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Home My WebLink About0059 GROVE STREET �� i ' �: .. .. 1 i ,� ,� ., ,. �� i R d, 71 I�G�''cWZ--�� —N0 AJ4-4" IS�Gclel — Town of Barnstable Regulatory Services Richard V. Scali, Interim Director '"KAM M Building Division i639. Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office:.508-862-4038 Fax: 508-790-6230 PERMIT# Z 3S� FEE: $13:�- V SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less �9 G ro yc It reZ t' co t Location of shed(address) Village Property owner's name Telephone number l6 � k l b� 020 // 0 8 Size of Shed Map/Parcel# PiA4/�, �v Signature Date Hyannis Main Street Waterfront Historic District? , M�a :-c Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway r;y Conservation Commission(signature is required) Sign off hours for.Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:110413 TOWN OF BARNSTABLE N 22038`21" E 162.27' LU cV o z O T oN Co 3 Gp CO 70, U m Iv0 oo, 20 �a z N 15' z 0 N p n O w N rn ? w O NLA . n O O _ # 59 GROVE STREET m N 23019'40" E 150.00' GROVE STREET . PLOT PLAN PLAN REFERENCE: BARNSTABLE REGISTRY OF DEEDS Z BOOK/PAGE: PLAN BOOK532, PAGE 21 LOT NO.: 1 PLAN BY: BAXTER AND NYE, INC. 1 inch = 40 feet DATED: NOVEMBER 18,1996 Assessor's map and lot number �Q7� � 7S �EPTie tSY . *W BE INSTALLED.[N--'Co r,4 IANCE Sewage Permit number �9./�. / �................. WITH ARTJC", 41.STATE SANITARY ` y0�7HE TO T TOWN OF BARN " Z EAHB9TODLE, i 2639. .e� BUILDING INSPECTOR O�G MPY p' APPLICATION FOR PERMIT TO ... !LD �� ...................................................:........................................................ ....... ®.� °..... /�9M. .................. TYPE OF CONSTRUCTION ............................................:....................... ........................ °�L'..........19.3F- TO THE INSPECTOR OF BUILDVNGS: The undersigneedaa�hereby applies for a permit according to the following information: Location .........5*.l...... G Klc�........S- ........67T 147............................................................................................................ ProposedUse ..........!.��!`e-c............................................................................................................................................ ZoningDistrict ......... .....................................................Fire District ...C�!i.............................................................. Nameof Owner ... .............Address ...11............................................................................. Name of Builder ... ✓4/ ......V....� j�/l/ L...........Address ...............................................................................:.... ........ . Nameof Architect ................ !.............................................Address ..................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exterior ....... ...............V" ..... ff� /LL ...................................Roofing .. 'S�/z` :T FloorsT...................................................Interior .......:............................................................................ Heating ......-.77-7--..................................................................Plumbing .................................................................................. Fireplace .........................................................Approximate Cost 0 l� Definitive Plan Approved by Planning Board ________________________________19________. Area '. . ......................... Diagram of Lot and Building with Dimensions Fee ....�/.�........................... SUBJECT TO APPROVAL OF BOARD OF HEALTH tSi t rv� �-(ovSF � f a`z� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Nam ••• •S!' .. ... . . ..............1. , . . Parker, Natalie ' \ ' ~ � ' i7715 garage No ................. Permit for .... ' --'^--------'-----------'---' Lo6zhon ............59..Qrmve...�tre.�t______. ' � -`---.---- ��----_-------.. 0a�alla Parker.. ^ Owner ---_---___.�_____................... ` � Type ofConstruction --. -------.. ' --------------------------. ` Pkot ............................ Lot ----------' _ . Ioom 2 7� ^ Permit Granted ------------.']P ` Dote of Inspection .. ,— -------lA ' Date Completed . --.---]A , . � . \ � ^' PERMIT REFUSED . - -----'---------_'.--.-.. lV ' . . ` --------_-----------------. ' . ^ ' _-----.------------^^-------. ! � � ` . ......................................................... > ' --.-------------------.--...— � . - / Approved ................................................. lg ` --------------..-------...--. ' or . ' _------------------------... � � Assessor's map and lot number ...�....'� �.� � 1 Sewage Permit number ...r.!..... ................... ��QyoFTHEro�°� TOWN OF BARNSTABLE Z BA"STOBLE, i "6 9 BUILDING INSPECTOR j APPLICATION FOR PERMIT TO ...�t.�� ........................................................................................................... TYPE OF CONSTRUCTION ........ ......:'.'..° f7 �r� ......................................................................................................... .........................� �:...........19... � y - TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .........?.... ......................E.I..... .............. ..................................................................................................................... Proposed Used�� r ............................................................................................................................................................................. Zoning District .................. .Fire District ...1..:.�.T: Name of Owner .... :: . .f Y,w. �`�! .............Address Name of Builder ..............fD.. ...........,�.+;).,7r..JJr .L:..........Address .................................................................................... .... Nameof Architect ................. ..).............................................Address .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exlerior ..........'r� ' �.. . yt.�..V. ...................................Roofing ...� hf�4 i �`.. 44...1 fl,.... ...................................................................... Floors ° ^ ........Interior ....................................................................... .........................:....................................... . ............. Heating .......^"`...................................................................Plumbing .................................................................................. Fireplace ...............""`'d-.........................................................Approximate. Cost ...... .:. ...o............................................. Ik Definitive Plan Approved by Planning Board _________________________ 19 ---. Area r_4. ............................... Diagram of Lot and Building with Dimensions Fee .........; ' ............................ SUBJECT TO APPROVAL OF BOARD OF HEALTH 1 I 7,ttLfr k • � r II i '1 !f I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ; LName :........'.. ....:. ..: .....:...:..`t................................ Parker, Natalie k=20-108 f ✓ garage _ No 1771-F permit for s .............................................................................. Location 59 Grove Street ............................................................... Cotuit ............................................................................... Owner Natalie Parker .................................................................. Type of Construction ..........frame ................................ ................................................................................ Plot ........................ Lot•................................ Permit Granted ...........June.,2................19 75 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED ................................................................ 19 ............................................................................... ..,.. . .. ..... .......... ...........:� . ..... ................. i........... 9 Approed ................ ............................... 19 •� TOWn Qf Barnstable *Permit# 00�O rxpires 6 months from 'sue date Regulatory Services Fee _ Thomas F.Geiler;Director RESS WIding Division 'P R omPerry, CBO, Building Commissioner 1410 Main Street,Hyannis,MA 02601 TOWN OF BAR NSI.A town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 � EXPRESS PERAUT APPLICATION ]RESIDENTIAL ONLY n . f �j Not Valid without Red X Press Imprint ap/parcel Number ycp0 to C operty Address aD r Residential Value of Work � ��,�' Minimum fee of$25.00 for work under$6000.00 miner's Name&Address Ve Dntractor's Narne �� e C5 ✓we i& Telephone Number �Q r 3 - �� ome Improvement Contractor License#(if applicable) l30 �C aa-��1� p ivisor�L�cEnse-�(�f-appii�able). �Work='s Compensation Insurance Che one: [ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance isurance Company Name 70rkman's Comp.Policy# D+�� l l�� Nil opy of Insurance Compliance Certificate must be on file. ermit Request(check box) ❑�-roof(stripping old shingles) All construction debris will be taken to -c.,,-^d 41?— ❑Re-roof(not stripping. Going over existing_layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *wher'e required`. Issuance of this permit does not exempt compliance with other town department regulations,ix,Historic,Conservation,etc, ***Note: Property Owner must sign P perty Owner.Letter of Permission, AAcco�py of the Home Imp v ent Contractors License is required. IIGNATURE: ' !:Forms:expmtrg ,evise061306 f 04/11/2007 11:39 5065647272 RIDER RISK PAGE 01/01 ... nnT�(MMr01)IYYY't)�, CERTIFICATE 1T INSURANCE �� 04� 11 07 r-CRD� ��T�F TE OF LfA��Ll THIS CERTIFlCATERS G ti��I;TS tlF6-M TmE CERTIFICATE FTER OF ON ONLY AW CONEOR ck Sp�cie�LiatsB HOLDER,THIS CERTIFICATI~DUES I'Iu r AMEN D,E,X S SE O [se A�®sLay, Tile, A4.TF.R THE COVERAGE AFFORDED:)*,THE F�IS'tEs 1�>rL0 11.5 NAICA t MA 02534 INSURERS AFFORDING COVERAGE08-5604-7200 Va-2 508�s64-727a INSURER A: - INsuRER B; 11dCSF.4A�Y & .SONS INSURERo. Ali N1tITt3�L SkaBU&tlfCF CO. DAN19b MCS'Ngr »Y 'DRA INSURER0: - 1 MAGNOLIA 1LLA'SE I NpEg K& 02649 �NO IUSURERE: -' COVERPOES LOW THS POLICIES OF INSURANCE Li NC�T pN OF ANY CONt R UCA OTHE ODCUMENT WITH tiESPEOT TOW MICt�iTHtS CERDFIC� MAY 9E 1,t4Jt5D OR IIAII ING ANY RSOUIREMENT,TERM OR CO MAY PERTAIN,THE INSURANCE AFFORDED BY TH6 POLICIES DESCRIPAD HEREIN IS SUBJECT TO ALL THE TI'"RMB,EffCLUStONS nND'ODNDT C 6d�OF S C — fOtiG1E8,AOGR6GATE LIMITS 9kOWN MAY HAVE SEEN REDUCED 3Y PAID CLAIMS, LIMITS POLICY NUMBER DATE MhaIDDtYY ATE MM112 EACH C7+,:(7URRENCC LTR NSR TYPE CF IPtSURANCE —�'- 90MRAL LIABILITY KGEENWRAL. Mye:Ei Ea occurance COMMERCIAL GENERAL.LIABILITY Gi5(Noy One Ferzan) CLAIMS MADE CCCUR Ir IAI,8 A_DV INJURY c __ ACoGREC++ATE I I i PRODS"C'fS- CQmPJOPAGO -S CENT.AGGREpgTE LIMIT AppLlfi$PER; POLICY PTi I. COVE.11,19t']SINGLE LIMIT 3 AUTOnaOSILE LIABILITY I Toil JL1iM) _ ANY AUTO BODILY INJURY is 1 1 ALLOWNFenUTO& I i SCHEDULED AUTOS I BOCaI."INJURYHIRED ALIT-09 g (Pr PJ;itl@Ol) _ 1 NCN.OWNED AUTOS I FflcPirY DAF,IAG`F R I _ �ALUJ'1%) cieAnt) II ONLY-EA ACCIDENT 1 h4ARj:LIA1B!LITY EA ACC'pr!JhGi THANALTOAUTIT ONLY: AGG�-P—A.'bi C,CCUP.RENCE $ 1 I EXCF9SiuMBRELLA LIABILITY 1 jt'REGATF $ OCCUR CLAIMS MADE I E ORDUCTIBLE �--- �- RETEt PI1ON a RIB - 0#tY LIMITS SR ----_ 1NGROSERB COMPENSATION AND -• C EMPLOMS'LIABLITY AWC 701559101. 03/01/07 03/07/08 e;AtlHncCIDENT s1C0,000 ANY FI�Ot�FtIETOR1Pn►2TtJERIEXECLITWE I E,L,fM_aG49E•EAEMPLDYEE B 1a d 000 OFFICER+A WSIVt EXCLUDED? IIII I ` yyeess E:,.1,�115EA,SE-PCLiCY LIMIT j 6 5+a O,Q 0 0�, SPECIAL PROVISIOIJ3 b+>tox � T^�•�,• i OTHER DESCRIPTION nF OPERATIONS r LDCnTI4N51 vEHICLEB 7I"xCt.USIDNa ADCED BY ENDORgEPAENT!SPECIAL PRCMSIeNS FAx; 500-790-6230 CE,RTIFICATI11 HOLDER CANCELLATION _ SNoUt,C ANY OFT IE AAOVE DESCRIBED POIX111S BE CANCELLED BEFORE THE EXPIRAnO t)ATE THEREOF,T4E 49SUING INSURER VUII,L.ENDEAVgq TO MA14 30 DAYS WRITTEN NOTICE TO R ERT1FiCATE HOLDER NAM PP)TO THE LEFT,BUT FAILURE TO DO sc SHALL IMPOSE OBL nTIDN OR LI ITY OF Ahrf KIND UPON THE INSURER,ITS AGENTS OR REPR ewrnr AUTH RIIED R r AGORD 25(2001108) Imo" ACORD cQft.POR A7I��M 198! 03/29/2007 00:43 5084778833 THE UPS STORE PAGE 04 EAVE VENTING: Perimeter cave venting will provide your house with the necessary intake ventiiationto prolong the life of the shingles and the wood sheathing to ensure properly balanced ventilation system in Compliance with FHA requirements and to provide cooler attic temperatures in the summer and less moisture- laden damaging in the winter. install Smartvent to eves to comply with cave ventilation,with full ridge and soffit venting in place,gable louvers must be blocked off to prevent negative air flow. MANUFACTURERS STATE THAT THE WARRANTY MAY BE VOID IF PROPER VENTILATION IS NOT iN PLACE. � I i SIDE WALL CHEEK FLASHING: (No guarantee against future leakage unless flashing Is replaced,)Strip side wall up just enough to install Ice&Water Shield, step flashing and replace shingles as needed. 4.1 L r ee—r A��S ;%I avd ed r4 ESN ~� 1 , Labor&Materialsr Job is estimated to commence approximately 4—6 weeks after deposit received unless otherwise noted here:_ I Work is scheduled to be substantially completed in approximately ew, If acceptable,(both)initial here: Any work above and beyond the specifications outlined in this proposal will be performed at$57.00 per man hour plus materials or priced on request. All add]- tonal work,including travel time and lumberyard runs will be subject to extra charge, In the event of rot repairs,roof repairs or any related work requiring imme- diate attention,we will proceed without customer approval. McSweeney&Son Home Improvement will provide cleanup on a continuing basis and all debris will be removed from site. All products Installed by McSweeney &Son will be to manufacturers specifications, All work will be performed by insured professionals, All material is guaranteed to be as specified and the above work to be performed in accordance with the drawings andlor specifications submitted for above work and completed in a substantial workmanlike manner. There will be no refund for special-order windows,doors or any other non-stocked materials after three days from approved proposal. Ail warranties will be null and void if account is not current and paid in full, Owner to move all personal objects,furniture,etc.,from work areas. All items against walls should be considered for removal during any exterior siding jobs, additions,etc. to guard against damage. In the case of any roofing and ridge venting,dust and debris should be expected and any items in the attic should be removed. McSweeney&Son Home Improvement is not responsible for any damages If said items remain in place. McSweeney&Son Home Improvement Is not responsible for any damages that may occur during construction to landscaping or any finish ground work, plant- ings,asphalt or stone driveway,etc. Flowers and shrubs against house may need to be repaired or replaced by homeowner. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate. All agreements ovntingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary Insurance upon above worts, Workmen's Compensation and Public Liability Insurance on above work to be taken out by McSweeney&Son Home Improvement. No lien or security Interest will be placed on the residence as a consequence of the contract. Owners who secure their own construction-related hermits or deaf with unregistered contractors will be excluded from access to the-guaranty fund. Payment will be made as such. 1/3 Deposit 113 when half.complete and 113 upon completion. All progress and final payments to be made to Fore- man at appropriate time. If any concerns eman to call offic . Olin We look forward to working with you;pl to call if you a� y q es ons. Acceptance of Contract: f. Deposit 1/3 Payment Lf7 U— Final Payment 3L,L1 Y 7 / 1 S' j 6 -4 u e S Results Page 1 of 1 Home Improvement Contractor Look Up Enter Search terms separated by spaces. Search terms can be Town/City,Name, or License number Select Search type: r AND C) OR Search g� Search Results Reg. No. Applicant Street City State Zip Name Title Expiration McSWEENEY & SON HOME 1 MAGNOLIA MASHPEE McSWEENEY, 130447 IMPROVEMENT LANE 02649 DANIEL OWNER 3/10/2008 Total of 1 Records matched. Back to Home Page BBRS Privacy Statement http://db.state.ma.us/bbrs/hicpl 4/11/2007 • r ands', Hof 3:ii lmb ti'�41 jE.jjARRodEMEft' ` p;{fi6w e �trat on 1:30x4�! ,. t .TYp� fl13P ; xj�.1� OivE i(v1Pf��°rs JT N1oa7V , r �fi+ PJ ; �A .IQL1A 41E v' .- ccC i • 1 he G•ommonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston, MA 02111 �K yY•�,. www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organization/Individual):. tZ '- lWLM-e� mil— Sa.j 46sn-e ✓��•-r,�y t Address: f A /%Gr City/State/Zip: A9<-h e e D2�& Phone:#: S b g ' 5_3 Are you an employer? Check the'appropriate boa: -Type of project(required):, . 1.❑ I am a employer with 4• ❑ I am a general contractor and I have hired the sub-contractors 6,.❑New construction . mployees(full and/or part-time). , 2. I am a•sole proprietor or partner- listed on the•attached sheet. 7. ❑Remodeling ship andhave no employees These sub-contractors have g, ❑Demolition working for me in•any capacity, employees and have workers' 9. .❑Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ Vice are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing ill work 11.❑Plumbing repairs or additions myself. o work ' co right of exemption per MGL y � workers' �• - 12,5a Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13:❑Other 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 affrda-Vit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policynumber. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy-and job site information. f� Insurance Company Name: 1let?_. A s F-- Policy#or Self ins.Lic,#: Expiration Date: v Job Site Address:$G. ✓d P � 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 tip 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I-do hereby certify under t e pains and penalties of perjury that the information provided above is true and.correct,' Sienature:. • Date• Phone#: Official use only,. Do not write,in this area, to be completed by city or town of frciai City or Town: Permit/License# Issuing Authority(circle one): . .-I..Board of Health 2,Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: x; Information and In'tructi®ns L` 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 =eceiY=nr trust_ee-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." AdditionaIly,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-cont'ractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other,than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. B.e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or.license is being requested,not the Department of Industrial Accidents., Should you have any questions regarding the law-or:if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate-line. City or Towii 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"aI1•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 dbg 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 questio__,�- please do not hesitate to give us a call. The Depara nenfs address,telephone-and fax number: Tie Commonwealth of Musachuwtts Departme t of lnustfial Aoci dents Offiee of Investigations 600 Washingtoai Street Rostan,MA 02111 Tel. #617-7-27-49-0.4 ext406 or 1-977-MASSAFE Fax# 617-727-7749° Revised 11-22-06 wwwmass.gov/6a it MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING ,11� (Pr' t or Typel I U • , Mass. Date 19,_ Per it # # T Building Location Owner's Name A a!�liL� Type of Occupancy. New p Renovation p Replacement Plans Submitted: Yesp No p w Y W iA •. N N V Z it N C y ccO W O V • O CC ~ > Z Q Z W S ¢ O o y W O ►_ N 0 W < _ = F� N d C < O W W W N j = < S e: C W r W Fr = 1A 6 . < W- A(Z J F� Z r W W O > LL F- W J I.. = Z C .. f' Y� N m Z O :. o < W > C W O " < C < < O O W a o %U M- C 2 O t7 Y LL O ; O O J U C > O 6 F- O SUB—BSMT. BASEMENT 1ST FLOOR 2NOFLOOR SRO FLOOR I 4THFLOOR STH FLOOR 6THFLOOR 7THFLOOR 8TH FLOOR Installing Company Name DW-01V Check one: Certificate Address ❑ Corporation Z ❑ Partnership Business Telephon �t ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a curt n liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked ye;, please indicate the type coverage by checking the appropriate box. - A liability insurance policy Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature 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 the permit issued for this applicatio will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the GeneW laws. TIJ11ourneyman of license: Plumber gn re o cense um er or as i ter Title asfitter aster License NumberCity/Town APP BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE N0. � APPLICATION FOR PERMIT TO DO GASFITTING NAME i TYPE OF BUILDING ~ LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE GAS INSPECTOR