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HomeMy WebLinkAboutBuilding Permit #457-15 - 47 CHICKERING ROAD 11/10/2014BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: �/ Date Received Date Issued: ifflull IMPORTANT: Applicant must complete all items on this /NORTH ,,LED , ti ? b o E, 03 IV LOCATION Print PROPERTY OWNER—_ Print _ ro MAP PARCEL:ZONING DISTRICT:Historic District yes no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building -B-Ane family El Addition ❑ Two or more family El Industrial ❑ Alt ation No. of units: ❑ Commercial Zl�epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer dent' ication - Please OWNER: Name: Address: 17"i/ Clearly C Phone: / %9���- 096 7- A� , W��446- Contractor Nam In Address: Supervisor's Construction License: '�� Exp. Date:. Home Improvement License Y/� Exp. 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: $ FEE: $ Check No.: 9-d 22 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to an n) S g ture. of Agent/Owner Signature of contra Location No. Date Check # l U 7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL $ Building Inspector -a Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPEOF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools 0. Well ❑ Tobacco Sales ❑ Food Packaging/Sales 0 Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature_ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Usgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 No 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/Cross Section/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 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 Doe: Building Permit Revised 2014 E r� 0� 4mI 0 C O H a _ O cc M p 2, .Q a� CD Q E Q. � to 0 0 E _ 3p- � E L L m a = N U) a N o �• O -a > _ Q c � y p E c a Qo (nz 0) o = � �. 3 am tm > o_ Q CL •� dOW �. �4W�oc� _ Q ev �a o COW CD- Q. as '� N F- O tov m p fn r+ L% •0 V .cL to O O 1- �y=�� Z W v v E v —CL L N w4) r— p mov > cn z O X. Z f— . U W a z xO H U W LU m HE .ti w Iv E QC 0 O z N ' L ,mo,wo V+ �M IL s 0 �+ 0 0 � O Q CL Q. � Q O CL 0 4) cz O U U) cv _ i CL U) B 0 0 0 a z Q W W a W d Q W 2 W d Z (A Z t/1 ? 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CL O 0 > I 4ii .ti Iv ti ti i 7 E Z CL O r.N a W 0 M mm G_ ~ t O 0 Q O a �a � ca �O- O CD z O U CL 5 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold, Furnished and Installed by: Branch Name: Boston Date: THD At -Home Services, Inc. d/b/a The Home Depot At -Home Services 908 Boston Turnpike, Unit ],Shrewsbury, MA 01545 Toll Free (800) 657-5182; Fax (508) 845-6017 Branch Number: 31 Federal ID # 75-2698460; ME Lic # C 02439; RI Cont. Lic# 16427 {� j� CT Lic # HIC.0565522; MA Home Improvement Contractor Reg. # 126893 C�(CJr Installation Address: T 7 kPr i��� /U /� v[r / t,,nt0/Pi�S city State Zip rurenaserts): Work Phone: Home Phone: Cell Phone: [ ] "Ir,I 9Go - [ ] [ Home Address: (if different from Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates): ❑ I DO NOT wish to receive any marketing emails from The Home Depot Proiect Information: Undersigned ("Customer"), 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 Sheet(s), all of which are incorporated into this Contract by this reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively, "Contract"): Job #: unmmaimm... ) Products: Snec Sheetfs) #: Proiect Amount Customer agrees that, immediately upon completion of the work for each Product. Customer will execute a Completion Certificate (one for 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 Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) included herein, at 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 home, environmental hazards such as mold, asbestos or lead paint, other safety concerns, pricing errors or because work required to complete the job was not included in the Contract. Payment Summar,: The Payment Summary # 6929 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 are 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 Home 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 HOME 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 supersedes 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 the terms of d has received a copy of this Agreement. Ac p y: Submitted by ` ' x x /c- -i stomer's gnature Date Sales Consultant's Signature Date X 0 Telephone No. C�3-" Customer's Signature Date Sales Consultant License Into. CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HONE DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. (as applicable) NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT ❑Roofing ❑Siding JU Windows ❑ Insulation d f ❑Gutters / Covers ❑Entry Doors ❑ Roofing []Siding ❑ Windows ❑ insulation $ ❑Gutters / Covers []Entry Doors ❑ ❑Roofing ❑Siding El Windows ❑ Insulation []Gutters / Covers []Entry Doors El$ Rooting Siding 0 Windows ❑ Insulation ❑Gutters / Covers ❑Entry Doors [1$ Minimum 25% Deposit of Contract Amount due upon execution of this contract Total Contract Amount $ / Maine Purchasers may not deposit more than one-third of the Contract Amount Customer agrees that, immediately upon completion of the work for each Product. Customer will execute a Completion Certificate (one for 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 Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) included herein, at 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 home, environmental hazards such as mold, asbestos or lead paint, other safety concerns, pricing errors or because work required to complete the job was not included in the Contract. Payment Summar,: The Payment Summary # 6929 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 are 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 Home 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 HOME 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 supersedes 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 the terms of d has received a copy of this Agreement. Ac p y: Submitted by ` ' x x /c- -i stomer's gnature Date Sales Consultant's Signature Date X 0 Telephone No. C�3-" Customer's Signature Date Sales Consultant License Into. CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HONE DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. (as applicable) NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT J �+ y.l Ynu L.I�w.J LY✓w u.. In 1S1y Ia 1�acLu IXSVl1ll/JM'RWDI LULS.1-LI Im.Lu uu loln s1�+�D'es N_t:IS tILIZTItDIu:SDI %t* r% . � L10ISCG2L11YSiD � ' . zL7L:,-1—S �g`Ilipil 1�acLu IXSVl1ll/JM'RWDI LULS.1-LI Im.Lu uu loln s1�+�D'es N_t:IS tILIZTItDIu:SDI %t* r% . � L10ISCG2L11YSiD � ' . zL7L:,-1—S I DATE (MMIDONYYY) AcaRD . CERTIFICATE OF LIABILITY INSURANCE 07/1912014 �. THIS CER7IFICATE 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 THF -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 it trio cons of the policy, certain policies may require an endorsement. A statement'on this certificate does not confer rights to the certlflcate holder In jleu Ci such endorsemeant(sT. CDN ACT 'PRODUCER NAME' FAX MARSH USA INC. PHONE A1C No! TWO ALLIANCE CENTER EMAIL 3550 LENOX ROAD, SUITE 2400 ADDRESS: ATLANTA, GA 30326 INSURERS AFFORDING COVERAGE NAIC 0 Steadfast Insurance Company 26387 100492-Home(}GAW14 15 INSURER A : 1E535 INSURED INSURER B ; 2urlCh American Insurance CO THD AT-HOME SERVICES, INC, New Hampshire Ins Co 23841 DBXTHE HOME DEPOTAT-HOME SERVICES NwaeR c : 23817 = 2455 PACES FERRY ROAD INSu 'ER 0 : Illinois National Insurance Company ATLANTA, GA 30339 INSURER E: '•' '• INSURER F: ' COVERAGES CERTIFICATE NUMBER: ATL•003242685-Oi REVISION NUMSER:3 NA W HAVE BEEN. TO THE INSURED MED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF. INSURANCE LISTED BELL) 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. ITR AODL UB POLICYE�FPOLICY EXP LIMITS TYPE -OF INSURANCE • ' I POLICY NUMBER. I rMMIDDl1•Y"Yy MMrOom'YY 9,OOo,D00 A EGENEPLAIL LIABILITY GL04887714-04 - 03101/2014 03A1/2015 EACH OCCURRENCE S c IE S 1,000,000 PRI cs c - rren e MMERCIAL GENERAL LIABILITY EXCLUDED LIMITS OF POUCY XS MED EXP (Any one person) S CLAIMS -MADE OCCUR 9,000,000 OF SIR SIM PER OCC , PERSONAL is ^^^ ^^^ C (WORKERS COMPENSATION. C WCD49101885 (KY, NC, NH, VT) WCD49101886(NJ) GENL AGGREGATE LIMIT APPLIES PER X POLICY n PRC n LOC GENERA! .-�A__c PRODUCTS. COMP/OP AGG BAP 2938863-11 B AUTOMOBILE LIABILITY 03101/2014 0310112015 X ANY AUTO ALL OWNED SELF INSURED AUTO PHY DMG AUTOSU�I AUTOS NON -OWNED BODILY INJURY (Per accident) S DAMAGE S LITos' AUTOS HIRED ALIT -HA uTOs �PROPERTY a I enl 2 S UMBRELLA LIAR. OCCUR EXCESS LIAB CLAIMS -MADE DED RETENnON S 188 ' C WORKERS COMPENSATION AND EMPLOYERS' LABILRY WM9101884 (AK, A2. VA) C ANY pROPRIETDR/PARTNEPJEXECUTIVE N N ! A OFFICERIMEMBEREXCLUDED7 WC 99101883(FL) D (Mandatory In NH) . H yes, describe C (WORKERS COMPENSATION. C WCD49101885 (KY, NC, NH, VT) WCD49101886(NJ) 14 0310112014 jOnjI2oj5(EL) LIMIT 03/0112014 03A112015 DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES (Attach ACORD 191, AddlUcnal Remarks Schedule, II more space Is required) EVIDENCE OF INSURANCE THD AT-HOME SERVICES, INC. DBA THE HOME DEPOT AT-HOME SERVICES 2455 PACES FERRY ROAD ATWNTA, GA 30339 MDEff _s EA E—MPLO—Y• ! SSS _ oro IrY'.T I S ANCELLATION 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 or Manh USA Inc. Manash( Mukherjee —MA O�s" © 1988-2010 ACOAD CORPORATION. All rights reserved. GENERA! .-�A__c PRODUCTS. COMP/OP AGG f. 03101/2014 0310112015 COMBINED SINGLE LIMIT i .....J E, accident BODILY INJURY (Per person) S BODILY INJURY (Per accident) S DAMAGE S �PROPERTY a I enl S 14 0310112014 jOnjI2oj5(EL) LIMIT 03/0112014 03A112015 DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES (Attach ACORD 191, AddlUcnal Remarks Schedule, II more space Is required) EVIDENCE OF INSURANCE THD AT-HOME SERVICES, INC. DBA THE HOME DEPOT AT-HOME SERVICES 2455 PACES FERRY ROAD ATWNTA, GA 30339 MDEff _s EA E—MPLO—Y• ! SSS _ oro IrY'.T I S ANCELLATION 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 or Manh USA Inc. Manash( Mukherjee —MA O�s" © 1988-2010 ACOAD CORPORATION. All rights reserved. rermrtZiervlces 4U1 'L40'Lbbt1 P I ���/ ��/V//L/ll (iLI'�ZI.VVvC'l/1�7 V. t/' \.'� ✓ ✓C�C��LrC•ti/VLL/.j t/�"`� . Office of Consumer Affai and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 0211.6 Home Improvement•Contractor Registration Registration: 125893 Type: Supplement Card Expiration: 813!2018 THD AT HOME SERVICES, INC. RICHARD TROIA 2690 CUMBERLAND PARKWAY SUITE 300 ATLANTA, GA 30339 cA I :t zut ni a� '^ 011ice orCucsuncr Ariairs & Boiiocss Rt; ulation !=• ''gom= UAPROVEMENT CONTRAC i OR ,"7.ts Registration: .126993 Type: Expiratiort.MN2016.; Supplement Card TND AT HOME S-EFVICES, INC. THE HOME DEPOT AT'F301+1` SERVICES RICHARD TROIA ' 26.90 CUMBERLAND PARKWAY S � — A`( mC'A30339 Undtritcretary update Abdrrss and return card. Mark rcason for change. Address J Rencnnl Employment J Lost _ard License or registration --alid for indiridul use on]" before the expiration date- if found return Office of Consumcr Affairs and Business Re„ 10 Pirk Pian -Suite 5170 Boston, MA 02116 . w ��-,, 7 Notvslidw' outsi ature I �N Address: ,:,ae t.,u114r,tu111l•t:cctul vJ 1t1c1J'J'Ut:rtUJ'L'ClS / Department of•IitdristrialAccider.� Qf Ice of r1pest1; a j.&, 1 Congress istr`ucte 100 Bbstori'--L62114-2017 nsass.gov/din actsranceA_ idavit:Builders/Contractors/Electticians/Plumbers -Piaan ce Print LeV-ibly sslOrganizati on/In di vi dtul) :, 0 Are you an' -employer? Check the appropriates b, 5x' I. I am a-mblo*ycr with 4• �d 1 am a general contracioc and I - cmploy " ---'s ( full and/or part-timv-).* have hired th..'sub-contractors 2. ❑ I am a sole'propricior or partn:r listed on the attached sheet. s:,jD and have no cmoloyecs These sub -contractors have worl•.ing for me in any capacity, ea-,ployees and have workers' [No workers' comp: insurance • comp. irsurance.t 5. 1 ..Yqt are a corporation and its . • required.].. 3. ❑ I am a homeowner doing•all,worl: . officers have'exercised their myself: [No worl•trs'. comp " ' right of exemption per MGL and• we have no i^Sura:'tce ie0ulred.] t .' , • employees. [No workers" comp. insurance required.] Type of project (required}: 6' r] New construction 7, Q Remodeling g, Dcmolition 9, [] Building addition E1ccLLit•al repairs or additions 11.❑ PlU-mlo.:.; repairs or additions 12.[] Roof repzirs' FF 13 Other�t%��,G'� 'any zppiicznt c: �i::ds box =1 r:r st ai fill out the s::tiot blow shoving their wor}:c s''comp:nsatioapglicy infomtation. t $o ncowT: who subctit .,-:s afi,davit indicating th:y arc doing all woS.k and then stir: outsid: conte -tors must submit a n:w afrtdavit indi=ing such. tContzctors that chick this box must zttach:d an adLtional sh:ct showing the na.•r: of the sub-.=nt-acto s and sat: whither or not thos::mitis hav: c-ploy:a, If the svb-:on�zctors hzv: cn�ploy::s; th:y must provid: th--ir work--r-s' comp. poli'cy�numb::. I ori a;i employer th is providing worriersc ' onipertsation insurance for fry "ihfor manor.. p %� I^Surz_-tce Company Name: Policy= or Self-irs. Lic. ogees.` '.Below is the polFcy and job site- .� ^(ti`s � �• ` - Job Site Address: / r� /.,. � City/StatdZi Attach a copy of the Nvorkers' compensation policy declaration page (showing the policy number and expiration crate). Failu e to secure cov:-, as reouircd under Section 25A of MGL c. 1�2 can 1 -ad to the imposition of criminal paL lties of a fine'up to S1,500.00 and/or one-year impr'so.=.!:nt, as well as civil p-naltits in the form of a STOP WORT. ORDER and a lint of up to S250.00 a day agaiicst•the violator. Be advised that a copy of th-is statement May be forwarded to the Office of Investigatio^s of the DLA for irsurance,covcrage•verincation — I do hcrciby c_rri.- u pQ .• and. er alj r arjur� that the information provided cbove is tru- e and corrrct /p//✓l2 Date �/ r Pnon r Ofj-ial _se only. Do riot write ir ria arca, to be completed by city or town official. City or Town: Permit/ .icense Ism >; g Authority (circle one): 1 1. Board of'Z-1th 2. Bi, ild`.^-g Depzr u ent 3. City/Tomn Clerk4. "Lc�.ical rrsn-ctor S. Plumbi^_; Inspector 6.Other Contact Person: Phone R: