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HomeMy WebLinkAboutBuilding Permit #557 - 280 Kingston Street 3/31/2008 BUILDING PERMIT OpoRrM �tt�ao ai9tio TOWN OF NORTH ANDOVER o ,a APPLICATION FOR PLAN EXAMINATION * ,� Permit 140: Date Received �/ SACHus� Date Issued: " 0O IMPORTANT:Applicant must complete all items on this page ,L0tA'R, ONLV�1/Z PROPERTY OWN- 4 tri _ Pray ft UAPX10 ",PAR CEL ZONII,G DjS�'<R�CT l�Iislor�c��str�trt " _ Ves Bio. Machjrae`Shgp,Village yes no 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 f/' Sep#ic' :. Weil Flsod .lietlar� stershed District . WaterlS�wer '.. DESCRIPTION PF WORK TO BE PREFORMED: a *0 Oki Identification Please Type or Print Clearly) E aivie,kow"o OWNER: Name: 11Uf a�)e Phone: 92 491 Address: CONTF �TOR Nare� R Prone- �. Andress D : " Su. ervisor' Construction'Lscense. Txp ' Date. P r a t Home Imaprovernent License- ap. Date4. ARCH ITECT/EN GIN EER r& Eix a Phone: 6100 – / p Tem Address: to // �ia� �u� ��6� �` &Ei—Reg. No. 3/ FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ `71, i�D D FEE: $ Check No.: l�f Receipt No.: 00 t 03 2— NOTE: Persons contracting with unregistered contractors do not have acces to the uar my f n �i nature.of A; ent/Owner �g ,Signature ofiofi c©ntractor 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 DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED W CONSERVATION V3 -0 COMMENTS �C��f -p *% 6 r e s A 4f sly 6ttlaov 00� DATE REJECTED DATE APPROVED HEALTH a�2 t,200 COMMENTS Zoning Boiird of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit Located at 384 Osgood Street IRE DEPARTMENT -'Temp Durnpstez on site yes . no :Located'at.12 'mainstreet Tfre.Departrnent.tignature/Mate �COMME-NT 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 SJRct c-;;,- .- ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 o Building Permit Application o 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 ❑ 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 ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location ���� ��'r1Ct� No. 55 1 ��'�rj ~Date I d NORTH TOWN OF NORTH ANDOVER D Certificate of Occupancy $ Mustc� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building Inspector Owner-President LIC.ifu3o4y/- CUNSOLO CONSTRUCTION CORP. General Contractors BITUMINOUS CONCRETE PAVING CONCRETE FLAT WORK LANDSCAPING—SITE WORK:BACKHOE-DOZER Web Site:http:/www.cunsolocorp.com Phone:978-689-9129 Alfred R.Cunsolp. Fax:978-689-3365 12 Palmer Street Email:acunsolocorp@msn.com Methuen,Ma 01844 ASPHALT PAVING—PARKING LOTS/ROADS I DRIVEWAYS BUILDING CONSTRUCTION—RESIDENTIAL/COMERCIAL SITE WORK—DOZER/BACKHOE/TRUCKING PAVING STONES—WALKS/PATIOS/DRIVEWAYS I POOL DECKS $RICK WORK—WALKS/WALLS/STAIRS WALLS_—FEILDSTONE/INTERLOCKING WALL SYSTEMS Construction Supervisors License: CS 056492 NORTH Town of And 0 6� i== o dover, Mass.,Y-Y/• a�� COCHICKEWICK\,, %p AORATE0 iP� �5 `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...b..1.11� ....... 4.!1.......ln..!4a.... .... ........................................... Foundation has permission to erect..................................I..... buildings on .......�I. .S.J.u ........zvr.,.................................. Rough to be occupied as...�dl �d 1:0I'11�'w .. ...�......?P.k.L..T�� $.e!►�.�.�O.orfir..�..................... Chimney ............. .............................. .................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTI TARTS ELECTRICAL INSPECTOR Rough ................. ... .........................:........................................ ........;. Service BUILDING INSPECTOR ' Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR ' Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. O� I10RTH 1 TOWN OF NORTH ANDOVER " _'`•"° OFFICE OF s p BUILDING DEPARTMENT ` 1600 Osgood Street 1 tom, Building 20 Suite 2-36 sS,� SE North Andover,Massachusetts 01845 Gerald A.Brown Telephone(978)688-95454 Inspector of Buildings Fax (978)688-9542 CONTROL CONSTRUCTION—SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 01845 I, P OAJ Gy9 ,HEREBY CERTIFY,THAT THE BUILDING CONSTRUCTED AT—I// �, �� •c„®z /r,�•�Gocf w/LL B� CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: AUTHORIZED SIGNATUR DATE: REGISTRATION: 3 NOTE: ENGINEER"WET STAMP'MUST BE AFFIXED TO THIS FORM kA OF 3 ? Renal dl J. O �G Pies C3 Structural y V 31369 0 BOARD OF:1P1'E,1I S 688-9541 CON El 9 �G T I3 688-9540 PLANNING 688-9535 srONAk- amu-._ Client#;51517 11 UNSOLOCON ACORD- CERTIFICATE OF LIABILITY INSURANCE 03/20,$°" ""'' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HUB International NE(WCL) ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 299 Ballardvale St HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Wilmington,MA 01887 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 978 657-5100 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Travelers Indemnity Cunsolo Construction Corp. INSURER B: Granite State Ins Co 12 Palmer Street INSURER c: Methuen,MA 01844 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DAT MID DATE M LIMITS A GENERAL LIABILITY 1680581W3041COF07 08101/07 08/01/08 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $300,000 CLAIMS MADE FE OCCUR MED EXP(Any one person) $5,000_ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGG s2,000,000 POLICY PRO- J C LOC A AUTOMOBILE LIABILITY BA491 K487307SEL 08/01/07 08101/08 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $50,000 X HIREDAUTOS X NON-OWNEDAUTOS (Peraccident)RY $100,000 PROPERTY DAMAGE $100,000 (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WC6876361 0$/01,07 08/01/08 1 TDITATUjj RYSLIMIT OTHEk - EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $100,000 ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under SPECIAL PR VISIONS bebw E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Village Green Condo Assoc DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL I_ DAYS WRITTEN North Andover,MA 01845 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR ,REPRESENTATIVES, �,. ,� AUTMOR�RESENTa 'r ACORD 25(2001/08)1 of 2 #M20471 J„W/ l/•7� EH002 © ACORD CORPORATION 1988 A CUNSOLO CONSTRUCTION CORP. CONTRACTOR AGREEMENT THIS AGREEMENT made the 11 day of MARCH, 2008 by and between CUNSOLO CONSTRUCTION CORP., hereinafter called the Contractor and VILLAGE GREEN CONDOMINUMS hereinafter called the Owner. Witnesseth,that the Contractor and the Owner for the considerations named agree as follows: Article 1. Scope of the Work The Contractor shall furnish all of the materials and perform all of the work shown on the Drawings and/or described in the Specifications entitled Exhibit A, as annexed hereto as it pertains to work to be performed on property at VILLAGE GREEN CONDOMINUMS,NORTH ANDOVER MASSACHUSETTS. -------- --------------------- THE STRUCTURE TO FOLLOW THE PLAN AS DRAWN BY R.J.PICA ENGINEERING CO., INC., 166 PLAISTOW ROAD SUITE 204,PLAISTOW,N.H.03865-(603)382-6166 SPECIFICATIONS: (AS PER LATEST DRAWING DATED:01/19/2008 • -PERMITS • -NEW ROOF ON EXISTING MAINTENANCE GARAGE BUILDING AND POOL PUMP HOUSE. • -SHRUB REMOVAL AND REPLANTING. • -REMOVE AND SAVE FENCE. • -EXCAVATION AND SITE CLEARING. • -CONCRETE FOOTING AND FOUNDATION WALLS • -LOCATE WATER AND SEWER LINES IN EXISTING BUILDING. • -POUR CONCRETE FLOOR IN NEW BUILDING • -DEMOLITION OF CONCRETE IN GARAGE AS REQUIRED FOR PLUMBING.REPAIR AS REQUIRED. • -FRAME NEW BUILDING AS PER PLAN. • -ALL DOORS AND WINDOWS AS SHOWN ON PLAN. • -ROOF STRUCTURE AS PER PLAN WITH BREEZEWAY FOR SHOWER AND FUTURE WATER SPOUT. • -SIDING AS PER PLAN • -HANDICAP BATHS AS PER STATE CODES AND ADA REQUIREMENTS.ALL FIXTURES SUPPLIED. • -DROP CEILING AND LIGHTING PER PLAN • -ELECRTICAL: AS PER PLAN AND STATE ELECTRICAL CODES. • -DOORS AS PER PLAN. • -INTERIOR WALL-FRP OR EQUIVALENT. • -FLOORING-VCT OR EQUIVALENT. • -INSTALL FENCE AS PER PLAN. • -DRAINAGE SYSTEM AS PER PLAN. • -CLEAN UP SITE AND REPAIR ANY PAVING OR LANDSCAPING DAMAGED IN THE PROCESS OF ADDING THE ADDITION. Article 2. Time of Completion The work to be performed under this Contract shall be commenced on or before MARCH 31, 2008 (OR AS SOON AS PERMITS ARE ISSED) and shall be substantially completed on or before MAY 31, 2008 (BARRING ANY DELAYS DUE TO CHANGES MADE BY VILLAGE GREEN, PROPERTY MANAGEMENT OR PICA ENGINEERING, DETRIMENTAL WEATHER CONDITIONS OR OTHER FACTORS OUT OF THE CONTROL OF THE CONTRACTOR). Time is of the essence. The following constitutes substantial completion of work pursuant to this proposal and contract: (Specify) Article 3. The Contract Price t r The Owner shall pay the Contractor for the material and labor to be performed under the Contract the sum of SEVENTY, THOUSAND EIGHT HUNDRED AND NINETY Dollars($70,890.00), subject to additions and deductions pursuant to authorized change orders. Article 4. Progress Payments Payments of the Contract Price shall be paid in the manner following: 20% DOWN ($14,178 ) , TO SECURE PERMITS AND BEGIN THE PROCESS. PROGRESS PAYMENTS TO BE AS WORK PROGRESSES AND WILL BE DICUSSED AND AGREED UPON BY THE CONTRACTOR AND OWNER PRIOR TO BEGING. Article 5. General Provisions Any alteration or deviation from the above specifications, including but not limited to any such alteration'or deviation involving additional material and/or labor costs, will be executed only upon a written CHANGE ORDER for same, signed by Owner and Contractor, and if there is any charge for such alteration or deviation,the additional charge will be added to the contract price of this contract. If payment is not made when due, Contractor may suspend work on the job until such time as all payments due have been made. A failure to make payment for a period in excess of 5 days from the due date of the payment shall be deemed a material breach of this contract.In addition the following general provisions aPP1Y 1. All work shall be completed in a workman-like manner and in compliance with all building codes and other applicable laws. 2. The OWNER (VILLAGE GREEN) or their REPRESENTATIVE, shall furnish a plan and scale drawing showing the shape, size dimensions, and specifications for the BUILDING, a description of the work to be done and description of the materials to be used and the equipment to be used or installed. 3. To the extent required by law all work shall be performed by individuals duly licensed and authorized by law to perform said work. 4. Contractor may at its discretion engage subcontractors to perform work hereunder, provided Contractor shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this Contract. 5. Contractor shall furnish Owner appropriate releases or waivers of lien for all work performed or materials provided at the time the next periodic payment shall be due. 6. All change orders shall be in writing and signed both by Owner and Contractor, and shall be incorporated in, and become a part of the contract. 7. Contractor shall at its own expense obtain all permits necessary for the work to be performed. 8. Contractor agrees to remove all debris and leave the premises in broom clean condition. 9. In the event Owner shall fail to pay any periodic or installment payment due hereunder, Contractor may cease work without breach pending payment or resolution of any dispute. 10. All disputes hereunder shall be resolved by binding arbitration in accordance with rules of the American Arbitration Association. 11. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes, casualty or general unavailability of materials. 12. Contractor warrants all work for a period of 12 months following completion. Article 6. Indemnification To the fullest extent permitted by law, the Contractor shall indemnify, defend and hold harmless VILLAGE GREEN and its agents and employees, from and against claims, damages, losses and expenses, including but not limited to attorney's fees, arising out of or resulting from performance of the work or providing of materials to the extent caused in whole or in part by negligent or wrongful acts or omissions of, or a breach of this agreement by, the contractor, a subcontractor, anyone directly or indirectly employed by them or anyone whose acts they are legally responsible. .- P Article 7. Insurance The Contractor represents that it has purchased and agrees that it will keep in force for the duration of the performance of the work or for such longer term as may be required by this agreement, in a company or companies lawfully authorized to do business in the State of MASSACHUSETTS, such insurance as will protect CUNSOLO CONSTRUCTION CORP, and the owner of the site, if the site is not owned by VILLAGE GREEN, from claims for loss or injury which might arise out of or result from the Contractor's operations under this project,whether such operations be by the Contractor or by a subcontractor or its subcontractors. The Contractor represents and agrees that said insurance is written for and shall be maintained in an amount not less than the limits of the liability specified below or required by law, whichever coverage is greater. The Contractor certifies that coverage written on a "claims made" form will be maintained without interruption from the commencement of work until the expiration of all applicable statutes of limitation. I 1 WnrlrPr'e(�mmnPncatinn ac nPr tl1P rPnll/YPm Pnte of the etatP of T/Ta CCa!}111CPttC a r, 3) Comprehensive Automobile Liability(owned,non-owned,hired)of S 100,000 each accident. The Contractor shall file Certificates of Insurance,naming the owner person hiring the contractor as additional insured, in duplicate, acceptable to all parties prior to commencement of work, which shall contain a provision that coverage's under the policies shall not be cancelled or allowed to expire or permit material changes until at least thirty ( 30 ) days written notice has been given to additional insured. Article 8. Additional Terms Name any Salesperson who solicited or negotiated this contract: ALFRED R. CUNSOLO President/Owner CUNSOLO CONSTRUCTION CORP. Signed this day of MARCH,2008 (year). Signed: Nai;e of CWr VIZLAGE AaR or REPREN�YATWE Name of Contractor By: By: � � s Signature Si ature StrAke-_ dre s,' � City/State/Zip Telephone No Contractor's State License No. � POOL #D7-1481 i CTI e �o�,r.�,tonu�eal!! a�. aaa�.clueael! 1.loard of Building Regulations and Standards Construction Supervisor License CS 56492 BlVthdZ-:--6a8/1958 8/2009 Tr# 17225 Re-CA&i' =00`-� ALFRED R CUNS 12 PALMER ST METHUEN,MA 01844 Commissioner The Commonwealth of Massachusetts t t Department of Industrial Accidents t Office of Investigations lid <r 600 Washington Street R/ Boston, MA 02111 c 3 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly I Name(Business/Organization/Individual): Co yls W�'t " Address: n 2 PAIP" er \r _.... __... City/State/Zip:_!_7,,(�'LY1u e4l , /"l a- U/ i y Phone#: Are ypu an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with Y _ 4. ❑ I am a general contractor and 1 6. VT�ew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. (],Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10 11 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I LCI P robing repairs or additions myself.(No workers'comp. c. 152,§1(4),and we have no 12. Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required..] Any applicant that checks boi#l must also fill out the section below showing their workers'compensation policy information. r 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. s I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: til � 6' Policy#or Self ins.Lie.#: A 7 • �a& Expiration Date: Sob Site Address: �1�t/1 Ct S l G 0 S Y `` // //// /J City/State/Zip: NUL 1T d'dVC� d��y� 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. I do hereby cert nde t e pains and sof perjury at the information provided above is true and correct.p• Si azure: Q / Date: _ C OCA oQ Phone#: / 2 (� 0 Qjflcial use only. Do not write in this area,to he 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#: