HomeMy WebLinkAboutBuilding Permit #74-12 - 41 OAKES DRIVE 7/28/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: ` — Date Received
Date Issued: --)
r 20—/
IMPORTANT: Applicant must complete all items on this Daae
Print
MAP *7q*ARCEL:JY( ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT
PROPOSEJD USE
Resid ial
Non- Residential
❑ New Building
Ertne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alt ion
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
,
(I ent' ication Please Type or Print Clearly)
OWNER: Name: s Phone:
- e
Address: 'hawc 9�, nliR4�
CONTRACTOR Name: Phone: 4Q9 � =�
Address:-,FL�py�l�l, �. eV � n yaa%
Supervisor's Construction License: ��� Exp. Date: `
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULD/NG PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ t Q�i FEE: $�--�-
Check No.: 34lnl Receipt No.: aq l
NOTE: Persons contracting with unregistered contractors do not have access=ear and
f
Signature of Agent/Owner ryl"'�`^Signature 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 OFFICEIONLY
INTERDEPARTMENTAL SIGN OFF - U FORM!
DATE REJECTED
PLANNING & DEVELOPMENT ❑
COMMENTS
DATE APPROVED
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS l
Y
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Com
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
yes no
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
NU I C5 and UATA — (For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
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)
o 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: Doc.Building Permit Revised 2008mi
Location J
No. �r Date ��_
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ •.—
Check #
244l1 .�
Building Inspector
s�
E
.moo
doomp
46
TrI
ol
s.1
7�
C o
C3
O
O
vU
CL
C2. C. _
�t O
O L
S' Nim'
O x>1 y m a
CD
co
's lr `ALO
ti v u cmp ,p s c
H
m m
L
o Z' 3
O N •J
co
' N R
N
Po
y O O
ca
O
e z
_ ` O
a :c
L : CL
L..
= m
COL.—
ca
r O
H O • CD 2
y r A i r m
O W_ C .O % s
LU � �N � � C=G r
N N �C..0 C
O �+ •N
LU E Li wW CD
• V CD o c
0 y Q. m '� O
z = CAy=
�-- 8 0.« m
E
L
CD
CL
y
v
N
C
O
cmv
CD
C!
32C
7
Ca
0
cm
c
N
al
t
r
O
Z
0
0
:O
U
:A4
.A
w
w
P-4
T
La
7
O
U
U)
I
I
R
0
L
V
Z
co
CL
O CO)
CD o,
IQ
h
FE m m
CD CD CD
� f+
co
CD
a7 0 i
Cc o a
C
C_. c�Q
CO3 'C
O Cc
v Cc
FL CD
CO2 ts
J •fl
C CD
0 CL
V CO)
c C
c
_cc
d
is
0
U)
LLI
Y♦
W
W
19
W
U)
O
vd
C/)
aRi
0
w
P-4
r,
o
O
C
G
w
x
0
p
q
x
U
O
v
U
A
O
Q
�.
w
w
w
°
Y
cn
Q
o
cn
C o
C3
O
O
vU
CL
C2. C. _
�t O
O L
S' Nim'
O x>1 y m a
CD
co
's lr `ALO
ti v u cmp ,p s c
H
m m
L
o Z' 3
O N •J
co
' N R
N
Po
y O O
ca
O
e z
_ ` O
a :c
L : CL
L..
= m
COL.—
ca
r O
H O • CD 2
y r A i r m
O W_ C .O % s
LU � �N � � C=G r
N N �C..0 C
O �+ •N
LU E Li wW CD
• V CD o c
0 y Q. m '� O
z = CAy=
�-- 8 0.« m
E
L
CD
CL
y
v
N
C
O
cmv
CD
C!
32C
7
Ca
0
cm
c
N
al
t
r
O
Z
0
0
:O
U
:A4
.A
w
w
P-4
T
La
7
O
U
U)
I
I
R
0
L
V
Z
co
CL
O CO)
CD o,
IQ
h
FE m m
CD CD CD
� f+
co
CD
a7 0 i
Cc o a
C
C_. c�Q
CO3 'C
O Cc
v Cc
FL CD
CO2 ts
J •fl
C CD
0 CL
V CO)
c C
c
_cc
d
is
0
U)
LLI
Y♦
W
W
19
W
U)
JUL-18-2011 08:SSAM FROM-HOMEDEPOT PLAISTOW + T-978 P.001/008 F-614
PLEASE READ THIS
Sold, Furnished and installed by:
Branch Name' Boston Date' au y (7r '� Q 1 / THD At -Home Servicer, Inc.
d/b/a The Hume Depot At -Home Services
345A Greenwood Street. Unit 2, Worcester, MA 01607
Toll Free (800) 657-518'-, Fax (508) 756-8823
Branch Number: 31 Federal ID # 75-2698460; ME Lic # C 02439; RI Cont. Lie# 16427
/ CT Lic ft HIC.05655'n: MA Rome Improvement Contractor Reg. # 126893
Installation Address: All (� 5 f 'rV� tvrl` N �(3 rn 14CS 19 `a
City State Zip
Purrhaser(01 Work Phone: Home Phone Cclf Phone:
191VI % ] [97W] `no s -7/y [774 793 17 $�
Home Address:
(If diffen`nt from Installation Address) City State ZZip
E-mail Address (Io receive project communications and Home Depot updates):
❑ I DO NOT wish to receive any marketing entails from The Home Depor
Project Informal Undersigned ("Ctutotner"), the owners of the property located at the above installation address, agrees to buy,
and THD At -Home Services, Inc. ("The Home Depot") agrees to furnish, deliver and arrange for the installation (-Installation') of
all materials described on the below and on the referenced Spec Shect(s), all of which are incorporated into this Contract by this
reference, alone with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively.
"Contrvd")_
V r, A- Sher shm(s) # Project Amount
S7y3S
Roofing QSiding _-window., ❑ Inv,lation
['Guuas / Covers [31iiiuY Door ❑
r
❑liooffne Siding Windows 011=1126011
$
❑Guuers 1 Lovas flEntiY Doors ❑
❑Roofing Siding windows insulation
$
[]Guaira / Covers pEnuy Doors n
Roofing QSiding ❑windows ❑ Insulation
$
❑Gutters / Covers Dalry Doors 0^
1b imm mm 25`!b Deposit otCont rmt Am arat due upon exeCo11011 of the COOM L
Total Contract Amount
$ a�
Mame purdig sers may not deposit more thorn onethird of the Corimm Amowu.
! 4
7
Customer agrees that, immediately upon completion of the wort: for each Product. Customer will execute a Completion Cortifrcate
(one far each Product as defined by an individual Spec Sheet) and pay any balance due_ As applicable, each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder_
The Horne Depot reserves the right to issue a Change Or cr or terminate this Contract or any individual Products) included herein, ut
its discretion, if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the borne, environmental hazards .such as mold, asbestos or lead paint, other safety concerns, pricing errors or because
wort: rtxluired to complete Ihe: job was not included in the Contract.
Payment Summary: The Payment Summary included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product (as applicable)_
NOTICE TO CUSTOMER
You arc entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate (note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets) before work on that Product
is complete.
In the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of materials, labor, expenses
and services provided by The Horne Depot or Authorized Service Provider through the date of termination, plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE ROME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire: agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersWes all prior discussions and agreements, either
oral or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts thu
terms of and has received a copy of this Agreement
Aempte4y:
X
Customer's Signature Date
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE 11F ONE iS
Submitted by:
Sales Consultant's Sign=Date
Telephone No.
Sales Consultant License No.
(ac aWlimblc)
SPECIFICALLY PRESCRIBED BY LAW IN I
CUSTOMER'S STATE
NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVEiLSE SiDEE AND ARE PART OF THIS CONTRACT
1 27-10 C -SC White- Branch File Yellow - CustuMf
C:=} `C
U'r3GC . • V,,�.:,.u+acad�;,••:eraje�r '
PEAFuRMA�10E RATINGS
p,DDCi OVAL
.. ••0•:.52 r • ....a . -:.. - •' - • '
>� �� �'Q;,,� me �f � � a d � � �?ma`d` �• -
• ROi�pr >1 b�� tr ckod ar,,t�r:n fsndu} �r de.r premp.•brnxsa
E* `ter + �+ mss+. ainda h a:i ar�smkn T'a+ tarr+r+e d P '
pre�im alp
tet rah:ier� Da FSG 1° r
n.id;* 6t 6"511 pn'i UP a4,"+a W SM m+ i
•�,� tf;tG rro rQsr3rda� Imrkanr � + � P'� ds a+r Rod�h r.ncr4�.aa .. '''
:jar:' _ • �.'• • q,sitCUa Yoc •CUCRCY lt.lc-t
,
cagtea(a)_ uoctKicn, Uoct:n
sat. C�nt.ai,••fo..EK C;Ont.al, lo..the.n. . ' ' -- •.
ShlAitef sua
)� ..nidAd asLLLlos•pl.s lx (al
Lenl��1'�y4a&aY,3rXA: uoct:. ,
,. 1locta cantcll, 3,%c cantcal, 34C ; -
• ... fuo. SALe'Ca%Ci�atl•1(]1'/x-RlJ',
• •I11Q: 8af�ac.o Ott/Ytdeio 2•3C Tsxlll-R13'
pcobido: 31.4 C1l x 1L4 cx.
• 44111 , •HJ Y,of fsiln :1lS1124.
E�9 �e9 � �i�t�p��alQyr.jlurn�ire�k)t'a��n��,rr,r:ttir�t¢�.�.' • .
6uacd4 i:tia � Paa � na�rbahas ps(16't 56C hn arrow ris a:m b(ato;�it� ����
OfGee or Consumer Affairs & Business Regulation '
OME IMPROVEMENT CONTRACTOR
t` TYp�
Registration _126893
..: Ezpintoi►_ 813i2Q12.
:: Sripplement
The (iome.DepoLAlarnsces
tv
RICHARD` FALLO.NE ` , -_
?F;qO CUP/IBERLAIVD..PARKWA(S ��
04-0 10 C19: C10 FRf.j[;]—'FHD PRI"IDUCTIC. bl 50 U L
(,r*l rIACMILLAN CONTRACTING
1-4
4.1
Ig
NONE ",:Z
I Al
Vol
AM:
NONE ",:Z
I Al
NONE ",:Z
Vol
NONE ",:Z
%� >tj�® �j /� q.
tdC�.,�/moi L1 CERTIFICATE OF LIABILITY INSURANCE
DATE21/2 lY1
02/212011
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 POLICIES ,
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
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 1-404-995-3000
Marsh USA, Inc.
•
CONTACT
NAME:
PHONE 1FA;(
(A!G No. E3S)._-----.--..--___.-._- (A1C�No _- __._ __..-.. _ _..
homedz ot.certre uest@marsh.com
p Q
Two Alliance Center, 3560 Lenox Road, Suite 2400
Atlacita, GA 30326
ADDRESS:
ADDRESS:
INSURER(S) AFFOROING COVERAGE
---
INSURER A: Steadfast Ins Co -_
26387___..
Fax (212) 948-0902
INSUREDINSURER
8: Zurich American Ins Co'.
16535
The Home Depot, Inc.
Home Depot U.S.A., Inc.
2455 Paces Ferry Road NW
New Hampshire Ins Co
INSURER C: P
23841
INSURERO: Illinois Natl Ins Co _—
23817 _
--
INSURER E: UNION FIRE INS CO OF PITTS r
Bsildin: C-20NATIONAL
19445
Atlanta, rA 30339
27960•
INSIIRER F: Illinois Union Ins Co
COVERAGES CERTIFICATE NUMBER: 19834682 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.* NO ,41THSTANOING ANY.REQUIREMENT, TERMOR 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.
NSR
.LTYPE OF INSURANCE
AOOL
INSR
VOR1.
WVO
''jj
POLICY NUMBER I
POLICY EFF
MMIOOIYYYYI
POLICY EXP
fIAMIOo/YYYYJ
LIMITS
A
GENERAL LIAMLITY
GLO4887714-01
03/01/1
03/01/12
EACH OCCURRENCE S 9,000,000
X
0AMAGETORENTED 1,0001000
COMMERCIAL GENERALUABILITY
PREMISES Ea occurrence S ____M•_._•
CLAIMS -MADE. � OCCUR
MED EXP (Any one person) f EXCLUDED
-- -
PERSUNALSAOVINJURY S 9,000,000-
X LIMITS OF POLICY XS
X OF SIR: $1M PER OCC
GENE RAL AGGREGATE f 9,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG S 9,000, 000
- -
.f -
X POLICY PRO- LOC
JE
B
AUTOMOBILE LIABILITY
BAP. 2938863-08
03/01/1:
03/01/12
(OMBINE0SINGLELIMIT
Ea accident 1, 00_0_,_0_00
-
X ANY AUT Q
BODILY INJURY (Per person) Y
BODILY INJURY (Per accident) $
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
_
-•-__._. _...
PROPERTY DAMAGE $
Per a cident __
HIRED AUTOSAUTOS
_•__ _
S
X SIR AUTO P Y
UMBRELLA LIAOOCCUR
HCLAIMS-MADE
EACH OCCURRENCE S
EXCESS LIAR
AGGREGATE
DEC) RETENTION S
f
CTDRY
WORKERS, COMPENSATION
WC061967352 (AOS)
03/01/1
03/01/12
X WCSTATU- OTH
LIMITS R '
AND EMPLOYERS' LIABILITY YIN
—'--'-'-'•'
E.I. EACH ACCIDENT $ 1,000_000
D
ANY PROPRIETOR/PARTNER/EXECUTIVE
WC061967354 (FL)
03/01/1
03/01/12
E
OFFICEfUMEMBEREXCLUDED?
(Mandatory in NF1)
NIA
WC061967353 (CA)
03/01/1
03/01/12
E.L. DISEASE - EA EMPLOYE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
—' _
E.L. DISEASE - POLICY LIMIT s 1,000,000
C
Workers Compensation
WC061967355(KY;MO,NY,W1,
)03/01/1
03/01/12
F
TX Employers XS Indemnity
TNSC46244151 (TX)
03/01/1
03/01/12
Occurrence/SIR 30M/1M.
E
Workers Compensation
WC1192378 (QSI)
03/01/1
03/01/12
SIR lAt
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (All ach ACORO 101, Additional Remarks Schadute, if mora space is rtquired) `
RE: EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
THE HOME DEPOT, INC.
HOME DEPOT U.S.A., INC.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
2455 PACES FERRY ROAD NW . I AUTHORIZED REPRESENTATIVE
. f
The Comrttonwealth o Massachusetts,
- T Department of Industrial Accidents
.. f
f
Office of Investigations
C. w I Congress Street, Suite 100 -- --
Boston, MA 02114-2017
.mass. bao�v/dia
�www.�,�
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly —
Name (Business/Organization/Individual): j4�` Yds i 1� ( _
Address:
City/St to/Zip: �l Phone #: t. CD .
Are u an employer? Check the appropriate box: Type of project (required):
1. I am a employer with —7n 4. ❑ I am a general contractor and I 6 EJ New construction
have hired the sub -contractors
employees (full and/or part-time).* listedlisted on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partAer- These sub -contractors have
ship and have no employees 8..❑Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers.'. comp. insurance comp. insurance.:
required.]
5. ❑ We are a corporation and its 10. F-1 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.[] Plumbing repairs or additions
right of exemption per MGL 12.❑ Roof repairs
employees. [
myself. [No workers comp. and we have no
insurance required.] t c. 152, employees.
[No workers' 13. Other
coma. insurance required.]
*Any applicant that checks box k1 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.
tCoatractors that check this box must attached an additional sheet showing the name of the sub -contractors and state wbethef or not those entities have
employees. If the sub -contractors have employees, they must provide their. workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. _ , i i r .
Insurance Company Name:
Policy # or Setf-ins. Lic. #: 1 C�� �� Y Expiration Date:
lob Site Address: _' City/State/Zip:
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 &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.
Ido hereby certr'fy un fi r the pilins pfd penalties of perjury that the information provided above i� true�tnd correct ,
Official use only. Do not write in this area, to be completed by city or town off eiaL
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3
6. Other
Permit/License #
City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
nr.--- u.