HomeMy WebLinkAboutBuilding Permit #067-2016 - 1055 Salem Street 7/15/2015 NORTH
BUILDING PERMIT
TOWN OF NORTH ANDOVER o ;� - ..<.-
APPLICATION FOR PLAN EXAMINATION
y
Permit No#: V0_20- L Date Received
S5
�I gCHU
Date Issued: l
.. ..
IMPORTANT: Applicant must complete all items on this page
LOCATION : �! JrJ .Sa Jrt-
Print
PROPERTY OWNER
Print `' 100 Year Structure yes no
MAP PARCEL::b ZONING DISTRICT:-' Historic District yes no
Machine`Shop Village yes.' no
TYPE OF IMPROVEMENT PROPOSED USE
Re ' ential Non- Residential
❑ New Building ne family
❑Addition ❑Two or more family ❑ Industrial
❑b1teration No.of units: 11 Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
Demolition ❑ Other
Septic ❑Well: D Floodplain Wetlands ❑ Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Q"W' rV(acrl 0) �`Sk- eA,� boor
'f 76 uL��
Identification- Please Type or Print Clearly
OWNER: Name: "("V 56h fl) 60PP- Phone:
Address: d Q c�rJ 5c tier-\ Nd 4) s t�
. ' ?a9-��z
Contractor Name: ,�o Phone: 9 7r3
Email:
Address: ? o �h �•. t rn't"�i
"Supervisor's Construction Liceri'se. �t9 7`f Exp: Date: V4 ,
Home Improvement License:. �.�? ? Exp:- Date: i LL(6
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMI $12.00 PER$1000.00 OF THE TOTAL ESTIMATED C T BASED ON$125.00 PER S.F.
Total Project Cost: $_�baa - �1 FEE: $
(A•0`
Check No.: 9 26 (, 2 a No.:
571 � 8 �� Receipt p U
NOTE: Persons contracting with unregistered contractors do not have access t uaranty fund
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
4, Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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 appeal 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:Building Permit Revised 2014
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ TanningfMassage/Sody Art ❑ Swumning 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 o U FORM
i
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
i
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
I
I
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
jPlafining Board Decision:£ Comments' r
Conservation Decision: Comments
Ater& Sewer Connection/Signature& Date Driveway Permit
DPS'Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT Temp Durnpste on site f•A
Located at 124 Main Streetr; r,x :�'` •:,.w s
Fire Department gig ature/date
T .{a`" J` �4•y. j • 5 2 by s� ;4 yf'a%.Qo�A S '.' T'w P1 � .ti +
JIw,.e s.� *�, t' :� r 11-�4....,,4^-T,1,!#.#..i.'r-v..}_:a�s......,:....6�.stL`._• ''f�",r..�'�.t_t
i
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 Ido
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date
Time Contact Name
t -
Doc.Building Permit Revised 2014
Location
No. Date
• - TOWN OF NORTH ANDOVER
$ D°i `
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
'Q.
Cheek
r Building Inspector
9. 9
Town of ? E n.dover
.�..
C=====
No. 0(91—gol _ : - ,� o
y fl aD�
h ver, Mass � C�
COC NICNl WIC.
�,q p�RgTED J'P��,`�5
S U
BOARD OF HEALTH
Food/Kitchen
PERM T Septic System
dfQ
THIS CERTIFIES THAT ......................... ..... BUILDING INSPECTOR
has permission to erect gt.b., Foundation
........... ....... buildin s o
e Rough
to be occupied as ......... .. ... ......0........Rcqa.... ... .. . . ........................................... 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. CONSTRUCTIOT TS 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.
Smoke Det.
STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO DOOR
LOWE'S OF SALEM, NH, STORE#2382 STORE PHONE: (603)681-4218
541 SOUTH BROADWAY SALESPERSON:JOSEPH CAVALLARO
SALEM, NH 03079-4499 SALESPERSON ID: 897831
Document Print nate - 0711312015
This is only a Quote for the merchandise and services printed below.This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree-
ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, and any
other addenda or attachments hereto, shall be referred to herein as this "Contract."
PLEASE READ THIS ENTIRE DOCUMENT INCLUDING THE "TERMS AND CONDITIONS." BEFORE SIGNING
Lowe's Registration or Contractor License Number/Lowe's Contractor Name
Lowe's Home Centers, LLC's MA HIC NO.: 148688 Lowe's Home Centers, LLC's FEIN: 56-0748358
Customer Name Home Phone
S TYSON MOORE 781-281-8637
O Customer Address Other Phone
1055 SALEM ST
L City State/Province Zip/Postal Code
D NORTH ANDOVER MA 01845
Installation Address
T 1055 SALEM ST
O Installation City Installation State/Province Installation Zip/Postal Code
NORTH ANDOVER MA 01845
MERCHANDISE AND INSTALLATION SUMMARY
MERCHANDISE SUMMARY
6550 : 329063 : STK : 5/8" J-CHANNEL WHITE 306-WH : .625-IN X 12-FT 6-IN WHITE VINYL SIDING J-CHANNEL : BLUELINX CORPORATION - QTY 3
98458 : 07526 : STK : RML 8-FT WHITE PVC BRICK MOULDING : RML 8-FT WHITE PVC BRICK MOULDING : EAST COAST MILLWORK DISTRIBUTI -
QTY 3
290270 : 290270 : STK : RB &PTO STL FCH HRMNY BBG-GBG RH : RB 6'PTO STL FCH HRMNY BBG-GBG RH : JELD-WEN,MILLWORK MASTERS-KNOX
- QTY 1
447374 : 1608LE : STK : 1 X6X8 APPEARANCE GRADE SELECT 1 X6X8 APPEARANCE GRADE SELECT : SPARTANBURG FOREST-QTY 1
Materials Price $ 860.11
Store 2382 Project No. 447024287 for TYSON MOORE Page 1 of 8
STORE COPY
INSTALLATION DESCRIPTION
Stock or SOS : Stock Door Type : Patio
Select Location : Back Door Select New Door : Hinged/French
Number of Doors to Install : 1 Side Lights or Transoms : No
Hidden Damage Description : None Number of additional holes bored for accessories : None
Install Specialized Mortise Hardware : No Lead Safe Practices : No
Total Linear Feet of Custom Trim to be Installed : 24 Deliver Door : Yes
Customer Understands Scope of the Project : Yes Permit Required : Yes
Who Will Obtain Permit : Lowe's Permit Fee : No
Additional Miles Traveled over 20 : 0 Bring Up To Code Description : None
Local Disposal Fee : Yes Describe Other Work Needed : cut back siding
Other Work Charge : Yes Comments : No Comment
Labor Charges $ 775.00
Detail Deduction -$ 35.00
Additional Specifications:
Notation: Lowe's will not make structural modifications, paint or stain or remove/reinstall security system equipment. Customer is responsible to advise if prop-
erty is governed by Historic District Regulations.
Additional Specifications:Federal law requires Lowe's to provide you with the pamphlet Renovate Right: Important Lead Hazard Information for Families,
Child Care Providers and Schools. By signing this Contract, Customer acknowledges having received a copy of this pamphlet before work began informing
Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit.
PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photograghs of the Premises where In-
stallation Services will be performed and all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right, title, interest in
and to the photographs for use in all markets and media, worldwide, in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in
print and/or electronically, and agrees that Lowe's may use such photographs for any lawful purpose, including, but not limited to, marketing, advertising, publi-
city, illustration, training and Web content. By initialing here, Customer agrees to the foregoing. >0 [Customer to initial to the left].
NOTICE TO CUSTOMER-PRICE CALCULATIONS: In order to properly perform the installation of certain Goods, the Contract.Price may include more Goods
than actually will be installed based on the measured square footage of the Project Area. As a result, the parties agree that the lump-sum Price stated in this
Contract is calculated upon both the value of the estimated Goods required to fulfill the Contract (including waste), which may exceed the actual square footage
of the Project Area, and the labor which may be estimated based on the amount of Goods required to fulfill the contract (including waste). By signing this Con-
Store 2382 Project No. 447024287 for TYSON MOORE Page 2 of 8
STORE COPY
tract below, Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the
Installation Services are performed..
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES where applicable
SUB-TOTAL $ 1600.11
*TAX $ 0.0
DELIVERY $ 0.0
ORDER TOTAL $ 1600.11
BALANCE DUE
Work is to commence upon reasonable availab�y of Contractor which is anticipated to be [fill in date].
Estimated completion date is 54,
[fill in date].
NOTICE TO CUSTOMER
All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing
on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation
necessitated by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custom-
er.
IF THE CONTRACT TOTAL IS $1,000.00 OR LESS Customer must pay in full
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00:
An
Customer to Pay in Full; OR
[_] Customer to use the following payment schedule:
(1) Deposit of $ to be paid upon signing contract. Any deposit collected at the time this Contract is signed will not exceed one-third (1/3)
of the contract price; and
(2) Payment of $ to be collected upon or after the commencement of work. I/We authorize Lowe's to do one of the following (check ap-
propriate box below):
[_] Charge my/our credit card for the amount of the payment indicated above upon or after the commencement of work; or
Store 2382 Project No. 447024287 for TYSON MOORE Page 3 of 8
STORE COPY
[_] Deposit my/our check for the amount of the payment indicated above anytime upon or after the commencement of work; and
(3) Final payment of$100.00, to be paid upon completion of the installation to both parties' satisfaction.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON-
TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE s . BY SIGNING BELOW YOU ARE ACKNOWLEDGING THAT YOU
HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY
OF THIS CONTRACT AT THE TIME OF SIGNATURE.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c 142A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON-
TRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET-
ARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB-
MITTO SUCH RBITR AS PROVIDED IN M.G.L. c.142A.
By Date:
Lowe's Ho e Cen ers LL
By: Date: ?• i� _ 2C)15
wner
By: Date:
Co-owner or Witness
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION
INITIATED BY LOWE'S PURSUANT TO M.G.L. c 142A THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION
EVEN WHERE THE SECTION ABOVE IS NOT SEPERAT//E,,LY SIGNED BY THE PARTIES
WITNESS OUR HAND(S) AND SEAL(S) BELOW THISDAY OF_,�vC�, _ J,
Lowe's Home Centers, LLC
fi�t, ./"-,/
By: I
(Seal)
Print Name:
r
Address (Seal)
Owner
Store 2382 Project No. 447024287 for TYSON MOORE Page 4 of 8
dvnll WMI-on iaout{t nun rax:ylor45;i�ni isI)r I 2015 U:22 P. U2
9MCNA01 OP ID:DP
CERTIFICATE OF LIABILITY INSURANCE °A04/01201�'
fl4/0112fl15
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(las)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terns and conditions of the policy,certain policies may require an endorsement. A statement on this eortNlcata does not confer rights to the
certificate holder in lieu of such endorsement s).
PRODUCER _ NAME: David G Bruen
John d Walsh Ins Agency,Inc R'a e,rt,978-745-3300 878-745-9557
P O Box 4447
Salem,MA 01974.8407
David C Bruett ADORES s:dbruett@Waishinsurance.com
INSURER(S)AFFORDING~COvERAOE I NAlC s
(USURER A.TraVelerb
INSURED McNary Constructlon
Joseph McNary INsuRERa:A.1M:Mutual Ins.-Companies
767 Woburn Street INSURER C:
Wilmington,MA 01887 INSURER 0;
INSURER 0:
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 PERM
INDICATED, NOWATHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR`OTHER DOCUMENT WITH RESPECT'O WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I T T
S SUBJECT O ALL TH
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY pAip CIhlN.Se E TERMS,
TYPE OF INSURAtUtEAUM INSR! POLICY NUMBER tJf:Y EFF LIN TS
GENERAL IAAQIiM !EACH OMURRENCE S 1,000,44
A (1-7C0MMERCLA_GENERAL LIAQLITY 68"621P22A-1642 02/0812015 02108120161 PF CWMK�rEeooarrD,)Wt 1 S 344,4
CLMMS41ADU 71 OCCUR. � rAEDEXP LAny onapetso,} 5,00
X Business Owners
i pew,OttALannvltuurzv s 1,OOO,flO
!
GENERAL A0ORFOATEE 3 2,000.00C
GENLAGGREGATE UAw MITAPPL!ESPER: , PRODUCTS-COMPQ Is 2,000,00
POLICY F-1!In LOC S
AUTOMOOLE LIABKJTY COFAar NEO SI
}
e I 3
ANY AUTOALL BOQILY pY AIRY(Pc Pcr-.qnj S
AUTOS Ea AUTOS LED WON Y INJURY(Par sczaocxn)'S
41RFDAIITOS �^AAUTOSYNUED
t SER ACGIDSN A E S
1
t UtdBREL1A LWB Or.Ct/R EACH OCCURRENCEI S
t EXCESS LIAa ' +,NAS AGGREGATE i$
i
! DEO ' I RETENTions 1 i S
W)RIUM COa1PENSATION I YtC STATITS f
AND EMPLOYERS'LIAOILITr
B
ANY PROPxtEr �
aRIFART►+ERECunv=ytN CC6005014081-2014A 111IN2014 111141,2016 F=L,OFFICGAfUDeeER EXCLUDED? H t a (s 500,00
(usadatoq in NH} E.L.DISEASE-EA EL4z;4 S 500,00
!I descaibc 0Q1
IPTrDN of OPERATIONS°errs E.L.USEASE-PcLjny uur, s 500,00
PROPERTY 5
DESCRIPTION OF OPERATIONS I LOCAnON51 vENICL.ES(Altsch ACORO tet,AddWonal Remift Sctrcdue,p mm space IS MgWmdl
Lowe's Companies, Znc and any and all subsidiaries are additional insured
with respect to commercial gouoral 11ablity. Waiver of subrogation .applies
per written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Lowe's Companies Inc TME EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
and any and all subsidiaries ACCORDANCE vvITH THE POLICY PROVISIONS.
Attn:Vendor Insurance
PO Box 1111 AUTHORIZED REPRESENTATIVE
N Wilkesboro,NC 28656 David C Bruett
Q 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD
Vie Commonwealth of Massachusetts
Department of Industrial Accidents
Office of In vestigation s
600 i1'ashington Street
` Boston, MA 0211.1
www.mass.gov/dra
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information +T!' Please Print Legibly
Min (F1n inrss(Orgnni�auttnflnchvidunl): �tJ P �► � /
Adds-;ss:
City/State/Zip: t M I Ilawkin Vh A 0 V7 Phone ` 7aq-6ra3
Are you an employer?Check the propriate box: Type of project{required):
4. I Int a_-caecal contractor and 1
am a emplo}ser with ❑
employee.(frill and/or pan-tintej.w have:hired the subs contractors b• ❑New construction
1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
shiployces These sub-contractors have S
'and have no em P ❑Demolition
work-in! for nuc in any capacity. employees and,have workers'
q- E].Building addition
(No workers'comp. insurance
comp.insurance.*
5. We area corporation and its 10.❑Electrical repairs or additions
required.] ❑ P
3.❑ I ant a homeowner dein;all work officers have exercised their .1 LD Plumbing repairs or additions
myself. INo workers' comp. right of exemption per MGL 12❑Roof repairs
insurance required.]" C. 1.52 §..1(4).and we have no
employees.[No workers' 13.�Other_ Bei'--[ Q�l
comp,insurance required.]
'Any applicant that check.box#t must also fill nut the section bcl6%t showing their workers'compensznion policy information.
t Homeowner.,who submit this affidavit indicating they are doing all work and then hire outside contractors roust submit a new;affidavit indicating such.
Contractors that check this box trust attached an additional sheet Showing the-narne of the sutrcontra(ctors and state whether or not those entities have
empinvecs. if the sub•contractorrs have employees.they must pr vide their workers'comp.policy nurnher.
1 a►n an emphlyer that is providing workers'compensation insurance for my employees. Below is the policy and job site
itr formation.
Insurance Company Name: A.'. M. Mo4va f �. t'Y} n i>?S
Policy#or Self-ins.Lic.#: U CC 50"01 y Dei IPC)l t>fa Expiration;Date: 11 �15
Job Site Address: �Q S� �Q�•en1 .S�• City/State/Zip: Or arclat . MJ
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. 1.52 can lead to the imposition of criminal penalties of a
fine up to S 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 tip to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
tnvestiLmlions of the DIA for insurance coverage verification.
I do hereby certif ender the pains and penalties of perjury that rice information provided above is true and correct.
fii�xnatttre; - Date:
Hip-
Official use only. Do not write in this area,to he 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 a.Plumbing Inspector
6.Other
Contact Person:—_—_-.-- -____ _- __-- Phone#:;----- ---- — --
M ss�chtisatts-Ef$P'a".P.ftt of Public Safet'
$aani of 8railding RcgW�oAS-and Standatt(s
t•�,nstrnctina:St!Da�`?str
llccnse: CSM1070
.TOSiip'G MGNA* ay
767'WOHURN S
Wx mrcr rr*A
1
a
Cn;±{trjSSj9iiCt Q'f���j��6.
AT r%) TZ0,10
I, r
S
OE�ct dFCoi�enmerAt�$3 do Buela
etn.Rt,�ittglton
pkfPROYEAAEMtC0tITPA=00
'I7�T56!
ptretian � t�� 'tntitvktuat � 's
!67•Vu.ORURN ST � -
tMl.td{NGTON,NIA Dt887
iloile�aeci�etrry .
I