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Home My WebLink AboutMiscellaneous - 56 Raleigh Tavern Lane 55 RALEIGH TAVERN LANE 210/107.A-0118-0000.0 1 4 4 II I i I III hPO Box 55098 Boston,MA 02205-5098 517-951-0600 v Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: ERIC B LOTH and ROSEMARIE A LOTH Property Address: 55 RALEIGH TAVERN LANE,NORTH ANDOVER, MA Policy Number: HMA 0267677 Claim Number: BOS00050217 Date of Loss: 2/19/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143 Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Joshua Terenzoni Claim Examiner 2/20/2015 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3287 Fax: (617) 531-6648 Email: JoshuaTerenzoni@Safetylnsurance.com Location 56- 74 J.A No. C) " c� Date 8 ^C 2 MORTN TOWN OF NORTH ANDOVER 0 A Certificate of Occupancy $ 30 Mu'<�' Building/Frame Permit Fee $ s,►csa Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 166J3 �� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLINGMa �1<`$IS�for t1<cRl USrr OHI rn BUILDING PERMIT NUMBER. � y'� � DATE ISSUED: ic SIGNATURE: Building Comnlissioner/19seSuor of Buildings Date I — a- Z SECTION 1-SITE INFORMATION l 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: c Let Aj+p" l'oqA (I f`j m F t�f g` 0 r�t- 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 Reqtfired Provided Recpired Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone tnfomation: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIPIAUTHORMED AGENT rn 2.1 Owner of Record Name(Print) Address for Service SignatuK Telephone 2.2 Owner of Record: Name Print Address for Service: O Z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable�! .+ T Licensed Construction Supervisor: O License Number Address Expiration Date 3 Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name rn Registration Number r Address r Z Expiration Date Signature Telephone v, 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.......0 No.......❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: � - C'cST �� t n lac").. SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OMCIAL USE ONLY Completed 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 r �- 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATI N TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ]E�P—1,C 9 . as Owner/Authorized Agent of subject property Hereby authorize to act on My ial�in allafters rel v work authorized by this building permit application.i 6-517 7 Signature of 0,vner Date 1 I—P— SECTION 7b OWNER/AUTHORIZE.DD AGENT DECLARATION I, ft l C - L:=n I c� 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 4 Print Si ature of Owner/A ent Date -�— NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMERS IST 2ND 3RD SPAN DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SU_,E OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover Building IDepartm'ent 27 Charles-Street -- North Andover, MA. 018,15 D. Robert Nicettaf• .Building Commissioner - �sn, �ij (978) 688-9545 978 688-9542 Fax HOMEOWNER UCENSE EXEiAP110N Please print ` DATE SOB LOCATION � t Number StreetAddress d Map/lot 10MEOWNER _ Name Home Phone W`xk phone ESENT MAILING ADDRESS City I n �P Code The current exemption for"homeowners"yaps extended i � of two units or less and..to allow such homegwnW to d ndude owner- up6ddwellings not possess a license. Provided that the owner acts as e an inuW�him�►'ho. . .DEFINITION OF Pervksor (Stateauadtng Code Secton108.35.1) HOME}/�tO1NlVER: Persons)who awns a parcel of land on which he/she resides or intends to there is, oris intended to be, a one or two reside on which cessory to such use and/or fafm p dwelling,adached or detached sues ac- considered a hor<rtecywr►er onehorne°n a . � �- Ape who�„ two-year pentxt shall not be --. . The undersigned"homeowner'assumes r Applicable codes, b ationssibility for c:ornpganCe with the State Building Y-laws, rules and re�r!atior►s, _ g Code and other The undersigned "homeowner"certifies that m inspection dover hPJshe understands the Town d No.An Building Department minimu . �►PIY with said Procedures and requirements-durQs and requirements and that he/she wiH OMEOVVNER'S SIGNATURE 'PRO',/Al_OF BUILDING OFFICIAL NORTH ED � Town of ... .A , Andover No. x= - o LA COCNIC 6' dover, Mass., ADRATED P'? 5 .9S H BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT...... "........ BUILDING INSPECTOR ......................... Zough un ation has ermission to erect....��...W#m�.. buildin s on ...5 .. .� C A � .... N' to be occupied as................ ....... .......L y......... .................. �► Chimney AA �1 si it of%&W .............................................................. provided that the person accepting this permit shall in every respect 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 In tion, Alteration and Construction of Buildings in the Town of North Andover. 160 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. F Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION START ELECTRICAL INSPECTOR CRough ............... ......... . ................... ....................................................... Service �I BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina, No Lathing or Dry Wall To Be Done FIRE DEPARTMENT .Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDD::E:]l smoke Det. Date. OfHORTM O TOWN OF NORTH ANDOVER 3�, ,a,r ....,.,• OL p PERMIT FOR PLUMBING ,SSACMUS� This certifies that . r.'?�. .� .: 1 r . !` . . .'/. . . . . . . . . . . . . . . . . has permission to perform . . . . plumbing in the buildings of . . . :. 6... . . . . . . . . . . . . . . . . . . . . . . . at. . s. .). . .!.'/.�,/-. . . . . �'�.'H , North Andover, Mass. Fee. l i/- . . . .Lic. No.. 1 .r!(.l . . . . . . . . . .moi �.L-«!�. . . . . . . . . PLUMBING INSPECTOR Check # ' 5 4 37 .MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT•TO DO PLUMBING .r (Type or print) NORTH ANDOVER,MASSACHUSETTS Q l I_ Date Building Location�<�`"+�-+ l"EVA-4n (2- .-- Owners Name Permit 3 7 Amount Type of Occupancy Yeuv--- New Renovation Replacement 1:1 Plans Submitted Yes No FIXTURES F a a H E~ Cn x w a w d A a SLBEM 1ST HUR . M HffR 3MRaR 4M FUM $IB FLaR 6MROCIt 7M HLM SIH FLOCR (Print or type) D 1 Check one: Certificate Installing Company Name i m 1r- 13 Corp. Add-- '/?- ddres /?- f 19)"U- q Lq- ark`k. Partner. i1 ,6)73b Business Telephone ,- 976 0 Firm/Co. Name ofLicensed Plumber. Insurance Coverage: Indicate the a of insurance coverage by checking the appropriate box Liability insurance policy Other type of indemnity El Bond 0 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 Signature Owner 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 M sachus Statg,ghbing ode and Chapter 142 of the General Laws. By: Signatureof icenssse um er Type of Plumbing License Title )ay(1(0 City/Town ►cense Numuer Master Joumeyman ❑ APPROVED(OFFICE USE ONLY NORTH own of QED- /. Andover No. - - - QL o C-COCMi- C �/AC^ dover, Mass., ` �ORA7E D P'PVCl 1`7 4 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......CA.t..Cw........kol* Foundation P buildings on ...5 . . .��x� . ..........� .....1N� Rough .. . ... ... . . has permission to erect.... ..... .... �� . . . .. T�'� . to be occupied as................ /� Movow ...�y.........�.. t y �► Chimney �N � . ... . . ................. ..................................................... provided that the person accepting this permit shall in every respect 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 Inspe tion, Alteration and Construction of Buildings in the Town of North Andover. ! /? ! , 8 30 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION START ELECTRICAL INSPECTOR C Rough ...... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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. GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stone/fabric filter/cover and outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip- Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. Joist hangers-fully nailed wl hanger nails. Sill plates 2-2X6(1 PT)w/sill seal. Girls-solid brick or steel plate bearing at foundations '/" air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0"clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces-"proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber- Finish Smooth parging, clean joints, 8" solid @ combust. Surf. DECKS: Separate permit required: Lag to house, provide flashing. Rails min. 36" high, Baluster max space 5"on center. Over 8' above grade, use 6x6 posts wllateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspection fee-$25.00(Be Ready). Certificate of occupancy required prior to occupying structure. I o/ Sony .� -!-L-� (0 s UNC,p tl� 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*********************** APPLICANTJ1._•Li.fl�?L� /�cawt /)CPHONE LOCATION: Assessor's Map Number i 14 PARCEL SUBDIVISION ^ LOT (S) STREET ,J 5- )k v`�J�X 06// Y G'}Vt ST. NUMBER �S **********OFFICIAL USE ONLY *********** REC MENDATIONS OF TOWN AGENTS: CO SERVATION ADMINIST OR DATE APPROVED /� �- / DATE REJECTED �261y COMMENTS�usST T c le. " "e_owhers Aon,. e- cif , TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm W 119 ORG c ` au u�,�fla'4��o b�uacsa a4a jo cl auua Will pa,»Ye sl �t 9unpAi U, uodn paoi8e'asin�»4�o csalun '30 JtZINAI'iNQ PTCI ! 1 f N �tTJNVWN():18:1�I 3tQC�p' a�� u n:tup a111 uu�j�l 'y��1.u' IO�011WOM141) .�0 Op �Y a4 0� ti ip 4.)l S 110tI f s 6 Sf ✓G�f.DA.�gs �pECD ww o nwP 4 tC!- _ I d rtr/&.0 4r014vyr ru 'i�vu�ito�dow yo /o '`W, 6ai�ol fx'�ajr` ens •p 0,O M1 M 74 E ND / Y If w' -7 Ow I O'& a �... .it&•, '�' Is, •X`.Y .�. •.�4A}LQ�{�,r.t1'�r.'!•}Y+':r .: +.u:` ^V.i�....a'•'-'5"�`a'�. ��- `3Yi':^..:.N'.'-:!.!..GL4 '' ... .. »,� '�{...3( s'sr��6��. � ,� ,. (4� � / � \ \ � e—�/ � 5a � / � I 2v �Ie.�J 5�,�,w -I��s � ne Town of North Andover NOR7N Office of the Planning Department Community Development and Services Division • 27 Charles Street �� ,..° North Andover,Massachusetts 01845 SSwCKUStt htW://www.townofnorthandover.com Bob Nicetta P (978)688-9545 Building Commissioner F (978)688-9542 INFORMATION REQUEST BUILDING DEPARTMENT Please use this form if the Building Department is unavailable to provide immediate assistance. The building applications are available on the labeled hanging bins to the right on the partition. The forms are also available on the Town of North Andover Web Site www.townofnorthandover.com listed under the Building Department. Please fill out the attached form in its entirety to ensure an accurate and prompt response. All requests for information will be handled as soon as possible. CONTACT INFORMATION Date: Name: Phone number: Fax number: Address: INQUIRY Property in question: (Please include as much information as possible, e.g.: address;tax map and parcel number. Inquiry: Thank you for your interest and inquiry. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 WILLIAM ROWE BUILDING &REMODELING, INC. PO BOX 995 MET"AN, MA 01844 978-794-0494 LICENSED INSVRFD June 17, 2004 Eric Loth 55 Raleigh Tavern Lane North Andover MA This contract is entered into agreement between Eric Loth and William Rowe Building and Remodeling Inc., on this day, the 17''of June. The following specs are to be included in the scope of this contract. Install 7 new Tilt Wash Anderson windows in the first floor. T1M windows to be painted interior, finelite grills, high performance glass and screens. Eaux of the windows will be natural pine interior, flm&e grills and high performance glass, with screens. 'CV%%ue The windows will have new interior and exterior trim to match existing, and the siding will be patched as necessary. Paint and/or stain is not in the scope of this project. Repair the decking by installing 10 new 10" sons tubes 4'deep. A new 12"mid span beam to support the deck better. The rim joist will be lag bolted to the house and new support posts with new bases will be installed. Install new pressure treated risers. Total job$8080.00 Payment Schedule: 1. $2500.00 Deposit on materials, Special order items 2. $1860.00 3 days prior to start 3. $1860.00 Upon completion of windows 4. $1860.00 Upon completion of deck Warranty: A one year warranty is issued on materials and craftsmanship on any and all materials and labor supplied by William Rowe Building and Remodeling Inc. Repair or replacement of defective item is up to the discretion of William Rowe Building and Remodeling Inc, and the original vendor. Warranty on Plumbing and electrical is limited to manufacturer's limitations, and labor would be covered by the tradesman. I PROPOSE TO FURNISH MATERIAL AND LABOR—COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS,FOR THE SUM OF: DOLLARS($ 8080.00). Payment to be made as follows: see above outline All material is guaranteed to be as specified All work to be completed in a Authorized ��/G�" ` C � workmanlike manner according to standard practices. Any alteration or deviation Signature / 'e from above specifications involving extra costs will be executed only upon written President orders,and will become an extra charge over and above the estimate. All agreements Note: This contract may be withdrawn if not accepted contingent upon strikes,accidents,or delays beyond my control. within 3 days, Acceptance of Contract The above prices,specifications,and conditions are satisfactory and are hereby accepted You are authorized to do the work as specified Payment will be made as outlined above. �r Signature Date of Acceptance: , TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1� Seddift for ;)Be BUILDING PERMIT NUMBER: DATE ISSUED: M SIGNATURE: Building Commissioncr/122L=tor of Buildings Date Z SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 5 etth "r VVV-h (AAL 1®7W f�� Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BU11 DING SETBACKS ft Front Yard Side Yard Rear Yard ReqWred Provide ReqWred Provided ReqWred Provided v 1.7 Water Supply M.G.L.C.40.1 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside blood Zone ❑ Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT !-tum t Is tr''c' e-s rn 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ LJ�.-�f�'Cl/l cSlnre C tcensed Construction Supervisor: z �A J( �rn Mft License Number Address 2k > II jj/, &.Z-- -U 4 �S � � Expiration Dad ic `signature Telephone e r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v I.cto4-w� V� c1A �h L /� Company Name V 11 0 m vqA,,� JA Registration Num r Address r A—e— elG Z 70 xe —0f Expiration Da ^ (igzairu?g Telephone V 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.......7 No.......0 SECTION 5 Description of Proposed Work(check sll a ble New Construction ❑ Existing Building 0 Repair(s) Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: J&UJ If) TV b ty 0140 s SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed 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 BUII.DING PERMIT I, 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 Print Nm /xx /tet Lo`f Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 No 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE u The Commonwealth of Massachusetts t d Department of Industrial Accidents F< Office of Investigations 0a Boston, Mass. 02111 PO 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 my employees workin on this job. Company name: r a Address CiPhone#: �715- Insurance.Co. Policv# Company name: U Address City: Phone#: Insurance Policv# G�a v(3— 7 a 5 —1-03 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'imprisonmentas_well_as_civil.penaltiesinJhe.fnrm-of-a_STOP WORK_ORDER.and.afine.ar.(.$1.D0..00.)_aday.against.me. 1 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 of perjury that the information provided above is true and correct. / Signature Date 7 /114 Print name GG� — G��^� Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required F� Licensing Board p Selectman's Office Contact person: Phone#: F� Health Department Other