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HomeMy WebLinkAboutMiscellaneous - 52 MARBLERIDGE ROAD 4/30/2018 52 MARBLERIDGE ROAD 210/037.A-0032-0000.0 Wational General ►► Aerto,Hme&Hrakth Insu ocr, PO Box 1623 Winston-Salem,NC 27102 June 9, 2015 Building Inspector's Office 120 Main Street North Andover, MA 01845 Insured: Paul and Barbara Theberge Property Address: 52 Marbleridge Road North Andover, MA 01845 Underwriting Company: Tower National Insurance Company Policy Number: HOE1352908 Date of Loss: March 1, 2015 Claim Number: H153027-01 Claim has been made involving loss, damage or destruction of the above- captioned property, which may either exceed $1000 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of this writer and include a reference to the above- captioned insured, location, policy number, date of loss and claim number. On this date, I caused copies of this notice to be sent to the persons named above at the address indicated above by first class mail. CUAto-w LmeW Signature: Clinton Lowell, Property Claim Adjuster 314-813-5957 N°- 9660 NORTq °;.���° •��° TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� r _ U T� This certifies that e has permission to perform . . . plumbing in the buildings of . . . . . . . . '?'. . ( ti!... . . . . ..1..°`Fj�C�, .�' ('., North An over, Mass. rt Fee . .Lic. NoJ5 �92 . . . . . . . . . . PLUMBING INSPECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# JOBSITE ADDRESS / OWNER'S NAME POWNER ADDRESS G i TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: E-1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOQ FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB .I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOORIAREADRAIN ._._-.J �_! ______J _.-......... INTERCEPTOR(INTERIOR) KITCHEN SINK �.l _..._._._J J I 1 .....__.! I J _...,.._. I I ( � f —! _-._.J LAVATORY __.._._J ----.-J ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[-1 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND F-11 OWNER'S INSU CE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachus t eneral La ,an y signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER �''i AGENT SIGN E OWNER 0 NT I hereby certify that aVA 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 G D _Gr . . _ LICENSE# _S J SIG T E MP JP CORPORATION 0# E PARTNERSHIP 0# - _ ! LLC E t COMPANY NAME ADDRESS _ _ ear CITY STATE ZIP FAX € CELL� j EMAIL I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 'M Ti The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ,Y 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: 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.E] I am a sole proprietor or partner- listed on the attached sheet.$ E]Remodeling shipand 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 employees.I em to o workers'insurance required.] p Y � k 1311 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. 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.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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is 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#: 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-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. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www,mass.gov/dia i Date-(.3-!?.� . � ��1 f1'ISI13�cfrg 3 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . IfiL,. .(�-� has permission for gas installation . . e ,. L . , -. . . . . . . - in the buildings of. . .?�u•l -['. r . . . . . . . . . . . . . . . at . . .Jr' .2,. .nq.L.r4 ,,,. , �;, ,North Andover, Mass. Fee ., ,�-). . Lic. No. . .1.�` Q . . . . . . . . GASINSPECTOR Check#_•�� 8427 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a _ CITY MA MA DATE /i-/ PERMIT# JOBSITE ADDRESS _r' f �lJ OWNER'S NAME - GOWNER ADDRESS -" TEL _ — FAX I__-- TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL DI RESIDENTIAL PRINT CLEARLY NEW:[RENOVATION: REPLACEMENT:F1 PLANS SUBMITTED: YES[�_I NOD APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER J T L:. __ II -:.Il_ BOOSTER ; ( I=J EZj(_ f. CONVERSION BURNER COOK STOVE ( a I '-j -� DIRECT VENT HEATER DRYER FIREPLACE -� --=:J I _._(l- ---I -I 1 - - ---� -- FRYOLATOR - FURNACE GENERATOR 1 �I I- =l I�-. .. ! - _1. GRILLE INFRARED HEATER _.� _— --- - - (!` - _..- — w __ � --1 LABORATORY COCKS _. I _ _.r- I , I- _--I --J.---JE-- J L- -J11---_ ---- MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER I WATER HEATER ILI J...-�-�I �I— OTHER Ir_ _ L-- --- ...... INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND I__I OWNER'S INSU NCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusel ener La s,a t my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [7�. AGENT [_J-.I SI E OW AGENT hereby certify that ATI 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-GASATTER NAME / j LICENSE# j' a MNAWRE MP 0 MGF __-I JP [ JGF[J`I LPG]0 CORPORATION FJJ# PARTNERSHIP 0#=LLC�J# COMPANY NAME: AC, ! ��ADDRESS CITY STATE�ZIP ]TEL �•_FS_J. 4 FAX CELL I EMAIL 1` ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No v tel/, /�.��Q—� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ —Z FEE: $ PERMIT# PLAN REVIEW NOTES f, 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: Ci ty/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.❑ 1 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. 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.❑ 1-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' 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 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 certto under the pains and penalties of perjury that the information provided above is 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 d 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 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.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Location X12 - _�- V NO. Date �- cu av 140RTh TOWN OF NORTH ANDOVER 0��« ° :•,�O � ; 9 ' Certificate of Occupancy $ • o a b''••°.stn Building/Frame Permit Fee $ �Ss+cMusE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 4 13 c ? 2Building Inspe TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building CommissioneEqRg=tor of Buildings Date SECTION 1-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: � u Map Parcel Numb .3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of R Name(Print) Address for Service Signature Telephone 1 2.2 Owner of Record: F Name Print Address for Service: M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date ic Signature Telephone r (1-2 Registered Home Improvement Contractor Not Applicable ❑ R Lk - Company Name � Registration Number Addre s 0 e?c � �_ Expiration Date Si ature Telephone 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 permit. —Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition . ❑ Other ❑ Specify Brief Description of Proposed Work: " 1 I SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to beOFFICIAL-,VSE QNLY om leted by permit applicant 1. Building �� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 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 Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. -Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 �K�6�6 Q_w�,A c k) Print Name 12 U Si aiu e of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T ABERS 1 ST 2 ND 3 SPAN DIN ENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH MNEY IS BUILDING ON SOLID OR FILLED LAND 9 IS BUILDING CONNECTED TO NATURAL GAS LINE Mario Castritone, Prop. Tei. 682-4266 CASTRICONE ROOFING & SIDING CO. 31 Court St, No. Andover, Mass. 01845 LK—) yy ria 'S�.x�i'�� �'•F3i.'x�'a� +�l .i ^CkrL ���siC"S"p . iA �;fib, •�.,.:::: ,5( r i �ri. NORTH Town of- Andover 0 J� . 11% No. 0 LA doverMass., COC HICHEWICK , ORATED BOARD OF HEALTH Food/Kitchen PER D Septic System BUILDING INSPECTOR THISCERTIFIES THAT............A............ ................................... .......................................................................................... Foundation 41*ar raw has permission to erec .......... ....... ............. buildings ............................ . 111!111 ............... 44.14..4. 'Rough to be occupied as. I....... ... ............................................................................................................................... Chimney ..... ...... provided that the person accep g tfils permit shall in every respect conform to the terms of the application an file in Final this office, and to the provisio s of the Codes and By-Laws 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STASA Rough ............................................................... .. ..................................... 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. SEE REVERSE SIDE Smoke Det. The Commonlvealth ofMassachusetts Department of Industrial Accidents � _ ' = Oflicenf/nvesUgatlnes 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit am r c ti f,ity phone it ❑ 1 am a homeowner performing all work myself. ❑ 1 am a sole proprietor and have no one working in any capacity ❑ ].am an employer providing workerscompensation for my employees working on this job. ont . : ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have e following workers'compensation polices: = Combatfy n8the. ........ k + FfJ4nt! ;; tnsurance cbr' {�9.1l�V#` � �ddreJJ. ctty t phonb d insuranct to A411S X.t ' Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 it 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. 1 do hereby certify under the pains and pen ties of perjury that lite information provided above is true and A orrec /))�\ Signature /�'/`"/ ��-2-;� �� Date Print name � Cl (� l i�LQ Phone official use only do not write in this area to be completed by city or town official city or town: permitAicense i! nBuildfng Department pLicensing Board p check if immediate response is required []Selectmen's Olrice 0Ilealth Department contact person: phone#; nOther (revised 3195 PIA) HOME IMPROVEMENT CONTRACTOR Registration 103317 Type - DBA Expiration ..07/07/00 a CASTRICONE ROOFING & SIDING C Mario T. .Castricone G� e Court,St. ADMINISTRATOR N. Andover MA 01845 F