HomeMy WebLinkAboutBuilding Permit #893-13 - 32 SANDRA LANE 6/20/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: S Date Received d
Date Issued:
IMPORTANT: Applicant must complete all items on this page
I LOCATIONS
�.
• � Pr t
PROPERTY OWNER
- Print` 016 rOJd'Structure
MAPiNO.' PARCEL`: ZO.NI,NGDIS�TtRICT �Histonc _Distnctf ills'e� yes no
MachiShop V g-
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
�eSeptie�` Ell 1Nell� _ a
=platni ❑ V;11etlard5�
.
y
DES RIPTION OF WORK TO BE PERFORMED:
Id
OWNER: Name:
Address: fid` J&10?
f --
°C®NTRACaTOR� :Name _
I 7
Adtl`es_s
Suparmso(sj;Constructi4oh ti
Please Type or Print Clearly).
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ARCHITECT/ENGINEER y 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: $ FEE: $ ��/•
Check No.: !�Zo Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of,,Agent/(D.W.h ,. �. Sig�atureof contrac
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Stamped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE -OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/BodyArt ❑ ..
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
. DATE REJECTED DATE APPROVED
❑ ❑
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
Planning Board Decision:
Comm
Conservation Decision: Comments
,Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow;L Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 MainStreet
Fire Depa�trneit-signature/date
COMMENTS
Dimension
i 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
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A -F and G min.$10041000 fine
NOTES and DATA — (For de
® Notified for pickup - Date
Doc.Building Permit Revised 2010
ent use
Building Department
The fohowing 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
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
a Certified Surveyed Plot Plan
a Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Ei Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apn,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.Building Permit Revised 2012
Location C X 6/v,
No. -7
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
Foundation Permit Fee
0 er Permit Fee
th
TOTAL $
Check #
26543 Buidna InsDector
rroposiai
HIC # 174377
0SRDamphousse
Roofing uP
A trusted name since 1938
Roofing - Siding - Windows
87 Belmont Street -North Andover, MA 01845
P: 978-683-4588 - F: 978-685-7446
NAME OF OWNERZ ev/
ADRESS OF JOB C:9i'r �_.4/)C' _ ,�� !�•G
TEL. DATE: 6-19 AM,
We will remove all roof shingles off total roof area, up to two layers. Replace any boards or sheathing at
additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane
applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing
step flashings to remain. A new base sheet applied. A.gAyr-architectural roof shingle installed. Install new vent
pipe boot flashings. Waterproof existing chimney flashing and remove debris.
Shingle Color: .":�,1J✓t�frli/tet Gt /./1y
Ridge Vent Upgrade $8.00 per ft. ._1) 1U t�/.-G.O 1/ A&A
Wood Sheathing Repair $8.00 per ft. / t d �-e.--
65-Ao
a A012 -�
i
ly
s�
We Propose herby to furnish material and labor - complete in accordance with above specifications, for the sum of:
dollars ($
Payment to be made as follows _boo// ,5 / � " �% d •�
�4✓I GL. 4
1 l F Authorized
Signature _
C.
��' ✓ ^�/ J J S /V'+ NOTE: This proposal may be withdrawn by us if not accepted with in`days
Acceptance of Proposal - The above prices,
specifications and conditions are satisfactory and are herby
accepted. You are authorized to do the work as specified. Payment
will be made as outlined above.
wT
Signature _ -�__ ._.•�'
Date of Acceptance pr Signature
HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS (M.G.L.142A)
1. WORK: Provided the Homeowner performs under this agreement, the Contractor shall perform the work on the Property as specified Proposal, attached
incorporated herein. The work does not include extraordinary conditions of which the Contractor could not reasonably be aware. If such conditions are
encountered, this shall be an additional cost to the Homeowner. Materials selected by Homeowner may have to be ordered or custom made, which items are
specified in the Proposal. The Contractor is not obligated to agree to any modifications, extras or change orders unless such items are agreed to in writing by
the Contractor. All extras and changes shall be at an additional cost to the Homeowner. Contractor shall perform the work in a good and workmanlike manner
using materials consistent with this contract. Lawn or Driveway may be damaged by dumpster or equipment. Due to material shortages Contractor may
substitute materials of equivalent grade.
2. PERMITS: If a building permit is required for the work, the Contractor shall obtain same as Homeowner's agent. Contractor is not responsible for any
other permits that may be required for the Work, and Homeowner is responsible to determine whether any zoning, planning or wetland related permits or
approvals are necessary. Homeowners who secure their own permits or deal with unregistered contractors will not have access to the Guaranty Fund.
3. COMMENCEMENT AND COMPLETION: Homeowner acknowledges the commencement date of the work is fluid, and is subject to numerous factors
such as scheduling other contractors, delivery of materials and weather. Contractor and Homeowner shall determine the commencement date of the Work
when a more definite determination can be made and shall execute a written acknowledgment of same. The Work shall be substantially completed within 7
days of commencement, except for longer periods as may apply to particular projects as Contractor shall notify Homeowner in the Proposal, and subject to
delays for circumstances beyond Contractor's control. Notwithstanding, the commencement date and substantial completion date may be extended, and the
Contractor will not be liable for delays caused by, labor or material shortages, delays in delivery of items selected by the Homeowner, governmental action, .
and unforeseen events beyond the Contractors control, including but not limited to weather, strikes, war, the acts of third persons or the acts of the
Homeowner. The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractors other jobs.
4. PAYMENTS: Contractor agrees to perform the Work and to furnish the materials and labor specified in the Proposal for the amount as stated in the
Proposal. Thirty percent (30%) of the total is to be paid as a deposit with the signing of this contract. Upon cancellation prior to commencement of the
Work, any remaining deposit will be returned less the costs for materials ordered for which Contractor was unable to cancel. Final payment shall be due
upon completion of the Work and Homeowner agrees it may not hold any retainage. Late fees may be applied for late.payments. Homeowner shall pay
Contractors reasonable costs of collection, including attorney's fees and costs. Time is of the essence hereof.
5. WARRANTY: For a period of Iyear after substantial completion of the Work the roof will be free of leaks caused by defects in workmanship,'
but not those caused by ice backing -up or extraordinary weather events, including blizzards, tornadoes, hurricanes or storms of greater than a twenty-five
year duration or intensity. Contractor gives no warranties with reference to any materials or equipment installed in the Premises, passes any such warranties
directly to Homeowner, and Homeowner agrees to look only.to the manufacturer with reference thereto. This limited warranty extends to the Homeowner
only and is not transferable to succeeding Homeowners. This Limited Warranty specifically excludes (i) all consequential and incidental damages; (ii)
damage due to ordinary wear and tear, abusive use, misuse, or lack of proper maintenance; (iii) defects which are the result of characteristics common to
materials used; (iv) defects in items installed or supplied by anyone other than Contractor; (v) work done by anyone other than by Contractor; and (vi) loss
or injury due to .the elements. There are no other expressed or implied warranties or representations made or given.
6. ENTIRE AGREEMENT: This contract and all documents referenced herein constitute the complete and final agreement between the parties. In the event
that any of the provisions of this contract shall be held to be invalid, the remainder of the provisions of this contract shall remain in full force and effect. Two
identical copies of this contract have been completed and signed. Homeowner acknowledges receipt of a completed contract signed by the Contractor.
7. HOME IMPROVEMENT REGISTRATION: In accordance with M.G.L.c. 142 A, § 9, Contractor is registered with the Bureau of Building Regulations
and Standards Registration No: 174377. Homeowner may verify by contacting the Director at (617) 727-3200, ext. 25205. A Homeowner's,'nj""h`E�k&
the Home Improvement Law (M.G.L.c. 142A) and other consumer protection laws may not be waived in any way. Homeowner acknowledges receipt ofd
copy of 780 CMR R6 and Massachusetts General Laws chapter 142A, and which are available online at www.mass.gov. Questions may be direci&137
Consumer Information Hotline, (617)727-7780.
8. ARBITRATION: 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 such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs
and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c. 142A. No lien or security interest is
imposed on the Property as a consequence of this contract; but Contractor has the right to record this contract or a notice of this contract, or seek a lien if the
Homeowner breaches this Contract.
9. HOMEOWNER COVENANTS: The Homeowner agrees, represents and warrants that (a) the Homeowner grants permission to the Contractor to enter the
Property to perform the work as covered by this contract; (b) the Homeowner has funds available to make full payment under this contract to the Contractor
upon completion; (c) the Homeowner understands that construction as contemplated by this agreement creates a dangerous condition, and agrees not to enter
portions of the Property under construction until the Contractor advises the Homeowner that the construction is completed; (d) Contractor may need use
landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and (e) that code requirements may result in
roofing nails penetrating through roof decking and will be visible on the underside of some surfaces. The Homeowner indemnifies, exonerates and holds
harmless the Contractor from any loss, damage, claim, liability or expense (including reasonable attorney's fees, deposition costs and court costs) resulting
from a breach of this provision. Contractor is not responsible for damage to landscaping that will grow back during the next growing season.
10. CANCELLATION: Homeowner may cancel this agreement provided Homeowner notifies the Contractor in writing at the address listed in the Proposal not
later than midnight of the third businer•ss y folliowe signing of this agreement.
HOMEONER: ` C -Q— ^ DATE: 'sW�J
Shingle: DEPOSIT:
4/2;5.�2013 8:32:27 AM
8435 ® 03/03
��R CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDNYW)
0412312013
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 POLIO.15t
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORif iJ
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 00474 - 001
Doherty Insurance Agency Inc
ACT
NAMpNE:
(AIC. No. Ext): (978)475-0260 [RC No.:
EMAL
ADDEtESS:
PO Box 1985
Andover, MA 01810
LIMITS
INSURERS AFFORDING COVERAGE NAIC t
INSURERA : A -I -M- Mutual Insurance Company 33758
INSURED
Damphousse Roofing LLP
INSURER B
INSURERC:
INSURERD:
87 Belmont Street
North Andover, MA 01845
INS E'
INSUR RF:
rnvconr_cc CFRTiFICATF NIIMRFR• REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
TYPE OF INSURANCE
ODL
INSR
UBR
VV1I
POLICY NUMBER
POLICY EFF
MMlDDNYW
POLICY EXP
MIDDNYW
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
P EM SES G' TOEa ocawrrence $
COMMERCIAL GENERAL LIABILITY
MED EXP (Any one person) $
CLAIMS -MADE � OCCUR
PERSONAL & ADV INJURY $
GENERALAGGREGATE $
EN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS- COMWOP AGG $
OLICY CT OC
EalagddentSINGLE LIMIT $
AUTOMOBILE LIABILITY
BODILY INJJRY (Per person) $
ANY AUTO
8001LY INJURY (Per accident) $
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
Pe08E�Ra DAMAGE $
HIREDAUTOS AUTOS
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAR
CLAIMS MADE
L
DED RETENTION $
$
W)RKERSCOMPENSATION
A DDpERMOPpL�OYYEERS'LIIARBILIETRY/E�E
X 4VC STATU- OTH-
TORYLIMIITTS ER
E.L. EACH ACCIDENT $ 500,000
A
OFF ICERItdEM8ER�EXCLUDED? �TIVEYa
NIA
AWC400-7028774-2013A
4117/2013
(Mandatory in NH)
E.L_DISEASE -EAEMPLOYEE $ 500,000
EL. DISEASE -POLICY OMIT $ 500,000
DESSCRIPTIO I OFOPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
e
No partners are covered by the workers compensation policy.
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
4454
A � 22-2013 MON 12:24 PM
Client#: 14415
ACORD,. CERTIFICATE OF LIABIL
PRODUCER
Doherty Insurance Agency, Inc.
P.O. Box 1985
21 Elm Street
Andover, MA 01810
IN
1N6URCO
Damphousse Roofing LLP IN
87 Belmont St IN
North Andover, MA 01845
COVERAGES �N
THE POLICIES OF INSURANCC; LIS rEn BELOW HAVE 13EEN I$S UED TO THE INSURED N
ANY REQUIREMENT, TERM OR CONDIT ION OF ANY CONTRACTOR OTHER DOCUMEN-r
MAY PERTAIN, THE INSURANCE A>'I'ORDEU UY THE POLICIES DESCRIBED HEREIN IR
POLIC,IES. AG(CREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS
VER TYPE OF INSURANCE _ POLICY NUMBER -t POLIS j
A GENERAL LIA80A
TQ UP159387
X GOrdMEHfIAL Gr.NERAL I IAea.IYY
cLnlMs MAUI: IJ OCC11k
X BI/PD Ded:1 000
l A(54_RI7GA-IF LIM11 APPLIa:S PER:
F01 Icy n PRO• �'�
IFr.T 1 oc
OMOBRE uaelL"
ANY AUTO
At L OWNI.O AUTO.;
$ChEDUt ED Au IOC
HIRCU AUTO3
NON OWNF-D All IDS
AGE LIABILITY
ANY Aul D
Or.C,lR I I CLAIMS MADC
11FDUC:TIH1
WORKERS COMPENSATION AND
ENIPLOYF,RS' LIABILrrY
ANY PHnr'RICTOKIPAR,NE111CXEt:UTIVC
OrFwFIVMQ61HER CX(Akil)C09
IrYns.(far"inq. ae,
SPFMAL PROVISIONN Miirnv
OTHER
FAX N0, 9784750303 P. 03
ITIY INSURANCEoATE(MM
sIrYYYV(
THICERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ON AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOL ER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALT R THE COVERAGE AFFORDED BV THE POLICIES BELOW.
SUR�ERS AFFORDING COVERAGE NAIC ri
su— A ain Specialty Insurance Company
32REI' A:_
---•-
04/12/13
i
OESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS RODEO BY ENDORSEMENT r SPECIAL
Covering operations usual to Damphousse Roofing LLP...
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
i
I
ABuvc-; FOR THE P01.147Y PERInn INUIr.ATEU. NOTWI rHSTANUINt3
?iL PECr TO WHK:IA THIS r,ERTIFICATF- MAY BE 163LIE-D or,
,T 10 ALL THE TERMS. EXCLUSIONS ANn (;ONr)ITIONs OF Sucl I
:TIVG POLICYEXPIRATWN
Y _DAT. EIMMID0im LIMITS
04/12/14 EACH OCCUHRENCF -11-000000
IIAMAGC 10 R[NT6n —
13 fF:d9[tar>•u•r1 $100,000•
MLU FXP IAnynn.,. uerxnl 15 000
PEr3ONAL 6 Auv IN-IUkY S1 000 000 -
CEN6HAI,AGUHFr,,Ar--'1'1210001000
PROuUCIg. COMPADPAW'. ,2.O00 nnn
C.OMnINF:0 INt(I I- LIMII�
(En acn4a,jQ a
BOUn Y IN.ItIRY
Iper
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PROFFRrY DAMAGE
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$
AUTO (7NIY•CA A(:!'.IDENI
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OTHER THAN EA AQj_
AUTO UNI Y
kAC410C,'UP I:NCF•-
3
SHOULD ANY jF T"G ABOVE OLSCRIBCD Pn1,ICIES RE CANCELI.ED BEFORE THE EXPIRATION
DAT[ YI,ERE I . THE ISSUING INSURER WILL ENDEAVOR TO MAIL __10_ DAYS WRITTEN
NOTICE 70 TM CERTIFICATE MOLDER NAMED TO THE LEFT, DUT FAILURE TO DO So SMALL
�MPOSt NO OD IGATION OR LIAOILIIY OF ANY KIND UPON THE INSURER, ITS ACFNTS OR
TEPRESENTAT ESQ
ACORD 2S (2001!08)1 of 2 #S29121/M29119 pfyl c� AC CORPORATION 1988
i miassaacnnusetts - Dep t <Lme07 Fu;!--ii—
rd
L ti rd Of `uIldina i!ev+.iiait.'?f
Construction Supervisor-
CS.;055108
!LLS
/J�(Dd�i77/I7G4�Z{OBCI,�� d�U!/�CfJ�CLCIL[CrG'L�1
\ Office of Consumer Affairs & Business Regulation
_ = ti ME IMPROVEMENT CONTRACTOR
ftgistration 174377 Type:
MY2/4/20-1 LLP
DAMPHOUSSE ROOFING LLP
SHAUN TWOMEY
87 BELMONT ST
N. ANDOVER, MA 01845 Undersecretary
The Camrnot werz `h of h assachusetts
'—� department of rAduMial Accidents
---_ 0i ice aaaons
600 Fi aSiZnb�tontrset
Boston, ami .02III
rsn� m�zs�govIM'
RTorkers'' ompezcsaf3ou insuranceRiders/Cgntraetors/E�Iectri - lP umbRrs
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:.
Please Frig€ -Lt -46
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city/Si te/Zip: r t a Ph '' A
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Type of
project(regnired)
am a employcrIvith- �. � I am a
_ _ _= eraI '-actor ane I b Nca= construction:
employees (foil gad/or va«-um j
have luted the snb-; onzractors
2-0 I am a sole proprietor Orparine-�- listed oz+ the attached sheet 7- .j� Rrmooeitns
ship.andlraveno employees Tnest sub=contractors have 8 -
ED bmnoytion
'woriang, .forme m any capacity_wo-ik=s' camp *, ,ce. _
[No workers' comp. ince,-�„� 5 f�T�Te am a corpararion and its ' 9 � J wu; a aaaiuon
rete ]. officers rave:45Xcrcis their, 10.07 .mectncai repairs 6r additions
3: I am iromeown dome 71r,air vroik right or ,=r_ p iOn_p, __MGL 11:n Ptpmbma sirs or additions
myself LNo vvariLmrs' co4ua: c,152_ l (4), and we have iio f �! r
l_ Ro6X r -lairs
insurance regtttred:j t eMDloyevs_ iNo cvorh.�rs'
comp- insLirancereauiree13.0 Other
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a z amts submit z M_ -w a�iaavit midi tin
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zrtformtrtion.
site
Insance Company Name
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'_Ej�pirationDas: 17, /
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City/State/Zip:
fi ttactt a copy of the workers' compensationpolicy d ation _page rshosz the poiicp number and eapirauon date).
railure.to s --m_ covem-ge as required und„-or Section 255A ofMGL c. I;2 can read to the imposition of cr;n„ ,Ll
penalties of a
fine up to S1P00.00 and/or one-year namisomnent as wall as civil penalties is the form:of a STOP WORK ORD�t gad a uric
of rip to ,5250.00 a day a__gains[ fne violator_ Be advises that a copyo this stat�mcn< may be forwarded tothe Once o;
Iavestigafions of the DIA for insurance coverage verification.
I do herebjr cerrifjr Cr the.pa=peaafiies of nerjun� ihatthe nfonnadon provided above is true'¢nd correct-
Signa
orrect
Signature:. -Data.-:_
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09isyr^biit this area. to be campy bj,. cifj, or torsnt offrcraL
City or Town: PenmitUcense r
Fssuiug Authority (circle one):
1. Board of Hearth I Buila132-11 Department 3. City/Tomm Clerk 4. Electrical Inspector 5. PItmtnirtg Inspector
6. Other
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