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HomeMy WebLinkAboutBuilding Permit # 7/27/2016 O� t%ORTH 9 BUILDING PERMIT eT" TOWN OF NORTH ANDOVER (� APPLICATION FOR PLAN EXAMINATIOIt - - Permit NO: t - I� Date Received 1 S r.o..s��c5 Date Issued: �% , ACHu I PORTANT: Applicant must complete all items on this page LOCATION 01 D feN11\ 5� Punt PROPERTY OWNER L S ?1-ZA Print MAP NO PARC'O:C-.M 2,S ZONING DISTRICT: ' Historic District, yes no-"."", Machine Shop Village yes �no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑:Septic ❑Well o Floodplain! ❑Wetlands o Watershed District ❑Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: �� L.",o 1 i Phone: q"? 9 - (o.""t Address: S4- cir.c (Aa 01:6,g3 CONTRACTOR Name: rt R Phone: 7711 Address: Supervisor's ConstructiorrLicense: Exp. Date: Horne Improvement License: ' Ext). Date: 177o677 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_ I 5,000 z,o FEE: $ Check No.: Receipt No.: 22,to NOTE: Persons contracting with unre istered contractors do not have access to the guaranty fund Si nature of A ent%Owner g g Sig `e of contractor Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Mas sage/Sody Art ❑ Swimming Pools ❑ Well El Tobacco Sales El Food Packaging/Sales El Private(septic tank, etc. ❑ Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OPE - U FORM LA:NNINO & DEVELOPMENT Reviewed On ����/ Signature MMENTS- CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Si natur f COMMENTS < I (tj, w,Dl(k_ Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: .. r r Located 384 Osgood Street t FIRE.DEPARTMENT'= Temp Dumps$er on site :y'es- Locatetl at 12? Mair _Street __ no _ -1Yd bepartment signature%elate GOMMENTS .. . ' . OORTM own of : Andover ® - 1 to No. T O tANE h ver, Mass, COC NIC �.QS R^reo ►`Pa,`�(5 tI BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT . 4?.. 'Fars ............................. BUILDING INSPECTOR ........... .... ... ....... ......tom►........ G has permission to a ect buildings on ....... Foundation .......................... ... ............ .. ......... ............. .................. CC a Rough to be occupied as . Q . ., ..... .,�1 ...Afflk'Repfftr... .. ... . .t............... Chimney provided that the person a' cce tin this permit shall in eve respect conform to the teras oOS f thea lication p p accepting p every p pp Final on file in this office, and to the provisions of the Codes and By-Laws rgla intothe Inspection,AlteLatio�nnaand Construction of Buildings in the Town of North Andover. - I PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TIO Rough Service ... .... ........... . .. .........:.......... Final DIN INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. it LA NQ-\-4 �k�sk►n �S�vss '� If L.aLLy � v �� POVv- Cone raft J-A�� C,6 AVL �. r� � t e � � � � �t ., � d y � � -- �,x-- t � . . .� .» [ � `, d _ _ - _u.._ .,_ ._ _� \V --� _ -.__�_ .-F 1 /''v'\ _�, i .� l .T �j>..`j �+ ` i j r -. " _ `� � ,.. l �`7 -. r 11,7 tjr. r-71 A B C D E N 0 I nil II REF. 1 NEW FULL HEIGHT MLL t I I 18'-9" 14'-0" II 1 \ MCN IiELUGAT C-U Ct711NJ1-.1t — INI-III 1-CI::1 WINDOW; ' V✓II L I nI1 Vl'.I 1pl I I I I IIinI-111 Wn11 w cru N QQ I 141 I'MM Pi III 111111,1 I-Ali IIAI 1u 11,111 HI wI'nIiI AlI .III❑❑II WAI1 - 1 I:I I I,�,II III i t I'IrU I�. C 1 I I I I I I III Illi � i I1 II �'I t III III Ill � , IIII III � III III � III III II ' ���' � Correct Build & Installations 5 Shoreline Drive Hudson, NH 03051 (603) 886-1792 (603) 759-1909 TO: Sal's Pizza DATE: 07/05/2016 490 Main St. North Andover, MA 01845 REF: Renovations / Repairs to Kitchen area. ATT: Greg Ryan(603) 421-5578 gryan(a)-sals-pizza.com / Phil (978) 852-1717 mccabe.phiI@comcast.net We hereby agree to furnish all labor as described below. Renovate / repair existing kitchen area (phase 1) as per final walk through on 07/01/16 with Greg and Phil. MOP SINK AREA: Remove existing FRP, drywall and tile floor as needed. Remove mop sink and fixtures. Remove any damaged sub-floor in general area of mop sink, if applicable. Remove and stud framing if applicable. Remove vinyl cove base. Repair/ replace plumbing lines, etc. as needed. Repair/ replace stud framing as needed. Repair/ replace any sub-flooring a needed. Install new drywall. Install new FRP with applicable moldings. Install aluminum angle 4'0" tall on outside corners of walls. Install new quarry tile. Install new mop sink with fixtures. Install new vinyl cove base. WALK-IN COOLER: Install 1/8" aluminum diamond plate panels on the interior walls and door of cooler. The height of the panels will be 48" high and adhered using both glue and mechanical fasteners. The door will have an exposed perimeter of what is there now so when panel is added the door will close and seal properly. Fill in all other damaged areas with aluminum colored silicone. CORNER WALL NEAR WALK-IN COOLER: Remove existing FRP, drywall (if applicable), shelves and brackets. Remove vinyl cove base. Install new drywall (if applicable). Install new FRP with applicable moldings. Install aluminum angle 4'0" tall on outside corner of wall. Install new wire or solid shelving with brackets. Install new vinyl cove base. NEW INTERIOR DIVIDING WALL: Frame new interior wall app. 14'0" x 10'0" (extending existing wall). Install drywall on both sides of the new wall, tape and mud to receive stainless panels, by others. INTERIOR VESTIBULE: Remove existing glass panels (by others). Remove existing casings and trim as needed. Frame in openings. Install new drywall, tape, mud, sand and prime in-fills to be paint ready. REPAIR OF EXISTING DIVIDING WALL (Sagging): Remove quarry tile on both sides of existing wall. Temporarily support existing wall from basement. Make relief cuts on both sides of existing wall. Lift wall as best as possible. Install LVL beam under the existing wall in the basement to include lally columns to support the existing wall as best as possible from future sagging. Install new quarry tile as applicable. INCLUDES: Applying for Building and Plumbing Permits. Disconnecting, re-connecting of plumbing for mop sink and fixtures to include any insignificant repairs if applicable. Removal and disposal of all debris to customers dumpster. Cleaning of all products installed by Correct Build & Installations. EXCLUDES: Any Permits, Fees and inspections, if applicable. Any materials of any kind to include all job supplies etc. Any other additional work other than what is listed above. NOTES: *** All permits, fees and inspections by others, if applicable. *** All work is to be completed during off hours as best as possible. *** All work is to be completed on a time and material type basis. The hourly labor rate is $60.00 per man-hour. *** All materials to include any and all job supplies etc. are to be by Sal's Pizza. *** Any and all architectural, engineering, stamps etc. to include all applicable fees and or expenses affiliated with, will be the responsibly of Sal's Pizza. *** If any existing / additional damage becomes present during construction and or other items need to brought up to code the customer will be notified. These repairs will be completed on a time and material type basis if needed. Both parties will agree upon legal repairs, prior to completing the work. *** No warranty/ guarantee of any kind now or in the future against mold, mildew etc. due to existing conditions. This is the responsibility of the Building / Business owner/ Insurance carrier and should be confirmed that there are no current issues prior to completing the repairs / renovations. **** THIS PROPOSAL IS FOR BUDGETARY PURPOSES ONLY AND IN NO WAY CONSTITUTES THE EXACT AMOUNT OF MONEY TO BE PAID FOR THE SCOPE OF WORK LISTED ABOVE. THIS PROJECT IS TO BE COMPLETED ON A TIME AND MATERIAL TYPE BASIS AS STATED IN THE ABOVE PROPOSAL. THE AMOUNT PROPOSED IS A BUDGETARY NUMBER AND MAY INCREASE OR DECREASE BASED ON THE MATERIALS USED AND THE TIME / MAN HOURS TO COMPLETE THE WORK STATED IN THIS PROPOSAL... TOTAL BUDGETARY PROPOSAL: $15,000.00 PAYMENTS: 25 % Deposit prior to starting work. Weekly progress billing and payments based on work completed to date. Final payment to be paid within 21 days after completion of work(phase 1) is completed. ACCEPTED BY: CORRECT BUILD AND INSTALLATIONS: OU9z,ez- -710?AN DATE: DATE: THANK YOU FOR THE OPPORTUNITY AND LOOK FORWARD TO. WORKING WITH YOU! o jautss �°0 1 ���� �nurnrnir�oca�/lr�����(dJJrrC/nJef/J�� •.uol)���dx3 . Office of Consumer Affairs&Business Regulation �_ HOME IMPROVEMENT CONTRACTOR 7 Type: tlW Otivgl-a' W I Registration: 177202 YP 098L0 Q1SNbn9 L Expiration: 11/14/2017 LLC 1Md�11tl33 S31,dv"o 5 ._ CHARLES E.GALLANT GEN CONTRACING LLC. suoO �. Jos�naadnS u°-.as aorl CHARLES GALLANT L061r6Wso leo8 301 EDGARWATER PLACE SUITE ,.�_t,_—i_.`tir,,,_� nf53b�uipiin9}'sseW V3IAkEFIELD, MA 01880 Undersecretary sp1epue,Sq d�o;uaewpeda0 s1}asnu Charles E Gallant General Contracting LLC. 285 Commandants Way Chelsea Ma, 02150 1-781-248-6290 gallant.charles yahoo com July 18, 2016 Correct Build and Installations LLC 5 Shoreline Drive Hudson NH, 03050 Job Location=490 Main St, North Andover(Sal's Pizza) Dear Ron: I propose to provide labor and materials as per scope of work listed below for the sums of; SCOPE OF WORK Include: Providing Labor for- Supervision General carpentry Metal work Tile work FRP Drywall and taping Protection and cleanup Excluded: Electrical and plumbing Supplying any Material Any Work not approved from owner Work is to be performed on a time and material cost. If any Material is purchased, Reimbursement is requested immediately. As noted at bottom of proposal 40.00 per Hr. Per man. Work is to be performed in a neat and clean manner Clean site daily. ,eco" CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD/YYYY) `.,..i 07/20/2016 THIS CERTIFICATE IS 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 policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Timothy LaRovere FRANCIS J. LAROVERE INSURANCE AGENCY INC. P,v"c"N Ext: (617)387-9700 A No: ADIL DRESS: tlarovere@larovere.com 492 BROADWAY INSURERS AFFORDING COVERAGE NAIC# EVERETT MA 02149 INSURERA: ATLANTIC CHARTER INS CO 44326 INSURED INSURER B: CHARLES E GALLANT GENERAL CONTRACTING LLC INSURER C: INSURER D: 7 BURNSIDE LANE INSURERE: MERRIMAC MA 01860 INSURERF: COVERAGES CERTIFICATE NUMBER: 70402 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 ADDLTYPE OF INSURANCE IVSD SUER POLICY NUMBER POLICY EFF POLICY M/D Y EXP LIMITS LTR WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ AGE ToRENTED CLAIMS-MADE D OCCUR PREM SES Ea occu encs $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- POLICY ❑LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident)__ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE F---1 E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? I NIA1 NIA NIA WCV01276600 12/09/2015 12/09/2016 --- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. TOWN HALL AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 M.Cr Daniel M.Cro,r ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD GALL-05 OP ID: MG A� ® CERTIFICATE OF LIABILITY INSURANCE DA07/2012016Y) 07/20/2016 THIS CERTIFICATE IS 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 policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT F.J.LAROVERE INSURANCE AGENCY NAME: 492 BROADWAY A/CNNo Ext): AA/C No): EVERETT,MA 02149-3617 E-MAIL DANIEL J.LA ROVERE,ESQ.,CPCU ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:WESTERN WORLD INSURANCE INSURED CHARLES E.GALLANT INSURER B: GENERAL CONTRACTING, LLC 7 BURNSIDE LANE INSURERC: MERRIMAC,MA 01860 INSURER D: INSURER E: INSURER F: 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. ILTR TYPE OF INSURANCE DDL R POLICY NUMBER MM/DDY EFF MM/DDY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY NPP8183921 09/09/2015 09/09/2016 PA A EREMISESS(RENTED 100 00 Ea occurrence $ , CLAIMS-MADE I A I OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 jECT POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS PER ACCIDENT $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICEWMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) ADDITIONAL INSURED: TOWN OF NO. ANDOVER CERTIFICATE HOLDER CANCELLATION NOANDOV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN HALL ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER,MA AUTHORIZED REPRESENTATIVE DANIEL J.LA ROVERE,ESQ.,CPCU ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 M www mass.govAdia NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl / p Name (Business/Organization/Individual): Qm Gil alAl Address: C)�S C-6✓V,,M r V\oA. 16 City/State/Zip: S AAA Phone#: Z"y) 6A0 Are you an employer?Check the appropriate box: Type of project(required): 1.E2/1 am a employer with _employees(full and/or part-time).* 7. ❑ ew construction 2.r-1I am a sole proprietor or partnership and have no employees working for me in $. CRemodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F�I am a homeowner doing all work myself.[No workers'comp.insurance required.] 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 i l.E:]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.17 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROof repairs These sub-contractors have employees and have workers'comp.insurance.' 6Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] IL Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 eutployer that is providing workers'conrpertsation insurance for my employees. Below is the policy and job site infOrnlation. // � /� Insurance Company Name: AIL6tV, I G l gg (,V' Policy#or Self-ins. Lic.#: C V6 QAC 0 Expiration Date: 0 Job Site Address: q Ayn�14 City/State/Zip: Qlo4 UN Attach a copy of the workers' compensation 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 DIA for insurance coverage verification. I do hereby certify and h pains m pe es of perjury that the information provided above is true and correct. Signature ( (l Date: `-02 Phone#: -2 / �y�`���'ig 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: