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18C-030 (3) i 906 BRIDGE RD ` J BP`-2020-0727 GIS#: COMMONWEALTH OF',MASSACHUSETTS Map-Block: 18C-030 ! CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY'FUND (MGL c.142A) Category:window replaced BUILDING PERMIT Permit# BP-2020-0727 Project# JS-2020-001246 Est.Cost: $19852.00 v Fee: $130.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: NORTHEAST SPECIALTY CORP 110285 Lot Size(sg.ft.): 14200.56 Owner: MAZZA Zoning,: SR(100)/ Applicant: NORTH EAST SPECIALTY CORP _ AT. 906 BRIDGE RD Applicant Address: Phone: Insurance: 148 DOTY CIRCLE (413) 739-4333 WC WEST SPRINGFIELDMA01 b89 ISSUED ON:12/13/2019 0:00:00 TO PERFORM THE FOLLOWING WORK INSTALL 8 REPLACEMENT WINDOWS.AND 1 , SLIDING GLASS DOOR • POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector i Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: I Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: i .. Final: Smoke: Final: f f THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid:. Amount: Building 12/13/2019 0:00:00 $130.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner I i Department-use only City of No rthar i pton Er tatus f Permit: , Building e a urb C it/Driveway Permit it 9 p me SEG 2 2019 212 Ma n Str et ewer/ epticAvailability Roo 10 ate rP Yell Availability Northampto , M�€fhJ 6�i©un Dir, I JsPEcTr rir�o S is of Structural Plans - phone 413=587=124 T Apo 01060 i Plans - - Other Specify. APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 4 -SITE INFORMATION . is section to be compl ed.tiyoffice . 1.1 Property Address: Map V Lot Unit - �1r�o�rn+P n. 6 o.►oO D 2one Overlay District Elm St.District CB District ,SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: pk Name(Print) Current r ling �� �V 1 l.li�� 7T"•, TelepHdne �"l Signature 2.2 Authorized Agent: IY-d 0c1 Name(P nt) Current Mailing Address: 1 -U�� ignature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only -completed by permitapplicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing• Building Permit Fee . 4. Mechanical (HVAC) 5. Fire Protection 6. Total=(I +2+3+4+5) Check Number This Section For Official'Use Onl Building Permit Number: IaQ�7 :Date ssued: Signature: '. J Building Commissioner/inspector of Buildings Date r .EMAIL ADDRESS'(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aaplicable) I New House ❑ Addition ❑ Replacement WjAdows Alterations) ❑ Roofing ❑ Or Doors K' Accessory Bldg. ❑ Demolition ❑ New Signs [EI] Decks [Q Siding[0] Other[EJ Brief D Work!1/Oiptionof Pi ��X 5\& rs �Ii��1�t��a and (^J���)t✓ in 11 11 77 I Alteration of existing bedroom Yes. No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No i♦h Plans Attached Roll -Sheet -- -- ----- - - - -- - ____ --------.--- _ _--- --- -- sa. If New house and or addition to existing housing, complete the following: a. Use of building: One Family Two Family Other b. Number of rooms in each family uriit: 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 form 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 Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, IV 1 zL�M MC.�ZW IOU rd as Owner of the subject property pp hereby authorize �C, Di eyon DEB aSff_y__ to act on my behalf,in all matters relative to work authorized by this building permit application. of) U0 Alin :)6 is qll Signature of Owner Date I, �C.OA) JJC.0 k2_ Iv ,u as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. V)6�0 U1n Print Nam — GPM l lq nature o Owner/Agent Date I I • i SECTION 8-CONSTRUCTIONSERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �l�1 J�X U 1� lJ0\6 License Number 34 nYA. n(, C IQI abab Address Expiration Date Signature Telephone i i Not Applicable ❑ Company Name Registration Number P , (OO(q�F Address ! Expiration Date Telephone �S i SECTION 10-WORKERS'COMPENSATION'INSURANCE AFFIDAVIT.(M.G.L.c.152,§25C(6)). Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the bu,ildi5g permit. Signed Affidavit Attached Yes....... No...... ❑ I i i i I i I 'I I i i i { l City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS ' 212 Main Street.•Municipal Building Northampton, MA 01060 �ss �10 . .Debris Disposal Affiidavit 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. . I The debris from construction work being performed at: ! .GO6 E)rde 9)d . (Please print house number ariV street name) Is to be.disposed of at: � �� � (� - �►�ela� , CSC �� �� (Please print name-ajd location of facility) i Or will be disposed of in a dumpster onsite rented or leased from: ! i (Company Name and Address) f f Signature of Permit Applicant or Owner Date i 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. I , .I . ! i i i i Page T of 8 i NIIR 148 Doty.Circle West Springfield MA 01089 1-888-Nescor-1. . 1-888-637-2671 413-739-4333 MA LIC.#1037.13/:.CT LIC.4,0545323/!RI.REG.#:42249. corn. ... c : . ... . . . . . . . . . . .. Nes ow. om Customer_Information. Nina&.Donna.Mazza-Ploued/ rpl6urd8@yahoo.com: Date: 11/20/2x1.9 413-297=7467 . .. . Rep: Mit ch Grant Mazza . . . . . 906 Bridge Road Northampton, MA 01060 The followin windows.will.be.installed by Nescor Home Remodeling] Total:number:of windows in the-home 25. T6ta1 number of windows being,installed y 9 . 3-Lite Slider- Nescor.3-Lite Sliders Location.. Living Room Quantity 2 Size .., Interior Coil Color 96.,.White. or.Color. White. Grid Style l -.No Grids Screen Type '. Half. . Tempered Glass Not included. 2 Lite.Slider- Nescor Heat Shield 19 _ , Location, Bathroom 1 Quantity 6; Size 'x,3:5 . 39 1 Interior Color: White Coil Color V1lhite r I Grid Style Nq Grids," Screen Type : Half' Tempered Glass `Not included 1 Patio Slider -:nescor Heat.Shield 19 (6 ft.) Location Kitchen Quantity,... _: . . . . .. 1 Size 72 x 80 Interior Color White Coil Color White Grid Style•:. No Grids Screen Type Half. Tempered Glass Not included Additional.•Information Only doing windows•on the second"floor Do'not do porch windows. Unforeseen costs that could.occur. . Homeowner.is responsible for remoYin;g:and replacing any window treat ment9 or air conditioning dnits.in or around any windowsao. be replaced. - Homeowner is responsible for removal and reinstallation of alarm components on any windows and/or,doors to be replaced. Contractor,will NOT replace'alarm components. (Customer Initials) / This space intentionally left blink LeapToDigital.com 1:5.3 . r Page 3of8 NORTHEAST SPECIALTY MA License#103713 1-888--NESCOR71 CORPORATION d/b/a NESCOR ! 148.Doty Circle. WEST SPRINGFIELD, 1-888-637-2671 MA 01089 nescornow.com All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170 Boston, MA 02116 - Phone.(617) 973-8700 Nina & Donna Mazza-Plourd/ rplourd8@yahoo.com Date: 11/20/2019 Mazza 413-297-7467 Rep: Mitch Grant 906 Bridge Road Northampton, MA 01060 i JOB NAME i rplourd8@yahoo.com Date: 11/20/201:9 JOB LOCATION 413-297-7467 Rep: Mitch Grant ESTIMATOR We hereby submit specifications and estimates for work to be preformed and materials to be used: I Specifications and estimates for work to be preformed and materials to be used>> Please See previous product specification pages. See previous product specification pages. Do not Do i Do Not Do Porch windows. Construction relatedpermits: Construction related permits: As Required WORK SCHEDULE Contractor, will not begin the work or order the materials before the third day following the signing of this. Agreement, unless specified herein. Contractor will begin the work on or about. Estimated Starting Date 12/20/2019 i Baring delays cause by circumstances beyond Contractor's control, the work will be completed by i Estimated Completion Date f 01/20/20.19 The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor including, but not limited to strikes, Acts of God, shortages or materials, accidents, and all other delays beyond its control, shall not be considered as violations of-this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects of materials of workmanship for a period of days. DAYS OF WARRANTY COVERED lifetime +50 WARRANTY CONTINUED j following completion and shall comply with the requirements of this Agreement. In'the event any defect in workmanship or materials, or damage caused by the Contractor, it's subcontractors, employees or agents, is discovered after completion of any job, including cleanup,the Contractor shall survive any inspection preformed in connection with the agreed-upon work. Total Contract Amount $19,852.00 to hereby to furnish material and labor- complete in.accordance with above specifications, for the sum of This space intentionally left blank Leap7oDigital.com 1.5.3 Pag6 4 of 8 . Total,Contract Amount $19;852:00 Payment to be made as follows $-Due at signing :$400.0.0: Measure amount . Measure. .$0:00 Enter $ Due for "Start". $0.00. Enter.$ Due for "1/2 Completion" $0.0.0 I Enter.$ Due,for-"Completion $0.00. Name of..Contrac.tor/Designated Registrant NORTHEAST.SPECIALTY CORPORATION.d/b/a NESCOR Street Address 4I 148 DOT;Y"CIRCLE-- . City/State T v � v �v y� ^WEST SPRINGFIELD, MA 0.1089 413-739-4333- Registrati'on No., 103713, Name of Salesmen Mitch Grant Authorized Signature i . Totals: Total Amount $19,852.00 Deposit Paid .$400.00. Form.of Deposit Payment: 'Check Remaining Balance k $:19,452 00 Remaining Balance Form of Payment Finance. Check.#:`. ., =1358:. . Check Date 11/20/2019 Ownership of Property:The undersigned.warrants that he/she is Owner of the property on which_the work is to:be performed or that he/she is otherwise authorized an behalf of'Owner(s)to enter into this Contract. Notice of Scheduling Changes: Contractor agrees to provide Owner with notice.when delays become known to.the Contractor. Concealed Conditions:Should concealed conditions encountered in:the performance of the contract be at.variance.with the conditions . indicated by,the-contract and/or.Owner or should unknown conditions of an unusual:nature,differ.from those ordinarily encountered and generally recognized as inherent in the work of the character provided for In this con-tract be encountered,the contract shall be equitably increased. Furthermore,-if unknown andyor concealed conditions prevent Contractor from compl.eting.the contract,the contract shall be . equitably increased or decreased,as the case may be: Delays in Completion Due to Concealed,Coriditions: Owner hereby acknowledges that in.certain remodeling work,the-demolition of portion Of: the pre-existing structure may reveal additional defects,'conditions or.the need for.additional worki which must be repaired;.altered or.* carried out in order to complete the:work described under the contract. In such case(s),Owner agrees that.the duration of the work and the scheduled date of completion may differ from the date stated on the front,and.that such variation shall not be.considered to be a violation of this contract. LeapToNgital.com 1.5.3 . i . . Page 7 of 8 We-ns ruc,io Re1 ,e a ontractor, under provisions of Chapter 142A of the Massachusetts General Laws, is r o appy Tor and obtain all construction related permits. Contractor shall not be deemed responsible for delays in the work described in this agreement caused by regulator, permit granting:or inspection agencies, authorities or individuals. NOTICE: If Owner obtains his/herr own construction related- permits for the work described under.this Agreement, Owner is hereby advised that in the event of a dispute,judgment and'nonpayment'of Contractor, Owner will not be entitled to. make claim to or collection from the guaranty fund established in M.G.L, c. 142A. Modification: This Agreement, except as to concealed conditions or delays occasioned thereby or by restarts, cannot be changed except by a written statement signed by both Contractor and Owner. However, cancellation by Owner is allowed in accordance with the-Notice of Cancellation..Owner hereby grants Contractor a limited.Power of Attorney to complete incomplete documents!on Owners behalf. Completeness of Contract for Execution: Owner is hereby advised not sign this.Agreement unless and until all blank sections have been filled in not applicable, and until all exhibits and related or referenced.documents that are incorporated herein are'attachedlhereto. I Attorney's Fees/Costs Owner agrees to pay all costs of.collection, including reasonable attorneys fees, cost and expenses. Furthermore, interest shall be charged at the highest lawful rate of interest on any and all overdue payments. i Copy of Agreement to be given to Owner: This Agreement is governed by the laws of the. Commonwealth of Massachusetts. It must be executed in duplicate, and an original, signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to Owner of a copy therefore. Disclaimer: Contractor, its affiliates, employees, agents and assigns are not tax advisers. Owner,acknowledges and Contractor confirms that no certification has been made or provided by Contractor to Owner as to whether the purchase or other criteria required for qualification of any such tax incentive has been met by Owner. Owner is responsible for consulting with a;tax professional or accountant to determine certification and-qualificationunder the IRS for any tax credit or incentive requested. Contractor is not responsible or liable for Owner's ability or inability to receive tax credits or incentives. *-Any dispute between the parties,hereto shall remain confidential. Customer.shall,not make or encourage-others to make any public statement.that is intended to or reasonable could be foreseen to;,embarrass-or.criticize the company or its employees, without obtaining prior written approval from the company" or marked as void, deleted or encourage others to make any public statement that.is intended to, or reasonable could be foreseen to, embarrass . or criticize the company or it's employees,.without obtaining prior written approval:from the,company. Mitch Grant Nina&Donna Mazza-Plourd/Mazza MA LIC.#103713/ CT LIC.#0545323/ RI REG'.#42249 11/20/2019 State License Date 11/20/2019 Date 11/20/2019 i Date I i i This space intentionally left.blank LeapToDigitaLcorn 1.5.3 I • i i Office of Consumer Affairs and Business Regulation a One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation NORTH EAST SPECIALTY CORPORATION Registration: 103713 148 DOTY CIRCLE Expiration: 07/13/2020 WEST SPRINGFIELD,MA 01089 Update Address and Return Card. SCA 1 v 20M-05117 ` /re�ianr�xa�rufea�/�u�'r``la,�c�ur:1c11� Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. if found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 103713 07/13/2020 One Ashburton Place-Suite 1301 NORTH EAST SPECIALTY CORPORATION Boston,MA 02108 ------------- SHARON M.TARIFF 148 DOTY CIRCLE �� — I WEST SPRINGFIELD,MA 01089 Undersecretary Not valid vuithout signat e ar trtkrie�t^�f f?ulyuc"3rY�t� ciao of F3uiidif g"Regulatirani.;and SYarndards enset CS 1102&5 o'onstruc`tiOrr Supervisa� j{ KEITH W bEVIN 3134 MOUNTAIN:ROA`D WEST SUFFIEWCTr'08093? 17 tZ�Ie.jbf i IY GJI+V-1 ,4 © CERTIFICATE OF LIABILITY INSURANCE DATE 071171201 YYj 07/17/2019 THIS CERTIFICATE ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOE OT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CE FICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the rtificate holder is an ADDITIONAL INSURED, the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION I AIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does t confer rights to the cortificato holder in Ilou of such AndersAmA_n(s_ PRODUCER 413-73 -5359 CT J Raymond Lussier Ins Agcy Inc J Raymond Lussier In gcy Inc PHONE 413-737-5359 FAX 413-732-2027 181 Park Avenue,Suit (Arc,No,Ext): (AIC,No): PO Box 499 ESL info ussierinsurance.com West Springfield,MA 0 90.0499 MESS: J Raymond Lussier In gcy Inc INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:COLONY INSURANCE CO INSURED INSURER BALM. Mutual Inst, Co. eorst Specialty Co NscINSURER C:Safety Insurance CompanyanY 39454 1q4nfleWestt Sprigld, I MA 0 89 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY T THE POLICIES OF]INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWIT TANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY B SUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CO ITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF I RANCE APDL SU8 POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR I SD WVD MMIDDIYYYY MIDD YYYY A X COMMERCIAL GE AL LIABILITY1,000,000 EACH OCCURRENCE $ CLAIMS OCCUR 101 PKGO094179-01 03/18/2019 03118/2020 PREMISESERENTED cec $ 100'000 `MED EXP(Any onePerson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIM APPLIES PER: GENERAL AGGREGATE $ 2'000,000 X POLICY❑j LOCPRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ C+ AUTOMOBILE LIABILITY Es accciidentSINGLE LIMIT $ 1,000,000 ANY AUTO 2433825 0311112019 03/11/2020 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY p BODILY INJURY Per accident $ X AURTODS ONLY AU OS ONNEY PPe�aCcR�nt GE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETE ION$ $ B WORKERS COMPENSAT N X I SER UT ER H AND EMPLOYERS'LIABI VWC6003962-2019 07109/2019 07/09/2020 10(),000 ANY PROPRIETORIPART RIEXECUTIVE YIN E.L.EACH ACCIDENT $ OFFIC.VMEIMBt� EXCL ED7 N❑ NIA 100,000 {Manda Ory n E.L.DISEASE•EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPER IONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATION i LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks schedule,maybe attached If more space Is required) it CERTIFICATE HOLDE CANCELLATION CUSTOME SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial.Aceidenis _ Office of Investigations o Lafayette City Center h 2 Avenue de Lafayette, Boston; MA 02111-1750 www mass.gov%dia Workers'Compensation Insurance Affidavit: General Businesses Applicant I ormation Please Print Legibly Business/0 nization Name: {��i( �11e � `k• r � Address: 0 6r City/State/ Are you an.em oyer? Cheek the:appropriate box: Business Type(required): 1: I'am a ei t'lo with o� employees (full and/ 5• []Retail or part-t' e)'.* 6. ,�<,Restaurant/Bar/—Rating Establishment 2.❑ I am a.s proprietor or partnership and have no 7. Office and/or Sales(incl,real estate,auto,etc.). employe ;working forme in any capacity. g. Non-profit [No wor rs' comp. insurance required] 3.❑ We are : orporation and its officers have exercised 9. E] Entertainment their rig of exemption per c. 152,§1(4);and-we have 10...n Manufacturing no empT ees. [No workers' comp.insurance required]** 11.0 Health Care 4.E] We ai e. ;on-profit organization,staffed by volunteers, with no -loyees. [No workers' comp.insurance req.] 12.[�Other Q ,( e — *Any applicant that 'cks box#1 must also.fill,out the section below showing their workers'compensation policy information. *If the corporate:of rs°have exempted>themselves,but the corporation has otheremployees,a workers'compensation policy,is required'and such an organization:should' 'ckbox#1. I am an employ, that is providing,workers'compensation insurancefiormy.employees. Bel~1s'the policy information. Insurance Comp y,Name: � InsuInsurer'sAddie `-r'1J, ' r- �1 ' City/.State/Zip. Policy#'•or Self Lic:# aU''1`�' Expiration Dates Attach•a copy.,. he workers' com ensation olic declaration, a e showin the,-nlie :numli.er.andi ex iration dafe). .. . p P. Y P g ( � P y P Failure to'se cur ' �erage as required under,§25A;of MGL.c. 152 can,lead to,the imposition,:of'criminal:penalties of a fine up 1o'$;1,500.00i an r one-year'iinprisonmerit,,as well as:civil'penalties,in the form.of'a STOP'WORK:© DER ands a,fine sof up to,: $25.0'00 a day,a ' nst;tlie'violator. Be,aduised'that a copy'of this statement may—he forwarded toAhe;;.Office�:of Investigations,of ` the DIA for in ce coverage verification. f , Iiloherebycee `' , riderth . iins,andprinalties,ofperjutytkat,ihe�information'provided,abo<v"is,,im land,cokreck i Si ature: --,]Date: Phone#': �i�; t' ?11A, 3 G Offish l,use D'o;not wr fe,aiz this area;,to be completed'by jezty',or towmof jleiaL City or Tow Permits�icense'#' , i - Issurng.Aut ty(clieck one) f 1 ]Board o I, ealth 2', - 1B:uild t Department 3',0'•:City/"Town CI'exk 4ii! '=Licensing-Board, 1 'S[;SelectI 's,Ofi+ice 6 1 i .;©"they _ Contact;Per ' Phone#•, i s w%v vw mass.govldia _t I I DEBRIS DISPOSAL AFFIDAVIT im ordance with the provisions of M.G.L. c. 40, s. 54,Building,Permit was issued with the condition that all debris resulting his work shall be dis osed of in a ro erl licensed solid waste al facility as defined by M.G.L c. 111 s. 150A. The ebris will be disposed of in: Name of Was2a. ty Address of Waste Facility 111.5 Debris! As a condition of issuing a permit for the demolition, renovation, rehabilitation or other 61teration of a b1diding or struclum,M.G.L.c.40 s.54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c.111 s.150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department.If the debris will not be disposed of as indicated, the holder of the permit shall notify the building official,in writing,as to the location where the debris will be disposed. I 780 CMR—6"Edition I I Signature pplicant Date I