HomeMy WebLinkAboutBuilding Permit #140-13 - 34 WILD ROSE DRIVE 8/20/2012 NORTFI
BUILDING PERMIT O�<tLID /616
6 O
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
oR ,`
Permit NO: o Date Received ��sS-lL CHus���y
Date Issued: 2,0 1 Z
IMPORTANT:Applicant must complete all items on this page
'LOCATT 10N
PROPERTY'01NNER h iC' 1i�[�SVii
Pnnt
MAP NO: PARCEL: -� Z_ONING DISTRICT;; Histonc.District yes no,
- MachineSfiop:Village yes no-1 . '
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.' V1laterslied',Distict"
Water/Sewer,. - y
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: -%06 le i Phone' 274 790 °��2�
J�
Address: . . .. -.
I Phone:. 617
CONTRACTOR Name:
Addres
s. SU s a e dl IaIJ 5-
Supervisor's,Construction License: 1021 b� Exp Date r2-
J
,,Home 11Drovementy,Li0-e0se:1 Ex p :Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 00o �il� FEE: $
Check No.: f Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/.Own re of contractor
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
CONSERVATION Reviewed on Signature
COMMENTS
4
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments '
Conservation Decision: Comments
Water& Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Loc d 384 Osgood Street
FIRE DEPARTMENT - Temp Du ps er oris Yye '> -- no-- ---=-,
Located at-124'Mam Street
e&2 c2
Fire'Departmentsignature/dat
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 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
❑ 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)
❑ 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
VOTE: 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 2.2008
Location&j�
No.�� Dat +�
• • TOWN OF NORTH ANDOVER
• �SyLC[�j(44 1
•
Certificate of Occupancy $
� Building/Frame Permit Fee $ �
Foundation Permit Fee $
Other Permit Fee �.$
TOTAL $
Check#ii/�—
25626 Building Inspector
NORTH
Town of TAndover
O - ~" 0
No.
13 ih
o h ver, Mass, e�►� eL
coc Mlc Ml W.cu y1_
�•4 q�A'�TEO I,PP�,(5
S U
BOARD OF HEALTH
Food/Kitchen
PER T L D Septic System
THIS CERTIFIES THATMEZ ........................... BUILDING INSPECTOR
.-...•...•.......... Foundation
has permission to erect .......... ............... Ab ' dings on ..`,�.(...W.Ad.jr. ..
Rough
tobe occupied as ....... .. �... .... . ...... ......... A -OV.f....................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in 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
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRU10 TS Rough
Service
...... ............... _ . . .......... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
Smoke Det.
SEE REVERSE SIDE
I
It
GN loel!`
10
Fbldb(g) FOSS 1 "/ ] p V
5�
CD
GASIw Wi�Jt?ow'tn l3�t r i N-� 0
i G-okbI N F—rs
301 t? +.i46 w
!
? o�Ec�55 2Ef~RIGFi�t� AS ► n
N j
°s�� Vw*r ROOD _ .__ .._ ... ._ ..M __ Muer, As p64`41 sj- 1WIV Wkt t,
i ( f-eF - �,MODFOL, tax is 2.6�/i� D
f ! B2tf�? Foss wl 10"H.�wcuJp� 40
b ' I>6,>,t
>1DtoON t�P.fj.) I- kte ES
w i g ! '5 Ob 22
�! 11 ` ...,,,,.� �``,,...,.E._....,• i 4. v 2PAW @
�
Gooqe
W
4ve,if
To v� o t�} �►3t-5 2 ►pit;• !02 ( r z
' 1�a aRowN ¢ 3 OIL
R#"1�.i N }I i hoo0 r,w G SN's o V v�- ($)e
PAZ Zt
WOOP TOC' 1104.: P1. 23
fill $
� w
Desion�s LLC 2012
To ids S�
u FINAL PLANS FOR INSTALL
i Per Approved Cabinet o r
Confirmation,Specifications z
and Shop Prep Detail$
z
DATE: August 19, 2012 REGATTA CONSTRUCTION INC.
1 10 M ►��
Homeowner Information
50 Jersey Street
Stan and Diana Zientarski Marblehead
Name MA 01945
34 Wild Rose Drive 781-639-1660
Street Address Lic#102163
North Andover,MA 01845 HIC#163531
City/Town State Zip Code EPA/RRP Certified
978-689-0028 978-790-7425
Home Phone Cell Phone
I. PARTIES
This contract(hereinafter referred to as "Agreement") is made and entered into on this 19th
day of August, 2012, by and between Stan and Diana Zientarski, (hereinafter referred to as
"Owner"); and Regatta Construction Inc., (hereinafter referred to as "Contractor"). In
consideration of the mutual promises contained herein, Contractor agrees to perform the
following work, subject to the terms and conditions below:
II. GENERAL SCOPE OF WORK DESCRIPTION
Kitchen renovation. Plans from TRK Designs dated June 6`h (final revision).
A. PRICE FOR ALL WORK ABOVE: It is understood that we have a
preliminary budget. TRK designs providing plans, cabinetry, appliances, etc. We provide
all building supplies, carpenters, sub-contractors and finish goods like switches and switch
plate covers,trim, etc. After the walls and floors are opened and existing conditions are
presented, final costs may be determined. See attached estimate for preliminary costs
estimated at aprox $22,000.00
B. TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
Regatta Construction agrees to perform the work described above and any additional work on a
cost-plus materials basis. Regatta will invoice for materials and labor bi-weekly. Invoices are due
upon receipt.
C. DATE OF WORK COMMENCEMENT AND SUBSTANTIAL COMPLETION
Commence work: 8/20/2012 (pending approval from Bldg. Dept). Construction time through
substantial completion: Aprox. 25 to 30 working days, not including delays and adjustments for
delays caused by: holidays; inclement weather; accidents; shortage of labor or materials; additional
time required for additional work;
q odelays caused by Owner, Owner's design professionals, agents,
and separate contractors; and other delays unavoidable or beyond the control of the Contractor.
Contractor OAer Owner
III. GENERAL CONDITIONS FOR THIS AGREEMENT
• Dust and dirt
Dust is an unavoidable byproduct of construction. Regatta Construction will make every
attempt to limit dust production and reasonably clean up debris at the end of the work
day. It is advised to the client that dust and dirt-sensitive materials be removed and
stored away from the work area to avoid damage.
• Tool Storage and Crew Facilities
In order to facilitate the set-up and cleanup of the job on a daily basis, some tool and
materials storage is necessary on site, in a safe area. Additionally, bathroom facilities
are required for normal use of the crew. If interested, a porta potty can be provided at
$125-150 per month charge.
IV. STANDARD EXCLUSIONS:
Unless specifically included in the "General Scope of work" section above, this Agreement
does not include labor or materials for the following work:
• Plans, engineering fees, or governmental permits and fees of any kind.
• Testing, removal and disposal of any materials containing asbestos (or any other
hazardous material as defined by the EPA).
• Custom milling of any wood for use in project.
• Labor or materials required to repair or replace any Owner-supplied materials.
• Repair of concealed utilities not located on prints or physically staked out by
Owner which is damaged during construction.
• Temporary sanitation, power, or fencing.
• Correction of existing out-of-plumb or out-of-level conditions in existing
structure.
• Correction of concealed substandard framing.
• Rerouting/removal of vents, pipes, ducts, structural members, wiring or
conduits steel mesh which may be discovered in the removal of walls or the
cutting of openings in walls.
• Removal and replacement of existing rot or insect infestation.
• Failure of surrounding part of existing structure, despite Contractor's good faith
efforts to minimize damage, such as plaster or drywall cracking and popped
nails in adjacent rooms or blockage of pipes or plumbing fixtures caused by
loosened rust within pipes.
• Public or private utility connection fees.
• While we go to great lengths to avoid this, however,repair of damage to
roadways, driveways, or sidewalks that could occur when construction
equipment and vehicles are being used in the normal course of construction.
• Cost of correcting errors and omissions by the Owner's design professionals and
separate contractors. Cost of correcting and repairing damage by separate
contractors and owner in the process of separate work.
• Cost of correcting/testing/remediating mold/fungus/mildew and organic
pathogens unless caused by the sole and active negligence of Contractor as a
direct result of a construction defect that caused sudden and significant water
infiltration into a part of the structure.
Contractor O er Owner
,
V. CONCEALED CONDITIONS:
This Agreement is based solely on the observations Contractor was able to make with the
project in its condition at the time the work of this Agreement was bid. If additional
concealed conditions are discovered once work has commenced or after this Agreement is
executed which were not visible at the time this Agreement was bid, Contractor will point
out these concealed conditions to Owner, and these concealed conditions will be treated as
Additional Work under this Agreement. Contractor and Owner do not need to execute a
Change Order for this Additional Work, but shall discuss and confirm prior to proceeding.
Contractor is released, held harmless, and indemnified by Owner from all pre-existing
mold, fungus, mildew, and organic pathogen problems and is not responsible for costs or
damages associated with correcting, containing,testing, or remediating the same.
VI. WARRANTY
Thank you for choosing Regatta Construction to perform this work for you.Your satisfaction with
our work is a high priority for us; however,not all possible complaints are covered by our warranty.
Contractor does provides a limited warranty against material defects on all Contractor-and
subcontractor-supplied labor and materials used in this project for a period of one year following
substantial completion of all work. This warranty covers normal usage only. You must contact the
Contractor at the address on page one of this Agreement in writing for warranty service immediately
upon discovering an item in need of warranty service. If the matter is urgent,you must also call the
Contractor and send written notice of the need for warranty service. Failure to notify the Contractor
of the need for warranty service within ten days of discovery of a warranty item may void this
warranty. Additionally, Owner's hiring of others or direct actions by Owner or Owner's separate
contractors to repair a warranty item are not covered by this warranty and will not be reimbursed by
Contractor if a minimum of ten business days has been given to remedy the situation.
No warranty is provided by Contractor on any materials furnished by the Owner for installation. No
warranty is provided on any existing materials that are moved and/or reinstalled by the Contractor
within the dwelling or the property(including any warranty that existing/used materials will not be
damaged during the removal and reinstallation process). One year after substantial completion of
the project,the Owner's sole remedy(for materials and labor)on all materials that are covered by a
manufacturer's warranty is strictly with the manufacturer, not with the Contractor.
Repair of the following items and related damages of every kind are specifically excluded from
Contractor's warranty: problems caused by lack of Owner maintenance; problems caused by Owner
abuse, Owner misuse,vandalism, Owner modification,or alteration; and ordinary wear and tear.
Damages resulting from mold, fungus, and other organic pathogens are excluded from this warranty
unless caused by the sole and active negligence of contractor as a direct result of a construction
defect which caused sudden and significant amounts of water infiltration into a part of the structure.
Deviations that arise such as the minor cracking of concrete, stucco, and plaster; minor stress
fractures in drywall due to the curing of lumber, shrinking/cracking of grouts and caulking; fading
of paints and finishes exposed to sunlight are all typical(not material)defects in construction,and
are strictly excluded from Contractor's warranty IF in fact Contractor is charged by sub-contractors
to repair.
Contractor bw er Owner
VII.REQUIRED READING:
NOTE: Owners who secure their own permits or deal with unregistered contractors are excluded
from the Guaranty Fund provisions of MGL c. 142A.
NOTE: All home improvement contractors and subcontractors shall be registered and any inquiries about a
contractor or subcontractor relating to a registration should be directed to:
Director,Home Improvement Contractor Registration
One Ashburton Place,Room 1301,Boston,MA 02108 617.727.8598
VIII.ARBITRATION
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor
has a dispute concerning this contract,the contractor may submit 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.
1 I ■
Contractor: CL :Homeowne A FS1 9 e
9,4-012-01:z :�
Date: 8'
Date:
NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT
OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY THE
CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN
WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES.
The prevailing party in any legal proceeding related to this Agreement shall be entitled to
payment of reasonable attorney's fees, costs, and post judgment interest at the legal rate.
I have read and understood, and I agree to, all the terms and conditions contained
in the Agreement above.
Lo 2v�Z &'t-41�
DATE CONTRACTOR'S SIGNATURE
g Zo/to lz Sign
DATE OWNER'S ST NATURE Her e
DATE CO-OWNER'S SIGNATURE
Contractor OwKer Owner
1 CW-HIGof�`r
REGATTA CONSTP VCTION, INC. Estimate
® U ' <�> 0 0 FAR,
50 Jersey Street Marblehead, MA Date Estimate#
01945 8/19/2012 76
Name/Address
Stan and Diana Zientarski
34 Wild Rose Drive Project
North Andover,MA
01845 Kitchen Renovation 2012
Description Qty Rate Total
Stan and Diana,
Thank you for the call and interest in working with Regatta Construction.
I have given three estimates for the kitchen based on the cost of several recent jobs of similar scope. Every
kitchen has it's own unique challenges,your costs may be a bit under this or a bit over depending on exactly
what we run into in the process,and all the variables;the cabinets,hardware,appliances,tile,lighting and
countertops. They can be all over the place,price-wise. Luckily,we aren't moving anything,the changes are
minimal,and it's a relatively new home,so the grey area as well as unknowns about plumbing and electrical get
smaller with each of those circumstances.
We work on a slightly different business model than most general contractors in that we have 100%
transparency. You get copies of the timecards,actual wholesale slips and subcontractor invoices and our
markup system is clear and straight forward. We take a small deposit that gets applied to the final payment and
bill you bi-weekly for services rendered,payment is due upon receipt.
We are$90 hr for a Sr.Carpenter and Apprentice together,$65 hr for any Engineering,Drafting and Design,
Architectural Liaison,Conservation Commission,Old and Historic,Planning Board or DEP work.
Our markup is 10%on goods and services over$3k, 15%on G&S between$1k and$3k,and 20%on G&S
under$1 k. We also offer the option of having you pay the sub-contractors directly and simply pay us hourly
rates to manage them and handle the logistics. It saves you about 5%for a few more checks and paperwork on
your end. We are okay either way.
Any questions at all,don't hesitate to call Craig or myself. I look forward to sitting down again and going over
everything together to hone a final budget.
Kind regards,
Christian Tosi
Regatta Construction,Inc.
617-894-5661
Total
Phone# Fax# E-mail Web Site
Ph:781-639-1660 Fx:781-990-3853 infb> g4attainc.com www.regattainc.com
REGATTA CONSTRVCTION, INC. Estimate
® A A0 110:
50 Jersey Street Marblehead, MA Date Estimate#
01945
8/19/2012 76
Name/Address
Stan and Diana Zientarski
34 Wild Rose Drive Project
North.Andover,MA
01845 Kitchen Renovation 2012
Description Qty Rate Total
Meetings:Client,Cabinet Reps,Building Dept,Sub-Contractor,Permits,Etc.(Christian's time) 30 65.00 1,950.00
Building Permits 31 18.00 558.00
Prep Site:Tape,tarp,cover,ventilate,tools,etc 4 90.00 360.00
Demo:Remove all cabinets and appliances,open ceiling and 4 ft path around cabinets for new lights and wiring 8 180.00 1,440.00
(4 men 1 day)
Clean up site after demolition work,and then every day at end of day. 16 40.00 640.00
Dumpster onsite 1 840.00 840.00
Plumbing;Budget for plumber to disconnect everything and install all new fixtures,ice maker,D/W,etc. 1 1,725.00 1,725.00
Assumes all venting is adequate
Electrical&Lighting;Budget to remove all lights and install new 5"cans adding one more,new 4"cans over 1 2,875.00 2,875.00
sink,new xenon under-counted lights and pendants over island,all on dimmers and new GFCI outlets as needed.
No new wiring assumed or home runs needed to panel.
Ceiling and patching by plasterer 1 1,380.00 1,380.00
Tiles,hardwood,carpet,etc.(NO BUDGET FOR FLOOR WORK)Should be fine. Option of a screening and 0 0.00 0.00
single coat depending on condition$700-1,000
Cabinets&Vanities:Install of cabinets,toe-kicks,island baseboard,soffit,molding,appliances,hardware 80 90.00 7,200.00
(Aprox 2 weeks)
Millwork&Trim:Baseboard as needed(allowance) 4 90.00 360.00
Electrical&Lighting:Lighting budget for pendants (all cans,switches,etc by electrician) 1 360.00 360.00
Supervision and Coordination by Licensed Construction Supervisor 40 55.00 2,200.00
21,888.00
TOTAL AVERAGE BUDGET FOR KITCHEN RENOVATION EXCLUDING CABINETS,APPLIANCES
AND COUNTERTOPS
21,888.00
Total $21,888.00
Phone# Fax# E-mail Web Site
Ph:781-639-1660 Fx:781-990-3853 infd>e§httainc.com www.regattaine.com
Office of Coasaa►er Affii-&Basin",(tt7u don
HOME ILIPROVEMENT CONTRACTOR
i Registration: 163531 Type:
Expiration: 7172t2013 Private Corporatio
,REGATTA CONSTRUCTION.INC.
CHRISTIAN TOSi
50 JERSEY ST '..—
MARBLEHEAD,MA 01945 Undersecretan•
�� i3eurd of 12uil�fir.;, itr•,u3ati .u. tta�1�1 .•- }'.-,�
\/
Construct rr 5• f•.
Lfr�r CS 102163
R,.. `. t7: 00
CHRISTIAN TOSI
50 JERSEY STREET
MARBLEHEAD, MA 01945
12/15M12
�... _..
Tr-,,- 102163
•- +.
0 D t3f3 '1
:'=EK7=73.CA
41 � r '
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
6114 Washington Street
Boston, MA 02111
{i www.massg ov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):__
Address:- _---50 J est . Vn—019q Jt�
City/State/Zip:- � DI°���Phone#: 617 g941 5(.61
Are you an employer?Check the appropriate box: Type of project(required):
1.Rt 1 am a employer with J- 4. ❑ 1 am a general contractor and 1 6 ❑New 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. 7. gRemodeling
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.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing 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 box#1 must also fill out the section below showing their workers'compensation policy information,
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information 6)"Wd Insurance Company Name: a
Expiration Date:#or Self-ins.Lic.#: I3
Job Site Address: 3 City/State/Zip: (� L
S= r1 � /VI� ►a 15
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 certd under the pains and penalties of perjury that the information provided above is true and correct;
Si ature: NDate: T Il Zo
Phone#: &17 gp/, ! �O I
Ofj?cial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Lieeuse#
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#: