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HomeMy WebLinkAboutBuilding Permit #158-14 - 1725 GREAT POND ROAD 8/16/2013 TOWN OF NORTH ANDOVER qAPPLICATION FOR PLAN EXAMINATIO �� 1 Permit NO: v Date Received l� Date Issued: IMPORTANT:Applicant must complete all items on this page - - - - pp LOCATION' L �`^ � !_ > � �L �6t1 2 _ PROPERTY OWNERt_ �.Jd�' ✓1 'lr6�- , S a < _._� �- m Pnnt ~ �- - 100 Year Old=Structure yes not - - - MAPFNO -PARCEL " ZONING,DISTRLCT �Histiiric+District yes no -. . T RMacliine S.liop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Reside 1 Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0`Septic3 ❑UVellr E! Floodplain, ®j -rid PIS x w - m Wetla s ❑ Watershed stntt c" x ❑Water%Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: 3b1) !n 6�22 /7 s� Phone: 2�-G�-g .. 043 Address: e jj CONTRACTORS Phone _ T - • 4 M J S AddreAn,- ss- _- peryiCXI sor,s onstruction Llcense Su _` '7 - -.!Exp.. #Date 2 # - /_Y `Home.Improvement. ld4gse'- 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. e Total Project Cost: $ f 5zo' y FEE: $ R Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund .... .v.�„ iat g ature�ofAgent/Owrier Sigature.of cont_racfora �1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived-0 Certified Plot Plan ❑ Stamped Plans ❑ TYPE_OF-.SEWERAGE.DISFOSAL 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 e 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 Toiv s Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMV- Temp Dumpster on site yes_ no Located at;124,Mair,'Street.s; Fire Departmeritsignatureldate{" g ,� 1 R �_ $ * .� <^ 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 El Notified for pickup - Date Doe.Building Permit Revised 2010 I 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 No MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA— (For department use El Notified for pickup - Date f I E f Doc.BuildingTermit Revised 2010 I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o 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 o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 apo%,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Bui?ding permit Revised 2012 Location f No. 'V I t Date t(/ r o - TOWN OF NORTH ANDOVER y o Certificate of Occupancy $ �. Building/Frame Permit Fee $3 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# . 26750 � 113puildmg Inspector NORTH Town of iAndover 0 No. I Z % h , ver, Mass, - �d AORATEO APP��S las V BOARD OF HEALTH Food/Kitchen PERMI T LD Septic System THIS CERTIFIES THAT .... ...� .. ........ ..... I ......... - BUILDING INSPECTOR ..7has permission to erect buil ings on .,�....r .�� Foundation %.( � • Rough pto be occU ied as ... .St J..4.. ..... ..... .V` ........................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS 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. SEE REVERSE SIDE Massachusetts Home Improvement Sample Contract :his form satisfies all basic requirements ofthe state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners Seek legal advice if necessary.Any person planning home improvemdrits should first obtain c r.;:py of"A Massachusetts Consumer Guide tc Home Improvement"before agreeing to any work an your residence:You may obtain a free ce ry by calling the Office of Consumer Affairs and Btisliness Regulation's Consumer Information Hotline at 617-973-8787 or l888-283-3757 or on our wahsit Homeowner Ii Orma ion Contractor Information ldxmti Company Name i�n.12214 ye'-) Sncci r'.dd:. s,C.o not use a Post Office!Box address). Contractor/Salespers a , , 9LC 7 S GAG ���j ej c-:rr �,1. 61 RJeZe A ire City/town State Zip Code Business Address(must include treet addr s ��, u><e> t 1 01970 Daytime Phone EyMing Phone City/Pown State Zip Code i0ing Address(It different from abo,e) Business Phana Feder¢l Employer ID or S.S.Number - Home improvement contractor aeg.Number Ezpirationdeto L requi Provemres thatme ramrs t � n vnad reglshnacn number 7 The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to complete,specifying the type,brand,and grade of materials to be used,use additional sheets if ne csaly) A. e, (2 Required Permits-The followingiliuilding permits are re cued Proposed Start and Completion Schedule-The following scLA-le will and will be secured by the contractO as the homeowner's went: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be eicluded from the Guaranty Fund provisions of A Q Date when contractor will begin contracted work- MGL chapter 142A.) ti.2/ Date when contracted work will be substantially completed. .i Total Contract Price andPayme[t Schedule {—� The Contractor agrees to perform ilii:work,furnish the material and labor specified above for the total sum of: Payments will be made according to She following schedule: upon stgnmg tiohract(n6tto ezceed7731fthe16talcop&adt"6ii6e Q'the etisi ofspbct ii dtdei iiems;wniclievei 7s gceateij"" $ by /,r or upon completion of by /� /�or upon completion of upon completion oIf the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction). The foltowing material/equipmedt must be special $ to be paid for ordered before the contracted ttl6k begins in order to meet the completion scbedule-�.-) $ 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 j(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 or4rod in advance to meet the completion schedule. $xuress warranty Ts an"MCNE11,1105111 elna orovided by the contr�ctor7 No Y (all to ms of the warranty must be attachrd to the Subcontractors The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third contractl party/subcontractor utilized by the ddntractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for matedal§and labor und a ee Contract Acceptance-Upon y 1,n g,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lie�t'!or other security interest has been placed on the residence, Review the following cautions and notices carefully before signing this coatractl Dont be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. v1 ce sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registeredl*ith the Director of Home Improvement Contractor Registration. You may inquire about contMotor 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. • Know 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�Aiere en signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day fothis agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE Two IdenARE ANY BLANK SPACESIdentical oopies.of the contract must be completed and signed.One copy should go to the homeowner.The other copy should be kept by��the fcontractor. )He4own s Srguature�� Con actor'siignat`ure Date EC`t / —e Date Aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `� 4/26/2013 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($), 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 a 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). . PRODUCERON ACT Construction NAM Eastern Insurance Group LLC PHONE (508)651-7700 Fax CNoll: 233 West Central Street ADM RLE INSURERS AFFORDING COVERAGE NAIC# Natick MA 01760 INSURER AArbella Protection Ins. Co. 41360 INSURED INSURER B•P+rbella Indemnity Ins Co. 10017 Atlantic Weatherization INSURER CNautllus Insurance CO 61 Rear Jefferson Avenue INSURER D: INSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER:NASTER 2013 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. INSR I TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 TO RENTED- X COMMERCIAL GENERAL LIABILITY PREAI E Ea occurrence $ 50,000 A CLAIMS-MADE a OCCUR 8500042816 /20/2013 /20/2014 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED eBBIINdE�D nt)SINGLE LIMIT 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED 020015871 /20/2013 /20/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Peraccident $ PIP-Basic $ X UMBRELLA LIABX OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS 4600047820 /20/2013 /20/2014 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N Pp ANY PROPRIETOR/PARTNER/EXECUTIVEF-1 N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C POLLUTION LIABILITY CPL2003786001 0/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS,/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if 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 TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Rosemary Fulham/PMA "�""-a " ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025/2mnnar ni Tho AnnDn nntnc nnrl Inn^aro rnniaforoA marina of Arnpn Right'fax N2-1 3/11/2013 %-55 :57 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYYI FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT OLDER. 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 hetr s and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the ceftificate holder in lieu of such endorsement(s).. PRODUCER CONTACT NAIL: EASTERN INS GROUP LLC PHONE FAX 233 WEST CENTRAL ST (A/C,No,Ext): (AIC,No): NATICK,MA 01760 ADDRt ADDRESS: 22MLW INSURER(S)AFFORDING COVERAGE NAIC# ------------ INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: INSURER D: 61 REAR JEFFERSON AVE INSURER E: SALEM,MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER. REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 CLANS. INSR • ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMMDIYYYY) (MMI)DIYYYY) LIMITS I GENERAL LIABILITY =ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE Q OCCUR. :'REMISES(Ea occurrence) ED EXP(Any one person) $ RSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ^ENERAL AGGREGATE S POLICY PROJECT Q LOC ODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB-58270121-13 03202013 03202014 1 LIMITS ANY PROPER ITOR/PARTNERIEXECUTNE OFFICER/MEMBER EXCLUDED? NIA E.L EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 U yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/RESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. I CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED) IN ACCORDANCE WITH THE'POLICY PROVISIONS. NORTH ANDOVER,MA 01845 AUTHORIZED REP TA C • r. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. { The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street - Boston,MA 02111 y Workers' Compensation Insurance Affidav t But de s/ Contractors/Electricians/Plumbers A licant Information Please Print Le ibI Name(Business/organization/Individual): ATLANTIC WEATHERIZATION, LLC Address: 61R JE RS N NUE SALEM, MA 01970 1 AZ City/State/Zip: FAX,(978)745=2200 Phone#: Are y an employer?Check the'appropriate box: _ 1. I am a employer with Jr 4. Type of project(required): ❑ I am a eneraf con g tr7shheet. 1 employees.(full and/or part-time).* have hired the sub-c 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached 7• ❑Remodeling ship and have no employees These sub-contractors have 8. El Demolition working for me in any capacity. workers'comp, insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition 3.❑ required'] officers h 10. Electrical have exercised the' ❑ ctrtcal r airs or I am a homeowneru• eP additions 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 insurance required.] t employees.[No workers' 12-El Roof repairs comp. insurance required.] 13.[] Other "Any applicant that checks box#1 must also[itl 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, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. am an employer that is providing information, workers'compensation insurance for my employees- Below is the policy and job site Insurance Company Name: 1, r; Policy#.or Self-ins.Lic.#: Job Site Expiration Date: � 20 �=y Address:_/9 �j— 61fe��� �iy�� / 'I / Attach a copy of the workers' compensation policy declaration page(showingCity/State/Zip: /� 11-12,ol.�/—L olicy Failure to secure coverage as required under Section 25A of MGL c, 52 can lead to ththe e0simpoimposition criminal er and expiration penaltiesdatea 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 and penalties of pet jury that the information provided above is true and correct i nature: Phone#: 51Z�--- ? FF-_72_0 cial use only. Do not write in this area, to be completed by city or town official { r Town: Permit/License# sug Authority(circle one): Ll.�Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Person; Phone#: d Unrestricted-Buildings of any use.group tia=hich =c_ se:CS-087977 contain less than.35,000 cubic feet(991 ni3}of enclosed space. 3 ETON S SALEMMAf Failure to possess current edition of the Massachusetts 0412312014. State Building Code is cause for revocation of this license. For DP5 licensing information visit, www.Mass.Gov/DPS aOffice ooCjo-nsa6mt--,r3,Q arsaAnene-ss; ,cxa.arfni'vn�IG` i .._ .-.....v..__....._-...............:......----._...._._.._._..._._.._.._�__ -HOME IMPROVEMENT COR4irRP.CTOR ' Registration: .142089 Type. License or registration valid for individul use only before the expiration date. If found return to: piration 3!#2/2014 Lfd Liabilitytorpor Office of Consumer Affairs and Business Regulation ATS C Vk/EATHTRlZATIORI t.l.,.C. 10 Park Plaza-Suite 5170 J ' Boston,1%4,42115 ERIC PALM 61R JEFFERSON AVE , y SALEM,fViA 01970 undersecretary {s✓ ,�'' f Not valid.v;-fiEhoutsignature . -. .__ _ ......._.. 3 f _ A