HomeMy WebLinkAboutBuilding Permit #73-11 - 230 GRANVILLE LANE 7/20/2010Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg -
Others:
Demolition
Other
Septic Well
FFloodplam Wetlands:
Wateished;Distnct
DESCRIPTION OF WORK TO BE PREFORMED:
4W^160 V wiNax-5 f' Z �4_5 (S�E oAAll"S) f e"00 c -
Q V- A AC AK114e63 ` S/ qe' GecA?7o-^1, Z/o /CoMeAb d/'L aec cwbo
Identification Please Type or Print
OWNER: Name: 4-- 0rI.ic C'iowE'ov
Phone:
ARCHITECT/ENGINEE
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: $ 7, ,SOo FEE: $_��
Check No.: a Receipt No.:a
NOTE: Persons contracting with unregistered contractors do not have. access to the guaranty fund
itracto..,-_
Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration ,/
No. of units:
Commercial
Repair, replacement
Assessory Bldg -
Others:
Demolition
Other
Septic Well .'
Floodpfam = Wetlands:
Watershed0istnct
DESCRIPTION OF WORK TO BE PREFORMED:
0 V 4//NZ%..5 f- 2
oAnul".5
961(o ):;ec-
,e vL /e C F;K/-W63- ,s'/ we- G.ecA?70AJ, X/o
OWNER: Name:
Identification Please
.JAIA 4- 00-Mtr c
Address:
or Print Clearly
4 6105
Phone:
IrT--M0
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: $ : Lo FEE: $ n
Check No.: e Receipt No.:.a
NOTE: Persons contracting with unregistered contractors do not have. access to the guaranty fund
Location l�Gr/V � l -
No. Date -,�o -1v
NORTH TOWN OF NORTH ANDOVER
OL
9
'�Certificate of Occupancy $
°...�::..: i
Building/Frame Permit Fee $�'�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # v
23 + . ; -----
Building Inspector
- Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/MassageBody 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
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Com
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
uocatea ;jt54 usgooa Wreet
FIRE DEPARTMENT Temp Dempster on site yes
Located at 124 Main Street .
Fire.Department signatureldate
COMMENTS - -
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH- Reviewed on Signature
COMMENTS
2'1• _C
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 3194 Osgood Street
FIRE DEPARTMENT Temp DumpSter on site yes -
Located
at 124,Main Street -
Fire Depart pq t 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 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
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
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
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
a Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o 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)
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
❑ 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: Building Permit Revised 2008
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
o 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)
o 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: Building Permit Revised 2008
F NORTH TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
o 1600 Osgood Street Building 20, Suite 2-36
North Andover Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
Please print
DATE: ? /Ixo
JOB LOCATION: 2 3e
HOMEOWNER
Number
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
C t.,
C�7QW.41V U.,W-
Street Address
Name Home Phone
PRESENT MAILING ADDRESS 236
City Town
?t. 7 -ST • 9,p pc)
(�;eAN✓/LC' Z,.
Map/Lot
5-4 -V,? . kyll
Work Phone
�4- Q /8?jr
SL.te
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
/requirements.
v HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
.r
7.
M
O
O
z
a
o
L2
C/)°
cn
U
z
w°
w2'
v
U
w
W
w
W
U
a
v�
w
O
u.
z
w
rA
°
U,
Q
o
Cl)
o
� C
C V
O L
p cc
O
O
2 C.3
c
1
Cc Cc
� o
0
Ea
C c
_ ts
ts
o.
EE
•�`om
C3
o
IL 5 W.
m c
i s E
+a o a
CM
�cm
•= h
a : _ � C
H
C=u
O
ICOL CC. 13,
iyBCD 0cm
oc
tCMoc
y Q ._
s
3 m a =0 m
: CO., y O O
R C Z
d O CM
c
Q : i O C •O
W CO OwlA is _
F. •_N G.=C.3 0Cie
to c Z
h CL m.0 O.O J
_ c e.y OCD
1•- _ $ CL m
91
U
O
y
0
U)
U)
I%
W
19
W
N
The CommonweQlth of Alassachusetts
ru Department o f £ndustrial _accidents
Office ofrnvesticrations
600 Washin"ton Street
Bostori, M4 02111
.massgov/tile
Workers' Compensation Insurance Affidavit: Handers/Contractors/Electri
30licant Information Clans/Plumbers
Name (Business/Organization/Individual):/t/O�I�i� ef`
Address:NV-/z [s .
City/State/Zip: o ✓G—
O%S Phone #: 97a'
Are you an employer? Check the appropriate box:
I • ❑ I am a employer with 4. ❑ I am a general contractor and I
2. ❑employees (full and/or part-time).* have hired the sub -contractors
I am a sole proprietor or partner- listed on the attached sheet x
ship and have no employees These sub -
working for me in any capacity. contractors have
[No workers' comp. insurance
required.]
? I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
workers' comp. insurance.
5. ❑ Weare a corporation and its
officers have exercised their
right of exemption per MGL
C. 152, § I (4); and we have no
employees. [No workers'
comp ins
Z ��- massa
Type of project (required): .
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11 Plumbing repairs or additions
12.[] Roof repairs
13 F7 r,
s �I
t ,^
=-u ' ;�t that ..ham.: bQ;; �? ars! a!so a,urance requu,,,d.] ther
nut
ice sectio= eeeow sh..0%.P .:
F3omeowness who submit this affidavit indicatingtheyc Wa ' "� a'otic-:s' con ^� s�oa
=t= doing all' ::ori- and thea hire o r Y� - . f67M tio,
*Contractor-, that che^k thi ho.+. oust z_„ -bed an additional sheet showine the utside con�cte - di,; . submit a new affidavit
name of the sub -con indicating such.
T _ tiaCtprs and their wrri.....•
w•� f", empuryer mat IS providing workers' compensadon insurance or m employ - - �y .ucu mmon.
information. f y ees. Below is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Sob Site Address:
Attach a copy of the workers' compensation policy declaration pane (showing Cr the go /Zip.
Failure to secure coverage as required under Section 25A Of MGL a hp numnof and expiration date).
fine up to $1,500.00 and/or one-year imprisonment, as well as ,v l 152 can lead to the imposition of criminal penalties of a
Of up to $250.00 a day against the violator. Be advised that a co Penalizes m the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. Py of this statement may be forwarded to the. Office of
/- - ---- -- y�" way K•'"':r nee pains
and penalties ofPerlm'J' �ezt the irtform¢l'on provided abov� is ire and correct
f� �iunafiiTP• �L 1.. _ I 11 _ n
e Date.:..._ _ 7/�S/
Ione 4 7(f ` Z�'- t{P/1O
Official use only. Do not write in this area, to be completed by cite or town official
City or Town:
#
Issuing Authority (circle one): P ermit/License
1. Board of Healtb ?. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumninR
6. Other b Inspector
Contact Persurr:
-Phone #:
Information an` d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute; an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
Df the foregoing engaged in a joint enterprise, and including t1ie legal representatives of a deceased employer, or the
receiver or trustee o` an individual, partnership, association o$ other legal entity, employing employees. However the
owner of a dwelling house having not more than three aparrtai<'ents and who resides therein, or the occupant of the
dwelling house of another who employs persons to domamte mance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be'deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal, of a license or permit to operate a business or to C--onstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coimpiiance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the. performance of public work un: -til acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with no employees other than the
members or partners,. are not required to carry workers' comp ensation insurance. If an LLC or LLP does have
employees, a policy is required- Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be stare to sign and date the affidavit. The affidavit should
be mtuued to the city Or tcmm that the ap'ulicdud}n for the erlJult bor license ing nsted, not
De-ow�:ent. of
Industrial Accid=ents. Should von have any questions mgardirz g t' e law o if you am � re;u^uured to obtain a wormers'
compensation policy, please call the Department at the number= listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to M out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under `.`Job Site Address"' the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stampesd or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permuits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i. e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would bice to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephone and.,fagnumber._.
The Ccarnmonwealth of Massachusetts
DcPartment of Industrial Accidents
Office of lnrestig
600 Washmptan Street
Boston, MA 02111
Tel. # 617-72.7-4900 ext 440.6 or 1-s 7/-MASS_AFE
Revised
Fax r 617-72.7-7749
www.mam._ Qov/dia
Information an_ d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied oral or written"
An employer is defined as "an individual; partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise; and including the legal representatives of a deceased employer, or the
receiver or trustee of an inaivimial, partnership, association og other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartnL eats and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintexiance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be cause of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal p of a license or permit to operate a business or to r--anstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=mpliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work ua-til acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and; if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their cerdficate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners,. are not required to carry workers' comp =sation ins rance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of ins *an_ce coverage. Also be siure to sign and date the affidavit. The affidavit should
be m ruued to the city or town tha' i the auvlicauor, far the pmrinitor hc=se LS being requesfBd, not the D artm—ent, of
Industrial Accidents, Should you have. any questions regarding the law ui if you are :..jui.vd za obMin a workers'
compensation policy, please call the Department at the number= listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to BE in the permit/liccuse number which will be used as a reference number. In addition; an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future PM-111its or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office oflnvestigations would like to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephone and_fimnumber....
The Commonweala of Massachusetts
DcPartment of lndustrial Accidents
Office of Inwesigafoas
500 Washing tan Street
Boston, MLA 02111
Tel. -#1617-72.7-4900 ext 4:0.6 or 1-8-7-Iv4_4SS_AFF
Revised 5-26-05
Fax # 617-72.7-77'49
urvru'.mass._zov/dtia
9
The Commonwealth of Massachusetts
Department o f rndust:.ial _,accidents
v
Office ofjnvestigaiions
600 Washington Street
BOStOn, M4 62111
WWW.Mas
Workers' Compensation Insurance Affidavit Builders/Contractors
Mlicaut Informa%on /Electricians/Plumbers
Name (Business/organizationandividual): / Qrt/l✓� d
Address: Z 3 0 �j iQfl-ivV�LL Ls �q�.
City/State/Zip: 90 ✓G—'7� oI�Y�."
Phone #: 97,P1 - Z S"�• ys f0
Are you an employer? Check the appropriate box;
L ❑ I am a employer with 4. ❑ I am a g
have hired
contractor and I
2. ❑employees (full and/or part-time). * the sub -contractors
I am a sole proprietor or partner_ listed on the attached sheet t
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 ha
3 •� I am a homeowner doing all work
myself. [No workers' comp.
insurance required_] t
ve exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
1 I.❑ Plumbing repairs or additions
17•7 Roof repairs
-�y w tiroscomp. ins�,nce required] f I3.❑ Other
±that ecks boxmust a?so lire cet the secna_' below shoe. -^
Homeowners who submit this affidavit indicatin = .^ ti-aorx�s' eoe^s�oa Y tic,—SyV
'Contractors * gam' a = dog€ aL' wer'e and t`nen j outside contractor,
that ch "'°'x'^ ^heti ar additional sheet showing the emit a new affidavit indicating such.
name of the sub -contactors and their wnrw—
I am an employer that is providing workers' compensation insurance for
informamy employees
tion.
Insurance Company Name
Policy # or Self -ins. Lic. #:
Below is the poficy and job site
Expiration Date:
Sob Site Address:
Attach a copy of the workers' compensation policy dCity/State/Zip:
eclaration aQ
Failure to secure coverage as required unders „ Section 2 p be (showing the policy number .and expiration date).
fine up to $1,500.00 and/or one-year imprisonmen aswell MGL c. 152 can lead to the imposition of
criminal
Of up to $250.00 a day against the violator. Be advised that a cc>s civil penalties in the form of a STOP WORK ORDER and of and
Investigations of the DIA for insurance coverage verification. PY of statement may be forwarded to the Office of
I do hereby certify under the pains and penalties of perjury
rnA MW dw form don provided abov is Ir a and
Official use only. Do not write in this area, to be completed
City or Town:
issuing Authority (circle one):
by cite or town official
P ermit/License #
OF correct
I. Board of Health Z. Building Department 3. City/To
6. Other WE Clerk 4. Electrical Inspector 5. Piumbinb Inspector
Contact Person:
Phone #: