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Building Permit #401-13 - 414 FOSTER STREET 11/14/2012
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �J Permit NO: � Date Received Date Issued: IMPORTANT:Applicant must' complete all items on this age LOCATION ql� fO�ST�/C v-rfe-Ee-/— Print J PROPERTY OWNER /9-3 d)6 14AZZ//0(r- Unit# Print MAP NO: f n Y PARCEL:ZONING DISTRICT: Historic District yeUnno Machine Shop Village ye 100 year-old structure ye TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building �6ne family 11 Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ,)R-Aepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 911Se0c D;WER �1IFloodplain ptiWetlands F ' f; Watershed�Distnct [fl dater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 6M l P R LAS H/NGl (Identification Please Type or Print Clearly) OWNER: Name: A-)D A) //-44,6/.c)G- Phone:7 V (o Vo 3 yd 7 Address: VI5/ CONTRACTOR Name: Cis 1"/Z 1 C d A3& Phone: 9?? 6 0 3 J Y,Z 0 Address: R Su T rbti S-r r6 3 A /yo &r-/1 a v& 1A U/d YI' Supervisor's Construction License: 67%J5�8 Exp. Date: 3 Home Improvement License: 10,1y( y Exp. Date: ARCHITECT/ENGINEER Phone: 6 Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST B ED ON$925.00 PER S.F. u Total Project Cost: $ ��� p FEE: $ Check No.: O Receipt No.:, � y� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund -v-�nai•i arca:n rtan � lA/nAf;�. _. _ :. : ., =_�"ICJIl9 L1rP n •COrI rAR t7 r: �. ., Location No. +) Date �' v * ' TOWN OF NORTH ANDOVER 14:v . K01 • Certificate of Occupancy $ Building/Frame Permit Fee $ L 7 bo ° a Foundation Permit Fee $ Other Permit Fee TOTAL $ y �( k Check# I V 25951 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS I Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments f 4 Conservation Decision: Comments Water& Sewer ConnectioniSignature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 4 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 lues No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— For department use LJ Notified for pickup - Date Doc:.Building Permit Revised 20117une/mi 1 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 o 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 nust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi NORTH Town. of t _E ndover No. LAME zh y o ,COCHIC"EWICK ►• ver, Mass X1,9 p°RArECD) ►`PA,��(�J S V BOARD OF HEALTH Food/Kitchen PERMI D Septic System • THIS CERTIFIES THAT BUILDING INSPECTOR has permission to ere ........ buildin on J Foundation .. ........ . .4 . .M .. �'}. ... ... ... . . . . ... Rough tobe occupied as .....K66.r). �......... .. . ... ...... . . �.�... ..... ............... .... .. ............... Chimney provided that the person accepting thi rmit 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 �a PERMIT EXPIRE NT ELECTRICAL INSPECTOR UNLESS CONST UCT Rough t5Service ...... ...................................................................... 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 DAVID CASTRICONE CASTRICONE ROOFING&SIDING INC. ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 .311Z_.299 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845 In North Andover 978-683-3420 In Boxford 978-887-6147 In HaverhX 97&374-7314 Uwe the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and conditions,on premises/below described:�f r� Owner's Name............! Aj d N rrAfL b/N ` 6 f �i �b 7 / .....f..............................................................................................Telephone#............................................. Job Address....y�.Z....... ? ... f.................................city.........1►�.�.,..... �,.✓..%............State.... iT........ Specifications: ................................................................................................................................. Strip existing shingles. I )( Apply new drip edge to all.edges. /y ........................................................................................................................................................................................................................ P/ Apply__(�._feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane in valleys and bottom edges of any unheated areas of house. .................................................................................................................... .................�............................................ ........................ Vl Apply felt paper underlayment.VInstall ridge vent to �?'nnl �'T--�.......�6-'Tj-..................................................... v'Reroof using ( ,rgg ���1,�---r4Jmca/'tc'c:.•r shingles with a year warranty. ....................................................................................................................................................................................................................... Counterflash chimney. New vent pipe flashing. le l cgal disposal of all debris. ...................................................................................................................................................................................................................... \ rea(s)to be workedon: ''" ........................................... ....� ......cko-z.�s..':-........(kY1� rru..�ta 1 ........... -... � �C. ............... 1�........��'.....;)Q.... . .. ...fit ..?.... :^ .... 5 ...t�.1r•.1 ....... .4.._111 t :./........................................................................................�...........................0................................................................. .......................................................................................................................... . Roof board replacement if necessary @ 464 /sheet ort.{�'i /foot. ....................................................................................................................................................................................................................... Two Year Workmanship Warranty(Not Transferable) l anufacturer's Warranty as specified by manufacturer The contractor agrees to dorm the coot d famish the materials specified above for the SUM of$...............................:....... Payable..........� y.........on. ................. Payable.............................on.................................. Balance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability while job is in operation. Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling platter,exposed nails)or conditions resulting from application of materials specified above(i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living spaces).Items in attic may need to be covered by homeowner.All materials are property of contractor. Any dumpster placed by contractor is for his use only.Upon completion of above work,all undersigned agree to execute and deliver to contractor;their joint note in accordance with his(their)above obligation as requested by contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable.It is agreed that,if permitted by law,contractor shall be paid by the owner(s)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith.It is further agreed that this contract may be assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates of the parties.The undersigned warant(s)that le is(they aro) the owners(s)of the above mentioned premises and that legal tithe thereto stands of record in his(their)names(s).There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to:Direetor,HomeAmprovement Contractor Registration, One Ashburton Place, Room 1301,Boston,MA 02108 Tel:617-727-8598 Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction- related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c.142A. Approximate starting date of work................................................ Completion date......................................................... Receipt of a copy of this contact is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation). IN WITNESS WHEREOF,the parties have hereunto signed their names this.....�..........day of.... .....20... Accepted: p_ Signed....... ..............L............�"�............ ............ .. Owner �J C Signed............................................................................. Owner ................................................................... David Cas tricone,President Massachusetts - Department uF Puhlic Sufeh Board of Buil(linl,, Re�aulatit�ns ;,n(1 St.ui(lar(I Construction Supervisor Specialty License License: CS SL 99358 Restricted to: RF,WS DAVID CASTRICONE 31 COURT STREET NORTH ANDOVER, MA 01845 Expiration: 12/16/2013 (l nmiis,iuncr Tr#: 7924 SCA 1 C; 20M-05/11 Office of Consumer Affairs&Busidess Regulation YOME IMPROVEMENT CONTRACTOR Registration: 104569 Type: Expiration: 7/14/2014 Private Corporati(n DAVI CASTRICONE ROOFING, SIDING 8 David Castricone 231 R SUTTON ST SUITE 3A NORTH ANDOVER, MA 01845 �L_ Undersecretary '`` CERTIFICATE OF LIABILITY INSURANCE 9T/1MMIDD/YY1/20122 PRODUCER 978 273 6368THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Willows Insurance Agcy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 51 Cochichewick Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I North Andover MA 01845 INSURERS AFFORDING COVERAGE ' NAIC# INSURED INSURERA:WESTERN WORLD INSURANCE CO DAVID CASTRICONE ROOFING & SIDING INC & INSURER B CASTRICONE ROOFING & SIDING INC _INSURER C: 231 Sutton St #3A INSURER D: NORTH ANDOVER MA 01845 i INS URER 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. _1FNS_R_ADD'LI POLICY EFFECTIVE I POLICY EXPIRATION LTR N D TYPE F INSURANCE POLICY NUMBER TE MM/DD DATE M DD LIMITS GENERAL LIABILITY EACH OCCURRENCE — $ — — 1000000 DAMAGE r — COMMERCIAL GENERAL LIABILITY PREMISESO RENTED— COMMERCIAL " 1$ 50000 f — F. (Ea occurrence _..-- ...".._ _.." A CLAIMS MADE LX_I OCCUR PP1332888 9/6/2012 1 9/6/2013 1 MED EXP(Any one person) .i $ 1000 PERSONAL 8 ADV INJURY $ 1000000 _._._....._.__ ____ GENERAL AGGREGATE $ 2000000 GEN'LAGGREGATE LIMIT APPLIES PER:I f PRODUCTS-COMP/OPAGG i $ 2000000 j POLICY ; PRO- I LOC! I j f-"- 1 AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS L BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS I BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ I 1 i(Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT ACC 1$ �ANY AUTO � i OTHER THAN L$. .".. ._ . _. ._...._ I I j AUTO ONLY: AGG j $ EXCESS I UMBRELLA LIABILITY TEACH OCCURRENCE $ 1 OCCUR ! CLAIMS MADE AGGREGATE I$ $ DEDUCTIBLE j RETENTION $ ---- $ —..—.._._ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN I WC STATU-I I 0TH- , ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N —� ----- OFFICER/MEMBER EXCLUDED? I E.L.EACH ACCIDENT $ (Mandatory in NH) I E.L.DISEASE-EA EMPLOYE $_ If yes,describe under r— SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I$ OTHER 1 I I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Castricone Roofing & Siding DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Unit 3A NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 231 R Sutton Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR North Andover, MA 01845 REPRESENTATIVES. AUTHORIZED R �ES ACORD 25(2009/01) ©1988-20 LORD CORPORATION. All rights reserved. INS025(zooeot).oi The ACORD name and logo are registered marks of ACORD AC" CERTIFICATE OF LIABILITY INSURANCE DATE(MM DD/VYYY) 9/24/2012 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(les)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 NAME: Dept ext 66807 Eastern Insurance Group LLC-Main P"C°NE 0 51-7 0 ac No: -653 8 233 West Central Street EMAIL Natick MA 01760 ADDRESS: c e s c INSURERS AFFORDING COVERAGE NAIC Ir INSURER A:Cornmerce & Industry 19410 INSURED 31969 INSURER B: David Castricone Roofing&Siding Inc INSURER C: 231 Rear Sutton Street, Unit 3A INSURER D: North Andover MA 01845 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1538501247 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. INSR TYPE OF INSURANCE AD S BR POLICY EFF POLICY EXP LTR INSR WVD POUCYNUMBER MM/DDIYYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $11 _ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE FIOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Pei accident UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION W0003989723 123(2012 /23/2013 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE= E.L.EACH ACCIDENT $100,000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $100,000 If ves,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Addltional Remarks Schedule,i1 more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Castricone Roofing&Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. 231 Rear Sutton Street,Unit 3A North Andover MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Town of North Andover NOR71� oE�s,ro Building Department o 27 Charles Street �' A Nortli Andover, Massachusetts 01845 i (978) 688-9545 Fax (978) 688-9542 0 0RAreo S'SA CHUS�� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c,l 1, sl50a. The debris will be disposed of in/at: � Z, Z Facility location ^ Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project tluough the Office of the Building Inspector. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street Boston, MA 02111 °� SV• ,, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Bu sines s/Orgarvzation/Individual): CA 3781 CoMe ?00ON !r Address: -r ro 14 ST(R .T .3A City/State/Zip: N o• Arn o o✓a HA b MS Phone #: 9q 1 - 4f-3 '3 qd 0 Are you an employer? Check the appropriate box: Type of project (required): 1.W I am a employer with Q 4. ❑ I am a general contractor and I 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 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 required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E:1Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12Roof 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: Homeowners wbo 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. ram an employer that is providing workers'compensation insurance for my employees. Below is the.policy and job site nformatiom nsurance Company Name: A(Z n S 'olicy# or Self-ins. Lic. #: C C)Q 3 t s 9 a,3 Expiration Date: 9- a3 -(A lob Site Address: 14 FDS TL/t- 57-12 City/State/Zip: NO2Ty A 0 b 6V�A, MA 0 V attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ,allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 )f up to $250.00 a day against the violator:- Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coveragCverification. 'do hereby certify underthhee pains and penalties of perjury that the information provided above is true and correct 3ipm `— ) ature: .9 �J— C .e Date: ?hone#: 9U ( 13. 3 ya 0 Official use only. Do not write in this area, to be 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#: