Peabody
Building
Department
Liability Waiver Form
Type of Application: Application # __________________
Electrical Plumbing Gas Sheet Metal
Owner Owners Agent
Name:__________________________________
Telephone Number: ______________________________
Location Address:________________________________________________________
License Professional Name:_________________________________________________
License #:_________________________
Owners Insurance Waiver: I am aware that the licensee does not have the
insurance coverage required by Massachusetts General Laws (Chapters
141, 142, 112). By my signature below, I hereby waive this requirement.
Owner/Agent Signature:___________________________________________________
Date:__________________