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Home My WebLink AboutBuilding Permit #827 - 66 JAY ROAD 6/22/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO 3 Permit J6�1,1_ Date Received7L3 % 6'"-7 _z-1,'!/ , Date Issued: c (O "Zr-- 10 or / ® IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTYOWNER (2crl, 2, v tttev 16,6,,, o =;runt MAP 210 t 1� PARCEL: S$ ZONING DISTRICT: RS Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Buildingne famil Addition Two or more family Industrial Alteration No. of units: Commercial Others: e-54 replacem Assessory Bldg emolition Other Septic Well - Floodplain Wetlands Watershed District Water/Sewer IJtbUK1V I ION OF WORK TO BE PREFORMED: Pcscil Identifcation Please Type or Print Clearly` OWNER: Name: cx — o i rr; eJ` �� e � �� /�c\ yer-�o Phone: oc1&.I0&. I &q- G Address: ?j n CONTRACTOR Name: Phone' ot-7g, (� R. ftc;-) Address; 7CJfne^ce W\A CJS !, Supervisor's Construction License: (' /OSSOExp. Date: C3? (t 9 Home Improvement License: Exp. Date: a-, /13/201L_ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED CB SED ON $125.00 PER S Total Project Cost: $ 21 3' k FEE: $ [� Check No.: Receipt No.: a3 6d, I NOTE: Persons contracting wi� I egi �e c tractors do not have access to the guaranty fund Signature nature of contractor 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. ,.' V ❑ Photo Copy of H.I.C. And G:SZ�iNenses �. c3 Copy Of ContractW4 ❑ 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 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: Building Permit Revised 2008 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 (riya9eptic 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 COMMENTS C� 1 _ �� — 1 Li C- + HEALTH Reviewed on -Z. 11 t-2 Signature s C COMMENTS�:r Zoning Board of Appeals:,Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision:.= Comments Conservation Decision: Comm Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: t-ocateo , ;%4 us o0o Street FIRE DEPARTMENT - Temp Dumpster onsite 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 No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — For department use S -1 7)n Az) ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 Location A J?// No. Date HQRTq TOWN OF NORTH ANDOVER 3?� .. •SOL F - p Certificate of Occupancy $ 'yes''••°''<�' Buildin (Frame Permit Fee $ CH Building/Frame Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1� 6-- 230�,1 Building Inspector 70 South Broadway � �� 45 Route 125 Lawrence, MA 01843 Kingston, NH 03848 Tel: 978-688-8307 l Tel: 603-642-9909 Fax: 978-688-1949 sinker �e" Fax: 603-642-9906 providing a full line of services and supplies fully licensed and insured wwws anin ipootsQnliniucom /i q r Zot0 :. Name -U ¢ > t t{tZ) Date _ 7 l�-�G r �lC2tS] Address `I� CRY State State � Zip 6 La Home Phone Work Phone Cell �7 4 0 Add'I # CtossStreeUDirections p� Q -' 1kJv1. Estimated Start Date v Estimated Completion Date We propose to furnish and install one In gunite ! fo Y 3 Z- ?_ ` n ' swimming pool for the sum of $ f � °t Sb .L..., l� ►- . ;_ (1.�re cr: ,�. _ THIS PRICE INCLUDES: q{ Normal Excavation up to 8 hours on day of dig�'j a1qt, Waterline Tile (6•) Backfill and Sub -Grade up to 3 hours(t t ✓ Liner Chace Z,0iA n . Underwater White Light 120 Vola ( and_✓""' Test Kit Steel Reinforcing per Engineered Plans for gunife Inks Surface skimmer(s Z. • Steal Structure per Engineered Plans for vinyl �mrbhcedieinicals • Dual Main Drains, Over -Flo Line for addedprotection _ . (sup 804 od sl� r t � � - Coping •Pressure testing of plumbing during construction ;,t,eaftret � � r 3 �. •Steps �ra_e _ Ten Year Plumbing Guarantee (see specifications) Wstl ) Handrails Transferable Lifetime Structural Warranty ExtenSon e' + Filter SMO b l -se t (plumbed no more then 25ft from pooh Pump & mote—=- i—� THIS PRICE DOES NOT INCLUDE: • Any plumbing over 25ft from pod. Additional runs are not recommended but would best a cost of $ 2� per foot per line. • Machine time in excess of that specified above. Additional machine time to be biped at $ 3 �r- including machine, operator, and laborer, due with second pod payment • Ati hours of trucking will be charged at $ --per hour per truck due with second pod payment Any dumping costs incurred for disposal of ledge, large rocks, garbage, stumps buried or otherwise, building materials, unsuitable or nonstructural soils, or any unforeseen material thatmust be removed. Removal of ledge or large rocks by way of a Starr bit, chipper, or blasting. • Additional fill, if necessary, for proper backfill or reshaping of hole, supply or spreading of loam, reseeding of grass. - Patio, fence, retaining wall, or any accessory items other than noted on contract. Electrical wiring, fuel connections, heater venting, fuel storage tanks or permits. Repair or replacement of sprinkler systems or any buried Items such as well lines, drywells, leach fields, electrical lines g0les, etc. that are damaged during constructs Coats due to water or soil conditions (ex. day, peat, live sand, excessive rock, etc.) requiring a stone pack of the hole. The stone pack will be at an extra charge of $ minimum to $_m mmum and at the discretion of the job supervisor. Additional machine time and/or materials necessary to rectify such a condition will be at a cost over and above the stone pa and will t e quoted by the job supervisor. • Water to fill pod. _ CUSTOMERS MUST SUPPLY: Initials • Access for all trucks and equipment • Building and Electrical Permits or assume the costs necessary to obtain such permits. Water and electric necessary for construction of pod • Customer must water cure Gunhe shell for 7 to 10 days if applicable. Water to fill pod immediately upon interior finish pj r ! ` r NOTES: C n je` PIT'S (`tis t� E'er' l t YYT-t - �/nvk u d �.J �� (' "�l� est 12 LA -App- r- gA Stl vE V0L o i'rrl� r_ �a sf rZ. ~� �( ?rCC - Ifega P- o--/ �jr. v,e..! e,.,,r htl�c... OoSS•�� • - TOTALS:____ ng __ { ) Solarcover { ) Additional Pod Lightings•rtt,b eel 13 )Ltt: ) Heater ( ) Environpod Plus, 6 hd 2 surface ( ) Additional Floor Heads ( ) Polaris Vac -Sweep ( ) � Polaris retrov_fitonly ( ) Via""y( ) Interior Finish ( ) spa m (...:. ...:........... Automated Control System ( ) SaltChlotineGeneratorEAC-- (p„CL. pec Other ( t.ro 1&—loge ) Basic Pod Price Options $ _ SUU13{TOTAL s %r, % bafalesTax ,(�$ I g TOTAL, Less 10% Deposit Balancebf Contract' $ PAYMENTS: 1/3 EXCAVATION 113 BACKFILL + EXTRAS 113 SYSTEM START-UP The buyer hereby agrees to pay, in full, the total amount of this transaction upon start-up of the installed pool. Your salesman or job supervisor will meet with you prior to excavation at which time all decisions including pool size, shape, elevation, liner print, and all options must be final. Changes after this date will be subject to extra charges, where applicable, and will result in unavoidable delays. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Credit card payments not accepted on contract amount. (� Z 3- µA • BUYER date ° �e,C.w�i Qt.rSELLEti=-- date 1 10 CO BUYER date �c J I u[.Ucc.uol uuUaleLl(6Ln uUl!RCrnauOudLCOttI I0:%-vruricaTe or msurdnCe JI000.74r 14UU) W;4T UTfZIdrTUWM L•TZ rg U3 -L4 r uardo. RICA9 ACORD- CERTIFICATE OF LIABILITY INSURANCE 1`M(DO YYYY, MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH 1!129122912 010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HUB IntSITla110rh11 NEW England ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 299 Ballardvale St HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR Wilmington, MA 01887 ALTERTHE COVE RAGE AFFORDED BY THE POLICIES BELOW. 978 6$7•$100 INSURERS AFFORDING COVERAGE NAIC Y INSURED INSURERA Nautilus Ins CO Family pools &patios Inc. INSURER a Technology Insurance Co 70 S. Broadway Safety Ins w:URERD urance Co NE RERD Lawrence, MA 01843 INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATEL`G. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OF, OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE 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. NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 60 SHALL TYPE OF INSURANCE POLICY NUAS3ERPOLICYFE E 0911912009 PO LINKS A GENERAL LIAEILnY NC939713 09/19/2010 EACH OCCURREWF S1 000 OOD X COMMERCIAL GENERAL LIABILITY M, —A a ", ART, TEU $101`000 MED EXP (Any a soot $5,000 CLAIMS MADE OCCUR X BUPD Dred: 62600 PERSONAL d ADV INARY S1 401`000 X XCLI Incl GENERAL AGGREGATE $2. 000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMPoOPACG s2,000,000 POLICY M PRO-jFCT LOC C AUTOMOBILE LIABILITY 3847232 1213112009 12131/2010 MENED ING'ELMT x1,000,000 ALL O'NNM AUTCS BODEYINdURY $ X SCHEDULED AUTOS ;Per persart X HIREC AUTOS X NON.OWNEDAUTOS BODILY INJURY S ilAx. ar 'deMj PROPERTY DAMAGE S IPe' a[.ud3n11 GARAGE LABILrrY AU10 a4LY-EA ALCICENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG S EXCESS T UMBRELLA LIABILITY OCCUR 0 CLAIMS MADE EACH OCCURRENCE S AGGREGATE $ - S DEDUCTIBLE $ RETENTION S B WORKS RB COMPBILITY ON AND TWC3229154 1213112009 12131/2410 X wR ST T':- on{. EMPLOYERS' EMPLOYERS' LIABILITY AV PROPRIETORiERRA EGUrNE � Ragry Binkt SUbro Waiver Included E.L. EACH ACCIDENT $100 ,000 E.L. DISEASE w EA EMPLOYEE $100,000 A I deaoftwdar E.L. DISEASE -POLICY LM.IT jIiW0,W0 SPECIAL PROVISIONS Md- OTHER DESCRIPTION OF OPERATIONS! LOCATIONS! VENICL.ES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECAL PROVISIONS OTA "S.11"WRIS97e43 W IV55-AMM AL:ORD CORPORATION. All rights reserad. The ACORD name and logo are registered marks of ACORD WR001 Icua SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION EVIDENCE OF INSURANCE DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL I In DAYS WRITTEN NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 60 SHALL IMPOSE NO OBDOATMN OR LIABILITY OF ANY HIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHOR RBRE6ENTATNE .9 OTA "S.11"WRIS97e43 W IV55-AMM AL:ORD CORPORATION. All rights reserad. The ACORD name and logo are registered marks of ACORD WR001 (c. ✓%te fi'air.,sitoa.��,ai� o� �%on��ium,,�a n- N Board of Building Regulatiobs and Standards l�1 HOME IMPROVEMENT CONTRACTOR r,Vw! Registration: 118204 Expirafiony13/201iTr# 280313 P.riyafe Corporation FAMILY POOLS'& PATfOS.INC .:.. WILLIAM GIANOPOULUS 70 S. BROAOWAY`..: LAWRENCE, MA 01843 Ad - ministratorr License or registration valid for individ'ul use only before the expiration date. if found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 -A' 4ov. d wi o na ' �cl)r n D n g!D 0 C >CnN 3 O.. o a fD m � c in N l CD o � s m m m m m EPmm v, 'O C � � d 'O O CD t7 Z y O. O CC) CM r� � � c CL =y >to = O O p CD Q O cr� �dCD CDo CD C CDCD Vf� CL O y CQ C=D z r m cn cn n O V' R 2 rn O z 0 C. y ON _ ao�m � y ® 0 m c O H COD d t7 - = Z �� N o = �►' O O T ?Fn o a?d o ca CD 0 N �m m = cCD 0 z 0121%:s. n C a �y7 ao m: 0 CD O y fCD C9'O ami •: O O1 H . H,? C d d C r C W oCL .c a H < :rte X CD y N O m ' CD CD s =mw IrCD0 -moo o CD CD WCO) @ O CD d C, 'O O O O .-w * O NEI C/) 0 dx Cn ° OtZ py 71 ?? G0 ►n� � �' Cn g,z � Cr1 ro n ?? '� O r- ; ro y ?� n jJ 'r] G CL r � � w rD b Cn '17 p ?5 0 y�y r 19 H 0 1 9 O C o o 0 02 'k �n�oa n OO I 11 01A, dd As� vZ 6688" EX OAA/NAGE FS41,1 o o 0 02 'k �n�oa n 11 As� vZ 11 Commonwealth ofassachusetts MOfficial Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Use [Rev. 1/07] Qeave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORKAll work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMP, 200 (PLEASE PRINTINAW OR TYPE ALL hVFQRM147ION City or Town of: NORTH ANDOVR Date: ETo the Iector By this application the undersigned gives notice of his or her intention to perform the el� electrical w Pies described below. Location (Street & Number) (; (,a Owner or Tenant 71-o v o 11p - Owner's Address _G Telephone No. 9l 6 � 0.y (Zd —_U8 /o Is. this permit in conjunction with a bwidmg per-mrt? yes Purpose of Building ® NO EJ (Check Appropriate Bog) g �� Utility Authorization No. Existing Service Amps / _Volts New Service Overhead ❑ Undgrd No..of Meters Amps / Volts Overhead. ❑ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: var•-12:3 o� fJr`O/sCJ'i�y i/o/m^P �w g's^®ter :. Po®G- Com letion af the ollowin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Sus No. of p (Paddle) Fans Transformers Total No. of Luminaire Outlets No. of Hot Tubs KVA Generators KVA No. of Luminaires Swimuning Pool Above ❑ �_. Generators ergency g d• d. ®Batte nit —, No. of Receptacle Outlets No. of oil Bummers , F"� ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and No, of Ranges No. of Waste Disposers No. of Dishwashers N. of Dryers o. of Water Heaters KW No. Hydromassage Bathtubs OTHER o. of Air Cond. Of Alerting Devices -__ Totals: ___� �� „ M "40- of Sell --C Detection/Ali Space/Area Heating KW Local(] ❑ Mu Heating Appliances KW Col Security Syysst Dei No. ofNo. Signs No. of Ballasts. of Data Wirin g:No. of Del No. of Motors Total Hp Telecommum No. of Dei g Devices don Other do or Equivalent .or -Equivalent ins Wiring: or Ennivalr•nt Estimated Value of Electrical Work Attach additional detail if desired, or as required by the Inspector of Wires. -Work to Start: (When required by municipal policy Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: -Unless waived by the owner, no permit for the performance of electrical work may issue unless the Licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covers a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEBOND ❑ under the OTHER I certify, ❑ (Specify:) p 'ns and penalties o perjury, that the information on this application is true and complete FIRM NAME• �qr eG �' p Licensee: G� . Q „yt�G LIC. NO.: 3K7�v` (If applicable, enter "exempt " in he license number e.) Signature LIC. NO.: Address: _ d� -- Bus. TeL No.: *Per M.G.L c. 147, s 57 61, security work requires D Alt. Tel. No.: fid.. 3q? t yW OWNER'S INSURANCE WAIVER: I am aware thatlr Lint Of a doles notehav1e't Liice bili Lic. No. required by law. By my signature below, I hereby waive this requirement. I am the check one Insurance coverage normally Owner/Agent ) ❑ owner ❑ owner's agent. Signature Telephone No. PERMIT FEE:.S' The Commonweatt`h of Massachusetts Department of 1ndustrizd Accidents Office of Investigations 600 N-"irshin ton Street Boston, MA 02111 www nzassgov/dia . Worken, Compensation JMkinance Affidavit: ;tiicant Information Builders/Contractors/Eiectricians/pltvmbers Name (Business/DWim iarL4ndividusl):_!-� Adaress: 4e 0M O Ayo oas employer? Cheek.the, appropriste'box: 1 Phone #:. am a employer with ___L_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am .a.sole proprietor or partner- Iisted on the attached sheet I ship and have no employees These sub -contractors have working for mem any capacity, workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 3. ❑required-] officers have exercised their I am a homeowner doing all work right of exemption per MOL myself, [No•workers' comp. c,'152 § L(4j,pti we have no insurance required.] t .empioyees. [No workers' Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10-❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other I — .Z ....ter. �,wacyuu otL� `An} appiicartt shat checks boar' # I must aiso fill out the section beim showing their workers' con t Homeowners who submit this affidavit indicating they are doing ail w 0 and than hire outside momsconmtars Poircy mtormaho L ;Carrhactors that chexlr this box must attached an additional sheer sho must submit a � affidavit indicaliag arch wing the mme orthe sub-catrhact n.,,,+ tti _ . 1 am an en{ployer that ispr? ' ::" •.:. up pollicy iniDr un on. p vrdurg:warkers 1 comperscation irisurancefore information. / M. mP oJ'� Below is the policy � job site Insurance Company Name: ' LgAt_-a v q� Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workeCity/State/Zip. rs' 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 penahics o, fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn of a STOP WORK ORDER and of a Of up to 5250:00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of fine Investigations of the DlA for insurance coverage verification. I do hereby cerfify under the pains and penalties o perjury that the information provided above is true and co rrea Si ttve:. O Date. Phone #: EE only. Do not write in this area, to be complete&by zily or town official n: Permit/License # ority, (circle one): Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector S. Plumbing Inspector on- Phone #. Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10-❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other I — .Z ....ter. �,wacyuu otL� `An} appiicartt shat checks boar' # I must aiso fill out the section beim showing their workers' con t Homeowners who submit this affidavit indicating they are doing ail w 0 and than hire outside momsconmtars Poircy mtormaho L ;Carrhactors that chexlr this box must attached an additional sheer sho must submit a � affidavit indicaliag arch wing the mme orthe sub-catrhact n.,,,+ tti _ . 1 am an en{ployer that ispr? ' ::" •.:. up pollicy iniDr un on. p vrdurg:warkers 1 comperscation irisurancefore information. / M. mP oJ'� Below is the policy � job site Insurance Company Name: ' LgAt_-a v q� Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workeCity/State/Zip. rs' 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 penahics o, fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn of a STOP WORK ORDER and of a Of up to 5250:00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of fine Investigations of the DlA for insurance coverage verification. I do hereby cerfify under the pains and penalties o perjury that the information provided above is true and co rrea Si ttve:. O Date. Phone #: EE only. Do not write in this area, to be complete&by zily or town official n: Permit/License # ority, (circle one): Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector S. Plumbing Inspector on- Phone #. I 2A �► a p P o� n� ��►�vp.�j°P � a m 2� 0� 9g s� ti *foF o 2 (p u � ! x � / � 553 \ o- \ : c� j H \• i' \"\�-1 i{\ t \�2 � c \�A tb { j r r r r oN oA �o o o } 1 } � � r r 1 i � { r r ,� : ;.: ,. _ _x- v t� /r r l t if // 1 ,•�P P A i ..—.(-5O//ill!/ i o o( i i d0 a \' W' iii/ i' P P ► 4E ^. —.. ..—.. �.,r.. �.. .. 25' RANDS BDF e --•4.,.•_ \ \�\ `� ``e \ \\ \\ t :: { 181 yg• ' � p • •P P p P P ''_' P: � :y.,= � � �-= . '►'i Q:i.k .._-_,�`"'J01�. .gip :. a a � � 66.88'P ► ' _.�::-?: _.r �v o a r OR41N401- eSA -L a m n 10 13 ..0' Ol'i in n Z y h 2 Z '^ O O n m� o oo a'� x �`o ' I• O I I I••I 4 8 rn mZ O Z o LO 0 z M � m m in 9 M