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HomeMy WebLinkAboutMiscellaneous - 5 CROSSBOW LANE 4/30/2018 (2) 5 CROSSBOW LANE f 210/106.B-0213-0000.0 I I I I i I i 9 i V Date....... f NORT1� TOWN OF NORTH ANDOVER o PERMIT FOR WIRING �SSACMUS� ....... This certifies that �./>.Sc�;i.....�-"i,!�������..................................... has permission to perform ...... t_.�. - ?v ............................................. wiring in the building of....../... M .................................................................. at......J.. ��?SS.f� w....... ........................... .North Andover,Mass. Fee... Lic.No.. O . .................... ELECPRiCAL INSPECTOR / Check # �Z— /b�J S �°� cnAosa $a� � 54 30 -,� �� �r M i TfND own oAndover 0 .. No. AKE 0 over, Mass.,- I L COCHICHEWICK Ids1�?ATE PY BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT..........A�4 L-1.......... I.......................................................................................... BUILDING INSPECTOR Foundation has permission to erect........................................ buildings .......... ApC ....................... to be occupied as............r_.10L........ ............ ta.c.......late44-1ir.. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the.app1`lcation­o*n"file*in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. BIN G_=IN7 INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ugh � 3f Z � PERMIT EXPIRES IN 6 MONTHS ELE&IURCAL INSPECTOR UNLESS CONSTRUCTK S 40_? Rough ,,:Vt, Service BUILDING INSPECTOROt- 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 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. a GENERAL BUILDING NOTES/CHECKLIST-NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stone/fabric filter/cover and outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip-Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. Joist hangers-fully nailed w/hanger nails. Sill plates 2-2X6(1 PT)w/sill seal. Girls-solid brick or steel plate bearing at foundations '/"air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0"clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. 1/2 of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces-"proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber-Finish Smooth parging, clean joints,8"solid @ combust. DECKS: La to house, provide flashing. 9 P 9 Rails min. 36" high, Baluster max space 5"on center. Over 8'above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspection fee- $30.00(Be Ready). OCertificate of occupancy required prior to occupying structure. Commonwealth of Massachusetts ofl7cial use only • Department ®faire Services Permit No. 1 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT" TO PERF®Rid ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 27 CMR 12.00 (PL E,4,SE PRINTHBVKORTYPEALLINFO TIOlt� Date: City or Town of: - 1 By this application the undersi ed gives o ' e of his or her i9- -nti"��oo PeWA rform e Inspector of Wires: the electrical work described Location ed bel � iron(Street�&Number) �� ow. Owner or Tenant l / I Owner's Address S Telephone No. .I Is this permit in conjunction with a building permit? yes No ❑ BLDG PERMIT# Purpose of Building 1 pr( , Utility uthorization No. Existing Service j C0 Amps �/ Volts Overhead Undgrd❑ No.of Meters New Service Amps ----L-Volts Overhead f Number of Feeders and Ampacity Undgrd No.of Meters Location and Nature of Proposed Electrical Work: W Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total. No.of Luminaire Outlets Transformers KjrA, � No.of Hot Tubs Generators KVA _ No. of Luminaires Swimming pool Above �_ M 0.0 mergency tg mg nd. rud. Batte Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners No.of Detection and No. of RangesInitiatin Devices No.of Air Cond. Total Tons No.of Alerting Devices 1 No.of Waste Heat Pum Disposers Number KW " p Totals ........."..'.'.........-Tons......... No.ofSelf-Contained No. of Dishwashers µ Detection/AlertingDevices Space/Area Heating KW Local Municipal Connection EJ Other No, of Dryers Heating Appliances KW Security Systems:* f No. of WaterKW NoNo.of Devices or Equivalent ' Heaters .of Signs Ballo.asts Data Wiring: } IlNo.of Devices or E uivalent No.Hydromassage]Bathtubs No,of Motors Total HPTelecommunications Wiring: OTHER. No.of Devices or E uivalent Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value o Elec ical Work: ' (When required by municipal policy.) Work to Start: l Inspections to be requested in accordance with AMC Rule 10,and upon completion. INSURANCE OVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee cert..OVERAGE: eprovides prothat s chof cover insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE EV BOND ❑ OTHER -�ce��, under the pains nd penalties o er' El (Specify:) fp I ,that the information on this application is true and cmrrpl F$ZM NAME: ti Licensee: iam& LIC.NO��- .: Signature LIC.NO.: (If applicable,enter "exempt"in the license nu ber line Address: U , � a)J Bus.Tel.No.; 24- *Per M.G.L.c.147,s.57-61,security work requires Department of public Safety S Licen Alt.LIC.NO.: OWNER'S INSURANCE WAIVER: In- aware that the Licensee does not ave the liability insurance coverage normally required g law. $y my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone NO.' PERMIT FEE: V ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH INSPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 2.FINAL INSPECTION: Passed—W, Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: .� (Inspectors'Signaf e-no!k Is) Date ' 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)- [ ] Inspectors' comments: t (Inspectors'Signature-no initials) Date - 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. J 9 r � The Commonwealth of Massachusetts Department of.1ndustrial',4celdents Office of Investigations 600 Washington Street Boston,MA 02111 U www.mass gov1dia Workers' Compensation InsuranoeAffidavit: Builders/Contractors/Electricians/Plumbers A liana reformation ]Please Print Z!e 'bl Nahl.O(B.usiness/Organizatiton/Individual): pnnA Address: CRWState/Zip: U EC� f-OY-Nx W-Phone#: Are yo an employer?Check the appropriate box: Type ofproject(required): 1. am a employer with 4. ❑ I am.a general contractor and I 6. ❑New construction. employees(full and/or part-time). have hired the sub-contractors 2.❑ I am a sole proprietor or patnex 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. 9. ❑B ding addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10. lecfrical repairs or additions required.] officers have exercised their p 3.❑I 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.E]Roof repairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] !.Any applicant that checks box#Z must also fill out 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. t'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lain an employer that isproviding workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: ac G Policy#or Self-ins.Lic.#: nation Date: — ,K-h6 A rob Site Address: S� C Rcss fs n\, L,A\�j 00kf 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,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Iuvestigations of the DIA for insurance coverage verification. .I'do her ehy e fify under the pa ns d na es ofperjury that the information provided above is frue andcorrect, ect. Siafore: Date: Phone#: I Q 1� 2 �I Official use only. Do not write in this area,to be completed by city or town official -' City or Totivn: PermitUcense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ContactPersan: Phone#: ' i 8866 Date. N�RTM oro 4�`•°„• 4Q- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSA US This certifies that .�rN.�.,I ��.l.,f. . . . . .��. ( . . . . . . . . . . . . . has permission to perform . . .�, .-- . .D.w. . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . .FI .. . . . . . . . . . . . . . . . . . . . at . . . � . .�.�� North Andover, Mass. Fee. . . . . .Lic. No../. . . . . . . . . �. . ^ . . . . . PLUMBING INSPECTQAe r Check x )� i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) AfA 1171b V&K , Mass. Date I �� City, Town Permit# Building � .��s,f_�A /� Owner's f • AT: Location b ls�/�- Name Type of Occupancy: 1 G� New ❑ Renovation Replacement ] FIXTURES Plans Submitted Yes ❑ No ❑ Y ZN W Z �4 Q F� N J > V Q = W W W X J Vf NCC W Z N Q OC _ ~ ? O Z N a O N W N N W y f' V W N Y Q N W Z _a Z ~ oc A. 3 x O Z O Oc a W Q yj = a Q N Z a s cc OJ u. cc W W W N x J O D t- V Q Z 6 Y Y Y d 0 ~ Z Y Q W W x W Q F- > F- O N O = al F- Z O O W _ W f' O V x Q Q x Q Q O Q J J Q fx oc WW Q O Q I- 3 Q 3 ft m O SUR"BSMT. BASEMENT, 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR, 6TH FLOOR, 7TH FLOOR ' BTHFLOOR (Print or Type) /Check One: Certificate Installing Company NameIt k An �°� El Corp. Address " C1 Partnership r /� ❑ Firm/Company Business Telephonee Name of Licensed /Plumbero asfitter 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 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. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. iSignature of owner/Agent n I have a current liability,insurance policy to include completed operations coverage. ❑ By Title Si ture of Licensed Plumber City/Town (�� Type of Plumbing License V _L 0 Master 13 Journeyman APPR O ED (OFFICE USE ONLY) License Number '1 FORM 1240 H&W HOBBS 8 WARREN TM BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME to TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR Pagel of 2 Fw:Final Grade_ 5 Crossbo�" � pelleChia1e,Pamcast.net� Icleonard@com Jan Leonard Ll 2006 2:2g PM from: June 18, Sent: Sunday' pamela l pelleChiaie, To: Grade-5 Crossbow Stem Re:Final tic SY ne Subject: had his 16 WhY did mi lem St lust ed June Hi Pamela i hbor at 1 d Ju a 6 and finish my ne q roan I noticed a red They o complete? take 6 Weeks t ----Original Mh ase Pamela from:QelleC— �eona�d 200611:38 p,M $entaFriday, June Grade_5 Crossbow ecri RE F incl Iflcate today en. d out your cert You should be all set. 1 will sen -_--Original Message ma ilto:jlcleonard@ cOmcast.net� Jan Leonard Le 151 2006 S-.04 pM fron►'ThursdaY, ]un Sento pamela 5 Crossbow ld be To: pelleChl 1 Final Grade- e W ou Subject': mentioned t We 11 it be okay to Hi Pamela inspection Scum and When the t oc Susan did en Will tha Wh ' led to me. Tanks ,Jan l pay WhYman? essage"_--- on _---Original M Pa---ela Dell Chla1e�— from: Comcast-n2006 2.02 PM To- AcThuasday June 08° 5 Crossbow Sent: , FW Final Grade- Subject. Jan, dont pay VVhyman until we tell you it's ok. Pamela D. original Message-- from: Sawyer,Susan 1:57 senPM t: Thursday,June 08,2()p6 70: oellecWale,Pamela 5 Crossbow RE:Final Grade Subject' to do that. ab solutely,itw°uld be mY pleasure S 1 611912006 --_- FW: Final Grade - 5 Crossbow Page 2 of 2 i -----Original Message----- From: DelleChiaie,Pamela Sent: Thursday,June 08,2006 1:48 PM To: Sawyer,Susan Subject: Final Grade-5 Crossbow Hi Susan, Canh see ou if y the Final Grade is okay on this address. I would hate for the homeowner to pay Whyman if not done correctly. Thanks, &W RqFaMs, AP40#1004 DaBB¢L�lfiwi¢ Health Department Assistant Town of North Andover 1600 Osgood Street Building 20, Suite 2-36 North Andover,MA 01845 978.688.9540-Phone 978.688.8476-Fax http_/Jwww,townofnorthandoyer,com healthdept@townofnorthandover.com I 6/19/2006 Page 1 of 2 DelleChiaie, Pamela From: Jan Leonard Ulcleonard@comcast.net] Sent: Tuesday, March 28, 2006 9:44 AM To: DelleChiaie, Pamela Subject: Re: 5 Crossbow Lane-Septic System My fax is 978-683-6023 thanks Pam. ---l-Original Message----- From: DelleChiaie, Pamela_ To: Jan-Leonard Sent: Tuesday, March 28, 2006 9:26 AM Subject: RE: 5 Crossbow Lane-Septic System Yes, the plan review came in yesterday, and Susan just left it in my inbox last night. The plan was disapproved, and will need to be revised by the engineer(Clayton Morin/Greg Saab). A copy of the letter will be faxed to them today. If you want to give me your fax number, I will fax you a copy as well instead of mailing it. [Dellechiaie, Pamela] -1--Original Message----- From: Jan Leonard [mailto:jlcleonard@comcast.net] Sent: Tuesday, March 28, 2006 9:13 AM To: DelleChiaie, Pamela Subject: Re: 5 Crossbow Lane - Septic System Hi Pam, its been 27 business days since my plan was submitted. I 've called Clayton Morin and left a message but no return call as yet . Any update from your end yet? thanks. Jan -----Original Message----- From: DelleChiaie,_Pamela To: Jan_Leonard Sent: Tuesday, February 21, 2006 9:34 AM Subject: 5 Crossbow Lane-Septic System Yes--a plan was dropped off by one of Jon Whyman's workers. Please note that all items relating to soil testing, and plans should be handled by the engineer you have contracted with -Engineering & Surveying Services, 70 Bailey Court, Haverhill, MA 01832 -978.556.0284, Attn: Clayton Morin; drawing completed by Greg Saab. Just so you know, Whyman submitted an incorrect application, with incorrect information, and I had to request him to resend the correct application (Still with wrong information - Pam Learned was listed as the homeowner). Perhaps it would be better to have the engineer handle everything until the plan has been approved and ready for installation? As I understand it, Whyman is the installer you hired, but he should not really be involved in the process at this point. I In any case, I have submitted the plan to our consultant, who has 45 days to review it. However, we do usually get them back sooner than that time frame. Sometimes there are issues that need to be resolved, and the engineer must submit a revised septic plan. That process would only take a week or so. You, and the engineer will be notified directly of a plan approval or disapproval. I'm not sure what else has been told to you at this point, so please let me know if you have any further questions. 3/28/,2006 Page 2 of 2 I Pamela t -----Original Message----- From: Jan Leonard [mailto:jlcleonard@comcast.net] Sent: Friday, February 17, 2006 9:52 PM To: DelleChiaie, Pamela Subject: Re: septic system Hi Pam, did you receive plans on Friday 2/17/06? thanks. Jan Leonard 5 Crossbow Lane -----Original Message----- From: DelleChiaie Pamela To: Jan Leonard Sent: Wednesday, January 25, 2006 1:02 PM Subject: RE: septic system Your engineer submitted a soil test application, and soil testing was completed back in October. I have not received anything else to date, such as a septic plan for review. Please contact your engineer and ask him what the status is. I -----Original Message----- From: Jan Leonard [mailto:jlcleonard@comcast.net] Sent: Tuesday, January 24, 2006 8:07 PM To: DelleChiaie, Pamela Subject: septic system My name is Jan Leonard, 5 Crossbow Lane. I am working with Jon Wyman Construction to fix my septic system. Has it come befoe the board and what were the results? Thanks for your help. I I I I I 3/28/2006 Date......�f�..l... .-�? ... NORTH °`,�``°;•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SgACMUSE� This certifies that .................................................../:�"�,��i ©............................... 4.,,Z,, has permission to perform zi7L � �`''''�.��d{✓.. ........_ wiring in the building of......... lest .l�.......................................... at............. .. .�Rr It ......�..t1/......... ,North Andover,Mass. dd Fee...:-��1'�...� Lic.No.....53.Yo ....... ... ...► - ./� 'G� — ELE f ICAI.INSPECTOR /' ]Check # T 422 r V [l ' Commonwealth of Massachusetts -77 Department of Fire Services Occupancy and Fce Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9 051 1 blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK N11 ,.%tjrk to he iierfOrillCd in UC01-thilCe\011 the NhI ,SUIILISCUS FIC01-ic,11 Code(%11:0. 527(AIR 12.00 PLE,ISE PRL%T LN INK OR T1 I L t INFOR.1 1.1 TION) Date: City or Town of: ro ilie in,peo,j. ()/,uji.e., 1 0• A-oa By this applirition the undersigned -Nes notice of 0 1.1 , or her intention to Pel-f0ril, the electrical work described below. Location(Street& Number)_ SC 6OSS6. 1-")E, Owner or Tenant 1-0 CL Telephone No.^7913 3Y?,3,- Owner's Add rens 9-(a (-O-ss(n <>w Is this permit in conjunction with a building permit? Yes El No Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service ®C) Al"Ps UQ/ IVO Volts Overhead F-1 Undgrd F-1 No. of.N11ders New Service Amps It Volts Overhead[:1 UndgrdF-1 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work- PO4 I.A 01 -Aj[I 601: 0-� Qt-000seD PC/;.A,o C 4 ctwt 6")-- i)q-, cible Inav be ll:,111,J;,v the 1115pect,w If No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.0 Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool %bo-te [j In- C] No.of E me-rge-"-C-y-T1-gfiti fig gi-rid. Battery Units I; erjK...- No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS IN o.of Zones I --- 11 No. of Switches No.of Gas Burners No of Detection and E7 Initiating Devices t No.of Ranges No.of Air CTotalond. Tons ;No.of Alerting Devices Ilea!�Pu Totals: Tons I KW fri,,�p Numb, -0.of Self-Contained No.of Waste Disposers o a fq—' otals: .1 Detection/,klerting Devices No. of Dishwashers Space/Area Heating KW LocalEl '"o"'c'Pal El Other Connection No.of Dryers Heating Appliances KW --Security , stems:* No.of Devices or Equivalent No.of Water No.of No.of Heaters KW S, Ballasts Data Wiring: Igns No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equiv alent OTHER: 1,611111-c'/h.1 litc F.,,tirriatcd Value offIcctricill WOrk: 11C11 required by municipal policy.) \korktuStart: L)il-L5M - Inspections to be requested in L(jrdance with \IEC RUIC 10, and Upon completion.INSLRANCE COMERACL: L n1Qss),vai\,o:d by the owner. no pci-nilt for the perlonnance orejcctricaj work may i'-;�LIC Ullk-, rhe licensee rl-(,-vJdes prourof liability ilisurilicc i lic lud ill,-, IctL:d 4)peratiml-covera,je or its substantial L:quiea1vilt. t hl.- Cel-tiFIQ', I0l-o-'C- ;lllkl IMS(,:' 1libit(--d proof to the Pci-Illit Inder the o 1-114NI NAME: 5 ir,4?-- Q0' 4*k-2— LIC. 1-ictrisce: ic. io.: dd, rs' rp , 3us. TO. No.11933707S' kes: ASM1-itySy,IcContactcjuc01;c 10. .11 w this t,,urk il-`�t pplicable. enter she license number here: ___ _ IMNEWS INSURANCE 'NAIVER: I mil my;lrc that 11le 1j,"Cli's.ce havc the liability iccluircd by law. my ro: below. I �,vLlivc thisrCCjLlil-Llll,.1lt. I ;mi the(JiL!ck one)r-j,.)��ilvr /11),X11 wir Owner/Agent T C'VX;', 1i 73�Lffj?