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HomeMy WebLinkAboutMiscellaneous - 95 SUMMER STREET 4/30/2018rl) O OD U) m (3) O m o m o A Date.. ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Tanis certifies that .. ... ................................................... has permission to perf ........................................... wiring in the building of ............. ............................................................ a .... ............. .............. North Andover, Mass. Fee ... Lic. No!L'r..Te� . ............. .... ......... ............. ... A("4' .... ELEcmcAL Irwlp-ScMdroR Check # 8529 Commonwealth of MassachusettsF[Rev-1/071 Official Use Only Mom HIMDepartment of Fire Services i�' d Fee Checked -- ql\VtV - — BOARD OF FIRE PREVENTION REGULATIONS ilravP i,i"vt 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 PRINTININK OR TYPE ALL INFOR LOTION) Date: City or Town of. NORTH ANDOVER nspector o res: / By this application the undersigned gives notice of his or her intention to perform the electrical workies nbed below. Location (Street &Number)_ S lJ, r -- G. Owner or Tenant Owner's Address Telephone No. Sn`� � Is this permit in conjunction with a building permit? Purpose of Building Existing Service Zoa Amps /Z,01 i t®v olts New Service Amps / Volts Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: Yes ❑ No Imo-_ (Check Appropriate Box) Utility Authorization No. Overhead L 4 undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �i111 (When required by municipal policy.) Work to Stark/Z / Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERA E: 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" fper enacoverage 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 [I(S (Specify:) I certify, under the a'ns and lties o p ) P p jury, that the information on this application is FIRM NAME: true and complete. � . � _ C � LIC. NO.: Licensee: /C 131 )-S Signature (If applicable, enter "exempt " in the license number line.) LIC. NO.: Address: _ %�/ %OL_lr� i �✓!_/i Bus. Tel. No.: *Per M.G.L c 147, s. 57-6 1, security work requires Department of Public Safety "S" License: Alt. L cl. No. 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ��� Com' No. of Recessed Luminaires Co- letion of the followin table may be waived by the Ins ector o{Wires. No. of Ceil: Susp. (Paddle) Fans No• of Total No. of Luminaire Outlets No. of Hot Tubs Transformers VV , Generators KVA No. of Luminaires Swimming Pool Above In -o. ❑ o mergency ig g -- No. of Receptacle Outlets d. md• of Oil Burners Batte Units �No. n' ALARMS N°. of Zones g No. of Switches No. of Gas Burners No. of Detection and No. of Ranges No. of Air Cond. Total Initiating Devices Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW Totals: No. of Self -Contained No. of Dishwashers Space/Area Heating KW Detection/Alerting Devices Local ❑ Municipal No. of Dryers Heating Appliances KW Connection El other Security Systems: * No. of WaterNo. of0. No. of Devices or Eq uivalent Heaters KW Si s Ballasts Data Wiring: No. Hydromassage Bathtubs . No. of Motors Total Hp No. of Devices or Equivalent Telecommunications Wiring: OTHER: No. of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �i111 (When required by municipal policy.) Work to Stark/Z / Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERA E: 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" fper enacoverage 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 [I(S (Specify:) I certify, under the a'ns and lties o p ) P p jury, that the information on this application is FIRM NAME: true and complete. � . � _ C � LIC. NO.: Licensee: /C 131 )-S Signature (If applicable, enter "exempt " in the license number line.) LIC. NO.: Address: _ %�/ %OL_lr� i �✓!_/i Bus. Tel. No.: *Per M.G.L c 147, s. 57-6 1, security work requires Department of Public Safety "S" License: Alt. L cl. No. 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ��� Com' to 11 'A It Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS (;Oifficial Use Only Permit No. S :�–? Occupancy and Fee Checked c--41 [Rev. 1/07] (leave 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 PRINTININK OR TYPE ALL INFORMATION) Date: Z_ City or Town of: NORTH ANDOVER % / To the Inspector o Wires: dK By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address G7, Is this permit in conjunction with a building permit? Purpose of Building Existing Service ZDa Amps /7-0/ 7 Volts New Service Amps / Volts Number of Feeders and. Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers o. of Dishwashers No. of Dryers No. of Water Heaters Telephone No. Yes ❑ No [�J— (Check Appropriate Box) Utility Authorization No. Overhead �ndgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No, of Meters the No. of Ceil: Susp. (Paddle) Fans INo. of Hot Tubs Swimming Pool �d e ❑ No. of Oil Burners ----------------- No. of Gas Burners No. of Air Cond. T� Space/Area Heating KW Heating Appliances KW KW No. of o. of Signs Ballasts No. Hydromassage Bathtubs INo. of Motors Total HP 7ab1neratorse maybewaived by the Ins ectorof Wires. KVA II �. o. ut emergency ughting ❑ Battery Units FIRE ALARMS No. of Zones ai IINo. of Alerting Devices 11 ❑iivviunicipal l .n"nPP1N-. ❑ Other No. of Devices or Data Wiring: No. of Devices or Telecommunications No. of Devices or / Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 7'Q11 (When required by municipal policy.) Work to StartIZ IF Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERA E: 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 pans and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: 7f 'Cl/Signature �-� (If applicable, enter "exempt" in the license number line.) LIC. NO.: Z Address: AW Bus. Tel. No.: �j �,12911d � ©/"0ZZ Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth of Massachusetts j I Department of Industrial Accidents Office of Investigations ' 600 Nrashinaton Street Boston, MA 02111 c ' www.nwss.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plumbers Applicant Information Please Print LeQtbly Name (Business/organization/Individual) Address:_/�� City/State/Zip: Phone #:. Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. Q Demolition 9. (] Building addition 10.trical repairs or additions 11.❑ Plumbing repairs or additions 12.[] Roof repairs 13.❑.Other Fl—en ron r,,,,ay mrormanon, 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 mustattacbed an additional sheet showing the name of the sub -contractors and their worrcers' comp, pori,—; in:ormadan. I am an employer that is prgviding workers' compensation inst[rance for MV employees: Below is the information. policy and job site ' Insurance Company Name: %/dve%C'%� Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address:_ 5a,� e=/ 1-; 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 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. Ido hereby certify under the pains and pence es of perjury that the information provided above is true and correct _ ,/l Phone #: FE___=�� only. Do not write in this area, to be completed by city or town officiaL ti Town:Permit/License # hority (circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: Phone*: Are you an employer? Check the appropriate box: L • 15_r�m a employer with Z 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a.sole proprietor or have hired the sub -contractors listed t partner_ on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity, workers' comp. insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required-] 3. ❑ 1 am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No•workers' comp. c. 1.52, § 1(4), and we have no insurance required.] t .employees. [No workers' comp, insurance required..] { Any applicaw that checks bo)' # I must aiso flit out the section below showing their worker,' bom sat' Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. Q Demolition 9. (] Building addition 10.trical repairs or additions 11.❑ Plumbing repairs or additions 12.[] Roof repairs 13.❑.Other Fl—en ron r,,,,ay mrormanon, 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 mustattacbed an additional sheet showing the name of the sub -contractors and their worrcers' comp, pori,—; in:ormadan. I am an employer that is prgviding workers' compensation inst[rance for MV employees: Below is the information. policy and job site ' Insurance Company Name: %/dve%C'%� Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address:_ 5a,� e=/ 1-; 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 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. Ido hereby certify under the pains and pence es of perjury that the information provided above is true and correct _ ,/l Phone #: FE___=�� only. Do not write in this area, to be completed by city or town officiaL ti Town:Permit/License # hority (circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: Phone*: 1 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 -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 cavy 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, notthe 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 numberlisted below, Self-insured companies should enter their self-insurance license number on the' appropriate line. - City or Town Officiais 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 permit/license 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. # 617-727-4900 ext 406 or 1-x.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.nnass.gov/dia r Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... :t ................ IW -Z ZZ, has permission to pe�Zrm ....... t�'. .42 . ........... wiring in the building of ......-'/ .. . ......... .%.1Z at ................ . North Andover, Mass. % Fee.... ...... Lic. Noz . ........................................................... ELECTRICAL INSPECTOR Check# 4997 ` Commonwealth of Massachusetts Official Use Only lqqq Department of Fire Services Permit No. Occupancy and Fee Checked . BOARD OF FIRE PREVENTIO R GULATIONS [Rev. 11/991 leaveblank APPLICATION FOR PER I . TO PERFORM ELECTRICAL WORK All work to be performed in accordance ' h the Massachusetts Electrical Code (MEC), 527 CM9 12.0 (PLEASE PRINT IN INK OR YPE AL INF ATION) Date: City or Town of: To the Inspectdr of Wires: By this application the undersigns g Yes no e of is or her intentioroo perform the electrical work described below. Location (Street &N ber) 6 Owner or Tenant , Owner's Address v . Is this permit in conjunction with a building permit? Yes. ❑ . No Telephone No. (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Installation of Security system Completion of the following table may be waived by the InSDector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑ rnd. grnd. o. o mergency rg rng Batter y Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. ot Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers . Heat Pump Totals: I Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers — Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kit Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs b No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER [I (Specify:) (Expiration Date) Estimated Value of E eccjjtrical Work: (When required by municipal policy.) Work to Start: W p( Inspections to be requested in accordance with MEC Rule 10, and upon completion. I cerdjy,.under th4ipaiA andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:A.DT Security Services 1_8 r1iA+An or mH LIC. NO.: Licensee: 'John S. Bassett Signature LIC.NO.: 1533C (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 603 594 59 8 Address: Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Lid, see 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Date. N° 4601 TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING This certifies that ...w7. .... P I.1..� • KKK.... • • • has permission to perform ...//�- .'.�. _- .. • • • • • • • • • • plumbing in the buildings of ... P� 1). /.`..)• . • ............. • • ............ .�. , North Andover, Mass. FeeLic. No...P..`//C ......... ....LJJ//--...... PLUMBING INSPECTOR i Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date o C Building Location CIS EUM arc?/ Sfirc� Owners Name kftAfj--, I -Ji c, , E)Y u,e;4Sr Permit # / ! l 6 Amount 7 j Type of Occupancy New �Renovation 0 Replacement �L Plans Submitted Yes 1:1 No 11 (Print or type) ,' ) / Installing Company Name �-�/es&o FfVA- = ]'je-Jbyg� Address Ph 0C / G << 01(60 Business Telephone (cTc(cl Check one: ElCorp. Lj Partner. 11 Firm/Co. Name of.Licensed Plumber. k)j jlj 4 uj E Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �r Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above F three insurance Signature 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 install o s performed er P it Issued for this application will be in compliance with all pertinent provisions of the M s h s to PI ng e Chapter'1�k`l of_the General Laws. By: igna o icens um e Type of Plumbing License Title iI -,a— City/Town i nse er Masterourneyman APPROVED (OFFICE USE ONLY i• (Print or type) ,' ) / Installing Company Name �-�/es&o FfVA- = ]'je-Jbyg� Address Ph 0C / G << 01(60 Business Telephone (cTc(cl Check one: ElCorp. Lj Partner. 11 Firm/Co. Name of.Licensed Plumber. k)j jlj 4 uj E Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �r Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above F three insurance Signature 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 install o s performed er P it Issued for this application will be in compliance with all pertinent provisions of the M s h s to PI ng e Chapter'1�k`l of_the General Laws. By: igna o icens um e Type of Plumbing License Title iI -,a— City/Town i nse er Masterourneyman APPROVED (OFFICE USE ONLY 3349 Date. ,•{ ..? ).-.G.-...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... U 1111: . F. ( . k ...J.1 ` • has permission for gas installation .. Q r . �V • :. ,N {.. - • •'f• • • in the buildings of . D:5fi-� ........................ • • at.>.. .......... , North Andover, Mass. Fee. Lic. No.. .......... �GASDINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ✓iASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS or print) tvvxIH ANDOVER, MASSACHUSETTS % Building Locations 4 ✓Uj4AU--rG�✓ ��Y- t,�A✓en I oitm Deyyi -&,s Owner's Name Date New ❑ Renovation ❑ ReplacementLogu Plans Submitted ❑ Permit -9 7 3 Y S 1� Amount S , (Print or e) / _ //�� Check one: Certificate Installing Company Name e llt�>r�b / P Aj ❑ Corp. Address 06 So - ` PC -"L" ❑ Partner. Business Telephone Ctn-_53 _ ,Ic?ct 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter (0) fl,'C. s es f"ooS INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes Iff No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy9F Other [vpe of indemnity F-1Bond❑ 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: Sienature 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett State Gas C#de aid Chapter 142 of the General Laws. By: Title City/Town JAPPROVED (OFFICH USE ONLY) Signature of Licensed Plumber Or Gas Fitter Q --Plumber Al- q)2. ❑ Gas Fitter License I umoer ❑�}btaster journeyman i i (Print or e) / _ //�� Check one: Certificate Installing Company Name e llt�>r�b / P Aj ❑ Corp. Address 06 So - ` PC -"L" ❑ Partner. Business Telephone Ctn-_53 _ ,Ic?ct 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter (0) fl,'C. s es f"ooS INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes Iff No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy9F Other [vpe of indemnity F-1Bond❑ 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: Sienature 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett State Gas C#de aid Chapter 142 of the General Laws. By: Title City/Town JAPPROVED (OFFICH USE ONLY) Signature of Licensed Plumber Or Gas Fitter Q --Plumber Al- q)2. ❑ Gas Fitter License I umoer ❑�}btaster journeyman