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HomeMy WebLinkAboutBuilding Permit #152 - 11 FERNWOOD STREET 8/25/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received S Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER ___ A,,Ar,,5�,� Print MAP NO:— —PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid Non- Residential New Building Onefamily Addition Two or more family Industrial Alteratio No. of units: Commercial Repai , replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: <3-liip z 11�1��j r�2 on entificat' n Rlease Type or Print Clearly) OWNER: Name: Phone 7 Address: CONTRACTOR Name: ` Phone: Address: Supervisor's Construction License: Civ Exp. Date; ' . t Home Improvement License: Exp. Date: / ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ ' Check No.: 7T Receipt No.: NOTE: Persons contracting unr istered contractors do not have acc4toemy fund Signature of Agent/Owner Signature-of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans Location /! «�✓W�� No. 15ZDate d5 NORTiy TOWN OF NORTH ANDOVER 3?O:t �ao ,a,�•C 9 Certificate of Occupancy $ CMUs<� Building/Frame Permit Fee $ _ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22505 Building Inspector it 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 Zdning 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: 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 2 1 A—F and G min.$100-$1000 fine NOTES and DATA— For department use) ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 J 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 NOTE: 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/Crossection/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ 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 ❑ 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 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: Doc.Building Permit Revised 2008 Jxea�nimar�cuea a�✓��adaac�ivaea ; Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration 126893 E'xpira6on 8%3/2010 Type Supplement Card 4 - The HomeDepot At Home Sernce RICHARD FALLONE f .2690 CUMBERLAND PARKWAY S ;.•+Gt-+�--� f A11AVft,GA 30339 Administrator `� d rM CERTIFICATE OF LIABILITY INSURANCE _ 02/20/09r�Y} ,';ion,_tc.t:rt ].-404-995-x000 j;llS C :PlIFIf;Aii' 1S IS`;LIED rt;. A N1 A ITFP OF PIN FOEtMA f 0 N -� IF- r ' t it ' rttlIr (r tr iltl 'Jf i.'I) it�� t. ti F010,1`,�11 Rd N71" S'.uc_ 1200 . . .—._ --- — I 212) 91•:f-U>(.. VJUIZ_F:,:�AFf0LQl (, t,v.,c: Y_1,4Cr - - ---. -- ---- ;i .t-Iloin P. Scr•.1.ce.., Ins co ---._. ..-----` ------ 7b337 iU : -----' I — — — — INS(isiER3: "ILmorican Ina Co 1653S Suit Cumberland Park:vay cite 300 NATIONAL [KAON FIRE INS CO OF PITT'S 19445 INSLR�R C. !Atlanta , GA 30339 INSURERD:New Hampshire Ins Co 23841 INSURERE:Illinois Natl Ins Cc 23817 COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR OD' POLICY EFFECTIVE POLICY EXPIRATION LTR N R POLICY NUMBER GATE MMDO DATE MMlOD/Yl' LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $4,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS DAMAGE GET RENTED ENT rePREMISnce $1,000,000 CLAIMS MADE [K]OCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Anyone person) $EXCLUDED PERSONAL BADV INJURY $4,000,000 GENERAL AGGREGATE $4,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMPIOPAGG $4,000,000 X POLICY PRO- JEC T LOC B AUTOMOBILE LIABILITY SAP 2938863-06 03/01/09 03/01/10 D;INGLELIMIT $1,000,000 X ANYAUTO (Eaaacccde ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Perperson) $ HIRED AUTOS BOOILYINJURY $ ' NON-OWNED AUTOS (Per accident) X SELF INSURED AUTO PROPERTYDAMAGE $ PHYSICAL DAMAGE (Peraccidenl) GARAGE LIABILITY , AUTO ONLY-EAACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESSIUMBRELLA LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $5,000,000 X OCCUR CLAIMS MADE AGGREGATE $5,000,000 $ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION AND 3566916 (CA) 03/01/09 03/01/10 X WC Y IMIT STATU- OTH- T R D EMPLOYERS'LIABILITY 3566915(AOS) ANY PROPRIETOR/PARTNER/EXECUTIVE 03/01/09 03/01/10 E.L.EACH ACCIDENT $1,000,000 . E OFFICER/MEMBEREXCLUOED? 35.66917 (FL) 03/01/09 03/01/10 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 51,000,000 OTHER D Workers Compensation 3566918 (KY, MO, NY, WI,WV) 03/01/09 03/01/10 F TX Employers Excess TNSC45694422 (TX) 03/01/09 03/01/10 ccurrence/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT-HOME SERVICES, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL 2690 CUMBERLAND PARKWAY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SUITE 300 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA 11172180 ACORD 25(2001108) us_hd ©ACORD CORPORATION 1988 111721 NORTH TO" of RAndover . No. - C�' - -_ = A K E dover, Mass., O COC MIC ME WICK y�. ADRATED `s BOARD OF HEALTH Food/Kitchen PERM: IT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.... ... .V.S'o.lv .............ltt�......... . !1►........ ...... .................................................. Foundation hasp buildings on g permission to er t............ (�......... ... .1�xt ......................................... Rough to be occupied as.. ...... ...... . ...�.. .... ... .... ....................................... Chimney provided that the person accepting permit shall in eve respect conform to the terms of the application on file in Final 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 CONSTRUCTI S Rough ................. .............................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit. Required to Occupy Building GAS INSPECTOR - 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. AUG-13-2009 05:05PM FROM-HOME DEPOT SEABROOK 603 474 0526 T-042 P.001/006 F-533 Yv.... PLEASE READ IMS ----- 001- ��jj,, Sold,Furnished and Installed by: Branch-Name: Boston Date: I l 7M At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street`Unit 2.Worcester,MA 01607 Branch Ktrmber.31 Toll Free(800)657-5182; Fax(508)756-8823 Federal ID 4 75-2698450;ME Lic#C 03439;RI Cont.Uc#16427 t ILlc w 565 23;MA dome Improvement Contractor Rcg.#126993 Ilnstaaatiou Address: city State Zip {s): Work Phone: �yr�/��/�y/��,H,�lome Phone: Cell Phone: 1yy�� Rome address-: i Ii different from Installation Address) Cfry Sate Zip I-nzo Address(to receive project communications and Home Depot updates): I DO NOT wish to receive any marketing ernaits from The Home Depot Proica Infot'metion: Undersigned(-Customer'),the owners of the property located at the above installation address,agrees to buy, :std THD At-Home Seri,ices.Inc.("ne Home Depot")agrcc.%to furnish,deliver and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec'Sheet(s), all of which are incorporated into this Contract by this refe^r^e�=.along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, Job W. foam a Rd.%=, Products: So=Sheens)#: Project Amount oofin4 USidins 0 Windows Insulation ❑cutlets/Covets ❑Entry Doors [] ,� ' Roofing OSiding 0 Windows ❑insulation ❑Gutters/Covers QEntry 0mrx ❑_ Rotlling []Siding ❑Windows Q Insulation []Guttrn/Corers ❑Enw Doors ❑Rooting oSiding El Window, Imulation CIGutter./Corers ❑Entry Doors F1^ �iatim®=+rr Depose of Contract;�t+>'ount due upon l�lxul;an of this colm�ct Total Contracc amount $ f Sime Ptu>�rs ma'nol.d�it morn than one-third of the Contract 4mmint. � Cu.Srom-er s._ree, that, immediawiv upon completion of the work for each Product, Customer will execute a Completion Certificate !'Cr r.--h P:txiue:u defined bs an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this Contra=agre-es to be jointly and severally obiigaLed and liable:hereunder. T.ie Fibra_Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(.`)included herein,at i�d:_crtJoz.i`Th;:Hom:Mpur or its authorized service provider determines that it calutnut perforni its obligations due to a structural vrz�b',^' ui:h tl:r lion,.-.ervirnnmental hazards such as hold, w;besto.i or lead paint,ether Safety concerns, pricing errors or bewuw uork rcnui-c.:to complete the job was not included in the Contract. Pavment Summarv: Th! Payment Summary r+! ��� J included wi part or this Contract, 5t:ti fOW1 the; local Ccrrnaz:`noun:and payments required for the depositsandTl payments by Product(as applicable!. Nona',''ro CEiS'['OMLi p.. You arc entitled to 3 aimpleludy filled-in copy of the Contraet a,the time you sign. Do not sign.a Completion Certifleme tnote. there is one (Completion Certifieaw fn:•euci+ listed Frudum as dutirrt:d by individual,Spec Sheets)hciare work on that Product is complete. it !hv i:%cm of terntlristivr_, ul ini.; ::uslomc,k."re;,a mr pn) 'rile ilullit:Dhpot t !e 'C)SIti t!:ttl.7ta'ri2L�, I'3(itlCS etipCnse': pro,itlta, t.< .,; ! Yi r ., .�.� r i vp :outs:rE'lS 'ACr1r:E' t1Y119C i!z'.`u i t•,� t till Ur:n lie :111 t't enlln_Gr tt ilii + !• ^�. `i i 'tlltt.r1Ui:, preel arty' FyfFlr: r, •4'(= UntYl:r;ip_l.tt-F.i]ic:low. '!"Y3Cs` HC)t�e= ••I'.':'::?' til.;: )�"�TH�Q;.I'r:t.:4iF)L1IrIT;t :'Iii: DEPO.9-T PAVN1FNe• (7I? J;II>✓S: P:15'4ir�N't;ti :tf�I'it:. `146'r'Qid)�I^€ .JNI11'!N(:I'll '•J)J-'P()T'S 0714[;R REMEDIES FK2R RICt.'O%-ER`•'OF tiI:CII A.tilOUNTS. A yyelit:lnyc 4:n(! a►utrlUClL.lItt)n: C S1,)I;1�.';;Tre:e� 'd11C1 11l1CIG1:11'clntlti Lll:ii Lt:!S .i�TC�- -n' k trlc t:nLi:= :geemcni helween Customer .latl :lee Hon.w Depot Vxlnh 1•egartl to til:Pro+iu;ts and Installation service:and supersedes ali prior discussions and agreements,either ,lr:li ,ir�kn,%n%. relatinu to Said Produc,:t;;n4 ln:raitat ion. This Agreement cannot be a.;sicrled or amend:d except by a writing signed hN Costumer and The ilome `)spot. t'u,t'rncr acknowledges and a-recs tha.Customer iia,read. understand., voluntarily accepts the tl.rrm of sn.t iia%rrr!•wmi n`lent otrill]; AUG-13-2009 05:05PM FROM-HOME DEPOT SEABROOK 603 474 0526 T-042 P.002/006 F-633 E-mall Address(to receive project communications and Home Depot updates): - 1 DO NOT wish to receive any marketina ctnails from Tht:Home.Depot Proiert Information: Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy, and T`rID At-Homs-Szrvizes, Inc_(-The Home Depot") agrees to furnish, deliver and arrange for the installation ("It.,0311 ttion") of' AT de inat`rbis ;cri;K.�i on the below and on cite referenced Spec Sheet(s)• all of which are incorporated into this Contract by this re erer.-d.alone ati:h any applizabic State Supplement and Piymenr Summary attached hereto and any Change Orders (collectively, 'Contract' _ job w. Products: Spec Sheet(s)4: Pro•ect Amount Doting Siding «`inflows ❑Insulation ❑Outten/Covers []Entry Doors ❑----, APO Rootln4 []Siding Windows Insulation OGuitcrs/Covcrs ❑Entry Doors ❑ Roo i ^1ng ❑Siding E]Windows ElLtsulation ✓Gutters I Coven ❑Entry Doors❑-,__ -:]Rooting []Siding 0 Windows ❑Insulation --Iicrunen I Corers ❑Entry Doors _--— Nfinimum 25`'c Deposit of Contract Ata m due upon"ft ution of this mntruct 'I atal Contract Amount Maur Por hwm may not deposit mote thaw om-third of tate C:ontract.AiwdnL Lus:zrne: air es dmL immediately upon completion of the work for each Product, Customer will execute a Completion Certificate o..z scr eazh Produm as defined bN an individual Spac Sheet) and pay any balance due._ As applicable, each Customer under this .:on'm.n agrees w tv jointly and ieverafy obligated and liable hercund 7i=lig neeN,,n reservcs the right to issue a Change Order or ierrttinate this Contract or any individual Product(s)included herein,at ::Th_home Oepot or its authorized seniec provider determines that it cannot perfo;ln its obligations due to a structural ^•::il_.T. l-'d:::-c home, ervironmcriLd hazards such as mold, ttsbestos or lead paint,ocher safety concerns, pricing errors or because u errk regtitrec:J complete the job was not included in the Contract. Pwvtnent Sutrtrmm: The Payment Surnmary r , included as part of this Contract, sets fortis the total :,coeurs and paymcnu;required for the deposits and final payments by Product i as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(mote: there is ont Completion Certific2te for each listed Product as defined by indhidual Spec Sheets)before work on that Product is complete. in th=evEnt of teratination of this Contract customer agree;to pay The Home Depot 1111e.costs of materials, labor,expense-a.. anti :c r<ice~s pravided by The Home Depot or Authorized Service Provider.through the date of termination, plus any other wn u,nts:!et forth in this A greemeni or allo%%ed under applicable law. TIMI;• HOME DIEEPO N'1MA'_'WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYi1E:NTS ,WADE, WIT11OII'I' LLMITLNG THE HOVE DEPOT'S OTHER REMEDIES FOR RECOVEIf Y OF SUCH AMOUNTS. Acceptance and Authorlgation: Customer agrees and understands that this Agreement is tht entire agreetnew between Customer 't`re Hem: Depot with regard to ihr Products and Installation services and supersedes all prior discussions and agreements,either s 0f,w-i-en. relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed b, Casiarncr an:'_Toe Home Depot.Customer acknowledges and agrees that Customer has road, understands,voluntarily accepts the. :-rrrt_of and has received a copy of this Agreement. Acce ted y: Sub C wr.wr's Si,rant: Date Sal s Consultant's Si ature Ds Telephone No, Custorrter's Sigrt_cura Date Sales Consultant License No. CANCELLATION: CUSTOMER :MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELrVERLNG WRITTEN NOTICE TO THE HOME DEPOT BY Nli[DNIGHT ON THE TESD BUSINESS DAY AkTF.R SIGNLNG TMS AGREEMENT. THE STATE SUPPLEMEW ATTACHED HERETO CONTAINS A FORM TO USE W ONE IS SPECIFICALLY PR)ESCRMED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITION-4L TERMS 4M)COtiZ1MONS ARE STATED ON THE REVSRSt SID£ANA ARE PART OF ITM CONTRACT 343-09 C-SC Wtute-branch File Yellow-Customer Pints-Sales Consultant The ;>rYi;�Pi t i_ rL1Sf�lt'�fy C.'rL ?f,S i 51. n 1Vame (Business/Orgarnizatiott/Individual):_ Address: IQ 1/0 /State/Zi T Y p Phone.#: Cit /State/Zip Are you an employer?Check the appropriate box: Type of project(required):. 1.kd I am a employer with / 4• ❑ I am a general contractor and I me Ino 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' 9. Building addition [No.workers' comp.insurance comp. insurance.$ ❑ required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plum ' g repairs or additions myself. [No workers' comp. right of exemption per MGL 12. oof 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#1 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: f. u Policy#or Self-ins. Lic.#: Expiration Date: -31,11 Job Site Address: City/State/Zip: "w Attach a copy of the.wbrkers' 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 tip to $:1,5.0.0.00 and/or one-year imprisonment as=,«� ole:r. �!+ c ..±r f ,vI�n z �bID��R ar}tl ^ r of up to$250.00 a day against the violator. Be advised that a copy,of this statement may be foiwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi un r e p s-an penalties ofperjury that the information provided above is true,and correct. Si ature: r 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#: 11-16- IRS .1t:t)2S rMM-IM) rhUVUUIjLUlV b t75bzl10w9� 1'10101/10101 1--104v AM �lsi<�iti'lltl�['ti• I�c�ll:t+ttft�ttt of Public.;arvt% = f3uartf++f Fittildite•� •,. R�ttdali++lt, :tni!!�taatl:rrQ% Construction Supervisor License '.{cease: CS 101433 _ RestriCterd ta: 00 SERGIO SANTOS Z !-!AWYI3NS STREET NO 1 60MERVlLLE.MA 02143 { EXP"I'M WWA12 �..quasi..{.�H.•t• T•r--: t01433 L:o iv