Loading...
HomeMy WebLinkAboutMiscellaneous - 990 JOHNSON STREET 4/30/2018Date.Y.: ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies G ....................................... has permission to perform ..,.t.� %. f.�d. ! ....!Y4 ..... ...... wiring in the building of .. 1d...�T ,�,'A.'2j ev? -rT— f...... at ........... /`� ............. .¢..........I..'a-L .f....................'".. , North Andover, Mass. Fee 1425 .....Lic. No. ELECTRICAL INSPECTOR Check # 660"6 PO Box 55098 . • • 02205-5098 •1-0600 Safety insurance / �'u.. er.,,,,,ess' ► '100 I 1480 J� 2015 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: DANIEL DUSSAULT and NANCY DUSSAULT Property Address: 990 JOHNSON STREET, NORTH ANDOVER, MA Policy Number: HMA 0116272 Claim Number: BOS00056970 Date of Loss: 2/20/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Joshua Terenzoni Claim Examiner 3/24/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3287 Fax: (617) 531-6648 Email: JoshuaTerenzoni@Safetylnsurance.com lfom.monwea& of //la4dachaaefj aCJepartmed of Jim S rvice! y` BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (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 PRINT IN INK OR TYPE ALL INFORMATION) Date: 1/77/6,9" City or Town of: V o ✓ f" P, J!) / y 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) C1 10 3-6 "J dLi Owner or Tenant �„5�� 1b Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ , (Check Appropriate Box) Purpose of Building t= i 1f"fe Utility Authorization No. Existing Service l 60 Amps / Volts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 3 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 911 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties of perjury, that the information on this application is true and complete. FIRM NAME: MAI.- 41 wvl:; '/f, LIC. NO,: Licensee: J ,L 11 ki/4191 a. Signature LIC. NO.: /y (If applicable, enter "exempt" in the license number line.) Bus. Tel, No.:%3l-is'� Y' Address: Alt. Tel. No.: Met r -Y Z -tit 77 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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: $ e ton o e o owtn table ma be waived b the Inspector o Wires. No. of Recessed Luminaires C No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets 5 No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In ❑ o, o Emergency Lighting rind. rnd. Battery Units No. of Receptacle Outlets /0 No. of Oil Burners FIRE ALARMS No. of Zones No, of Switches 1' No, of Gas Burners o. of Detection and Initiatin Devices No, of Ranges No.. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons KW No. of Self -Contained Totals Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal [I Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No.KW No. of No. of Devices or Equivalent Signs Balts Si Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 3 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 911 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties of perjury, that the information on this application is true and complete. FIRM NAME: MAI.- 41 wvl:; '/f, LIC. NO,: Licensee: J ,L 11 ki/4191 a. Signature LIC. NO.: /y (If applicable, enter "exempt" in the license number line.) Bus. Tel, No.:%3l-is'� Y' Address: Alt. Tel. No.: Met r -Y Z -tit 77 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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: $ I The Commonwealth of Massachusetts k� f Department of Industrial Accidents t�1Office of Investigations glfit 600 Washington Street °,i� Boston, MA 02111 "````���r i www.nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ac►ulicant Information Please Print Le�bly Name (Business/organization/Individual): Address: �, O 4f ti m, -se ,,, c•'I City/State/Zip: ,i i✓/'# G t kel l Phone #: 7t /­ 97.7 - M. k Are you an employer? Check.the appropriate box: I . ❑ I am a employer with 4. ❑ I am a general contractor and I onployees (full and/or part-time).* have hired the sub -contractors 2. I am asole proprietor or partner_ listed on the attached sheet x ship and have no employees These sub -contractors have working for me .in any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officershave exercised their right of exemption per MGG myself [No-worke'rs' comp. c. 1.52, § 1(4),and we have no insurance required.] t employees. [No workers' FA - comp. insurance required_] Type of project (required): 6. ❑ New construction T 2-femodeling S. ❑ Demolition 9.❑ Building addition 10.❑ Electrical repairs or additions 1 I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other r, ••- ••• •••.• w — ��I, 7I must also nu out the section below showing their workers' compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xConttactom that check this box must attached an additional sheet showing the name of the sub -contractors and their r,,,,rk—' comp. policy information. I am an employer that is providing: workers' compensad&n insurance for my employees,Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State2ip: 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 WORT{ 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. I do hereby certify under the airs and penalties of perjury that the information ,, f provided above is true and correct 'hone #: 7 Z,_ Y17-7 Official 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 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not mquiredto 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 t 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 nurnberlisted below, Self-insured companies should enter their self-insurance license number on the appropriate tine. 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 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 flrture 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 Investiptions 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 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 4vww.mass.govIdle Date. Oq NORTH.1 TOWN OF NORTH ANDOVER 'A 0- PERMIT FOR PLUMBING This certifies that ........................................... has permission to perform ....................... plumbing in the buildings of ................ at. .......... North Andover, Mass. Fee..... Lic. No. PLUMBING INSPECTOR Check# 13,91 MASSACHUSETTS UNIFORM AppLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH A rNDOVER MASSAMUSETTS Building Location "1��(�I- New 11 Renovation ,---' of Replacement Date _ �3U--49 Permit 7_013 p} Amount `Sr Plans Submitted yesi�7 No Installing -Company Name l: Address Check one: Certificate . 11 Corp. r y E Partner. !- -17/i U Fum/Co. Name of Licensed Plumber:Y1f1,y� Q a C- C-0 Lab Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ility insurance policy �/ Other type of indent u ty ® Bond Insurance Waiver I the undersigned have been made aware that the licens three insurance ee of this application does not have any one of the above Signature Owner ❑ Agent El hereby certify that all of the details and information I have submitted or erste best of my knowledge and that all plumbing work and installa ' s m above application are true and accurate. to the compliance with all pertinent provisions of the Massach PeO under permit Issued for this application will be in 1 o and Cha ter 142 By: P of the General Laws. 61g _ s Own ZOVED roFcE usE oNL.Y License NumUeI .Luter EIr Journeyman ❑ rte. ne (.omenonwealth o .Massachusetts Department 0 Industr 1 ; t. jl� ial Accidents Office of Investigations WashinQton Street L'asto n, MA OZlll WWII,. Pa:asS.CFO v1dia Workers' Compensation Insurance .A ildavit: guilders/Contractors/Electridians/piumbe Ac, licant Information rs Please Print Leoibb Name (Business/Organization/Individual): G City/State/Zip: Are y an employer? Check t e appropriate box: I 1_ Phone #: —2 at . a employer with (full and/or part-time).* 4. ❑ I am a general conir-actor and I have hired the 2. ❑]employees I am a sole proprietor or partner- ship and have no employees sub -contractors Iisted on the attached sheet. 4 These working for me in any capacity. sub -contractors have workers' comp. insurance [No workers' comp. insurance 5.. ElWe are a corporation required.] 3. ❑ I am a homeowner doing all and its officers have exercised.their work myself. [No workers' comp. insurance right of exemption per MGL c. 152 c- e l (4), and we have required.] t no 1Q= P Y s [No workers Type of Project (required): .6. ❑ New construction 7• ❑ RemodeIing . 8• ❑ Demolition 9. ❑ Building addition 10:❑ .Electrical repairs or additions I l .❑ Plumbing repairs or additions 12,11 Roof repairs comp. insurance required.] I 13•❑ Other *Any appiicant.that checks box #I .must also fill out the section below showing th-,ir workers' compensation policy inrottnation. t� riomcowners wlro submh.fiiis affidavit irrdicarirrg &jae' al- doing e! c-;rrL: :trcf Eben hire outside eontrnc(urs rnusi sumnii x 7Contn crors that check this box musi attached an add' tYional sheet showing tiee name of the new amuavir indicating such. / ,. _ r__ s c�ctors and their wnrirP t L/tf(►rin!!t/O I `V — Af9`u Is prcv1Wrz workers' compensation insurance for ng, e 1 eeS. Be - 11 r,•—• Y .-WI nazton. mp oy low is the poficy and job site Insurance Company Name:- Ci'(—�, ,,:�--L / Policy#or Self -.ins. Lid.#:C_�a.a� Expiration Date: Sob Site Address: —r—_ y ration Attach a copy of the workers' compensation Policy decla Ctty/Statr/Ztp. pane (showing the poiicy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can iead to the imposition of criminal enalties of fine up to $1,500.00 and/or one-year imprisonment, as well as civil P a Of up to 5250.00 a day against the violator. Be advised that a co Penalties in the form of a STOP WORK ORDER and a fine Investigations of the DIA for msiza c� cove age verification. � of this statement may be forwarded to the Office of Ido hereby certify r fh c and pahaideS ofperjury that the in or f oration provided above cc true and correct SiQrtature• A Official use nnlp. Do not Write in this area, to be completed b , j city or to Wn ofj-f/�a/ City or Town: Fssiuiaa Autb PermittLicense # ft or Ly (circle one): 1. Board of Healtb 2. Building Department 3. City/Tow,, Clerk 4. Electrical Inspector S. Plumbing 6. Otherc, Inspector Contact Person: Phone Date....J.�l..... .%..... e���._��-•�_erypp` TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ ........................................................................ has permission to perform ....... :-%`e��:`���I/ r wiring in the building of at ......... .....)....... 'S a...... `_:........�.. , North An/ddo�verr„IIvws. ......................................... Fee.7�� ............ Lic. No.,9- �x / .. f !J ELECTRICAL INSPECTOR Check # 5180 THE COMMONWEALTHOFMASWBUSETTS Office Use only �j�/ DEPARTA1E TOFPUBLICSAF= Permit No. BOARD OFFIREPREVE7MONREGUL4HONS 527 12:00 Occupancy & Fees Checked APPLICATIONFOR PERMIT TO PERFORMIELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date J, O Town of North Andover %� To the Inspe for of Wires: The undersigned applies for a permit to perform the electrical work described beloyG Location (Street &Number)9�Dt/.50,1/ S Owner or Tenant�Y,Qy,(/� Owner's Address Is this permit in conjunction with a building permit: Yes r�o r (Check Appropriate Box) Purpose of Building( - Utility Authorization No. Existing Service Amps / Volts Overhead Underground No. of Meters New Service Amps/ Volts Overhead M Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work S'C�7?e /P wjo A,v4 Hyl C ni��✓;t� No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA 41 round ground No. of Receptacle Outlets No. of Oil Bumers No. of Emergency Lighting Battery Units No. of Swich Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones Tons No. of Disposals No. of Heat Total Total No. of Detection and Pumps Tons KW Initiating Devices No. of Dishwashers Space Area Heating KW Ng:of Sounding Devices W of.Self Contained Detection/Sounding Devices No. of Dryers HeatingDevices KW Local Municipal Other Fi Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydrp Massage Tubs No. of Motors 0 Total HP )THERy- mancnCoveraga Pursuant to the legim>rrcrltsofMassachusetts CknerdlLaws ©/O lave aamWLlabilirykwancePblicyinchwklgComplete0 e<aticmCoverageOfiisAixlmtialegtliValent YES tawsubm,wdvandptoofofsametodr0ffm YES Y3uuhave cherl�edYES, pleaseindicato the type ofcoverageby box [S'LRA,NCE OINM (Please Spa*) U Date Estimated Value ofElachiCalWodc$ odctostart ,j# h Tection Date Ralucsted Rough Final 7led urx]er t n P4nalties of per" ZNINAME LioerlseNo. Signature ��� � I icerseNo BusinessTel No. 2 7,�. 977 -1V7-7 /71��, ���f`/ Alt Tel No. 971— VNER'S INSI JRANCE WAIVER; I am aware that the L omse does nothav e tyle insurance coverage orits st>t�ltial equivalent as mqukedbyMassachuse8 Gffoal Laws thatmysigoaluteon thispermit application waives this requireamt �/ ease check one) Owner ® Agent / 1 CJ Telephone No. PERMIT FEE $ d lgnature 5T Mwner or 7gent The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address r. City: Phone #: Insurance. Co. Policy # Company name: Address 1: City: Phone #: Insurance Co. Policy # r. Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 y and/or one years' imprisonment -as _vkell_as_civil..penaltiesin.theform nf-STOP WORK ORDER_and_a fine.of.($100.00)._aAay against..me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing []Check if immediate response is required Contact person: ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other Date. S �.I..(- .� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ��This certifies that .. .►....I..''.�.' �.5..:. ..... .......... . has permission to perform ....... i. .................. . plumbing in the buildings of .. D.�...S.....`..................... .1 t . :^............. . North Andover, Mass. r- ` Fee. 1� Lic. No.../. �. L �. ? ......... ..... PLUMBING INSPECTOR Check # 3 4 > MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) L�� N'Ap114�K . , Mass. Date /, 20 Permit # `G Building Location`� 7� ti l lit/ rOAI SJ- Ow 's Name IN - New ❑ Renovation ❑ B.P. # Type of Occupa Replacemen 'SEWER # �: .�°• - Plans Submitted: Yes 0 No 0 SEPTIC # - Installing Company Name A��J A /✓f O14Check one: Certificate Address ❑ Corporation Business Telephone qv o G4 !�/ /�a ❑ Partnership /�Irm/Co. �"50,(/ Name of Licensed Plumber or Gas Fitter. �7 /"/�td?/��AlJ d A INSURANCE COVERAGE: I have a curve liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142. Yes X No ❑ If you have checked ves, please indicate the type of coverage by checking the appropriate box. A liability insurance policy ❑ .Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner ❑ ' Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above'appiication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the p mit issued for this pplication will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and C the ral By SignatuK of Licensed Plumber Title City/Town APPROVED (OFFICE USE ONLY) Type of License:fiaster 0 Journeyman License Number_ /O8 l z I— z r z VO Y z ¢ = C7 � w �_ LQ O `-' w ¢ '� to H_ to Ow z z w O m .w ¢ .W g¢ U-) W Y z 0- . J C7 Z CL O LL U> F— 'S O a z N z � O O, ¢ z z LU .0 u_ U z ¢ m = cn 0 � O g ¢ O _ ¢ w to J u_ ¢ O _ .0 ¢ 0 ¢ w SUB-BSMT ¢ m O BASEMENT 1ST FLOOR 2ND FLOOR > 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name A��J A /✓f O14Check one: Certificate Address ❑ Corporation Business Telephone qv o G4 !�/ /�a ❑ Partnership /�Irm/Co. �"50,(/ Name of Licensed Plumber or Gas Fitter. �7 /"/�td?/��AlJ d A INSURANCE COVERAGE: I have a curve liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142. Yes X No ❑ If you have checked ves, please indicate the type of coverage by checking the appropriate box. A liability insurance policy ❑ .Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner ❑ ' Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above'appiication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the p mit issued for this pplication will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and C the ral By SignatuK of Licensed Plumber Title City/Town APPROVED (OFFICE USE ONLY) Type of License:fiaster 0 Journeyman License Number_ /O8 l