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HomeMy WebLinkAboutMiscellaneous - 70 WINDKIST FARM ROAD 4/30/2018 (2)N A J `r , -r Date../ .................. TOWN OF NORTH ANDOVER �PERMIT FOR GAS INSTALLATION This certifies that ..................... `.'.... r a has permission for gas installation ........................... . in the buildings of .......................................... at ..........:.... `..... "... � ... � :......... North Andover, Mass. Fee......... Lic. No........... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer $'9S'00 w MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING z.a (Print or Type) ? u AJ /4"n d Q l e& , MA Date 20 Receipt# Permit# ✓ l l y Building Location Owner's Name ) L Map: Lot: Zone: Type of Occupancy New Renovation ❑ Replacement ❑ Plans mi�tted: Yes ❑ No ❑ Installing Company Name EASTERN .-PROPANE & OIL, INC. Address 131 WATER ST DANVERS MA 01923 Estimate Value of Work: Business Telephone 800-322-6628 Name of Licensed Plumber or Gas Fitter Checkone: Certificate Corporation ❑ Partnership ❑ Firm / Co. 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 checkedrtes, please indicate the type 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owners 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 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 of License:S. Plumber Lgnataureof Licensed Plumber or Gas Fitter Title Gasfitter Master License Number City/Town Joumeyman APPROVED (OFFICE USE ONLY) Revised 05/17/00 ��o�n�nonuu�n�nun� ��iiiiiii�o��iioaiiiiiiiiiii Installing Company Name EASTERN .-PROPANE & OIL, INC. Address 131 WATER ST DANVERS MA 01923 Estimate Value of Work: Business Telephone 800-322-6628 Name of Licensed Plumber or Gas Fitter Checkone: Certificate Corporation ❑ Partnership ❑ Firm / Co. 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 checkedrtes, please indicate the type 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owners 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 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 of License:S. Plumber Lgnataureof Licensed Plumber or Gas Fitter Title Gasfitter Master License Number City/Town Joumeyman APPROVED (OFFICE USE ONLY) Revised 05/17/00 r-] m V', m 3 O a a z m v T m m z 0 U) X m 0 m U) M O O m C4 En z in 0 m 0 O z d U n -7 Date ......... 9., No UU0 ff 40RTH Of TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING F --t r This certifies that ........... t.,/ ... , - & ....... -... .......................S a`" wiring has permission to perform .......... fA!?.fl.(1,! ....... �11- �Aff��7 .................... Q� wiring in the building of ...... . ......... ................. at ....... 7.6 ........ ...... ........ _yorth Md-ov el�asis' Fee.... .... Lic. No...., . ....... ............. ............. Yc;;W,C- 4'NSPEcrOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer FORWARD t3' d4P GamuWaMIM10 of &,61,0ustffs E>r mrtme nt of grablic -%&tg BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 office Use only Permit No. Occupancy & Fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 9 Z/- 99 City or Town of �! //VQp U f'fL. /�1� To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 70 M / z pi -IST FAIZM j? n . Owner or Tenant Owner's Address U/L hiF Is this permit in conjunction with a building permit: Yes E.' No ❑ (Ch Purpose of Building _12e -s,, c%, -f, / Utility Authorization No. Existing Service Amps _I Volts Overhead ❑ Undgrnd ❑ No. of Meters New —Service Amps —J Volts Overhead ❑ Undgrnd ❑ No. of Meters Dumber of Feeders and Ampacity Location and Nature of Proposed Electrical Work 4u ✓r2 /a /i..0ii" j No. of Lighting Outlets No. of Hot Tubs Total No. of Transformers No. of Lighting Fixtures — Swimming Pool Above In- I❑ KVA ❑ grnd. grnd. Generators KVA No. of Receptacle OutletsI No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of RangesI No. of Air Cond. total No. of Detection and tons Initiating Devices No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of DishwashersNo. Space/Area Heating KW of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW _ Local Municipal � Other Connection No. of Water Heaters KW I No. of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES O., NO ❑ 1 have submitted valid proof of same to the Office. YES e' NO checking the appropriate box. ❑ If you have checked YES, please indicate the type of coverage by INSURANCE re�BOND ❑ OTHER ❑ (Please S ec' c� P �fY) Estimated Value of Electrical _ / " �W Work $ `� Work to Start `� Inspection Date Requested: Rough Signed under the Pe/aJes of penury: ury: "VO n Atr/-JFIRM NAME Srt%G Licensee rF - 21 LU' P" (Expiration Date) Final LIC. NO. 87 S G LIC. NO. Address -Z% /y/ 2 C'9 / .4� S7. Alt. Tel. No. G171V1ZENCr� lf% 2 Bus. Tel. No.9 7h? -(o �Z� (� q "% OWNER'S INSURANCE WAIVER: t am aware that the Licensee does_ not t have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner A (Please check one) gent (Signature of Owner or Agent) Telephone No. PERMIT FEE $ x6565 142 1 u % J Date........ z' f,�....... .k 00P TOWN OF NORTH ANDOVER PERMIT FOR WIRING I€ •SACNUS „4`� / Phis certifies that ....... +............................................. ............ R I has permission to perform ..... ...................................................g wiring in the building of...:...: f :.......'. ...... ...�-�....- .............. . --,.&C� at.................................................................<............. ,North Andover, Mases Lic. No.'!&- ... ...._ .—J-02_ .... *".SP...C...OR.................... ELEALI C7RICNBT WHITE: Applicant CANARY: Building Dept. PINK: Treasurer M,10 i 1 _V&_W_.A Weel: WV527CW-17 XP TBE C0AA10N9E4LTH0FA"MC7JUSErJS Office Use only Permit No. Occupancy & Fees Checked 51 APFLICATIONFORPRR1 ffT TOPF.RFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. P PARCEL Location (Street & Number) 76 (1) , ill A P'/ <, 1' A O M, 5 Pd i9 � /�d'i , l 17 Owner or Tenant Owner's Address l 6 f g `T vOn/PI O J T Is this permit in conjunction with a building permit: Yes Eallo r7 (Check Appropriate Box) Purpose of Building St W G L £ y�,J f4t/NG Utility Authorization No. bZ 7� Existing Service Amps / Volts Overhead Underground No. of Meters New Service dOb Amps/oO /d'/G Volts Overhead Underground © No. of Meters I Numbefof Feeders and Ampacity Location and Nature of Proposed Electrical Work V d lghtf. No. of Lighting Outlets • n : i . r u r a • ••.r No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Bumers No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burncrs FIRE ALARMS No. of Zones No. of Ranges ! No. of Air Cond. Total Tons No. of Detection and No. of Disposals .No. of Heat Total Total Pum Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices LocalMunicipal Other No. of Dryers Heating Devices KW Coxmcct... No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No.rof.Motors Total HP fro 1 51•, ei n :• i• un;:• . r.• • •••• �:� • i • •ii•- 9► © • . • - • :•r:• • ter• parr• r - •• • •r : •. • • :•v •• i 1111 ••amr 1111 V �. :• I• . • I'J• 'rr •:•i ui.n.•. •an - •n su:• -• '�arur, u WE - I F.11 Uy 1 /i[A/7I1�:'.�I�I17l1l�tfr��J BusinmTUL ,b. Aries /,�L GrJ7% U yi �1��/.C/1� -- AItTeLN, /1�� —67 7 i OWNER'SMiff ANCEWANER;Iamaw&ettntlheL=mdoes not irawtheit>stuar=crnmM- or saiswnbdegtuvairlasreqzcedbylybsmdxB&Cenaa laws aryl thatmy signature on this peQr>¢ app}kation wars this (Please check one) Owner F7 Agent !7Od Telephone No. PERMIT FEES tgrawre o wner or Agent Location 76 tdt;ifk, �rot HCS No. a Date S k4 l4- TOWN OF NORTH ANDOVE% Q Certificate of Occupancy $ -5— A — , Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ r Sewer Connection Fee $ Water Connection Fee $ e Z• OD TOTAL _. 9P,53 B it Inspo4or „�„ Uv. PIAWWorks wA G T N H Q Q z W q\ In > I z �° `n �} \v Rm -� O m m LA (V�� W > z H \ m y ri m v \ N \ O _^ ! Ve C ¢ C T Z m r Z f1 Z Y m 7 k z T T T Li > 70 y N rt —_ V v Z r V — 0 m \ C X •� N N N G v' n N \ � d CD O W .off e • o re -tit ►;3 6 11 it x -A n h ri .s U) C N 11 It ,i v� �00 0 rnm0.9 �mM(Y)Mm�l 43 ry rr ' r6 -tit ►;3 6 w Growth Management Bylaw Exemption Statement Town of North'Andover Building Department This forth shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address of Property for Permit (below) L L C kk, Map and Parcel: Purpose of Application (check below) PhanNumber of Applicant Single Family Two Family 2� — 1 the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit ig issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. A,The lots) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning . This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.care met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a property executed and recorded deed restriction running with the land. For purposes of this Section "senior' shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental condMons of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection.. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination' that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit. Z/ A-3 -9 *ignature-oif UWnerdr AuthorKed Agent who bgrietThe Attacned Budding Permit Difte This form must be attached to the Building Permit upon application for such permit FORM U - VERIFICATION FORM 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: �iUCC��iS �Ld/l Lz G Phone LtZ LOCATION: Assessor's Map Number /l? % Parcel Subdivision K%s �q2/y/ Lots) /y Street ���G��i 0=���I St. Number RECOMMENDATI NS TO AGENTS: Conservation Administrator Comments Towh P Comments Use Only************************ Date Approved Date Rejected Date Approved Date. Rejected Date Approved Food Inspector -Health Date Rejected Date .'approved 7 0� Septic Inspector -Health Date Rejected Comments Public Works - sewer/water connections -[`—'� S1 3y /72 - driveway permit- Fire DeptZAJJl It ,a 51 �11�Jzelzcl ' Received by Building Inspector Date 0I MAScheck COMPLIANCE REPORT Massachusetts Energy Code MAScheck Software Version 2.0 CITY: Lawrence STATE: Massachusetts HDD: 6235 CONSTRUCTION TYPE: 1 HEATING SYSTEM TYPE: DATE: 6-21-1999 DATE OF PLANS: or 2 family, detached Other (Non -Electric Resistance) TITLE: 70 Windkist Lot 14 COMPANY INFORMATION: William Barrett Homes COMPLIANCE: PASSES Required UA = 793 Your Horne = 774 Permit # Checked by/Date Area or Insul Sheath Glazing/Door Perimeter R -Value R -Value U -Value UA CEILINGS 1946 38.0 3.0 54 WALLS: Wood Frame, 16" O.C. 3600 15.0 3.0 241 WALLS: Wood Frame, 16" O.C. 198 19.0 3.0 11 GLAZING: Windows or Doors 698 0.500 349 FLOORS: Over Unconditioned Space 1927 19.0 92 BSMT: 4.0' ht/0.0' bg/4.0' insul. 98 19.0 5 BSMT: 8.0' ht/7.0' bg/0.0' insul. 100 0.0 22 HVAC EFFICIENCY: Furnace, 86.0 AFUE COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in sections 780CMR 1310 and J4.4. Builder/Designer Date Cl) m m Cl) 0 m v y d -- -: CO)to CD "o CD 0 ELSJ C) CD O �M CD CD CD O O co 0 CD co) ClQ N A c'o�m 'v ti a m o m c-) 90 y ci a mf �� H 4 _ 5C CD a o su Mn O• m a :rd y qm O m N C 1 N 3E am: m n c'(Acc III �0 0 O ZS.;':� W �y Z ,,....:� � m m H :b► m 1 C.)� to o m n y D1 N n (`] y mCD cp �. c N 5 CC' • • O p� Z D Z W o CID �. _CD: �P T co): co cm a*g d N p �: \•� : n = .� oCDaF%h 0 o In w aG4 ono w aha no aGc rb r C� mn�o w GQ z CL R �o Q x 5 d p x rA 0 C lD. 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B ............ ....... . plumbing in the buildinfs of at ...` D ... ............... North Andover, Mass. Fee... < ... Lic. NoP�r .. .. �. } � PLUMBING INSPE C/ 09/10/99 10:55 375.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ,«'� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �\ (Print or Type) V, 0�?^Cti Mass. Date /h 19-±y_ Permit # #16p Building Location 70 Owner's Name Type of Occupancy &." + New Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES Instaliing Company Names L7 /" f a Check one: Certificate Address % �'L`�'-r ��' je p /Corporation o 3u 3 U ❑ Partnership Business Telephone 4,r) r , 3 ,o�-- Cl Firm/Co. _ Name of Licensed Plumber 2 - S1 L V / "T5LLA INSURANCE COVERAGE: I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes I/ No ❑ If you have checked ysj, please Indicate the type 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 docs not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permg application waives this requirement. Check one: Owner ❑ Agent ❑ nature of Owner or I hereby cerlrfy that all of the details and information I have submitled (or entered) in "vi appl"bon are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this appl canon will W in compliance with all pertinent provisions of the Idassachuselts Slate Plumbing Code and Chapter 142 of the General I-Aws. By gnature of Ucent&du r Title Type of Ucense: Waster 2-" Journeyman ❑ Cty/Town le? -7 NL License Number z Z N � N Z O Y Z H Z ) N W r W V1 J t U < V) D 0 W ¢ ¢ V) O Z V1 W U V) ¢ Vf m N Z VI W W >- < F- Vf ? ¢ < N u Z Q D ¢ O r = Q W < N O ] < W J N ¢ Y Q a LL S W r U V < S Z O a Z = N f. Y Z O 0 O r N < _Z Z < W W H LL O U U W = < < S N Q < 0 < J < ¢ ¢ ¢ < O < F 0 SUB-BSIAT. BASEuENT 15T F L 0 0 R 2ND FLOOR Z 3A0FLOOR d 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR a T K FLOOR Instaliing Company Names L7 /" f a Check one: Certificate Address % �'L`�'-r ��' je p /Corporation o 3u 3 U ❑ Partnership Business Telephone 4,r) r , 3 ,o�-- Cl Firm/Co. _ Name of Licensed Plumber 2 - S1 L V / "T5LLA INSURANCE COVERAGE: I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes I/ No ❑ If you have checked ysj, please Indicate the type 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 docs not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permg application waives this requirement. Check one: Owner ❑ Agent ❑ nature of Owner or I hereby cerlrfy that all of the details and information I have submitled (or entered) in "vi appl"bon are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this appl canon will W in compliance with all pertinent provisions of the Idassachuselts Slate Plumbing Code and Chapter 142 of the General I-Aws. By gnature of Ucent&du r Title Type of Ucense: Waster 2-" Journeyman ❑ Cty/Town le? -7 NL License Number 0 1 In 3 % J . _ Date... ! ?.-%.. l..!...... . A NORTH TOWN OF NORTH ANDOVER —9 Of ,oto Ie,�00L PERMIT FOR GAS INSTALLATI ft ui This certifies that ...:' /:� ....:.:.:.. %'� ..... �. has permission for gas installation ...... • • • • in the buildings of ....:... .. *.. !........ ............... o . i at ....: 7 �{'. :...-'`'. ... ........ North Andover, Mass. Fee ff -'l .. Lic. No!9'i!ep..... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer f L"'z ot*v MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date 19 !Pf Permit # Building Location 70 Owner's Namee' Type of Occupancy---4L.:5-- f ccupancy4QxG G New / Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ i N (r h W Y Z N N N U CC F Z N Q W N 5 Q O O U ]f m t - = n W V J N W r= Z O r W �\ < r0 N )- w ,¢ o O d M N O R i Y� 2 0 W L)= <= N Z F- < w CC o a >W = /. W 5 W W W O O W > W W F F' w J H f. CL W V 2 < W2 W ~ < Ix N Q m < O o O W O •1 X '= G Y 7 U. 3 o c7 J U C > o a M- O SuB—BSMT. BASEMENT / 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR. 77 7TH FLOOR 8TH FLOOR Installing Company Name /1,ttr.X��e A,- H `� Check one: Certificate Address aZ X Corporation p f'% o ❑ Partnership Business Telephone U� r7 93 !�3 J ; l ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter rL Sk=yyrTE�LA INSURANCE COVERAGE: I have a curve liability Insurance policy or its substantia) equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please Indicate the type 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 112 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ 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 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 T License: Q�4'd x :�gP4*1 umber Signat3 re of Ucensed Piumber or Uas fitter t Title itter EIMter License Number City/Town Journeyman to z D C m a V T Q C IN. V V r- 0 0 D 0 z T 0 m V = m 0 a 0 0 0 Q D N z a T m rn T_ 2 D r z N T m 0 O z x m i 0 S m N a r