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Home My WebLink AboutBuilding Permit # 12/9/2016 tyQRTy BUILDING PERMIT of TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION i. i Permit No#: t ! Date Received p�R.TEa�p¢` c5 �Ssa C 1iUS Date Issued IMPORTANT Applicant must complete all stems on this page �zm ,3. ':F�Tl]llk� �� r "a. "' 'y=• ,r "" pROPEF�TY44 OV1lNER4r � ,el" rr � nnt k'v,:�.' �. .� �,�;. ^a:r -„«... raves" 'k' '- MAP PARCEL ZONING DISTR]C7 Hisor D�srlct yes; no K � Mage yes o Machine S�iop Vi -F - TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑1Nell ❑ Floodplain L Wetlands VIlatershed D�strtct r a f DESCRIPTION OF WORK TO SE PERFORMED' Identification- Please Type or Print CIearly OWNER: Name: A� f-� Phone: • 1 Address: 1 S' ,S)D�e- )�2d Contractor Name �r��'x1Act� �t�.. [ t Phone -Emaii ' t16 Address _ _ 6. Supervisors C�nstruct�on License � _ P �, � � , V 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: $ "tS FEE: $ Chec€c No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund -- - Si n _ - �itznati irp- n#Ac�pnt/Owner q atu e of contractor y %AOK*r own of F, Andover ® :#1 No. _ p - .AK. h ver, Mass, 24 � a +p cacHcncw"� '�- �,e A0 Ar E D aS BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .. . .0 PA e.M ft k....YAUC ....... .514004. BUILDING INSPECTOR has permission to erect ........ buildings on ... aFoundation ......... ... .... .. . Rough t0 be occupied as ,......,,. ceitut . ..,.. .. .... ... ... ..................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION IR?// Rough Service ................ .......,..... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupv Ruildin 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. RISE, Enginecring RI Contractor Registration No 8106 MA Contractor Registration No 120970 CT Contractor Rogistration No620120 RISEw 611 Shammit 11(tiol,0INton,NIA 02021 ENGINEERING' CONTRACT 339-502.6335 FAX339-502-63-15 Pago PROGRAM 'HIS CONIRACT14 ENTE RED IN 10DEME"Ell RISE CNIA411-JS Int NEERINO AND 1HE CUSWX.R Fort WCRK AS DESCRIBED VELOW CUSIONER plium DAIE CUENto WORKVIDER (979)921-5924 11/29/2016 +12048 23 rx)2' A1(rew Du fires ne .......... SERVICE VREET 11.11140a7 EET 21 Silsbee Road I Silsbee Road GUAM MY,STAIE,ZW North Andover,MA 018, Noah Andover,MA 018,15 ,JOB DESCRivriON Afk SFAIANO:provide labor and materials to seal areas ofyoUr h(NNC njilil)Sl WISM'111,eXCVq air Ir al This,work v,ill be performed in concert with the nw of special tools and diagnostic tests to assure Illat yolif home W11 K.,left with it healliffill level of air exchange and inthoi air(Itulity. Materials to bo ascd to witl your home can illdide Cilillks,1,611111sand ollw products. primary ilrew�fol-scilling ineltu,k.air Iciik;lge to allies,Imsenwills,intlached pirago and other willeated areas(WIlLhms,me,not generally ilddressed) This swill I-quile(8)Nwrking hours, A reduction in cubic rcet per mililltv(cfill)ofair infiltultioll\till occur,but the acliml number of dni isnot guarllwc& At the complotion ofthe mathei -ization\%oj k,and atno additional Cost to the lunneowler,it final blo\%vr door and/or combustion '.4trety illullysis;\\ill bm-conducted by the subcontractor to unsure the silfety of tile indoor i1ir quality, $680J)o DAMMING:provide kitmr and nintcrials to Nislall it 12"layer ofR-38 miliaml filvighiss Kitts to(50)sqwmc feet for damming ptirposcs, $10150 ATTIC FI,AT:provide I;ilx)r and material to install it 7"layer ofR-26 Class I Cellolo.se added to(720)square fect of open attic space. $930.00 for tire allic access foldi ir A ATTIC AC()"N instoull) easily moved,NisuIiitiNVc(tvm ligsta "malt ffik surface of plywood vsill IV Created around the opening Nvit 11 ill the attic„ This said allow0w covel"s interrol twather- stripping to restrict air leakage. $237,65 VENTILATION:provide laIxN-and materials to install(2)iwd e allatexhilust hose\011 pilble%wm il ounted 11appo VOW to exhaost existing bathroom fini(s). $237.50 Mill T'ls to,—ZNntainair flow, VI�I I I A I TON F,o, d,I lbo, Ind it S84,00 Rl SI fan i gi i icer i ng app I y till it 1)p I icitbl e,el igi hl e in co i t i Yes t t t 11 i s Co I I t I act Youswill only he hilted t I ic Net an i A)i in t. Current!y tier el igibi e measures,ires,(70 1 trin bin Gas offers ffers 7 5%i i we i i I i ve,not to exceed$2,000 1)cr calendar year,and;in i n cer I t i vv of 100`o tO,I' the Air Seli I in g measures tip Io I I i e first$680 it nd it it lidd i t ion ill$310 i f sav it i gs arc justified by Iiia atdil o r, I"or IIIc saCCty and h Cil I 111 o I'y o t ll,home's indoor 11ir(11 Kil it y,twc w 11 be co n(It let i it g it blower decor(I iagn osl ic orf I,Iie it va it able air flows ill Your how Wth bc I'mc tile\\ork is(~gall,and after the malherijiltioll\kt)rj; is complete.We swill also condliet it full assessment of the Combustion salety of your treat inr systeill and water licater.This has it vans:of 590 and is at no cost to you. Total allowable mitheri/iwion incentive is$3,t If), The permit will Iv secured try the insulation contliletor.,ill [to ildditiolull cost 11 is the hortleo"ller's respollsibilily to close cut this permit by contacting Ilicir municipality ill the Completion of this N\ork, rodaral ID 0 05•0405629 IMSE, Engineering RI Contractor Registration No MG MAContractor RoUlstration No'120979 c'r Contractor Registration No620120 RISE (io SIjNNvNjRt Road,Conton,NIA 02021 ENGINEERING' CONTRACT J39-502-6335 FAX 339-502-63,45 page 2 PROGRAM 9110 CONItACT IS ENIERE-1)MOUE'TMEN RISE CMA-I I E.S ENOMEERINO AND'HE CU3rAT-.R FOR WORK AS DESCRIBED DELON U I-KME-R PHONE DAIC CLIENra WORKORDER Andrew Dtifiresne (978)821-592,1 11/29/2016 44AY18 23902 SERME STREET BILUNG 5'RVI:T 21 Silsbee Road 21 Silsbee Rawl SERVICE My,STATE,ZIP fiJLJJNo CITY,STATE,ZIP Noah Anclover,MA 01845 North A n(lover,NIA 018,15 .1013 MeSCRIMION $900) ........................I....... /* Total: $2,367.65 Program Incentive: $1,968.24 Customer Total: $399.41 WLAGREE IIEREBYTO FURNISH MIMED-COMPLEMIN ACCORDANCEWITH ABOVE SPECIFICATIONS,FOR THESUM OF ",'Three Hundred Ninety-Nine &41/100 Dollars $399,41 UPON FINAL IBM DID APPROVAL BY FUSE ENCINEERING.COSIOMER AGREE$10flVATAM"NTOUE IN FULL-INIERESTOVII'A WILL BE CHARGED MONTHLY ON ANY UNPAID B:AL.ANC F71ER 0 PAYS.SEE REVE FOR IWORTANT1 4PORMAMI ON GUARANTEES.RIGOIS'OF RECISION,SCHFUUMM,ADO CONTRACIM IRCUMAVON. 01'SIGN THIS CONTIRPICT IF MERE ARE ANYBLNIJK 0II/CES Zu—TIZIaD'NORA,)t E RISE Enghtering M.11 AIC c E '%11) ACCEPTM4 NOIE:1113 CUIVA07MAY UEWMDRAINN BY US WTIOVEXCCLIVEDWIVIIN DATE OF ACCEPTANCE ACCEPTANCE CC CONTRACT OTIE ABOVE PRICES,SP ECIFICAVON5 ANN Cmtlow ARE 300AISFACTORY TOUS A140 ARE HCRE(W ACCEPTED.YOU ARIS AUVORM10 TUO01Hr WORK DAYS, As spEcinED.PAYNIENTWILLBE MADE AS OUILINEDAOME RISE60 ShawMLIt Road, Unit 21 Canton, MA 020211339-502-6335 ENGINEERING" www.RISEengineeritig.com OWNER AUTHORIZATION FORM -41 (Owner's Name) owner of the property located at: C (Pr,o-perty Address) (Property Address) fij Merrimack Valiey Insulation 23A Suitivan Rd hereby authorize Foierica.MA 0186'? (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a Wilding permit and to perform work on my property. This form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to Close out this permit by contacting their municipality at the completion of this work. 6inPCsSi�gZur Date 6,2016 �{ j 9�{ INSURANCE j�' MERRVAL•-03 WE.1E CERT CATS OF ��Fl�BM E! Y fif3�SURANCE DAT/1 31201YYYY) 6fR3f20Rti 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,ANO T14E CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the poliGy(ies) must be endorsed. if SUBROGATION lS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s)- PRODUCER CONTACT NAME: _ Automatic Data Processing Insurance Agency,Inc 1 ADP BoulevardAIC ExI: wn,No E-PSAILIL Roseland,NJ 07066 ADDRESS: INSURER(S)AffoRDING COVERAGE _ MAIC=- INsuRERA:5StarV3 AAIC Arnerican AifernaYive lnsjaran. INSURED Merrimack Valley Insulation Corp INSURERs: _—. 23a Sullivan Rd INSURERc: -------. North Billerica, MA 01862 IIaSURERn: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEES(ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WfrH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 13Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE SEEN REDUCED BY PA)D CLAIMS- 0 LA_IMS_ �A0�-Fsw�RT_ ____ .._..___�.-__.-_POLICY EFF 7 POLICY EXP j 1LTR I TYPEOFINSURANCE IINSRILUvRn POLICY NUMBER r19AMI))YYYY I M?.wDDlYYYY I 17h}Tr5 1 GENERAL LIABILITY 1 EACH OCCURRENCE j 5 OFRiA ENTE I CO3A35ERCIALGENERALLNHILTTY l PRETAk)S jEaoccu- Ce],�S -- TAI- -- ---- `- I CLAIMS-MADE OCCUP. vEDE7CP(Am�anePersan) [S 1 I PERSONAL .ADV INJURY t S I I 1 GENERALAGGREGATE _ a--— GEN'LAGGREGATELIMI-oAPPIViSPER: I LPRODUCTS-Co -AP10P - AGG S t PRC- f�1 I S POLICY ,IEcr I I LOC I AUTOMOBILE LIABILITYi I I 1 COMBINEDSINGL'c LIMIT 4 Eaacrident S j ANY AUTO ; BODILY INJURY(Perpersan) S. ALLOwNED SCHEDULED ;BODILY SiJJURY(Peraccidenl) S —_ AUTOS AUTOS — NON-OWNED i PROPERTY DAMAGE S HIRM AUXOS AUTOS jFerauciderq -___-•-- ------,-------- UMBRELLA LIAR i EACH OCCURRENCE 5 - EXCESS LPAB C[nGhi5 tIA[}E F AGGREGATE---- S pen RETENTION 5 I S WORICERSCOMPENSATION x WCSTATU- OTH- AND EMPLOYERS'LIABILITY _TORY LIA1rCS ER .______ A prlYPROPRIETORIPARTNERIEXECUffrcc YfN 1l9If 0749118 W181.20'16 61/812017 E.LEACH ACCIDEh�' � S 1,000,000 OFFlCERfPlEFfEEP.EXCLUOED? NIA .---_ s S(PhnpclatnryinNH) F-L.DISEASE-EAEMPLOYE S 1,000,0011 I IFyes,describe underRIPTION OF OPERATIOM DESCRIPTION 5S Ue;w.f L E. DISE1tSE-POLICY LIP.rr" S 1,OGD;GD I l i I f DESCRIPTION OF OPERATIONS(LOCATiONSIVERICLES (Attach-ACORD 101,Addi[ional Remarks Seherluln,ifmom space Isrequire+I) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED.BEFORE THE EXP)RATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of NorlhAndoUer,Massachusetts 120 Main Street North Andover,INA 01845 THORIZED REPRESENTATIVE 1 Q 1 S88-2D'l0 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD TE ACS CERTIFICATE OF LIABILITY INSURANCE DA 11/07/20 iN�. 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, EXTENT) OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHOMEED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL,INSURED, the policy(ies)must have ADDITIONAL INSURED provisions or 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 Carolyn A Coughlin Charles J Coughlin Insurance PrioNae FAX 14 Dinley Street Ernwl . (978)957-3588 Ara No�L�� P.O.Box 10 ADDRESS: -arolyn@coughlinins.com Dracut,MA 01826 ..__ INSURERIs�AFFORDING COVERAGE._.., NAIC 0 iNSURERA: Northland Insurance Company 24015 INSURED Merrimack Valley Insulation Corporation Joseph A.Ryan,Jr. INSURERS: Safety Standard 3$4554 23A Sullivan Road INSURERC: Torus Specialty Insurance Company A0159 N. Billerica,MA01862 INSURERD: 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 13Y 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 I ADDL SUER POLICYEFF POLIGYEXP LTR TYPEOFINSURANCE INSD WVP POUCYNUMBER MIDD MM1DDNWV1 LIMITS A COMMERCIAL GENERAL LIABIUTY WS274182 01121!2016 01!2112017 i=ACHOCCURRENCE $ 1,000,000 GAMAQE-TO CLAIMS-MADE �OCCUR PREMISES Eaoccurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL s ADV INJURY $ 1,000.000 GEHLAGGREGATE LIMITAPPU1zSPER GENERAL AGGREGATE S 2,000,000 JJEo- EJ LOG PRODUCTS 5 2,000,000 POLICY ❑ OTHER: 5 B AUTOMOBILE LIABILITY 6205006 1112512075 11!25!2016 COMBINEDSsNGLELIMIT $ 7,400,004 Ea accident ANY AUTO BODILY INJURY(Per person) 5 I OWNED / SCHEDULED BODILY INJURY(Per accident) 5 AUTOS ONLY v AUTOS j HIRED NON-OWNED PROPERTY DAMAGE S �3 ALTOS ONLY AUTOS ONRY Pet accident $ UMSRELLALIAB OCCUR 87593L161ALI 0112112016 01121!2017 EAcHoccuRReNcF 5 1,000,000 EXCESSLIAB CLAIMS-MADE AGGREGATE 5 1,000,000 DED I RETENTION 5 O S WORKERS COMPENSATION STATLfT>~ AND EMPLOYERS'LIAB1UrY Yi N ER ANY PROPRIETORIPARTNER/EXECUWE ❑ NIA E.L.EACH ACCIDENT 5 OFFICEMMEMBER EXCLUDED? (Mandalory In 141,1) E.L DISEASE-EA EMPLOYEE 5 If yes,describe under DESCRIPTION OFOPERATIONS tMowv E.L.DISEASE-POLICY OMIT S DESCRIPTION OF OPERATIONS ILOCATIONSIVEHICLES(ACORG101,Additional Remarks Sthedulo,maybe allach,9MOrespace'isrequlred) insulation Installation i CERTIFICATE HOLDER CANCELLATION SHOULD ANVOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover,Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 M aln Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE OO 1888-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD i !i Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement;Contractor Registration Type:. Corporation Registration: 180506 Merrimack Valley Insulation Corp Expiration: 11/23/2018 28 A Sullivan Rd Billerica, MA 01862 Update Address and return card. Mark reason for change. SCA T 20M-05111 CI AdCfxE!s-s ❑ Gtcann.nr?I i--I FmpInyrnant 0 l nc,4 t"::prrl _._. �"`��r'ti`n�rrrrrnxruc°trl�/rr ��i�rr.iiar�rr;t�(l't Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only Type: Corporation before the expiration date. If found return to: 1 °�` Office of Consumer Affairs and Business Regulation r� Rdgtr io Expiration 10 park Plaza-Suite 5170 ";� 180506 11/23/2016 T> Boston,MA 02116 Merrimack Valley Insulation Corp Joseph Ryan 23 A Sullivan Rd Billerica.MA 01862 Undersecretary J N6 t v id ithout signature 7 '' ;asp iYusen [3op s -nn ouo C S x mar a 'n �.u,. CS-n75541 JOSLI>R A R YAr t 200 fSinh Rail Dr:apt.201 _. LynnfieldMA 01'910 02/W2017 I i ' 0 The Comrnonivealth orf Maswelitisetts Denartrnent of Int1mvirialAccidents Ojfice of Investigations v� ) 600 Washington Str-eet 1losion MA 02111 >v ww.nrass.gov/ctio Workers' Conipensatioln Insurance Affi ,,vit: Bluilders/(;ontrac9ovs/Electricians/Plunibers Applicant Info>r>ination Please Print Legibly Nance (Business/Organization/lndividual)_�Merrimack Valley Insulation Corp. Address: 23 A Sullivan lid. C,.ity/Share./lip: Biilerica,_.MA01862 Phone #: 978-888-3495 Are you an employer? Check the appropriate box: 'T'ype of protect(required): I El employees Toyer with 18 4• 1 am a general contractor and I l _._._.. ._.__., 6. � New construction ` (full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet, 7. ❑ Remodeling s1lip and have no employees "These sub-contractors have g. F1 Demolition working for me in any capacity. employees and have workers' 9, ❑ Building addition [No workers' comp. insurance comp. insurance.-1 required.] 5. oration and its IO.❑ Electrical repairs or additions 5. We are a corporation 3.El I am a homeowner doing all work officers have exercised their 11.[:] Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.❑ Roof repairs insurance required.] t' c. '152, §'1(4), and we have no employees. [No workers' 13.[X:1 Other Insulation comp. insurance required.] "Any applicant that checks box#fl must also fill out the section below showing their workers'compensation policy infonnation. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors niust submit a new affidavit indicating such. xC'ontractors 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. Tf the sub-contractors have employees,they must provide their workers'comp.policy number. I(lilt an employer that is providing wor/cers'compensation insurance far my ernd)loyees. Belo iv is the policy anrd job site information. Insurance Company Name: SStar V3 AAIC American Alternative Insurance Policy# or Self-ins.Lic.#: V9WC749118 Expiration Date: 6/18/2017 _. ,,.._..._. Job Site Address:e_.._..._ .... . w.... C;ity/State/Zip:._________...___._.____. Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as reclui.red under Section 25A ofMCr1..,c. 152 can lead to the imposition of criminal penalties oi'a fine ftp to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the forth of a STOP WORK ORDER and a fine of up to$250.00 a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of'the DIA for insurance coverage verification, I do hereby certify under the pains andpenalties of'perjur;y that the information provided above,is true and correct. Snattlt_e;__-- .. ._ ..._. .. __ ................_... .__.___w._._._.._�..__ .____.� Date: . Phone It: 8-888-349 Official use only. Do not write in this area,to be conrpletead by city or toren officiaL L City or Town: P'errnit/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#: