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HomeMy WebLinkAboutREPLACE EXISTING DECK WITH NEW 13X16 DECK BUILDING PERMIT �aoRrH F o KRLEo ;bptio ' TOWN OF NORTH 0 APPLICATION FOR PLAN EXAMINATION rE'_s my Date Received—s- eceivedoRc.,i�N:e Permit NO�: ao n 4 �SSNC HUS Date Issued: eslIZ4 IMPORTANT:Applicant must complete all items on this page LOCATION k r-ct S 1-->c Print ` ; PROPERTY OWNER It r, ` ' '°� �1 Print 100 Year Structure yes o MAP 1 PARCEL: a`� ZONING DISTRICT: Historic District yes 6M Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building P+One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other MEMO= DESCRIPTION OF WORK TO BE PERFORMED: e C,� N'-w Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: 31Phone: "-?`�— ; Email �"e5 d az, c 4 �- , 4�l+-c. Address: r A-\I Supervisor's Construction License I Exp. Date:. ' t Home Improvement License: 1 oma- `( 6 Exp. Dater �` i Ct I 157 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ C ` FEE: $ Check No.: 44 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ,,. /!9:iz /��!I,f"a; ii c1.7•i7/%, ,r,/Tlv/r,r!//iu,.,T///Ii'!„ii.i„a,1 i./��0l^i/,�!„l'/✓Ji"h..�/TiJ�o lIc,..ri/l.,//G i / / /I'�l l/�' / .i,i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSA 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 m U FORM PLANNING DEVELOPMENT Reviewed Ong [ _.._. '"� Signature COMMENTS CONSERVATION Reviewed on � Signature t COMMENTSUL A.. v'-11-� HEALTH Reviewed on Signature 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 Tem Dum sfier onsite es,,, , f%,,,,,fnaG �„/ rl „si +r r,. ��.. ,7ir'�.✓I/.�, i,.,,, ,, r 'i!�.,,u,/r t/�///i r,. ,-1.,, i,//./ r r ,,:a. r ,,,, ,, : , r i ,/ /. r tY, i// �.%/IP/lr rr 1 r/.J/. n �; rl //,r,,!r / /c r ri i ',,, ir/ / r ✓Orrc/, t,,/1ll/�% r/�/,,,//, , 1 rri,.,:,Jl1/1� /r:.,✓n0{ r/�%1/fil%l�/ :;".� /r�0ida.:/M Ir /r� r„i ,�, � ,, n ,,,,,,, ,, �-,,,i; ,. / r rt ���,,..H ��///r/ /y/,.,�,.rr� // �, /I r �//r, ,� �� / / ,.f / l/// r r/ .,/%// //://%%�/G��ft`����i/ l/%�,rrri�l�� ,dry/f//✓//���fl� r�r��i ,,,,,gip,” /,,,i, ,/ J/Gr llf��r /ri �, / �; ,f/ r //�/,/°fir�� � �,✓���r ��/��%�/�rf/�/ COMMENTS/%r tAORTH It Town of '�► e 7, Andover ® �- To No. lid 50-1 - LAK. h ver, ass, COCMICMl W[CK ORATE D S V BOARD OF HEALTH Food/Kitchen PERMIT T Lu Septic System THIS CERTIFIES THAT ,,,��, .. „ BUILDING INSPECTOR has permission to erect buildings on ..... Foundation ......................... . ...... ( ............................... Rough tobe 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO T S Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Bulldanz 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. TES TA Building and Remodeling Start date 6/15/15 5 APPLETON STREET Finish date 6/30/15 NORTH ANDOVER, MA 01845 MIC Lic. 120296 Expires 11/19/15 (978) 682 2023 CSL Lic. CS 54718 Expires 6/8/16 Proposal May 28, 2015 Proposal Submitted To: Paul Tanglis Cell Phone: (978) 390-1153 79 Glencrest Drive North Andover MA 01845 Job: New Deck 13x16 with a set of stairs Obtain building permit Complete removal of all demolition and construction materials generated By Testa Building and Remodeling and its subcontractors. DEMOLITION: Remove the current deck. CONSTRUCTION: Dig 3 holes and pour footings 4 feet deep. Remove siding where deck will be attached to the house. Properly flash the house. Frame a deck approximately 13'x16'. Attaching the deck to the house. Frame the deck with 2x10 and 4x4 posts. The decking will be River rock using the hidden fasteners. The railings will be white Radiance railing system. A landing and a set of stairs will come down along the side of the deck. A finance charge of 11/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications, for the sum of- -$ 14,508 Fourteen Thousand Five Hundred eight Dollars One-third to start, one-third after rough inspection, one- third upon completion. Authorized signature I reserve the right to cancel this contract if not accepted in 30_days A Signature �.1..�- Signature DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners.Seek legal advice if necessary.Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Expjess Warranty-Is an express warranty being provided by the contractor? No 11 Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor.The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance-Upon signing,this document becomes a binding contract under law.Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence.Review the following cautions and notices carefully before signing this contract. •Don't be pressured into signing the contract.Take time to read and fully understand it.Ask questions if something is unclear. •Make sure the contractor has a valid Home Improvement Contractor Registration.The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration.You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. •Does the contractor have insurance?Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. •Know your rights and responsibilities.Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement.See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identic les of th must be completed and signed.One copy should go to the eowner.The other wp ould be kept by the contractor. Homeowner's Signa Contractor's Signature / a Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor.The same right is not automatically afforded to a contractor,however.The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provide - Massachusetts General Laws,chapter 142A.la , Homeowner's Sign re Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law.The contractor is responsible for completing the work as described,in a timely and workmanlike manner.Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose.An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights.If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor.Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure.However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/ficenseelist.as For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 Version 2.1-11/22/201 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DESPISE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT[Address of Seller's Place of Business] NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: North Andover MIMAP May 29, 2015 104.0-0045 1Q4.0=0038 10.4.0-0039 I 104:C-0052 104:-0097 104.0=0040 104:0-0053 6T _3 VK, D[t 104.0-Q096 t 104:C=0095 �e�G r' R1 104.c-Q054 7 CoLENNCRES-/DIS 68 GiUNNIC EST D �/ 104 C�0061� Water'Protectian " 2C3 SC1.t9T1t E RAtDF0 D, it k33.7 CaLENNCRE T/DR 104:--0060 104.0-0055 I 104.0-0101 / 1.66.131-ENNCRES /D 1 104.0-0056 99 GL ENNCKEST DFt 104..0-0059 104:C-Q057 ` Rail Line '1 Wetlands Zoning Interstates Exempt Lands Busine s 1 Distnct -s Busine s 2 Distnct Hodmirtal Datum:MA Stateplane Coordinate System,Datum NAD63, —SR M Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack M Busine s 4 District NORTH Valley Planning Commission(MVPC)using data provided by the Tmvn of Roads IS Genens Business Distinct Of sae '4� North Andover.Additional data provided by the Executive Office of 61 Easements LIII Planne Commercial Dev ? brit re�a QO Environmental AHairs/MassGIS.The information depicted on[his map is Corrido Development Dist •� (• for planning purposes only.It may not be adequate for legal boundary r MVPC Boundary G£k Corrido Development Dist O —•- /h definition or regulatory Interpretation.THE TOWN OF NORTH ANDOVER Municipal Boundary TIG Corrido Development Dist h A MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Zoning Oveday Industn I 1 Disldct * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY Industn 12 0isticl i, i n�. OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Adult Entertainment Ci''s. Industn I3 Distnct �. °o i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF (�Downtown Overlay District M Indust n S District 9q •' w Historic Distnct Reside ice 1 District `,r(9 THIS INFORMATION 0 Water Protection Reside—2 District SggCHUS'� ❑Parcels R—ide ce 3 District Hydrographic Features de ce 4 Distnct Steams 1"=80 ft ..de ce 5 District Ede ce 6 District���age esidenfial District North Andover MIMAP June 1, 2015 I'I , i 7 a G�e� II �f y Ili �r ll I I i�,il'iY II�IVII�111111 it lii' 111111 lig. i I i, 111 � I II(�I'illil I,H r 1 x I I I Interstates —I —SR Horizontal Datum:MA Staleplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack NORTH Valley Planning Commission(MVPC)using data provided by the Town of q'r Easements Of �lC 'a� North Andover.Additional data provided by the Executive Office of MVPC Boundary ? bsr`eb 00 Environmental AffalrslMassGIS.The information depicted on this map is Parcels3' L for planning purposes only.It may not be adequate for legal boundary O —• definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING {t * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY It OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT M ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF q� n THIS INFORMATION �SSACHUSj 1"=60 ft F i MORTGAGE INSPECTION ALAN LDGA71®N. 79 GLENCREST DRIVE 7305622 C17 STATE- NORTHANDOVER,MA ������ APPLICANT.• TANGLIS 8,PAIS cFRT'.,I I ro: SURVEY, INC. SCALE•91nch=60 feet PRIEPARED: 07-30-2093 a d•aox2ao22o Tf���SrSCY 6in3<2•Y6t8 f L'hLW.BQSTOM3l1RS$'1y,"GCO,SS i f 1: R•+928 4a�S,9 4161 LOT 9 9 45t070 Wifif- �DJECK i STORY ffir! 079_ 7 ° 9 -93,34 fi84(W Baaaa�swva7•sa'T.'+n FLOOD DBTERMIT1Amold REFERENCES dradin^9F:�..set F�w±nsety Muuarntav ABa�Y aups;�e DEED/CERT. 10688.42 rtujortmp+evarm6 on NFaproy tp'flJl 1paaalsa dcltgnaatedas PLAN Ill #•4251 ZQw� NOTE Te thawta aaeuah stele lhftPlantwtl ECAN GEORGE F� WmmuNal PANEL No,o150DQ`10QQ onCOLONS BFFECnVBDATB: Ho.41784 he penaanrat epagiaram alrPtv�ate7y rota+d m me groa+6 cs crown 7ec5'ddase°a�+e�d m U+rs:,betk+�vl�mm oftf�eloxlamlaSoad, <AA�S��oau7a�."a�atueWn� af �lry+�mamod�wc�amaPm7�V' �'fH URv6 bLOL Y1tk YII.Clapsr Iinq exaptse thowa and no7ed tazsts N018 T51aUnota 6owideryorGtle lnA+reata ssT•cY•YA1s Pr�+�DmD�dJ ao�der�wymcea9sxlsaf rctbotnl omnittmntortgasatoanra:�eoasa,aEv ay,noMaasrnvx�m� o isniatote�icat trr oa. a—CADIZ PLS Lazd Maya��vvn,130 rAtRS.Of.andvae farmD•aNxpvryat Ft�d. ' Prs�rG1§c'addtuiptioar atmnetnxriaa 0u=' 111 �-s -- � -- _ - - - � - -� ll Rip im I - � �I - � i-- {� € �(i! Iv, l .,i I i C mini� , _ iI--' I�! I'� ilk - � - "tk - ti_ - "ii '�� - � �t r' IMF, {�. € I,,`i i .1 ItiE!il I i PlUffir JIM RPM �-�`�—�- t r I s�� �' i l � � `'� 1 5• �i €' ,I' ( E I I� � a €a { �� t, - IP - -.�� - il, - a — a_.� - �>* � �hi_a''`' a- � 7' _d � �`�i�� !VIII`Ia i�' I�I �tl- "�•�:� - .'�i 1�`mak,_ a €ltt�s,}�,}".G t-I s --�, } v - �~' ,�1, E -� :s. �(II -' � '�j4�—til•a€I �`I� (' (� � ��) aI � t3� �� },1' { �3>„�i -�( { I�t��_�. `�1�'�-� � 1, IIaE� -� �('�fil C-"••�� iI`� f �Ii _E� a a`'i( I€ €`,IC,:�1�. ' �_� f(��I �s i t , I 1 .t r i The Commonwealth of Massachusetts f Department of IndustrialAccidents 1 Congress Street,Suite 100 ' d Boston,HA 021142017 www.mass.gov/dia Workers' Compensation insurance Affidavit:Builders/Contractors/E lee.tricians/Plumbers. TO BE FILED WITH THE PERW TTING AUTHORITY. Please Print Le 'bl A licant Information Name (Business/Organization/Individual): —Te— Address: e-�0^' J City/State/Zip: Nd Ar,.�o,jC r A CW$y Phone 4: 9 Z h - G 9 1' ��a' Are you an employer?Cheelc the appropriate box: Type of project(required); em to ces fiill and/orpart-time).* 7. F1 New construction 1.Q I am a employer with P Y ( 2.K I am a sole proprietor or partnership and have no employees working forme in 8. ®Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 10[]Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12;h Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other 6,Q We are a corporation and ita officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. idavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. I Homeowners who submit this affContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#: City/State/Zip: Job Site Address: ompensation policy declaration page(showing the policy number and expiration date). Attach a copy of the workers' c ed under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 Failure to secure coverage as requir fine enalties in and/or one-year imprisonment,as well as civil pi d d to the Offi ORDER of Investigations of the DIA.for insurance0 a my beflu day against the violator.A copy of this statement coverage verification. c v hereby certi under the pains andpenalties ofpeijury that the information provided above is true and correct. ��s Date: S Q f Si nature: Phone#: e[-?�— (,,"6- � -,-Q_4-35 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 Phone#• Contact Person: �ssaC�usetiPartment cif public SaWl Ueu,,titons and Standards 1 s - Board of Building Reg Construction Super�'isor ru license: CS-0547181 v.,;. JAMES M TESTA P� � ST% r 5 App�ToN 01845r i = N ANDoR '. I f U6j0812016 Commissioner ��e�a�Iv�nanracalll n�C��l(iitt�ic•�utn//s � MCC of Consumer Affairs 8c Business Regulation ME IMPROVEMENT CONTRACTOR gistration: 120296 Type: xpiration: 7111912015 DBA TESTA BUILDING&REMODELING JAMES TESTA 5 APPLETON STREET N.ANDOVER,MA 01845 Undersecretary