Loading...
HomeMy WebLinkAboutBuilding Permit #801-13 - 282 BLUE RIDGE ROAD 5/22/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 9-0 t " i 3 Date Received Date Issued: —7�2--` 1-3 IMPORTANT: Applicant must complete all items on this page LOCATION Z,2� �/ Print PROPERTY OWNER � �L' oz Print 100 Year Old Structure yes (no MAP NO: PARCEL:.. DISTRICT: Historic District yes Machine Shop Villaqeyes o 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 ❑ Floodplain ❑ Wetlands ❑ Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: AHrlracc Cor Supervisor's Construction License: 4 �2 C—i.3e Exp Home Improvement License: I' Exp Date: Date: ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED FEE: CQST BASED ON $125.00 PER S. F. by - - • Total Project Cost: ��y�l1d $ Check No.: 2— Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ;Signature of Agent/Owner Signature of contractor Di--- i-1 Dlanc Waivarl F-1 hartifiarl Pint Plan n Ian-, n Location a�� No. Ro l Check #q6D- 26432 Date - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED Q DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comme Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit I'DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at'124 Main Street Fire Departiment-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 EI 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 ❑ 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 ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) L3 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: Doc.Building Permit Revised 2012 v N C Ej N n 'a O CD 0 Z N CD CL =r o CL -D co. � 0 vCD Q c S — CD CD O �o �o � Q: o U. C � v 0 Z CD 0 riek r -r O CD 3 CD coo h m X U) z a) ic z V 0 3 0 O 'a ;4L S 5. CD CL CD C O' CD n CL C) c V U) CD o O O rt C. � y o W CD O �. 0) N CD C C O C to CL rt O n c S CD Jv S CD 'a � O O O < to o 0 U) oCD 0, nCD Cn o. O 0 C. O D] co N CDy= �g< W .N r� C) y O n .Ot C rt � O O S S CD CD y � cD cD r D CD CD -0a O ci C rt . p� O O C C. 2 y 0 m m cn -SS • 41 (n ON M Q ID �+ V7 Z O co c j T m V > m T 3 d Zo O m S y N � O T O v NZo O Z O 3 m m A N V m n 0 T O' ;o O S M r W G1 m n 0 T O' (� 3 7 Kfp rD O S T O 3 0 C p Z N m 0 (n N rr f1 ,L 3 T O Q. \ ri n m 3 0 > O m D _ 01 v *mss T. mbe Rooting N Sevuei2932 CO- Haverhill MA 978.374.9224 Lawrence MA 978.687.7339 Hampton NH 603.929.9224 Hampstead NH 603.329.8200 Toll Free 1.888.SOS.ROOF 265 Winter Street Haverhill MA 01830 +Ij *Licensed *Insured *Factory Trained *Factory Certified_ Name: �_�\ l i �� t 5 r (�`!r'`7 Date: 13 Telephone: Alt. Telephone: Email: _ Billing Address: c ' 0 r Grtiu� City:( C + , ` f ''r Cy C 4� State: it Job Address: City: State: Scope of Work aSt"rip and Re -roof ❑ Re -roof Approximate Roof Area: _313 a. (VPrepare for re -roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. t;.,Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site. 1�-Inspect wood deck, if we discover any rotted wood, replacement will will performed at *$_?. -�,!5 per LF for roof deck boards. If substantial deck rot is discovered, re -sheathing of roof deck can be performed at *$ per SF. If individual sheets are found to be rotted/or de -laminated, removal, disposal and replacement will be performed at *$' S_ per sheet. If any trim boards are rotted, replacement will be performed at *$ 4 ) - per LF for new pre -primed pine. Inspect siding at roof line and all flashing behind siding, if we discover any damaged flashing or siding at the roof line, replacement will be performed at *$ 1 a — If wood deck, siding, and flashing is sound, we will re -nail any loose wood to rafters, sweep deck, and prepare for roofing. PJ`Install 8" drip edge to all rakes and eaves. Color .E1 Apply ice & water shield (UNDERLAYMENT) as per manufacturers' specifications and/or 1 *. �' LIA 01pply premium (UNDERLAYMENT) to the balance of the exposed wood deck. Re -flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensure water tightness. CYIf upon inspection, we discover chimney lead to be worn or deteriorated r Placement will be performed at *$ ^ r e"Ife— ..--W* j El Install a new: l__1Year ❑ Traditional Fr Architectural ❑ Designer Colors Q -Furnish and Install a new shingle over style ridge vent system ❑ Soffit vent system *$ a1lIl debris generated by Lambert Roofing Co., Inc. will be cleaned up and disposed of from the job site in a legal fashion. Under no circumstances will the watertight integrity of the buiding be compromised. ( Special Notes _ ` i V,,i A �1 `i' 4 c \,c �, "'0;`l l., Wit' !i ( 0 ro i, cam c F' � r �I,ey UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE ANORKMANSHR GUARANTEE FOR A PERIOD OF `- YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY ANDr - ,YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER. ❑ MANUFACTURER UPGRADE *$ *Denotes potential additional costs above the total estimated price. ~ TOTAL CONTRACT PRICE AND PAYMENTISCHEDULE The Contractor agrees to perform the w/rk, furnish the terials and labor specified`above for the total sum of: $ / ` � CV r' (*) rrot Payment will be made according to the following work scheduler $ V at/t% n Ideposit upon signing contract $ by _/_/_ or upon completion of $ ��� �'�� ©� upon completion,of contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) You may cancel•this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram or by delivery, not later than midnight of the third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES Acceptance of the Contract Proposal Home Owner(s) Signature(s): .. t •�' it ` Date: r l l /`' f Contractor's Signature: t—`'��"'' r �' Date: - / / www.lambertroofine.com (Please see reverse side) # 51-050-3313 f�lEIN MA Reg. HIC # 149221 j BBB_ MA,lric. UCS # 78130 Single-Ply License# 1711 T. mbe Rooting N Sevuei2932 CO- Haverhill MA 978.374.9224 Lawrence MA 978.687.7339 Hampton NH 603.929.9224 Hampstead NH 603.329.8200 Toll Free 1.888.SOS.ROOF 265 Winter Street Haverhill MA 01830 +Ij *Licensed *Insured *Factory Trained *Factory Certified_ Name: �_�\ l i �� t 5 r (�`!r'`7 Date: 13 Telephone: Alt. Telephone: Email: _ Billing Address: c ' 0 r Grtiu� City:( C + , ` f ''r Cy C 4� State: it Job Address: City: State: Scope of Work aSt"rip and Re -roof ❑ Re -roof Approximate Roof Area: _313 a. (VPrepare for re -roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. t;.,Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site. 1�-Inspect wood deck, if we discover any rotted wood, replacement will will performed at *$_?. -�,!5 per LF for roof deck boards. If substantial deck rot is discovered, re -sheathing of roof deck can be performed at *$ per SF. If individual sheets are found to be rotted/or de -laminated, removal, disposal and replacement will be performed at *$' S_ per sheet. If any trim boards are rotted, replacement will be performed at *$ 4 ) - per LF for new pre -primed pine. Inspect siding at roof line and all flashing behind siding, if we discover any damaged flashing or siding at the roof line, replacement will be performed at *$ 1 a — If wood deck, siding, and flashing is sound, we will re -nail any loose wood to rafters, sweep deck, and prepare for roofing. PJ`Install 8" drip edge to all rakes and eaves. Color .E1 Apply ice & water shield (UNDERLAYMENT) as per manufacturers' specifications and/or 1 *. �' LIA 01pply premium (UNDERLAYMENT) to the balance of the exposed wood deck. Re -flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensure water tightness. CYIf upon inspection, we discover chimney lead to be worn or deteriorated r Placement will be performed at *$ ^ r e"Ife— ..--W* j El Install a new: l__1Year ❑ Traditional Fr Architectural ❑ Designer Colors Q -Furnish and Install a new shingle over style ridge vent system ❑ Soffit vent system *$ a1lIl debris generated by Lambert Roofing Co., Inc. will be cleaned up and disposed of from the job site in a legal fashion. Under no circumstances will the watertight integrity of the buiding be compromised. ( Special Notes _ ` i V,,i A �1 `i' 4 c \,c �, "'0;`l l., Wit' !i ( 0 ro i, cam c F' � r �I,ey UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE ANORKMANSHR GUARANTEE FOR A PERIOD OF `- YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY ANDr - ,YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER. ❑ MANUFACTURER UPGRADE *$ *Denotes potential additional costs above the total estimated price. ~ TOTAL CONTRACT PRICE AND PAYMENTISCHEDULE The Contractor agrees to perform the w/rk, furnish the terials and labor specified`above for the total sum of: $ / ` � CV r' (*) rrot Payment will be made according to the following work scheduler $ V at/t% n Ideposit upon signing contract $ by _/_/_ or upon completion of $ ��� �'�� ©� upon completion,of contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) You may cancel•this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram or by delivery, not later than midnight of the third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES Acceptance of the Contract Proposal Home Owner(s) Signature(s): .. t •�' it ` Date: r l l /`' f Contractor's Signature: t—`'��"'' r �' Date: - / / www.lambertroofine.com (Please see reverse side) Materials and Specifications Product Quantity Product Shingle Counter Flashing (Size/Type) Color Hip & Ridge (Type) Pipe Flashing (Size/Type) Drip Edge (Size) Chimney Flashing (Size/Type) Starter (Type) Valley Flashing (Size/Type) Ice & Water (Brand) Caulking (Type) Underlayment (Type) Roof Deck Boards (Size/Tlype) Roof Vent (Brand/Type) Roof Deck Plywood (Size/Type) Nails (Size) Siding (Type/Style) Step Flashing (Size/Type) Miscellaneous Dumpster Location: Material Location: Special Instructions: Roof Drawings Quantity 06102/2014 hl�i a — Office of Consumer Affairs and business Regulation 10 Park Plaza - Suite 51 i0 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 1492211 Tvpe: Private Corporation Expiration: 1.2/6/2013. Tr# 218746 T.G.L.R.0 dba Lambert Roofing Company RICHARD LAMBERT 265 WINTER STREET HAVERHILL, MA 01830 -..-- Update Address and return card. Mark reason for change. Address j Renewal F-1 Employment i Lost Card %--pox"CLATE (&,NVDD,'YYYY) ERTIFICATE OF LIABILITY INSURANCE 08/27/2012 7PIIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFiCATE-HOL-DER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES SELQWTHIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND T14E CERTIFICATE HOLDER. WIPOR TIANT: If the certificate holder is an ADDITIONAL INSURED, the POlicy(ies) must be endorsed. If SUBROGATION IS WAIVED, sub;ect 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 ze-tificate holder in lieu of such endorsement(s). I PRO �DUCER 00-NIACT �4 t., E , Jerrold Kcurieras 'aT;L-AN INSURA14CE AGENCY INC. PHOWE AAIC Na(978) 745-5905 Ejjj�_ 163 1/2 jefferson Avenue 2nd Floor Jerroldftlianinsuxance. co, 1p -o, BOX 5ii SALEM MA 014970-0511 INSUPEMS) AFFORDING COVERAGE NAI 11 IINSURER A.Seaeca IN FAII RE D I R INSURER B -Saf et,,r Insurance Co anv WSURERC-Alterra Excess & sualus Ins. C Inc, kiba Lambert Roofing CampingiNSURERD:Ace Winter American Insurance Co. INSURER E 465 Stireet iHaverh.411 MA 01830- I .... . ..... .... INSURER F rJ A f, E=0 ------ CERTIFICATE NUMBER, REVISION NUMBER: f. t4 IS 10 CERT 07Y THAT THE POLICIES OF INSURANCE LISTED BELMN HAVE BEEN ISSUEDTCSTHE INSURED NAMED ABOVE FOR THE POLICly 71 11'tai ,-,AIED NO71AATHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT V' IJITH RESPECT 10 "ArKICH, THis C�ER.'-H--DATE fv11AY BE ISSUED OR 44AY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEIREIN IS SUBJECT TO ALL THE T`ERkjc, L,,,*CUUS1ONSAND CONDITIONS OF SUCH POLICIES, LIMITS S'40'JVN MAY HAVE= RFFM QFnw1,Pr) Ry Pain r-1 A19PIQ A TYPE OF INSURANCE 7A L sue OLIC POLI 79CY UP MIRI wVD I POLICY NUMBER IMMIDDYIE-tFyl 01MIDDly LIMITS GENEIZAL LIABIf-IT-Y --1, OGO 0071 X C`)M , f,V-F:,C-;AL G,-- N- Rk L' HII. nl- D,%NIA—= 4 PREMISES S 5 o , 0 0 c MADF 11/ 12 2012 - ------------ !�ERSONPM, & ADV WURY E KI F R AL A G Q R. LQ ATE E 2,000,000 (,L,N; 1'v,GR7 CAT- 1v ,PPI -IFS PER I I P-R'00,UC TS - COMPIOP AGG 2,000,000 Loc AUTOMOBILE LIABILPT, Y ANY Ljo,-o —Go I 1— — I x ALL 0,00N r P X 1 SCHEDULED, Akj OS 16203819 P7/16i2012 BODILYINJQRY�Prter �or's. 01/16/20'-3 Auros FX1--11 NON-OVNED U) AUT(IF AUTOS FRG—PE07 UMBRELLA LIAS X OCCUR EXCESS LIAR 3EC50000040 EACaf 01-CuRrENCE 1�11' ::LAIFAS-MADE DED I I f--,ETFN.--,!0N x1121/2f11'11:12{20121 V-'ORKERS MAPENSATION AND EMIPLOYIERS'LIABILITY j c� x ytu fvim-1 NIA I _J_I�JC * 81 L. -- CH '411andator} in NHt 0142954 -A 08/28/2013 El DMEASf� CA EM rj 0 W� SCM!, �)—PAT o 0 E L MS�ASE 110i I TGLRC, Inc. DBA —Iambert Roofing Co. 265 Winte„ Street a v e r b- i' I S. AGORD 25 (2010105) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE 'WILL BE DELWERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTFORIZZED REPRESENTATTWE lv—k 01830- 1988 -2010 ACORD CORPORATION, All rights, reserved, The ACORD name and 11090 are registered marks of ACORD Name($usiness/Or,,anization/Individual): Address: City/Sta /C r=. � z eld Phone #: 7�,? ,3'7 AXeyou an employer? Check the appropriate box: lam a employer with. GrL,_1— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp, insurance required.] 3.0 I am a homeowner doing all work myself. [No—workers'. comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.? 5. El We are a corporation and its officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' e4;�p Type of project (required): 6. [] New construction 7. ❑ Remodeling 8.Demolition 9. [] Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other comp. Insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:__z4,%'����� Expiration Date: Job Site Address:fJ %��� %Ae RV City/State/Zip: � KQ� r Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). �J 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifyunder e ains and penalties of perjury that the information provided above is true and correct. vZ Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License # 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: . The Commonwealth of Massachusetts department of Industrial Accidents }r Office OfIII vestigations 600 Washington Street Boston, MA 02111 �- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers replicant Information Please Print Leaibl, Name($usiness/Or,,anization/Individual): Address: City/Sta /C r=. � z eld Phone #: 7�,? ,3'7 AXeyou an employer? Check the appropriate box: lam a employer with. GrL,_1— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp, insurance required.] 3.0 I am a homeowner doing all work myself. [No—workers'. comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.? 5. El We are a corporation and its officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' e4;�p Type of project (required): 6. [] New construction 7. ❑ Remodeling 8.Demolition 9. [] Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other comp. Insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:__z4,%'����� Expiration Date: Job Site Address:fJ %��� %Ae RV City/State/Zip: � KQ� r Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). �J 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 certifyunder e ains and penalties of perjury that the information provided above is true and correct. vZ Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License # 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: .