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HomeMy WebLinkAboutBuilding Permit #236-11 - 89 BLUEBERRY HILL LANE 9/20/2010 BUILDING-PERMITF µORT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO• Date Received • A ,.. / �R'%rro Date Issued: / [ �ssgcwus�� IMPORTANT:Applicant must complete all items on this Page 051- <,c - _ d z .:n:.-_,��a.. -•y,� .-a• t. .y- _ S�•.e. - `Viz. 011 u'C+....,w:nr2��'�. +b:- "�.�.^..=:� - 3,G' - - - _ ..1:-•.�i=v�:^__�T-1...5:4�r�ii:c:T:�: '"f,_--'�-->Jr: �.v 4::J -,. ten_.--..r- _`T•,r„'c��i?:. _:a:=c:4E>.., ....W .Jls:^ - - _ _ _ . .......:.: �:5_?��Ki•3'If �w4�,�-. �:Yr,. :'-. .:•tt3• i'hT'='ib iF.4i _"�`.� .�(4.� �'-. _f.?�' - ?^�^:S' --^,'�'^ �,+�,t' %'fir � :U di.•c`'.�P - ...�:3.:" _ -.�:``S.c:�i}:..r3a_•��`_'-�•...1::,> f, ..[.Ati.• �1� � M•+'•..-Y:^_ _. \.F�v 1. :' __N��- '.{(v". - ,t;�t.�'iit• -�.. -='.FY�:jF.y= _ ...5 :..>x'.�t-, r.�-.a. sa,... ^-.�,; `�= tic'.:`T= 's"l--....: �,_.'._a_is�Y;�.":,�tivf%'.Pi.�.. =!°�'L':�c�.,_•�: -.-+_ g':r%s�'-C x? '- _ -- -_ - - ^-•�:� '�.�:zy,.'=" _5�-+� ':y.+_ Berta'':. ?`3.. v,-:.�=t.``�:,_'-T� -,. `a..x-� .-s-.r._-„-.;.,_ ;f;Xn.,.?,.:., {;L:�'i��-"'.s';:�iu_C%c�:�i:r::�;. � x.���- _..,.a r• - 1 ,.� - __.�,�a -'�Y:Y=t-`�;;-:;,•-:....yr-- ',-��'t�a.:ar.._'':- -..�',: h{a'� .+;m;••..pr-��'•=_.._-=--�T"'.',..��,,r_;-f.;, I er ,.��.. =Gr-- - r.�, _ _ _ _ .r=•.:���,._._.�);..—_..��s »y�,z�.,a=�z§,�.,,.t:...7._,;.u�_.:._ - _-.�-;�:,.. _ etc;' � .el:�*��a•_='.;.tr-.-.�r.:1..•-�.:;."w,+�-:�J�:at; ?i?�;.'ieti� •ii ec^:'� -'='ta,r--.�,' -;:at�'-�� - _ - - n�..,,..may;.�..,- :�i'arc-a-,...a..•�•i wJ9gz .:fir,-�ia`..',-`,:'_ .;,..,�1"i, rr�n$.^-'}`'`s'..-,rro-`�t��� -T.-.;?�;'_T=Et,�c,.�:•• .-..r_,':.• 4„0.._ `."n�'xA�.��•.En:�•�. "a :i1.<�- .�. x _cr�ri.=.t,''�,,.,� -_,_yea, x:f:�: 4,_�i,.: __•sa,,.:-^�':�,.t,i'..�'r•,�-.-..�".ti,�- 'a`.,r;'<,��asCur.;��_tw•;i;'s���r._r. ,}.F. .�iL :� _ „�„ �4-..� t ' '��.. ;�rs„^< _ �:asi. _ .•�:': .=rs�_....11f��r': �'S-.�w� ,r a 5•�--,-�- - - r^... .h �.G,_�- -'�” m-rtle��.Rv.. - �:,ea�,.. - v:� �'.F�F'':�1;.GSn�I.t.i`�rt,�,w,•ic,..,.<:•_rFa�:,.5� _.�,}'�_�,'•1"�'.:`'5�,�-�.�.r,ti�,a.�: =.'_--��:h~~�..!:c'4Y,�,.,a:a' G Ir�' -�x:14' i)T. .'.' YI ����4�Tt_-'1?y.-5•.f,�Ty'3,�a�;'F-A,_.�ntNvrr�'_�r•.1-_a" /-1""4'tb 3'_'- ',. r .>•.J i,.�, .a_ wl , k1.,n_�'fY:.'.,.-4"�'..�.PS';F.,.,c r::1,_.�.-�.f{ <:Y'•� � ry'�1, `Jz L4.•FJ•� fi :IF ii kms."��.,,N �.fir..;R.,r�]Sti�'[n'3= - 45Yi m�.-,b3• ..k... '•,.J, ...,s;:a^•taz-. _.W,� -:M:.� ..MT,��'. _ _ _ "•`:3.;_ - .�� .�=�:=�4,.1..- '��isfr^� -,:r ssx.,ie_ ._r.:x ..J_� =,'`si. ..,r._.:.1+. �,.}�..,_ _ .c=� - -'i:�-=.. =t'r�-a- �.z T ?ti --ci'�'.-.':: �:v_.. .�""a,.:7,�'r�.-.,-rr�•�:_•r. '..::,r.r.;�.-- ,�.....,,« ,� .-]�'.`'6'c:_3,,�-. ,.,.r.:;su.- .,�.u�'r,=::. ;ris',:vR�..,ti��.'e�aa. .L�,tns.. - ;��4;. ,,..s.r?, _ _- �_•ilir"':- ;5__. - _r� -u:-� -- ..J. .d.; - s_-:rL: _! .,+ ._l:,.t._: '+:!:%cid. _ - �`; _•._..ts�."•--7...^ _ ...w,�=s - - - - - - - �t.�/., _�:r� r.-�:meq-:,•.�Gs�^%:r-��r=:r_sti.-_ .... .�-'. ter, ., ..... �'�,-�.� ...:...,, :,:•L =�; . - - TYPE OF IMPROVEMENT PROPOSED USE Reside 'al Non- Residential New Building ne family ' Addition ' Two or more family Industrial Alteration No. of units: Commercial Repair, replacement- Assessory Bldg Others: Demolition _ Other kE^-�7k=^-��t-i�l`�l�,u,-��i�'1.,d1"� -`'e•I wv+Pitb.i^- _F.}:I l:��'�,.'�:1�.,.- - _ :aR:_ i T�y -`;"iiM u4•V_ 4:J'�.-`'-v_- _ _-';�'�.-�r..r S.Xr. _ _ � ✓ ^A�A.A-..Ff. :5 ;'L+�-,...,,1,^_ss;;jr'rs•+ Via... "=-.''.cam..2 .r..t x - -r�'S' ' �; '`i''.vL�«.z._x.�•-;_:�'t'�: 's-ua•� cral"'ty..:' ..,y � _r, ..�. _ _ `;'t�,e � .W"':iLtdir+'�=:�;,r..y;.:.,a� _ i �` $.-.-�".•-' .•r- }-s.-.==- aeic;'?. :?>'.,�•��;,:,,=-F-•� �=z-::� �,. '-���--;er�''��` ��a _.��-f.r ;p=::��-.:'�?_.' _ ��'.it��J�i{��:G�rr,�:.-fir "�:--�''•-'":;_ '.�if�.c 'e�`•�' - - :zr _ ."�--_.,^'�� :�•,y�._� �Ir'--.,z_�,r,�:_r�-'�. TF;s.-�,�'ti`c:�l..�,=-zea. t.���'+�tw�J.�ui� ?"` X..._;e"l. � :�..�� �•,-„rJ.�:.,:.P : .7 - -_�_{� ir,._ -=r'�• '-."'i 7>r'� - -^r.r. =-,.,. x::. Y,s .=,s.q,�1 �, :fey CCa ����•ri�:'�'rir` ..n,:r i3 ^�`� �.'��,.1s1`e'i��t��. '-�_ •S,. i'=.�t!4, �,,� _ �'�'-.=ss.� "�•� - '3 .-'z-,-,•- :�_ .,'-�Y�.���::.ti.; =�--,..'.'.Y�-. _ - ._cT- _.Sic3,;;.r_°e14:ee er2F7 �-"nmgr„=:::;we"��4._,^..�Yr ;'..Ce;;..t}'t�•:ti'x�i.'�'_• .fir,.r�F+n,='�_9..�:7,tt ,a 'ci,rer tTM. - - �_ - - -__ - .-i_:i!f_ =_Ji__.-np,y.�;Nr_,4-,,�• �'=':a,.,�fna-+Wi-^�":,«�..;,.v�•Fi: Location v '� No. CO"" Date �oRT� TOWN OF NORTH ANDOVER a Certificate of Occupancy $ CMUE<� Building/Frame Permit Fee $ O� s45 Foundation Permit Fee $ ` Other Permit Fee $ TOTAL $ Check # 2-72 2346 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Pians TYPE OF SEWERAGE DISP7Tanning/MassageffiodyArt Public Sewer SwimmiugPools Wellacco 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 Sia riature ("10MMEN Ts HEALTH Reviewed on Signature d COMMENTS ' Zoning Board of Appeals-- 'Variance, Petition No: Zoning Decision/receipt submitted yes Plannirir,. aoard Decision: Comments Conservation Decision: Comments Water & Sewer Connection Driveway Permit DPW Town Engineer: Signature: Located 384 Os ood Street — y.•F:r .•.� - .'Til. >t�....—. -.:.4.. _ <'.'-.r�.-mss.._+s- r�. M1 • .. .�. r�:�:�ter����t�:. •�e�s.�:�.T,•_ ,r_:._.;�,�..<..:.,., �z��,^- -.,,:;�-�. _ _tom x r�:;����r -—_- - -==�:r�;K^• ��_:;�,� _ _ _ _ ..rte.°,4,=f.• cafe' � ' _ - - - - ;,tom_ - -;,�,=K-�::� ��;=+• - - - - - - - - - 2� —iJ.— J.:�i — .clitw�,T_...a�•� 7 :'.moi - — '-•�..,...�•.,•F.' - - _.y•._.:sy .,I—.:-Ne_:, - S - ,.._...:�.. — 3�c:-n.:— >-- .•t:- ��. ^='ate` - - ....r—�•' r:�,--' - -- - �.3. - ,.�•:� .:r::. �;;�::,� �"s. ti:� �:�;�:_ _ .vim, J:j r• _ - /� - - .+-T_^^mai.:,• - — �•• _ tiS'x .i 1' -- - 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) ❑ Notified for pickup- Date E Doc.Building Permit Revised 2010 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 A� ilding Permit Application Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses 'Icr"`Copy of Contract Floor Plan Or Proposed Interior Work r, ❑ 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 Pp Permit Application. ❑ Certified Surveyed Plot Plan o 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 Constructiori,(Single and Two Family) ❑ Building Permit Application ��.i.r:e' nn--oseJ ' vL i"i ai❑ d - f Lt:: , L ❑ 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 MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit fn all cases if a variance or special permit was required the Town CIerks 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:Buildin°Permit Revised 2008 NORTH 0 o over f And a dower, IVlassb LAKE ., COC RICHE WICK �O'? TE D 7 v V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System 1 BUILDING INSPECTOR THIS CERTIFIES THAT.......... vG�.......... .......1 .........�Q �........... .......... � ............ . Foundation erect............... ......... buildings on .... & ........ . Roughhas Permission to � ......... 71 to be occupied as.............. .. � 1... !`.�.,r. a•..��.c...... J44 � W! � �C'I•�l. ............... ...... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC TAR Rough .............. ... .................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the- Premises — Do Not Remove J Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE Smoke Det. ib NORTH 0 of over It -o� over, Mass.,LAKE �.' Z•a ' 1 � COCMIC EWICK %p�oRAT E D P? BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..........��n �►. ....... �'!�........... ............ �... ............... Foundation n ..1. .......... .. .. �• Rough has permission to erect............... .. ........... buildings o .......8.1 1 g M: eriMmeyw'- to be occupied as.............. % .. ................. 1... !`,�,..........®... ��.b.......��....... ....w�.. provided that the person accepting this permit shall in every respect conform to the terms of the applicatidh on file in Final 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 PERMIT EXPIRES IN 6 MONTHS ^ � ELECTRICAL INSPECTOR UNLESS CONSTRUCT TAR Rough .............. ... .............................................................................. .......... Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. + I f C O IV E3 T FR U C T I O N 1149 Main Street,Reading Ma.01867 Phone 781-942-1546 June 12,2010 The following proposal is for work to be done at 89 Blue Ridge Rd.North Andover Ma.02145 Description of Work Removal of all of the existing cabinets and woodwork. Remove bathroom door and install a new one. Prepare flooring for new wood floor. Install a new double window unit. Install new toilet and bath vanity. Install all new owner supplied kitchen cabinets. Re-trim the entire work space. Prep affected area for paint. Update electrical and plumbing in the work area to comply with current building,plumbing and electrical codes. Payment Schedule Total Job Cost...............$24,500.00 Estimated Labor Price................... $13,600.00 Deposit............... .......$4„534.00 due upon signing contract. 2nd Payment..................$4,533.00 due upon completion of rough inspection. 3Td Payment..................$3,533.00 due upon installation of all finish carpentry,plumbing and electrical. Final Payment...............$1,000.00 due upon completion of contract,and final walk through by both parties. The following materials must be paid for up front(special order)to be ordered prior to contract work begins in order to meet the completion schedule. All payments are to be made in full upon presentation of each completed invoice. If payment is not made according to the terms above Accelerated Construction Co.will have the following rights and remedies. Accelerated Construction Co:may charge a monthly service charge of one and one half percent(1.5%),from the first day of default. Accelerated Construction Co.may use legal counsel and representation in the efforts made for the purpose of collecting monies owed to it. Accelerated Construction Co. may seek compensation for any costs incurred while attempting to collect overdue monies. Accelerated Construction Co. may seek compensation for legal fees and other costs of collection to the full extent that the law allows. (617) 727-3200 oi-1-800-223-0933 JUN-22-2010 11:43 A&K FOWLER INSURANCE LLC 1 978 664 2209 P.001i001 AeCC)P& CERTIFICATE OF LIABILITY INSURANCE DATE(MMMVYYYY) 6/22/10 THIS CERTIFICATE iS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THiS CERTiFICATE DOES NOT AFFIRMA71VELY OR NEGATIVELY AME1131, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. TEAS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(3), AUiHORfLED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: 9 the ce - ate h der is an i U MAL INSURED,the pol e6 must be endorsed. i S CSA N 113 Al11ED,subject tD the terms and conditions of the polfay,cartaln policies may require an endorsement A statement on this certifiaate does not confer rights tD the aertifloate holder in lieu of such endorsements). PRODUCER OONTADT HAMEf_ A & K Fowler Insurance LW PHONE FAIA&Nd Fitt x N 200 Park Street W6 North Reading, MA 01864 CP FUI DLKM2180 fNSUIGIk9j AFFOROM COVERAGE NAI INSURED I A:Preferxe-d NUtuMl jAsurance Com Acceleirated Construction Co. iNsuReia_Pil rim Insurance Company _ 1149 main St. INSURmc:Travelers Insurance Coan�ny _ Reading, MA 01867 INSURERD: i ERE; INSURER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 19 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PEF40D INDICATED, NOTV0THSTANDI G 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. 1 R TY13EDFINSURMCE AINSPIVAM DD SU POLlCyNUMer� LIMi6 GENERAL LIABILITY EACHOCCURRENCE % S00,000 BRI A X C ERCiALGENERAL LLQILITY CPP0170561941 5/31/10 5/31/11 DAN^GETDEN�O s 00 000 CLAIMSMADE ©OCCUR MEG EXP Ony area ersan PERSON4L6ADV INJURY S 500,000 OPNERALAOORWTE 6 11000,000 OEWLAGGREGATE LIMITAPPLESPER PRooucrs-cowjoPAGO s 1,000.000 X POLICY F PRO D LOC S AUTOMOBILE UABIUTY GOWNED SINGLELMIr rl aawtOrt) a 1.000.000 $ ANYA(UTO PGC10008223441 Z/6/ICI 2/6/11 80DA.YiNJURY(!'6rpBISaR) 6 -- -- ALLOWNED AUTOS 80LNLY INJURY(P8/9adafiril) $ X SCHEDULEDAUTOS PROPERrYDAMAGE S X HIREDAUros (P�accidcrd) X NONIGWtNED AUTOS b $ UMe1TELLA UAe OCCUR EACH OCCURRENCE S 6=958 LIARCLAIMS-MADE DEDUCTIBLE ET ON Y6DRKERS COMPENSATION wC$rATy. OTH. C: I REN #6=991X381509 6/lino 6/11/11 g AND EMPWYETtB'LIABILITY —•-•-•- ANYPROPRETOWPARTNERIEIECUTiVE Y� NIA E.L.EAGHACQDEW $ 100,000 OFFICERWIVIRER EXCLUDED? Irltandaelsrr in NH) E L.DISEASE-EA E1dPL0YE 8 100,000 DESCR PTION OF r RATIONS be b. El DISEASE-POLICY LIMrr $ 500 000 WWRIPTION OF OPER"NS U UXIATIONS U VEii)CLES IAHwh ACORD 101,AdMwar f6wA i a Sdmduls,R mora ap*m ismgdmdy Insurance verification CERTIFICATE HOLDER CANCELLATION SNQULD ANY OF THE ABOVE CE8CRISED POLICIES 9E CANCELLED BEFORE TM EXPIRATION DARE THEREOP. NOTICE WiLL BE DELIVERED IN ACCORDANCE WrIIN THE POLICY PROVISIONS. AUTNORQED REPRESENTAnA T{erri A. Boutin, CIC CRM CISR 01988,7009 ACORD CORPORATION. All rights nmervad. ACORD 26(2009109) The ACORD name and logo are registamd marks of ACORD TOTAL P.001 Dt partsuent of Pu: ioc Safct-% Board of Building, Regulations and Standards Construction Supervisor 'License License: CS 79682 Restricted to: 00 SEAN C PINEAU • 1149 MAIN ST READING, MA 01867 Expir"ation: 1/31/2011 t'„mrei:•;«nx•r Tt#: 12080 a, HOME IMPROVEMENT CONTR;l.CTOR Registration: 137945 Expiration: 1/30/2011 Tr# 282237 Type:_OBA ACCELERATED ONSTRUCTION CO: SEAN PINEAU 1149 MAIN STREET , READING,MA 01867 Adminish ator i The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrintLegibly N2Tn0(Business/Organization/Individual): Address: //C/9 A11414 City/State/Zip: Aww__z_�, . �U`!�. Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with 4. ❑ I am a general contractor and I 6. ❑N construction employees(full and/or part-time).* have hired the sub-contractors 2.F_] 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.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#I 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:(,/ / 4 y, � of #j>pr$e iii c.#: I�U 1, �X $ 57b 9Expiration Date: 9 Job Site Address: 177t4- AfZyz� Y si I City/State/Zip: Attach a copy of the workers' 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 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 certify under the pains and penalties o peijury,that the information provided above is true nd correct. Si nature: ' Date: 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#: