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HomeMy WebLinkAboutMiscellaneous - 9 AMELIA WAY 4/30/2018DSA I Dewing & Schmid Architects July 13, 2009 30 Monument square Property Address: #9 Amelia Way Suite 200E Edgewood Retirement Community Concord, MA 01742 Tel 978.371.7500 North Andover, MA 01845 Fax 978.371.3388 Subject: Final Construction Control Affidavit 280 Elm Street South Dartmouth, MA 02748 Tel 508.999.0440 In accordance with Section 116.0 of the Massachusetts State Building Code, I Fax 508.999.7709 Allen Dewing Jr., MA Registration #4301, being a registered professional cwtiwdsarch.com engineer/architect certify that I was present on the construction site on a regular basis and observed that work was completed in accordance with our Construction Documents and the State of Massachusetts Building Code and the requirements of the Town of North Andover and its officials for the construction of the dwelling referenced above. Q No. 4301 v, 7, 3 CONCORD, Allen Dewing Jr. Date j yJ A. J CERTIFICATE OF USE &OCCUPANCY TOWN OF NORTH ANDOVER Permit # 339 11/14/00 Date; May 15, 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 9 Amelia Way MAY BE OCCUPIED AS Single Family Dwelling , ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to; Edgewood Retirement Community Cottages 575 Osgood St North Andover MA 01845 Buildi g Inspector t' m m m m CO) m m v y .p C � CA n nzy 06 O �. r d °« o = W aC O CD v CDCL o 9 CD CD �. CD o. v vs C I S v CA O 'O Z CD o CD 0 CD R C O CN °z� C/)O �C/) C ,=-* = w C dN cr m N y m 40 n m m CA m .. = 3. ?-c 01 10 N W '� �a-'►a 02r m �� CA _ ?O I mco O Zs n (� �om:OJ' ? h CLgr, O m H �am:c? CA d CO) CL mc , -d C W — _:D IE a H Go G Q O m RL ca !D co • ~ _ CD =CA o IF a'o cl C2 _ _C h Cf) cn sl o w O w C p G�`r_ .. 00 tz m VU �� tz m y 0 0 c I Date. oil NORTH �ti 0 0 0 4. TOWN OF NORTH ANDOVER oil PERMIT FOR GAS INSTALLATION ��SSACNU5E This certifies that ............... has permission for gas installation ...... in the buildings of ...................... at -.,,X No h A ndover, Mass. Fee.,M!Lic. No. 3X2 . ... .'' .�-) ...... Check #- Y30t RAW A, . N° TD 6513 1 3 Date��� v,�........I B t� O� NoRrti qti TOWN OF NORTH ANDOVER �4RECEIPT SSgCHU`�� This certifies that!%bl--.'cE/�<.Cl,?�!!'S has paid . .,.—I's�.:..a.................................................................... .-... I k*r.,1�.............. Receivem�x ? r% 0 ?7w ..................................... Department.......1/.. 6................................................................. WHITE: Applicant CANARY: Department PINK: Treasurer LIM erg........ f N°N7H � TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �SS�cMUSEt This certifies that.......... ..... has permission to perform :,,a!` ................................................. wiring in the . ilding of ....: .... ................................................... at.2 ............................ ..... . ............................... , North Ando Mass. Fee/Q. .:......... Lic. N L?... � ..................................................... n C�� ELECTRICAL INSPECTOR Check # 0602 Project Number_ Project Title: Project Location: Scope of Project: Registered Architectural and Engineering Services Construction Control Affidavit DSA Project #0706.00 Edgewood Retirement Community Cottages #9 Amelia Way, North Andover, MA 01845 22 Individual Cottages In accordance with Section 116.0 of the Massachusetts State Building Code I, Allen Dewing Jr., MA Registration #4301 being a registered professional engineer/ architect, hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project Architectural Structural Mechanical Fire Protection Electrical Other (Specify) For the above named project and that, to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code. All acceptable engineering practices and all applicable laws for the proposed project. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 116.2. 1. Review for conformance to the design concept, shop drawings, samples, and other submittals, which are submitted by the contractor in accordance with requirements of the construction documents. 2. Review and approval of the quality control procedures for all code -required materials. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. Upon completion of the Work, I shall submit a final report as to the satisfactory completion and readiness of the project for occupancy. �R`a—ti a__ lien Dewing Jr. F:\DSA Project Files\Edgewood 0706\05. Project Word Documents\a. Correspondence and Transmittals\vi. Misc .. '� b . � �• ' Registered Engineering Services Structural Construction Control Affidavit at Completion of Structural Work Project Number: DSA Project #0706.00 Project Title: Edgewood Retirement Community Cottages Project Location: #9 Amelia Way, North Andover, MA 01845 Scope of Project: Wood Framed Cottage with Concrete Basement and Foundations In accordance with Section 116.0 of the Massachusetts State Building Code, I, Geoffrey S. Conway, MA #32753 being: a registered professional engineer (structural), hereby certify that I have prepared or.directly supervised the preparation of all design: plans, computations and specifications concerning.- Entire oncerning:Entire Project Architectural XX Structural Mechanical Fire Protection Electrical Other (Specify) , For the above named project and that, to the best of my knowledge, such plans, computations .and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. I further certify that I have performed the necessary professional services and have been present on the construction site on a regular basis to determine that the work is proceeding in accordance with the documents approved for the -building permit and have been responsible for the following as specified in Section .116.2. 1. Revievr for conformance to the design concept, shop drawings, samples, and. other submittals, which are submitted by the contractor in accordance with requirements of the. construction documents: 2. Review and approval of the quality control procedures for all code -required materials. 3. Been present at intervalsappropriate to the stage of construction to become generally' familiar with the progress and quality of the work and to determine, in general, that the work has been performed in a manner consistent with the construction documents. t� GEOFFREY s� Geoffrey, e(hWay, P.E. U Date S. cONWAY Q STRUCTURAL -tet Pfo.32753 �S�itlAli+i-�` APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION Buildina Permit # �_ ADDRESS&OCATION OF PROPERTY:- (q Ma -14 11JAi Zo� O Map Parcel Lot Number SUBDIVISION C�6 x)�(t (Zelu� DATE REQUESTED FILED/READY FOR INSPECTION CLOSING DATE ON PROPERTY: FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE UOE5 NOT MEET ALL Permit Issued to: Address SIGNED CONSERVATION PLANNING DPW - WATER METER SEWER/WATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUP,►NCY/IRSP„ECTLON REQUEST DPW Fife: Application for OC form revised Jan 2007 koRT" 0 ,ssACHU Daft.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........&... .... . has permission to perform ... ...... I ................................................. wiring in the building of ....:r.... . A ............................................................ at ........ .......... . ......... ,North North A—ndover., Mass. Fee/ ...... . . . . . ..........NOO.A.--a .......... Q ELECTRICINSPE(STOR% Check # /lj I / 8662 q 4 C-\ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ( C), 5(0q 7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: ©;Q1 H �i1MVlEK To the Inspect r of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) A�(1'� j j '; W A� Owner or Tenant 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 ❑ New Service f1D0 Amps ►Z,o / 2QS( Volts Overhead ❑ Undgrd No. of Meters No. of Meters Number of Feeders and Ampacity . i A 2JOQ YAYY\ P Location and Nature of Proposed Electrical Work: ►®11 YJt l; lir 1.! GiQQLJr�:i'Ar°112g) T.)itiD1 ,LL llhlCr (nrnnjehor nflhp fnllnwinv tahle rnav he waived by the Insaector of Wires. No. of Recessed Luminaires 3 No. of Ceil.-Susp. (Paddle) Fans No. of TotalTransformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators I`�t�` No. of Luminaires (� AboveIn- Swimming Pool arnd. ❑ grnd. ❑ o. oEmergency-Lighting BatteEy Units No. of Receptacle Outlets 1 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatingDevices No. of Ranges Total No. of Air Cond. Tons No. of Alerting Devices Disposers No. of Waste Dis P eat Pump Totals: Number Tons KW No. of Self -Contained (Detection/Alerting Devices No. of Dishwashers Space/Area Heating e KW Local ❑ Municipal F1 Other Connection No. of Drvers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of Water p Heaters / KR No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach addrtlonai detail !J aeslrea, or as reyuveu by ane uupcuui vl .. .. Estimated Value of Yectrical Work: (When required by municipal policy.) Work to Start: 9 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO ERAGE: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Interstate Electrical ServiErs porpor.atLO LIC -:A-5217 Licensee: Pasquale A. Alibrandi Signature (If applicablrater 11 i Cin the license number line.) Bus. Tel. No.:9 7 8 — 6 6 7 — 5 2 0 0 Address: �� Tre�ple Cove Rd., N. Billerica, MA 01862 Alt. Tel. No.: *Security System Contractor License required for this work: if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's anent. Owner/Agent PERMIT FEE: $ Signature Telephone No. 0 I Date.....s ..'P..........- ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING ACHU This certifies that ... .... ............................................... ..........+ ........... has permission to perform .......... . .................. wiring in the building of .......... r---4 ........ at ........,./1...... ,Ayvle-e,,q ...... �q. . . ........ North Andover, Mass. ................. Fee ... ........... Lic. No. . .... .. ............. .............. ......... ........... EucmcN.Itvs R Check # 8651 'k -N Commonwealth of Massachusetts Official Use Only Department of Fire Services F[Rev-1/0711] �� BOARD OF FIRE PREVENTION REGULATIONSd Fee Checked eave blank 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 WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER 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).. � Owner or Tenants ( r Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building f N0 (Check Appropriate Boz) �'P ' _�_ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps 1 Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: /I ✓ree Completion of the followin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No, of Ceil: Susp, (Paddle) Fans No. °f Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires iNo. of Receptacle Outlets No. of Switches No, of Ranges No. of Waste Disposers Totals: No. of Dishwashers No. of Dryers No. of Water Heaters Hydromassage Bathtubs No. Swimming Pool Al No. of Oil Burners No. of Gas Burners No. of Air Cond. ❑ in- ❑ !vo. of Emergency ig g grad. Batter Units IFIRE A LAI< 4S INe. f :.o :es Tons Space/Area Heating KW 'Heating Appliances �, KW No. of No. of Si s Ballasts . of Motors Total HP o. of Alerting Devices :al ❑ inumctpal Connectioi urity Systems: ** No. of Devices or :a Wiring: No. of Devices or ecommunications No. of Devices or Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: /� l4 a'le �/ (When required by municipal policy.) Work to Start ? 7 5d � Inspections to be requested in accordance with MEC Rule 10, and upon completion. 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 is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE � BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete - FIRM NAME: .-i//li �G/�G /-� LIC. NO.: Licensee: 112,9 t1 , d%lyE-- Signatur (If applicable, enter "exe i - in he license number line.) "'- LIC. NO.:ZZ 117ZP Address:,,i 6t% f L v� ��t �% a/,F% f Bus. Tel. No::j7�' *Per M.G.L c. 147, s.'57-61, security work requires D „ „ Alt: Tel. No.: Dep ent of Public Safety S License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage no rmally 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: $ 1 7� J The Common wealth of Massachusetts Department of Industrial Accidents dice of Investigations 600 Rlvshirig ton Street Boston, MA 02111 www.nwss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricsans/Plumbers Dpllcant Inf[irmaiian Name (Business/Organization/individual):-d111&dri Address: -2 Cityl.State/Zip: r. -r 0 1 A Phone #:. IF 7? - ., 1 7y Are you as employer? Check the appropriate box: 1.0 I am a employer with 4. ❑ I am a general contractor and I Type of project (required): employees (full and/or part-time).* 2. ❑ I am .a sole proprietor or have Lured the sub -contractors listed G. few °onstrvction 7. partner_ ship and have no employees on the attached sheet = These subcontractors have ❑ Remodeling 8. Q Demolition working for me in any capacity. [No workers com . insurance ' p workers' comp. insurance. 5. ❑ We are a corporation and its 9• Building addition required.] 3. ❑ 1 am s homeowner doing officers have exercised their 10.0 Electrical repairs or additions all work myself. [No•workers' comp. right of exemption per MGL C. 1.52, § 1(4), and we have no 11.0 Plumbing repairs or additions insurance required-] t q j employees. [No workers' 12•❑ Roof repairs comp. insurancerequired..] 13-0 Other 'Any applicant that checks bob# I 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 end then hire outside contractors must submit Contractors that check a newaffidavit indicating such. this box musratraehed an additional sheet showing the mare Of the sub -contractors and their work._.-' comp, policy h, &. I am an employer that is providing:workers, compensation insurance for nry. employees Below is the policy and job site information. Insurance Company Name:�j Pelicy 9 or Self -ins. Lic. Expiration Date: '-5�-%d i Job Site address: City/StatelZip. 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ! do hereby certify under the p and p aloes of perjury that the information provided above is true and correct 09y ficial ase only. Do not write in this area, to be completed by city or town. officio( City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other �� Contact Person• Phone Information and Instructions Massachusetts General Laws chapter 152 requires all emp I oyers 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'foregomg engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or ftmtm 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 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 -contractors) 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 requited to obtain a workers' compensation policy, please call the Department at the number listed below, Self-insured companies should entertheir 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 permitnicense 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 Accident Office of Investigations 600 Washington Street Boston, MA 02111 TeL 9 617-7274900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7745 Revised 5-2645 vv<ww.mass.gov/iia Registered Engineering Services Structural Construction Control Affidavit at Completion of Structural Work Project Number_ DSA Project #0706.00 Project Title: Edgewood Retirement Community Cottages Project Location: #9 Amelia Way, North Andover, MA 01845 Scope of Project: Wood Framed Cottage with Concrete Basement and Foundations In accordance with Section 116.0 of the Massachusetts State Building Code, I, Geoffrey S. Conway, MA #32753 being a registered professional engineer (structural), hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project Architectural XX Structural Mechanical Fire Protection Electrical Other (Specify) For the above named project and that, to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. I further certify that I have performed the necessary professional services and have been present on the construction site on a regular basis to determine that the work is proceeding in accordance with the documents approved for the building permit and have been responsible for the following as specified in Section 116.2. 1. Review for conformance to the design concept, shop drawings, samples, and other submittals, which are submitted by the contractor in accordance with requirements of the construction documents. 2. Review and approval of the quality control procedures for all code -required materials. 3. Been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, that the work has been performed in a manner consistent with the construction documents. ` `�N OF � Zr0 T�79 ���' sr�c o`er GEOFFREY yG Geoffrey way, P.E. U Date g S. CONWAY O STRUCTURAL -4 v NO.32753 ca 4 p5TV- FFSS�aNAI. Ea�� Date. 33. ��.7........ TM Of °. O TOWN OF NORTH "ANDOVER • PERMIT FOR -GAS INSTALLATION } 'S,'SS,C NUSEt 5 This certifies that . .fir .moi'. S. .t . e.... ))v. ( { ....... . has permission for gas installation ...`... ,gref?'.-:...... . in the buildings of. !-�- G. �. �� ...................... at X? .. 14 .6.9.. Y.. No h Andover, Mass. Fee.,�Ud Lic. No.). �.j' i ? .... ... . AS INSPECTOR • Check # 3 6741 P Z IM a v� v = 0 W C W Z O W _ III W V W O W Q W Z m O Ha W 00 F > W V Z W 8~ W a' ~ W 0C a O _ d V W Z O tW- 1= O Z J 8 u. IW- _ FW- W W V S O O I x O 4>>> O ll_ 4 Installing.Company Business TZ979 '� d N I gave a current Ilabillft Insurance policy or its substantial equivalentwhich meets the requite of MGL Ch. 142 Yes o No ❑ If you have checked Yes. Please kWl= le Vle type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: i am aware go the licensae does not have the hmunnce coverage required by Chef ler 142 of the Al aChttseito General taws, and that my signature on this permit apOkellonry at esv this requiremenlL Check One Only Ae,nfth wn M r1,.w.er w....... Owner ❑ Agent ❑ www. • .«..n s..w.awa (W enwWa) 9 � appeaauwa are tnua and ate. to the gest of my Knowle�e and dW all phmdrhg work and Installations performed under the Denali Issued for this aonncsnnn Wer he in r---- ..�. M ........ws p.,.w.a... w uW .wmwwG Umous J{H@ rnnrong U?!paanclUhWlor IQ of the General taws. r -- _ , ber Twe 13 G=Fftw 13 Marler gnature of PlumberfiNis Fitter APPS OFFlCE USE awn ❑ LP❑ M n Ucense Number.1 _. 4. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING citer-1, • A ndo7 r MA. Date: 3a C� Pennitg ? W" Loawtion: Q f���1 a `� Owners Nam • ke W6 R �� ce Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: [;I-- Alteration: ❑ Renovation: ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ Z IM a v� v = 0 W C W Z O W _ III W V W O W Q W Z m O Ha W 00 F > W V Z W 8~ W a' ~ W 0C a O _ d V W Z O tW- 1= O Z J 8 u. IW- _ FW- W W V S O O I x O 4>>> O ll_ 4 Installing.Company Business TZ979 '� d N I gave a current Ilabillft Insurance policy or its substantial equivalentwhich meets the requite of MGL Ch. 142 Yes o No ❑ If you have checked Yes. Please kWl= le Vle type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: i am aware go the licensae does not have the hmunnce coverage required by Chef ler 142 of the Al aChttseito General taws, and that my signature on this permit apOkellonry at esv this requiremenlL Check One Only Ae,nfth wn M r1,.w.er w....... Owner ❑ Agent ❑ www. • .«..n s..w.awa (W enwWa) 9 � appeaauwa are tnua and ate. to the gest of my Knowle�e and dW all phmdrhg work and Installations performed under the Denali Issued for this aonncsnnn Wer he in r---- ..�. M ........ws p.,.w.a... w uW .wmwwG Umous J{H@ rnnrong U?!paanclUhWlor IQ of the General taws. r -- _ , ber Twe 13 G=Fftw 13 Marler gnature of PlumberfiNis Fitter APPS OFFlCE USE awn ❑ LP❑ M n Ucense Number.1 _. 4.