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HomeMy WebLinkAboutMiscellaneous - 475 GREAT POND ROAD 4/30/2018 (2) 475 GREAT POND ROAD _ 1, 210/064.0-0071-0000.0 I Date.!.` . .�j. ..... V ,tOF T1{ Of ,°1,x,, - 3r TOWN OF NORTH ANDOVER t - PERMIT FOR GAS INSTALLATION �1SSACMUSE� This certifies that ! - . . . . . . �... . . . . . . . . . . . . . . .!1. . has permission for gas installati A—'�-6.y' ---?—-�. . . . . . . . . . . . . in the buildings ofd .. `.ra':��i".. . . .. .... . . . . . . . . . . . . . . at V � ryAndover, Mass. J Feer.'''. Lic. No .,.� �r GAS INSPECTOR Check# 7048 MASSACHUSETTS UNN ORM APPUCATON FOR PERMIT TO DO CAS (� (Type or print) Date /,7) NORTH ANDOVER,MASSACHUSETTS Building Locations 7 r74—' "r'� Permit# -2&,1,P Amount$ 75 Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ o U F x oW F F z Z O F W �' F W� O a0. C Z < U W CG W O W V' F ZF d F W Grj C� 0 (Fy W U /� W w > w z ¢ a d �¢ o o w p w m o x w 0 3 o c7 .a U a > SUB -BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or L Check one: Certificate Installing Company Name 7 Corp. Address P er. BusinessTelephone --- �---- Firm/Co. Name of Licensed Plumber or Gas Fittel' 1, G �j INSURANCE COVERAGE Check one: I have a current liability Insurance icy or it's substantial equivalent. Yes13 No 0 If you have checked,yes,pleas ' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity C] 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 0 Ag I hereby certify that all of the details and i formation I have submitted r ent )in above plicat' a true and accurate to the best of my knowledge and that all plumbi work and installations perf rme der rmi sue s application will be in compliance with all pertinent provisions of the e, ha ter of th eneral Laws. B Signature of censed P ber Or Gas Fitter By: Title umber /6-3 U/ City/Town Gas Fitter Licenst Number aster APPROVED(OFFICE USE ONLY) ❑ Journeyman The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of fnvestigations 600 Washington Street Boston, MA-02111 www.massgov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaplicant Information Please Print Le2ibiy Name (Business/Organizadon/Individual): (AA6 "C� Address: City/State/Zip:—��� Q/ Phone#: Are a an employer? Check the appropriate box: Type of project(required): 1. I am a employer with�_ 4. ❑ 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 in any capacity. . workers' comp. insurance, g, 0Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[1 Electrical repairs or additions 3.❑ 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 12,0 Roof repairs insurance required] t employees. [No workers' comp. insurance required.] 13.❑ Other �•••y applicant,wat checks box R, ...;:s<a„o..Il ourt the section below showing their workers'compensation policy information. t Homeowners 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. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:_ , Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: l 6VT r- 1 V 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 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, well as civil penalties in the form of a STOP WORK ORDER and a fine . against the violator. Be a ise that a copy of this statement may be forwarded to the Office of vestigations of the D or ins a cov a ve fi n reb certify undWthe d nalti of er' ry that the information provided above is true and correct Si e: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged.in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please.fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability.Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit .The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current . policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog Iicense or permit to bum leaves etc-)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents �fice of Inves6gafaons 600 Washington Street Boston, MA 0.2111. Tel. # 617-7274900 ext 406 or 1-877-MAS.SAFE Fax # 617-727-7749 Revised 5-26-OS 'Aww.mass.L'Ovf iia Location "1 �z�� Pte() " �, } n F ` V GT No. a n Date ,.ORTFTOWN OF NORTH ANDOVER O F • 09 Certificate of Occupancy $ +s" •E<� Building/Frame Permit Fee $ s� i SArwl Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ( _ 15999 J ./ Buitdin Inspector g s TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMjyO�LISH AONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. C9 /) DATE ISSUED: n ` 1\ X ic SIGNATURE: Building Commissio=42Epector of Buildings Date z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 4,41� 1�eltCL �q 111 — Gryyr Map Number Parcel Number j� 1.3 Zoning Information: 1.4 Property Dimensions: V Zoning District Proposed Use Lot Areas Frontage ft 1.6 BULLDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Reqwred Provided Re red Provided 0 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Mood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record Name(Print) Address for Service: r Ts" �3x Signature Telephone R> 2.2 Owner of Record: Y� Name Print Address for Service: O Z rn Signature Tele hone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: ,�y, / O S r // ``F.y� `i/ /� License Number Addrej"A D Expiration Date Si$ a e Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v �a 39 Company Name 1 1 ,7 Registration Number P Address �l Expiration Date Sign2Ve Telephone Y' 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 at1 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 'E"il R P 4- 1 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFkCIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee �S 5� Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC l 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 1, 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. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 a Print Name t e Signature of Owner/A 04 ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T ABERS 1ST2ND 3RD SPAN DIlvIENSIONS OF SILLS DIMENSIONS OF POSTS DE\,ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHHVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Jean Sirois Woodworking Invoice No. P.O. Box 246 Methuen, , MA 01844 978-685-4504 Invoice. , — Customer Name MR Henry Nassar Date 11/5/02 Address 475 Greatpond Rd Order No. 1 City No Andover State MA ZIP 01845 Rep Sirois 978-685-8392 Qty Description _ Unit Price TOTAL Strip roof on house garage and installed black paper one row of grace paper and in valley Architectural roofing Material and labor $15,150.00 Thank You SubTotal $15,150.00 Payment Details Shipping& Handling $0.00 O Cash Taxes O Check O Credit Card TOTAL $15,150.00 Name CC# Office Use Only Expires Insert Fine Print Here Insert Farewell Statement Here ACORD CERTIFICATE OF LIABILITY INSURANCE OP IDC DATE(MMIDD/YY) ROI-3 11/07/02 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Landmark Insurance Agency, Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 198 Massachusetts Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover MA 01845-4190 Phone: 978-688-8829 Fax: 978-975-3987 INSURERS AFFORDING COVERAGE INSURED INSURER A: Preferred Mutual Insurance Co. INSURER B: Sirois Woodworking Jean Gu DBA INSURER C: 77 Elm Street PO Box 246 INSURER D: Methuen MA 01844 INSURER E: COVERAGES 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. INSR TYPE OF INSURANCE POLICY NUMBER DATE MM/EFFECTIVE PDATE YMM//DD/YY EXPIRATION LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A COMMERCIAL GENERAL LIABILITY CPP0160526510 FIRE DAMAGE(Any one fire) $50000 CLAIMS MADE F� OCCUR MED EXP(Any one person) $ X Business Owners 03/12/02 03/12/03 —PERSONAL BADV INJURY $ 1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 1-1 POLICY PROJECT 7 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR EICLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITSI ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Woodworking CERTIFICATE HOLDER N I ADDITIONAL INSURED;INSURER LETTER:_ CANCELLATION NORTAN2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of North Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Sutton Street North Andover MA 01845 REPRESENTATIVES. AUTHO REPRESENT ACORD 25-S(7/97) ©ACORD CORPORATION 1988 92. 1611.6-vvvald a�✓iiltr4aac�iuvv�f6 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 126398 Expiration: 5/26/04 i Type: Individual Jocelyne Sirois Jocelyne Sirois 77 Elm Sty Methuen,MA 01844 Administrator A ,�_ Jfre {nam�nf»uveal!� o�'✓� �,�iu BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number.. CS 065857 - Birthdate: 12129/1952 Expires:12/29/2002 Tr.no: 4655 Restricted To: 00 JOCELYNE SIROIS f PO BOX 246 t METHUEN, MA 01844 Administrator j i . t ONM ® _ ED Andover o NO• 210 ` �-- - '� D o�A > > dover, Mass. �A RATED P? C:) 4 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT...... 1. .NBUILDING INSPECTOR .n.. ...............�V.�...S..S,p►.r..... . ::: Foundation has permission to erect..&4r#,1.. ........... buildings on ..4 r. � .......P� Rough .......... ....... ... ....................................... to be occupied as e r ei►�U Chimney ..`..... ...................O0................. '}.................... .......... , . 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-Ljws relating toection, Alteration and Construction of Buildings in the Town of North Andover. n/ the Ins Is-&o PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCT-ION STARTS ELECTRICAL INSPECTOR Rough A.....III ............................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. Date. .y . • _may r 375 . HORTM 3?��<;��•°;•.',�o0L TOWN OF NORTH ANDOVER t p PERMIT FOR PLUMBING i SS�cMusE� This certifies that .,�� .�` .� . . .�� . ` . . . . . . . . . . . . . . has permission to perform . . 4f.L4. . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . at. . �Y . . C'A c-G9.{. ,&r P/. . . . . . .. North Andover, Mass. Fee Lic. No..9":JJ:.?. . . . . . . . . . . . . . . . PLUMBING INSPECTOR 07/08/98 10:25 25.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer r u�.hss�ev r %jn rcrimss sv uv 7-- (Print a Typei Of�) NORTH ANDOVER, Mats. Oats Building ,/ Permit It Location / C �p�i✓� �- Owner's Name/ New ❑ Renovation ❑ Replacement 0 Plans Submitted: Yes❑ No.❑ a FIXTURES . . M Z r » A a U < • Ys r Y M Z M < K < (~ i p 0 N L � J M .. M h = t r U R M er < » s • i s N at W 0 s it < o ' er • a y I. o Y ; � ; o K S 1 i w a o is s I- eJs Lr i s a 640 =i sup—saMT. •A44M4INT 1GT FL0011 2140 FLOOR 380 FLOOR 4THFLOOR ITH FLOOR j STH FLOOR. (� ITN FLOOR eTH /LOOM Check one: Certificate Installing Company Name—A N D 0 V E R PL B G &. H T G CO . , INC �orp. 2122 Address 573 S(1 _ IINT(1N STRFFT ❑Partnership I AWRFNfF MA 01843 ❑Firm/Co. fluslness Telephone q 7 R Fi R 5-8 3 3 3 Name d Lkensed Plumber _ G F O R G T A R O S INSURANCE COVERAGE: Check I have a current Ilabifty Insurance polcy or Its substantial equivalent. Yea No ❑ It you have checked y.", please Indlcate the type coverage by checking the appropriate box A-liability Insurance poflcy � Other type of Indemnity ❑ Bond C1OWNER'S INSURANCE WAIVER: I am aware that the Ilcensee does not have the Insurance coverage required by C japler 142 of the Mats. General Laws, and that my signature on We permlt application waives this requirement. Check one: gQ velure o Owner a Owner s en Owner ❑ Agent ❑ I hereby certify that all of the details and Information 1 have submitted be ontaredl In above application ere true and accurate to the best of my know4edge and that as plumbing work and InsteAstions Wormed urges the permM Inued be thla applkallon will be In compliance with aA putlnenl provisions of the Massachusetts Slate Plumbing Code and Chapter 142 of til tiara. eY --- TN4e51290me of Ucensed Plumb*( Ctty/7own License Number 9983 11fT"(M0 (OFFICE USE ONLY) Type of Plumbing Ucenss: Master Journeyman ❑ a Date.... .. ...�.. .� .... NORTH 3?of, �6"a0 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACMuSEt f p This certifies that'."/ ..... . ..�} f tet_. ..��.:!�. has permission to perform ......`' .. .a UP—LI................................ wiring in the building;of at...... ......... , ..7"...{ ?./€..../. •,North Andover,Mass. coFee.....1....3.. ELECTR[CALINSPECTOR WHITE: Applicant CANARY:Building Dept. PINK:Treasurer GOLD: File Ctk*Uae 0 � E Cram Imniumit4 Df 's Permit No. 13tltar=z d of Vuhlit *UfLtq O=prancy 3 Fee Checked _ Fpeave blank) L BOARD OF FIRE PREYE.'MON REGULATIONS 527 CUR 1200 jd► . APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ,V All work to be performed in accordance with the Massacnusetts E?ectrical CedeZS27 CMR 12:00 _ (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Qej or Town of NORTH ANDOVERTo the Inspector of Wires: T he uderstgned applies for a permit to per`orm the electrical .vcrx described below. Location (Street 2L Number) `f 7j 6d` 'PCao26� p1j> V, Cwner or Tenant lle.-!)( Cwner's Acdress '.s :n:s _erre:. in C^^;uraction with a _,aicinc Permit: Yes — No X (Ctieck ACefCCfiat2 30x1 _ ci Utility Aut!^crizaticn No. Amcs )20 e Un.cgr-c C Nc. of Meters Nel.v Service ArnoS rots C Jer ._ c _ no_cr 7 a No. of %%eters =,eecars arc .-..mcac:tv :c•a� Nc. _. -anstorrrers K';a -'z;_,45 3.v:^1 -C-J@_ - _ v2neratcrs K'lA Z. Nc. v :,mergency -gnttr.g _. -----=c" --..els - =_•-ems 3attery Units -as s rs :f _Cnes ------------------ f i %a. _. :etec-cn ar.c C. C. ?ar es c. _. v^5 �/ n::.a..nc �avtcas _. _.sccsais "c -_s ons G. I Nc. Bouncing -evcas I Ne. serf Canta nec j _. _ar•vas.^.SrS -----•� '3 <,v Za:ec::cnl ouncing �zv.cas Munic:cai —Ctn.er No. a --r,ers �eannq Zewces ev I _eeat Connec:;on :c. _. N,c. _. 1 Lbw ';c,taco `tater =+ea,.9rs _'.. `.c. -vcro .iassage acs �s ?AAE. ?•_rsuar.t :o -a ac_race^a `.iassac-usa-s ;er.erat '_.aws NC - -a�e a - -�r.t '_.ac:ii•v !nsu:anca ?Duey -"' - e ='era::er.s z average or rts sues:anuat aeu+valent. YES - `._`. .. r �easa ;icicate .ns c� coverage nave st.c^+nae vane :.,cc*. same :o :ne :"!c9. =3�X-C = ycu'nave cnecxeC "Ea. _ -y. -recx+r.g ane accrocnate box. :NSL;RANC=- X -3CN0 - OTHEP _ .P -ease Szem:+J trat:c (E<o n Za:ei Es::rn.atec `+atue of E acmcat '.Vcrx S -J ' QS ::c:x .o S:a: :s=---- --- 3;ynec ::near •ne Fenaittas r"N: _censee �� :C�l r cY9aZ� No. t Ait. Tei. No. >c=mss %VV►rER•S iNSURANCS'WAIVER: i am aware -a =,e _ce^see cces -et nave the nsuranca c�•erase or!ts suestantial equivalent as r@- burrea ay Massacnuseas Generat Laws. arc :flat ny signature an :ns :err.:tt acc+icaucn waives ants reeuirement. Cwner Agent .Please cflecx ones eteoncne No. --- PERMIT FEE 5 tsigrature at Cwner or Ayint) trisr