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42-058 (4) 686 WESTHAMPTON RD BP-2019-0095 GIs#: COMMONWEALTH OF MASSACHUSETTS MMUock:42-058 CITY OF NORTHAMPTON Lot: .001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cameo: shed BUILDING PERMIT Permit# BP-2019-0095 Project JS-2019-000154 Est.Cost: $17000.00 Fee: $68.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sp ft.): 286189.20 Owner: RUSSELL KEVIN A&JUDITH FIONA RUSSELL Zoning, Applicant. RUSSELL KEVIN A &JUDITH FIONA RUSSELL AT: 686 WESTHAMPTON RD ApplicantAddress: Phone: Insurance: 686 WESTHAMPTON RD FLORENCEMA01062 ISSUED ON.7/27/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.12X28 ACCESSORY BUILING POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy signature: FeeTvoe: Date Paid: Amount: Building 7/27/2018 0:00:00 $68.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File N BP-2019-0095 APPLICANT/CONTACT PERSON RUSSELL KEVIN A&JUDITH FIONA RUSSELL ADDRESS/P ZONE 686 WESTHAMPTON RD FLORENCE PROPERTY LOCATION 686 WESTHAMPTON RD MAP 42 PARCEL 058 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out s 01 Fee Paid Typeof Construction: 12X28 ACCESSORY BOILING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN RMATION PRESENTED: _Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed _Other Permits Required: Curb Cut from DPW Water Availability Sever Availability Septic Approval Bond of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay , In/ Signature of Building Official Dale Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. Section 4. ZONING )y 4111nlarry,dnml 7 I."in aeC alor Got Size K al permit fdn pronto e ` ProPo &�'gltb Sttb�'ks °ae To/,c e 111101000000, '\ The Commonwealth ofMassaehusens Department of Industrial Accidents 1 Congress Street,Suite 700 Boston,MA 02114-2017 Workers' arkers'CompensationInsurapce Aftidavib Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information T _ Name Bu/sin((e''sss�s/Organdieaiodlndividoap: 41AOsT1i \DW(` ZN e— lL AddressLU 1RCSPt1) i City/State/Zip` — Phone lfi: Are you an employer?Check the appropriate box: Type of jec[(required): LE]I am a employer with employees(hill and/or pen-[erne)' 9. construction ?❑1 am a sine pmpriemr or paMenh p and Mve no employees working for me in 8. ❑Remode mg any capacity.[No workers'comp.insurance hammed] 1❑1 am a homrowner doing all work myself.[Nu workers'comp,insurance required]' 9. ❑Demolition 4 I am a hnmenwner and will be handstractors to conduct all work on 10❑Building addition con ye sole twill ure shat all contractors either have wnrkms'compemaliov Wsmanee or are sole 11.❑Electrical repairs or additions pmprietors with am employee;. 12.❑Plumbing repairs or additions 5 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs' These subcontractors have employees and have workers'comp.insurane. c 6.❑We are a convention and its officers have exercised the.right of exemption per MGL c. 14.QOther 152,p1(4),and we have vo empluyees.IN.workers comp-insurance m,,mdI 'Any applicant not checks box a1 mmt also fill out the section below showing theor wodcem'compensation policy information. t Iturruccovocis who submit this afTWuvit indicating they me doing all work and then hire outside contractors most submit anew ew zffduch indicating such. lCommetors chat check this box mstu .trached an sdel Boreal sheet showing We name of We sub-contractors and state whether or not those entities have employees, time sub-contractors have employees,they most provide Wed workers'comp,policy number. 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 author 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.A co is s Cement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 7 do herehy certify un r the sand penalties oriperjury that the information provided obove is true and come t Si nature: rDate: Phone#: '— _ ArcGIS Web Map Gv- 1 i v r , _W�sthampt°n Rd-Route 88 -- �.., "g 14a 1 r I RECEIVED City of Northampt Building Departme t JUL 2 1 212 Main Street Room 100 Northampton, MA 01 60 oeauOF Hnnnvip phone 413-587-1240 Fax 413-587-1272 ) Ill " APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address; This s aWon tobe completed by office �l�} 'rJLST•{-t fYKp-rot's } \(�t�� r MapLot061 ..,unit *C oO _ viA o a Zone... Overlay DistrictDistrictet 1 t Ott V 1 EIm.81.04tribt. Ca Oisoip SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: _ C Harzre tP- } GurzeN MaAeg— � Adp=4,3 Fc7 >c � , a� Telephone f Signatus 2.2 Authorized Agent Name(Pont) Current Malting Address: Signature Telephone SECTION 3.ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dodam)to be Official Use Only com feted by ermit a licanl t, Building (a)Building Permit Fee 2, Electrical (b)Estimated Total Cost of Construction from s 3. Plumbing Building Pormit Fee �r 4. Mechanical(HVAC) fg UY 5. Fire Protection ('( 6. Tota1=01 2+3-4 41 r7 (J'rV Check Number This Socdon For Official Use Only Dam Building Permit Nwnber. issued; Signature: Buii,imq Commissionedinapector of aamk,ga Date Trkblil�WS @ J EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING Ali Intorrnatbn Xµst Be Compteted�.Permit tart Be Denied Doe Ta Incomplete Information Existing Proposed Acquired by Zoning Mis ceWmn m be tilled in by &dtding DepeenM For Size FrontA a ...._- Setbacks Front - " Side LAR:>. J L: R_ ._ Rear --. Building Height Bldg. Square Footage % Open Space Footage (Lotama minus akin _... ._.... A of Parking Spaces ---- ---" '-- Fill: ___ ._. .. _. . ...... .... ..... volume&Locaton) ...__ _... ..._.. ___. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT,KNOW O YES. Q... .,,.._. IF YES: enter Book Page and/or Document N B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: . D. Are there any proposed changes to or additions of signs intended for the property? YES © NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing grading excavator,or filling)over nacre or is it part of a common plan that wiG disturb over i acre? YES O NO 0 IF YES,then a Northampton Slone Water Management Permit from the DPW is required, SECTION c DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) RooRng Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks jp Siding[Ell Other[a Brief DescU.-n of Proposed• (Dr— f. _ _�� - r _ Work (NOTA-L�ATV1t� P IfC.C. Z N1��1I.1 �axa' Alteration of existing bedroom_Yes—No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes NO Plans Attached Roll -Sheet Ba;N New house and or addition to indsting housing, complete the following: a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms C. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance fans attached? h. Type of construction i. Is construction within 100 ft.of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes_No . I. Septic Tank_ City Sewer_ Pnvate well_ City water Supply_ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owni Date LL as Owner/Authorized Age y declare that the statements and information on tha foregoing application are true and accurate,to the best of my knowledge and elief. Signed under the pains and penalties of perury. v.SSC 1.L. Pdnl Name �� Signature of Own Agent Date 1 X SECTION 8•CONSTRUCTION SERVICES 8.1 Llcensed Construction Supervisor: Not Applicable ❑ Napre of Eyaanae Holder',_„ License Number Address Expiration Date Signature Telephone $.ReaWWW Nome IRROa aill Contrhlor: Not Applicable ❑ Company Name Regiafrabon Number Address Expiration Date Telephone SECTION 10•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this appiicaiion.Failure to Proxide this affidavit wit ni in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No__.. ❑ City of Northampton yds.'-si Massachusetts '<<� l mi i DEPART1W1fr OF B➢ZLDSNG INSPECTIONS y, g 7 ` 212 ,,in straat a Municipal 9u.1di., \. Northampton, Ma 01060 '"'"y"o�, AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("1110). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation,repair, modernization, conversion, improvement,removal, demolition, or construction of an addition to any preexisting owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: Est. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above p erty: V ono gTt Date Owner Name and Signature City of Northampton Massachusetts fr t t 10 DEP.1RT11LN'!' OF BUILDING INSFECTIONS 7t 212 8 in 8tramt a m nie pal ftlldYng Northampton, 191 01060 Massachusetts Residential Building Code Section I IO.R5.1.2 Homeowner: Person(s) who own a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section I IO.R5.1.1I Any homeowner performing work for which a building permit is required shall he exempt from the licensing provisions of 786 CMR I IO.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. 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 ajoint 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 ofcompliance with the insurance requirements ofthis 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 your insurance company's name,address and phone number along with a certificate 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 pennit/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). A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant m 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents _ I Congress Street Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Fo,m Revised 02-2}I5 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 ajoint 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)camels),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 Off'cials 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia City of Northampton Massachusetts " y fa �c s 4 DEPARTMENT OF NNZSDZNG INSPECTIONS � 212 Mai. Street a Municipal suiltl ng Nar'N ton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: YA (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: hA (Company Name and Address) Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. <C�x The Commonwealth of Massachusetts Wilitrkers' Department ofIndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02714-2017 www.massgov/dia Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �r- Please Print Legibly Name(Busin((a''sss�s//IOrganiza/tioWIndividual): NONT"1 � c>tJit t`-vxSStl� Address:At 7-C I) i rr�� City/State/Zip` — Phone#:rk � �jJ o'-c1�� Are you an employer'Check live appropriate box: Type of jest(required): Lo l am a employer with employees(full andlor pan-Wac)l 7. construction 2.❑lamasolepmpdetor or paMersbip and have nu employees working formeW g. ❑Remodemg any capacity.[No workers'comp insurance retained.] 9. ❑Demoliton 3❑l am a homeowner doing all work myself,[No woneers'comp announceregmred] l am a homeowner and will Ire hiringtmcmrs m conduct an work on , Iwill IO❑Building addition a gf ran y property, me Wal all contractors either have workers compensation immance ar are sole I1.❑Electrical repairs or additions pmVrimom wish no employees. 12.[]Plumbing repairs or additions 5 l am a general container and l have hired the sub-contractors listed on rise attached sheet 13.[]Roof repairs These sub-contracmrs have employees and have workers'comp.compo 6.❑We are a corporation and as officers have exercised their right of per MGL c 14.❑Other 152,g I lal,and we have no employees.[No workers'comp.insurome required] "My applicant char checks box d1 mover also fill out the section below showing Weir workars'compensation policy iaformadon. t Homeoweem who submit this affidavit indicating they are doing all work and Wen hire outside commons,most submit a new alHdava indicating such, lCono-acmra that check Wis box most alkmhed an additional sheet showing the name of We sub-contractors end state whether or rat those entities have employees. If the sub-cimmicars have empleyess,they must provide their wodrers comppolicy number. I am an employer that is providing workers'compensafion insurance for my employees. Below is the policy andjob 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 w required under MGL c. 152, §25A is a criminal violation punishable by 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.A co Is s tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify on r tNe s andpenaIdes of perjury that the information provided abow'1e is nae and come L Signature f� Date: T a Phone#' Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit(Lieense# Issuing Authority(circle one): L Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: