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43-145 (2) 1 s 1 GREENLEAF DR BP-2022-1137 Map:Block:Lot: COMMONWEALTH OF MASSACHUSETTS 43-145-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-1137 PERMISSION IS HEREBY GRANTED TO: Project# Est. Cost: Contractor: License: Const.Class: BARRON & JACOBS 060475 Use Group: Exp. Date: 1 1/10/2022 Lot Size (sq.ft.) Owner: LAPLANTE HICKS KATHRYN & DAVID Zoning: WSP Applicant: BAR ON &JACOBS Applicant Address Phone: 70 OLD SOUTH ST Insurance: NORTHAMPTON, MA 01060 WMZ80080063652020A ISSUED ON:09/13/2022 TO PERFORM THE FOLLOWING WORK: FIRE REPAIRS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector ' Underground: Service: Meter: Footings: Rough:/-/�--Z c I/I - 9 ough:, �M House # Foundation: Final: y-�-Z3 Final: 1 fi2J2,, ij `!� 1• 'I 1� Final: Rough Frame:f-AR-�'►7 /I-ZZ-ZZ 1��+2 Gas: Fire Department 0,IC i I- Zcj' ZZ P` Driveway Final: Fireplace/Chimney: Rough:T'_ 2,6 _zz. Oil: Insulation:0,/4. / -(o,_2? 11 P 7co.Smok ; 3 Final: O. 4.27•Z3 K(g THIS PERMIT MAY BE 16VCVED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I • + i • f1 • 1 .,`. Fees Paid: $1,248.00 212 Main Street, Phone(413) 587-1240,Fax:(413)5`t7-1272 Office of the Building Commissioner` r rJiv� f() 7 VfrOa C�lZli��'L 'PuSSc=} 1 [719 .1-101 a 01-2 OF- 5 I Y/t/ C.om :ono/ea/j1 o/f/laddaehudeffd Official Use Only WVr� cc77 ��77 Permit No. E` _ k 2aparfmara ol.}irs Jeruiced 4i, s Occupancy and Fee Checked /2 yt j o . - BOARD OF FIRE PREVENTION REGULATI•NS ev. 1/071 leave blank 00 APPLICATION FOR PERMIT TO PE i• FORM ELECTRICAL WORK 1 All work to be performed in accordance with the Massachu etts Electrical Code(MEC),527 CMR 12.00 c; (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: i k\ t\9-Y City or Town of: ,. ' — c, 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) 1 S( ' 1�ice: L iz f}--,c Pk , Owner or Tenant �tq-T�I 1-f r(.-K 5 Telephone No. y/7-)sz.--46,7 Owner's Address 5; C i 1 t.� Is this permit in conjunction with a building permit? Yes 1?-4- No 0 (Check Appropriate Box) A6D ' tyll' Purpose of Building Utility Authorizatio o. it( .1,�' Existing Service Amps / Volts Overhead El Undgrd 0 No.of Meters 4 �Uy New Service Amps / Volts Overhead❑ Undgrd D No.of Meters 11° Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 4l4. / 4 i7j $ )¢' ?q-n,R,,,�,y,_ /C o.72 I9.5"rf f L.`2t ..G goo*., Completion of the followinvabie may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.:Susp.(Paddle)Fans Te.of Total. Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- 'No.of Emergency Lighting No.of Luminaires Swimming Poo] grnd. grnd.. ❑ Battery Units _ No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS ,No.of Zones —No.of Detection and i No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.o f AlertingDevices Tons No.of Waste Disposers 'beat Pump Number Tons IKW No.of Self-Contained ....._ Totals: "" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municip•al ❑ Other Connection No.of Dryers Heating Appliances KW ecurity Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HPTelecommunications Whin: g: No.of Devices or Equivalent 4. OTHER: . Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Eleitrical Work: (When required by municipal policy.) Work to Start: I t t * e-} 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains itd penalties of jut that the information on this application is true and complete. FIRM NAME: ` t LIC.NO.: P C Yip Licensee: /f l/ Signature 6. ' lc,D�Q,.,,,., LIC.NO.:A-/6S—Ft, of-applicable,en " e+npt"in the license n n er 1' e.) •Bus.Tel.No.: (.f t 3-- cY-3C.::)�.- Address: r4 G,f Alt14 k t1 1 1 Alt.Tel.No.: *Per M.G.L.c. 147,s. 7-61,securitywork requires artment of Publ "S"License: Lic.No. p Safety OWNER'S INSURANCE WAIVER: I am aware that the Licensee do not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement I am the(check one)0 owner ❑owner's agent. Owner/Agent / v • Signature Telephone No. PERMIT FEE:$! Z� I b 1 C'Pc b 1V t. r-i r e..iC. Commonwea&oil l7taseachweite Official Use Only i. " jx '� c� Stroked Permit No.ee�2Z-- O iJ'�7 5— - 2eparfmani'ot. ira Stroked e 1 ��� Occupancy and Fee Checked 201 4— '•;. --,,. BOARD OF FIRE PREVENTION REGULATIONS [Rev.I/07] (leave blank) of AP-LIGATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 Na �- N (PL.�4SE PRINTW INK OR TYPE ALL INI'ORM4TI01� Date: ��/3/ :z i. ity or Town of: /1/6/t_fAcinl pfolr To the Inspector of Wires: "; By this a lication the undersigned gives notice ofhis or her' tention to perform the electrical work described below. Location(Street&Number) /J~-/ G/LQQ/t 01/4.12 d l( Owner or Tenant 019-I-//, L/-p_//j-,/re_ Telephone No. 4/3-S'3 7-o/�3 Owner's Address • Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building &,Q 5/0.e/t -/b,/ Utility Authorization No. . Existing Service 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: T"..e/k1 p 0/Z/ - S P C) /t°"Completion of the following table maybe waived by the Inspector of Wires Po.of rans Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVAformers I{VA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- 1Vo.at Emergency Ligetrng grnd. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection anti Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number•Tons _KW_ No.of Self-Contained ( Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal 0 Other Co on No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 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: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [�BOND ❑ OTHER 0 (Specify:) I certify,under the pains and penalties of er ury,that the information on this application is true and complete FIRM NAME: /,'2 t /e c_/ / C LIC NO.: Licensee: 1 / tie Signature _ LIC.NO.:22 7c/5—, (If applicable,ent ' rpt"in lic e nun line.) e Bus.Tel.No.:WW3'3.2S -6r-3 Address: piU%} 5 I Glue r1 fy 2/i i(/I/� — Alt Tel.No.: *Per M.G.L.c.147,s.57-61,security wor 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)0 owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ 571 00 Clittar . 0/OD MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK e ,v_;I:i_ - CITY I IVrfc'IV coat p4-1,0 I MA DATE Li, t< I' PERMIT#(`''n ,A.)--0 of/C( JOBSITE ADDRESS ISI (?tcc' t-i. 4' Il . OWNER'S NAME eit Cl/t Lc(IIs,t74' P OWNER ADDRESS ` TEL f , -r 4 er ,FAX TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCATIONAL IJ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: . PLANS SUBMITTED: YES❑ NOD FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB : j wa _ .—! .; 1�: .1 I� CROSS CONNECTION DEVICE r j DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM I MK I DEDICATED GREASE SYSTEMDEDICATED GY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM lMN ,i ,. . ._,Eill! DISHWASHER DRINKING FOUNTAIN i? FOOD DISPOSER � ` NMI 11.—, OE FLOOR I AREA DRAIN IIIIIIIIIIIIIIIIIFIIII 11111111M11111, ( - INTERCEPTOR(INTERIOR) pi -j I 1; KITCHEN SINK MI 1 _II , ; LAVATORY I 1, 1 I ROOF DRAIN ! SHOWER STALL i I II I >�, i SERVICE f MOP SINK 1 TOILET _� _ s URINAL ( I i€ ' L! g 1! i i 1( ai 1 WASHING MACHINE CONNECTION �I ��' -`r, !I WATER HEATER ALL TYPES I —5 ow ' WATER PIPING S ! OTHER ' j __ I 1 _ mil -_. I ;nimi I have a current liability insurance policy or its substantial equivalent INSURANCE which meets the requirements of MGL Ch.142. YES 0 NO EI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru n acc to to t best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co e all Pe ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME'Mark Wendolowski LICENSE# 12394 S TURE MPD JPD CORPORATIOND# 'PARTNER IPD# ILLCD# 3675 COMPANY NAME Express Plumbing, Heating&Solar LL ADDRESS 131 Prospect St CITY Hatfield STATE I MA j ZIP 01038 TEL 1413-626-3862 FAX CELL EMAIL mwendolowski@comcast.net Oki/rdd MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =::nib ':s I( y CITY � ,,127,,,,,,,t 1 MA DATE ///iala ?-- I PERMIT# 6'p Aa' oci24 JOBSITE ADDRESS I/S-/ r� .n Lr� /I( OWNER'S NAME I(- t tc=T_ 6 ,L GOWNER ADDRESS TELI {-X-i ill JFAX i TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL,,®' PRINT CLEARLY NEW:❑ RENOVATION:© REPLACEMENTS I PLANS SUBMITTED: YES❑ NO❑ APPLIANCES Z FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ............. ...-a_ --....._ BOILER BOOSTER - —,;— CONVERSION BURNER COOK STOVE DIRECT VENT HEATER ;, DRYER ,1- —r. — r ;ifH— , FIREPLACE ... FRYOLATOR F `1 FURNACE GENERATOR a ERR GRILLE INFRARED HEATER 'i 4 a..ti LABORATORY COCKS _ ,_ MAKEUP AIR UNIT --R _ _._ __�_ i ---4-- OVEN W _ �.m �.a �I .. ._. 1 4.1 IV f! C- Y e. N-S1 �'�✓ C�1 POOL HEATER - _ _ _ L (3 TH , ,-T _7.N ROOM/SPACE HEATER , .f'Pr>0 L.D NOTAPrfj`.- J-D_ ROOF TOP UNIT _ TEST ___.— UNIT HEATER UNVENTED ROOM HEATER - _�1 --1-- r _WATER HEATER_ r �__. OTHER ,____. i _ . _.. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I NO U I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1-74, OTHER TYPE INDEMNITY E] BOND Li OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT r a SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur to to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli w' ,all Pe ' nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Mark Wendolowski LICENSE# 12394 IG TURE MP I MGF 171 JP® JGF 0 LPG!0 CORPORATION D#U PARTNERSHIP❑#[— LLC[I# 3675 1 COMPANY NAME:[Express Plumbing, Heating&Sola-rIC1 ADDRESS I131 Prospect St 1 CITY rH atfield STATE MA IZIP[01038 ]TEL 413-626-3862 FAX L.... i CELLL Ii EMAILF--� — -�.�..._I L '""' L-2 - 92 1-7 / tf7P7t 7 ! I b 1 (i fcL zI/Lc '-iI" 1...1C. ComnwnweaK o/MadlachWaffd Official Use Only ' .4 `t Permit No.e p��22-- r0S55— . . 1 2epar nt°lairs sewu� c - -.•,). ? Occupancy and Fee Checked 2D/-7 .r— '�'..,,r BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank) c„) AP'LIGATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 ry (PLEAS 7//3/2 7 2 2 o L S: PRINT W INK OR TYPE ALL INFORMATION) Date: I r" 1_ ity or Town of: it ott f Agna pfoi,) To the Inspector of Wires: By this a..lication the undersigned gives notice ofhis or her' tention to perform the electrical work described below. Location Street&Number) /5/ Gee/1 Q4 l7i( Owner or Tenant 0/4 k//' L#e_j -1/7--.2._ Telephone No. e.,/3-.c 3 7-o/—3 Owner's Address • Is this permit in conjunction with a building permit? Yes ❑ No Er (Check Appropriate Box) Purpose of Building R a_51 0 /I -h al Utility Authorization No. • Existing Service 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: 77.e/fr.?p a 2/ -X S pv e-e Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.Susp.(Paddle)Fans To.of Transformers KVA KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA • No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers —Heat Pump Number._ Tons ._KW __ No.No.of Self-Contained Totals: -"� �- Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Munnecnicipaltio n ❑ Other Co No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent Heaters KWBallasts Data Wiring: Siting No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications NofDevices or <rquival No.of Devices 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: • Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE r BOND ❑ OTHER ❑ (Specify:) • I certi,under the pains and penalties of er ury,that the information on this application Is true and complete. . FIRM NAME: De. f/ C I / L LIC.NO.: Licensee: t / tS' Signature exam LIC.NO.:227(6- (If applicable,env- rpt"in lic se nw line) Bus.Tel.No.:Y/3—3:ZS-6.ro 3 Address: 2 c e. )Ly 5 f Clue r1,4 Q l' ie./l/9- Alt Tel.No.: *Per M.G.L.c.147,s.57-61,security wor 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)0 owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 5—s 04 7 - (le- Wv. /5I 6..IK / L-b H .U12— "\ C Coto ea&of Naaaachuaeth Official Use Only t - `t aft intent of.}ire Jervice9 Permit No.G!'—�ZZ—0 12 5 N = . Occupancy and Fee Checked/2 yyj o `r ;�' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) co APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 6 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: t k ` R V})-- City or Town of: -1l be Ci( To the Inspector of Wires: By this application the undersigned gives notice otitis or her intention to perform the electrical work described below. Location(Street&Number) /ci ' t�,.i Lfz A-4 D fZ , Owner or Tenant C,iCi T l y J-1 t‹..(k-S Telephone No. ((/)..)5 --64.7 7 Owner's Address c II ) Is this permit in conjunction with a building permit? Yes P"' No ❑ (Check Appropriate Box) l e Purpose of Building 'Utility Authorizatia o. l(G � `n l,� Existing Service Amps / Volts Overhead El Undgrd No.of Meters �T�'4C,1'"ov� New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters (1 o Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: k/c. /►l,- ues gel)1' g TiNgoe e,- /Si fj°�R g. - Lr.i, .2- FO te• _ Completion of the following table may be waived by the Insgecfor of Wires. al No.of Recessed Luminaires No.of Ceu,Soap.(Paddle) Transformers I�VA Fans No.of KVA. No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 1S�vimmist Poot Above In- o.of Emergency Lighting g grad. 0 -grad. � Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS :No.of Zones No.of Switches No.of Gas Burners No.of Detection and I Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices No.of Waste Disposers Heat.Pump Number Tons KW o.of Self-Contained Totals: __ _'_' Detection/Alertin Devices al No.of Dishwashers Space/Area Heating KW Local❑ co niennecttiQn [1] Other No.of Dryers Heating,Appliances KW Security Systems:* No.of Devices or Equivalent. No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunicati+aas`Wirin : No.of Devices or Equivalent OTHER: ' Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Eleitrical Work: (When required by municipal policy.) Work to Start: i t . 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains''nd penalties of jut that the information on this application is true and complete. FIRM NAME: LIC.NO.: 4/4 ,51, Licensee: • Signature ' IC LIC.NO.:Al6S-1-6 (If applicabiliter" surpt"irctke license n n er l' e) -Bus.Tel No.: f/i J—WV—17t Address: / All)d{ d I a cP 5' Alt.Tel.No.: *Per M.G.L.c. 147,s. 7-61,security work requires partment 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. 1 am the(check one)0 owner 0 owner's agent. Owner/Agent a Signature I Telephone No. PERMIT FEE: $I Zg U 7fyfi )1,4\„1., `'‘cie30 -fe -}