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HomeMy WebLinkAboutMiscellaneous - 58 MEADOWOOD ROAD 4/30/2018 58 MEADOWOOD ROAD 1------------------- 210/025.0-0087'0000.0 Q Date.. ..t ...... . .. .. ...... ... . ..... 4, 6 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING C u U Thiscertifies that ............................................................................................. has permission to perform ... wiring in the building of ........ .—•....................................... at ........ .... ... ..... ......................................... .......... ...... North Andover,Mass. ............... ELEcrRI Fee.!.................. Lic.No/�' 4� !i� .CTO Check # 67?_0 Commonwealth of Massachusetts � Official Use Only i°' Pennit No. (p7 -2Z)kv' ) Department of Fire Services Occupancy and Fee Checked .�� BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/99] leave blank °r-'- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION). Date: 6 - 8- 06 City or Town of: P, An dQoe r To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) -6,69 m cto t, wwd Owner or Tenant TA-0 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No, Existing Service Amps / Volts Overhead❑ Undgrd❑ No. of Meters New Service Amps I Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 6✓1 Completion of the followin /able may be valved by the/ns ector o Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans r o ota Transformers KVA No.of Lighting Outlets No,of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming rnd. rod. BettPool Above ❑ n- ❑ o.o e Units cy g ng } No.of Receptacle Outlets No:of Oil Burners FIRE ALARMS No.of Zones i( No.of Switches No;of Gas Burners lqo—.of Detection as Initiating Devices No.of Ranges No,of Air Cond. Total Tons —3 No.of Alerting Devices No.of Waste Disposers eat amp I. um er ons o.o e -Contained Totals; Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ un t pa 0 Other Connection No,of Dryers Heating Appliances KW SecuritySystems: No.of Devices or Equivalent o.o atero,o o,o Data Wiring; Heaters KW Signs Ballasts No.of Devices or Equivalent No,Hydromassage Bathtubs No.of Motors Total HP a ecommunications ng: No,of Devices or Equivalent OTHER: Attach additional detail ifdaired.or ur required by the lrwpectur of Wirer. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. ' CHECK ONE: INSURANCE 9 BOND ❑ OTHER ❑ (Specify) (Expiration Dace) Estimated Value of Electrical Work: (When 44u(red by municipal policy.) Work to Start: Inspections to be requctted in accordance wit EC Rule ,and upon completion. I certify, under the pains and penalties of perjury,that the Information oY/�/ a p11 '0 1 i and complete.FIRM NAME; / LIC, NO.:Licensee: �JID X46Eyf< Signature LIC. NO.: (If applicable, ler "exempt"in the license numberline.) Bus.Tel. No.:-77g6S2 67-6 2 Address: S � :57— Z4� AAn!F'/1Y¢ Alt.Tel..No 17 9'3 75-5-7 3� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw, By my signature below,I hereby waive this requirement, 1 am the(check one)❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: S S ".ocation No. Z30 Date `� 12-q/Z/Z,) °RTS TOWN OF NORTH ANDOVER Oft.. o , 1ti0 /�y a6 i7/ T „ Certificate of Occupancy $ + s + ; • Building/Frame Permit Fee $ (7 '5 ��- ss c►+5� .. Foundation Permit Fee $ " � ev 1 CC!'-P- Other Permit Fee $ Sewer Connection Fee $rt06-1713�f X13 993 -Water Connection Fee `� 9 TOTAL $ jlt'r Building Inspector 1 6223 Div. Public Works Location_S�3 No. 530 Date „ORTm TOWN OF NORTH ANDOVER Certificate of Occupancy $ 41 Building/Frame Permit Fee $ Cj Foundation Permit Fee ss HU "t - Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ ��l ��•� 1993 Building Inspec or "` 6173 Div. Public Works Location �No. 3 , Date 6 49-c NpRTiy TOWN OF NORTH ANDOVER F A Certificate of Occupancy $ Building/Frame Permit Fee $ ,rcF�sE� Foundation Permit Fee $ voRTH�s=L� .. Other Permit Fee $ Sewer'Connection Fee $ ! m +� Water Connection Fee $ 1 r? 16Z uou 993AL $ Building Ins ector U 4 U S Div,�.Oy lic Works Location e-{n )W 1 x- 4No. Date j a b • ko*Th TOWN OF NORTH ANDOVER ? •• oc p Certificate of Occupancy $ Building/Frame Permit Fee $ t �,SSACMUSEt� Foundation Permit Fee $ • �y - Other Permit Fee $ Sewer Connection Fee $ r..J Water Connection Fee $ TOTAL $ rj-vN, GN t Building Inspector i� Div. Public Works PERliiT NO APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. -.. � PAGE 1 MAP 4J0. LOT NO. 5 - 2 RECORD OF OWNERSHIP DATE BOOK ;PAGE ZC7NE SUB DIV. LOT NO. I LOCATION PURPOSE OF BUILDING .�7Lz3• ��MlI9('+C OWNER'S NAME NO. OF STORIES % SIZE OWNER'S ADDRESS/ j �/ ASEMENT OR SLAB ARCHITECT'S NAME `Ji'l j �Ur ,V /v SIZE OF FLOOR TIMBERS 1ST n o 2ND �n�D 3RD BUILDER'S NAME 77Z,-*m 5 SPAN DISTANCE TO NEAREST BUILDING //`/ DIMENSIONS OF SILLS --- DISTANCE FROM STREET 2,61 GJ POSTS r/I►/(/,p DISTANCE FROM LOT LINES-SIDES _/r/ REAR I / "' '" GIRDERS AREA OF LOT 'S5 FRONTAGE !!! HEIGHT OF FOUNDATION •7/1 G `�'x/10 a / THICKNESS t IS BUILDING NEW L Va C SIZE OF FOOTING ® // X 11 y IS BUILDING ADDITION MATERIAL OF CHIMNEY �J IS BUILDING ALTERATION IS BUILDING O OLID R FILLED LAND �1 WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 6 IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY V86IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE. INSTRUCTIONS 3 PROPERTY INFORMATION r�t �7,�b LAND COST SEE BOTH SIDES OLD ►•i/T f C'E g3 �° (� Cr 4� �,,,,ate EST. BLDG. COST ��(�( �•� LESS FDA FE �� EST. BLDG. COST PER SQ. FT. PAGE 1 FILL OUT SECTIONS 1 - 3p`� r - - -�- s,r nA hQF P(.rllYil l $&4���m EST. BLDG. COST PER ROOM /�� /ti PAGE 2 FILL OUT SECTIONS 1 - 12 L J • • SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING �'- �a00 n�4 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGJ"j4T FOR FOUNDATION ONLY • PLANS MUST BE FILED cc7ANPPPROVED BY BUILDING INVIEW"TED BY PARA 114.8,E DATE FILED ✓ w ��TC ���•`rFIX s�1e� BOARD OF HEALTH SIGNATURE OF OWNER O HORIZE GENT f FEE PLANNING BOARD y PERMIT GRANTED j t.e19 Q3 C14AITl, %2I 975 /-W BOARD OF SELECTMEN CONT-4 LJG ad2.9 211� . c.:►C'� t�36 �. 40S-- - BUILDING INSPECTOR i —%A P `5. BUILDING RECORD 9 1 OCC U PA NGY 12 's SINGLE FAMILY S-ORIES THi.S SECTION MUST SHOW,EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY,; oFF10Es _ _LOT` LINES AND EXACT DIMENSIONS OF 'BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED.THIS REPLACES PLOT PLAN. " CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH yy CONCRETE _ 3 1_ ? CONCRETE 131.K. PINE k BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ UNFIN. r^ 3 BASE/NENT2 AREA FULL ,FIN. B'M'TAREA •. _ A 114 y, V4 FIN. ATTIC AREA _ NO B M FIRE PLACES'`•.' HEAD ROOM MODERN KITCHEN r' 1,t. 4 WALLS �� 9,., FLOORS ' CLAPBOARDS B 1 2 3 DROP SIDING -CONCRETE WOOD SHINGLES ;EARTH ASPHALT SIDING HARD+N'D _ ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE —{I_ STUCCO ON MASONRY, STUCCO ON FRAME I o BRICK ON MASONRY N :.ATTIC STRS. & FLOOR _ �/ j BRICK ON FRAME, I _ ..�.,«t31 AQ rt?.I CONC. OR CINDEM+ . STONE.`ON:MASONRY, WIRING T+ Y s' STONE ON FRAME _ SUPERIORPOOR _ ADEQUATE I NONE 5 ROOF 10 PLUMBING (� +a GABLE HIP BATH (3 FIX.) Y �_ O KOITIA� .t#1 ¢ i ♦ t j GAMBREL MANSARD TOILET RM. (2 FIX.) M4 a U11 � I v Q-TiAll.J l— FLAT SHED WATER CLOSET 0118 rx3r' ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ ik TAR & GRAVEL STALL SHOWER _ _ � �iFr.�.,w,.� ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO A 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. &COLS. HOT W'T'R OR VAPOR t WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd ELECTRIC 1st 13rd NO HEATING .h FORM U - LOT RELEASE. FORK INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Phone ��S- ) LOCATION: Assessor's Map Number Parcel Subdivision _ 2Adk"=12 Lot(s) Street St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Eip, Town Planner- 0Date Rejected Comments Date Approved / Health Agent Date Rejected Comments f i Public Works .- sewer/water connections �g 3 - driveway permit Fire Department s 1 Received by Building Inspector Date NORTH Tovm of �cX ) Andover o = .:=sem 1 o `+ o No. 2ZO dower, Mass.t7c.4 toletole16 19 Q3 COCMIC WICK ADRATED PC BOARD OF HEALTH Food/Kitchen PERMIT T D .Septic System BUILDING INSPEC'T'OR THIS CERTIFIES THAT.................M `�1 `!�00 ......�� 1 ................................................................... Foundation has permission to erect..... .............. buildings onRough N tN CA4E �..., QQ Chimney to be occupied as.................. 1...... �....�!. .U........ ...�44LA... .....vi�r-i-n_s . provided that the person accepting this permit shall in eve respect conform to of.the application on file in Final P P P 9 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. PERMIT FOR MUNW011 ONLY PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA. 1142& B.C. Rough PERMIT EXPIRES IN 6 MONTH FEE PAID /�' Final UNLESS CONSTRUCTIO STARTS r ELECTRICAL INSPECTOR • A A Rough ......................................... .............................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR gh Display in a Conspicuous Place on the Premises — Do Not Remove F nal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. CC%A/CD /%AJATCR Finial DRIVEWAY ENTRY PERMIT _ 1 o� X31 2 w o . 0 0 1 , 0,6 / 1 ti t 0 JUN 2 9 Ig93 0 S f/EPEBY G'E.c'T/FY TO TyE'T/T(_E/,l/SU.PO.P ANO RG. O T ,?oL,/Y. TD Ts✓E B.4,11e X1147 T.yE Oy'ECG/.ti6 IS LGCATEO ON Me LOT qS-T1,GMV AND T/I.4T/T OGEES LO.t/FGtPAf AIV IY/TN Ts1E ZON/NG c�EG�/LATif9.t/S A .�6r0.P0/.✓G SETBAC.t'S FE0�1 STPEETS LoT L/,vES." Ao6 27,t/ N,VOd vEL'� �A3 j� Af LOG4TEO/i{/ THETFEOE�AL, FiC O H Z.4 O A.PE aT ��A`✓N f��P SryoWN Oit/iEM•t'CO•NMe/N/TY P•INGL '� 2saa98 c�/o B /J7�,o�wcbo .��,o�yy CocP ,'', c z9 9 / .�¢� � .�a.�/� ✓993 JE S. of 5' 0,47E WA 7'7/jS PG ��c• , G PacPdSES-LVOT FD.P BOvvO.PS� A'J''� � BD!/NOA.PY ,4rov rA,r .e �� .sr�.ve .ee-coevs. 6G Pq.P�ST.rEET A.VODYE.� �l•4S.S.4GY!/SETTS O/8/O • NORTH oVM Of over too- No. 230 oCOCHICdover Mass. ���� 6 19 Q3 ADRArED ,9S H BOARD OF HEALTH PERMIT T Food/Kitchen Septic System � BUILDING INSPECTOR THIS CERTIFIES THAT Nle w� r1 RP ""' Foundation has permission to erect.....Wo ............... buildings on Rough N t ItV 011e A Chimney to be occupied as..................'S.1.. .. .........��.. .�........ .... .... .....:�-......... ........................................................ thprovided that the arson accepting this permit shall in eve respect conform to th terms of the.application on file in is office, and to the provisions of the odes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PER FM ORY PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGM A70 BY PARA HUM &C. Rough PERMIT EXPIRES IN 6 MONTH EEE PAID iiQv �- Final UNLESS CONSTRUCTIO STARTS ELECTRICAL INSPECTOR • 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 P Y P Final No Lathing or Dry Wall To, Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. _ ,,•� Smoke Det. c%r_�nrr n itnrnTrr� MR1AI �l 3�0 llw /ZZQ)RI\/MA1AV I=NITPV PFPRAIT CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number 230 Date AUGUST 13, 1993 THIS CERTIFIES THAT THE BUILDING LOCATED ON 58 MF"WOOD ROAD (Lot #5) Upe A MAY BE OCCUPIED AS SINGLE FAMILY DWLELING W/GARAGE IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO Meadowood Realty Corp. �� •`^ ry °p 733 Turnpike St. ADDRESS North Andover MA Building Inspec or NORTH Tovwmn of. RAndover No. 220 coL AQ rt dower, Mass., S�� 1(v 19 Q3 COC HIC MF WICK ARRATED PPa\ �C9 'x,95 . H BOARD OF HEALTH Food/KitchenPERMIT . T D /` ) Septic System . y/ UILDJ�T ISP C�7'9R� .� THIS CERTIFIES THAT Nlt� �+-�� �- R� �1111�� ..................................1�..................�.....................�.......................�........................................... Fou��nd�tion �� wo �.............. buildings on �..... '...SS N1t4W �... o Rough has permission to erect...................... U-9 10J C�Il1C �A'12 A Chimney _ tobe occupied as.................. S wt.!�. ...... F �....... .... ...... .......... ......................................................%C provided that the arson accepting this permit shall in eve respect conform to th terms of.the-application on file in Fina •�^/3 �� P P P 9 this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction ofO1�Y ('�•-fid y� Buildings in the Town of North Andover. MW FOR RR MWION PL B G SPEC R Voids this Permit. MGMATO BY Pte' 11� 2-& &C. ou G�z � � � VIOLATION of the Zoning or Building Regulations PERMIT EXPIRES IN 6 MON J'-L E UNLESS CONSTRUCTIO STARTS ELECTRICAL SPS CTOR " A Rough ................... . .................................... ..... ........ Service .............. BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough L J� Display in a Conspicuous Place on the Premises — Do Not Remove F. No Lathing or Dry Wall To Be Done FIRE D PA Until Inspected and Approved by the Building Inspector. Burner 91� �I AL CONSERVATION �' Street No. PLANNING � Smoke Det. SEWER/WATER -1,-'fW09'3 FINAL/f 14 C*!2-7,4RIVEWAY ENTRY PERMIT &) 3 0 4 SDate. �,�,a ��. ....... j. t A NOHTN TOWN OF NORTH ANDOVER a ,^1�0 ' e 0 PERMIT FOR GAS INSTALLATI01 f P OO � • N •y� +o �SSACHUSEt M This certifies that . c1 G V z I . `. . . . m• cm has permission for gas installation . . . . . . . . . . . . . . . . `' in the buildings of . . . . . . . . . . . . . . . . . . . . . • • • • • ." at I A. �'.G.:1. (?.`�• • • ., North Andover, Mass. c Fee. J . . . . Lic. No. . . . . . . .... . ASINSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO G FITTING 1 (Print or Type) c NORTH ANDOVER , Mass. Date 1iuilding Location 5� ��/��p/,�DDtJ Permit # Owners Name 4;#,A/6 New 77 Renovation Replacement Flans Submitted D L� O �s F I X T U R N W (A � v tL Cf y C N C O W = . W a QfCJ O V CD Fr' w to _ C _ W • ` O W a O ' O Z F- d m N �' y� W O 0. C W 4 CC W • h N y to C W Z V W y W .t Q 0 Q h W W W a7 J _ C C O ¢ W W U h W O F- -d 2 y N YW- N m T O = W O 0 t'1 W 2 d W Ot: Q u y C W = < C d Q O O W O W F- cr O tl Y u. 3 G O J U C > G o. F- O SUI%-9S7.1T. BASEMENT I ISTFLOOR 2NOFLOOR 3RO FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR IN 8TH FLOOR (Print or Type) Check one: Certificate ' Installing Company Name ANDOVER PLG. & HEATING CO. , IN . Corp. 2122 Address _ 573 1 /2 SO UNION ST. Partner. LAWRENCE , MA. 01843 [_J Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber or Gas FitterGEORGE ' AROSE Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy OdOther type of indemnity Q Bond �( Insurance Waiver: I , the undersigned, have been made aware that the licensee o(' this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner Agent El I hereby certify that all of the details and information I have submitted (or entered)in above application see true and accurate to the best of MY knowledge and tlrat all plumbing .pork and lnstAdstions perfomud undo'Permit ittced to: this spptication will be in eomplianoe with tli pestlneat provisions of tho 14suchusetts State Gas Cuda and Qupter 14.of the Genual Laws. B /TYPE LICENSE: : YPlumber Title G�sfitter Sign Eure of Licensed Master ' Plumber or Gasfi.ttaer City/Town: Journeyman 99n� APPROVED (OFFICE USE ONLY) License Number Date. j/ ..... . . Of HOR7ry 1ti ._ 32 y` TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �9SSACHUSES a i This certifies that . . .'. . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . , in the buildings of . . .k,&.L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a at . . . . !!1 '.T! .:� �.U.:�. . .p!`. , North Andover, Mass. } Fee." Lic. No../.7.l.4!. . . . . . . . . . IA;INSPECTOR v Check# —?C7 622 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING s (Print or Type) - . l A"hd��e r , Mass. Date © — 2007 Permit# Building Location�� Me/c Or Owner's Name V�! Owner's Tel#-)'�I j o�, 7 Type of Occupency New❑ Renovation ❑ Replacement Plan Submitted: Yes No w w W N Y z W F- U Q F- U) W W O it � Ch x w m x m U) w a W O p a 0 W w cn to O U w x z ~ ix O > W W W 0) J Z Q x w W Lu Ve W LL W UJ to z Q w Q F-J H >- fn m z O Z w O Fx T: X W z a lY a Q O O w 25 O y i— x o a) x LL_ a o 0 J U w > o a. UJ 0 SUB-BSMT BASEMENT 1st FLOOR 2nd FLOOR R 3rd FLOOR 4th FLOOR 5th FLOOR 6th FLOOR 7th FLOOR 8th FLOOR Installing Company Name Addario's Plumbing&Heating LLC. Check one : Certificate Address 20 Cooper Street X Corporation 2720 Lynn, MA. 01905 Partnership Business Telephone 339-440-8100 Firm/Co. Name of Licensed Plumber or Gas Fitter Steven J. Addario Jr. Insurance Coverage : I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch.142. Yes Ex No If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑x 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 : Owner El Agent Signature of Owner or Owner's Agent I hearby 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. 9 By Type of License: Title x Plumber A City/Town Gasfitter Signature of Licensed Plumber or Gasitter F'9 Approved(OFFICE USE ONLY) x Master Journeyman License Number 13106 BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME &TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE ,2007 GASINSPECTOR