HomeMy WebLinkAboutBuilding Permit #352-13 - 810-812 Salem Street 10/31/2012 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Z' ' Date Received AI
L�_-z
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION -
-- - Print
/1
PROPERTY OW ER M(Ac _ ( ulfley
Print 100 Year'Old Structure yesnno
MAP NO: _:PARCEL:ZONING DISTRICT:. HistoriciDistrict yes
Machine,Shop Village, yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
❑ ition ❑ Two or more family 11 Industrial
&"Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other,
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
rA)Ug DS IAI���sOF�WORK T� BE PER
O RM :19 fir J -iI_
e xZ Deop Q_i--& ,r AJ& eq T 7`1/ f, Pbat 72) 4� usey ,g-S- e4 icy w
Identification Please Type or Print Clearly)
OWNER: Name: 6t 64ow Phone: 9)g 37C 7/9Z
Address: 8/0 S&46415�-.
CONTRACTOR Name F 7?�
Address: loD St�9tJincr7- Z1)L/
�
Supervisor's Construction License:' _ _ . ..._ Exp :Date:
Home Improvement License: ) 3 - _ : ;Exp. Date: 1'eq l'3
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 26S; FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting ith nre ed co ctors do not have access th guaranty and
Signature_ofx g ' Owner Signature of contracto s
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Bui Wing Permit Revised 2012
Plans Submitted mltted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑ �.
COMMENTS
CONSERVATION Reviewed on _ Signature
COMMENTS
HEALTH Reviewed on Signature
`F
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street--
Fire Departmerit-signatbre/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use
® Notified for pickup - Date
I
Doc.Building Permit Revised 2010
I
Locatioo—
NoC Date J�--
q
t
i
e • TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
RFoundation Permit Fee $_ _
}
Other Permit Fee $
' } TOTAL $
Check# !
R.
l
25891 Building Inspector
r 1TH
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No.
h over, Mass,0 ' ' �1• ��
COC MIC"t WICK
�d p0Rg7ED
S U
BOARD OF HEALTH
Food/Kitchen
PER T T Septic System
THIS CERTIFIES THAT ... 1 LD
4. 0 C. �'e BUILDING INSPECTOR
... ... ....... . ..
Foundation
has permission to erect .. ...................... buildings
ItRough
to be occupied as ....... ...... ..... .... . ... ...................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in 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. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6jkNTHS ELECTRICAL INSPECTOR
3r� UNLESS CONSTRUCTI T Rough
Service
................. .............................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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
CONTRACT TO INSTALL OWENS CORNING BASEMENT WALL FINISHING SYSTEM
Owens Corning Basement Finishing Division(the contractor)hereby submits this proposal to sell and install the Owens Corning Basement
Wall Finishing System and related items as described herein at the residential premises set forth below.This proposal shall not become a
binding commitment unless and until it has been signed by the Contractor and the Customer.
Contractor:
Owens Corning Basement Finishing Systems
a division of LUX Renovations,LLC.
60 Shawmut Road,Canton,MA 02021
Telephone#(781)821-0060
Facsimile#(781)821-8552
Federal Tax ID#14-1855297
ca Mass.Home Improvement Contractor Reg.#137943
Date 1 "Z 2—
Customer:Customer:
Customer Name !S�t Ca n-OR-1 (A t-1711
Street Address �i I) ,,,R IPM S`f r
City,State,zip On r*k A n ,Aa I/e r 01941-
Telephone
lK4TTelephone( J 7 KL 31E S )-713 2 )K — .fj b 1-I-
This
LThis is a contract between the Contractor and the above named Customer to sell and install the Owens Corning Basement Wall Finishing
System and related items specified herein at the Customer's residential premises identified below:
Installation Premises:
Street Address ct M F
City,State,Zip a NL 12
Scope of Work:
Are Sketches and/or specification sheets attached).' es' ❑No
'All attachments are incorporated into and Mme a part of this contract
Description of Work/Specifications: Tn a• •Y �t 9 P w
� � l �I /L-f rt c 1 l Ci.�P ML1✓�Ipp �N�_�
-7y C Gt C O� �E: j n -P r i•� K.yid
c�vA �' :rid ri a k rs . i
-2Z1 ✓+fir' IJ- II o,r11_ Z) �s_",-SnIWvJ.l��'�)�,Olsf;(nur�lsl c(tl�1
1 n,�,, t n� 7�-t M�0.�S n��0 f' �(�O ��iM T7'�I G�-Itr1`tS r�Mu�'F rV TQ'"�M eil 1b I
L1r1eh /y1i ��hi > s t7
Work Schedule'':
Approximate Commencement Date:
Approximate Completion Date: _-IS Zfl i L
"The proposed work schedule is approximate and subject to change
Contract Price:
Total Contract Price: $_ 11'Lr
Deposit with order: $ z- 6 4'.3 ❑ Cash M, eck# D
l _
Balance Due:
Terms: ash ❑Finance
(Cash terms are 10%deposit,50%on commencement,'40%on completion) - -
$
13 243 Due on Commencement -
$ S 6 / Due on Completion
DO NOT SIGN THIS CONTRACT UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ
AND UNDERSTAND THE ENTIRE CONTRACT,INCLUDING ANY ADDENDUM ATTACHED HERETO,AS WELL AS ANY ATTACHED
SKETCHES,MATERIAL LISTS OR THE LIKE,AND THE TERMS AND CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT.
YOU ARE ENTITLED TO A COMPLETE,FULLY EXECUTED
COPY OF THIS CONTRACT AT THE TIME OF EXECUTION.
Witness our hand(s)and seal(s)below on this R A1 Gt day of S, -t,M LL,, rJ I 2-
LUX
LUX Reno a' ns,LLC uthor�izeedd Representative:
tok
Sigileturyand Title
�r ) r1 o�(10-
Print ame
DO WIGIS ONTRACT IF THERE ARE ANY BLANK SPACES
us
Custo er ignature
Print Name
Customer Signature
Print Name
Contractor may have certain lien rights in the premises until the price is paid in full.You have the right to cancel this contract,without any
penalty or obligation,at any time prior to midnight of the third business day after the date you signed this contract.See the notice of cancellation
below for an explanation of this right.
"'Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to customer's execution hereof.
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
26,;425.00) m
$ - $ 317.10
Plumbing Fee $ 39.64
Gas Fee 100 comm. $: 1100.,00
Electrical Fee $ 39.64
Total fees collected $ 496.38
810 Salem Street
352-13 on 11/1/2012
Finish Basement
Curry, Samuel
810 Salem St
North Andover,NIA 01845
978-335-7192
978-685-0125
1,4
CONTRACT Customer Name C-4-r c-'l Customer Signature
SKETCH Contract Date y-Z..rC-2 a I Z Sales Representative Signature
ATTACHMENT Customer Phone 9 79 - 3 3 5 — 71 q 2— Contract Price 7.4 42 j
1 2 3 4 5 6 7 8 6 10 11 12 13 14 15 10 17 18 10 20 21 22 23 24 25 26 27 26 29 30 31 32 33 34 35 36 37 30 39 40 41 42 43 44 45 6 47 48 40 60 51 fit 53 54 55 56 57 58 69 60
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NOTES: i^4! "., r,5'• > n - : [) (!Cs�i�:�� Each box equals one foot unless otherwise noted.This sketch Is a good faith
ff representation of the work to be done,It is understood that all dimensions
derived from this sketch are approximate,and that all locations of outlets,light
fixtures,plugs,jacks and/or switches are subject to change if necessary.
J/W
Office�of Consumer Affair and Businessegulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home ImprovementnContractor Registration
Registration: 137943
F _ }
Type: Supplement Card
. ` Expiration: 1/29/2013
OWENS CORNING BASEMENTS 1NG
DANIEL WALSH
60 SHAWMUT RD w
CANTON, MA 02021 `
Update Address and return card.Mark reason for change.
--' Address [] Renewal R Employment F] Lost Card
0 50M•04/04•GlOI216pp
\ ,lftC TD697?m7.04t1!/2CLGCiL o�✓vGaddac�ze[teltd
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
JEWNOME IMPROVEMENT CONTRACTOR
before the expiration date. If found return to:
>r Office of Consumer Affairs and Business Regulation
Registration- B 943 Type: 10 Park Plaza-Suite 5170
Expiration: , Supplement Card Boston,MA 02116
HENS CORNIIy65ASEMPVNISHING SYS
kNIEL WALSH :F
SHAWMUTRD-;,.,'ti==_;%.;r
\NTON,MA 02021``'".':" Undersecretary Not valid without signature
�lassachuzctts- Department of Public Sitrch
Board of Building �r
Rculutions and Standard,
Construction Supervisor License
License: CS 79893
DANIEL F WALSH a `
488 KENDALL RD
TEWKSBURY,-MA 01876
Expiration: 10/5/2013
( mmissioncr Tr#: 6504
i
ACORO° CERTIFICATE OF LIABILITY INSURANCE F91612'012°A1MM�°'YYY„'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Andrew G. Gordon, Inc. PHONE FAX
680 Main Street AIC No Ext: - -92 62 AIC No:
P. O. Box 299 ADDRESS: info@aqordon.com
Norwell MA 02061 PRODUCER
CUSTOMER ID#:444 0
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A:Peerless Insurance 24198
Bay State Basement Systems, LLC INSURERS:Pil rim Insurance Company21750
60 Shawmut Road
Canton MA 02021 INSURERC:Star Insurance Company 18023
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:619962880 REVISION.NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADD SUER POLICY EFF POLICY EXP
LTR POLICY NUMBER MM/DD MM/DD LIMITS
A GENERAL LIABILITY CBP8512851 9/5/2012 9/5/2013
EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE R N E 50,000
PREMISES Ea occurrence $
CLAIMS-MADE F OCCUR MED EXP(Any one person) $10,000
PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000
POLICY PRO- LOC $
X
B AUTOMOBILE LIABILITY N N PGC10007161409 1/17/2012 1/17/2013 COMBINED SINGLE LIMIT $1,000,000
(Ea accident)
ANY AUTO
BODILY INJURY(Per person) $
ALL OWNED AUTOS BODILY INJURY(Per accident) $
X SCHEDULEDAUTOS
PROPERTY DAMAGE
X HIREDAUTOS (Per accident) $
X NON-OWNED AUTOS $
$
A X UMBRELLALIAB OCCUR CU8511953 9/5/2012 9/5/2013 EACH OCCURRENCE $1000000
EXCESS UAB CLAIMS-MADE AGGREGATE $1000000
DEDUCTIBLE $
X RETENTION $10000 $
C WORKERS COMPENSATION WC0428715 5/24/2012 5/24/2013 X WCSTATU- OTH-
AND EMPLOYERS'LIABILITY y/N TORY LIMIT R
ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $1,000,000
OFFICERIMEMBER EXCLUDED? ❑ N/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1.000.000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required)
Sales and installation of Owens Corning finished basement systems
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
Bay State Basement Systems, LLC.
dba Owens Corning of New England
60 Shawmut Road AUTHORIZED REPRESENTATIVE
Canton MA 02021
r
@ 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
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 full 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-MAASSAFE
cussed 5-26-05
Fax#617-727-7749... /I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,AM 02111
U www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information &olw,
Please Print Legibly
Name (Business/Organization/Individual): 6�� 96MMwi— SQVS0�1
Address:- 6Q 5wwmuJ' �9
City/State/Zip:_ 6&W /6-13 ad 2/ Phone#: -7cff 5121 45VC)
Are y n 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.El I am a sole proprietor or partner- listed on the attached sheet.# ? emodeling
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.❑ 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.❑Other
kny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
formation.
tsurance Company Name: Ttf— 7;SU&, 9C—
�licy#or Self-ins.Lic.#: YZk I � Expiration Date: <-
Expiration i{+�3
►b Site Address: 001/0 Sit'C SJ— City/State/Zip: ii/9a,11Jr R 618��
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
t.ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
le 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
up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the for insurance coverage verification.
to hereby cer fy unde the s and penalties of perjury that the information provided above is true and correct.
nature: Date:
tone#: l
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: