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HomeMy WebLinkAboutMiscellaneous - 841 CHICKERING ROAD 4/30/2018 (4)N 00 Date ..... 4041 ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,This certifies that rvrv-or,,A . . ..................................... has permission for gas inst Ila M6�rs ... .......... in the buildings of .................. at4mo... 6 4v I .................. Fee6.0 ... W ...... Lic. ... . .. w .. Check #3 c�OU r - 100-17 ................................................................. ........ , No A dover, Mass. P.I., I v A. -ii�-��R ............................. S� P"I MASSACHUSETTS UNIFORM APPLICATION, FOR A PERMIT TO PERFORM GAS FITTING WORK CITY F MA DATE— PERMIT# OWNER'S NAME 'G OWNERADDRESS TE TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL . E] RESIDENTA CLEARLY NEWJ- BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM /.SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Z No El I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYFK-1 OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I'am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement CHECK ONE ONLY. OWNER E] AGENTE:1 SIGNATURE OF OWNER OR AGENT I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate t th bestofmyknovAedge and that all plumbing woric and installations perfon-ned under the permit issued for this application will be in compliance * all 40ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. fEE --.]LICENSE#z ISIGNATUR CITY STATE EDIPL�� % Z 31 5 Ks i 4� 6 Location S y 1 (f k, c ks ,,.A Ul No. 22—:>\ Date "GRT" TOWN OF NORTH ANDOVER O.•,AOR F?•,,`•D i y Certificate Occupancy • ; # of $ SACMus l� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3 f 22446 v Building Inspector µORTHTOWN OF NORTH ANDOVER cF,steo l` qti OFFICE OF BUILDING DEPARTMENT �o * 1600 Osgood Street Building 20, Suite 2-36 Q Ca[wr[n�c� y9' North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please ,print DATE:— 2/;) y,D JOB LOCATION: P y1 C 8 /G Number Street Address Map/Lot HOMEOWNER 000(yt,- D.468& FSr- Name Home Phone Work Phone PRESENT MAILING ADDRESS S City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 a- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance `Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): b CD 5S IVl4l�`er� Address: �q � CN -1o; iz-al o (9- City/State/Zip: W=2, A w % 0 r-',/2 KA k Phone #: F 7 t= 6 � c -rlllo Are you an employer? Check the appropriate bog: 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 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for in any capacity. [No workers' comp. insurance ,,,(required.] 3. L�,I am a homeowner doing all work / myself. [No workers' comp. insurance required.] t workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9.-E] Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any appiicant u M Ci2CCkS box a i mu -SO rill 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. :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 is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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 x day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: CDate: Phone #: Offwial 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 permittlicense 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 license 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 Office of Investigations 600 Washington. Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-977-MASSAFE Fax 4 617-727-7749 f Revised 5-26-05 v*,ww.mass.gov/dia N. tP Oaa .� u 0 O w v v cn ox H U z A o p w O w , C U CO XC p cs: C w" � W U U p u: v cn p ir, x O a C7 O cx p w z W �¢ W ate' O a] ° z cn Q v) O z cm f a� O CD O v Z 0. O y D � � c cm ca!!ww � Q y CD m m O O CD 0 � O d c o � c �cc O co C Z C.3 V CO) � C 0 LLI 0 U A 19 W W U) c c m c c o ` C N O_ C _o Ci 'a,o I eo ev O c t o � L m o 3= a a :.. CD CDd 3 ... y cc � o cm m C O. i:. CA !p • mm o : m 3 C Cm M-0 cq. 11: y O Q • E o V L A: y r^ O :moc T:CyQ •act Q? CD 1��Z F �C c0 Qo y C O\ O = O H H O � W r0+ C r0.. ::s •y •y .n 0 r"' v o-0 c c tNIP H _ ` O cm f a� O CD O v Z 0. O y D � � c cm ca!!ww � Q y CD m m O O CD 0 � O d c o � c �cc O co C Z C.3 V CO) � C 0 LLI 0 U A 19 W W U) MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINCs (Print or Type) Mass. Date D P—C S 19 Permit # �GG� y: —__ — 'I r = — Building LocationPq MCNEPiAtt, RPwner's Name &Mf L° '04 R Type of Occupancy of c -,Lt--- 11 New ❑ Renovation V Replacement ❑ FIXTURES Plans Submitted: Yes ❑ No ❑ Installing Company Name P3 R uce, We I NAa L Check one: Certificate Address '� PL.f M c U i h st ❑ Corporation e'-\� U e 0, M ta�- ❑ Partnership Business Telephone 693 -no(- ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Q• INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑ No 0j], - 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 th my signature on thisIt application walves this requirement. a s �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 the 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 Title City/Town APPROVED (OFFICE USE ONLY) Type of License: O Plumber ❑ Gasfitter ❑ Master Signature of Licensed Plumber or Gas Fitter &4otrneyman 717 &.u3 License Number ■■■■■■■■■■■■■■■■■■■■■■■■■ •• ■■■■■■■■■■■■■■■■■■e■■■■■■ W"Mrs ■■■■■■■■■■■■■■■■■■■■■■■■■ NEW .. ■■■■■■■■■■■■■■■■■■■■■■■■■ Installing Company Name P3 R uce, We I NAa L Check one: Certificate Address '� PL.f M c U i h st ❑ Corporation e'-\� U e 0, M ta�- ❑ Partnership Business Telephone 693 -no(- ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Q• INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑ No 0j], - 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 th my signature on thisIt application walves this requirement. a s �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 the 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 Title City/Town APPROVED (OFFICE USE ONLY) Type of License: O Plumber ❑ Gasfitter ❑ Master Signature of Licensed Plumber or Gas Fitter &4otrneyman 717 &.u3 License Number z O W H, -i J W m W W W LA W U W H v os ri • r, " Li p V Z W W O � m J LL W Owi m a V CL 66 0 O Z O W O LI d � U Z Z 0 a V �i Date/.-?�/! � :........ . -7G /' LD aORTh TOWN OF NORTH ANDOVER rOy<.eo ,,MO o PERMIT FOR GAS INSTALLATION r . 8 This certifies that . ........f j. d � has permission for gas installation .... - : r :...' .. ........... in the buildings of . ! ............... '...f ................. . at . `.� ! . �.-.,f f .........,! •'. ....... North Andover, Mass. Fee../., :... Lic. .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File 5 of Date .... ?r Z - ©s ...... i A TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ei 4. Ll has permission to perform ................................................. wiring in the building of ....... ............... ! .. ............................... at ........ "'.y J. /. ...... . , North Andover, Mass. ........... Fee J'�.r.`F.'P ..... Lic. ....... No. P1 D z. 7 4......... ................................r , ELECTRICAL IN..SPECTOR Check # "T `5'D 14 Commonwealth of Massachusetts Official Use Only it Department of Fire Seryices Permit No. S,7 BOARD OF FIRE PREVENTION REGULATIONS Map & Parcel R V V. APPLICATION FOR PERMIT TO PERFORM EL RICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MBC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE AL4TION Date: City or Town of: O 41, To the Insp for of Fres: . By this application the undersigned gives notice of his or er intention to perform the electrical work described below. Location (Street & Number) Road Owner or Tenant M k,-, Telephone No. l Owner's Address Is this permit in conjunction with a building ermit?r Yes ❑ NoBuiidl'ng Permit #5! r Purpose of Bullding 2� G �l/L )\a ( Utility Authorization No. Existing Service Amps /OW 090 Volts Overhead Undgrd ❑ No. of Meters o� New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followin table may be waived by the Ins ctor of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans °• ° Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool ve ❑ n- ❑ O. o mergency g ng It rnd. rnd. Bette UNta No. of Receptacle Outlets No. of 00 Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of De tion an Initis Devices No. of Ranges No. of Air Conti. Tootal —ns No. of Alerting Devices No. of Waste Disposers Heat ump _ um r ons o. o e ont n Totals: ....__._..._.... _ _.._._w. DeteedoNAlertin Devices No. of Dishwashers Space/Area Heating KW Localc p ❑ Connection Other . No. of Dryers Heating Appliances KW Securrty ystems: o. o Water No. of Devices or E uivalent AO. o o. o Heaters KW Sl ns Ballasts Da Na of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP ITelecommunications ng: nu"un uaautonat aeratt qaesaw, or as required by the Inspector of 11res. 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 cove a iin force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (Bs OND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work:(Expiration Date) /�/ (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the ns and penalties of perjary, that the information on this application is true and complete. FIItM NAME: M. 1 ' _ LIC. NO.: � Licensee: Qo I'm 4 Signature LIC. NO.: 02 ti Afapplicable, enter "exempt "in the lis a mrmbe lute. $ns. Tel. No.• --8� Address: r ^ © 8 Ale. Tel. No.: OWNER'S INS CE WAIVE • I am aware that the Licensee des not have the liabili insurance coverage normally required by law. By my signature below, I hereby waive this requirement I am the (check one owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: a -INSPECTIONS Trench Temp Service Perm Service Rough Bonding Final �► Commonwealth of Massachusetts Official Use OW Department of Fire Servlees Permit No. y � % � y BOARD OF FIRE PREVENTION REGULATIONS Map & Parcel APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with � WORK assachusetts Electrical code 527 CMR�r2,W (PLEASE PRINT INflff OR TYPE IN, TIO �� f: ' N} Date. � r ; ' City or Town o€: O �/ To the Insp for of Mires:. By this Application the undersigned gives notice o his or intention to perform the electrical work described below. Location (Street & Number) 0 1 C Road Owner or Tenant1A 2a Telephone No. f Q Owner's Address CIA Is this permit in conjunction with a b hiding yermlt? Yes ❑ No Building permit # IS ` Purpose of Building ec.� ��R Utility Authorization No. Eng Service 42-0 Amps /o�Voits Overhead B-' Und grd ❑ No of M tors New Service Amps / Vo to Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: e Overhead ❑ Undgrd ❑ No. of Meters ZVI No. of Recessed Fixtures No. of Lighting Outlets No. of Lighting Fixtures No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers KW Hydromassage Bathtubs Of C&-Susp. (Paddle) Fans of Hot Tubs mmin Above g Pool omd. ❑ ¢rnd. ❑ of 09 Burners of Gas Burners of Air Cond. Tot 'cc/Area Heating KW sting Appliances KW of o. o Signs Ballasts of Motors Total HP KVA ALARMS INo. of Zones of Alerting Devices ❑ munrctppal Conn22". ❑ Other . a, aaamonat detail jdesbvA or as repired by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the perfonnance 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 cove is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work (Expiration Date) (�� required by mrmicipal policy,) Work to Stare Inspections to be requested in accordance with NECRule 10 and Ic upon completion. under the acrd pena&W of perjury, that the Oformadon on this appUcatlotr tate and complete. FIRM NAME: � ' LIC. NO. Licensee:13— CIA 1A 1 Signature (Ifappllcable, enter "exempt" to the lk /� LIC. NO.: D Address: Bus. Tel No.• e2 OWNER'S INSURANCE WAIVE • I am aware that the Licensee d es not have the liabili Alt Tel. No.: WT — required by law. By my signature below, I hereby waive this insurance coverage normally Owner/Agent regrvrement. I am the (check one owner owner's ant. Signature Telephone No. PERMIT FEE- 9 Office Use Only -- 1 talth of Magsar uarfts Permit No. _ ul�e L � 3 Occupancy & Fee Checked �epat-imEni of Vublit �ttfie2q (_ `Y BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3190 (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 /_J M* or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the, electrical wor described below. Location (Street & Number) Owner or Tenant ill 'Pr— Owner's Address Is this permit in conjunction w' a ilding ermit: Yes !_ No (Check Appropriate Box) Puroose of Building PS Utility Authorization No. Existing Service Amps _J Volts Overhead ! Undgrnd ❑ No. of Meters New Service Amps _J Volts Overhead Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical lNork &4t u I No. of Transformers Total No. of Lighting Outlets � No. of lot Tubs KVA Above'-- In - No. of Lighting Fixtures I Swimming ?oo: grnd 'I- grna Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners I Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No. of Air Ccnc. tons Initiating Devices No. of Disposals No of 'eat Total Total Pumps Tons KW No. of Sounding Devices i No. aof Self Contained No. of Dishwashers ScaceiArea Heating KW Detc;ion/Sounding Devices r Municipal r— Other Heating Devices KW --7 L �— Connection No. of Orvers / No. of No. of Low Voitag` No. of Water Heaters KW Signs Sailasts Wiring No. Hvcro Massaqe Tubs 1 No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws_ I have a current Liability Insurance Policy inc:ucinc Ccrn sec Cperaticns Coverage or its substantial equivalent. YES _/NO — ! have submitted valid proof of same to the Office. YES NO = If yo have checkea YES, please indicate the type of coverage by checking the appr ovate box. ��__IIJLJL{ �/0 INSURANCE _ BOND = OTHER = (P!ease Scec:fy) (Expiration Date) t-� Estimated Value of Electrical Work 5 �- Work to Start �� /y 9 Insoec::on Date Recuestec: Rauch� Final Signeo under the Pen sties of perjury: C FIRM NAME Q LIC. NO. Licensee P 9 r' Signature LIC. NO. �4��c ,D Bus. Te I. No. Address ' + d • % �/ y9� � (I Ica Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- guirea by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (P!ease check one) Teieonone No. PERMIT FEE 5 (Signature of Owner or Agents 31J X-6565