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Miscellaneous - 18 COTUIT STREET 4/30/2018 (2)
N J 0 N A Q pO O 0 0 a Cunningham Lindsey U.S., Inc. P.O. Box 703689 Dallas, TX 75370-3689 Telephone (888) 738-8714 CLCAT@CL-NA.COM Facsimile (214) 488-6766 ***********************AUTO**3-DIGIT 018 785 T3 P1 95000058975 Building Commissioner or Inspector of Buildings 120 MAIN STREET N ANDOVER, MA 01845 Claim Number: Policy Number: co Company Name: LO 0) Cause of Loss: co LO CD Date of Loss: 0 Insured: Property Location: Cunninfiham l�Lindsey Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 313 1630862 1630862 22 BAY STATE INSURANCE COMPANY ICE DAM 3/24/2015 JOSPEH & MARGARET LYNCH JR 18 COTUIT ST D Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143; Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B.; No insurer shall pay any claims (1) covering the loss, damage, or destructions.to,a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss; damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings. are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 Location I ���t-u T - *-'eCE No. _ �� Date r Building I J�3123/R 13:37 375.0 PPID Div. Public Works TOWN OF NORTH ANDOVER Certificate of Occupancy $ sd"" Building/Frame Permit Fee `$ 3J�� crU Foundation Permit Fee $ —' Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $� TOTAL $ r Building I J�3123/R 13:37 375.0 PPID Div. Public Works .i Locatioml r No. Date 9-ld 4zl ,.ORTq TOWN OF NORTH ANDOVER ;aiawaiagftA Certificate of Occupancy Building/Frame Permit Fee $ $ s+caus Foundation Permit Fee $ 1 Other Permit Fee $ t� ' Sewer Connection Fee $ �•U�% Water Connection Fee $ TOTAL $ j iA 1 i ing In for }, 7 5 Div. ti Pub is Works PERAIlt N-3.� , J APPLICATION FOR PERMIT 10 BUIL6 — NORTH ANDOVER, MASS. PAGE 1 MAP J.Aj LOT NO. I 2 RECORD OF OWNERSHIP iDATE I BOOK 'PAGE I — ZONE �.. SUB DIV. LOT NO.WIA LOCATIONco-romr ST PURPOSE OF BUILDING �1/ / s+ `r- - OWNER'S NAME'oSFrPF} W Lywao, �l� NO. OF STORIES ��RL SIZE -7 -76g/vF S � OWNER'S ADDRESS ' $ orwir C7- i J BASEMENT OR SLAB n.4s`, aµ ARCHITECT'S NAME O,,// SIZE OF FLOOR TIMBERS IST /LY IQ 2ND SPAN /1 -LXg 3RD BUILDER'S NAME O,./MYN/Y�� DISTANCE TO NEAREST QUILDING TOAH / b FTS 1 ,l DIMENSIONS OF SILLS POSTS c• /� 1102 h • C, L DISTANCE FROM STREET 3o ecit fWA DISTANCE FROM LOT LINES - SIDES dy 0 iD REAR 3o T/ " GIRDERS ZX 10' AREA OF LOT I,7, sso C r.' J FRONTAGE ��s� pr HEIGHT OF FOUNDATION ,, �� �/1�. THICKNESS 1,D If 1 IS BUILDING NEW No SIZE OF FOOTING ZAi 4 i all -` X IS BUILDING ADDITION YSS MATERIAL OF CHIMNEY IS BUILDING ALTERATION N - EscepT %%.�....Aa.'�^S,ft"(d GIl IS BUILDING ON SOLID OR FILLED LAND SOLID WILL BUILDING CONFORM TO REQUIREMENTS OF CODE YES IS BUILDING CONNECTED TO TOWN WATER EC BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER c (56Pric IS BUILDING CONNECTED TO NATURAL GAS LINE NO INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS i - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR � G�+ DATE FILED 7� ■ S NATU E O ER O A HORIZED AGENT a /n� F E E .7 va C� S'o �y joj PERMIT GRANTED �. .1 1 at SEP 1 5199 k 3 PROPERTY INFORMATION LAND COST EST. BLDG. COSf4i4f+tj' / EBT. BLDG. COST PER SQ. FT. „ EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY L BUILDING INiPECTOR OWNER TEL.# (o 1-g2?6 CONTR. TEL. # fc2-, 62� CONTR. LIC. q. 0 653 H.I.C. # �K i Ir • i r r BUILDING RECORD 1 OCCVANCY1. 1 r 12 - SINGLE FAMILY STORIES MULTI. FAMILY OFFICES' APARTMENTS _ CONSTRUCTION s 2 FOUNDATION CONCRETE _ CONCRETE BL K. BRICK OR STONE PIERS _ 8 INTERIOR a1 PINE HARDW D +PLASTER DRY WALL UNFIN FINISH _ _ 2_I3 _ _ 3 BASEMENT AREA FULL FIN. B M AREA - Y, r/] l/. NO 8 M T � FIN. ATTIC AREA �I FIRE PLACES _ HEAD ROOM MODERN KITCHEN o a QKLoQ ii 3 4 WALLS II 9--1 FLOORS CLAPBOARDS( . � B 1 — 2 �_ 3 _ DROP SIDING WOOD SHINGLES V, CONCRETE ASPHALT SIDING U(WU�� HARDW D ASBESTOS SIDING COM/,ICN AS�Tl VERT. SIDING _ STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON',MASONRY ATTIC STRS. 8 FLOOR _ BRICK -ON FRAME CONC. OR CI DER BlK WIRING STONE ON MASONRY I- STONE ON FRAME SUPERIORPOOR _ ADEQUATE I.- NONE 5 RjQOF 10 PLUMBING GA8LE HIP BATH 13BATH 13 FIX) GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR l .TILE DADO 6 FRAMING 11 HEATING WOOD JOIST- PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 8 COLS. - STEAM STEEL BMS. 8 COLS. - HOT W T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS oll B'M'T 17 2nd ELECTRIC I _ 1.r 3rd NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE- FROM LOt LINES AND EXACT DIMENSIONS OF' BUILDINGS. WITH,. PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. , R' oe I ------------ u 4------------�� 0 L 0010 W U = U z J � (o zw T- o 0010 0 Floww ---__ L ------------------ o a QKLoQ ii 3 r U � oILF-=- U(WU�� - -- - -- , CL CID _z� I I . E iuSC 0, co hill vel Z STC�� vim- �'� 2l7 2c��-' Lc n� t� L� !'J7�iia %�-�► o�'7Z r r2 c , �, L o e r�A,\ W x o a v u o w a V) a cin ° � z z A 7 S w w° to v U m x ° � z °�° C4 0 uz z U W W °�° x4 > cn � w x U W co °° rL o � z A W v 2 N v i W 8 W 0 AV, `--�_ \�A ll�xl.. 40 w O O F=04 uj n c r;^y x L G� 0 E oc i 0 o � C_ O CO) C C co cm C y -0 F mm CLco 0 co~ co O i � W 16. CL. a�a y C 'O o Cc Q J CD 4-0CA Z O C. V m �C m CO2 J Q z Z O Q w c/) Z O U J Q Z LO Z QZ J /O1 c �- o e� c o � L a�oy 0 :OLD LO O : CO) r�O+ co �. o o. A o N E� c o c t: o C.3 CD C ...t 1, E CL:= • O L � N N N 3 > = m A' = C co) L/ y m O I y o v ;Z' �: �-C3 : C, O L Gi C: y • • .� d s = o cm coo G m Z cm H � C O D. y m C C •O Q = o : oc N O O. O F- 41 coev r•+ N o r ,C o = .., W W. 2 we 0 L .. c .. O H •� & 2 C v � V •N Z O v4DEmCISCO COD d o O .5 = a N •O O = A Z 4- C.L m n c r;^y x L G� 0 E oc i 0 o � C_ O CO) C C co cm C y -0 F mm CLco 0 co~ co O i � W 16. CL. a�a y C 'O o Cc Q J CD 4-0CA Z O C. V m �C m CO2 J Q z Z O Q w c/) Z O U J Q Z LO Z QZ J Y FORM U - LOT RRT RASE FOM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements.- ' ****************Applicant fills out this section***************** ------ // 6V- & aoa wbek ✓APPLICANT: V�1�G� Phone W-$a7G H&VC LOCATION: A_=_essor's Man Number 2'/ Parce_ Subdivision r�( Lot (s) St. Nurj--er **�iic F�tic**�c***icic�t**�t�c�t�kycicOfilCial Use RF,COMIENDATIONS OF TOWN AGENTS: C�ZDate Ancroved % Ccr.=_er': at_on Aam-nistrator Date Re; ec ted Cc= e'a_ Date Approved q Town P'_ -annex Date Rel ectad Cc=er.t_ Fcc:: Sept__ Inspect.,_- ea_ _� Date Approved Date Re-�ect_� Date Ancroved / `g Y¢ Date Re;ect__ C�i/Au 6 /iV 76 Wcr�:s - se:'er,' ccnnect_on_ driveway permit ✓F -re Departner- 1,7 / 5 SUP l.�lY Ri 2_i'v by Building Inspector Data I'- t i` SP 1 51994 �7 110 r56 A 0 FF-------------- Z J A 0 FF-------------- Z ` J U- O LL�L z U A FF-------------- ` ci LL�L U I Vi 1 l L ------------------I V ________ __________ ----------------------- --- -------- u co T -j- U J/ co z< �- O w _(Y- H E) C W W VQ // a/a> O Q W f- .<V' 6- 0=��6- [LwQ�—}. � coU O J fL � OD vw- 4 U I Vi 1 l co T -j- U J/ co z< �- O w _(Y- H E) C W W VQ // a/a> O Q W f- .<V' 6- 0=��6- [LwQ�—}. � coU O J fL � OD vw- 4 It 1 --------------- I m O E \ D 7 0 Ll1 U •z O az O -1-J co U o- I- Lo O O �� 4 w -Lw z > �I. uj Z "- J .I I'Q 1-1 'n1 v J uizz3 w >-I-O_O U I UA u 1 --------------- I m O E \ D 7 0 Ll1 U •z O az O -1-J co U o- I- Lo O O �� 4 00 -10 � -Lw z > (L N < uj Z "- J 1 --------------- I m O m \ D 7 0 Ll1 U •z LO Z az -1-J co U o- cyv- O0D a u 00 LO 1-1-1 > LUZ I'Q 1-1 'n1 v J uizz3 w >-I-O_O U I UA u O WDLWW(LO: OL f - LO Ln OD w xLU z O 00 z (LZ t- ui CL < 0—�- F ~ F O nN T z II J � cn = OW �^ oOW W fo Q�cnQ Cn qtr 0NU�� E (LC) 73 0 0�lb'OS .Ob = .I lM1NOZINOH =3IbO9 DOIAND9 N:gMDG aDSOdONcl 9114ONd 5E 05 5L 001 SEI 051 5L1 OOE 08 56 501 lb m�nl�la 'DNI LSIXD =10 AaIS Hlno6 ND >00N1 10 AN iNldd IV 00'00 >21d HONA9 id00-i c�wgSd /t HDI q +� AV WS �► w v rDi.1 -4O il0 5 'bb 'ANIcy �l I:40�id a�i V,k 06'00 'n�MD Tlvm =10 dOi O \� n� -nCO oC) z 0 56 501 ro v O LL co III L ill m V l (�T X W (v 6c C L M 0 t N <69-4/ 4. 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TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION" SACHUSESty A This certifies that ...�.�'<. �.... ,%�'`�f .... . . .. . . . . . .. . . has permission for gas installation .....?�? , -c ........... . in the buildings of .lr`�'d��!:.�.. .................... at ... C. f,. . t.. � ........... North Andover, Mass. Fee.,,7G !-� . Lic. No. )C.?.? ... ..... . ..: � �...... . r.AS INSPECTOFf Check #�_ MAS.SACHUSEM LT'ORXIAPPIKATONFOR PERItillTTO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date "/ 0 Building Locations % C O tr T< Permit # Amount $ Owner's Name New ❑ Renovation 0— Replacement ❑ Plans Submitted (Print or type) Name v J Address 4.1 M,2-., S 414.11 S L04.— t r, ( wt (4 ess 7 Name of Licensed Plumber or Gas Fitter p `_ Check one: Certificate Installing Company EIXorp. 11 Partner.. E]Firm/Co: INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [2— Nor] If you have checked yes, please indicate the type coverage by checking the appropriate -box. Liability insurance policyaOther type of indemnity Bond13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1.12 of the :Mass. General Laws; and that my signature on this permit application waives this requirement. Check one: ' Signature of Owner or Owner's Agent Owner 0 Agent 0 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the - best of my knowled,e and that all plumbing work and installations perfon-ned under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts StattKias CAand Chatter 142 of the General Laws. rB : le 4ty�Town APPROVED (OFFICE USE ONLY) Signaturof Licensed Plumber Or Gas Fittcr Plumber 7,(t ? Gas Fitter Eicense7umber 01faster 0 Journeyman • 'B A SEM ENT �IST. FLOOR SEEN ME MEMENEEN MENE ME MEN NEEMENNEE NOMMENMEN (Print or type) Name v J Address 4.1 M,2-., S 414.11 S L04.— t r, ( wt (4 ess 7 Name of Licensed Plumber or Gas Fitter p `_ Check one: Certificate Installing Company EIXorp. 11 Partner.. E]Firm/Co: INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [2— Nor] If you have checked yes, please indicate the type coverage by checking the appropriate -box. Liability insurance policyaOther type of indemnity Bond13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1.12 of the :Mass. General Laws; and that my signature on this permit application waives this requirement. Check one: ' Signature of Owner or Owner's Agent Owner 0 Agent 0 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the - best of my knowled,e and that all plumbing work and installations perfon-ned under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts StattKias CAand Chatter 142 of the General Laws. rB : le 4ty�Town APPROVED (OFFICE USE ONLY) Signaturof Licensed Plumber Or Gas Fittcr Plumber 7,(t ? Gas Fitter Eicense7umber 01faster 0 Journeyman C 0 M MON W EWL'rI4-d-Fm-A-SVA-CTlTj SETTS PLUMlE1ERSWN]D-GWS`R I I h Kb 2 REGISTERED AS A PLUMBING CORP ISSUES THE ABOVE LICENSE TO: JOHN P TURCO TURCO PLB & HTG INC M 8677 10 PRINCESS AVE CHELMSFORD MA 01824-000 1839 05/01/12 79159.8 1, COMMONWEALTH OF MASSACHUSETTS FLUMb t bA LICENSED AS A JOURNEYMAN PLUMBJE -ISSUES THE ABOVE LICENSE TO: JOHN P TURCO 10 PRINCESS AVE CHELMSFORD MA 01824-0000 17168 05/01/12 79159q6. ..C.OMMONW9-A-CTfj-0E-MASSACk - USETTS LICENSED AS A MASTER TT PLUMBER ISSUES THE ABOVE LICENSE TO: JOHN P TURCO 10 PRINCESS AVE .11 CHELMSFORD <14 .11 MA 01824-OOOOC' �"..'� 8677 05/01/12 791597 Date. . 7�- /j? /.- 1 404'. TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING • D This certifies that .... )4 . l.............. • • • • ,bas permission to perform ..... . C. It.U.:<I-t .6q : • • • • • • ...... • • plumbing in the buildings of . !int l e.(.. <:...... • ... • • • • • • . at ... h. -1 e ... C .G 4k , ..�`'............ . North Andover, Mass. Fee 4� Lic. No......... �.. ..... .,....... . PLUMBING INSPECTOR Check # 1 `} 86 1 { MASSACRUSETTS UNIFORM APPLICATION FOR PERMIT TO D O PLUMBING . (Type or print) NORTH ANDOVER, MASSACHUSETTS pate _ 7i �T t ( Owners Name °"�/0' ° ° ` ��� CLC Per C Omit # Building Locatidn g Amount e o£Occup anc New Renovation pe lacement Plans Submitted Yes E] No � � R FJAI UkL n Check one: Certificate (Print. or type) r 1-{- r'; ]•torp. Installing CompanyName % !/ C-- Address a �( 1� a-� Partner. k 0[ t :^^ W Q t 4 f Firm/Co. Business Telephone 9 i F--14 j L -ro 9 6 Name ofucense i Plumber: ©�► ►-- � J �– O Insurance Coverage: Indicate the type of insurance coverage by checicmg�appropnate box: Liability insurance policy 0— Other type o£indemnity ,Insurance waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one ofthe above three insurance _ Signature ' Owner � Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are.true and accurate to the best of myowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the MassachuseitS.yState — bin e and Chapter 142 o£the General Laws. Ilitie CityVTown APPROVED (oma usa ONLY Type ofplumbing License 86-2 icense umo er Master �' Journeyman • s •J tt • - - r s u � Check one: Certificate (Print. or type) r 1-{- r'; ]•torp. Installing CompanyName % !/ C-- Address a �( 1� a-� Partner. k 0[ t :^^ W Q t 4 f Firm/Co. Business Telephone 9 i F--14 j L -ro 9 6 Name ofucense i Plumber: ©�► ►-- � J �– O Insurance Coverage: Indicate the type of insurance coverage by checicmg�appropnate box: Liability insurance policy 0— Other type o£indemnity ,Insurance waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one ofthe above three insurance _ Signature ' Owner � Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are.true and accurate to the best of myowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the MassachuseitS.yState — bin e and Chapter 142 o£the General Laws. Ilitie CityVTown APPROVED (oma usa ONLY Type ofplumbing License 86-2 icense umo er Master �' Journeyman The Co mH10Mvealth of,IV.fassachusetts Depattnent of rndusts iaz_4ccidents Office ofiivesd6l V ons 600 Waslzintaton Street Boston, .1(vM 02111 w11W_mrzssgov1dia 'workers' Compensatiion Insurance Affidavit: BnUders/Contractors/�+lectrici nans/Plumbers .kficant'�ormation .. Please Print Le�ib�,'y Name (BusinesslOzb nira/In tiondividual):_ U %/' C14H ' Address; R/J� / 1 /kar S City/State/zip: -Are you an employer? Check the appropriate box: 1.0 I am a employer with Q` 4. ❑ I am a a Type of project (required): beneral contractor and I employees (full and/or part-time).* have hired the sub -contractors 6- ❑ New construction 2. ❑ I am a sole proprietor or par(ner_ •listed on t%(-- attached sheet t 7. ❑ Remodeling ship and have no employees These sub --contractors have working for mein any capacity. workers' comp, insurance. 8. Demolition [No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑ Building addition 3. [1required.] of"ems ha. -ire exercised their 10.0 Electrical repairs or additions .1 am a homeowner doing all work right of ex eempiion per MGL 11.[g -plumbing repairs or additions myself: [No workers' comp, c. 152, I (4), and we have no insurance required.] t employees. [No workers' 12•❑ Roof repairs S c°mP• msuranct,, required.] 13.❑ other +� R ths±Checks boxQ1 -MUSL cts0 it ` I —.i -i vat f sw^e I'elot:• ^o c� and d r •,•r Vr'Ol".C<5S co FIo�eowners who suumit'tliis affidavit indicating they are dc�^ all wo9t "Contractors that check the hex = an¢ thea hireoutside contmvtors 41ist adi it a new of davit indicating such. n<'.:sY attached on additional sheet showing the name -of the sub -con tractors and their workers, coup. policy information. .tarn an employer that isproviding workers' compensarion insurance for information my employees 8e10it, is tFieppfic0) and job site. Insurance Company Name:_Lr. Policy # or Self -ins. Lic. #: Expiration Date.- �-off Job Site Address: /-5-- /(6 Cp -rt TU T_ / City/state/Zip: /1� Attach, a copy -of the workers, compensation policy declaration page (showing the policy Aumbe'r.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 $1,500.00and/or one-year imprisgnment, as weIl as civil penalties in the thf Of up to �250orm of a STOP �rVORK ORDER and a fmc S250-.00 a day against the. violator. Be advised that a copy of this statement maybe forwarded to the Office of Jnvestigations of the DIA for insurance coverage verification. Ido hereby Ge7i9? th ains a pcizalties ofperjur�, thrzr the znforraationprovided abov8 is true and correct Sig taft l c: Phone #: EOZher e only. Do not writd in this area to be completed bj, cit), or town official t n: -1ermitUcense # hority (circle one): Health 2. Buiilding Department 3. 0ty/Towrn Clerk 4. Electrical inspector S. Plumbing 7uispector son- -- - Phone'#: