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Home My WebLink AboutBuilding Permit #794-13 - 10 DUNCAN DRIVE 5/20/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 1 3 Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Prin PROPERTY OWNER A C , Print 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes �� Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial KRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: y TuC ��i dentific ionase y e or Print Clearly) �� OWNER: Name: G�°2 �f Phone: Address: CONTRACT R Name: nC- Phone: ,L Address: Supervisor's Construction License: �� 1 f 7 Exp. Date: Home Improvement License: 5Exp. Date: 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: $ e d FEE: $ 31 , Check No.: Receipt No.: C?, L 3 NOTE: Persons contracting with unregistered contractors do not have access to thy'" ara Signature of Agent/Owner Signature of contractoti Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ ped Plans ❑ Location U No. L — Date s • TOWN OF NORTH ANDOVER e h-,v'V l r)j�44e e Certificate of Occupancy $ Building/Frame Permit Fee $ �� a " w Foundation Permit Fee $ N Other Permit Fee $ TOTAL $ Check# 26423 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE.DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS IL 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 Tow;! Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT '- Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA— (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fol owing is a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application Li Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appy al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building permit Revised 2012 � r10 R TFC Town of A G O {+ 0 No. i1ok"TOW-i _ h ver, Mass, COCNICM/wkC y1' A0R�TEO ►Pa�,�S S u BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System I l THIS CERTIFIES THAT ........16.1 �.......... e'u.�................................................ BUILDING INSPECTOR has permission to erect .......................... buildings on ....... .....an.G!4.:'.'�:......�.(.!:V..... ........ Foundation Rough to be occupied as .......fi!.�......V.I.'�.`.l} .....�.�1.�,. . .... .. .............................................. Chimney provided that the person accepting this permit shall in every respect 6bnform 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 CONSTRUCTIO AR Rough ! ...... ............... .................. Service "" Final BUILDING 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. SEE REVERSE SIDE Smoke Det. Maggae-li,. ge,44g rrome Improvement Sam 1e Contlract This form satisfies all basic requirements of the slate's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard ass ah se protect homeowners. Seektome Iegal advice if necessary. Any person planning home improvements should first obtain,a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeingto any work on your residence.You may obtain afree copy by cal]ing the Office of Consumer Affairs and Business 1.cgulation.'s Consumer Information Hotline at 617-973-87$7 or 1-888-283-in a re on our website. ome er rm�tn®� Contractor][>m ®><mation Name . Company Name ., Street ddre (d otu a Post Of aceBoxaddress � G Contractor/Salesperson/OwnerName Gr�O ity/Town State EZip Code Bpsiness Address(must include.a stree address Daytime Phone EveningPhone City/Town �,/� f "'! State Zip Code Mailing Address(It different from above) �� us' ess Phone Federal Employer IDor S.S.Number Law requires tLat most liomc HomeImpmvementcontmetorxteg.•Number Expimtiondate • Improvement contractors iinyc a valid reg;strafian number The Contractor agrees to do the following work for the Homeowner: (Describe in detaRthe w0rlctO completed,specifyingthe type,brand,and grade of materials be used,use additional sheets ifnecessa Required Permits-The following building permits are required Proposed Start and Completion Schedule-.The following schedule will and will be secured by the.contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (OWners who secure their OWnn permits SVM be excluded from the Guaranty Fund provisions of A - /3 Date when contractor will,begin contracted wozlc. MGL chapter 142A.) l —/)-/-3 Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule f� The Contractor agrees to perform the work,furnish the material and labor specified above for the total suns of. Payments will be made according to the following schedule: (5_L/;_06Vuupon signing contract(not to exceed 1/3 of the total contract price or the cost of special,1 p al order items,whichever is greater) Oby /�� or upon completion of_ ! g ' by �/��/ J or upon completion of $_6411upon completion of the contract. (Law forbids demandin full a g p yment until contract is completed to both patty's satisfaction) . The following material/equipmentmust bespecial $ ordered before the contracted-work begins in order to be paid for to meet the completion schedule.(,*) $ to be paid for NOTES:(I)Including all finance charges(**-)Law requires that any depositor down payment required by the contractor before workbegins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warrin -Ts an express arrar beim0 El rovided b the contractor. Subcontractors-The contractor agrees to be solely responsible for Completion of the work described regardless ofthe actions nty must be eh an{o fhe ontract Party/subcontractor utilized by the contractor. The contractor fiufiher agrees to be solel re onsible for all a y aterials and labor under this a cement y payments to all subcontractors for Contract all not imp -Upon signing,this document becomes abinding contract under law. Unless otherwise noted within this document,the contract shall not imply that any Lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. C Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear, Malce sure the contractor has a valid Home hn rovement Contractor Re 'stration. The law requires most home improvement contractors and subcontractors to b e registered with the Director ofl3ome Improvement Contractor Registration. You may inquire about contractor registration by writing to the.Director at 10 ParlcPlaza,Room 5170,Boston,MA.02116 or by calling 617-973-8787 or 888-283-3757. c Does the contractor have insurance? Aslc the Contractor for his insurance company information so that you can confum coverage,or aSlc to see a copy of a"proof of insurance'document. o Know your rights and responsibilities. Read the Important Information on the reverse side of this foram and get a copy of the Consumer Guide to the Home Improvemenj Contractor Law: You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main ofrii cc or branch office by ordinary mail posted,by telegram sent:or by delivery,not later than.midnight ofthe third business day following the signing ofthis agreement. See the attached notice of cancellation form for an explanation of this tight DO NOT'SZGN 7['MD[S CONTRACT IF TIRE ARE Two idenfical copies ofthe colazact must be completed and signed. One copy should go to the homeowne The �� SgAC�S t f P b t by the contmetor. Homeowner's Signature COn ctor' Signature 'Date Date ` Confra.etor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an 'alternative to court-action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is atiorded to the homeowner by the Home Improvement Contractor Law. S The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract;-IIhe contractor may submit the dispute to a private arbitration f-m which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to 'such arbitration as provided In Massachusetts General Laws,chapter 142A.. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the pasties above apply only-to the agreement of the patties to alternative dispute resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way, even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded'from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and worlananlilce manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold-in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have gtitestions about your consumer/homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract • The contract must be executed in duplicate and should not be signed uncal a copy of all exhibits and referenced doc=ents have been attached. Pasties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the own:1•a d tl e other kept by the contractor, .'-y modification to t'u e.original contract must be in writing and agreed to by both partes. Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be 5nancially insecure,the contractor may require that the balance of feuds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said•accolmt would require the signatures of both parties. Additional Information if you have general questions or need additional ixl-or.►nation about the Home Improvement Contractor Law or other cons-umer rights, or if you ti wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Off-ice of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABRwebsite at-ttp://wwrv.mass.gov/oc Lbr/ If you want to verify the registration of a contractor or i:f you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration office of Consumer Affairs and-Business Regulation 10 ParkPlaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at IiM://ww-,v.tnass.zoy/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: htt7.3://db.state.ma.tiMi.oineimurovem ent/licenseelist.asp For assistance with informal mediation of disputes or to regisi;er formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4.800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 ® Page No. of Pages C�C''7 �' i � r 7 PROPOSA`-SUBMITTEp 70 / PHONE ' DATE '� •r 1r STREET JOB NAME CITY,PgTRTEtand ZIP.CO0 •.` JOB LOCATION It ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates fpq ��'��-�e�,ti!�/�C�✓!/�✓''r1'+�.;.,Ir/" `,'/ i�1,%j/•/ice✓/ 1��i.�f(,�• � !� /��/�/ .12 .00 /61�1.��_(, 07 42 i` _We Propose n�Leby furnish ma�Xfi 1 and labor—,compl� in aceprdance with above specifications, for the sum of: � t� dollars,-($ Payment to be lade� ollows:' / /� I• �i , � �/ 41 r. .ice`�' ri•/ �%1Y�e 1� J,", All material is guaranteed to be as specified. All work to be completed in orkmanlike /1 manner according to standard practices. Any alteration or deviation from above specifications Authorized JJ involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our Mote:Throp sal may be workers are fully covered by Workman's Compensation Insurance. withdraw`h by hot accepted within – days. Acceptance of Proposal -� —The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature �'7' work as specified.Payment will be made as outlined above. Date of Acceptance:Z4 /� Zy Signature L 5/20/2013 12:24 PM FROM: Fax Gerald T. McCarthy Insurance Agency Inc. TO: 1-978-688-9542 PAGE: 002 OF 002 ACORO CERTIFICATE OF LIABILITY INSURANCE FDATE 0/20/YYYV) 05/20/2013 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(ies) 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 Ileu of such endorsement(s). PRODUCER Phone: (978)744-6433 Fax: (978)744-3575 CONTACT NAM Deb Tournas GERALD T MCCARTHY INSURANCE AGENCY,INC "N92 NORTH ST a (978)744-6433 DNo. -3575 P O BOX 839 no AILS . debbiet@gtmccarthy.com PRODUCER 3682 SALEM MA 01970 U TOM INSURER($) AFFORDING COVERAGE NAIC f INSURED LAWRENCE LEBLANC INSURER SAFETY INSURANCE COMPANY P O BOX 5389 INSURER LIBERTY MUTUAL INSURANCE COMPANY HAVERHILL MA 01835 INSURER C INSURER D: NSURER E NSURER F COVERAGES CERTIFICATE NUMBER: 23510 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 POL AITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD'L SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR IN MM/DD/YVYV MM/ DlYYYY A, GENERAL LIABILITY BMA0003851 08/03/12 08/03/13 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED R MI a 'cur n $ 100'000 CLAIMS-MADE I-XI OCCUR MED.EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY BMA0003851 08/03/12 08/03/13 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION WC531S352562012 09/28/12 09/28/13 WC STATU- FTH $ AND EMPLOYERS' LIABILITYY/N ORY IMITS $ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 500,000 OFFICERIMEMBER EXCLUDED? F—] N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 it yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) SIDING,GUTTERS,DOWNSPOUTS INSTALLATION LAWRENCE LEBLANC AS A SOLE PROPRIETOR IS NOT INSURED UNDER WORKERS'COMPENSATION CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ' Attention: Gv� eeg ahUrTCi 4(a ACORD 25(2009/09) 0 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Print ForF71 Department of Industrial Accidents Office of Investigations ' 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Larry LeBlanc Address:po box 5389 City/State/Zip:Bradford Mass Phone#:978-869-6575 Are you an employer?Check the appropriate box: Type of project(required): 1.2 I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑✓ Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' insurance. 9. E]Building addition comp.[No workers'comp.insurance p• required.] 5. ❑ We are a corporation and its 10.F] Electrical repairs or additions 3.❑ 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' 13.0 Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t 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 employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:liberty mutual Policy#or Self-ins.Lic.#:wc5-31 s-352562-012 Expiration Date:09/28/2013 Job Site Address:10 Duncan Drive City/State/Zip:north Andover Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. 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 o er'u that the information provided above is true and correct. Si ature:E Date Phone#: 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#• ?fit Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supen icor License:CS-090414 ``.,1:1'7:4 -11' LARRY J LEB�`ANC �� PO BOX 5389C BRADFORD— ,;MA 01835 � �lf�f�+tgij1i4�a Expiration Commissioner 01/28/2014 H dee of C�C MF 1 mer A a,zrocf` e MPR ffai 8istratio .�VFME 's LARRY; xpiravoh:n5/ 13S89rcONTR,4CTsRegalat�o6r'sel�j cFg�Nc 1412p1q OR L -RN RV individualXPe: Ark//�SQN Mq D LANF 3g11 UIderse eretary