HomeMy WebLinkAboutMiscellaneous - 130 Kingston Street 130 KINGSTON STREET j
210/023.0-0006-0130.X_
71
Date...........
i .....................
i
r►ORTF
3�01f TOWN OF NORTH ANDOVER
s PERMIT FOR WIRING
CHU�t4g
This certifies that ...... ..!.0
.............................. ........................................................
r ,
has permission to perform .... .��J .(��}C� ..( , ` !r4�'... --..........
wiring in the building of........ +..t .........................................................................
at .......................... 9. ...... ........,North Andover,Mass.
. ....� .
Fee..... ..^......Lic.No. �--
i
ELECTRICAL INSPECTOR
Check#
12663 -%
�.--
--V
4cx
(f1Mrrwnu1ea& ol __7-------
Fop:
k G-) Occupancy and Fee Checked Official Use 01))y
Permit No,
Ivy
BOARD OF FIRE PREVENTION REGULATIONS oc
Rev. 1/071
---!Lave btanl:j _
APPUCAMN FOR PIEROMT TO P)PERFORM ELECTMCALVNIORC__
All work to'be performed in accordance with the lMassac�.,,setts Electrical Code gVMC), 527 CMR 12,00
(PLEASE PRINT IN INK OR 1V0r
TE ALL INF,ORAM TION) Date:
City or Town of: +\r% AAL4ove
r Tor/7e
By this application the L1ndcrsj, 1 of r1lil,6,,
undersigned gives novice 01 tils or her intention to perforin the electrical
*firLocation (Street&Number)_j3_0 work described belov,,.
Owner or Tenant
_ C.�_ft r; ---------
Telephone No,
0':vner's Address 1-7
0 j<
Is this permit in conjunction -n'ith a Uildingpermit? Yes 1\1 0 (Check APPropriate Bo.,�)
Purpose of Building Res�af L Q)
0 - 4- Utility Authorization No.
Existing Service Amps /;r,
jyo _
Volts Overhead No. of Meters -J
New Se Amps
-1d Y�C--)V 0 1 t s Overhead Und-rd
Number of heelers and Arnp2city of Meters I
Location and Nature of Proposed Flecirical Work:
_RIA�ale, Cott e,
WA Rlfl Z0%A1(_A16A) �do
Camp eller,07'(h
tie following fable Mail Wires.
No. Of Recessed Luminaires
Of Cell.-Susp, (Paddic)Fans INIO. fes_
To7E--
Tr KVA
(Transformers
No. of Hot'rubs
No, of Luminaire outlets _ DLr a--risf 2-r-T
Generators kVA
o 'y
rnege�n
ove
ling ool H1
No. of Luminaires -F-
Swimn A.- I I n- �o. o _Eerge`n_E7Y� 2h -r—ig —
_��nd. Lyrnd. ❑ Batten,'Units
No. of Receptacle Outlets
r
No. of Oil Burners S fz
ALARMS No. of Zones
No. of Switches
No.
et
o 8
.NO. of Gas Burners tNo. of Detection and
No, of Ran-es Total -
Initiating Devices
NO. of.-Air Cond. __J
Tons N0- of Alerting Devices
Hept Fur N
No. Of Waste Disposers, 0 If pelf-Contained
Totals: of
Devices _Q1,
No. of Dishwashers �';?=
SPace./A.rea Heating KW ----q
0,h.,
Connection ❑
No. of Dryers Heating Appliances
KW
------- Equi aI Cil
of Devices or.
N o. o f
Heaters KIN 1"o 'Data �`;rjrjg
Signs Blallas;LS L2 V
D�'ViCeS Or E.Quiv,_Alent
No. Hydromassage Bathtubs No, of Motors Total HP elecozni,9jjnjca'-�F�1cl 6;i rijja.
OTHE4 R: 2io. of Devices or Equivalent
A Itach additi- �ci_Gcm' Se theA�
Estimated Value of'EI cc lCal Work: C'It,- a/detail if desired, or as requiret, by the 1'�Upeclor of Wires.
__ (Whenr.equ-iTed by municipal policy,)
Work to Start: to Inspections to be requested in accordance with
ENS U R_A_N(YC'0—N,_R �E
Unless MEC RUIC 10, and upon C;orjjplt'Cjotj'
waived tine
the jicensee ,Ow'rel, permit for the perforinancc of elects'cal work may issue unit-
DFOVides proof Of liability insurance including "co...,,, f=-.. . . I including -. I d uDeration"coverage or its substantial equivalent, The.
1,111CIP"sig-11cd certifies that such co�/� f, A
[BOND
IS In force, and has�xhibilzed W-001 0'-sann" to thepermissuing Office.
CHECK ONE: INSURANCE [9 BON"D [] OTtIER
I ceraj,51 under the ains cydpenalfieS of�puriyn'. that th6
(rue and comple(e,
14-IRNI NAME: A4Le I —A. LIC. N O.,A d
Lice r — __"D
11see:
LIC. NO.:
ease nu.��ber lin
Address:' ' 13 ns. Tel. No.:
WO' L!4�pe 0 4 1 V
*Per M.G.L. c, 147, s. 57-61,security workrequiresOr lublic SafetySafetynsc: Lic, No,
Aft. Tel. NO.:
OWNER'S INSURANCE WAIVER.- I am, P.ware that r'1. Licensee does Dil't),insurance coverage
required by law. By my signature below, hereby waiv,- j'-'':s requirement. I am onc) ❑El owner
owner/.Agent
Signature
Telephone No. S
Uaf UJf LU IJ UO:JO IVC I I a Iva I I insurance agency (VAX)14137316629 P.001/001
i
S
' ) 0 F'1 DATE(MM(ODMM')
CERTIFICATE OF LIABILITY INSURANCE 09/03/2015
THIS CERTIFICATF. 10 ISSUED AS A MATTER'OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. It SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain pollcles may require an endoreement. A statement on this certificate does not confer rights t0 the
Certificate holder in lieu of such endorsement(s).
PRODUCER Neill&Neill Insurance
Agency Inc David Jarry
.4137(413)732 e;(413)731
882 RNerdale Street ooeWest Springfield,MA01089 AOaal -61129
INSU R9R(SI AFFORDING COVCLRAOti NAIL 0
INSURER AI State Auto:Insurance Gompany 8TA
INSURED Michael Farellf Electrical _ INSURaR a: Acadia Insurance Co. ! 31325
9 Applewood Lane
Methuen,MA01844 INSURERC:
NSU E 0•
INS RPA I[r _
INSURER F: I _
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR PoseUCYFXP
TYP!OF INSURANCE POLICY NUMIAR M D M MD I LIMITS
A OENERAL LIABILITY SOP2745517 06/1012015 08/10/2016 EAcuDCCURRENCe s 1,000,000
COMMERCIAL GENERAL LIABILITY p 1DITCNTEU me S 50,000
I C4AIM8-MA0E 7iOCCUR MED EXP(Any oneperson) s 51000
PERSONAL A ADV INJURY s 11000,000
GENERAL AGGREGATE S 2,000,000
GEN'LAGGREGATELIMIT APPLIES PER:
PROOUCTS-COMPIOPAGG S 2,000,000
POLICY PR LOC I S
AUTOMOaILE LIABILITY
ANYAUTO BODILY INJURY(Per parson) S
AUTOS ED SCHEDULED CODILY INJURY(Par eodrdent) 6
AUTOS
NON-OWNED PPRO CRTY AMAGE S
HIRED ALTOS AUTOS
S
UMBRELLA LIAR OCCUR EACH OCCURRENCE s
I I
LXC[SS LIAe HCLAIMS-MADS AGGREGATE f
OEDRETENTION 6I s
B WORKERS COMPENSATION WC-20.20-001461-05 03/2012015 03120/2016 0re
TH•
AND EMPLOYERS'UABILITY - --
ANY PROPRIETOn?ARTNERMXECUTIVB 0 NIA E.L.EACH ACCIDENT 6 100.000
OFFICERIMEMBER lXCLUDLD7 -
(Mandatoryln NH) E.L.DISEASE•EA EMPLOYEE S 100.000
Ir Yea desembeunder 500,000
DESCRIPTION OF OPERATIONS below E.L.OISEASfi•POLICY LIMIT S
i
DESCRIPTION OF OPiRATIONS I LOCATIONS I VEKICLES(Attach ACORD 101,Addldonal Remarks Schedule,If mon space II mquImd)
t .
Foxed to: 978.682-1480
I
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DCSORIBEO POLICIES BE CANCELLED BEFORE
Town of North Andover TH EXPIRATION DATE THEREOF, .NOTICE_ WILL BE DELIVERED IN
1600 Osgood Street,Building 20 MORDANCI'- TH THE POLICY PROVISIONS.
Suite 2035
North Andover,MA 01845 AUTHORIZED REP SH ATN
i
1988-2010 ACORD. ORPORA All rights reserved.
1
ACORD 26(2010106) The ACORD name and logo are registered marks ofACORD ;
}
1E
T'he Commonwealth of Massachusetts
rJ Department of Industrial Accidents
` I Congress Street, Suite 100
Boston,MA 02114-20.17
www.mass.gov/dia
•sJE
1
ectricians/Plumb ers.
• uilders/C
ontra
ctoi
Workers'Compensation Insurance c
eA
Affidavit:B
k
Wor p
Ell WITH THE PERNIITTING AUTHORITY.
A� licant Information TO BE FILED Please Print Le ibl
5 �
Name (Business/Organization/Individual): ►1 i Gyl 6'L� 1 t i Q�t �' 0 1
Address: 9 APC} Q_W uo
City/State/Zip: Z. V ) 9ftone#: r� / ��.. 4d 3`)cQ L
Are y au employer?Check the appropriate box: Type of project(required):
1. am a employer with_employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp-insurance required.] 9• ❑Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole
1 I.VElectrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp-insurance.# 14 E]Other
6.Q 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.]
*Any applicant that checks box#1 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 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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. fj
Insurance Company Name:-A i J V�' i Sti�� ;��r —
Policy#or Self-ins.Lie.#_ C O C/ I `' Expiration Date: 5 a G � ._
Job Site Address: Q Y. n - A � City/State/Zip: G(+1 - ' f �;(� o 16 A S
cM ,
Attach a copy of the workers' co npensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA,for insurance
coverage verification.
I do hereby cer ify u7z er the ai and penalties ofperju�y that the information provided above is true and correct.
Signature: Date- ! I I 0 f S
Phone# /7� `�a� 3 c):
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 S.Plumbing Inspector
6.Other
Contact Person: Phone#: -
t'
Location E l(% a c(-J►n �T
�j
No. Date -� 40
t� A_
C
• NORTH TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
s�CHus -fir
Other Permit Fee $
Sewer Connection Fee $
M
O
Water Connection Fee $ /
TOTAL $
03 Building Inspector
9767 Div. Public Works
; r
Tow i of No dover
1
North.,' t dower, Mass., 3 v 19 9�
r;
BOARD OF HEALTH
PERMIT TO B LD Food/Kitchen
Septic System
THIS CERTIFIES THAT....... .!..!.!n. .V +c, "c1lZ -`- �2No�
BUILDING INSPECTOR
�/
t f Foundation
has permission to erect.....IUA..................... buildings on ........V.-3..0........1 .�.!^�.�1 ?.V►....5 Rough
to be occupied as.............�-xa,_A-e c)c)..vn.......... e.wt ...
..�............... ....................................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in
this office, and to the provisions of the Codes and By-Laws relating.to the Inspection, Alteration and Construction of Final
Buildings in the Town of North Andover.
PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
R. Final
r _E. T': ELECTRICAL INSPECTOR M
Rough 4
... ....... .....!......
Service
BUILDING INSPECTOR
Final
---- _ GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be rare
Until Inspected and Approved by the Bu i1dian Inspector. FIRE DEPARTMENT
Burner
e
cl 77�o 7 Street No. .g
Smoke Det.
f
F
��e Lanvrnanuea�fl aj✓`l 33_
}
?s; current ediT G, o .°e
s ..-._. ....a Buiiiciq
:ion of
HOME IMPROVEMENT._CONTRACTOR..
Registration _1018.41_ "'
Type - PRIVA,TE CORPORATION
Expiration 06/29/98.
PAYETTE CONSTRUCTION CO., INC
G. Payette
ADMINISTRATOR 1110 Methuen Street - -
Dracut MA 01826
_ I
1
o PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE ;
MAP 4-40. 0.23-1
LOT NO. co 2 RECORD OF OWNERSHIP DAT BOOK ;PAGE —
ZONE SUB DIV. LOT NO. i
LOCATION PURPOSE OF BUILDING
OWNER'S NAMEt A fA�1 i 1�) �ZQ Z N NO. OF STORIES SIZE
L r 1 l3 fe� _
OWNER'S ADDRESS Vic,,,E,^3,
ST
BASEMENT OR SLAB
ARCHITECT'S NAME iA �'VV ,v J SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME .'f.tT F7 PAN
DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS --
DISTANCE FROM STREET AIPOSTS
DISTANCE FROM LOT LINES—SIDES ��//► ) REAR GIRDERS
AREA OF LOT ,I y FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW 'V/,® SIZE OF FOOTING X
IS BUILDING ADDITION MATERIAL OF CHIMNEY
IS BUILDING ALTERATION yGS gaQj F� toA- IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE (jIS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. COST
PAGE I FILL OUT SECTIONS I - 3 EST. BLDG. COST PER SQ. FT.
PAGE 2 FILL OUT SECTIONS i - 12 EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
y PLANS MUST BE FILED ANDAPPROVEDBY BUILDING INSPECTOR
DATE FILED ®r
a / BUILDING INSPKditf
SIGNATURE 45'F-OTVNER
LT AUT-145RIZED ENT / v)
FEE C7 /. �� / OWNER TEL.# 4,902-v
PERMIT GRANTED L36) 119 CONTR.TEL.# 5d t�Sy`�'S 3
��
/.1� / n_ J CONTR.LIC.# .a
H.I.C.#
F'x
112- o> �>�ll�� ���/�a�r dol' /' 7 t P 33
a""rr c(-7h� .
40.
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY _ S-ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
Q FOUNDATION 8 INTERIOR FINISH
CONCRETE 3 I 2 13
CONCRETE SL K.
BRICK OR STONE � PINEHARDW D
PIERS PLASTER
_ DRY WALL
UNFIN.
3 BASEMENT 11
AREA FULL FIN. 8'M'T' AREA _
1/ 1/1 r/. FIN. ATTIC AREA
NO 8 M FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH
ASPHALT SIDING HARD'✓'D _
ASBESTOS SIDING _ COMtACN
VERT. SIDING ASPM. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
... .....
B IC N MAS NRY ATTIC STIRS. 6 FLOOR I_
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME
SUPERIOR ADEQUATE (� NONE
5 ROOF 10 PLUMBING
GABLE I HIP BATH 13 FIX.) _
GAMBREL MANSARD TOILET RM. 12 FIX.)
FLAT SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY f
WOOD SHINGES KITCHEN SINK
SLATE NO PLUMBING _
TAR & GRAVEL STALL SHOWER _
ROLL ROOFING MODERN FIXTURES Y
TILE FLOOR
TILE GADO
6 FRAMING I 11 HEATING
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. 3 COLS. STEAM `
STEEL BMS. & COLS. HOT W'T'R OR VAPOR `
WOOD RAFTERS _ AIR CONDITIONING
- RADIANT H'T'G
UNIT HEATERS
- -
7 A
NO. OF ROOMS OIL
B'M'T 2nd I— ELECTRIC
1st 13rd NO HEATING
r
2609 Date
NORTH TOWN OF NORTH ANDOVER
00 '� o<A PERMIT FOR
����N TALLATION 9
y,SS�CNUSEtt
This certifies that
has permission for jinstallation � t�'} . 4'.r� y✓.r4s�
in the buildings f .K-''7. . . . . . . . . . . . . . . . . .
at " �ccr
pp
, North Andover, Mases
Fee.46��. Lic. N&aCvss
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CL-4
z1`0 5�5 GAS INSPECTOR
WHITE:Applicant CANOY: Building Dept. PINK:Treasurer GOLD:File
!!''II (� }} Office Use Only
V4f �UMMUnlUgato If fJaggCCJt4UJJJtfJJ Permit No.
19epaItment Of Ilublic -_96ufEtq Occupancy&Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 2,:
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
(M* or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work de ribed below.
Location (Street & Number) -
�Vrc..L,4G� Gk.��N Ca,J►�,js
Owner or Tenant LCj-o P_
Owner's Address
Is this permit in conjunction with a building permit: Yes El No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps _� Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps Volts Overhead ❑ Undgrnd ❑ No. of Meters
Number of Feeders and Ampacity h
Location and Nature of Proposed Electrical work )650- 0 U1X
Total
No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA
No. of Lighting Fixtures S I Swimming Pool Above In- Generatorsgrind. grind. KVA
No. of Emergency Lighting
No. of Receptacle Outlets No. of Oil Burners Battery Units
No. of Switch Outlets p9 I No. of Gas Burners FIRE ALARMS No. of Zones
No. of Air Cond. Total No. of Detection and
No. of Ranges tons Initiating Devices
No. of Disposals Dis No.of Heat Total Total
P Pumps Tons KW No. of Sounding Devices
No. of Self Contained
No. of Dishwashers I Space/Area Heating KW Detection/Sounding Devices
t. Local Municipal Other
No. of Dryers Heating Devices KW ❑ Connection ❑
No. of No. of Low Voltage
No. of Water Heaters KW I Signs Ballasts Wiring
No. Hydro Massage Tubs I No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws —
I have a current Liability Insurance Policy including Com
ole d Operations Coverage or its substantial equivalent. YES `INO I
have submitted valid proof of same to the Office. YES — NO — If you have checked YES`please indicate the type of cov rage by
checking the appropriate box.
NC
INSURANCE 'Z` BOND OTHER _ (Please Specify) Expir tion Date)
Estimated Value of EI tri Work S �/�(. CA
Work to Start 9 Inspection Date Requested: Rough Final
Signed under the Penalties of perjury: V j �(/e
FIRM NAME FA14NG6 61), c S /C u LIC. NO.
Licensee S/Im� Signature LIC. NO.
ens.
TN
7� Alt. No.
Address ,
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re-
quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Age
nt
(Please check one)
Telephone No. PERMIT FEE S
_1(�
(Signature of Owner or Agent) x-5565