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h2n a cuTi'�r¢LabTitv insurance poGry or i"s suhsC3n3z1 equn2lz�whieh,mz�d�e 2quirmz�c MC-L Ch SL Yz;�iNo❑ .
Ir YOU CI-IcCfO yE6, pLcp,SE It�D1CAi c TFIE �1'PE OF COVERAGE SY C}icC1QNG THe PPPROPRIATE BDn6EL0lN
' LLASfLTTY FhSURAN�?pL{CY�.. 01'c�R iY2E OF INDr�[HIT`7 ❑ BOI�ID ❑
OWf�fER'S WSURANCE WAIVER_t am awarr.ifx3f 3-,e 6eensae dces not havz ihe insurancz coverage requird by Chapter ia2 oi�!
Idassaehuse�;s GeneraI Lav.�s,and ihat my sgnahirz on this permii appGcaSon waives�is rzqtairemznt
CHECK ONE BOK ONLY: OWNER ❑ AGEN'f ❑
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J1 hereby cer6ry fh��II oi the dz�s and iniormaYion 1 hava submif]�d �or erR�redj regarding 3iis appfica5on a2 hve and accura�x to
best of my Knowledge and 'ihaf aIl plumbmg work and installafions pzrietmed under fhe permit issued for fhis pG 'on un11 be
Icompfcance with all perfinent pro�ision of the Massachuseff's St�e Plum6ing Code and Chaptes 42 of ihe G er
PLUMB621�AME .i'� l`HA �y-� • SIGNA \
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