31A-067 GARDINER HOUSE &ardt'nrr 5-v44.4- BP-2023-0654
186 ELM ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31A-067-001 CITY OF NORTHAMPTON
Permit: Lilts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2023-0654 PERMISSION IS HEREBY GRANTED TO:
GARDINER HOUSE REPAIRS
Project# 2023 Contractor: License:
EMPIRE HISTORIC
Est. Cost: 337415 RESTORATIONS IN
Const.Class: Exp.Date:
Use Group: Owner: COLLEE SMITH
Lot Size (sq.ft.)
Zoning: EU/URC Applicant: EMPIRI�HISTORICAL RESTORATIONS INC
Applicant Address Phone: Insurance:
3 PODUNK RD (774)241-0705 WC5-31 S-383610
STURBRIDGE, MA 01566
ISSUED ON: 05/19/2023
TO PERFORM THE FOLLOWING WORK:
REBUILD EXISTING MASONRY EXTERIOR STAIRCASE
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: IcD1/
Fees Paid: $2,359.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissi ner
'r \-1CC t,rtS
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c\PThe Commonwealth of Massachusetts
„,---„--,c,\\‘',-.0.:_r
' ---,0)‘\--,4°00:-. - Office of Public Safety and Inspections
\II / .c 0,.\\Alt, - Massachusetts State Building Code(780 On)
9 \funding Permit Application for any Building other than a One-or Two-Family Dwelling 1
.-
-- (This Section For Official Use Only)
Building Permit Number: 2 3 • 4sti Date Applied: Building Official:
SECTION 1:LOCATION
I•1 .; ' 61 - ___ : Eick:thom...(c_viii ,,GLf.,‘ ,
1 —
Na and Street City/Town Zip Code Name of Building(if applicable)
I
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORk
Edition ot MA State Code used If New Construction check here 0 or check all that apply in the two rows below
Existing Building 0 Repair 114 Alteration CI Addition 0 Demolitioi 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:!
Are building plans and/or construction documents being supplied as part of thi permit application? Yes 0 No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No 0
Brief Description of Proposed Work:
.\ch.A4 e-k‘S.Twk. ov.xSt:o.C-‘
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq,ft.)and Total Height(ft.) 1
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational CI
F: Factory F-1 0 F2 0 I H: High Hazard 11-1 0 H-2 0 1 1-3 0 H-4 0 1-1-5 0
t
I: Institutional 1-1 0 1-2 0 1-3 0 1-4 0 1 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage 5-1 0 S-2 0 1 U: Utility 0 Special Use 0 and please describe below:
Special Use Description
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA CI 1B 0 HA 0 118 0 1 111A 0 IIIB 0 1 IV 0 VA 0 VB 0
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information: 1 Sewage Disposal: Trench Permit Debris Removal:
Public 0 Check if outside Flood Zone 0 I Indicate municipal 0 A trench will not be Licensed Disposal Site 0
required 0 or trench or specify:
Private 0 or indentify Zone: I or on site system 0 .
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: mA i 11,•torlk C,,I11,1,1,slon Rk>vie>1.% Prot,9--:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction
Does the building contain an Sprinkler System?: Special Stipulations
Design Occupant Load per Floor and Assembly space: _
__.
SECTION 9: PROPERTY OWNER AUTHORIZATION 2
_____........_
Name and Address of Proper),g r r#1 Owner /6 No 6 4/ 1 S 1
/ -
----, rggi5EES" Of ile- .cor6s4 C.t:766- arfrArdP rae4 14A
i
1 Name(Print) No and Street Cit.\ 'Town Zip
I rro v Owner ontact Infomiation:
AMESi...
UCEy ill s..sv 2y2- yis os' 5to6
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Title . Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
.,,,.....,
EITIClcx.E. V\li-.:,•?..“...i_A
Name Street Address City/Town State Zip
to a • ly for and it ton the property owner's behalf,in all matters relative to work authorized by this buildins permit application,
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 11
liii building iS itSS than 35.300;Ai It.of enztosed space aivi/c,r ris,i i.indyi ConstisKtion Control then chef k here 0
Othirhiiie triode.:.ft•jr,trl!itr,Ltalli0 tiirrn_t(see wction 107 in ilie eotiei as required
10.1 Re -stered Professional Responsible for Construction Control (the professional coordinating document submittals)
Oci.eCCA0a.1 L-11,1..5`Act -.1 Lo‘6 Tc.kaaLe_caNA NA Atonatef3.4" I CA
Name jRegistrant) ,0 Telephone No e-mail aqdress I Registration Number
4Ct > V\eayiarc ' ""C 3c t PitA\r‘euf _ l'Atzk c,%ca., I _32-141_
1
Street Address City/Town State Zip I Discipline Expiration 1,3ate
....„.._
_ ..„..
10.2 General Contractor
E.MR Ss.E. k-k tVra 'U>•\, Re.../Tvc-i.A‘criNS Irv._ .
Company Name
ko W\c:.MCC
Name of l'erson Responsible for Construction License No. arid Type if Applicable
.. ..Z.N ,Ira. (•.1.3 SI Lat01)f 1\\ A is‘SLAk
SITt`et Address City/Town State Zip
"3 Lfr -4S.Li- ... 3 ANNCS"Na.(r.>OCs.CN• (.._,.-•.;x\N
Telephone No,(business! Telephone No.(cell) e-mail address
SECTION 11: tycINKI.X. i,,..4,•?\II'LNL1,11!".).N t'C'il RA\CI %i I II i N\tt(M.G.L c.152.§25C(6)) ..
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted s ith this application Failure to provide this affidavit will result in the denial of the issuance of the building permit
Is a_signed Affidavit submitted with this application, Yes!'" No 0
SECTION 1Z CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs (Labor .
Item and Materials) Total Construction Cost(from Item 6) =5 ."1:1 i S' C'LI
1. Building 5
Building Permit Fee..Total Construction Cost s: 1 (Insert here
2.Electrical S appropriate municipal factor) ,=Sg4)..64
3.Plumbing S i I
1 i-Vi
4 Nlechanical tHVAC) 5 Note-.Minimum lett S 1 s_is,ari/ (contact municipality)
5 Mechanical (Other) 5 Enclose check payable to
t, Total Cost 1$ ‘b)1..1 1 5. up (vontact municipality)and write check 1111111bix here
,.......
SECTION 13:S1GNA'TURE OF BUILDING PERMIT APPLICANT
By entering my name below.1 hereby attest under the pains and penalties of perjury that 311 of the information contained in this -I
application is true and accurate to the best of mv knowledge and understanding.
liarst1e. i\)(;:nilt. ' Sksd SN\Cs %esdko's TN -224,1 - 4ic,
_
a
Pleaserrint and 5ign name 1 Title Telephone No. Date RG'sno* 122 IttiZAts..‘ti icC. MIN t.....1 5 LA, .tIACY.I'tilL.ii 631CLCZTA
_
Street Address City/IOW n State Zip Email Address
.... , _
NV
Municipal Inspector to fill out this section upon application approval: Afaj,46,-.° . xi iir l?.3
s,s
I. Name Da
1
City of Northampton
,....,
Massachusetts
,.. T.,
..„ ...
' *
, - DEPARTMENT OF BUILDING INSPECTIONS "--
212 Main Street * Munlclpal Building
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility:
The debris debris will be transported by:
Name of Hauler: E. ‘.\\,,‘,.. tc,,,c.,. \,,..\\,..,..t. ‘,....\..k.,,,\ i.„....,:,..\L„:„A\,,,\ , \ \„\t:
, \
Signature of Applicant: '_,),,,,,I ,_,,.c._ \.\\,. \.\k- Lo Date: - '1 )
"--.
.
Initial Construction Control Document
To be submitted with the building permit application by a
1111
Registered Design Professional
for work per the 9th edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Gardiner' tioisw (it Smith College Date: 21 April 2023
Property Address: I Paradise Road. Northampton, MA
Project: Check (x)one or both as applicable: Existing construction
Project description: Rebuild an existing masonry exterior staircase. [Wei ence plans dated 07 Feb 2023.
I, Thomas Rt. Hartman, Al A. MA Registration Number: I044S Expiration date: 11'23,am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
krehitectural
for the above named project and that to the best of my knowledge, information,and belief such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted
engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports (see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a'Final Construction Control Document'.
Enter in the space to the right a"wet"or
electronic signature and seal: c4.4 •
atiEfIST
Phone number -'49-3616 Email: roil C:.indtliVrehiteaN.com
Building Official Use Only
Building Official Name: Permit\ Date:
Version 06_11_2013
C 0 F'Y
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston,Massachusetts 02118
Home Improvement Contractor Registration
Type: Coroornibn
EMPIRE HISTORICAL.RESTORATIONS.INC Registration: 205435
3 POOUNK RO xp4talion: OSl182024
fli'BRIOGL.MA 01566
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs A Business Regulstiun Regtatratbn titdid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration data.If found return to:
TYPE:CotporaPun Office of Consumer Affairs and Business Regulation
Unbitten 1000 washtnplon SCaet-Suits 7t0
205436 06,1812024 Beaton,MA 02110
dPIRE 1ISTOPICAL RESTORATIONS,INC
J2ANNE MON*CO `
POLRINK RO r6 ,':Wert.; NI. i� WALL (\r\Gtk/��t t.
[#fURBRID .MA 01560
Undersecretary ( t valid without.ignohno
Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required. The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural X
. .
2 ; Foundation i •3 1 Structural i I
1 i
4 : Fire Suppression
••5_ Fire Alarm_Lmay require repeaters) ••
. ! I
6 1 i VA C7
1 .
i .
, .
7 Electrical 1
8 Plumbing(include local connections) . ••
—
9 Gas(Natural,Propane, Medical or other)
. ,
10 Surveyed Site Plan(Utilities,Wetland,etc)
11 Specifications
12 Structural Peer Review
13 Structural Tests Sr Inspections Program --.!
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
1 17 Architectural Access Review (521 CMR)
1 18 Workers Compensation Insurance K
I19 Hazardous Material Mitigation Documentation •
2(1 Other(Specify)
1 ,
21 I Other(Specify)
22 I Other(Specify) l
I i
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
:•
-1\r‘c t+ARS VVx_<-1 Zneoc‘ MCI_c•z-Lici_lia U.:. N.-0,-c.„„A vk Akc..\\.-icos.com'' I u-vi%
Name(Registrant) Telephone No. e-mail address I Registration Number
e % a)
4,1 c.,,R\c p,&11,m SA "tx.,I No-\11E4 Si IV Ot 61 ociL
Street Address City/Town State Zip Discipline Expiration Date
Unt(IA lAS S6c6 - l - V)(l'A (0.0-Yrti 0101:A4 A i fV1 (..c..,M
Name(Registrant) Telephone No. e-mail addressRegistration Number
5% Mft t hi S'i .-.'n.ktkes,'Ls t.t,C MA Cl (01,
Street Address City/Town State Zip Discipline Expiration Date
- -
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address • City/Town State Zip 1 Discipline Expiration Date
I
Please follow this link for;,,., ,T, Of1,:tgl•r,i h ,m,to be used by Registered Design Professionals,
a DATE(MMlDONYYY)
ACORO CERTIFICATE OF LIABILITY INSURANCE
05/12/2023
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 have ADDITIONAL INSURED provisions or 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 Melissa Lotter
NAME:
Hometown Insurance Center,LLC (P(gqH/!ONE (508)347.9394 FAX (508)461-2035
(Nc,No.Ern: (A/C,No):
590 Main Street ADDRESS; mlotten@htownins.com
PO Box 541 INSURER(S)AFFORDING COVERAGE NAIC S
Sturbridge MA 01566 INSURERA: The Burlington Insurance Company
INSURED INSURER B: MAPFRE/Commerce Insurance Co. 34754
Empire Historical Masonry Restoration,Inc. INSURER C: StarStone National insurance Co
3 Podunk Rd INSURER D; Liberty Mutual Agency Corp(Formerly Peerless)
INSURER E:
Sturbridge MA 01566 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL2212706291 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 ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER (MM/DD!YYYY) (MM!DOIYYYY) LIMITS
X COMMERCIAL GENERAL LIABLITY EACH OCCURRENCE S 1,000,000
CLAIMS-MADE X OCCUR PREM SES(Ea occu ence) S 100,000
MED EXP(Any one person) $ 5,000
A Y 807B004326 12/07/2022 12/07/2023 PERSONAL 6 ADv INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER, GENERAL AGGREGATE s 3,000,000
X POLICY n JECT LOC PRODUCTS-COMP/OPAGG $ 3,000,000
OTHER $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) S
B OWNED SCHEDULED Y LP6889 04/29/2023 04/29/2024 BODILY INJURY(Per accident) $
AUTOS ONLY X, AUTOS
HIRED v NON-OWNED PROPERTY DAMAGE $
X AUTOS ONLY ^ AUTOS ONLY (Per accident)
$
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000
C EXCESS LIAB CLAIMS-MADE Y XS22039705 12/07/2022 12/07/2023 AGGREGATE s 1,000,000
DED X RETENTION S 10,000 $
WORKERS COMPENSATION PER
r AND EMPLOYERS'LIABILITY X STATUTE ERH
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT S 1,000,000
D OFFICERIMEMBER EXCLUDED? n N 1 A WC5-31 S-383610-022 12/08/2022 12/08/2023 1,000,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S
H yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Masonry Contractor. Suzanne Monaco is excluded from Workers Compensation coverage.
Location:1 Paradise Rd,Gardiner House,Northampton MA 01063
The Trustees of the Smith College and any present or former trustee,director,officer,administrator,employee,student,volunteer worker or Agent,is added
as an additional insured to the General Liability,Auto,Employers Liability and Excess Policies,as their interests may appear,when required by written
contract.This insurance shall not terminate without at least thirty(30)day's prior written notice to the college,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
The Trustees of the Smith College Attn:Purchasing Office ACCORDANCE WITH THE POLICY PROVISIONS.
10 Elm Street,College Hall 204
AUTHORIZED REPRESENTATIVE ,, p
Northampton MA 01063 `""7t'
I VV
(01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
t,7,7
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Leeiblv
Name (BusinessfOrganizationf Individual): EMPIRE Historical Resstoraticns. Inc
Address: 3 Podunk Rd.
City/State/Zip: Sturbridge, MA 01566 Phone#: 774-241-0705
Are you an employer? Check the appropriate box:
Type of project(required):
1.CI I am a employer with 11 4. 0 I am a general contractor and 1
6. ED New construction
employees (full andlor part-time).* have hired the sub-contractors
These sub-contractors have
listed on the attached sheet. 7. Remodeling
2.[3 1 am a sole proprietor or partner-
ship and have no employees 8. Demolition
working for me in any capacity. employees and have workers' 9 oBuilding addition
[No workers' comp. insurance comp. insurance.:
required.] 5. El We are a corporation and its 10.0 Electrical repairs or additions
1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] C. 152, §I(4),and we have no
13.0 Other Masonry Repairs
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.
*Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their 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: Liberty Ins.
Policy 4 or Self-ins. Lie.. 4: WC5-31S-383610-021 Expiration Date: I 2/08/2023
Job Site Address: 1 Paradise Rd. City/State/Zip:Northampton, MA 01063
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Cii.A.N.As_a_ LL Date:
Phone 1TA
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
10Board of Health 20 Building Department .1ECity/Town Clerk 4.0 Electrical Inspector 51:Plumbing
Inspector 6.00ther
Contact Person: Phone#: