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HomeMy WebLinkAboutMiscellaneous - 41 NORTH CROSS ROAD 4/30/2018 (2) 41 NORTH CROSS ROAD i 210/038.0-0023-0000.0 \\ Location No. ��� Date / - 7-o? r �oRT� TOWN OF NORTH ANDOVER � a Certificate of Occupancy $ �'�s'„• tt� Building/Frame Permit Fee $ AC MUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ zl •`J Check # 16096Building Inspect j� TOWN OF NORTH ANDOVER BUILDING DEPARTMENT / T REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �/ T1115.Se+c#i08 fo!-X €ICI use, U� rn rTUMBER: DATE ISSUED: X SIGNATURE: Building Commissioner/Inspector of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Yl No, cf%as-s No,A ty L,,Fr 3 6) 6� 3 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided v 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private ❑ Zone Outside Flood Zone Municipal ❑ On Site Disposal System SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of Record �. tU ill It c ^� S S t3, (a Name(Print)/ Address for Service �-tf 1515Si4aature Telephone 2.2 Owner of Record: L4(, Naen-t- Geass �+� p Name Print Address for Service: z Signature , Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ P111#P .S !Ac,KkG'A/ / Licensed Construction Supervisor: Q -5-0 O License Number � .2 � , F N L,10e L,{w/T/�/r C l" ��?SS 11 Address Expiration Date Z Signature /^� Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name v / o :3 .S—�17 m Registration Number r Address ✓ /'yf��C -�"4l/� Expiration D t � Signature Telephone Y� SECTION 4-WORKERS COMPENSATION(KG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check ail applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other VK Specify /=/#/I// cyF /1771 C Brief Description of Proposed Work: (7�k t.C/� &VI/ ���. SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee F-5-0 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC /gig , j 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owne/Authorized:A:ge,)tof subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building pennit application. a Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION r I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief ' rent Name Signature of Owner/A ent Date r OF STORIES SIZE ` B SEMENT OR SLAB j RD S E OF FLOOR TINIBERS 1 2 3 SI? D NSIONS OF SILLS DIMENSIONS OF POSTS D24ENSIONS OF GIRDERS HEI HT OF FOUNDATION THICKNESS SIZ4 OF FOOTING X MAAERIAL OF CHIMNEY IS B DING ON SOLID OR FILLED LAND -ISB . DING CONNECTED TO NATURAL GAS LINE FORM 'U - LOT RELEASE FORM A 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 or requirements. ****************�***/*/********* A *** PPLICANT FILLS OUT THIS SECTION*********************** APPLICANT V�1//�� J�C/S�oN PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISIONf ' LOT(S) STREET �/� CPoss S T— NG. /I'N/>Ofi'�/� ST. NUMBER_ ************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED - 5 DATE REJECTED SEPTIC INSPECTOR--HEAL--T#— DATE APPROVED C3 COMMENTS �� CL PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm 4 ��— - - ✓�ee �om)nomaeal!/i aj'. Ilrrtuzc/use�o BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 050976 Birthdate: 08/25/1939 Expires: 08/25/2003 Tr.no: 4183 Restricted: 1 G PHILLIPS JACKSON 2 RITA LN L LAWRENCE, MA 01843 Administrator _ �11C VO'))t'!)tlNZr!/EI�U� O� 6(LrkNYCJlrld�6 Board of Building Regulations and Standards I HOME IMPROVEMENT CONTRACTOR Registration: 103547 Expiration: 7/8/2004 Type: Individual JACKSON BUILDING&REMODEL PKTlip Jackson 4 Rita Lane Lawrence.MA 01843 Adnunioralor North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: PR OG/'Ss/A/I 9 ,7 L q ly%zhL /?/y S/,�1� y N. 11 (Location of Facility) Sigfiature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Z a The Commonwealth of Massachusetts "` = Department of Industrial Accidents d Office of Investigations Boston, Mass. 02111 �Q+M SV1b Workers'Compensation Insurance Affidavit Name Please Print Name: (I h I��i I 4 c A s a 4/ Location: AID C fi Us S A/l A ivy-DaZI 4 City ND, d 1V hz1 i1g Phone # 3- aI am a homeowner performing all work myself. �I 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: 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_welLas_chdi penalties in-thetorm-d-aSTOP WORKDRDPR-aid_afire_of._($1-00M)-aday.againslme I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 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 El Building Dept ❑Check if immediate response is required p Licensing Board E] Selectman's Office Contact person: Phone A Health Department Ei Other CALK ' c.nvIYopy NcN I `x 141• 2 �• �`� , / C40 FAM ► ty Room j57— l.// IIA V L TEP CeF IZ IVA,417R5 P/_;RFA V111KC-A CON7'f?AcTd - p'A ZrA -R-, 7 �/ /Y0. C �dss99�=683-G6�9 Iva A/YO D 1N1/v RM _ Ll v11V R M 1 .2 X 13 LI � � a Lo vol�dvlivo a X 1Y�, ssoYJ ON wAo J Yy/Y7VM y-Vi 3ld 5,yW -ev w 61106 IX17 � 07� 01 � 1 7� iL0 7� v��oHS - •E YIO / p wooZlCl7�J 7 X01 b 4 �X� �M � r • r :2 ST'oRy coLoN1.4L /V s 0 r.ATG GCI,LIN s ` AttS G/4QLEs v /4rn fAojvl_ LIZ K V77, FOAM vel rr l� f� .�zxvs A� /.-GO 3 - RR9-33 aS- IDENNiS / Iv o i 3 I - S - LirCs s;"A�F , i�vp��%iG ! , SAcg s /Oc 0HVVch _ - - - .1=978-6 S—-1 Y26 I ; iK +Ale u/ �c/iiGL i t , I � I I II s rC'A'A6-d els lD v�'�=NtN.�� 'II I i FORM U LOT RELEASE FORM 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT� /// -T� Cly 50 PHONES-`7'79 4 9 LOCATION: Assessor's Map Number PARCEL SUBDIVISION11 LOT(S) // A� STREET Y,i 5� ; 10. 14-1jac-Ve''" ST.NUMBER ************************* *********OFFICIAL USE ONLY******** * ******************* RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED &,A/a,, DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED 1,R D 2 DATE REJECTED COMMENTS GQ/-hQ Q H Q r, IJ OL-571r�/,e I-'e h/lcD Vcf 01 PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm NORT1y Town of over 0 TO No.344V -; - �A dover, Mass., ORATED PPa� S H E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT....... ()e,l, W4 kBUILDING INSPECTOR ................... Foundation has permission to erect...... !+!. s / /l�o . rrm ss *I o/ .. ................. buildings on ....'�.n...... .... .. .. .........../.......................................... Rough to be occupied as...........�.....12�m �N ��c- ar �b/�`�N Tfdl v S ti Chimney ....................................................... .......................................................... provided that the person accepting this permit shall in everyrespect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 3g /,2 ,3 �(/8©• y" PLUMBING INSPECTOR VfOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough ......................................... .................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 7566 Date. .? .. ..... Of NON1M �? °p TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION 'ISS ��.�Et�yu�� SACMUS L This certifies that . . . . ' ". has permission for gas installation . :. . . . . . . . . . . . . . . . . in the buildings of . . . .. . . . . . . . . . . . . . . . . . . . . . . . . at . . . C.n G.I. . . .A. . . . . . . . . ..., North Andover, Mass. Fee .�... . . Lic. No..(?'. : . . . . . . . . .Cl . :: : �L-. . . . . . GASINSPECTOR Check# J -CN— MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: MA. Dat U1 1 Permit# All Building Location: �'' _ Owners Name: rz��)aa(W Type of Occupancy: Cominercial❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [� 4 New:❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES W Q p = rn rri W O W v rn I_ O a W x ~ J` WIxZ Oz Z w H W O O W W CL aa X W > GV Z w w o g x T W O w lW x ti W W i- t): W I-- u Q ul O J W z J O tL to x W F W W Z W �. WQ ¢ m w O z O y > Z x O a W W > O 0 ~ > > > 3 0 V a G W O t9 x x 0 a I F SUB BSMT. k BASEMENT I 1 FLOOR I 2 FLOOR I 3 FLOOR 4TH FLOOR 5 FLOOR [ 6 TH FLOOR VH FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name. � U",,- ration Address: City/Town: State: ❑Partnership Business Tel:1 _, __ ��� i Fax: (, ku to ❑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 Yes alio❑ I If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 1d' Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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❑;1 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 P"ng Code and Chapter 142 n he General Laws. Type of License: OF By ❑Plumber Title A A, '91- a. Waster, Gdster�Fitter ature of Licensed lumber/Gas Fitter ash i Cityrrown ❑Journeyman License Number: �Cl� APPROVED OFFICE USE ONL E]LP Installer Date. .. .. . ... OF No DT1y 1h o� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,SSAG'NUSE� t This certifies that . . .1.< r C � '.! . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation !:{. . . . . . . . . . . . . . . . . . . . in the buildings of . . . J- - at . . �/�. . ./g f��. . .C 1�. �. '. . . . . . . .. North Andover, Mass. Fee. . . . . . Lic. No..c}.zi. '. . . . . . . . . . .i . . . . . . . GAS INSPECTOR Check# 2 t- 55 u Y MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DU7 G ��Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations ql Owner's Name &U2v% �,, flew Renovation ❑ Replacement ❑ Plats Submitted ❑k> y `^ } 96 FA kJ L = i..• .Ms..l w3 \ yr m en '� Z — L F z " r z z +I L' z j� mit Z U. su4 -6 :� SE.rt ENT SE .w ENT ( ^'"• 5T. FL (?A K CD . F L 0 0 R 1 T I I F L u Q K �d'r5 . FLUu R 6T 11 . F L u A K S;: .f: ::; 7T II FLuuK - NTII . FLnu R ?nnl or rype) Ch rc one:..Certifitie Installing Company ,,amt: Andover P1bd. & Hta. Co.. Inc. Corp.: Address 20 Agean Dr., Unit-10 ❑ per, Methuen. Ma. 01844 Business Telephone (978) 685-8383 ❑ Firm/Co <ame of Licensed Plumber or Gas Fitter georae Lag CP INSUR.wCE COVERAGE Check 006: ! have a current liability Insurance policy or it's substantial equivalent. Yes ED No !!'you have checked ves,please dieate the type coverage by checking the appropriate box. .-iablliry 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.Chapmr 142 of the ::Mass. General Laws,and that my`signature on thiset�mit application waives this requirement. p - Check one: A �4. �i_narure of Owner or Owner's Agent Owner El Agent± ..❑h " herebv certify that all of the details and information I have submitted(or entered)in above application ar ;and Rccurate W the. oesl ar'my knowledge and that all plumbing work and installations performed under Permit Issued For thjs.a��tcadon will be in. _ompiiance with all pertinent provisions ofthe Massachusetts State Gas Cand Chapter 143 oftlie GCne Laws.06 B V: ipature of Li erased Plumber Or Gas Fitter Tale ✓❑Plumber 9983 CiryTuwn P�Ia, -Fitter icense t umberfer A,PPR0VEDioFF1cF1JSF0 Nl.Y� ❑ Journeyman Date. 2. K. No , 74. 05i TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'SSAHUS� This certifies that . ,A. .' .� '. . . . .? . .� " • . " . . . . . • . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . .1.�/�/?'�.�. . . . . . . . . . . . . . . . . . at . . . .4//. . IL".�.�.'. .� . ./.'r. . ?. . . . . . .. North Andover, Mass. Fee. . . . . . . .Lic. No.. . r s!. . . . . . . . . . . . . . . . .. . . . . r PLUMBING INSPECTOR Check # J WHITE: Applicant CANARY: Building Dept. PINK:Treasurer -MASSACHUSETTS UNIFORM APPLICATION FOR PERMITTDO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date L/7 L/ � Building Location N l A )0,,L`; r 9:2r,< PA. Owners Name �_I I Eyl t rr-O \CL-i- Permit#L-iw Amount Type of Occupancy //fJt� New Renovation r] Replacement [2- Plans Submitted Yes No FIXTURES rnarz w El nod rcw SLBEeyz Y BA9R W w M KaR ZUKOR 3M rJ.00R 4MI LOCO smRaR 6MRaR 7M lJ.l.M 81HRaR (Print or type) Check one: Certificate Installing Company NameA n d ny P r` P1 h n_ R H t g En T n r Corp. 212 2 Address -2n Aognnn nr;4Q Unit-10 Partner. Methuen. MA n1Raa Business Telephone�(Q7o A ti R F,-R g R 1 0 Firm/Co. Name ofLicensed Plumber. George" L a Ro s e Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate boat Liability insurance policy IT Other type of indemnity Band D Insurance Waiver. L the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance sign== Owner El 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 my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts PhrmbiC d Chapter 142 of the General Laws. BySignature ot Liganseaum er Type of Plumbing License Title 9983 ' City/Town icense i um r Master Journeyman APPROVED(OFFICE USE ONLY V- Date�.... ....'. . ......... O� NORT",M ? �".:• ooh TOWN OF NORTH ANDOVER o PERMIT FOR WIRING �SSACHUS� This certifies that .�,.........'...:......,...:._ ....... : ...........�. �'................ has permission to perform ...:........::.. - ........... .................. wiring in the building of....:..........:. North Andover Mass. Fee&............... Lic.No.............. ........:................................-✓ r ........................ �ELEcmicAL INSPECCOR Check # 436 'U TIZECOA MONMEALTHOFMASSACHUSETIS Office Use only DEPAKiAMW'0FPUBU'CS4FE1Y Permit No. BOARD OFFMEPREVEMONREGUZ477ONS527CAIR12-00 Occupancy&Fes Checked APPLICA77ONFOR PERMTT TO PERFORM ELECTRICAL 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) Date Town of North Andover To the Inspector/of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) Owner or Tenant kc Owner's Address (eo Q Is this permit in conjunction with a building permit: Yes Elu No (Check Appropriate Box) Purpose of Building \fie g: C-e_ Utility Authorization No. Existing Service -)0 _ Amps 7-40 Volts Overhead Underground � No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity - Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Totat No.of Lighting Fixtures r� Swimming Pool Above Below rNo.of s KVA ground round KVA No.of Receptacle Outlets 3 No.of oil Burners ergency Lighting Battery Units No.of Switch Outlets L No.of Gas Burners No.of Ranges No.of Air Cond. Total RMS No.of Zones Tons Vo.of Disposals No.of Heat Total Total ction and Pum s Tons KW Devices lo.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices `o.of Dryers Heating Devices KW LocalMunicipal ^ Other Connections o.of Water Heaters KW No_of No.of Signs Bailasis �.Hydro Massage Tubs No.of Motors Total HP 4 HER r �Coraage Ptns�altlottlelEgtricanerYsOfMassach>sdlsGa�-alIsws aamaitliab�ityh arrePblicy �rlp)�pp � or st ialatpivalerY YE NO �. stet nxWdvandpmofofsametotheOliim YES (F-1 � F)mhavedledcEdYEB p4mwmtatethetypeofm by ffbd__... box RANCE BOND ORIER Expita>ionDale EshM*d Va)WdHaetrical Wotk$ to Start 3`V kFet60rlDaE�Retp>es10d Raugtt Fatal i urxkr ,tTie Penahies of pajtay. NAME Z c - ��,e,,L�,c tZ IimwNo- V LAN \vac e1>r Signhu �'ae � _' w LxemeNo Bus>mTel No. Am Tel No. TR'S INSURANCE WAIVER;I am aware that the License does nothave the iristnarrce comnge orits a bslarrtial egttivalalt as regtmed byNl%xhusetls Gff)etA Laws mysigrialureonthrisperrrntapphcaticnwaivesthis reg irement check one) Owner ® Agent Telephone No. PERNITT FEE Signature o caner or gen �` , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations T Boston; Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers'compensation for my employees working on this job_ Company name: Address City: Phone#: Insurance.Co. Policv# 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 or,a fine up to$1,500.00 and/or one years'imprisonment_as_welLas-civilpenaffiesin2belorm-cfa-STOP.VYORK aRDERand_afine-cf.($1DOM)arlay,agairss2-mom I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. do hereby eertly under the pains and penalties ofpagury that the rnforrnatian prom ed above As true and correct. p jignature Date ' rint name Pbone.f _1 c►a! use only do not write in this area to be completed by city or town officiar City or Town Permit/Licensing D Building Dept EjCheck if immediate response is requked 0 bcCensing Board p Selectman's Office tact person: Phone A n Health Department El Other