HomeMy WebLinkAboutBuilding Permit #724-14 - 43 CHRISTIAN WAY 4/16/2014TOWN OF NORTH ANDOVER
AP LICATION FOR PLAN EXAMINATION
Permit NO.' , Date Received
Date Issued:
ORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER ��
//�� Print
MAP J(/ PARCEL ZONING DISTRICT: . Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
❑ Alteration
❑ Repair, replacement
❑ Demolition
PROPOSED USE
Residential
ne family
❑ Two or more family
No. of units:
❑ Assessory Bldg
❑ Other
s 0_Sep cit C1t OBWellT 4 :. ! t.'utrloPLO"
Water%Sewer: - -- -=
DESCRIPTION O WO
Address:
CONTRACTOR Name:
Address:
Non- Residential
❑ Industrial
❑ Commercial
❑ Others:
�D�.Wetlands` _ ,IS ❑��?
TO BE PERFORMED:
PhoneAf%
Supervisor's Construction License: C— ,�,! slcX� Exp. Date:
Home Improvement License: =�� Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL EST/MATED COST BASED ON $125.00 PER S.F.
Total Project Cosi: $ c� FEE: $
Check No.: Receipt No.: t S
NOTE: Persons contracting with unregistered contractors do no e , s tot guaranty fund
-_ _ Signature
Location �1,� r f S G W k6 -
No.
No. �� — Date y
i
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
AD
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 SEGTIONS FOR OFFICE'USE ONLY;
INTERDEPARTMENTAL SIGN OFF - U FOAM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
0
DATE APPROVED
10-1
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comm
Conservation Decision: Com
Water & Sewer onneGfion/Sianature &Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -Temp Dempster on site yes no
Located at 124 Main Street
Fire Department signature/date
COAQvMNTS
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
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
d,/ uildin Permit Application
g pp atlon
orkers Comp Affidavit
/Photo Copy Of H.I.C. And/Or C.S.L. Licenses
r� Copy Contract
❑ Floo Ian Or Proposed Interior Work
❑ EnOneering 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,
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
'it the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
Ist be submitted with the building application
Doc: Doc.Building permit Revised 2008mi
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Pro o§al
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DmnOUsse
Roofing LLP
A trusted name since 1938
Roofing - Siding - Windows
87 Belmont Street - North Andover, MA 01845
P: 978-683-4588 - F: 978-685-7446
HIC # 174377
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, aft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing
step flashings to remain. A new base sheet applied. A'96yr architectural roof shingle installed. Install new vent
pipe boot flashings. Wqterproof existing chimney flashing and remove debris.
r//tW���Shinnlp (:nlnr f141(1
Ridae Vent U
Wood Sheathi
oa Trle�L/
1U -
We Propose herby to furnish material and labor - complete in accordance with above specifications, for the sum of:
da
dollars ($ !017to ).
Payment to be made as
Acceptance of Proposed - 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.
all�
Date ofAcceptance
i
Authorized
Signature
NOTE: This proposal may be withdrawn by us if n ccepted with i7Aays
Signature
Signature
HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS (M.G.L.142A)
1. WORK: Provided the Homeowner perform ' under this agreement, the Contractor shall perform the work on the Property as specified Proposal, attached
incorporated herein. T -he -wow, Qe not i 1 e extraordinary conditions of which the Contractor could not reasonably be aware. If such conditions are
encountered, this shall bl i'n%dihtnal osL o the Homeowner. Materials selected by Homeowner may have to be ordered or custom made, which items are
specified in the Proposal. T e Cdnt ctor s not obligated to agree to any modifications, extras or change orders unless such items are agreed to in writing by
the Contractor. All exit# ) cha � all be at an additional cost to the Homeowner. Contractor shall perform the work in a good and workmanlike manner
using materials consisten wttI on act. 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 Contractor's 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 Contractor's 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
Contractor's reasonable costs of collection, including attorney's fees and costs. Time is of the essence hereof.
5. WARRANTY: For a period of lyear 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 ReEistration No: 174377. Homeowner may verify by contacting the Director at (617) 727-3200, ext. 25205. A Homeowner's rights under
the Home Improvement Law (M.G.L.c. 142A) and other consumer protection laws may not be waived in any way. Homeowner acknowledges receipt of a
copy of 780 CMR R6 and Massachusetts General Laws chapter 142A, and which are available online at www.mass.gov. Questions may be directed to the
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 business day following the signing of this agreement.
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f � t 't f . S
HOMEOWNER!1 -�� e DATE: L p
Shingle:
423-/'2613 8:31:14 AM 8935 Q 02/03
all,
CERTIFICATE OF LIABILITY INSURANCE DATE(MM,,0D/YYYYj
04123/2013
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 00474-001 CONTACT
NAME:
Doherty Insurance Agency Inc PHONE
PO Box 1985 (Alc. (978)475-0260 FAx
(A/C. No.:
Andover, MA 01810
EMAIL
INSURED
Damphousse Roofing LLP
87 Belmont Street
North Andover, MA 01845
A.I.M. Mutual Insurance Company 33758
COVERAGES ...... I
---- -- nCVIZIUN NUMtYtt(:
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 OOL UBR POLICY EFF POLICY EXP
LTR I SR VWD POLICY NUMBER MM/ODNYYY thiM1DD1YYYY LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAWS -MADE ❑ OCCUR
Er'.r_41) tIRRENCE S
DA1dAGE TO RENTED 5
PP.Et11SES Eaoccurrence
trEO EXP (Ary one person) 5
PERSONAL P ADV ItdJJRY 5
GENERAL AGGREGATE S
-EN'L AGGREGATE LWIT APPLIES PEP.:
OUCY FT,, -O- OC
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{j
PP.ODUCTS- COt�iOP P.GG $
AUTOMOBILE
LIABILITY
r'Nl' AJTO
ALL O'.NED SCHEDULED
i
(
CfO?MINED SNCLELltidi
tEa accident'.
Book INJJRY (Per person' $
1
BODLY INJJRY ;Par accident) w
r ITOo AUTOS
HIREDAUT03 NOr1-0`:/NED
A IT05
PROPERTYD?IAr=.GE S
Pa. accident
UMBRELLA LIAB
OCCUR
EACHOCCUP.RENCE $
EXCESS I IAB
CLAkIS 14ADE
AGGREGATE
DED RETENTION 4
f
A
WORKERS
ND EMPLCOMPENSATIONYS' IIB !
ANY FAOoPRETo FLPAP.Tt•1 P. KECUTIVE Y / N
OFFI^�Rrn1Et,,S £xcLu�E� (Mandatoryin NH) n
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DESCR��tt��G'r WW'M&ERATIONS bdovt
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AWC 400-7028774-2013A
4117/2013
4/17/2014
x T'p y LI;,YT$ 0T11 -
ER
EL. EACH ACCIDENT 500,000
El. Ob'F�;SE-EAF�SPLOYEE S 500,000
EL. DISEASE -POLICY LNIIT , $ 500,000
DESCRIPTION.OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
No partners are covered by the Workers compensation policy.
�crc r rrl�m I c nvwcrc CANCELLATION
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
01988-2010 ACORD CORPORATION. All rights reserved.
M1-%JT[V LJ 14UIUIUJI Ina HCUKu name ana logo are reglsterea marxs or ACORD
4454
APR -22-2013 MON 12:24 PM FAX NO, 978Q750303 P. 01
A CoR�ry I DAMPHOUSSE
C,RT#f#ATE Of L#p�gtt#TY #NSURANCE�LCATE(MMlOOrYYYY}
PRODUCER 4/22/13
Doherty Insurance Agency, Inc
THI CERTIFICATr 1S ISSUED AS A MATTER OF INFORMATION
P.O. Box 1985 ONLLf AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOL ER- THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
21 Elm Street ALT R THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Andover, MA 01810
INSURED INSUR RS AFFORDING COVERAGE ENAIC
Damphousse Roofing LLP INSURERA: Atain SpeClalty Insu)nsrance Company—
87 Belmont St rN3DRGkHNorth Andover, MA 01845 +N- URE COVERAGES
THr SOLI 'IES UP INSURANCE LISTED BELOW HAVE PEEN ISSUED TO THE INSURED NArdE I AGOVE FOR THE POLICY PERIOD
ANY REC}UrRc1r1ENT, 7=Rh9 Of: CONDITION OF ANY CONTRACT OROTHER nOCUMI[a•:T ,L'11l r. , t: PERIOD INDICATED. NtY(WITN jTANDIW
MAY PERTAIN. YHC INSURANCE ArF0r+t7e0 By THE POLICIES DESCRIBED HEREIN !s -508JE UT TO f L 'i r� 1 ERMICH . EX C USIO CATs MAY M 110.v:1 Or•:
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN RCO1ICED uY PAID CLAIMS5 70 ALL 7I�E 7 tFb(S, Ex(:t tIaI+JNS ANC! t ONpI i ID 1 r
' ' 0 •.,UCH
TR N.rlcyM
OF INSURANCE POLICY NURiBGH PDUCV EFFEC E pOUCy EXPIRATION —
A BILITY . ATE t +DOrry DaT - FAWDO YY LIMffS •�
CIP169387 04/12/13 04/72/14 Fgr,H Ot;CI)RZCNI:1
Glnt GENC•KAt LlAmtny =1 000 000
OAMAttF TO REN, ED "�---
ItAG MADE a UCCUH �Mt..e!: Iia L�-rr.rr<•nLps $100.000
Ded•1 000 +N 1 EXP (A".Y:mvpzfTtrtr1 35 000
PeR50NAL A. ADV I,i ITRY sj 000.000
GATF ! 11AtT At LIES Pr-K:UENERARCUAr = !2.000 000
�K�T i�..... PRn[IUCr::_ ;OfAYK]rAGG .7 nAn Ann
UNIOBILE LIA211.ffY
ANY At ITO
ALL OWNED AUTOS
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EMPLOYERS* LIA8iLITY
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Covering operations usual to Damphousse Roofing LLP... i
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SHOULD ANY QF TWE ABOVE UESCRIBCU FOLICICS SE CANCELLED BeFORF TI,E EXP,RATION
DATE THERGOf• THE ISSUING INSURER WILL ENDEAVOR TO MAIL _Q DAYS WRITTEN
NOTICE TO TI Ij CERTIFICATE HOLDER NAMED TO THC LEFT. BUT FAILURE TO DO SO SHALL
MPOSE NO OB+ lr?ATION OR LIABILITY OF ANY KIND UPON TfiE INSURER. ITS AGENT5 OR
1EPRESFNT�ATIVE-3.
ALITHORRSOREP(tESFItTEfrTP�i—
ACORD 25 (2001106) 1 of 2 #S2912D/M29119dr -.c.t.w
ML 0 A 3 CORPORATION 1956
•
>x
9 assammisetts - -et?r3P'lmen o' t .Satz-
30arCi Of Building R2gUfatCt"'.S
Sat',Cai.`%s
Construction Super%icor
_cese: CS -067560
SHAUN M TWOMEY:
61 PATROIT ST
N ANDOVER MA 01845
J'J• ,t Fit'`
_X37"
Commissioner
10/25/2015
DOUGi AS J UGARE =
79 GARY AVE
H-AVERffILL IiL,k oI830
09/02/2014
Office of Consumer Affairs & Business Reaulation
ME IMPROVEMENT CONTRACTOR
i= y yRegistration_ 174377 Type:
'.Expiration. 2W2015 LLP
DAMPHOUSSE ROOFING LLP
SHAUN TWOMEY
87 BELM0NT ST
N. ANDOVER, MA 01845 > ndersecretarc
The Commonwealth of Massachusetts
Department of IndustriqlAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lep-ibly
Name
Addre;
City/State/Zip -I I Phone #: _ / l��` [�/ Z_ y 7
,zz
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and 1
Type of project (required):
_
6. ❑ New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet, t
7. ❑ 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
10.❑ Electrical repairs or additions
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11. ❑ Plymrbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. oof repairs
insurance required] f
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 ate 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. A^ _
Insurance Company
Policy # or Self -ins. Lic. #: %'V � [S(�3 8 77�-�� ),3 E piration Date: �✓ y 7 �7
Job Site Address:_ ��`� L�irA• A City/State/Zip•
.1 LZ - 1_,&O
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL 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 cerfiffy pndar the pains and penalties ofperjury that the information provided aboveVrue�dcdcorrec4
Sipnature__.2%r te' Date: /// / 7/ '7
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
PermitUcense #
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 #: