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number Y SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r r I, as Owner/Authorized Agent of subject property Hereby authorize to act on : ,. My behalf,in all matters relative to work authorized by this building permit application. 312 o s{ Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ; v 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 Pri am , o Si ature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRVWEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE BUILDING DEPAR 1 i DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 S 54,a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: YV Location of Facility Signature of Permit Applicant /02 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector i ��m�,.a..w,�lr.E o�✓�(aiwaLwetle E _ HOME IMPROVEMENT CONTRACTOR l Registration 104569 Type - PRIVATE CORPORATION 1 Expiration 01/14100. DAVID CASTRICONE ROb*(IN6,* SID 1 DaVA*�d T. Castricons t !f t i llside Road ; .1 ! ADMINISTRATOR Boxford MA 01921 ' .J ACOR�3, 08/25/5/ W CERTIFICATE OF LIABILITY INSURANCE ( 1999 PRODUCER THIS CERTIFICATE I$ISSUED AS A MATTER OF INFORMATION INTERNET INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 522 CHZCREAING ROAD HOLDER.THIS CERTIFICATE DOES NOT AMEND,WEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NORTH ANDOVER, MA 01845 INSURERS AFFORDING COVERAGE INSURED W INSURER k TRUST ASSU111ANCZ DIAVID CASTRICONE INSURER B: EASTERN CASUALTY NOOSING AND SIDING INC INSURER 0: 7 HILLSIDE ROAD INSURER D, SIOXFORD MA 01921- INSURER E: C VERAGE$ 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. INSLTP? TYPE OF INSURANCE POLICY NUMBER 11 UCY EFFECTIVE POLICY EXPIRATION LIMITS -� GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 A COMMERCIAL OFNERALLIABILITY TO BE ISSUED 08/06/1999 08/06/2000 FIREDAMAGEAn one fire a 50,000 CLAIMS MADE 10 OCCUR MED EXP(Any one ereon a 5,000 PERSONAL 6ADV INJURY 6 1,000,000 GENERAL AGGREGATE a 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG i$ 1,0001000 Ell POLICY PRO- F^I LOC AUTOMOBILE LIABILITYIQ I COMBINED SINGLE LIMIT ANY AUTO (EsamIdert) S ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (perecodart) $ PROPERTY DAMAGE 6 (Per acoidenl) (G�A_RAIIELIABIUTY AUTO ONLY-EA ACCIDENT $ L ) ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR 117 CLAIMS MADE AGGREGATE 6 $ DEDUCTIBLE I a .' RETENTION 6 $ WORKERS COMPENSATION ANDH- EMPLOYERS'LIABILITY 100,000 s WC V2001976 09/23/1998E.L.MH ACCIDENT S ! 09/23/1999 — El,DISEASE-EA EMPLOYE4$ 500,000 E.L.DISEASE OTHER -POLICY LIMIT $ 100,000 r I DESCRIPTION OF OPERAnONSILOCATIONSNEHICLEIIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ROOFING AND SIDING CeRTIFICATF HOLDER • ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING iNbURER WILL ENDEAVOR TO MAIL 010 DAY$WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 30 SHALL IMPOSE NO OBLI"TION OR LIABILITY OF ANY KING UPON THE INSURER,ITS AGENTS OR REPRESS V AUTHOR E TATIVE ACORD 23-5(7187) RD CORPORATI043'1888- N TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING -1T6i5 See#iog for twxid Use 00-V,-:- WELDING 0 BUILDING PERMIT NUMBER: DATE ISSUED: -677 1 ic SIGNATURE: ldinCommissioner/lEEt of Buildings Date z SECTION 1-Sjj INFORMATIONAhl O1.1 Propett ddress: 1.2 Assessors Map and Parcel Number: { _'V lam— 6 y 4l ` ) d 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 Re red Provide Required Provided Re wired Provided v 1.7 Water Supply M.G.L.C.40. 54) . 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of ecord �Lr Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Tele hone M SECTION 3-CONSTRUCTION SERVICES 7� 3.1 Licensed onstruction Supervisor: Not Applicable ❑ 1j I Licensed Construction Supervisor. O 2 3 j c )' t�� License Number C J yt_ `�/ y� o s ` I ?l n Expiration Date ic ignature Telephone r 3.2 Register d Home Improvement Contractor Not Applicable ❑ sv 'pill Company Name 1 Q M 31 S T-n � A 9' ,^ cz�X Registration Number r I Q J / �V /�f _r r n� L _j G S 3-2 C�aZ O Expiration Date Signature Telephone v' NORTH Town of Andover No. � i 0 C l LA 0 dover, Mass. LAT COCHICHE ICS5 _C;6W K 0"�ATE D P"? \\' Cl BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ...... ............10-04 ......... ............. Foundation has permission to erec .......... buildings on .... ................ .....— e Chimney to be occupied as._,e_U....... Rough 00 L - .0 4 i..............................I......... provided that the person accepting this p9- hall in every respect conform to the terms of'tihiie'...application"*** **"* '"* o n file in ' this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION SS ELECTRICAL INSPECTOR Ery'" Rough ................................................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough No Lathing or Dry Wall To Be Done Final Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. NORTH Town of No. . .. . ....... o Q L A O dover, Mass. I. COCHICHE WICK 1' Jr ATED p`Pa��S BOARD OF HEALTH Food/Kitchen PERMIT . T D Septic System THIS CERTIFIES THAT................. BUILDING INSPECTOR Foundation has permission to erec buildings on ., -., Rough .. ..................... to be occupied as.— A,...... ......,.. ...... ......... ......... . . ..... .... . ..... .... . . .... . Chimney provided that the person accepting this p it shall in everyrespect conform to the terms. ..of...the.application. .. . ..on. ..file..in.. this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTIONSS ELECTRICAL INSPECTOR jo� 'T' Rough ................................................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough No Lathing or Dry Wall To Be Done Final Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. Date.(..Z.."'. .'OSS NORTH °f'"`°:•1"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACMUSEt This certifies that ....:... `.......-.:: ...-.......�=............ ................................ has permission to perform ....., - ... '... �-- -f.?.- ''",........ wiring in the building of `' �5 . - North Andover Mass. at..........:.. .......0...... ...... ..........f I , Fee, ............. Lic.Nc5r,7/ r�1 ............ t ..�JAA:�..: ... ............... 7` ELECTRICAL INSPE R Check ti DEFAXIBOWOFPENZ94MY Pedt No. w BaMOFFMPREVEN7 ANRBOCL4?XM1S2laMLLSPy� Fees – Checked A.PPUCATION FOR PERMIT TO PERFORM ELEcnuCAL WORK ALL WORK To BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSrS MSCTMICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL lIM MATION) Da Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical wort descri bed below. Location(Street 3 Number) jo 4VSa n Owner or Tenant De v 11D t4/ Owner's Address Is this permit in conjunction with a budding permit: YeaE3 No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service AmpsVolts OverreadUnderground IM No.of Meters / New Stsivc� �� Amps//�� nits Overread R Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work cam- cAny-e� No.of Lighting Outkn Na of Har Tubi No.of Tnnibnoln Told No.of UBhting Fixrma Swimming Pouf Above &�, OatI lei KVA KVA No.of Re*ub Ou" No.of Oil Bernws No.of Emergency Ughting Battery Unit's No.of Switch Outlets No.of Oes Bemars No.of Ranges No.of Air Cond. TOW FIRE ALARMS No.of Zones Tool No.of Disposals No.of Hat TOW Told No.of Deacti000 and Ps Ton KW Initiating Devices No.of Dishwulian Space Ams Heathy KW NO.of Sounding Devices Na of saK C Jained Owectiao/Soonding onim No.of Dryer Heating Devices KW Loadtt mukipal O No.of Water Hasten KW Na Of No.of EDConnections S BallesM No.Hydro Massage Tabs No.of Motors Total HP 4 '` ttxs>3naeCovasg�Ptamottbfertx}imebotivla�dssttlrQemiLawa 1h�eaaa��tLirbiyhsstxFbicyir�rdr�llornpiet ori ritidegtiyalat YM NO a IhwWbrtibdvsi PMf0fstmeloheCft Y$4 ryoubredrededYEMpkaird Lgpe(lfwmmwby PELRANCE BtxD 1:3 an= 0 rleeseSpediSr) BgtioliooDie WadtbS�rt /� / a� Eft*dVatlecfllzt WWak S Irapedi<nDteRer} lurid Sgrredunk Pa�bofpecpl►. E�tMNANE Li=Nb, lues .G Pp�l ��y� .S Vol= BuskSTliNa AdJeNa ,� ✓ aWMrSMMANMWANFR;IanauYaefrl d-T#cala: �lheitetsarrne A!Tel.Na arctthrtrrWsipMcnlhbpearftMp—lot mmulmakirrlem 0� 0�' �1°��bYMaasadsaasDtGmahlLaat (Please check one) Owner a Agent f Telephone No. pgRM[f FU Ili W0FPEWxSAFW BCWRDOFFIIf�P�RJ JZA11l�M1tSSd7C11Dt12� Lhimd�t Ra Checked .��. APPUC'ATIONFOR PERMITTO PERFORMELEcnuCAL WO ALL WORK TO BE PEUORMED Rr ACCORDANCE WrrN TFB; +u� MASSACHUSSTS ELECTRICALCO (PLEASE PRINt IN INK OR TYPE ALL INFORMATION DB,527 cMR 12:00 Dam /, Town of North Andover To the Inspector of Wires; The undersiped applies for a permit to perform the electrical work described below, Location(Street A Number) 4«t S Jo iYS�✓ S I} Owner or Tenant � C owner's Address is this permit in conjunction with a budding permit; Yes No (Chea Appropriate Bo)L) Purpose of Building Utility Authorization No. Fatisting Service Amps// ,,Volti Ovedwad Underground No.of Meters / New Service ,r 0 Amps//- /L'��Volts Overhead Eg U . � ��d C3 No.of Meters Number of Feeders and Ampacigr � Location and Nature of Proposed Electrical Work ;n �� - r�An y v Na of Usbdns Outlas Na of NO Tubs No.dTrurimm" Total Na of Lighting PlMM Swintating pont Abo„� 0 BeiowKVA vound Osaenton KVA Na of Receptscis Oudde No.of Hwows Na of Emeraeacy(ja�na Hapary Units Na of Switch Outlets Na days Bwnen Na of Ranass Na of A4 Cond. Tod FIRE ALARM No.of Zana.�,Ili Taos Na of Dispasis Na Of Hest ToW Na ofDacdoa and PUMP Ton KW Initialing Devion No.of Dishwuhen Space Ara Hptin KW NL Na of Sounding f� Dwioss contabw No.of Dryers Hesthy Dsr(osKW Locd MuWdpd ot i No.of Wats Hester KW Na Of Na of Cennecdan 3111011 Bdlds No.Hydro Musep Tubs Na Of Motor Total HF t 'ate CMWF AN 1Dtzx@*m>a>ticfil'tas dlrilCimmlL" lhneaa=1Liit*jsarczFckm ftCM#* oris rsitl lhare i�dvaidplmfdsenedn t20ffi ym �°"' e4" o C3 � ` h�e �, p� NgRANCE f771 BCNDoOM WbilcID tst �� z' j Rec}z�d EAn*dVAzdEh'ftW* W unk Fknftcfpdjiay. � firr FIRM LimaNa LicasleI+lo �a OWDWS1IV5URANCEWAIVH-1=m a tm*zLcaadmughmlher mme ALTdNn *r xdd*ffWerzondibpeQnitappicatbtvtsitmt�ire4imlmt � o�s'��e a° �dbYM�dastbCmdLaiM (Please check one) Owner Apo W Telephone Na PER Mtf FEES �Z5 7 5 6 / Date. NORTF� 1 o? TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 4,5'0•. o.•'�tqh � SACHUSE This certifies that . . . . q. . . . .�. . . . j. . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . ill.-t. .S. �•r/. . . . . . . . . . . . . . . . . . . . . . . . . . . at . . G��/. �� . . :�. G./ ,.r . . . . . . . . . . . North Andover, Mass. c� Fee..) ��. Lic. No.. Check# AS INSPECTOR t 7 j , MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING t, L . �,Mass. Date I —Z 3 20 1` Permit.# Building Location 41 & J, E± Owner's Name j _ Z", /<c ff Type of Occupancy WNew ❑ Renovation ❑ Replacement C2- Plans Submitted: Yes•❑ No❑ 0 F ¢ z z 14 W � x vQw 1>1 � Nzw ¢Gx � 94 �~ Ax Hx W -) z 0 0a IQ, ° H1 ao 1 SUB +-BA7�SwETMENT BASEMENT FIRST IST FLOOR SECOND 2ND FLOOR THIRD 3RD FLOOR FOURTH 4TH FLOOR FIFTH 5TH FLOOR SIXTH 6TH FLOOR _ { SEVENTH(7TH)FLOOR EIGHTH 8TH FLOOR installing Com any Nael e)(&2 'e�-f'/t/ryj{fir Address C 'rnr� r _ _ Check one: Certificate Corporation Business Telephone ° ❑� �Partnership Name of Licensed Plumber or Gasfitter 4 �� r tgrtrm/Ca. INSURANCE COVERAGE: I have a current liability surance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes fr7' No❑ If you have checked es,please ind' to the type of coverage by checking the appropriate box. A 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 MGL,and that my signature on this permit application waives this requirement. Signature of Owner or Owner's A ent Owner ❑ Agent Q. 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type ofLicen�se�� ,t, /1� Title ❑ Plumber Ur1 Master Signature of Licensed Plumberr//Goasf City/Town ❑ Gasfitter ❑ Joumeyman License Number /iZ a I. APPROVED(OFFICE USE ONLY) I� c. Date .. . "pR'M TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CHUsf� This certifies that l/ has permission to perform . . . . . . .l . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . .�/ . . . . . . . . . . . . . . . . . . . . . . at , North Andover, Mass. Fee . )�. Lie. No. ,1.� �.�.�. . . . . . . PLUMBING INSPECTOR Check ." MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING ). ` (Print or Type , zo Oik -N tz -�_ Lt, rl Mass. Date /— Z 49 �� Permit# Building Location I/VS— It b ti R �9 t Owner's Name Type of Occupancy New ❑ Renovation ❑ Replacement F-1 Plans Submitted: Yes ❑ No ❑ FIXTURES z a C-9 co -j GO0z r� t� cc ww wca M CC z cc z W CO 11 CL D 0zMMrs039 0 w �- � COZiCau- c` a. 009 ¢ w0Zw `t n `x COCCI Baru- LL HOO cp t _ � -C _ � T n � 0 d cc _ d 0tc � 01CC 0tcl- - - � .� tr � mr9aim -j � zF-- GoLL. a : 0d39immO SUB-BSMT. BASEMENT 1 ST FLOOR 2ND FLOG 3RD FLOG 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR nn-H . . . . .. Check one: Certificate Installing Company Name1Q&a'L'erP1i149 ❑ Corporation Address,m ❑ Partnership ye-a O/C700 ®'Rrrn/Co. Business Telephone •- W- Q/ Name of Licensed Plumber 1' 16 INSURANCE COVERAGE: I have a currentf+' bility policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes L ' No❑ if you have checked yes, please indicate tie type coverage by checking the appropriate box. A liability insurance policy C9' 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: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information t 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 342 of the General haws. By ts Title Signature of Licensed.Plumber CitylTown Type of License: Master Bl**' Journeyman ❑ APPROVED (OFFICE USE ONLY) License Number 2Z�