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HomeMy WebLinkAboutBuilding Permit #916-14 - 175 SOUTH BRADFORD STREET 6/16/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: (/ — I (i - L 4 IMPORTANT: Applicant must complete all items on this page LOCATION PROPERTY OWNER '/, el 11920{i'Z14 Print 100 Year Old Structu MAP NO:�PARCEL:-'7 ZONING DISTRICT: Historic District Machine Shop Vil yes EEyes e ves TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial eration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: US t i5'/e Ard 7-1V .Identification Please Type/or Print Clearly) OWNER: Name: A,07 -1-4,v Phone: Address: --z2 S CONTRACTOR Name: "i�� ,��Z'- Phone:.S"a Address:S-77 luaiyOG�/rs"/�, Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. 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: $�, �� ©i �� S�� FEE: $ _ P- Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fun Signature of Agent/Ovvner Signature of contractor Plans Submitted Li Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - Plans Subm itted ❑ Plans Waived ❑..:.,-Certified Plot Plan ❑ Stamped Plans ❑ ,T'YPE:OF;SI WERAGE,DISPOSAL - Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ .: Food Packaging/Sales ❑ Private,(septic tank, etc- ❑ - - _ .. -Permanent D' i npster on Site ❑ 3HE"..FO.LLOWING SECTIONS FOR -OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM -:,:-.,DATE. REJECTED - DATE:APPR:OVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS -CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature r 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 TowAo Engineer: Signature: FIRE DEPAX-t lI;L-�NT= "­ Temp Dumpsfer on site yes Located -at 124,Mair, Street - Fire DLpartinerifsigiiaitu"re/date- _ COMMENTS r' Located 384 Osgood Street no Dimension- - Number of Stories:_ .Total land -area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of. Meter, location, mast -or service drop requires approval of :Electrical Inspector Yes No DANGERZONE LITERATURE: Yes No MGL -.Chapter 166.Section 21A -F and G min.$100=$1000 .fine NOTES and DATA — (For department use EI Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department Thefol;-awing is'a list of the -required.#orms to be filled ouffior the appropriate.permit to be obtained. Roofing, 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 ❑ 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 o 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) o Building Permit Application Li 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 apu,?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 - S: &-d W a -- Location --L3 nr No. A Date Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $— Building/Frame Permit Fee SQ-L—O I— Foundation Permit Fee Other Permit Fee TOTAL $ Tuilding Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 17,5'500.00 m $ - $ 210.00 Plumbing Fee $ 26.25 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 26.25 Total fees collected $ 362.50 175 South Bradford Street 916-14 on 6/16/2014 Master Bath Remodel m I� C no Z 0 � 0 co O O Y O O LL E N TO N O. N Ln O W N ? Z co O Y N 7 O LL :3D O = U1 C L U O LL O N z Z m d L Z) O W O LL OW ta/f z U ~ W J L7J L � O d' U i N Ln LL ~ j ( a LA Z N C7 : O d' S7 LL W F- L Q CL w � ui L= LL i Cn O Z N t; Ln N 0 w O E Ln O O i+ O CL �a - � o a� 0 c r t0j i U, CL d cc c °' CD o o C �: 0 -0 � O = t Q 'a y d ++ t t o a� 0 z ) oCL 0 CD CA • c0) 0 0-0 c Q L i :C 'C y •� N CD m W 'o ��-+ O O LU LL •2 N cLo WL- 0 m •- v 0 oCD COCL � C 2 o O a O F- t -W O_ 0 L) O W a Z Z m Cl) C) CO Z H W j a cf) N�/ Z o LJJ O woW c W J Z m 0 c O N O r 0 z O Q J O f., —I w ti w Rich Hadj ian 175 South Bradford Street North Andover, MA 01845 (H) 978-794-9689 (C) 978-930-9993 hadjian@msn.com June 13, 2014 Master Bathroom Remodel Work to be included includes: • Acquire Building Permit • Demo of existing bathroom. • Complete all required plumbing. • Complete all electrical. • Install vanity. • Install copper pan in shower. • Install new blueboard and plaster. • Install DenseShield Tile board on shower walls. • Install tile on shower floor and walls. • Install DenseShield tile board on floor. • Install new tile floor. • Install new baseboard heat cover and baseboard. • Install new toilet paper holder, towel bars. • Removal of all debris. 12 �a V TOTAL LABOR AND MATERIAL $ 8,500.00 L400u Note: This quote does not include any plumbing fixtures, vanity, tiles, grout, granite, or paint. Proposed Start and Completion Date- The following schedule will be a ered to unless circumstances beyond the contractor's control arise. 71711,V Date when contractor will begin contracted work. -� //f/Date when contracted work will be substantially completed. Terms: $ 2,800.00 upon signing of contract (not to exceed 1/3 of contract price) $ 5,700.00 when job complete Submitted By: Chris Rivet MA Lic #CS072173 HIC #139962 207 Winter Street (C) 508-265-3115 (H) 978-794-1165 North Andover, MA 01845 All Home Improvement Contractors shall be registered. Inquiries about a contractor relating to a registration should be directed to; Registration Division, Program Coordinator One Ashburton Place Room 1301 Boston, MA 02108 Tel: 617-727-3200 ext.25239 All building permits required will be the obtained by the contractor. Homeowners who obtain their own permits are excluded from access to the Guarantee Fund. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are au ori ed to do the work as specified. Payments wil be, ad as outlined Bove. Date Homeowner Signature Date �J / Contractor Signature Contractor 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 afforded to the homeowner by the Home Improvement Contractor Law. 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 and the consumer shall be required ty submit to such arbitration as pr ided `n M sachusetts General Laws, Chapter 142A. S Homeowner's Signature ; Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties 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 workmanlike 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 questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in du licate 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 original signed copy of the contract with attachments is 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 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 due 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 Consumer Guide to the Home Improvement Contractor Law", contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 (617) 973-8787 or (888) 283-3757 Rich Hadjian 175 South Bradford Street North Andover, MA 01845 (H) 978-794-9689 (C) 978-930-9993 hadjian@msn.com June 13, 2014 Garage Siding and Trim Work to be included includes: • Acquire Building Permit • Remove and replace siding on end of garage. • Replace rotted trim boards as discussed. • Removal of all debris. TOTAL LABOR AND MATERIAL $ 5,000.00 Proposed Start and Completion Date- The following schedule will be adhered to unless circumstances beyond the contractor's control arise. /d /%Date when contractor will begin contracted work. i ate when contracted work will be substantially completed. Terms: $1,000.00 upon signing of contract (not to exceed 113 of contract price) $ 4,000.00 when job complete Submitted By: Chris Rivet MA Lic #CS072173 BIC #139962 207 Winter Street (C) 508-265-3115 (H) 978-794-1165 North Andover, MA 01845 All Home Improvement Contractors shall be registered. Inquiries about a contractor relating to a registration should be directed to; Registration Division, Program Coordinator One Ashburton Place Room 1301 Boston, MA 02108 Tel: 617-727-3200 ext.25239 All building permits required will be the obtained by the contractor. Homeowners who obtain their own permits are excluded from access to the Guarantee Fund. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments w'41 be in de as utl' a abo. e. Date IA/Y Homeowner Signature c Date Contractor Signature Contractor 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 afforded to the homeowner by the Home Improvement Contractor Law. 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 Off of C sumer Affairs and Business Regulation and the consumer shall be required to bmit to such arbitration as pro ed4 assa usetts Gene al Daws, Chapter 142A. i Homeowner's Signature Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties 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 workmanlike 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 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 original signed copy of the contract with attachments is 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 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 due 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 Consumer Guide to the Home Improvement Contractor Law", contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 (617) 973-8787 or (888) 283-3757 OP ID: SHHE ,ac�oizo, CERTIFICATE OF LIABILITY INSURANCE DAT09/30D/YYYY) 09/30!13 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 lieu of such endorsement(s). PRODUCER Phone: 978-688-6921 Macdonald & Pangione Insurance Fax: 978-688-5350 P.O. Box 428 CONTACT NAME: PHONE FAX _(A/C. No Ext): A/C No): EMAIL 104 Main Street North Andover, MA 01845 Michael Pangione PRODUCER CUSTOMER ID#: CHRIS -5 INSURER(S) AFFORDING COVERAGE NAIC k DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 INSURED Christopher Rivet INSURER A: Preferred Mutual Ins Co 115024 207 Winter St. North Andover, MA 01845 INSURER B GENT AGGREGATE LIMIT APPLIES PER: X POLICY n PROjEC- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ INSURER C : LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS INSURER D : INSURER E: COMBINED SINGLE LIMIT $ (Ea accident) INSURER F: BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) COVERAGES CERTIFICATE NUMBER: REVISION NUMIRFR- 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/ D/YYYY I MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY _ CLAIMS -MADE OCCUR Michael Pangion CPP 0180 57 0105 09/26/13 09126/14 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY n PROjEC- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) $ I$ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE S DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATIONI AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F-1NIA (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEEI $ E.L. DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER rANrFI I ATInN ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St No Andover, MA 01845 AUTHORIZED REPRESENTA IV Michael Pangion ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 1 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS -072173 r% CHRISTOPHER FiUVET 207 WINTER ST N ANDOVER MA 01845 554,�j. l.� Expiration Commissioner 06/02/2016 'TxcJJtir.�rr irl�'• \Office of Consu'!ner Affairs & Business Reba} itinn ME IMPROVEMENT CONTRACTOR eegistration: 139962 T7pe: xpiration: 9/8/2015 Individual CHRISTOPHER F. RIVET CHRISTOPHER RIVET 207 WINTER ST.— j N. ANDOVER, MA 01845 Undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 >� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /�,�jPlease Print Legibly Name (Business/Organization/Individual): C % �/ /�� �1f' Address: ce O f G,%A,11kr T4 S City/State/Zip: �C.1�. ���.acL�. �%'/F o, jF V/ , Phone #: Y"S', Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I (full and/or part-time).* have hired the sub -contractors Vmployees 2. I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] T employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [ emodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name:A//r'e-.65"o �l 7lii't- Policy # or Self -ins. Lic. #:—C— 6 0/ 90 S rZ 0% 0 f Expiration Date: Job Site Address: / %� �5oaY-1j eouoe-wo City/State/Zip: IVO �tipD✓C�,//' ����� 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. f do hereby certify u�derie paints andp%. alties of perjitry that the information provided abboovee truee a :d/correct. Phone #: 4r, >F — 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 #: