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HomeMy WebLinkAboutMiscellaneous - 102 BRADFORD STREET 4/30/2018ll� 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-with the provisions of M.G.L. c. 143, § 3L, the Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall-be limited as to the time Of ongoing construction activity, and maybe.deemed.by the_Inspector_of_Wires abandoned_and_invalid_ifhe____. or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period. Upon written t application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or-the installing entity stated on the permit application. The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extendingthrough August 15, 2012. Rule 8—Permit/Date Closed:�—�2, —/� * emote: Reapply for new per ' 117 Permit Extension Act — Permit/Date Closed: S l2. - _ .� . _...: _....,.._. .�. �� ...,... � _ .., _ -_ .�. _�.,:.-.�-...-...., ti �--mow-+ .,.�.,.Rs.�✓r�,.:,.. z. _-_ ;x -: � � .-� Date .... . `. .:.. '::Q TOWN OF NORTH ANDOVER PERMIT FOR WIRING This%certifies that .......................................................... %/Ii ...............:...... has permission to perform... /¢ .std !/! ... ..©d........................................................... wiring in the building of ............'.(-............................................. at ........................................02. .................. 20.. s ...:.., North Andover, Mass. Fee... `r b. Lic. No. `�?.�� /o ...............�.... rl� . ..y ELECTRICAL INSPECTOR / Y Ch6ck # 8-6 1 3 Commonwealth of Massachusetts BEE VNKM Department of Fire Services lop BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. t -2 Occupancy and Fee Checked Lev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MSEC), 5Z7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her inti Location (Street & Number) Owner or Tenant Owner's Address Date: �J /0 To the Intpector of Wires: dorm the electrical work described No. Is this permit in conjunction with a buildin permits Yes ❑ No � (Check AMk iate Box) Purpose of Building%� ' Utili Authorization No. Existing Service o)d Amps / . O Volts Overhead �K/Undgrd Undgrd ❑ No. of Meters New Service Zt2 Amps /ZO / (`Volts Overhead ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion o th llowtL. J f n«acn aaamonat aetatt y desired, or as required by the Inspector of Wires. Estimated Value of ectrical Work: (When required by municipal policy.) Work to Start: ydInspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability '.nsurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of s e t the rmit issuing offic . CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) �'� f (1�� I certify, under the pain and pen lues of perjury, that formation on is applicatton is true and co ple e. FIRM NAME:tJ lke LIC. NO.:Licensee: , �j gnatureLIC. NO.: (If applicable,ente ' exem, th icense numbeBus. Tel. No.: Address: NrIn4 Q Alt. Tel. No.: ' *Per M.G.L c. 147, s. 57-61, security*wQA requires Departure t -of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ e o n to a may oe watvea o the inspector o Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimmin Pool Above In g o. o Emergency Lighting rnd. rnd. Bette Units No. of Receptacle Outlets No. of OR Burners FIRE ALARMSNo. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. TotaTons) No. of Alerting Devices No. of Waste Disposers Heat Pump Number "" Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal E] other Connection No. of Dryers Heating Appliances, Security Systems:* No. of Water Heaters KW No. of No. ofSi No. of Devices or E uival ent DatN W s Ballasts . o. f Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: _ j No. ofDevices or Equivalent OTHER: %/ ! � J f n«acn aaamonat aetatt y desired, or as required by the Inspector of Wires. Estimated Value of ectrical Work: (When required by municipal policy.) Work to Start: ydInspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability '.nsurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of s e t the rmit issuing offic . CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) �'� f (1�� I certify, under the pain and pen lues of perjury, that formation on is applicatton is true and co ple e. FIRM NAME:tJ lke LIC. NO.:Licensee: , �j gnatureLIC. NO.: (If applicable,ente ' exem, th icense numbeBus. Tel. No.: Address: NrIn4 Q Alt. Tel. No.: ' *Per M.G.L c. 147, s. 57-61, security*wQA requires Departure t -of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ i4 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFIT 1NG (Print or Type) ! Q Mass. Date / ' 19 " Permitif /6�2— " Building Location /e494�'Vxl Owner's Name /lncie— le 4" 1-77 Map: Lot: Zone: Type of Occupancy !/LV c?if/ ✓ New I---- Renovation J Replacement J Plans Submitted: Yes J No J Installing Company Name East ern . 'r O': `a 21e Ga -s. IIAC. Check one: Certificate Address 1. =:1 Water S t. ?) I '__ e r s, NA 019—P7- :!P�rplration Estimate Value of Work: :J Partnership ==No ' ����1� EMENNEENNEEN Z vi Installing Company Name East ern . 'r O': `a 21e Ga -s. IIAC. Check one: Certificate Address 1. =:1 Water S t. ?) I '__ e r s, NA 019—P7- :!P�rplration Estimate Value of Work: :J Partnership Telephone (5L 6 ) ! r `� —1 `"� Business Tele p , i :::1 Firm / Co. Name of Licensed Plumber or Gas Fitter% / / G Q�� Ale DC -A, .0-70,7-3-- INSURANCE 0-70 ,7-3-- INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes J No ..1 If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy J Other type of indemnity iJ Bond J OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner J Agent J Signature of Owner or Owners Agent I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this plication will bit compli oe with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General ✓� By Type of license: rGaLsfitter r Signature of Licensed lumbefor Gas Fitter Title License Number City / Town yman APPROVED (OFFICE USE ONLY) r 9 r Z O C o M A D �. T m m m m r O T 0 O T T A M c N m 0 z r Date... NpaTh TOWN OF NOR*Ii NDOVER 0`p PERMIT FOR GAS INSTALLATION, ► o ,' a71�` i 9SSACHU5E� 17 This certifies thatf..r:`!-: has permission for gas installation . �) ./�.. .. •1 in the buildings of .......... ... ./fF T at t�. _.:..'...;North Andover, Mass. Fee::,?:�"... Lic. N.'.... J F !07 ) GAS INSPECTOR WHITE: Applicant i CANARY: Building Dept. PINK: Treasurer GOLD: File Permit No#: Al—t 05 Date Issued BUILDING PERMIT:. TOWN OF NORTH. ANDOVER - 4 APPLICATION FOR: PLAN -EXAM[NAT ARWIL- Date, Received..,,?31-4� TYPE OF IMPROVEMENT PROPOSED USE'' Residential None Residential [I New Building 0 One family El Addition 0 Two or more family 01ndustrial 0 Alteration No. of units: 'Commercial El Repair, replacement Ej Assessory Bldg Others: 0 Demolition 0 Other -F7 haft—ed �-Djs:tfikd- --(F VWxetibF, ku AtI.Ffffi�6W-ei* OF WORKTO BE PERFORMED: ni=-qrPIPTION 5 OWNER: N ') t P,—[ ) f) CAJ ARCHITECT/ENGINEER Phori'e't',-, Address: R0q:.,:No-.- FEE SCHEDULE. BOLDING PERMIT; $IZOO PER $1000:00.OFTHE .TOTALESTIMATEDrCOSrg ASED ON $125.00 PER S -F=- 306, Total Project Cost: $ R6ceii).t,`.Nd.--"- Check No.: (017 NOTE: Persons contacting with -unregistered. contractorsn , do, Whave- access, to the g"Iquty 4 -.. . . ., _r, . 4 ';q�fyd d Location }}��- No. �a J �7 `1(5 CheckIn 27 # 5 /- Date f ,"-ITOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Building Inspector Plans Subfnitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ Typ-F F SEWERAGE DISPOSAL . Public Sewer ❑ Tanning/Massage/Body Art ❑ Swunming 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 PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature_ CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature oi ning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation. Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: mIk-LV 1:aLlT 24iMam St��eet� �ment sign Located 384 Osgood Street ter onWCS ieyes Dimension MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine 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 o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o 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 } VOTE: 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 2014 x Q WCL 2 LL. p 0 mO U += \ O LL E to U Q N � 0 V LLT Ln Z Z m O •�, -6 7 LL i 7 w �, C E U N LL oc 0 W CL N Z Z J d L - LL oc 0 W CLG M Z Q LJ V W W L O V 'L N LL 0 w Z Q 0 OC c0 C LL W C ~ a W W oc Y. i UJ c a CO Z a-+ v In " 0) Y C !n F i Z G to Z w/�/ w CLw W CL c- 2 I.: d N r = O 0 O «s O i 0 - CL O m Q I c 0 c I CL L � E cm O % _ V i Fiv � O L4 Q. J m ••�>`� d O = d > to_ a O ah• Cn O "- • O �z y O O = o0 L C� CL m s 0 ... c �--V L12 O = _ CL W O LL •y .� O y O Vi 0-00 •a,.��. co a� •� CL F i Z G to Z w/�/ w CLw W CL c- 2 I.: d N r h • Yi • FoderatlD n No RISE Engincering FAA Contractor FAA Contractor Registration No A division of Thicisch tngincering CT Contractor.Registradon No 60 Shawmut Unit_ 02. Gunton, ;11,102021 CONTRACT �a 339-502-6335 1�t1.i339+502-6345 Page% 2 PROGRAM THtSCONTRACT aENTERED DITOD WEMf"54; CiVIA-iiFiS DESCRIBEOBEimYTtIECtR<TOMERMwORKAa ENGINEERING ..,.. ....�..._,. PHONE DATE- CUENTB WORKOROER CUSTOMER Gregory Penney (508)245-0 8 4 31 12/08/2014 40079 00003 SERVICE STREET 02 Bradford Street 102 Bradford Street SERVICE CRY,STATE.7JP._.._.,_.__..—.._..._-.x-- M�tO CRY.STATE.ZIP North Andover, MA 01.845 North Andover, MA 0184 JOB DESCRIPTION Total: $2,393.00 Program Incentive: $11967.175 Customer Total: $425.75 we AGREE HEREBY TO FURNISH SERVICES - CoMpLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF ***Four Hundred Twenty -Five & 751100 Dollars $425.75 UPON FMALINSPECTICN AND APPROVAL BY RISI UNPAID 8ALANCE AFTER 20 DAYS. SEE REVERSE BE CHARao M04MY ON ANY DO NOT SIGN THIS CONTRACT It THERE ARE BLANK SP ES AUTxoRUSo stcNATUIuz • RISE ENcrcLEERwc. CUS NOTE:1ifIS CONTRACT NtAY 8E YATHOItAYRI BY US IF NOT EXECUTED wrTi+rct GATE OF ACCEPTANCE ..__.,_,._,.......,---_ __ _... ACCEPTA!!CE 00 CONTRACT -THE ABOVE PRICES. SPECIFICAMMIS AND CONOnION9 ARE SATISFACTOR DAYS. ASSPECR7EDY TO US AND ARE HEREBY ACCEPTED. YOU ARE AMORIZED TO 00 THE WORK ..�._...__. ,.. . PAY6M WILL BE' MADE AS OUTLMED ABOVE OWNER AUTHORIZATION FORM 11 owner of the pmpedy tqcded at W hereby authorise (Subom*aftr) an authorized subconvactoribr FUSE Engineering, to act an my behalf to obtain a bWldlng permit and to perfom work on my property. - �e �panrnto�uuecrll� a��ezt�ttr�rrsel� Office of ConsumerAfrairs & Business Regulation License or registration valid for individul use only, ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 9iraiion: :.x04800 Type: Office of Consumer Affairs and Business Regulation iration: _ :75201& Private Corporation 10 Park Plaza - 5tute 5.170 HUGH'S ENERGY COPORA'[ON `'= Boston, MA 02116 DANIEL DRISCOLL "'•==`=z 259 MILTON STREET:*-_ DEDHAM, MA 02026 Undersecretary Not valid without signatu Massachusetts Sward of Su. -e artmenf of P Safie# ubiic %Oi3S$3'`lfij, JrsBiiOr,S d.1d Q.Ia^;aru y License: CS450 84 isut Thomas.pk: �►: r., 1)259 *"t' ragapte 012 MA t dham. 0 4 206 i,' Comm'ssioner kxpiration 10/2212016 c s �r CERTIFICATE OF LIABILITY INSURANCE `SINS -1 OP ID: I CAPE I$ ISSU® AS A tlAArfER OF INFORMATION O �� CELOW oafs Nor AFFtR11tfA t0/06/2D74 . TMS CERTIFICATE OF INSURANCE pNa"TATLOH CO NCY AND COOF NO RIGA IS UPON TFIEE HOLDER.THlS SENTATIVE OR PRODUCER, AND THE CERTIFICATE HO NS D' �D TR W ALTER E � VERAGE � BY THE POLICIES N$riiilTE A CONTRACT BETWEEN THE rSSUING MSUR IMPORTANT: if th'e imrilflt•,abe holder is an ADDIITONAL rNSURED. the Pott( AUTHORIZED the terms and conditions of the policy, Certain pottcies ey([es) must be endorsed, R SUBROGATION !$ WAtVEp, sub Certificate holder in Iteu of such endors nw Cequtne an endorsement: A statement on this Ceraoste does not coMer .-s-0 o the PROnucER s• ect to TYa Insurance , Inc. Be Freeman Adingfon, MA 02474.5614 _ 789.64.3002 VAURM 259 Mltton Street: Dedham. MA 02026 fH15 (S T4 CERTIFY - •••••`c wvne6eee; _ INDICATED. N Ay BES7ANDING ANY REQUI rVuuES OF IREMENT CE LISTED BELOW HAVE BEEN ISSU® TO THE INSUREDED NAMED A90VE FQR THE POLICY PERI00 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE "'-'1 OF ANY CONMCT OR OTHER DOCUMENT EXCLUSIONS AND CONDItION3 OF SUCH POLICIES. LIMITS SHOWN A HAVE BEEN REDUCED CY PND CLAIMS. W!7 H ECT To TO WHICH THIS AFFORDED BY THE POLICIES DESCRIBED HEREIN 13 SUBJECT TO ALL THE TERMS, 161 TrPEOpasuRANCE even _ a OCCUR UNITSCLA41M*ADE -EACH X X PSW2M2 UN41MI4 08H412ptS C-Ml.AGGREGATELUrAPPU SPEIir �E� aftm POUCV [] eG ❑ Loc PHiSor�lALaaavinuURY G91IS .AcoEeGA-M g AUTOM01 .ELIABRJr1I S-- AGO 3 C ANYAWOALL AQX 1020032764 s I - 06/44/2044 OBP14/2015 BOOeY n►IF'eramson) HIRMAUMS S AUTO$ awfur N,NRYIPet Wano S USI LA LIAR X OcMg S A DCCENUA9 CLM WMS•MApg DEO X REtENTIONS 10000 044410 s OCWRFiENCE 10/0712014 06!14/2015S WORKERBCOnPEHSpnON S 8 ANYPpOp YIN PLuddw °"DED?PCI� MN IA PYes R2WC513035 S StATUTB ER 08H?12014 08/12/2015 08safeMwer oEscRlFrron OF OPERAnoxsoaln.. EL EACH ACCIDENT S CommerctatAppilca E4 DISEASE- AMBOY S D13CpIPT10NOFOFERAT[ON5ILOCAi10RS/itEHICLEs142 IACORpIOi.Apy�gppB Y bodifmme is rY AMCHE SHOULDANYOFTHEABOYE DWMWW POLtC!>:,SBE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED 1N ACCORDANCE WATT THE9 POLICY PROVISIONS: RrA7NE AUTHorazSD 4�rAWsa / P oor ACORD 25 (2014101) nTSe ACORD ®1988.2014 ACORD CORpORA�Op. AU right nR:d. Hanle and IDgD ale regist9red marks OfACORD The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 021142017 S< www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly t 'F:::5 J Name (Business/Organization/Individual): Address: AA.1 t6di City/State/Zip: Phone #: % �l' C'� 0 6 /3 66 Are you an employer? Check the appropriate box: _j,Q-I-ffl a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors flava employees and have workers' comp. insuranc6J 6.❑ We are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof r'epai'rs k- *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. j 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 -contractors and state whether or not those entities have . employees. If the sub -contractors have employee's, they must provide their workers' comp, policy number. I am an employer tlzai is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: U Policy # or Self -ins. Lic. 6 �L W L,4_� � d i 6�— Expiration Date: Job Site Address: 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. : •.�l /) I do hereby certify under Phone #: that the information provided above is true and correct. -)__- )_j 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 #•