HomeMy WebLinkAboutMiscellaneous - 49 FURBER AVENUE 4/30/2018 (2) 49 FURBER AVENUE
210/067.0-0040-0000.0
9714
Date J :.. �..... l .....
NORT/�
TOWN OF NORTH ANDOVER
O p
PERMIT FOR WIRING
�,SSACMU��
This certifies that ../4.u `?v2...... .U.y .�' ........
nn /Odti
has permission to perform ..4�!��..�.. .....�..l.�6?- /........ . ............. .
wiring in the building of..... . Imo/
17
AS at.. :`�`h..... T• 1... ,G�s orth Andover,•Mass.
Fee....: . ...... Lic. .... .
•ELECTRICAL INSPECTOR
Check # __
N Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
77-//
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[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),527 CMR 12.00
(PLEASE PRINT WINK ORTYPEALLINFO ITION) Date:
City or Town of: l N To the Inspector of Wires:
By this application the undersi ed gives not' e of his or her intention to perform the electrical work described below.
Location(Street&Number)
Owner or Tenant xA'A34 _'4-4 SG Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No [9 BLDG PERMIT#
Purpose of Building AI e, ) S Q d' /i L E' Utility Authorization No.
Existing Service d00 Amps ?oc) 11'/2,, Volts Overhead ® Undgrd❑ No.of Meters
New Service o?o J Amps goo /1 , Volts Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and Ampacity J
Location and Nature of Proposed Electrical Work: let,, o v s e
2
Com letion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total.
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool�bln- ❑ o.o mergency ig mg
rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.ofZones
No.of Switches No.of Gas Burners [No.
of Detection and
Imtiatin Devices
No.of Ranges No.of Air Cond. Tonsl of Alerting Devices
No.of Waste Disposers HeatPump Number Tons KW .of Self-Contained
Totals: ..........................................
Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
N
No. of Water No.of No.of o.of Devices or E uivalent
Heaters ' Data Wiring:
Signs Ballasts No.of Devices or Equivalent
f No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or E uivalent
OTHER:.i o ri LJ S.Q..
Attach additional detai if desired, or as r fired by the I ector 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 Rfl BOND ❑ OTHER ❑ (Specify:)
I cert,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: ,r�� ,t- LIC.NO.: S"fes
Licensee: — Be A-.-;L`Lcx_A S Signature LIC.NO.:
(Ifapplicable, enter "exempt"in the license number line.) Bus.Tel.No.:0/7 *d 3cx�5
Address: tZ Alt.Tel.No.:
*Per M.G.L. c.147,s.57-61,security work requires Department of Public Safety"S"Licen LIC.NO.:
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. $
ELECTRICAL PERMIT NO. INSPECTION REPORT: t
ELECTRICAL INSPECTOR-DOUG SMALL
1.ROUGH INSPECTION:
Passed-[ ] Failed-[ ] Re-inspection required($50.00)- [ ]
Inspectors' comments:
(Inspectors'Signature-no initials) Date
2.FINAL INSPECTION:
Passed- . Failed-[ ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signature-no initials) Date - A-Go
jl 2�tri
3.UNDER GROUND INSPECTION:
Passed-[ ] Failed-[ ] Re-inspection required($50.00)-[ )
Inspectors'comments:
(Inspectors'Signature-no initials) Date
4.INSPECTION-SERVICE:
DATE CALLED NATIONAL GRID: NAME:
Passed-[ ] Failed-[ ] Re-inspection required($50.00)- [ ]
Inspectors' comments:
(Inspectors'Signature-no initials) Date
5.INSPECTION-OTHER:
Passed-[ ] Failed-[ ] Re-inspection required($50.00)-[ )
Inspectors' comments:
(Inspectors'Signature-no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED.
7
~r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 0211.1
www.mass.gov1dia
'workers' Compensation insurance Affidavit: Builders/Contractors/FIectricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): A f4, esz&ae
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.ElI am a employer with 4. ElI 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 or partner- listed on the attached sheet. 7. ❑Remodeling .
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. y, ❑Building addition
• [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
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.]i employees.[No workers'
comp.insurance required.] 13.FI Other
*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,
lContractors 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.M 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 flue
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenaldes ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#:
[6.
ficial use only. Do not write in this area,to he completed by city or town official
ty or Town: Permit/License#
uing Authority(circle one):
Board
off
f Health 2.Building Department 3.CiWTown Clerk 4.Electrical inspector 5.Plumbing Inspector
Otherntact Person: Phone#:
Location
No. Date
,40RTN TOWN OF NORTH ANDOVER
i0. A
A
i Certificate of Occupancy $
1's'"•°''tom
Building/Frame/Frame Permit Fee $
scNusE 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ °
Check #
1 57z' U Building Inspec
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISHA ONE OR TWO.FAMILY DWELLING
v
BUILDING PERMIT NUMBER: DATE ISSUED:
�r 17 doZ
SIGNATURE:
Auja
Building Commissioner/I for of Buildings Date
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District ProposedUse Lot Area Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided red Provided
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
2.1 Owner of Record
a ✓L '7`Z ��a « � y% /pct.-�C � �v�
Name(Print) Address for Service
Signature Telephone
2.2 5Zer of Record:
Name Print Address for Service:
Sigeature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor:
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvveement Contractor Not Applicable 0
Company Name
Q / Registration Number
Address
�^ Expiration Da e
i nature Tele hone
SECTION 4-WORKERS COMPENSATION(M.G.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 it.
Signed affidavit Attached Yes.......0 No.......❑
SECTION 5 Descri tion of Proposed Work check all a livable
New Construction ❑ Existing Building ❑ Repair(s) i Alterations(s)/E' Addition 0
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify a►, t
Brief Description of Proposed Work:
ver-A
17
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be
Completed by permit apphcant
1. Building (a) Building Permit Fee
D Multi Tier
2 Electrical (b) Estimated Total Cost of
Construction w
3 Plumbing Building Permit fee(a)x(b)
4 Mechanical AC pTJ�
5 Fire Protection 9•
6 Total 1+2+3+4+5
100 Check Nufnber
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf a atters relative tow autho ' thi permit application.
v.. k 7-/moi -!a?
Sign a of Owner Date `
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, 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
Print Name
Signature of Owner/Agent Date
NO.OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TMMERS I.ST 2 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIlvINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
"Urs I tj
Town of over
0 0
No.
0 - 7- �9: zoo:
'" W '°
��L A
3AI �=*
0 t�L- 1.A I dover, Mass.,
COCHICHEWICK
0RATED P"\p
BOARD OF HEALTH
Food/Kitchen
PERM Septic System
L ......JT T BUILDING INSPECTOR
THIS CERTIFIES THAT.. .. ......... .0.0...........
.=,of...... Foundation
.has permission to ere ........................................ Uildings on ...... Rough
..........
Z6�-�.......................................
tobe occupied as ....................................................................................... Chimney
provided that the .111610110.r* g this.1ploeshalllI'lilln e respect conform to the terms of the application on file in Final
- &111111111
person ai��q
n
0 mod
this office, and to the provisl of the Codes and By_ s relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION STiELECTRICAL INSPECTOR
A
Rough
..........Z... Service
BUILDING INSPECTOR Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE I
Page No. of Pages
PROPOSAL
,ATOM sulfa's License:Sat.Bch.#915
BERTHOLD HOME REPAIRS AND PAINTING Brev.Co.#009850548
w
Int/Ext Painting (321) 773-6066 Siding and Soffit
• Windows / Carpentry
• Doors Renovations
Fully Insured •Over 10 Years Experrence•Free Estimate
PROPOSAL SUBMITTED TO PHONE DATE
STREET JOB NAME
CITY,STATE AND ZIP CO�DEE/ JOB LOCATION
We hereby submit specifications and estimates for:
s _
-
ut. . . ;'7
WE PROPOSE hereby to furnish material_ and labor — omplete in accordance with above specifications, for th-,e) sum of:
dollars($ C7
Payment to be madeas follows:
All material is guaranteed to be as specified.All work to be completed in a workmanlike' Authorized
manner according to standard practices.Any alteration or deviation from above speafica- Signature
tions involving extra costs will be executed only upon written orders,and will become an
extra charge over and above the estimate.Alt agreements contingent upon strikes,accidents _
or delays beyond our control. ote:This proposal may be
withdrawn by us if not accepted within days.
Fconditions
CE OF PROPOSAL—The above prices,specifications
7
are satisfactory and are hereby accepted. You are authorized
s specified.Payment will be made as outlined above.nce: Signature
P
1
f,
�l
1 HOME IMPROVEMENT CONTRACT4 r�
Registration 122153 R
j
Type - 084
ti{s
Expiration 07/26/98 ?
JOHN BERTHOLD CONSTRUCTION 1�
— j ohn 6. Berthold
ADMINISTRATOR 15 Popular Rd
Sale# NH 03079
�R\ MASS'ACf4USETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINC
(Print or Type)
NORTH ANDOVER Mass. Date –U
'- Luilding Location �� �, Permit #-C-27
*� Owners Namer/T-2,j// j� j�
New '7 Renovation Replacement p Plans Submitted
FIXTUPES
cc
o9 V x a c
N OC N a p j to
H
o w '�� � a x � o N w \
4 R1 N N W w O 0. w t
Cr. w d F. N a 4
u� cc w z v w x W Wcc 0 a a ° C1 > w
LLJcc Wr r x
Z 4 w " LLI
t < rr ~ H yw- N ? O z w o 0 z
_ 4 ,EU > a w z z a \
Q a a
a z o 0 Y w a 0 -1 U a > Q ao Iw o
• sua—esa�T.
SASEMENT
IST FLOOR
2ND FLOOR
3RD FLOOR
4THFLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
(Print or Type) Check one: Certificate
Installing Company Name Corp.
Address Partner.
��✓�� �� Firm/Co.
Business Telephone:
-Name of Licensed Plumber or Gas Fitter 147FIL
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box: -
Liability insurance policy Q Other type of indemnity Q Bond
Insurance Waiver: I , the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner Agent
I hereby certify that all of the dcuils and information I have tubmitted (or entcrcd)in above application ate true and accurate to the best of my
knowledge and that all plumbing work and Installations petfomted under'Permit iuced for this application will be In compliance with alt pertinent
provisions of the Massachusetts State Gas Cude and Quptcr ISI of tho Genual Laws.
By rTYPE LICENSE: �
Plumber
Title Gasfitter Signature of Licensed
City/Town: Master Plumber orOG asfitter
Journeyman
APPROVED (OFFICE USE ONLY) License IJumber
Date, , `.. . . . . . . . . . . .
g
NORTH TOWN OF NORTH ANDOVER
Q�t�tED .6.4,
O
3� h° Q` PERMIT FOR GAS INSTALLATION
A
• i �
• 09 .��.e 0„}
QDA�iFDµEPP���S
SACHU
�S E•`rj J l� '�ro
This certifies that .. . . . . . . . . . .
has permission for gas installati n
.. . . . . . . . . . . . . . . . . . . . . . . . . . .
in the buildings of
at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass.
Fee. ?. . . . . Lic. No.. � ..'J. . . . . ._F .... . . . . . . . . . . . N:<.
GASINSPECTOR
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File
h
THE COMMONWEALTH OF MASSACHUSETTS
DISTRICT COURT DEPARTMENT OF THE TRIAL COURT 9118 UW 87
ESSEX, ss LAWRENCE DIVISION No.
WARRANT TO EXAMINE OR REMOVE
General Laws (Ter.Ed.)Chapter 164, Sec. 116
TO THE SHERIFF OF COUNTY OF ESSEX OR ANY OF HIS DEPUTIES, OR..TO ANY
CONSTABLE OF THE CITY OF LAWRENCE, MASSACHUSETTS:
Complaint under oath having been made this day before Keith E. McDonough
A=MUfit Clerk-Magistrate of the Lawrence Division of the Trial Court
by James Diozzi an officer or servant of Town of
of XbXK) yXS=XXZ1txg9nYp'A1k�E duly authorized in writing by No. Andover
of said company, that said company has considered it
necessary to enter the premises of 49 Furber Avenue S1
NO. Andover, Ma (owner Barry Fitzgibbons)
and having been refused entry, for the purposes of examining the quantity
of gas consumed and for the purpose of removing the-gas meter:
WE THEREFORE COMMAND YOU to take sufficient aid and repair to the premises
of 49 Furber Aveneu S1
NO. Andover, Ma (owner Barry Fitzgibbons)
accompanied by such officer or servant who shall examine such meters, pipes,
wires, fittings and works for the supplying or regulating the supply of
gas consumed or supplies, therein, and shall, if required, remove any meters,
pipes, wires, fittings and works belonging to said company.
And return this precept to the Lawrence Division of the Trial Court within
seven days of the date, hereof, with your doings noted thereon.
WITNESS, KEVIN M. HERLIHY, FIRST JUSTICE, at the Lawrence Division of the
Trial Court, in the County, aforesaid, this seventh day
of October in the year of Our Lord, One Thousand Nine
Hundred and NW�x 'ninety one
i
t C agistrate
f
r
ESSEX, ss.
A
By virtue of the within warrant, I have this day taken sufficient aid and
repair 6o the withi described premises accompanied by the within
named a,.w."
Al. *wAuvoji (rrgs ;n,1Pecfon
as witMn directed, who in ithin described capacity, examined said
gas meter and ascertained the quantity of gas consumed in and upon
the said premises and thereupon discontinued the service as herein
directed.
Fees:
Services:
Copy:
Demand:
r
n
(D
E �t vri v'
>4 O
� 0 w R
r• m ►t �,
:3N O
H H �t9�f
M0 g H H t�
N. C: O t'
ad rt ars x
w •• 5 0 r+ rO
ll� o cr w a' w
N M (D
O rt PI phi M N H M
M :r (D 'U ►i 0
(D rt O z W 0 to
rt H " H �7 O � tD n
cn n 0 rn d x
H.
a. o .4 cn
w f-' O c w t7l
^ rt (n C " m H
rD n O (D trl rt Fl-
o O to
rt (D N O
• I-' M
ON
v
Date.... ..�.y.�. .
�aORTI{
3?0 "`.. •.'s�-� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
41
�i�SS^cMusE�
This certifies that ..... ►` ! ro �os� 0 '`� I
..............................................................................
has permission to perform ....1.k. w........ ' .........................
— � f
wiring in the building of..... .!...... ..�.!.. .. ? ...'.....�......................................
r f r J ... ,North Andover,Mass.
Fee......y.. ...... Lic.No. .......
5 ELECCRICAL,'INSPECTOR
Check #
1. 1-3 7 .
Official Use Only 0011,
Permit No.
Voolt-x 71-&&Sally Occupancy&Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 5527 CMR12:00
Q
(Please Print in ink or type all information) Date ( / 7 -03
To the Inspector of Wires:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location(Street&Number ri r-
�r/ r
Owner or Tenant � ("i �j�, ,�
Owner's Address ( k IG l7ng /r-dyor+4 Tf�yer
Is this permit in conjunction with a building permit Yes ❑ No AL(Check Appropriate Box)
Purpose of Building 1S[
Utility Authorization No. �f 6-
Existing Service avo Amps Lf® Voits Overhead 44'- Undgmd ❑ No.of Meters
New Service Amps Volts Overhead ❑ Undgmd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of oposed Z44;��q-e* S
k
MLS,Cx.�G/ JW r ,
Total
No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA
Above ❑ In ❑
No.of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA
No.of Emergency Lighting
No.of Receptacles Outlets No.of Oil Burners Battery Units
No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone
Total No.of Detection and
No.of Ranges No of Air Cond Tons Initiating Devices
Heat Total Total
No.of Di sal No. Pumps Tons KW No.of Sounding Devices
No./of Self Contained
No.of Dishwashers S /Area Heating KW Detection/Sounding Devices
❑ Municipal ❑ Other
No.of Dryers Heating Devices KW Local Connection
No.of No.of Low Voltage
No.of V44ater Heaters KW Signs Bailases Wiring
No.H ro Massage Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
Liability Insurance Policy includ Co pleted Operations Coverage or its substantial equivalent YES= NO =
have submitted.61id proof of same to the Offi YE NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANC = BOND = OTHER = (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work$
Work to Start I tion Date Resquested Rough Final
Signed under atties ,�/ y
FIRM NAME S 11)I +� LIC.NO. eC,, �d
♦ /♦ r e
Lkense N N Signatu C46ALIC.NO.
/� f/n {d.,,n /y. ( ,,,�A Bus.Tel No.
Address V`�L!/dliw `v Yl Alt Tel.No. 2
OWNER'S INSU CE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General taws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
f 01—
Telephone No. PERMITfEE $ 71z ,
(Signature of Owner or Agent)
u F The Commonwealth of Massachusetts
Department of Industrial Accidents ,
d
= Office of Investigations
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
I am an employer providing workers' compensation for rry employees working on this job.
Company name.-
Address
ame:Address
City: Phone#.
Insurance.Co. Policy#
Company name:
Address
City Phone#
Insurance Co. Policy#
Failure to secure coverage as required under Section 2M or MGL 152 can lead to the imposition of criminal penalties c f.a fine up to$1,500,00
and/or one years'imprisonrriern asves-as_c omimakm-m-thelwn-f-aSTDPYAORKDRDFR-acid_afare.of.(,31jWM)-ajjayagaumt.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 hereby certify under the pains and penalties ofpef)wy that the inlormabon provided above is true and correct
Signature Date
Print name Phone.# c�
Official use only do not write in this area to be completed by city or town official'
City or Town Permitkicensing
El Building Dept
❑Check if immediate response is required I] Licensing Board
E) Selectman's Office
Contact person: Phone# EJ Health Department
Ei Other
r