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HomeMy WebLinkAboutMiscellaneous - 46 WINTERGREEN DRIVE 4/30/2018 (4)Date . � / �/� o 8758 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACH'i lY This certifies that l:.......... . has permission to perform ... 13 .f.. ......................... . plumbing in the buildings of . .--T ..................... at..r ................... North Andover, Mass. Fee. 7P .. Lic. No../ . ......... � ............. LUMBING INSPECTOR Check # r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: ,i✓Lr1�r�/� /7�% , MA. Date: /414 / Permit# Building Location:'"c'z- lery �1 V-- Owners Name: /re 4 Z�94e Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ No FIXTURES f INSURANCE COVERAGE: ' I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes*No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Aaent Knowledge and that all plumbing work and Installations performed under the pe Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 zy i itle City/Town _ APPROVED USE ONL Type of License: Sign fding this application are true and accurate to the best of my sued for this applicati rf will be In compliance with all General Laws. n License Number: r DEDICATED SYSTEMS LU w O v 0:Q Y iii 0 O Z d W ? ~ Z H N Z Q H CCLA G fA 0 Z M F'- Q W H W ~ 3 Q m N C 0 D Q W z Q Z > = W Q z Y Z "' W Z u a x LL = d a W 3 LL H 3 Q K 3 i O LL W a = W W O N H LU Q Q H V1 G O OJ ~O H > g > OO = Q OC a 3 Q 3 Q 3 U Q 0: 1 Q a m m LL S W o: �, ►- 0 a Q U) 0 SUB BSMT. BASEMENT 1" FLOOR 2"o FLOOR 3RD FLOOR 4T" FLOOR ST" FLOOR T" FLOOR 7 " FLOOR t3T" FLOOR Check One Only Certificate # Installing Comp ny Name: ' Corporation Address: City/Town: State: ,,5 ❑Partnership Business Tel: `7 �l"�� Y Fax: (�� 1e - / pp/� 6 7- � e� i� ❑ Firm/Company Name of Licensed Plumber: �- f INSURANCE COVERAGE: ' I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes*No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Aaent Knowledge and that all plumbing work and Installations performed under the pe Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 zy i itle City/Town _ APPROVED USE ONL Type of License: Sign fding this application are true and accurate to the best of my sued for this applicati rf will be In compliance with all General Laws. n License Number: r z 0 F U W a W c7 O a. C7 E- Q a O a cG �' Q w O w 0 x u U w � z 0 F W x to z W � .a a z 7 0 City/Town: AJAxM66 Plumbing & Gas Inspector: Date: / p� would like to cancel permit # For the installation of In my my home/address C Climate Designs, LLC has completed the installation under the existing permit. M Work to be completed under the new permit will be the final inspection. Sincerely, Location q * lA) • No. Date NaRTM TOWN OF NORTH ANDOVER • Lp F i Certificate Occupancy $ of 'SsncMusE< Building/Frame Permit Fee / `l $ L Foundation Permit Fee $ Other Permit Fee $ TOTAL $ L U Check # 0 I. �-- 1 6 1 9 9 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: I0Lha 19 3 Map Number Parcel Number [ ti 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS B Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private 0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record ��am Oant p A dress for Service igna re. %��J,� �J� telephone /j� ` �f E P14 0 4, UJ S4,0 C�a' 4 2.2 Owner of Record: I Name Print Address for Service: r Signature Telephone ECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 'Company Name Registration Number Address Expiration Date Signature Telephone ,Z 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 atl applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ JAddition ❑ Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFI+`ICIAL IJSE ONLY 1. Building (i G (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 SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT T_ as Owner/Authorized Agent of subject property Hereby authorize to act on My MainJall afters ative k rarized by this building permit application. r e 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 Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3 SPAN DHvIENSIONS OF SILLS DIMENSIONS OF POSTS DR ENSIONS 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 j The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation .insurance Afdavit Name Please Print Name: ,t'��il010 /I' /' F LocaiionFCi.df�G5/W 1Ir 4) /?.. cit, 11jo lJ e Phone #- 06 r - F 1 I am a homeowner pertonningi all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensationfor my employees working on this job. Company name. Address Cibr: Insurance Co. Policy Comoarn name. AddQesa Folure to se=ecoverage verage as requlnr¢ under See ion 25A of MGL 152 can' lead tothe iqgcis." of criminal perces ofafit and/or one years' Imprisorrnent.as s:n47 m The EmafaSTOP fine -f j-ajlay understand that a copy of tins statement may tie:ftmarded to the Office of Investigations d'ft DIA for coverage verifcalioit, / do hereby eaertiy under the pains and pena/tias ofpenury that the Morma6w pro+ A*d ab" is true and eaofrect Signature Vate Print name Pbom-# Official use only do not write in this area to be completed by city or town dfidar City os Town 0 Bt�ilthng .� (]Chmk ifi immea6ate mspmse is reguin d Selectma/ Contact person: Phone #: i] Health De, Other 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 a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location(df Facility) J //- I -Ir Signa ure of Permit Applicant k,6 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Tel: 978-688-9545 Please print. DATE (i JOBLOCA mber "HOMEOWNER O ' Town of North Andover * c Building Department ' °?4 ��-•°' 27 Charles Street �9SSACHUSEt� North Andover MA 01845 HOMEOWNER LICENSE EXEMPTION f Number '-tome PRESENT MAILING ADDRESS UIZ, (4Z_ City Town Address -400 �- Section of Tc q7J`_ 1 hd Phone Work Pho i Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of 1 or 2 units and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section (108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which of two there is, or is intended to be, a one family dwelling, attached or detached structures accessory to such use and and/or farm structures. A person who constructs more than one home in a. two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 108.3.5.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedL HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFFICIAL Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. Revised 4.30.03 Home owner Exemptions Form . rd ,; Date. !. � r> � TOWN OF NORTH ANDOVER - ' PERMIT FOR PLUMBING 49 This certifies that ...P. .......... • .. . has permission to perform ..............?.:,.?f ....... plumbing in the buildings of�-1''- ..................... at ... i .. t J -v ......... .............. , North Andover, Mass. Fee-'�.. f. Lic. No. r-5.. �� 5 ............. PLUMBING' PSPECTOR G Check 0 73- 5874 0 I MASSACHUSETTS UNIFORM APPLI (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Loc New M Renovation ON FOR PERMIT TO DO PLUMBING f f �� # Date - )wners Name Permit # �$ � Amount of Occupancy cg Replacement F1rYT1 TID V Q Plans Submitted Yes No (Print or type)Check one: Certificate Installing Company Name Co Address l -- /u/� 1C _ � Partner. U, An iAg3, iezo Business Te ep one — Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type Sf insurance coverage by cflecking theappropriate box: Liability insurance policy 'X 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus� State Plumbinj)Codgand Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License AL k"9 icense Number Master Journeyman .i .N .M`D D , , ..o mmsmmmmmmmmm OMMMMM��■��� „WMMMMW.=MM®WWMWMM MW� (Print or type)Check one: Certificate Installing Company Name Co Address l -- /u/� 1C _ � Partner. U, An iAg3, iezo Business Te ep one — Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type Sf insurance coverage by cflecking theappropriate box: Liability insurance policy 'X 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus� State Plumbinj)Codgand Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License AL k"9 icense Number Master Journeyman /` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION I �SSAC HUSE` �(7I% l �� This certifies that ... ......... ............ ......... . has permission for gaf installation . e.I a..,. 1. to.2 in the buildings of ./4. 1e... &.. //.. k./. y.�� ).�........ at .. 'el, � ....//'. -' � !�7� :. , North Andover, Mass. Fee. ���. ... Lic. No. � / b �j .. / ::"s?.'' .............. . q0 1 � JGAS INSPECTOR Check # / 45 4" 4 JP�E MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) >/A(('h%i�� Mass. Date Nov 14—d<) Permit ti ,/ /f , / Building (option J Owner's Name /f'! Type of Occupancy(°/ lig New p Renovation ©,-' Replacement ❑ Plans Submitted: Yesp No (g/ Instafling Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET i$ Corporation 103C MIDDLETON, MA 01949 ❑. Partnership r Business Telephone 978-774—'2760 Fart/Co. .Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRIS NSURANCE COVERAGE: I have a current liability Insurance policy or Ks substantial equivalent which meets the requirements of MGL Ch. 142. Yes M No ❑ If you have checked Yes. please ksdicate the type coverage by checking the appropriate box A liability Insurance policy Q Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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: Owned Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are tru an a rate to the best t knowledge and that all plumbing work and installations performed under the permit this applica I pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen By TjGa of license: Plumber Signature o tuber ar mer Title sftter Master license Number 3785 City/Town Journeyman APPROVED( I NL n � s W N Y = Q ri y ry Q W y rL Q O O V m fd S ycJ v < ¢ y= Cl 0 - c -y W =.m s A W W h .19 J Z WW<¢ = Q 0 I.- ° 1- V S F Ix 2 < W P u < b �. W t• W 1P. M O> m 2'0 ri t- 2 W J O M W S < ry > Q W z t. < r. < < O O W E O tM 1- sue—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TK FLOOR ' 6TH FLOOR Instafling Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET i$ Corporation 103C MIDDLETON, MA 01949 ❑. Partnership r Business Telephone 978-774—'2760 Fart/Co. .Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRIS NSURANCE COVERAGE: I have a current liability Insurance policy or Ks substantial equivalent which meets the requirements of MGL Ch. 142. Yes M No ❑ If you have checked Yes. please ksdicate the type coverage by checking the appropriate box A liability Insurance policy Q Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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: Owned Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are tru an a rate to the best t knowledge and that all plumbing work and installations performed under the permit this applica I pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen By TjGa of license: Plumber Signature o tuber ar mer Title sftter Master license Number 3785 City/Town Journeyman APPROVED( I NL L Date.. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... --�- �'� • • •/J' �"� has permission to perform ........... ...t�:. .. . . plumbing in the buildings of.......,{�................... at. ����. v/ .......�! • ....... North Andover, Mass. w.00 Fee ...... Lic. No.. . ....1202 x .............. . PLVM 1NG INSPECTOR Check # c%9is`Sy 7413 ,4nl ;iF ' ?,� i. �1l€{ p l + We aE a P, e. E E •.s�F € E�.e et u<{'� r l,.F �f F3 n fi-i'Gt(� .T. (T,'-, .F nit t, {11?F„i ti 1<t a �..-nT. �� 1 - /h! ,G,v ✓ !!/ C;•'c j�' t -a.....»..a-.- '� - - ...,. /VY�.v•6.[-tc„Vf�rr4..f?+F.E: �'l% E�fE'rrf.'�t•.�[�.,`�!. I�f,., 0,.f�.„a,...! ' ���L1T E� T:;Iper.'i G .G/ 14r'«lTt :J "iereOv ° l...e I'� i). tica,t pa t�.eE�t � Pia:r°rs ,{-abrsllttvi: Yes ❑ C`qEaT-17- �l FIXTURES 76 M Z cc z h C� W E6 ` �. � tat ® a QX a�3 SG O u. 0 LC J N < x z �° z s rr. 0 m a Sind-OSMT, BASEMENT IST FLOOR 2N® FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR �6THrf Installing Company Address Business Telephone CLIMATE DESIGN HEATING and AIR CONDITIONING, LLC E Name 5 South Summer Street Check one: e..emficate Bradford, MA 01835 978-372-9999 (phone) /Corporation �(�. 06, - 11 978-372-0882 (fax) =' Partnership �— Lic. plumber `,DAD f Name of Licensed Plumber ' q INSURANCE COVERAGE: I have ayes encurrent liability nsura ce policy or tts substantial equivalent Which meets the requirements of MGL Chi. 942. It you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy Z Other type of Indermnkyy ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am awrare 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: Agnature or Owner or Dwner's Agent Owner ❑ Agent (] I hereby c0rW that all of the details and information I have submitted for entered) in above - knowledge and that all plumbing work and installations Perl& Bred under the permit iss md {� kation are true and accurate to the best of my' Pertinent provisions of the Massachusetts State Plumbi=CddOwler�11P 0filia neral ��plication-will be in compliance with all BY. d...� Title Yon 'J-1 e o bcensed umber _ Ty fLicense:Master�'� Journeyman ESR fO SIG` `'JNA L') — License Number 4� Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... .... . . has permission to perform ........ ....... ......... wiring in the building of ........ G.J.wA.-I ...... 4LOL .................. at ..... .. ............ .... 201, North Andover, Mass J, Fee .Ji� .......... Lic. No. . .' S'�"- LgC (INS EP CfOR Check # eAL 4550 ?ie�rauixust od u�ie Sa�a� BOARD OF FIRE PREVENT& REGULATIONS 527 CMR 12:00 Permit No. � Occupancy & Fee Che( APPLICATION FOR P RMIT TO PERFORM ELECTRICAL WORK All work to be performed: n ac rdance with the Massachusetts Electrical Code 527 C R 12:00 (Please Print in ink or type all information) Date G To the Inspector of Wires: Town of North Andover ` The undersigned applies for a permit to perform theelectrical workdescribedbelow. Location (Street & Number Owner oi;IeaaaC k I — Owner's Address Is this permit in conjunction with a building permit Yes 0 �'41 No 0 (Check Appropriate Box) Purpose of Building S /~ D/v G F Utility Authorization No. Existing Service Amps New Service Amps Voits Number of Feeders and Ampacity Location and Nature of Proposed Electrical -I& Voits Overhead 0 Undgmd 0 Overhead 0 Undgmd a S,e GAG t F.4 X,t., A — No. of Met( No. of Met( INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivatent YE = NO - ( have s bmittied valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box. {�/enOG•Gv-l+L� INSURANC - BOND - OTHER - (Please Specify) 111 JJJ " C (, ` 6/ (Expiration Date) Estimated Value of. Electrical Work� Tl�d , V Work to Start Inspection Date Resquested_ G' Rough Rnal Signed under the Penalties of perjury: FIRM NAME LIC. NO. Address OWNER'S INSURANCE WAIVER: General Laws. And thatmv siam ent) Vv;v'v- t , Gid` 6,47 /?� 1,0 77 7 qLf,�, NO. Bus. Tel No. Alt Tel. No. i aware that the Licenses does not have the insuranage or its substantial equivalent as required by Mass on this permit ap lication waives this requiremen Owner Agent (Please Check one) 3 Telephone No. A BGG — PERMIT FEE v qV--vi-Y)w 1�10glr Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above 0 In 0 No. of Lighting Fixtures Swimminq Pool gmd 0 gmd 0 Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone _ No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices _ Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices NoJ of Self Contained — No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices 0 Municipal 0 Other No. of .Dryers Heating Devices KW Local Connection No. of No. of Low Voltage -- No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivatent YE = NO - ( have s bmittied valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box. {�/enOG•Gv-l+L� INSURANC - BOND - OTHER - (Please Specify) 111 JJJ " C (, ` 6/ (Expiration Date) Estimated Value of. Electrical Work� Tl�d , V Work to Start Inspection Date Resquested_ G' Rough Rnal Signed under the Penalties of perjury: FIRM NAME LIC. NO. Address OWNER'S INSURANCE WAIVER: General Laws. And thatmv siam ent) Vv;v'v- t , Gid` 6,47 /?� 1,0 77 7 qLf,�, NO. Bus. Tel No. Alt Tel. No. i aware that the Licenses does not have the insuranage or its substantial equivalent as required by Mass on this permit ap lication waives this requiremen Owner Agent (Please Check one) 3 Telephone No. A BGG — PERMIT FEE v qV--vi-Y)w 1�10glr m m X m m EPmm v■ H CA Cl) C � � d 'O O az CA CD CL o �, � � o d� CA aC o O CD co O CC � CTG ? CD CD o CD CLD y �■ O CD C =� o O e a< Q I _ EL" O m CO) 7 a m c ; m OH � * C Z -- �-C H O. .0-► �vlo m =r O y m .1Omy p 4 O P='rOm m = m -00 ® O t0 O m d O N CD CA O m . A m o s ?'� m omy b a n� a 3 t . O o 10 0: CL C=r vJ O0" �••� ' r'19 y � � m fG cl e -a l J X-9 ® ® a o z � gat s c� 10 m CO � . cn cn H :00 li oq W d ♦ W = C=oCA � C 0 omi 0 9 '�7 O y b '�z7 DC7 rC&ro � ',:tib r to � �r1 n qd •r7 o b t b •r1 8 n � x