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36-185 (15)
398 BURTS PIT RD BP-2017-0523 GIS r: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 36- 185 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category ROOF BUILDING PERMIT Permit# BP-2017-0523 Project e JS-2017-000854 Est.Cost: 58100.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq.ft.): 31232.52 Owner: REYMOND WENDELIN K&HEIDE E ERIKSEN Zoning: Applicant: RCI ROOFING AT: 898 BURTS PIT RD Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAM PTON MA01073 ISSUED ON:10/19/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:ST RI P & SHINGLE ROOF 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: FeeTvpe: - Date Paid: Amount: Building 10/19/2016 0:00:00 540.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 6P- iti Ca i ---- D'apaezrt'at is/exat � := . IGlty of Northampton �Scatus of pb4crcrt E3uRding Department r Nrb kern4sisty Permit MT 1 8 � 212 Main Street S2N/o)IEEptI¢AvauabuRy_Room 100 'Water./Wall AVartsb'llty�, pmr of r Northampton, MA 01060 Two 6et1-of Stmauret Pians_...,.. ..,_ S14.1-3587-1240 Fax 413-587-1272 mtot'Slie Plains APPLICATION TO CONSTRUCT, ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING j 4,47 41 r SITE INFO MATIDN' V_ I _pert, Addtr ,t,{', l'hlh�geofion to�Se completed 16y 0fnce 7 b`a�f g tern.& PI Fd Map ___ Lot. Unit F Toren a MA ai06,?— Zan.___ _____ Overlay Olstriet Elm St©lathe_ '4l€teNt 0330N2 PROPERTY OWNERSHIP/AUTHORIZED AGENT I __Gv .er of Recut thiztedFriMen _. gqg &rA iii—?.( Ito-ri a. islet o/o& . ,int) Goren'Melling Address; -via.1.i-tit- 5T6G• — _ Telephonn — — — _ !"_' ed A6ela.k 1 4 K foh,csio. . _ P., C . T icot4 -10C �(' l ft:r_.. 3.h ,44-4bmr-VGn ,M2,_ n Y1. ,g Curren)Nellfng Add ass ho ; .25 ) , %._t 'e`�r7:> eph .��one J ne -IOb, 3 :ESTIMATED CQNSTcSUCTION COSTS ____� �� Estimated Cost (Dollars)to be I — Official Use Only completed by permit app0esnI ( ,:ding 8 } (a) Building Permit Fee 'r,:u Lue 'IOD. _ —_ —41 EIeOntca. 0 ( (b)Estlmat.d Total Cost of Construrollon NH-nig) 'Ivmamg ' Budding Penn itFee 1 M thon:cal{HVAC) F-o(eolion /{�y�,�/y/ nl= ;1 +2.3+4+5) ��1q 4-Y ��I ,m t 00. - WReek Number This Section For Official Use Only.._ _ O ng Permit Number_ ....n. Ise I BUSdrng Comm_&sl© Buildings Il In&s Dale I — , 9.f 37,ON 5. DES6P.1P11OffrOE R3oPOSED WORK toheck MI aPelleableh New Mouse i: 1 Addltlorl _ Replacement Windows I Atteretlon(s) Roofing Or Doors D L_ __,,_ `_ ___ _ =ceessore Bldg. ❑ 1 Demolition New Signs (OI Decks (p Siding 1M] Other jCI vler Description of Proposed • ;A_racon or exlsling bedroom_Yes No Adding new bedroom ___,_Yes No -ste ned Narrative Renovating unfinished basement Yes No • =ens Alleened.Rol -Sheet_ _ _ ' sa. If New hoelQE$an ior.aa'a"Aion 6o.existtlina4hrausVn , complete-1hir_toilowinq, N • Use of bolding • One Family_, Two Family_ Other N,'moer or rooms in each family unit. Number of Bathrooms___,_„__ 's Mem them a garage attached? _. Proposed Square footage of new construction. Dimensions o Number of stories? ___ Method of heating? Fireplaces of Woodstoves Number of each Energy Conservation Compliance., Massoneok Energy Compkance form attached? ,_ Tune of construction Is oonsamcston within 100 N.of wetlands? Yes __Nois cosst,uction within 100 y;. floodplain_Yes _No Depth of basement or Cellar floor below finished grade .firm ba!ding Perform to the Building and Zoning regulations? Yes No Serfic Tank__ City Sewer Private well City water Supply EO,TiCN 7a -OWNER AUTHORIZATION r TO BE COMPLETED WHEN MERE AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT H2lGyrr err kti>trl _ as Owner of the aunjer+ :Mcperil (��\( �' / not soy authorize I . l 1 y f 1.�1 _04- i'] ,C i,]Cacara • a r. on my behalf in all matters relative to work authorized by this building permit aR, I[cation. _.,±)b±! a c l)ecf. /0- /3_/4, _--_— nnlure of Owner Date _ _J rr1®1� . ____W_ ____. __LAWS CA S Ne\lk\k a.0fl `4'uirw Pr I(obiY1+' as Owner/Authorized :part hereby declare that the statements and information online foregoing application are true and accurate, to the best of my knowledge %no oecef 3yned order the pains and penalties of perjury, �'—' i'� /0—/3 di& _ ._._ efittattoor c(,J.vr�efLG,:!nt _ _ Pate __— _ __. City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: ?91431<-4-A��11e--f %lir `7crorec- Mr/The debris will be transported by: CO W1e-mo• [) \S ()05P L e_.3 The debris will be received by: +vP/64-e--. (H joU Q 1`R ^-6CfA- d i“ i Building permit number: �) Name of Permit Apptcan12_12_01-� � "url N�l/ t/_( Date Signature of Permit Applicant /( - /3-/G The Commonwealth of Massachusetts ". Department of Industrial Accidents 7 Ereto - 1 Congress Street,Scute 100 '� wit=' Boston, MA 02114-2017 ' www.mass.gov/dia (Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TILE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(RRusiness/OrganizatioMndividual): ,p C 1 Rpp-4',,S LL P Address: 6 L./h e, Uf City/State/Zip:,,Soar/!Impure, 0/1 O/973 Phone #: 69/3) �.�7 - 1 75� Are you an employer?Cheek the appropriate box: Type of project(required): I. ,[ tam a employer with e24 employees(full and/or pan-time).' 7. Ei New construction 2.0i am a sole proprietor or pannershi p and have no employees working for me in 8. L^I Remodeling any capacity.(No workers'compinsurance required.) 3.0 I am a homeowner doing all work myself (No workers'comp.insurance required.J' 9. �Q�tt Demolition 4❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will I IJ Building addition ensure that all comractors either have workers'compensation insurance or are sole ti.0 Electrical repairs or additions proprietors with no employees. 12,0 Plumbing repairs or additions 5 E I em o general contractor and I have hired the sub-contractors listed on the attached sheet 13.t-1+Roof repairs These sub-contractors have employeesand have workers'comp insurance' LSI ft We are a corporation and its officers have exercised their right of exemption per MGI.c. Id. Other 152.gl(4),and we haw no employees.Into workers'compinsurance required.] "Any applicant that checks box Utmost also fill oia the section belowshowing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mus:submit a new affidavit indicating such. (Contractors that cheek this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. C -r- Insurance Company Name:" (3 r _2";)Pt,/✓/I/7/tP .. Policy#or Self-ins.Lie.if: L((i '_�ji,. Z��/))hn�'38/0,f Expiration Date: /0 -5-/7 Job Site Address: ext.,GYf/:.7y R.6 _ City/State/Zip 14)i($,ndl, MA?0706,2 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL e. 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t do hereby certify under( airs d penalties of perjury that the information provided above is true and correct. S' oat re_' `. Date: /It-/3 `/6 Phone It: P'/'.r) .5`-827- 75' 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#: Ge!. S. 2016 9: 50AM No. 0218 P. 1/2 ACOID® CERTIFICATE OF LIABILITY INSURANCE `'"�`n:Dr""' 1' ‘_--- 10/5/161 TICS CERTIFICATE 15 ISSUED AS A MAI i tR 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 COES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: U the certificate holder is an ADDITIONAL INSURED, the polioy(ise) must be endorsed. If SUBROGATION IS WAIVED,subject to the tens and conditions of the policy,certain policies nay require an endorsement Astatement on this certificate does not confer rights to the certificate holder In lieu of such endorsemenfts). 'RODLIEER 0047ACY -- arsE Michael R. Uands Sanas & Fickert PHONE Insurance Agency mbfi RC 'GRAF (413) 527-2700 PVCC Nm: (4PVC PEA $21-0949 63 Main Street ADDRESS: banasinsun race.corn F.eaGlaSQtOn, MA 01027INSURERS)AFFORDING COVERAGE NAIL# IWReEA Admiral Insurance Co. j2496 6' KURED pin ROI e:Safp RCI Roofing, LLP fsY Insurance Co. 35434 .INSURER C:...c Vanston In9ttrano9 Co. 3$371 6 Zine Street rmsuRFR D:Star Insurrance' Co. 24562 Southampton, MA 01073 :rf:IRex E: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY nikr THE POLICIES OF INSURANCE USTED BELOW HANE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR'ma POLICY PERIOD INDCATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHICH THIS Cf RTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TFE PCUCIES DESCRIBED HEREW IS SUBJECT TO ALL THE TERMS. EXCW S1ONS AND CONVTICNS OF SCOT FOUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED 6Y PND CLAIMS, NER. "--A6TC56eR) Po ((.'.T€iF`-6tllTcv'EA�—"'—'--_.. ER TYPE OF INSURANCE POti NUMBER MMr M MUtD4trrfl c**17 A I G2NaRALiIA91Utt X CA000020963-01 3/4/16 3/4/17 EACU OCCURRENCE 00* *00 - X VOIDDERCl41.PEnemu.wmrY _ReytigzR,OFTIS am„'�➢ . e 0 000 -1 C AIMS-#AOE OCCUR MEC ea.tee .14,4r361) t 10 000 1 PERSONAL AAov INJURY I$ 1.,000 900 _ GENERAL AGGREGATE S 2 000,000 GEN%AGGREGATE LIVTAPPUCS PER PRODUCTS-OD I.PIOP AGC b 2 00' 000 I IPOLIO, Yy v LPO • rt B IAUTOM09I ELIA%IGTY X 6207761 413&/16Nciml msGL xo 5 1 000,0 D �� g4YAUID BODILY INJURY(PO,'semen) 4LQ WAEO x ACME➢ULE? ACTED TOS WYLY INJURY rP,D REAMED S X HIREDA'UTOS x AUX NON-OWMIEO PROPER-PT MNLE t I wTos PREP ASCiden'.i C I -EIRELLALI0 UR X C1,1BW5757915 3/4/36 3/4/171 EACH OCCURRENCE t 5x000,000 II mess LIA9 CLAIMS-MACE • ASOREGAyh s 5,000,000 1 DEO X 114TENTION4 10.000 ( •4 D RvoRHo EIs COMPENSATION WC0683405 10/x./16 is/5/ZIr WE DIVED- •om- APED EMPLOYERS'GAeStTY T.IN 1 DE F.2. ANY PROPRIP.TOPRARME,WF%ECUTIW_ �-1 E.L. M C rM s 1,000.000: OFFPX GAGGER EXCLUDED* y NIA E °��. (Ram'vaFA II%MH) „E.L.QISEA9e-EA EMP LOYEE 5 1,000 000 waa, If oaseln1ci)ma gN a OPERATION4 beep _ Et.Et ESE-POLICY LYE! t 1 000 000 — msec Pnos as 0PEWADONq I VOCATIONS IVO-ECUS IMGEE ACM 10,Ah'Ipaml R,corks Setrade,Ir mors PAPER A ng W ql ROOFING CONTRACTOR, Che General Liability Policy includes an Additional Insured endorsement that provides additional Insured status to the certificate holder, only when there is a written contract that eegaires such status, and only with regard to work performed on behalf of the named insured. CERTIFICATE HOLDER CANCELLATION SHOULOANY OF INF AEOVE GESCRInEDpouCIEs BE CAN ELLE0 0EFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ***REFERENCE COPY*** ACCOROANCEWlTh4 SHE POLICY PROVISIONS, AUl -•AENTAirvE �.. ._ sG 1$S&201oAW RD CORPOEtATIO_[i_Ali right;reserved. _ i. ACORD 25(2010/05) The AC ORD name and logo are register?d marls orA':ORD 'hone: car It 9A ew_e«a CUrea, inMassachusetts Department of Public Safety ~ — sc> a 2w.mn; ipyC Board of Building Regulations and Standards e,rF - oeat% /e�/l1fkolYd License'. CS-074334 Office of Con a Affairs&Bi es Reg Iation :.onshucUan Supervisor . Y}7: f HOME IMPROVEMENT CONTRACTOR MARK T DELISLE I - �" Registration 126235 Type' 69 BRIGGS STREET It Expiration N6120+18 Partnership EASTHAMPTON MA 01927I mit-it RC.i.ROOFING MARK DELISLE 6 LINE ST Expiration: �� ------ CommissionerOfle1 05r03nois SOUTHAMPTON, MA 01073 Undersecreuuy. tria I " �� n w Q* C�rtNI 1+11 •wG1H o hl A `�#AGWUsz;I�9 i 4Wt. €6�'s. [ ^z Ig'4 ), 6; '1EssiONA %MMACEMSiili :s 1 HOMIL PRpiV N',1ty ONE'RACTOR ' rr ECAFRIGY <?:3..0'Pk ORIIISiU;i4.P I„ EH�EI(rt "t+TAL 1!£1iFKn+RS r',I AT sr ISSO S SM1° F 004 LD+l47G7= 7CENEA soft 4 SPI s1NSOA73 Ott ktikeTE4 4101`4ITRIct&O ,� 6 • t r r1A,K('3 6EI riSLE 11 1 1 e rvs II Brt, t E i:ICGC24741 "rr u�9E✓1fl,�,31m1Na r /39/2614 59 BiYip�, 'ST ,n y� Ir alcueo �/ r'�°r._.2"ul✓'�T^'E ... .�.. �...,., , .P�S�i °UrN Ca I`A'A 41027 1759 tj 3��G.,. ; o lad a 21 .41 1un3eF3�.'IPr''fflktAtlC=y'{�p7 FivawRE ! SERI 4 *r 4YOMMONWEALTH OF MASl'AOHUSETT$ . r'iOtdISlONOEPi'OFESSIDNALLICENSUR 7 2 9rsAo GP ,., sNcEt METAL WORK ISSUEg SHEFOLLOWING,M, NR`aSE AS A € BUMNEAS ,- MAR}4'I.DELISLE tl �- RCIrRdOFJj4QLt . p �� w "' EASTHAMPTON,MA 010,3 ' '11Ci . 4 001 .98dee1201T,,,un2430 ti. NSENN RR : flPIR TION AT : SE'NO:.NUMNER' Roof g Estimate G Cine St.t. Southampton, Ma_01073 919/2016 Phone(413)52747i? Fax(413)52X8469 Name f Address Job Location HeidiEriksen 898 Buns Pit Rd. Florence, MA 01062 Description Remove existing roofs. 8,100.00 Furnish&install aluminum drip edge, pipe Flashings, chimney flashings (if needed)and step flashings. Furnish& install CertainTeed Winterguard ice&water barrier, 6 feet along eaves and 3 feet in valleys. Furnish and install synthetic underfayment over existing deck. Furnish and install Lifetime CertainTeed Landmark Series shingle. Furnish and install CertainTeed approved ridge vent. All exterior roofing related debris to be removed by R.C.I. Roofing. All work will be perfonned according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by RCA.Roofing. Add$2.50 per.sq.ft.for wood decking replacement if needed, For front main, only: 53200.00. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. - Total $8,100.00 TERMS OF PAYMENT •" . 55aDeposit Customer Signature: lA , IA, Valance upon completion w✓'�'�� it( Vl o'pVS, Registration d 126235 Date: IV Construction Licensed 074334 fl Insured by Bann&Fieken.Ins. G014I% t is a 11, (413)5'27-2740 Shingle Cola Selection: (�(jV 14'Lr+l -/ '71wP+ 3 • CONSTRUCTION SERVICES Co ratrgetlon 3ypeNbLp[: Not Applicable ❑ }y� ;J _it& se cst- t •ion_ b 7ai L Jcense Number Expiration Oats / .� 1e11,ee Telephone c tared_korue mmnnoysgrent Cmntrae` Not Applica^blle/ ❑ ViRLSII make' loam° Reolstration Number L .ee. 5.±- mese Expiration Date SCIUstn\01 Telephone lyk3} � 11t-! rar-s 6CfL :15 , SON iO WORKERS'.CMPENSATTON INSURANCE AFfiDAVlT(TA,G,L ._& 02;§ 2SC(l) I ineses Compensation Insurance affidavit must be completed and submitted with this application. If allure to provide this aHid evil will reaull demo'' DI the issuance of the buntline permit, tex *iic'svil Attached Yes ,_... 11. - ILoa ale Owner .xe ati x$ The current exemption for"homeowners"was extended to include Owner.camel ed Dwellings of one(1) or Iwo(2)families and to allow such'homeowner to engage an individual for hire who does not possess a license, provided thatae owner a ole Fos supervtgor. CMMR118 os Sixth Edition Section 1O8,3,5.1 Definition)of Homeowner;.Person(s)who own a parcel of lad on which he/she resides or intends to reside,on which the:e is, or s intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who onstruet. .t ore than or ome In a Inv •137117 period shall not be considered gAmneewnef. Such "homeowner"shall submit to the Building Official,on a form acceptable to the Building Officialthat e she shall he responsJple for all such work ierft,.sod unde ty ulldln• r ill. As acting Construction Stwervis;r your presence on the;ob site wilt 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 twos for person(s) you hits to perform work for you under this permit the undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local ZoninglLaws and State of lvtassaohuoeius General Laws Annotated. Horn towner Signature_______ 'SA 0 k The Commonwealth of Massachusetts tae l Department of Industrial Accidents s.,o." I'= s I Congress Street, Suite 100 CcL= Boston, MA 02114-2017 www.mu.rsgov/die -047 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): RCI ROo-4, LL/0 Address: ' Lin' 6- St '775ACity/State/Zip: Soufhcimpirin, 444 0/073 Phone#: (51/3) .a7 - .4[773— Are re you an employer?Check the appropriate box: Type of project(required): Lgleam a employer with 4.4-0_employees(full and/or part-time)." 7. ❑New construction 2.0l am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'compinsurance required.] 3 I am a homeowner doing all workm elf[No workers'coml insurance d 9. ❑ Demolition -❑ gmyself p n eagmm 7r 4 I am o homeowner and will be hiringcontractors to conduct all work on my10 ❑Building addition ❑ prnperty. (will ensure that all contractors either have workers'compensation insurance or are sole II.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5 l am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.[(?j'Roof repairs These sub-contractors have employees and have workers'comp.insurance[ 6 We are a corporation and its officers have exercised their right of exemption 14.D Other ❑ F gper MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.1 "Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t 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 cheek 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'comppolicy number 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: SSfar li,510,21/2/7- Policy /!✓!s/2/7Policy#or Self-ins.Tic.#: Afe. C64'39O5" - _ Expiration Date: /0 -5 /7 Job Site Address: //3 /✓ {}7qp/y (.c/I City/State/Zip: P7erei,ee, Intl 0/06,=2- 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 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tf tains a ed penalties of perjury that the information provided above is true and correct Signature: Date: /0 - /9-/(o Phone#: (Y/3) 3;27- z7775— 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 Contact Person: Phone#: