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Home My WebLink AboutBuilding Permit #190-12 - 112 LYMAN ROAD 9/7/2011 TOWN OF NORTH ANDOVER . APPLICATION FOR PLAN EXAMINATION permit NO A Date Received Date Issued: YNLPORTANT:Applicant must complete all items on this age LOCATION Z YMAN t- Print PROPERTY OWNER MARS Print MAP NO:C ()_PARCEL: 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 ❑Al ation No. of units: ❑Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑Demolition ❑Other - DES 01T►ON O, WOR-C TO BE PERF 0_RMED: - (Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Y-'�U�s�f (I Phone: Address: c' 3/RWK�'�7-( 4�Uy-1 i AM r-21%1514 Lo a I Supervisor's Construction License: / o 8/ _Exp. Date: Home Improvement License: /5-/0-75 _Exp. Date: { 9 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: $ FEE: $_ S Check No. Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaran snd . erif�Own _•� --�=�_:= - - - = �` nafure�.ofcoi�racto - _ �=..-- �,�: -��_:�� Building Department The€ollowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Inferior Rehabilitation Permits ❑ Building Permit Application ❑ '"porkers 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 o Workers-,Pomp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses n Copy Of Colrtdact ❑ 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 i�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 Doe: Doc.BuildingPermit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL ' Public Sewer ❑ Tanning/Massage/BodyArt ❑ SwimmingPools `"❑ Well ❑ Tobacco Sales ❑ Food Packaging(Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF' d-FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVA T ION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature — COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlrecelpt submitted yes Planning Board'Decision: Comments Conservation Decision: Comments !Nater& Sevier ConnectionlSi�nature&Date Driveway Permit DPW Town Engineer: Signature: i Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Mod*Street Fire Department signature/date COMN1ENTS i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq.ft.: _ ELECTRICAL: Movement of M ter location, toast or service drop requires uires a E pproval 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 i i i ® Notified for pickup - Date Doc:.Buffding Permit Revised 2008mi Location No. Ad Date MORTH TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL Check # 24549 Building Inspector AORTH Town of No./9 o -,?o lA °W o, dover, Mass., ✓� COC MIC MEW ICK ✓gip AO'Z?ATED 7 S V ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR Foundation M444-1 THIS.CERTIFIES THAT...:.......... . ...........Mc....�......Lam. has permission to erect........................................ buildings on .....( , ..... . ..1! h...... .. ........ Rough to be occupied as........................ . .I^�......-r......... ..r'�- .A ...............................................................:....... Chimney provided that the person accepting this permit shall in every respect c form to the terms of the application on flle 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 rNa PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR . UNLESS CONSTRUCTI tTlRough ................................................................ ....................... 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. ,,.,,,.,«,;�. ,.......� ""..�'..-.-. �Re ion � "• ,,7� ��Bj'"ncss galati • Office of nsumer Affairs& CT ,. `* HOMEJIMPROVEMEI'!T CONT' Type . ? Registration: A51273 pgA _ EXpirat'lon 512612012 CO 1ITUTION �` + r _ � — a PAUL TRISCHITTA, a, 231; ,SPARKS ST v.`r 'UndcrsecTetary • �_, ��-�,, LOWELL,MA 01854 r a5,:tChu�tts t.r A ttiL'Yt 4•�-s E�rrs3; C�+I�t+„ } � Buartl r�!`.)i3u�lrlan�s�c�ul,ltaorr�+.ancl"Si�.t;nal.rd:ila snstructiozlttpervIsrpecia{ty Lien License: CS,•SL 101112 # Restricted to: RF,WS I� "f-?AUL~TRISCHITTA k. 231*SPARKS STREET LO1p/ELLMA 01854 I r� w Expiration 1/8/2012 t Tri '101112 a �r,I1FY711 `,f a1iYC'a' -M(111 Ac Ro�V® CERTIFICATE OF LIABILITY INSURANCE DA04/1 /201 YY) `...•� 04/14/2011 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 poliicy(ies)must be endorsed. 9 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). PRODUCE T NAME G.B. NICKERSON INSURANCE AGENCYMIC.N x;978-443-3332 1 F"&N,;978-443-7527 321 BOSTON POST ROAD,SUITE 4C ADDREss:DN GBNICKERSON.COM MILL BROOK IIODUCER CUSTOr1ER lot. SUDBURY,MA 01776 INSURER AFFORDING COVERAGE NAICs INSURED INSURER A:WESTERN WORLD INSURANCE CO PAUL J.TRISCHITTA JR. INSURERa:ACADIA INSURANCE COMPANY DBA CONSTITUTION CONTRACTING INSURER C: 231 SPARKS STREET INSURER D: LOWELL, MA 01854 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. IN TYPE OF INSURANCE POLICY NUMBER SR ADOL SUERPN CY EFF MP MD MM E%P LIMA A GENERALLIABILITY NPP1235477 08/04/10 08/04/11 EACH OCCURRENCE $ 1,000 000 TO RENTED — X COMMERCIAL GENERAL LIABILITY PREMISES a 000mence E 100,000 CLAIMS-MADE I—XI OCCUR MED EXP(Any one person) E 5,000 PERSONAL 8 ADV INJURY E 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG E 1 OOO OOO POLICY PRO- LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per aorJdent) E SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTO (Par accident) S NON-OWNED AUTO / S / $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LlAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE E RETENTION S E B WORMS COMPENSATION WC-20-20-001678-02 11/8/10 11/8/11 X iwu� eTM AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVEI NIA E.L.EACH ACCIDENT E 100,000 OFFICERIMEMBER EXCLUDEDr (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE E 100,000 ar SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(20091091 The ACORD name and loco are reaistered marks of ACORD Massachusetts Home Improvement Sample Contract Ii This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeownersISeck legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. . Homeowner idormation Contractor Information Name Company Name street Address(do not use a Post Officb.Box address) Contractor/Salesperson/Owner Name y City/Town State i Zip Code Busin ss Address(must include a street address) Daytime Phone Evening Phone City/Town State Zip Code G - 7vv D ✓Ib9 0 Mailing Address(It differeat from a oye) Business Phone Federal Employer ID or S.S.Number Home Improvement Contractor Reg.Number Expiration date Law requires that most home J improvement ationnumbhave � f7 /^ / n valid registration number / �//p[61//.2U/ The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) �,6-v co F ti 0nJtv6 Required Permits-The followinglliuilding 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 own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work MGL chapter 142A.) Date when contracted work will be substantially completed. i Total Contract Price and PaymentlSchedule The Contractor agrees to perform the work,fiunish the material and labor specified above for the total sum of- (*) Payments will be made according to the following schedule: $ V upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by or upon completion of $ by or upon completion of $ upon completion of the contract. P P � , (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of 11(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 warranty-7s an express warranty beine provided by the contractor? ❑No❑Yes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work'described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for II materials and labor under this aereement Contract Acceptance-Upon signm'g,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lienor other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract.1 I � • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has alvalid Home Improvement Contractor Re istration. The law requires most home improvement contractors and subcontractors to be registeredlwith the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • I{now your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement 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;dffice or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THAPE AE ANY BLAND SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The copy sho a the contractor. Homeowner's Si re c atu Date / Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate aniarbitration 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 contnactor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. i ! The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm'which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation er shall be required to submit to such arbitration as provided In Massachusetts General Laws, ch a 42A. 1 omeowner's ignature tr ctor' ignature NOTICE:The signatures of the parties above apply only to the agreement of the p ies 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.i 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 workmanlike manner. Homeowners may be entitled to other specific legal righipif 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 questions 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 until a copy of all exhibits and referenced documents have been attached. Parties 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 ori . � pp genal signed co of the contract with attachments i copy s to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day p P 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 financially insecure,the contractor may require that the balance of funds not yet duel be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement!Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: I Consumer Information Hotline I Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 j 617-973-8787, 888-283-3757 or visit the OCABR website at http://v ww.mass.Rov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: I Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: hltp://db.state.ma.-Lis/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 Professional Roofing Services • Roof replacement contract for Mary McDonald, 112 Lyman St. North Andover MA • Present owner with all permits for work to be performed • Tear off and de-nail existing roof down to bare wood, hanging heavy duty tarps from eaves of roof to protect house and yard from debris • Clean all debris on a daily basis into onsite dumpster to be removed at completion of job • Inspect all wood roof sheathing, re-fasten any loose sheathing and replace any damaged sheathing up to 100 SQ. feet at no addittional cost • Install GAF Stormguard ice and water shield six feet up from all eaves of roof, in all valleys, around all chimneys, skylights and pipes and against all side and vertical walls • Install GAF Shinglemate premium roof deck underlayment to remainder of roof • Install 8"aluminum drip edge flashing to perimeter of roof • Install GAF Prostart starter strip shingles to perimeter of roof • Install GAF Timberline HD lifetime shingles to roof using six 1 1/4" round head galvanized roofing nails per shingle for 130 MPH wind protection • Ensure 1 3/4"gap is cut on each side of all ridge beams • Install GAF Snowcountry externaly baffled ridge vent continuously to all roof ridges • Cover all hips and ridges with GAF enhanced hip and ridge cap shingles • Replace flashing around all chimneys (aluminum step flashing and lead counter flashing ) • Replace flashing around all vent pipes • Replace flashing at side walls • Remove existing aluminum on main house soffit, drill (2) 3" holes between each rafter bay and install new, fully vented, white soffit pannels • All work guaranteed 10 years • Includes GAF Systems Plus Weather Stopper Warranty( 50 year non-prorated coverage on entire roofing system • Total cost of investment:$9,574 • Less 5%Angie's List discount:$479 • Total contract price:$9,095 • Payments to be made 1/3 at start of job, 1/3 at halfway point, and remainder upon completion ACCEPTANCE: HIC# 151273/CSSL 101112 231 Sparks St. • Lowell, MA 01854 • 978-502-9601 • Fax:978-453-5989 • poul@constitutioncontrocting.com 1 r• . r The Commonwealth of Massachusetts UVDepartment of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 021X1 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationffndividual): PL li UWM p j � ✓?`� (l am Address: . City/State/Zip: JCW&t /44 011'F4 Phone#: YEO Are you an employer?Check the appropriate box: Type of project(required): 1.1XLam a employer with t, 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition workingfor me in an capacity. workers'comp.insurance. Y9. E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.n-<oof repairs insurance required.]t employees.[No workers' comp.msurancerequired.] Un Other *Any applicant that checks box 41 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 their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name: C [ Policy#or Self-ins.Lic.#: OJC-Ro - 6_0_0_ Expiration Date: f Job Site Address: JJ,-9, LYAAA ) !—IT City/State/Zip:AJ / JIYJQ .MN 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer a pains andpenaltie of perjury that the information provided above is true and correct. Simature: Date: Phone#: - F l use only. Do not write in this area,to he completedby city or town official Town: Permit/License# Authority(circle one): d of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Persoin: Phone#: