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HomeMy WebLinkAboutMiscellaneous - 79 MARIAN DRIVE 4/30/2018� (° Date.. / - dl� 3530 ........ ..... TOWN OF NORTH ANDOVER \p\ PERMIT FOR GAS INSTALLATION This certifies that :................... has permission for gas installation f''�' !............. in the buildings of .-� ......................... . at .. �1� . ` ! rww^"'• :. , North Andover, Mass. Fee.. .... Lic. No.. . . ... .` . '� , ........... . " GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING /a' (Print or Type) tin 07 mat r4 AxjDo Q4e— , Mass. Date �� i 19� Permit # Building Location '"7 � M Ae ( zwi -D ►ey'-' Owner's Name -fit DC LI O:l S N+ I T H 4II0L7cf MA MIS Type of Occupancy -_ IR ESl int:= N -ri rq L C!' New ❑ Renovation ❑ Replacement 211" Plans Submitted: Yes❑ No 0-- Installing Company Name r2A (2 T A • `elm MA T r2O Check one: Certificate Address ODA C H m A_ ►y L ( ❑ Corporation ME 7HUEO 01 a 01 N y ❑ Partnership Business Telephone % 2 — 9 9 -7 f 2-Firm/Co. Name of Licensed Plumber or Gas FMer "Rr)AE PT A • 5AMM 14AP(-) INSURANCE COVERAGE: I have a current j Ibility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 2 No ❑ If you have checked ye, please indicate the type coverage by checking the appropriate box A liability insurance policy 0' 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: Signature of Owner or Owner's Agent 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 thepe • r ed for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne taws. BY T of Incense: CZ er n Plumbure of a u or titer Title tter license Number V a3 ) City/Tovvn Journeyman I Y Y Installing Company Name r2A (2 T A • `elm MA T r2O Check one: Certificate Address ODA C H m A_ ►y L ( ❑ Corporation ME 7HUEO 01 a 01 N y ❑ Partnership Business Telephone % 2 — 9 9 -7 f 2-Firm/Co. Name of Licensed Plumber or Gas FMer "Rr)AE PT A • 5AMM 14AP(-) INSURANCE COVERAGE: I have a current j Ibility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 2 No ❑ If you have checked ye, please indicate the type coverage by checking the appropriate box A liability insurance policy 0' 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: Signature of Owner or Owner's Agent 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 thepe • r ed for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne taws. BY T of Incense: CZ er n Plumbure of a u or titer Title tter license Number V a3 ) City/Tovvn Journeyman I NI W S U uj I W Y N 1v I O Z h - h W N a v O G O M' _H ¢ o z d 0 W Z o F- a v IL IL � . NI W S U uj I W Y N 1v I Location No. ro. �'hA//C,A Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee �OthyP rmit Fee 1 ,Sewer Cerise ytlon Fee ,. s rConnection Fee TOTAL - Building*lndpecto Div. Public Works k 0 r &§ 4 § m 0 � G � k 0 0 k ) ■ � m m m ® - 0 k k k Z . . . � \ ) ( k \ \ k x m k ■fir � � z � � M c 0 �i 0' $� w1 � � 0 'U m ■ � z 0 ■ ■ J 0 z m a» 0 o a.» o o r N &; 7 Z m r c c c§ |� -i r) Z 0 m m� m °• F r F o||| q; q[ v o e m m m 2 0 0 » z » o§ o§ o m m_ ° ' z ; z » » z 0 ! 0 § 1 \ 0 m 3> m 2 q; ; o M; m■ o i a » § / ) k § G °z o E ■ r °U)5 . ` ° q z_ 0 - / § % I a q � m m 4 @ 0 q n ; k z m ; � @ m m � L � , a |§& S;' a 0 c N c c E z » m . . 9 0 z o 3° 0 r r F r ,�.: m nm 0 § 2 2° P m o o ,,, m m a§ o 0 o 0 m m 0 0@ 0 0 2 • -1 o 0 o , c � 0 o 0 n z c�` . 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I I O 00zz O A N IO� I I I1 I C) -j N m m NDN zm ao zz COc MkN Di 0�0 wa* p3m • mx =Nn moo �z- mN3 rvOZ m0o0 �- NsN v_ r room 2 iG)r -0000 Dia �n ?-Z A �a nz; 10, mm P t 00 a3 , I I onC . z vSv vpzl OD :0 C ON ; 0 •� a m A O H O N N 0 s Z C) -j N m m NDN zm ao zz COc MkN Di 0�0 wa* p3m • mx =Nn moo �z- mN3 rvOZ m0o0 �- NsN v_ r room 2 iG)r -0000 Dia �n ?-Z A �a nz; 10, mm P t 00 a3 , 5 Jm/ pW � O O ei O '� POOH CL ®. -v Mi > eb 13 a OR q H ® y C eD CL L (A � T 11 (A M' •- T ?1 n :X)3 ►i C O CD O1 3 O O �1p O m C co < c T N c y c CD rm c J O kA Z n v a O PP1 m -4 -4 v 'a 0 T T T n R1 a 0 LocationNo. Date Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ d .p o Building/Frame Permit Fee $ ,3y C) d Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ ---__..-----. TOTAL MW' (% 08194 15:56 7308 $��yGoy Building Inspector 284.00 PAID Div. Public Works PFRMIT ND.� APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. �1-rAE 1 MAP d,40.110-'1 � 11 1 LOT NO. Ll5 2 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE LOCATIONJ� SUB DIV. LOT NO. �`/ �.�l,d .meq,c eV- n/ PURPOSE OF BUILDING t-��. -� t- ,(3 OWNER'S NAME - NO. OF STORIES IZE OWNER'S ADDRESS-,I_�� BASEMENT OR SLAB Li ARCHITECT'S NAME V' SIZE OF FLOOR TIMBERS 1STi,2ND ��Gt� 3RD BUILDER'S NAME �n n \ _ '., �, ( a T1 (/ SPAN T'K) r jo C & (y" DISTANCE TO NEAREST BUILDING �/(6 !'�uu DIMENSIONS OF SILLS apLo POSTS DISTANCE FROM STREET iJ1 DISTANCE FROM LOT LINES — SIDES 46± T I, 6 REAR GIRDERS AREA OF LOT V N•V FRONTAGE / ! HEIGHT OF FOUNDATION L/, D THICKNESS - IS BUILDING NEW y�y�J "JQr� SIZE OF FOOTING (P X 't'i`(/ IS BUILDING ADDITION ] MATERIAL OF CHIMNEYO IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO EQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY d� i6 - n v IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE 'w INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 b ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE c L. N "1 PERMIT GRANTEI OWNER TECONIR. TEL # L"l, 19 1-�- CONTR. LIC. N 3 PROPERTY INFORMATION LAND COST --�" EST. BLDG. COST Q . EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. �- 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY [�FF �oRlEs I THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY ICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. I r CONSTRUCTION 2 FOUNDATION CONCRETE CONCRETE BL K. BRICK OR STONE PIERS 8 INTERIOR 3 PINE HARDW D PLASTER DRY WALL UNFIN. FINISH 1 2 13 _ _ 3 BASEMENT AREA F LL FIN. B M T AREA '1, r/, FIN. ATTIC AREA _ NO 8' T FIRE PLACES _ _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 ��_ ✓ 2 _ 3 _ DROP SIDING CONCRETE WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING STUCCO ON MASONRY STUCCO ON FRAME _ _ EARTH HARDIV D COMMCN ASPH. TILE BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. & FLOOR _ CONC. OR CINDER BILK. WIRING STONE ON MASONRY STONE ON FRAME r' B SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I GAMBREL FLAT BATH (3 FIX.) MANSARD TOILET RM. (2 FIX.) SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING II 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COlS. HOT W T'R OR VAPOR WOOD RAFTERS �_ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ 1st j 13rd I ELECTRIC NO HEATING I r 0 FORM U - IAT RELEASE 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. ***************1*Applicc`ant fills out this section***************** APPLICANT: c� 61 `� V'PsA�. y� mac, e -r Phone LOCATION: Assessor's Map Number Q Parcel Subdivision Lot(s) o� Street St. Number I ************************Official Use Only************************ RECOMMENDATIONS/ -\ OF TOWN AGENTS: Date Approved / Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comnents Food Inspector -Health Sept -'c Inspector -Health Co=ents Date Approved Date Rejected Date Apprcved Vim` j - h -5L Date Rejected Public Wcr::s - serer/water connections _ - drivewav permit 1, Fire De arttm"enntt Olt U` eceived by Building Inspector Date AGREEMENT Agreement made this 20th day of April 1994, by and between Michael A. Collins, d/b/a The Collins Company (the "Contractor"), and Jean Krieger and William Krieger (collectively, the "Owners"). WHEREAS, the Owners desire to retain the Contractor to construct a 640 square foot addition located at 79 Marian Drive in No. Andover, Massachusetts (the "Property") and to build an addition on the residential dwelling on the Property (together, the "Project"). NOW THEREFORE, the parties intending to be legally bound, hereby agree as follows: 1. Scope of Work. The scope of work or Project shall consist of the construction of a family room, bedroom, bath and deck, in accordance with the plans prepared by Keith Belair, dated 4-13-1994 (the "Plans"). As well as an entire new heating system. 2. Owners responsibilities. 2.1 The Owners shall provide to Contractor full information regarding their requirements for the Project. The Owners hereby designate Jean Krieger as the person who shall be fully acquainted with the scope of the work, and who has authority to approve changes in the scope of the work, render r decisions promptly, furnish information expeditiously, and execute all necessary documents on behalf of the Owners to complete the Project, including requests for payment and all necessary applications to governmental authorities. 2.2 If the Owners become aware of any fault or defect in the Project or non-conformance with the Plans, they shall give prompt written notice thereof to the Contractor. 2.3 The Owners shall provide and pay for the builders risk insurance required for the Project. 2.3 The Owners shall be solely responsible to retrieve all property, real or personal, from the existing structure where work will be performed on the Property and, within 48 hours of written notice from the Contractor, shall turn over the existing structure to the Contractor for demolition. The Owners agree that the Contractor shall assume no risk for loss of any contents (real or personal) within the existing structure on the Property. 3. Contractor's Responsibilities. 3.1 The Contractor shall be responsible for obtaining.the completed Plans and for obtaining all necessary permits required by by governmental authorities in order to complete the Project. The Owner agrees to pay for or reimburse the Contractor for the cost of the Plans, Engineering and all necessary permits or application fees incurred to construct the Project over and above the guaranteed maximum price. 3.2 The Contractor agrees to use his best efforts to complete the Project (scope of work). C 3.3 The Contractor shall be free to retain any subcontractor or agent whom the Contractor desires to employ in order to complete the Project. 4. Cost 'of the Project; Contractor's Fee. The parties agree that the Contractor shall construct the Project for cost plus a fee of 15% of the total cost of the Project. The Contractor shall be paid his 15% fee with each progress payment received and the balance, if any, shall be paid at the time of final payment. The guaranteed maximum price including contractors fees shall not exceed 5. Changes in the Work. 5.1 The Owner may make changes in the work provided that the Contractor shall agree to such changes. The Contractor shall be paid 15% fee on all changes which increase the cost of the work. The estimated value of each change in the work shall be added to or deducted from the guaranteed maximum price. 5.2 If changes in the work are required to comply with local, state or federal laws, rules, regulations or requirements which are not applicable at the time of the execution of this Agreement, the guaranteed maximum price shall be adjusted to reflect the cost of such changes. Such changes shall include, by way of illustration and not limitation, compliance with the Environmental Protection Agency rules and regulations, air and water pollution control or wet lands regulations and other agencies and authorities. 6. Payment for the Project. On behalf of the Owners, the Contractor shall submit requests for progress payments. As indicates in Paragraph 4, each progress payment shall include the Contractor's fee for that proportionate cost of the Project. 7. Hazardous Waste. The Contractor shall have no responsibility with request to any hazardous waste discovered on the Property. If the Contractor encounters hazardous waste at any time during the Project, the Contractor shall notify the Owners, who shall have the sole responsibility to remove said hazardous waste at their sole expense. The Contractor shall be entitled to suspend all work on the Project until said hazardous waste is removed to the satisfaction of all necessary federal, state or local governmental authorities. If the Project is suspended due to hazardous waste on the Property, the Contractor shall be entitled to payment of his proportionate to the cost of the Project up to that time. 8. Termination of the Contract. If the Owners terminate this agreement for any reason, the Owners shall reimburse the Contractor for any unpaid costs of the work due Contractor plus the unpaid balance of Contractor's fee computed upon the cost of the work to the date of termination at Contractor's 15% fee. 9. Miscellaneous Provisions. This Agreement shall constitute the full and complete Agreement of the parties. Any modifications or amendments to this Agreement of the parties. Any modifications or amendments to this Agreement shall be in writing and signed by all of the parties hereto. This Agreement shall be binding upon the heirs and executors of the parties, and shall be governed by the laws of the Commonwealth of Massachusetts. V 10. Driveway. The contractor takes no responsibility for any damages present or past of existing driveway. Landscaping. The landscaping shall be rough grade only. And no repairs to the bituminous material. WHEREFORE, parties execute this Agreement as of the date and year first written above. Witness Witness Witness Michael A. Collins Jean Krieger William Krieger T z C) O z C/) m m D C) z CA 10 �. Z CD O CL r d Q �. nco Q cov CL c CD O FL, to O O O cm CD W Cl) CO) C9� O C CA E C7 CD O �F CD CDa y. CD CO) O CCD O CD I u co O CO O 7 _ 0 S 5 CO c tV 0 N 4-1O CO) CO) W �.. _ �.. va �:z :'F'Y6` r ' i'.:St+�*°�'1.`�i�"^,�`1'Y.� .� -Y' �Sn't`,��.... i y � � 3�': �4.�� •,: ,..3�aL L•a �RkAwIJi��M'+'wsi{l'b9.,i.:.t a.k ,.�.-..�:.:..� W ?.O O c G O cr aO C CD .0 y O • CD Q 0 C) • CAe'ja. m n Z ��• H �_to ® d?d y W CA O N CC�'p CD G CD 003 �. O O H• C2 k W O W y fl : ` � O a a S. CL .. C) - CD n�, ` - �W �= CO) Q m, c �G CL tz 4 O O. , W �CC W .� N H `�1.9 �M y ' y-4 �. •O = W :im y �O C7 b *#* AL W O n CD CD 3 CD o N r► I n '+ CA , .� .. s C* CD b� d'�r O o_N CD •y + lY r. z= W �1 � Ov (n O orrD C,/) rs ro Co " �rD d y z7 ,C1 G 'v �t7 y CA < CD �1 C lTj y r z y 71 a w 7y G GO y m w p� n ? DC7 O G T C 7 C r zd W ►�•3 C/1 fDU y c n rD 'r1 p a. x n rD to O a O x H c OFFi(:h.b UF: APPEALS BUILDING CONSERVATION HEALTH PLANNING uNORTH ANDOVER DIVISION OF PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR North Andover. Massachusetts O 1845 (617) 685.4-15 In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number 1q1 D is that the dcbris resulting from this work shall be disposed of in a properly licctucd solid waste disposal facility as dcfincd by 41GL c 111, S 150A. The debris will be disposed of in: c, "% �-C- (Location of Facility) e Signature of Pcrmtt Appiicant (_// — /— 9 �/ Date NOT_: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. claw The Commonwealth of Massachusetts 0e1r Department 0 �vrnlc b. / 7� \ J Public &jctv 1 oCeYlNlle L Qlftkfd� %�+ 1 BOARD OF FIRE PREVENTION REGULATIONS 5I7 CmR 1200 3/90 V \ ` (leave blank) APPLICATIONabe FORTeP�orosacg � All work PERMIT TO PERFORM ELECTRICAL WORK tlh e MaWchusens E3earlcal Code, 527 CMR 2:00 (PLEASE PRINT IN nM ORE IITFORMLTION) Date /O City or Town of The undersigned applies fora permit to To the Inspecto of Wires: p perform the electrical work described below. Location (Street b Humbert �_ ,� I / Owner or Tenant 4) 041• ) , Owner's Address A._ _AP Is this permit in conjunction. with a building permit: Yes Cl v❑ (Check Appropriate Box) Purpose of Building, -,-1 t 1,,, Utility Authorization N0. Yaiscing Service _Amps / ❑ Volts Overhead Undgrd ❑ No. of Maters _L_. �c� �P+ / Volts --� Overhead ❑ Undgrd ❑ No. of Meters Humber of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hoc Iubs No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above ❑ In. KVA red. No. of Receptacle Outlets rnd• ❑ Generators KVA No. of Oil Burners No. of Emergency Lighting No. of Switch OutletsBatte Units No. of Cas Burners FIRT, ALARMS No. of Zones No. of Ranges No. of Air Cond. Total cons No. of Detection and No. of Disposals No. of Heat Iocal Total Initiating Devices ..___. Pueos TonsKW No. of Sounding Devic:s No. of Dishwashers Space/Area Heating KW No. of Self Contained — No. of Dryers Heating Devices Detection/Sounding Devices —""— KW Municipal Local ❑ Conneeclon�Other No. of Water Heaters KW No, of o. o Si ns Ballasts Low Voltage Nlrin No. Hydro Massage Tubs No. of Motors Total HP OITIER t INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liabilit Insurance Policy in Completed Operatiops,Coverage or s substantial equivalent. YES Q NO L I have submitted valid proof of same to this office. YESE NO ❑ If you have checked YES, please indicate the type of coverage Oy c ecking the appropriate box. INSURANCE t BOND ❑ OTHER T (Please Specify) r / Estimated Value of Electrical Work S p r cio e) Work to Start + Inspection Dace Requeatedt Rou 611 Final Signed under the enalties of perjury: FIRM NAME . /!//� i7 f GG�� ri� /C �l/ ,L – LIC. NO. .593 --2 Licensee s %1% �f /,Q `%jL Signature Address �' LIC; H0. 1Vll / us. Tlkl. No. h 3 — L_ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General vsia ,'anand ihac my signature on this permit +PPlication waives this requirement. Owner Agent (Please check one) Telephone No.. Signature of Owner or Agent PERMIT FEE S %.-i"�rF`�r''�Y�4-7.��--+"f1+'-s�w''k'...... �'.",;r-.'�i' . . ..e•;.. `i'/v.;y:".'�....,�v, .ar��.,�:�'ti.^,, Date.... ""./..0 `..:%�'. 777.. NORTH Ott��ao .e�ti0 - 3? �•,, O� TOWN OF NORTH ANDOVER, PERMIT FOR WIRING A .� ,SSACMUS� 4r" / This certifies that ..........................................................:...�........ .................. has permission to perf rm - 44 . a wiring in the buildin ................................. ;n at ...... �r:j...�.�{�-c-......! ... , North Andover., Mass.°' w y �. M Fee ..... ....-...... Lic. No ..�� ............ ...............a ELECTRICALINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer NORTH F 9 �SS CHUSE� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..7�l.r!i4!7 G..... . has permission to perform ............... plumbing in the buildings of ...t! .................... at L..... Q .......` .. , North Andover, Mass. Fee. ) ..... Lic. No... � . ...... ......... PLUMBING INSPECTOR Check # e 5309 3z F - MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) &1?_^1 , Mass. Dat 20o2 . Building Location '79 A&rDI", Owner's Name V 4 A 4/) LY.,e, Type of Occup 19 New ❑ Renovation ❑ Replacement 2-11 FIXTURES Permit Installing. Company Name f 0P)EI,T - SPmm,4-TAe7 Check one: Certificate Address_ �� o C0 4 c i4 /Y)An) t, pj ❑ Corporation 1y) E % N4 o Ell VYi A U 1 rf VL/ ❑ Partnership Business Telephone C,q-7 1 9-6;i /Co. Name of Licensed Plumber�►� F;e T ftp S/ -I ,�Vlo'Vl d9 �r4 fir" INSURANCE COVERAGE: I have a current 4biiity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes p' 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 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: _ 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 ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and qapter,11 of the eral laws. By Title re of licensed Plumber Type of License: Master Journeymah ❑ City/Town APPROVED -OFFICE USE ONLY) License Number 1 z D r Z N V m A O z N "I m r O D co C A r � .r m O fn O. A' m A 31 Z c •� O m O z z m r o c r s v V z z rn o a ; z O O O T r C z Q 1 z D r Z N V m A O z N "I m co m r m O O. m A m c N m O z r