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HomeMy WebLinkAboutMiscellaneous - 2 KINGSTON STREET 4/30/2018 I I a 9247 Date. .d-T 1 Z . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSE� f This certifies that . . .vo .N. .Bt9clKe�T. . . . . . . . . . . . . . . . . . . has permission to perform .TWo . 1w'g4f .)U;�r-t' plumbing in the buildings of . M&50 . .+!r�r �. .&Aa. .�IS�G at. . .I/iZ4;;�0. 4�ef ?. .AnVe. .17. ., North Andover, Mass. Fee.t/e,7�.Lic. No..119 Y�1. �- ... . . . . . . PLUMBING I SPECTOR Check # Z Z 31 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS \ Building Location 0 K�c G �1Ot� �1 Date ' —� Permit# Owner Amount New ❑ Renovation 0 Replacement ❑ Plans Submitted Yes No FIXTURES SIBMBBM>c M E KK M EOM 3M E.iOM 4M EDOR kOw 6I)fi EOfIi '1IH IIDQR 9M E M (Print or qpe) Check one: Certificate Installing Company Name ❑ Corp. Address 40 Pec,`�d 777\ Partner. Business Telephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not three insurance have any one of the above Signature Owner 0 Agent E I hereby certify that all of the details and information I have submitted(of entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under permit Issued for this application will be in compliance 'th all pe tm provi ions of the Massae usetts State Plumbing Code and Chapter 142 of the General Laws. B y: rgn�"atur" iceneP�r Type of Plumbing License / o rcense um er APPROVED(OFFICE USE ONLY Master Journeyman i � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ..600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: [2.0 .❑ I am a employer with 4• Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 1 am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling ship and have no employees These sub=contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers'comp.insurance 5. 9. ❑Building addition p ❑ 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 1 1.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no insurance required.] t employees. [No workers' 12.R Roof repairs COMP.insurance required.] 13.❑Other Any applicant that checks boy:4i must also fill cut the section below shoes their wod=s 1 compensation I policy _ 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.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. I do hereby certify under the pains and penalties 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#: � 1 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 15.2, §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 tovm that the application for the permit or license is being requested,not the Depa-rtTMent 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 permittlicense 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 homeowner 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 Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-8 77-MAS SAFE Revised 5-26-05 Fax#617-72.7-7749 www.mass.gov/dia Date.. .I. l/. l � .... .. TH Of o� TOWN OF NORTH ANDOVER ti .� D ' PERMIT FOR GAS INSTALLATION SS CH SES This certifies that . . . . . .'. .? . . . .. . .. .. . . . . . . . . . . . has permission for gas installation Arkar le !r. . . in the buildings of !? � . . �b . . . . at 131j J,, No h Andover, Mass. Fee. �-�. . . Lic. No..l.�oy�. . . /JiF. . T GAS INSPECTOR Check# ZZ Z- 7989 7989 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING A City/Town: Q(}� ��� �-'� MA. Date:\Z2��\ Permit# Building Location:'2,`{,6,?,10 Owners Name:y\�� Q`eD-7) Qv)�0 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No K FIXTURES ui Z W Y = W W X O = V) N m = O J U c4 H N 0 2 W W z H z o W W W W O O W to w m 0 Q a O O X > W z � C9 H W U) 0 Q W _ M V) v W w Z = w w I— 0 > U W z O J F- F- O z J 0 u. = ILLI IW- W W z W W rn J Q Q m w O z 0 co F- F- O D Q tY w w Q > O O co z Z W a F Q O w (D 0 2 z J O a W F > > > O d SUB BSMT. BASEMENT 1 FLOOR ►-' 2ND FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 --FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: �� c�I'y'\C�S c �� El Corporation Address.Q() I City/Town qz y State:,(� � ❑Partnership Business Tel. -'���—���a , Fax: cam\ Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yesg No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy '& Other type of indemnity ❑ 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 ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑;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. T A pe of License: BY Plumber Title ❑Gas Fitter Sig re of Licensed Plumber/Gas Fitter ,Master 1 City own ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer ..-J The Commonwealth ofMassachusetts ' Department of Industrial Accidents Office of. nvestigations . 600 Washington Street Boston, MA 02111 Workers' Compensation Insurance Aff davit gguii ers/Contractors/Elec Applicant Information tricians/Plumbers Please Print Le ibl Name(Business/Organization/individu.9): L i Address: City/State/Zip: Phone#:���'•�(�-(� Are you an employer?Check eck the appropriate boa: _ 1• I am a employer with___� _ 4 ❑ Type of project(required): employees(full and/or art-time *. I am a general contractor and I sub-contractors 6. EJ New 2•EDI am a sole proprietor oPpartner) have fisted on the attached sheet# 7. ❑Remodelingconstruction ship and have no employees These working sub=contractors have fang for me in any capacity. workers' comp,insurance.e 8. .❑Demolition [No workers'comp.insurance 5. ❑ We are a corporation and its 9• ❑Building addition required.] , officers have exercised their 3•El.I am a homeowner doing all work right of exemption per MGL 10,0 Electrical repairs or additions myself, [No workers'comp, right ht 1 4 1ZPlumbmg repairs or additions C.insurance required.]fi ,§ ( ),and we have no 12.❑Roof repairs employees. [No*orkers' p comp.insurance required.] 13•❑Other *Auy applicaut that checks box#I roust also fill out Fhe sebell.,,, fi Homeowners who submit this affidavit indicating they are doing an work and thec b W-sw��.w'cor YsaionpoLcy inform acron. #Contractors that check this box must attached an additional sheeshowing then hire outside contractors must submit a new affidavit indicating such, the name of the sub-contractors and their workers'comp,policy informafion. I o an employer that is providing workers'compensation insurance for my employees Below as the otic information. P y and job site Insurance Company Name: �p,(�-�ot'd �S�y QQ_ CU . Policy#or Self--ins.Lic.M G$ U�G LP 6-7 Job Site Address: 'J- Date: . ;-1,�0�� 1 0 1�. c�� C\ �T Attach a copy of the workers' City/State/Zip:�3 (, !LOA compensation policy declaration page(showing the policy number and expiration Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal n afion date). fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WOE{ORDER of up to$250.00 a da a al penalties of a Investigations of the DIA for insurance coveragedverificativised o�copy of tthis statement may be forwarded to the Offiand a fine I do hereby certify under the pains and penalties of perjury that the information prow Sienature: P de above is true and correct `S�.�.� Date: �(�i Zr� I Phone#: i i Official use only: Do not write in this area, to be completed by city or town o ,- .fftial + City or Town: j Permit/License# Issuing Authority(circle one): j Department 3.City/Town CIerk 4.Electrical Inspector 1.Board of Health 2.Building5.Plumbing6.Other Inspector Contact Person: • Phone#: Date....... A f NORTH 1 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SSACMUSEt This certifies that. W �' G�s�t . �.............................. has permission to perform .......AC .... - ................. wiring in the building of.......... STcr/moi!/ ....... ........................................................... at................` ... ?? ..�.��'.�?F-... . ......... ,North Andover,Mass. o� Fee...,�.49.....�:�a Lic.No../7./1-IP-4....... . .. ....... ...... �I ELECTRICALINSPECTOR Check # 8243 mommcntue //��// o // �a66achu6o.tt6 Official Use Only a€th (� Permit No. c� V 21 partment op",Service6 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),521 CMR 12.00 (PLEASE PRINT TN INK ORTYPEALLINFORMATION) Date: July 9 , 2008 City or Town of: N. 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) 9 Kingston Street Unit 15 OwnerorTenant Sean Steven Telephone No.(97 89 307--1441. Owner's Address dame Is this permit in conjunction with a f uil, ing permit? Yes ❑ No ❑ (Check Appropriate Boa) Purpose of Building Re s i.den Utility Authorization No. se:-vice - / ;�. ovc a n d ., - r.:a,;S :,.ts' vv�. ::d.. t_J %i Tiugru i� No. 6f iViCiE:F'S New Service Amps l Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location,and Nature of Proposed Electrical Work: Replace panel t i Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceii.-Susp.(Paddle)Fans No.of Total a Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KyA AboveIn- o.o Emergency Lighting No.of Luminaires Swimming Pool arnd. ❑ arnd. ❑ Batter Units I No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of hones No. f Detection nd No.of Switches No.of Gas Burners o- tiatiL vic 1 v Initiating Devices No.of Ranaes No,of Air Cond. Total No.of Alerting Devices c Tons a Heat Pump Number Tons IKW No.of Self-Contained No.of aste Disposers Totals: Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security o.of Devi es or Equi alent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts I No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications NofDevices r Wiring: b No.n. Pe.�iiiS nrnnEyrlc^t OTHER: L Attach additional detail if desired, or as required by the Inspector of 141'ires. ' 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 the pains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: Crowe & Sons Electrical Corp . LIC. NO. 17-168A Licensee: James B. Crowe Signature D LIC.NO.: 17168A (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: (9 /8 ) 45a-6696 Address: 576 Middlesex Street , Lowell , Ma 01852 Alt.Tel.No.: -6696 *Per M.G.L. c. 147,s.57-61,security work requires Department of.Public Safety"S"License: Lic.No. SS CO 001051 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 30 .00 a . > . > -, .. 1 I I i I Date.. ... .... .................... .. . 00RT#j TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..0.............0........c... .....1..... . ................. ........ ... .............. ................ has permission to perforni . ............. .. 2 4 � . +....... D- in the building of..v wm e4.N�J�� )A# .............. ar 0 C' R ki rJ t� North Andover,Mass. ...................... ...............I.................. ......... ........ ... Lic.No. 210 �z ELEc-mcAL INSPECTOR G' Check# 11437 r Commonwealth of Massachusetts Official Use only fir Permit No. 119, Department of Fire Services Occupancy and Fee Checked � BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 yi (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 3/29/13 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 be ow. � v Location(Street&Number) VILLAGE GREEN DRIVE , lu"J�SEu vJ �- Owneror Tenant VILLAGE GREEN CONDOS l Telephone No. 978 683-4101 3 Owner's Address C/O PROPERTY MANAGEMENT OF ANDOVER Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) N 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 Location and Nature of Proposed Electrical Work: NEW SECURITY LIGHTING AT 24 & 36 VILLAGE GREEN DRIVE, 2 KINGSTON ST. Completion of the ollowin table may be waived by the Inspector of Wires. < No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting No.of Lighting Fixtures Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones r No.of Switches No.of Gas Burners No.of Detection and ' Initiating Devices No.of Ranges No.of Air Cond. TotaTonal No.of Alerting Devices No.of Waste Disposers Heat Pump I.Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other _ Connection No.of Dryers Heating Appliances K�,i, Security Systems: % No.of Devices or Equivalent No.of Water Kms, 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: Attach additional detail if desired,or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless S 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:) (Expiration Date) I 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. _ I certify,under the pains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: CROWE & SONS ELECTRICAL C2RM. LIC.NO.: 17168A Licensee: JAMES B. CROWE Sign ture .5 LIC.NO.: 191(0 Irl (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.• 9 7 8 453-6696 Address: 5G0 S`(1►dellea2xa., Ly"kt .1` R (�1 1651 Alt.Tel.No.:C1'lR �15'sc6ta9b OWNER'S INSURANCE WAIVER: I- aware that t e 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. $ 165 . 00 Signature Telephone No. P + i Y 1 I E �y / � � r Apr. 1. 2013 3: OOPM Crowe & Sons Electrical Corp. ---------No, 3144—P. 1—� L' i The Commonwealth of Massachusetts i ." Department of Industt'ial Accidents ,a Office of Investigations 600 Washington Street f Boston, MA 0,2.111 j _ www mass.gov/dire ' i ' Workers Compensation XlRslt>t•agce Affidavit: Builders/Contractors/Electricians/Plumbers I Applicant Information Please Print Legibly, Name(Business/Organi2atiomandlvidual): CROWE & SONS ELECTRICAL CORP. Address: 590 MIDDLESEX STREET City/State/Zip: LOWELL, MA 0165 . Phone#: (978) 4-53-6696 Are you an employer? Check the appropriate box: Type of project(required): 1.d 1 am a employer with 4. © 1 ain a general contractor and 1 6 ❑New construction employees(frill and/or part-time).' have hired the sub-contractors 2.❑ 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' y9. E]Building addition [No workers'comp. insurance comp,insurance.t +� required,] 5. E] We are a corporation and its 10.V1 Electrical repairs or additions officers have exercised their l I.El Plumbing repairs or additions 3,C1 I am a homeowner doing all work p myself, [No workers' comp. right of exemption per MGL 12,❑Roof repairs insurance required.)t c. 152, §1(4),and we have no employees, [No workers' 13.❑ Other comp-insurance required.] •Any applicant that checks box A must also fill out the section belowshowing their workers'compensation policy information. t Homeowners who submil this eftiduvlr Indiceting they are doing all work and thcn hire outside contractors must submit anew a idevit indicating such. tContractors that check thls box must attached an additional sheet sho%vmg the name of the sub-oontraetors and state whether or not those entities have cmployccs. If tho sub-contractors have employees,they must provide their workers'comp.policy number. I ain an employer that is providing workers'conrpensallolt:111surance for my employees „Below Is the policy and fob slle inforplation. Insurance Company Name: CHARTIS Policy'#or Self ins.Lic.#: 003788075 Expiration Date: 5/24/13 Job Site Address: 24&36 VILLAGE GREEN DR/2 XINGSTON STCity/State/Zip: N. ANDOVER, MA 01845 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration da(e). Failure to secure coverage as required under Section 25A of MOL 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 tip 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 I do hereby cerlJ&under the pains and penalties of perjury dial the Information provided above Is tare and correct Si atu Date' 060APRIL 1, 2013 l phone#; (976) 453-6696 Official use only. Do not rvrile/n this area, to be completed by city or town official i City or Town; Permit/License# Issuing Authority(circle one): i I.Board of Health 2,Dullding Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector l 6.Other ' Contact Person; Phone#: I I 1