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Miscellaneous - 191 GRANVILLE LANE 4/30/2018 (2)
191 GRANVILLE LANE 210/106.C-0062-0000.0 Date,-V7/3. . . . . TOWN OF NORTH ANDOVER 4 PERMIT FOR GAS INSTALLATION This certifies that . . . . . G �=- . . . . . . . . . . . . . . . . . . . has permission for gas installation . 1� . . . . . . . . in the buildings of. . . . . . . . . . . . . . . . . . . . . . at . . . —�!�. . . . . . . . . . . . . . .North Andover, Mass. FeeSCAJ' . . Lic. No. .,21,,©./.7. . GAS INSPECTOR Check#1.>])N 8807 r I •` MASSQa,HUSgTTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYJQ,n/���i Jy1 MA DATE / PERMIT# JOBSITE ADDRESS �'�ry! ✓/ OWNER'S NAME �v GOWNER ADDRESS TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:D RENOVATION: REPLACEMENT-0 PLANS SUBMITTED: YES E-11 NOM APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER �R BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR -�-I - _-� ..1 I - FURNACE -- GENERATOR GRILLE INFRARED HEATER [�-�-� ( ..- LABORATORY COCKS MAKEUP AIR UNIT (.- J = I _ _ L.WEN lqsz- POOL HEATER F*OOM/SPACE HEATER ROOF TOP UNIT TEST --�.( UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER [731- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NOD-( IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-0 OTHER TYPE INDEMNITY EI 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 th _my signature on this permit application waives this requirement. ��- CHECK ONE ONLY: OWNER—n AGENTI SIGNATURE OF OWNER Oft79AENT 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 co 'aa with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME J^ cC � _ j LICENSE# 1� SIGNATURE 1� MP El MGF[M]I JPD JGF[] LPGI 0 CORPORATION F � �� n PARTNERSHIP©#___ I LLC .j# COMPANY NAME: v ADDRESS CITYSTATE ZIP 1 TEL FAX CELL EMAIL _ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ` FEE: $ PERMIT# PLAN REVIEW NOTES M 7 y. Y,i f i The Commonwealth of Massachusetts -" Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. []New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor orpartner- listed on the attached sheet.# �• E]Remodeling These sub-contractors have 8. E]Demolition ship and'have no employees working for me in any capacity. workers, comp.insurance. 9• []Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 3111 am a homeowner doing all work g p right of exemption per MGL 11.0 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#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie 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 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:. 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 requiredunder 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 cert fy un�der the pains and penalties of perjury that the in provided above is true and correct. Siamature 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#: l i Information and InstructIl®lmS 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 ofhire, 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 be 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 ofpublic 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 bum leaves etc)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Zndustrlal Accidents Office of Investigations 600 Washington Street Boston,MA,02111 Tel,#617-727-4900 ext 406 or 1-8777MASSA.FB Revised 5-26-05 Fax#617-727-7749 WVttw.nlass.gov/( a l,.U1Y1MojgWEri'Clw?0t""" A A'CHUSt llr PLUMBERS AND GASFITI'ERS LICENSED AS A JOURNEYMAN PLUi 1,�E ISSUES THE ABOVE LICENSE TO: I k BRUCE D LACRETA NIA 40 EAST RD ATKINSON NH 03811-22x8 26017 05/01/14 163598 # �c� - - • •.oar ml�.¢¢� - 10081 Datesh//3.l3 . . . . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . . .G � has permission to perform . . �s�. al . . . . . . . . . . plumbing in the buildings of .191, . . . .+.. . . . . . . . . . . . . . . . . . . . . . . . at . . .,� .c.0�r.E . . . . . . . . . . . . . . .North Andover, Mass. Fee 7 .7.00 . . Lie. No.�/.?0,/' . . . . . . . . . . PLUMBING INSPE60R Check.# /S2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE -- PERMIT# fy JOBSITE ADDRESS / y;f OWNER'S NAME OWNER ADDRESS ! TEL FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL EI EDUCATIONAL Ell RESIDENTIAL 1 PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT. I PLANS SUBMITTED: YES No FIXTURES'l FLOOR BSM 1 2 3 4 5 6 1 7 8 9 10 11 12 13 1 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _1 _-A __, I ._____j ,___.J I _i _ ! DEDICATED GREASE SYSTEM _� ______] _1 ______E DEDICATED GRAY WATER SYSTEM k _- ( I __,...___-I DEDICATED WATER RECYCLE SYSTEM .-.__._1 DISHWASHER DRINKING FOUNTAIN I ._._....-.k _.._--- FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) .._..___I -___.i ..........___1 __1 I --� KITCHEN SINK -_—.I __-_--_-.I E _....___-f 1 _ ___..1 LAVATORY ( .____- _ ROOF DRAIN _-_a _.__.._f k __._,( ______Jj SHOWER STALL I 1 1 .____..J _._.-_.._ 1 .___--1 � SE VICE/MOP SINK ......._j ,.-.I ---.-...__-! I ._.� _._._.f .__._._k I .___.� I TOILET -_f -___ I __.__ _._._� ____r __ k WASHING MACHINE CONNECTION _J _ ,_-- WATER HEATER ALL TYPES WATER PIPING I ! OTHER -----__-- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES __-! NO c t1< IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW V) LIABILITY INSURANCE POLICY a OTHER TYPE OF INDEMNITY i 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. M CHECK ONE ONLY: OWNER-0 AGENT 10 SIGNATURE OF OWNER ORA ENT 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME t Y Lj_9. _ (LICENSE# i SIGNATURE MP _-( JP .�! CORPORATION DI# __. -. PARTNERSHIPLLC _± COMPANY NAME _J SS _ +r� CITY 'STATE ® ZIP TEL i V FAX l . �_. ; CELL�JEMAIL _ _.- __.._-..__-_ .-.._-- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FffLL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES - I The Commonwealth of Massachusetts = Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name(Business/Organizatiorvindividual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ` 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g• ❑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 required.]insurance re t employees.[No workers' q ] 13.❑Other 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 aie 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: 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. I do hereby cero under the pains and penalties of perjury that the information providedaboveis true and correct: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: c, f 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 be 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Dopartment ofludustrial Accidents Office o£Investigatlons 600 Washington Street Boston}MA 02111 Tel,#617-727_4900 at 406 or 1-877rMASSAFF, Revised 5-26-05 Fax#617-727-7749 www.mass.8oV1dia - �I Date. ..1.1.2,1..). ........... j' NopTti�tioo� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 83�C�gf� j a This certifies that .... b.&4 d.A................... .... "`':.............: ......................... has permission to perform .....T�.l...t' ................................................................... wiringin the building of.........1.................................................................................................... at .............��.!.?�..��. (../............. ..(..l . North over Mass. Fie, Lic.No. AL Irrs Deck# 11785 A Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN.lNKORTYPEALL) FORMATION) Date: �_ l 7--2-0 /-3 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) /Cf/ C/2 f4/Jy r L t-E t-PJ Owner or Tenant Telephone No. Owner's Address 19/ G/.�Ny f 1-L'E L- Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 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 a Location and Nature of Proposed"Ellec ical Work:i ' � o D O. ),Ce5 e t h move -� Jyat Qec -6c 5 aS ee L Completion of the following table may be waived by the Inspector of Wires. No.of Recessed LuminairesNo.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency ig ting No.of Luminaires Swimming Pool rnd. Elrnd. BatterV Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons g No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection -0 No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: I Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsNo.of Devices or E u valent OTHER: 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:) I certify,under thepams andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: . N WN LIC.NO.: Licensee: 4ff10Signature LIC.NO.: 6tMP- (If applicable,enter " ✓em t"in Z lic e numbe e� Bus.Tel.No.: Address: / wYi N(--1 a 36C4S Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. � OWNER'S INS ANC WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by 1 i low I her by waive this requirement. I am the(check one)❑owner owner's agent. owner/Agefit ? 92 '/� PERMIT FEE:$ Signature Telephone No.k,> ' 3�7 ❑ 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 shallbelimited 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 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: J SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Y Failed Re-Inspection Required($.) ❑ Inspectors Comme Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Com e --1 Inspectors Signature: Date: DEB WEINHOLD ....TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com L .t t The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Leizibly Q Name(Business/Organization/Individual): ��pi1 0 GAG �r r C —C Address: S V M 411, City/State/Zip: a4�w Y1 Phone#: 603 a73 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.t ❑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.n'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 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:. Policy#or Self-ins.Lie.#: 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' surance coverage verification. I do hereby ce derteya' d p ties o erj that the information provided above is true and correct Sinature: % Date: Phone#: Q 3 - q2 . ' 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#: 0. 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, 11 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 be 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-contractors)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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel,#617-7274900 ext 406 or 1=877rMASSAFB Revised 5-26-05 Fax#617-727-7749 wWW.Mass,9ov1dia Dated.. ti. OF NCRT/�,��C o��;. c� TOWN OF NORTH ANDOVER * PERMIT FOR WIRING B�q,CHUgE This certifies that ...... ,I......... O.L..4-0 .. ... ........................... has permission to perform ....../`a�.. '�%!r-..../! .A/ .:.......................... wiring in the building of.........,1}'�1.���(,.r..... 2(...� ................................ ........�-.R..& ......... 'a ................. / �1 ...............A* — nd ver,Mass. Lic.No. .�4,,,�J„P�...�........... ,.... . .. �ELE OR Check# r r I 7 K r is //J�ommonweaR of fil — n�// Official Use Only l� �//�amacl e� a c� 19 ,e(J¢parEment o/Jiro�ervices Permit No. d Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS .[Rev- 1/071 eaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: l�r 113 City or Town of: To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1wea (ZA S'r -0366 �- Telephone No. (�It)-59 a- 12 i L Owner or Tenant• p-l•�� ����-�"� ,°0 0 Owner's Address ro nate Bog 7 0 fl. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Chce4 App P ) " Fa d o_ c= Purpose of Building S n!�{ w�. H w <<�a i Utility Authorization No. L" m No.Of-Meters ,°�-a 3 0, Existing Service Amps / Volts Overhead❑ Undgrd❑ u a + New Service Amps / Volts Overhead❑ ' Undgrd ❑ No.,of Meters � co. cm H a o c • Number of Feeders and Ampacity o dR o �,,� �E,•noa _w L Location and Nature of Proposed Electrical Work: �-rgEk 0 M C,LU ce' d F- Completion o the ollowin table be waived the I ector o Wires m tnv c 0 No..of Total n o s W No.of Recessed Luminaires No:of Ceil:Susp.(Paddle)Fans Transformers KVA Q�wa+m KVA No.of Luminaire Outlets No.of Hot Tubs Generators Above In- o.o mergency ig ng • No.of Luminaires �- Swimming Pool.mining ❑ md; ❑` BatteryUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMC No.of Zones o.of Detection.and i No.of Switches No..of Gas Burners Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges G aS Tons Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices Municipal Other �O No:of Dishwashers Space/Area Heating KW. Local❑ Connection ❑ S�. Security Systems:* No.of Dryers Heating Appliances KW No.of Devices or E uivalent iNo.of No.of Data Wiring: a� ! o.of ater KW Ballasts No.of Devices or Equivalent 'tr Heaters signs � 4-0 � Telecommunications Winn . (U O' I No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent 4-4 OTHER: Attach additional detail if desired oras required by the the 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. -��1 3 of electrical work may issue unless . INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance equivalent The the licensee provides proof of liability insurance including"completed operation coverage or its substantial office. 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:) I certify,under the pains and penahies of perjury,that the information on this application is true and complete. LIC.NO.: FIRM NAME: Licensee: C o co Q o c�+ Signature cn 9�--� ca LIC.NO.: 3(o S B$ Bus.Tel.No.- (If applicable,-enter"exempt"in the license number line) Address: eliE a b o Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public 5arery License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability msu mice coverage normally required by law. ByCmy si ature bel ,I hereby waive this requirement I am the(check one [owner El owner's.agent Owner/Agents/! / PERMIT FEE: $ (J Signature / TelephoneNo. Sala-D b �f Za 1 �f4A The Commonwealth of Massachusetts Department of Industrial Accidents Office.of Investigations 600 Washington Streef Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Bu ilders/Contractors/Eleetricians/Plumbers . Applicant Information Please Print Legibly Name(Business/Organization/Individtial): Address: City/tate/Zip: Phone#: Are-you an employer?Cheek the appropriate box: Type of project,(required): 1.❑ I am a employer with 4. []-I am a general contractor.and I 6. ❑New construction ",-,Mployees(full and/or part-time).* have hired the sub-contractors 2.M 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 workingfor me"in an capacity. employees and have workers' � Y p � .comp.insurance.t 9. ❑B ilding addition . o workers comp.insurance mp p 5..❑ We are a corporation and its 10. Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself._ [Nd`'wdrkers'comp. right of exemption per MGL 12.E]Roof repairs' insurance f�tiired]t c. 152,§1Q.4),and we have no employees..[No workers' 13.n Other comp.insurance required.] .%-Any applicant that checks box#1 mist 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. tContraciors.that cheek.this box must attached an additional sheet showing the name of the sub-contractors and stgee,y hether or not those entities have employees. If the sub-contractors have employees,they must provide their:workers'comp.policynumber. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: _ City/State/Zip: Att2th 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 thepainsand penalties ofperjury that the information provided above is true and correct Signature:- rn Co tom rte,. Date: (,Z) — Phone#• k rl 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#: 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 be deemed to be an employer." .. MGL chapter 152,§25C(6)also states that"every state or.local licensing agency shall withhold theissuance 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-ofcompliance with the)iwurance requirements_of this chapter have been presented to the contracting authority." r Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to-your situation and,.if necessary,supply sub-contractors)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 employegchother than Zhe members or partners,are not required to carry workers'compensation insurance. If anLLC or LLP does•havA,,., _ employees,a policy...is required. Be advised that this affidavit may-be.submitted to the:Department of Industrial; Accidents for confnination 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 ilie-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 permitllicense 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 Office of Investigations would like to thank you:in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone.and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 640 Washington.Street Foston,MA 42111 Tei. #617-'727-4900 ext 406 or. 1-877-MASSAFE Revised 11-22-06 Fax #617-727-7749 www.mass.govfdia 1 � INFORMATION REQUIRED FOR PERMIT APPLICATION Address of Property Name of Contractor coeoc-i+uc, Cell Phone Number of Contractor bL = G,"?g 6 Contractor Email Address N-co coo z-s-( Contractor HIC# Contractor License# �g Name of Homeowner °t O Cell Phone Number of Homeowner Home Phone Number of Homeowner Homeowner Email Address i.,\�Ceor w,p.T ��' ' ►JAS -co M A copy of the most current License and Insurance information needs to be with the application. Faxing insurance information is no longer accepted. The application can not be processed if this information is not received. r 7 3 5 7 Date.. . .. "...... HORTM or TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION fo.••',�9 SACHUSEt This certifies that . . . . . .S ./��!. `"u . .F? . . . . . . . . . . has permission for gas installation . . .G.!¢. S. . . . k.. . . . in the buildings of . . .I,. ykV.c.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . .i. 9 .1. . . !:. t?'�t ti 4. .Y. !(11'<'' ' 1.<'. . North Andover, Mass. Fee. . . 3.0. . Lic. No.. .�q � . . . . GAS INSPECTOR Check# 213 NLASSACHUSEITS LNMK I APPLICATON FOR PERIM TO DO GAS FIT NG (Type or print) Date �� 111d f' NORTH ANDOVER,MASSACHUSETTS _ Building Locations c'1 I c-, � Permit# Amount$ Owner's Name New❑ Renovation n Replacement ❑ Plans Submitted F t'" 14 " r" a 1 Z z F q n Ew- Z O w Ja O W�z > C g4 - -0 E> D OO e� 3 q Cti .d U x y A a F C SUB -BASEM ENT BA SE N-1 ENT 1ST. FLOOR i 2ND . FLOOR 3RD . FLOOR 4T 1I . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR , 8TH . FLOOR (Print or type) ` 41 `� FI S Check one: Certificate Installing Company ( � Corp. Address r1 v i� K F, /L,a �- Partner.. 13usmess re ephone 1 7 g /P f G r-1-firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 19/ No 13 If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy � Other type of indemnity Bond1-3 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 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 Agent11 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the, hest of mN knowledge and that all plumbing work and ittstalic ins rFnrm,it mider P(-.-unit issued for this application will be in compliance with all pertinent provisions or the Massachus is. to Gas Code ane ( haptcr 42 of the eneral Laws. By: Signature of Licensed Plumber(. as Fitter Title �'PlumberXz CityiT67n Gas Fitter License r mer Master ,WPROVED(OMCF USE ONLY) Journeyman Date.....7/�/ .Y......... ♦ ORTI, TOWN OF NORTH ANDOVER p PERMIT FOR WIRING o ; t AT- SSACMUSE� This certifies that ...... r'.D Q N..F ............... ............................................................ has permission to perform ..... ?P-/(G �`�`h' ......s t ... ... ... .......... wiring in the building of N at........ .j.....�-�/w u ! ( �-........: . U.:....... ,North Andover,Mass. Fee... . Lic.No. laa......... FC.GI . rlt1 - --- ELECTRICAL INSPiCfOR Check # G 531 THECOAMONWE4071OFAASMCHUSETTS Office Use only_ DEPARTIVIEVTOFPUBLICS4MY Permit No. BOARD OFFREPREVEMONRWULAHONS527CAR 12:00 Occupancy&Fees Checked i APPLICATTONFOZ PERMIT TO PERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat-e7— Townof North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) �ihdGL Owner or Tenant vi Owner's Address ' Is this permit in conjunc ' n with a building permit: Yes M No (Check Appropriate Box) Purpose of Building NIA—k--6z 7-1171 L 1 /-/- 9 6 Utility Authorization No. Existing Service 76Amps` ,? /0 Volts Overhead Underground No. of Meters / New Service Amps/� Volts Overhead r7 UndeFground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work i;; TLL .-'Z' USG-AnF- Gr2✓i7! P6474 A--A Case .�7 X;ql l� No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round rou No.of Receptacle Outlets No.of Oil Bumers No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Tot FIRE ALARMS No.of Zones T ns No.of Disposals No.of Heat Total Total No.of Detection and Pumps Ton KW Initiating Devices No.of Dishwashers Space Area Heating KW Nq..of Sounding Devices No'of Self Contained Detection/Sounding D ices _ No.of Dryers Heating Devices KW Local nicipal Other onnections N,,.of Water Heaters KW No.of No.of Si ns Bailasis No.Hydro Massage Tubs IVo. A Motors / Total HP )THEA s1>< mCovaage,PW&Mrttothe iegimWrMOfMa%adulgeBCefielallaws iaveaamuntIzahhtykmancePt)c I chldmgCOmplete CowmgeoritssttbshantialaWivalent YES ©/ NO uwsulxr02dva1idproofofsametothe0ffm YES 1 1 IfyouhavEcrdodYES,pleaseindicatethe typeofcovetageby "fig the WM&box 1_I ISURANCE BOND r7 OTHER F-1 (P1easeSpaafy) FxpuationDate Ce 1/e-4 e,464- EsWr21edVa1ue0fEbctiiealW0dc$ AtoSlart _ �� InspearonD&R Rough Feral ;ted undcrTe Pefl-Acs of p#i1y: ?N1NAME u- LioawNo. /9f� Signattue LiNo Bt>,sur�sTel � S-0i`7 la7 No. � � " % is 5't/ / 5��� /��7 s Alt Tel No. ZZ 2 fry'/ Vi R'S TENVJRANCEWAIVER;Iamawarethatfir Lcerwdoes not have theinauancecovetage,oriNsutslantialequivalentasRgxelbyMassachusenGaretalLaws that my signature on this pemrit application waives this regtraem t ease check one) Owner ® Agent Telephone No. PERMIT FEE$ rgnature of UwneFor 7gent �ayt rn W The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations Boston, Mass. 021.11 Workers'Compensation insurance Afildavit Name Please Print Name: Location: Ci1Y Phone # I am a homeowner performing all work myself. . I am a sole proprietor and have no one working in any capacity F-1 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone#: Insurance.Co. Policy# Company name: Address City Phone#: Insurance Co. _ Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,500.00 and/or one years'imprisonment-as_well_as_civil.,penaltiesin.theformnfa..STOP WORKARDER_and..a fine-of-($1.00.00)_aiday against.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. Y I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required Licensing Board F-j Selectman's Office Contact persona Phone#: ❑ Health Department Other