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Location
No. Date
HORT1y
SOWN OF NORTH ANDOVER
A
Certificate of Occupancy $
Building/Frame Permit Fee $
,SSACHUSEt�
Foundation Permit Fee $
Other Permit Fee $ ,•
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
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Div. Public Works
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The Commonwealth of Massachusetts T
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
City Phone
am a homeowner performing all work myself.
01 am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name: ..�VIV4:,j Cis "Irgelfaa
Address n2.� ,974';; .soa beQd kit,
City: e6 f Phone #• 60) ?Ca. -0 i'14
J
Insurance Co. pel.4--ice --)�Js- Policv# w4j - A11gz 8S -p
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 penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature
9S
Print name /%r!9M 14e sy%91W Phone # -6P'a,a
Official use only do not write in this area to be completed'by`city or town official' ❑ Building Dept
❑Check if immediate response is required Building Dept ❑ Lincensing Board
❑ Selectman's Office
Contact person: Phone #: ❑ Health Department
❑ Other
BUILDING DEPARTNIENT
DEBRIS -DISPOSAL FORM
In accordance with the provisions of MGL c 40 S 54'
-a condition of Building Permit Number
Is that the debris resulting form this work shall be disposed of in a property licensed solid waste disposal facility as
defined by MGL c 11, S 150A
The debris will be disposed of in:
Location of Facility
oe2g<
ignature of Permit Applicant
Z -O/
Datd
NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of
the Building Inspector
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