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Home My WebLink AboutBuilding Permit #934 - 50 MAIN STREET 6/27/2012BUILDING PERMIT 0 6 0 TOWN OF NORTH ANDOVER 00 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received . 0 ?Arm 0- C1 Date IssuedLo—k1h EMPORTANT: Applicant must complete all items on this page 'LOCAT-ibN A/ PH nt �PROPERTY OWNER_ 121MI S Ll -f) AA n r Zd I 9 1; IP06t7 'MAP NO: .'PARCEL: ZONING DISTRICT' -Hist.ori.c.Dis-ffict Y6� n7 -o6\ 0 Machin6Shop Village Yes :no TYPE OF IMPROVEMENT PROPOSEDUSE 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 §ePtic W611 Floodplain Wetlands atershed District Water/Sewer OWNER: Name: Address: CONTRACTOR -Narn PTION OF WORK TO SE PREFORMED: Type or Print Clearly) N NA, A N i M 0, � � I Address: C) --anz 119,4=_ r u P. 'ervi§o.r!.s Construction License., Eko. Date-, /0 Home- Improvement. Liberise., 'Exi). Dc;i t e: ARCHITECT/ENG I NEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIPM00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 3�2,N7 FEE: $ c&72 Check No. Receipt No.: ;Q NOTE: Pers6ns contracting with unregistered contractors do not have access to iheg'y6r ,antyfund ture of Aaent/Owner Signature of contractor Si6 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL - Public Sewer TanningiMassage/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 Sianature COMMENTS HEALTH Reviewed on Signature (COMMENTS Zoning Board of Appeals: Variance, Petition No: —Zoning Decisionlreceipt submitted yes Planning Board Decision: Conservation Decision: Cornments Comments Water & Sewer Con nection/signature & Date. DrivewaV Permit DPW Town Engineer: Signature: Locateci ;RS4 USgo0a 6treet e i. FIRE'DEPARTMENT T "�mp ump§i.er, on. site -y e§, 'no L.o'catdd.-;dt�,124,Ma.iin'Str-det Fire, Depprti-nent.,-.-�ignature/dat,e 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 2 1A —F and G min.$100-$l 000 fine NOTES and DATA — (For department use LJ Notified for pickup - Date Doe.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 o 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) (3 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) Li Building Permit Application 9 • 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 d.umpster 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 Doe: INSPECTIONAL SERVICES DEPARTMEENT:BPFORM07 Revised 2.2008 Location Date TOWN OF NORTH ANDOVER Certificate of Occupancy $—t. . Iw Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee TOTAL Check 25460 1300lng inspector 0 uj LL 0 0 co 0 0 L� E a) >. Ln u a) Ln 0 u (A z z c 0 w 0 E :E U LL 0 L) CA z z co bn 0 — cc 0 LA z uj to 0 u cu in Li- Ir 0 u LLI CL (A z to 0 L.L z LU 2 CC LLI LU w ca CU tn cu cu 0 E in in mmi Td:7; 0 4mo 0 E ENO LLI a LU CL CL (1) Cl) < 0 0 E CL (D Cl) 0 0 Cc Cl) GOA CL Cc E CL MA 0 a Cl) > Cc CD cn r_ LLI U) 0 4) > 0 0 CO 0-0 > cn x .2 LLJ 0 E 0 m 0 z 75 Cl) rL (n tm r- W Cl) .2 w ui Mn tm tm > 0 LLJ —i 0 CL .5 CL 0 0 0 cc 0 0 tm tm s 0 CL u w m CD C0 -W m -*- :5 LU r- -0 — Cj — 2 w �g cn r 0 w EL L LU E u 0-0 0 co (n —1 FE 0 4- = o " = 0 0 CL 0 L) > 0 E 2.0 0 z 0 C a 0-- U) 0 0 4) fm 0 U 0 CL U) c 0 Cc Cc .2 —J -a 0-0 CD 0 cc r_ r_ cc 'a CO) LLI CO) LLI U) 19 LLI w 19 LLI LU U) Lmm� Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 1 1 -$ :482500.00 M $ - $ 1,782.00 Plumbing Fee $ 222.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 222.75 Total fees collected $ 2,327.50 44-50 Main Street 853-12 on 5/31/2012 Shell improvement only Remodel 46 Main Handicap Ramp OLYMPIC HIC #167567 EIN# 27-3470462 Job #: I Roofing — Siding - Painting %imce: via-aat-aaiu 239 Boston Street — Topsfield, MA 01983 Fax: 978-887-5875 Mark Yanowitz Verdeco Designs 20 Wild Rose Dr. Andover, MA 01810 (978) 409-2217 (978) 857-9191 (cell) Email: marknaverdecodesigns.com Job Location: 44-50 Main Street — North Andover, MA Dear Mark, March 15,2012 Revised: May 10,2012 Revised: May 23,2012 Revised: June 12,2012 The following estimate is for the roof replacement for the property located at the above address. The following paragraphs describe the work that will be performed. In addition to installing your roof, I would like to offer you the opportunity to obtain a warranty directly from Versico. We are a Versico Master Elite Certified Installer and have the ability to provide you with a 15 year labor warranty directly from the manufacturer and a 20 year material warranty. Rubber Roof- • Strip existing rubber roof, small lower rubber roof and lower asphalt shingle roof down to the roof deck • Install !/z" fiber board with screws & plates • Install new nailer around the perimeter of the roof • Install all new flashing around the perimeter of the roof • Install.060 fully adhered EPDM rubber roofing • Install 3" scam tape on all seams • Install L -Stock drip edge on entire flat roof -perimeter • Install 6" cover tape on all aluminum L -Stock • Small 3 x 3 roof and porch roof on south side included in price • Replace any rotten or damaged decking @ $70.00/sheet • Replace any rotten or damaged ledger board (we allow 20ft. at no charge, S4.00/ft. thereafter) • Remove all debris from property • Labor cost of roof is $9,000.00 — Material cost of roof is $10,750.00 • The Roofing Permit cost is included in the price for the rubber roof. Initial options V" are cheosiAg bdow: Cost for Labor & Material for Rubber Roof $19,750.00 Cost for Labor & Material to Install (2) New 4" RAC Drains: S 590.00 Cost for Labor & Material to Re -lead & Re -flash (1) Chimneys: $ 350.00 Cost for Labor & Material to Demo (2) Chimneys down to roof deck- $ 695.00 Cost for Labor & Material for metal cap on left side parapet wall: $ 395.00 Cost for Labor & Material to New Gutters on north side shed dormer: $ 575.00 Cost for Labor & Material to Install Copper Flashing in front of building: S 950.00 Cost for Labor Only to install white rectangular soffit vents: No Charge__ Payment Terms: 1, &.q 0 1/3 deposit due upon signing contract: $ 1/3 payment due upon start of job: $ 1/3 payment due upon completion of job: $ Total Amount Agreed To Be Paid: vb. I Pleme sign and date ail pages. Remit to: Turnpike General Contracting Inc. - P.O. Box 365, Topsfield, MA 01983 The following schedule will be adhered to unless circumstances beyond Turnpike's control arise: Work Scheduled to Begin: Job expected to be completed within 60 days of actual start date. occur we will cover the Waan=-dnty: 1pappike General C Inc. guarantees all work performed for a period of one year. If any problems correct blern and meet the customer's satisfaction. cost of4 6hr and niffteriaal correct �� -e�zu 0 1 Connors, Project Mark Y*4wit- General Contracting c. Date Verdetjsigns Date ---IN TURNP-3 OP ID: CA 1441CC)OR" E (MMIODfYYYY) 1`.� CERTIFICATE OF LIABILITY INSURANCE 01/25/12 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 e9dorsed. 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). CPRO C .DfCjER 978-462-44341 ONTACT Chase& untLLC A ME: P 0 Box 590 978-465-6204 Emil, 47 State Street M. Newbu ort, MAmso ADDRESS� S'T Marco ; HP. Shaner INSURER(S) AFFORDING COVERAGE INSURED 239 Boston Street Topsfield, MA 01983 A:Scottsdale Insurance Co. B: Commerce Insurance Coi .2 : Peerless Insurance Co. D: Hanover Insurance Corni COVERAGES CERTIFICATE NUMBER- - 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 TH S r CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMT � EXCLUSIONS AND CONDITIONS OF SUCH POI_IrlF!_1 I IMITR qI4nVM kAAVWA%lr QrrK1 OM -1— — A — INSR rool- LTR TYPE OF INSURANCE IN rUBRI POLICYNUMBER _1(MM1DDffYYYl POLICY EF YF Y, IMMIODPM (MMIDDNYYY1 POLICY EXP LIMITS prERAL LIABILITY COMMERC A IAL GENERAL LIABILITY F_V_1 CLAIIMIS-MA13E ', OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: 7 POLICYF x-� PRoi F] LOC BCS0026080 10121111 10/211`12 EACHOCCURRENCE $ 1,000,000 50,000 MED EXP (Any one person) is 5,00 0 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE 5 2,000,000 PRODUCTS - COMPIOP AGG S 2,000,000 S AUTOMOBILE LIABILITY ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDALIMS NON -OWNED AUTOS BDBRJM 10120111 10120112 COMB'NED,,—SINGLELIMIT (E, acciden 1,060,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) S PERTY DAMAGE — accident) 5 A X UMB:LA LIAB 6 Or -CUR CLAIMS -MADE XLS0077698 10121111 10121112 EACH OCCURRENCE S 5,000,000 AGGREGATE Is 5,000,00C DIED X RETENTION$ 0 Is WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLU (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WC STATU- OTH TORY LIMITS ER E.L EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE S E.L. DISEASE -POLICY LIMIT S C Inland Marine D FiTmerclal rime 8883151 F200939 12J01111 1 01117112 12/01112 1 01117113 Materials 260,00( 1 Limit 100,00( DESCRIPTION Or OPERATIONR I LOCATIONS I D r VEHICLES (Attach ACOR 101, Additional Remarks Schedule, if mom space is required) ACORD 25 (20i0/05) 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 19B8-201 0 ACORD CORI The ACORD name and logo are registered marks of ACORD TION. All rights reserved. Unrestricted - Buildings of any use group which contain less than 35,000 cubic feet (991m 3) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For I)PS Licensing information visit, Www-Mass-Gov/I)PS I Massachusetts - Department of Public Safetv I 0 Board of Building Regulations and Standards* (,onstruct i( it) Supcoisor License: CS -080145 GEORGEVA4"ES 5 PITCAIRN *AY EPSWICH 69125 0 "of a'- Expiration Commissioner 1012612013 0/1- sumero Office of Consumer A airt and Business Regtuloati'o'n 10 Park Plaza - Suite 5170 - Boston,=hu= 02116 Home Improve ontra tor Registration TURNPIKE GENERAL CONTRAI GEORGE VASILIADES 239 BOSTON STREET BOX 365 TOPSFIELD, MA 01983 Registration: 167567 Tiviie: SupplementCard Exii1ration: 1014J2012 Update Address and return card. Mark reason for change. :)PS-CAl 0 SOM-OVO4-0101216 Address [] Renewal [] Employment [:)Lost Card ,'Office of Consumer Affairs &'B'sluess Regulation License or registration valid for individul use only OME IMPROV_kMENT CoNTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration-ki;W\567 Type* 10 ParkPlaza - Suite 5170 Explra Supplement Card, Boston, MA 02116 TURNPIKE ING INC. GEORGE VASIL 1p 239 BOSTON S7 jj� TOPSFIELD, MA 01 Undersecretary Not valid without signature 0 CERTIFICATE OF LIABILITY INSURANCE DATE (NWIDEYYYYY) 1 GENERAL LIABILITY 6/25/ld 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), AUrHORIZED REPRESENTATIVE OR PRODUCER, AND THE CE917IFICATE HOLDER. IMPORTANT: If the certificate holder is an ADD11IONAL INSURED, the policyoes) must be endorsed. If SUBROGA11ON 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 end orsement(s). PRONICER R '-ER CONTACT ... ACT A - NAME: C r -le B U S Circle Business Ins. Agay, Ina Ho E PtiuNF AIX 247 Newb u 247 Newbury Street N� xn- (978) 777-5619 IFA 0 ! (978) 777-4898 NJ E-MAIL ADDRESS- ADrArSS'. PaulaHalaseCirclelnsurance. net Danv M .r Danvers, MA 01923 INSURERS) AFFORDIN3 COVERAGE NAICS Ns I INSURERA:The Hartford Fburyport, INS URED U, Turnpike General Contracting INSURERS: Company Inc INSURERC, JNSURERD: 4 1 New Pasture Rd I NSU RER E New MA 01950 INSURER F; COVERAr.FR r%QV1Q1%J1)1 NUIVU31--11: 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. LT AODLSUBR TYPE OF INSURANCE WVD P OU CY NUMBER IYYYYI I WPO LIMTS i aw 114 GENERAL LIABILITY SHOULD ANY OF THE ABOVE DF SCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ty P.W. W., COMMERCIAL GENE PAL LIA13 IU TY F� s a a s� CH OCCURRENCE $ DAMAGE TO RENTED R_:1 CLAIMS -MADE OCCUR MED EXP (Any ona person) S no MERALAGGREGATE PERSONAL & ADV INJURY S G L 'C T GEN'LAGGREGATE LIMIT APPLIES PER Loc _� POLICY Q ZELI_ PRODUCrS - OOMPIOP AGO $ $ AUTOMOBILE LIABIUTY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS -CORB—IN-E-D—SPULTED—MIT _LEaaccidart) $ — — BODILY INJURY (Per person) $ BODILY INJURY (Per c1dant) S PROPEI� �AMAGE -5 _per sechlant] i U MAMB RE LLA LI EXCESS LIAB OCIOUR CLAIMS -MADE I'S Ft M1.E EACH OCCURRENCE $ AGGREG E DED RETENTION $ A WDRKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PPATNERIEXECUTNE YIN OFFICERIMEMBER EXCLUDED? 7N (Mandatory In NH) "06d"'fr"Ou 13 S IP ION &deQrPERAT,CN,b.,.. NIA OBWECCK0343 6/25/12 6/25/13 S WC STATU- I TORY I NMI; I x FR_ E.L. EACH ACCILP-W 1,000,000 EL. DIS EASE - EA EMp L 1,000,000 _gL__ DyEE S �E _ POL" E.L. oil EASE -POLICY LIMIT $ 1,000,000 "IT 'Y L'+ DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is reqd red) CERTIFICATE HOLDFR I W !V00 -Lu lu A'�VK U LoUKFUKATION. All rignts reservea. ACOR D 25 (2010105) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: i aw 114 SHOULD ANY OF THE ABOVE DF SCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ty P.W. W., P a u I a H I s a a s� W !V00 -Lu lu A'�VK U LoUKFUKATION. All rignts reservea. ACOR D 25 (2010105) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 kvi . www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2ibly Name (Business/Organization/Individual): Address: 1QPrfAi,_S1) 1YA'_4aM,3 Phone#: 'A-r—e-y-o-u---a-n---eiii0l-OYEe?'Ch-Cckth-"---p-p--r-'o-p--ri-abe--b-o-x:-- 1. 1 am a employer with 4. El I am a general contractor and I employees (full and/or p9 -_time).* have hired the sub -contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insuraficeJ required.] 5. E] We are a corporation and its 3. 1 am a homeowner doing all work officers have exercised their myselE [No workers' comp. right of exemption per MGL insurance required.] t C. 152, § 1(4), and we have no employees. [No workers' coniv. insurance reauired.1 Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9. E] Building addition -IO.E]Electrical repairs or additions I I.[] Plumbing repairs or additions 12,R Roof repairs 13.E1 Other *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.. tContractors that check this box must attached an additional sheet showing the name of the sub-contractbrs and state whether 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 I compensation insurancefor my employees. Below is the policy andjob site information. Insurance Company Policy # or Self -ins. Lic. M Expiration Job Site Address: !Y!V- 1-5,_0 City/State/Zip:AVL 11W1)MA_AA;_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failur!6 to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penaltiesof a fine qp 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 he n provided above is true and correct. Phone#: 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 #: