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Home My WebLink AboutMiscellaneous - 1360 SALEM STREET 4/30/2018 1360 SALEM STREET J 210/106.A-0164-0000.0 i II I Z Date H.11 !` r NORTH �;�"':;':�•��op TOWN OF NORTH ANDOVER o * , PERMIT FOR WIRING T"`1 �ss�cMus� This certifies that ............................................. ....�. ............... .. ....,........................................... ... ..................°....�...'.....has ermission to perform .....,........ � C. wiring in the building of.................On...`3........................................................................ at .........�. ..... y<.. '.......................................................,North Andover,Mass. �� Fee.....-�...�.....'"'.....Lic.No. ............32.... ELECTRICAL INSPECTOR Check# 1305 -/ + i Official Use Onl Commonwealth of Massachusetts y Permit No. Tne Department of Fire Services Occupancy and Fee Checked 'QM Y BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION ON FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeYC),527 C 1 00 (PLEASE PRINT IN HK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of fires: By this application the undersigned gives notice of his or er intention to perform the electrical work described below. ( ) 3 (� Location Street&Number Owner or Tenant ��c N R 1 r-i G CC/J Telephone No. Owner's Address �/'� j Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building `A t (1 i A) Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: J U CC- 1 b Completion of the following table maybe waived by the Inspector of Wires. 1K 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` "1 n S Above In- o. mergency ig tmg No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batteo Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.oSwitches No.of Gas Burners No.of Detection and f \ Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Dis posers Heat Pump Number Tons J.K.W No.of Self-Contained P Totals: Detection/Alertin Devices L No.of Dishwashers Space/Area Heating KW Local El Municipal ConnectionSystem E] other No.of Dryers Heating Appliances KW Security No.of Devices s -� es or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs - Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: `r-I-C4, 43 Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) a I certify, tinder thepains and pen aldes of. ju tlgat the information on this application is true and complete.II�3,7 3,z FIRM NAME: . ��S C �`G LIC.NO.: L-- Licensee: 1� k ei o� Signature LIC.NO.: (If applicable,`ter "exempt"i th ,icense umb 1.T. �--- i s.Tel.No.: Address: r; , ('°� �/ Alt.Tel.No.: G *Per M.G.L c. 147,s.57-61,security ork requires Department of Public Safety"S"License: 111c.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 PERMIT FEE: $ Signature __ Telephone No. I ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the r permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed 1 fj 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 may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written 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 extending'through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: 1 Inspectors Signature: Date: SERVICE INSPECTION: d Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: } FINAL INSP CTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: I DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 4 v' ------------- 1' The Commonwealth of Massachusetts M Department of IndustrialAceidents 1 Congress Street,Suite 100 d Boston,MA 02114-2017 www mass.gov/dia y�• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibl Name(Business/Organization4ndividual): Address: 2 Cv City/State/Zip: ��r (D Lt v one Are you an employer?Check the appropriate box: Type of project(Tequired): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.1I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 EJ Building addition <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ • 14.0 Other 6.Q 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.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i 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 have employees,they must provide their workers'comp.policy num employees. If the sub-cofi6ctors ber. I am an employerthat is providing workers'compensation insurance for my employees.•Below is the policy and job site information. an /� c J� Insurance Company / v l Name: J 0 U Policy#or Self-ins.Lie.#: Expiration Date: /tk Job Site Address: C(Y� ` el 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 DTA for insurance coverage verification. Ido hereby certify unde ze pains and penaltie ofper'u he information provided above is true and correct. Signature: 1 Date: 1(� 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#: i, Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia COMMONW • • �AIT(y OF M�5S1kC1 us ELECTRICIANS; ISSUES: THE >FOLLOWING ;LI..CE. Sf: 1 AS f Er,' JORlL�( 4 . = 14l�1 L E f'tr 1 Y,4 , JOSERH A 126 PR I MGLE5TR1=s" fa Date....9. . .K......... 11351 RTH TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'CHU This certifies that..Q, .. ....¢- 6 d 09� 01 ... ............................................................. has permission to perform.............I_,;( ........................................................................ 'plumbing in the buildings of.............C-1.4.14.......................................... at..,.......1—................................ ..... ................... North Andover, Mass. Fee......................Lic. No. ..6.11A ................................................................................. PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION,FOR A PERMIT TO PERFORM PLUMBING WORK MA DATE PERMIT# t CITY _—d'_. JOBSITE ADDRESS _�? OWNER'S NAME^/ �- Z' jr OWNER ADDRESS _ TEL FAX /,7 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E] RESIDENTIAL PRINT CLEARLY NEW:F-1 RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES[I NOD FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM I s DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHERLAL DRINKING FOUNTAIN - FOOD DISPOSER I�r FLOOR l AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY - -- - ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ WATER PIPING OTHER __ - ------------- EE MEEi INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NOE] IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYE] OTHER TYPE OF INDEMNITYE] - BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [D AGENT E] SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this 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 application will be in pliance with all Peltinent pFeWision of the , Massachusetts State Plumbing Code and Chapter 142 of the General Laws. zw PLUMBER'S NAME GEORGE POUDRIER LICENSE# 15764 SIGNATURE MP[] JP[:] CORPORATIONQ# PARTNERSHIPD#_ 1 LLC Q# COMPANY NAME IGAPS PLUMBING ADDRESS 115 EAGLE DRIVE CITY DUDLEY STATE1 MA ZIP 01571 TEL 5087893486 FAX _ _ CELL 5087893486 EMAIL GAPSPLUMBING@CHARTER.NET E / I ! II__ � I ,: I f h i I i I 1 1 I i �� ;�� The Commonwealth of Massachusetts ., Department of IndustrialAccidents A ; V Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly oe Name (Business/Organization/Individual): Address: City/State/Zip: f `� Phone#: Are you an employer? Check the appropriate box: 1.ElI am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees (full and/or part-time).* have hired the sub-contractors 6. F1 New construction e2.® I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling g ship and have no employees These sub-contractors have g. E]Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance 9• ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L® Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152,§1(4),and we have no 12.E] Roof repairs employees. [No workers' 13.❑ Other comp.insurance required.] *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. :Contractors 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 employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: m 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 W of u t WORK ORDER and a fine p o$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. under the pains and peva ofperjury that the information provided above is true and correct. I do hereby cern Signature: 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): li 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person- Phone#• n OMM�ONWEAL7FI OF MAStIISETtSa t UES T€1'E 0 L L 0 W I LJ-C-1 t` E .,1OURE3EYiAh� GEORGE A POUORI ERS F a,� W � MAa5�b 36x5 . 2670, s 5 01/16 22E42 - .04lVIMt3R�WF .7'H OF MPS �KCt°IUST1' rT � �J'`jIiL rliLt dW kfilG1.w7 A:.f iYlf OS f A� A I-MASTER t-A h• i } t }y E AA 0 5703665 /€?ll�h 2.264'4 ,. yD L - - - PUFM " ..:...:. III its C+OMMQNWEpTH AF MS1HtSETTS w AAA F, ' F SHEET BT 4JORKERS i. f n (SSi1ES'THE FOLLOWC1�Gr L1` E1�SE' ; AS A JO1ftNEYPfRSON UNRESTRIzCT�E v GE(}RGE A POUDR I ER .:''• i. - -nsaF - 15 EA6UE ,; a .�MA 01571 60z3 7025 5 a x/28/a 6 R 380'45 ._ . II ^ I i t i Date �7 Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 2) No copy of current license 3) Insurance Binder not on file or expired 4) No Workers'Compensation Insurance Affadavit Form Please call with any questions 978-688-9545. Fax 978-688-9542 I Workers'Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1600 Osgood Street, Building 20,Suite 2035, North Andover, MA 01845 I AvW&-L 2,Z MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK (J CITY t/ T��. GlG'L��i MA DATE / PERMtT# n*:N z., JOBSITE ADDRESS OWNERS NAME POWNER ADDRESS -._ TEL7 / � ... :FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT RESIDENTIAL CLEARLY NEW: A RENOVATION:;__ REPLACEMENT:},r: PLANS SUBMITTED: YES FIXTURES Z FLOOR BSM 1 2 3 4 BATHTUB 5 6T 6 9 10 11 12 93 14 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM - DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM .__-- DEDICATED WATER RECYCLE SYSTEM - DISHWASHER - DRINKING FOUNTAIN - FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 Y-6/ e LAVATORY 1 �`� ROOF DRAIN ✓J SHOWER STALL -- SERVICE!MOP SINK - - --- TOILET - FINAL G ..-.THING MACHINE CONNECTION - WATER HEATER AL - - LTYPES WATER PIPING OTHER - _. IMSUCOVERAG F. 1 have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.942. YES , NO . f IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-!,, OTHER TYPE OF INDEMNITY BOND ._ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have theinsurancecoverage required by Chapter 942 of the Massachusetts General Lags,and that my signature on this permit application waives this requirement. _. CHECK ONE ONLY: OWNER .'.: AGENT PIN PIN GAN 5-7515/110 6369 d accurate to the best of my knowledge 1360 SALEM ST. ;emfith all Pe inent ision of theNORTH ANDOVER,MA 01845 � ! (� � DATE I SIGNATURE �z� M LLC #' f I DOLLARS �� -Santander"' PREMIER 11193486 Santander Bank,N.A. MEMO 1:0 1 10 7 5 1 SO1: 6 76000 3 3 2EIS11' 6 369 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 o�M yre www.massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApyHcant Information Please Print Le ibl Name (Business/Organization/Individual): Address: / r . City/State/Zip: �l Phone#: 7f%7 Are you an employer? Check the appropriate box: L❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 42.® I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have g Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.t 9. ❑ Building addition required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.® Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no l2.[�Roof repairs employees. [No workers' 13.❑Other comp.insurance required.] 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-contractors 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'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 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. Ido hereby certi under the pains and pena of perjury that the information provided above is true and correct. Si ature: 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#• ti to COMMONINE�LTH OF MASSA�HE�SETTS,> .. , � s UABBS ? FITTER. 'SUES TH 'oLL0WIM�r} �h " A ,!_O RNEYM4N FiM HEl GEORGE A POUDO1 1 WE MA 115/0 a -q: ' OMM N1yEAL1`H OF MASU (US1`7T �N A 0 . 4 P� MD1z RNAFI-F=1 R v ' .fir a A t IAS i..L`R GE ! t :A 'Pl viii Jr � { Y1NT adt 70 36' 5 ,'Ars0 /01/ 0 2264-, 6 tiv COMMONWEA.TH OF 1HRSSACiHUSETTS r �. s 84AftQ bF` SHEETM�71L WORKERS. ISSUES THE FOL LOW 1.N L ff ENSE : ` AS Ay J{ IR EYPERSQN UNRESTR)CTE2#.: > s ,., fir` GORf A POUDRI ER 15 EAGL ''bR ¢< �Oi LEYL —iMA 01571-60 �J 7025t' x."VI 2/2.8 380645 ;