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BP-86278
Permit No. BUILDING BP 86278 690 ,e,a aFt A tfr 4034 00 Co `w Lot: 0024 - 400 c Sub7-1101- 0002 - pit ..) 0 , 8 Gntegory: '-W1NDOR`s. a / e pro7e��'�"` 7 01s-O0°75i PERMISSION `r 300-� --_ Contractor e nse 0 one si<G�oSt m$(52m r , X 2E 00 kEee' $1 :OD BRIAN D DE11 j x : rE* e � USeOrpap .R3 Engineer. $ l g . :L"ot:srre t ft.) yi40b97 .._ 9 Zening `. `* .`_-- Applicant:. . } -�ne AqulfetZone NIA SOUTHERN , �E�1i�c AND 'k - ( ; 4 80 Flootiione WNE`' ANDREW SW& 4 s NewCenst tNIA a- j. ' OwNeR: >B Alt;C9u Ff/A WD KINSONHE a{ �i r ISate Typed 09 20 2U17 > ■R 4 r g$ .t.. DATEISSUED nV W7 / f '•erg "' ' ,; : TO PERFORM THE FOLLOWING WO' Install four replacement windows; SA EJSIZE, SAME OP ri j. - .. ` Proj� 'Lo,Aation:/2.S . ' GLE IS ND LN i _ / Approved/Issued By: I ' ,t - -> ,t / ... ,,A,,,S,DAVID BRUNETTE,LOEAL BUII,DING INSPECTOR All work shall comply with 780 CM 8'e Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. Schedule appropriate inspections as required. Upon completion,final inspection is required. I hereby certify that the proposed work is autbo n iztdby the owner of record.and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understa other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Building/Zooin erniit. i .-_'"'~" Signature of Owner/Agent: ,-� i "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service#: Footings: - Underground: Oil: Underground: - Service: Foundation: Rough: Smoke: Rough: Rough: Sewer Service#: Rough Frame: Insulation: Final: Final: Final: Cross Connection Final: Final: Board of Health E-911 Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET 1 -hv TOWN OF DART-M OUTH - BUILDING DEPARTMENT RECEIPT d 2. ., 8 PHONE: 508-910-1820 FAX: 508-910-1830, I f.( iladv\.. 3 i .� ,u -t , Name: -,.� !' f f fGl1la Owner: ( Da j // Job Location: + Fi/ir+al. G A /a a'L Map: rat Lot 1 e i, — Description General Ledger#'s ''' R1 OF DART Amount `r (Ms ti40G� Building & Building Misc. 01000-44105 Kihci(/ u>S ti 7) Electrical 01000-44106 1 AUG sr7017 Plumbing & Gas 01000-44107 /! To4 Trench Safety 01000-44129 :' *CDLLEC�O� Other Department Revenue 01000-42420 White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received Byz" 71.7neaf t) THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS RESIDENTIAL ❑ Phased Approval(R1Q6.3.3) S25.00 APPLICATION FEE IS NON RE-FUNDABLE & NON-TRANSFERABLE DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT tric400 Slocum Road y 1 Dartmouth, MA 02747 Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY. BUILDING PERMIT NUMBER: / DATE ISSUED: SIGNATURE: r�nt� ,i%Ct, DATE: — /3 `7 Building Commissioner/Inspector of Buildings Zoning District; C/!E. Proposed Use: 1'Q_ Zone: air0 B D A U V Aquifer Zone: THE`FOLLOWIMG'AGENCIES SHOULD BE NOTIFIED: DPW ❑Board.of ❑Board of 0 Cons. ❑Planning. 17 Address ❑Engineering El Cross. Appeals -:--Health Commission Card - Connection ❑Fire O.Gas ❑Electric -0 Other 0 Water Card 0 Sewer Card Chief - :Cut Off -.Cut Off - -:Cut Off Cut Off DEPARTMENTAL APPRQVAMS) Board of Health: Signature: Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: Brief description of work being performed: {60 S f*1t,(�) 'Gt P 11/gat 14.3U)l / SECTION 1 -SIT [NFORMATIQN '. 1.1 Property Address: 02 SA,n '(a IC(and' L✓l. 1.2 Assessors Map&Lot Number:: � Contact Person: r4,--1 c I nil IS r Map 7 {a Lot ( (( - tT Phone Number: kc (— J 2 g-At CO 1.3 Historical District 0 Yes 0 No Year Built 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal 0 Municipal ❑Altering more than 25% per side of building ❑ Private Well 0 On Site Disposal System Has application been submitted to the Historic Commission? ❑Yes 0 No Date: Revised 5/13 ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT RESIDENTIAL • SECTION 2•,PROPERTYONfNERSHIP/AUTHORIZED AGENT p 2.1 Owner Record: 2 sk: ^5 (c Xs(an�X LP , cos -fti nA o� 747 ' pQp-9o8�{ �f/'r C ;ea (a✓a/-e S . � N. .�.iir .�'fdu Name(print) Contact Address Phone Number �PGJCr 'f- bf; /Ktnsovn 2.2 Authorized Agent: bon Rd Airroln RI0-2865 10/-22 4,cPW Nam (print) Contact Addfess Phone Number I�rca n r nnl50n /SnI� GI7//a/c/ SECTIONS 3-CONS) UGT1ON SERVICES 3.1 Licensed Construction Supervisor/Specialty License: &Can ni So✓t License Number: o 70 q 3 7 Company Name/Contractor Name: atnitern /(k-1 /0,7 0 Jaw S Address: 2-6 A-U;o R j_ , ncal/'t 2L JJ Wr6.2r4(o,5— Expiration Date: !— Y-/3 Signature „ 7 Telephone: _vet-ZZg_7,,Q00 3.2 Homeowner Exemption-One&Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner"is defined as follows: Person(s)who owns 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. If you are applying under this section sign below: Signature: S -00$41 VOR tip:00t►Perits:aTi0014s10►34N E} e1pgv_tT MO c Saz5) . Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failuretof rovide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ` Yes 0 No SECTIO t S-fES RIPTION OE PROPOSEDWORK(Check a jilicable}' . s ❑ Deck 0 Pool ❑ Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑ New Construction* 0 Accessory Bldg. 0 Addition 0 Roofing/Siding n'"Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No.of windows &f Doors_ ❑ DEMOLITION (specify): Location of debris removal (per MCI_C.40 Sec 54): 0 Dumpster on site ❑ Dumpster On Street Facility Name: Location: *If new construction, please complete the following: Single Family: No.of Bedrooms No.of Baths Two Family: No of Bedrooms Unit 1 No.of Baths Unit 1 No of Bedrooms Unit 2 No.of Baths Unit 2 ❑ Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify): ❑Air conditioning-(separate unit) ❑ None of the above to be provided ❑Hot Water: Gas - Electric Fuel Oil Other L SECTION 6-ESTIMATED CONSTRVCTION COST Item Estimated Cost($)to be completed by permit applicant 1. Building 0 , Ca 3 -- 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =(1 +2 +3+4) r!vll S S SECTION TA-OWNER$ itTE(ORW{ ION (to be completed when owner's agent or cor(trdctoiappifes for building permit) (Please Print) , 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. M- ackecl' (A-frac- — Signature of Owner Date SECTION 7B-OWNER/KUTHORIZED'AGENT DECLARATION I, Br''tU n ,min i Sc✓I , 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 pain and penalties of perjury. Signatu Own ut ized Agent Date SECTION 8-OFFICEJANSPECTOR;S NOTES Less Application Fee:$25.00 Remaining Balance: $ Total Permit Fee: $ Other$Amount$ Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: �i/A AefizfL 9. y ee/r ?T /XY't/y// LbLOC - �a�' ,.Gc i• agrn.-i1S //7 Si&/r/ (q ) lefo/lirem tie"- G✓.1 d tv s , Stu c74/Jcc. Permit No. BP-86278 Project Location: 2 SHINGLE ISLAND LN Commonweade, � ` $sachusetts 4. TO 1 UTH „f3 A . lt ' r - ��400 loc $ ➢ r a a 9 'vy 41 �5'�P n., -.I82Q� a 10-' � $ i �. ° s`iz?.i a, I xc� ui� '� CM Contractoftt a �e e: one#: - L BRIAN ) SON " °h � C I 07 1',co )228-9800 '�— Igi �% -) " 9 ' p » O. S r �e, « i _ m-: .-ems 'F r z Architect: 47 et tietr Phone#: Diu ti ,52 tOttil.M.A.c.ceet° Fe AV ^� m!t xxr Applicant .x a� "f Phone #: � ,,4' rra �a€ � . SOUTHERN LAP 6 i Obi S I �401) 228 9800 u, ° � OWNER: = . •—.., m'°°4 '"' WILKINSON HE RBER DATE ISSUED: TO PERFORM THE FOLLOWING WORK: Install four replacement windows; SAME SIZE, SAME OPENING DATE TIME TYPE OF'INSPECTION&REMARKS INITIAL-1- Massachusetts Department of Pubiic Safety TyBoard of Building Regulations and Standards icense CS-095707 ` BRIAN D DENNISON 7 LAMBS POND CIRCLE CHARLTON MA 01507 N." � Expi-anon: Commissioner 09i0812018 Office o,Consumer.Maus and Business P eeu aLors 19 Park Plaza-Suite 5 70 Boston. Massachusers 02115 Nome improvement Contractor Reaiscation ReDiSt2don: 173245 Type: Supplement Card E1plretlon: 9/19/2018 SOUTHERN NEW ENGLAND WINDOWS LL - - BRIAN DENNISON - _ ____-___ 25.ALBION RD — ._._ LINCOLN, RI 22855 - ----- ----__- UpdateAddress end taunt on/.Man.:reason,or au' . A 7-address Renewal Employment — =a C =r01lm ConsumerAffairsasi a toms Regulation Reistrannv-mild for individual ate only flare die' •xPir tine data if found return to: HOME IMPROVEMENT CONTRACTOR °MMr siCartsnmer alTair tad Easiness Re-astatine ReSistranon:p73245 Pme: 19Park Pima-Stitt 51-0 - Eapiratlarr.:911912013 Supplement Gard Bunton.MA 031t1} SOUTHERN NEW ENGLAND WINDOWS CD. RENEWAL CV ANDERSON BRIAN DENNISON 26 ALBION RD _ LINGOIN-Rl02865 •yedernerury Note aprrc • a Renewal• � Agreement Document and Payment Terms �- "rderSen' dba:Renewal By Andersen of Southern New England Pat Tavares&Herbert(Bert)Wilkinson Legal Name:Southern New England Windows,LLC 2 Shingle Island In. I4 WIND \•PCEMEXi 2R6 I Albion Rd L#36079, i n R 02865I 245,CT#0634555, Lead Firm#1237 North Dartmouth, H:(508)998-9p 4 MA 02747 Phone:866-563-22351 Fax:401-633-66021 salesearenewalsne.com C:(508)353-8812 Buyer(s) Name: Pat Tavares & Herbert(Bert)Wilkinson Contract Date: 08/10/17 Buyer(s)Street Address: 2 Shingle Island Ln., North Dartmouth, MA 02747 Primary Telephone Number: (508)998-9084 Secondary Telephone Number: (508)353-8812 Primary Email: pattslp@comcast.net Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement'). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $6,523 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $3,261 Balance Due: $3,262 Estimated Start: Estimated Completion: Amount Financed: 6-9 weeks 6- 9 weeks $6,523 Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.-1T,e installation date that we are providing at this time is only an estimate.We will comet nicare,Bo ial-date and time at a later date.Rain and extreme weather are the most common causes for delay. L Notes: 50% deposit-GREEN SKY; 50% balance due upon completion-GREEN SKY Buyer(s) agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s) and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement, understands the terms of this Agreement,and has received a completed,signed, and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 08/14/2017 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:Renewal By Andersen of Southern New England Buyer(s) �� d Y6,3l4Ik r Signature of Sales Person Signature Signature Chris Hutson Pat Tavares Herbert(Bert)Wilkinson Print Name of Sales Person Print Name Print Name UPDATED: 08/10/17 Paget / 11 ----°1 ESLERCO-01 SANDERSO ACC:PL.---- CERTIFICATE OF LIABILITY INSURANCE DATE 06/07/201 7 �/ 06/07/2017 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(ies)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 ME: CoBiz Insurance,Inc.-CO PHONE FAX 1401 Lawrence St,Ste.1200 • (wc,No,Etl):(303)988-0446 I(Arc,Np):(303)988-0804 Denver,CO 80202 ADDRESS:COMail@cobizinsurance.com INSURERS)AFFORDING COVERAGE NAIC P INSURER A:Acadia Insurance Company 31325 INSURED INSURER B:Firemen Insurance Company of WA, D.C. 21784 Southern New England Windows,LLC.dba Renewal by INSURER C:Liberty Surplus Insurance 10725 Andersen of Southern New England 26 Albion Road,Suite 1 INSURER D: Lincoln,RI 02865 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INE I TYPE OF INSURANCE ADDL UBR INSD SWOO POLICY NUMBER POLICY EFF POLICY EXP Leans A X COMMERCIAL GENERAL LIABILITY /MnvoolYYm IMMIOOIWYYI 1,000,000 EACH OCCURRENCE 5 CLAIMS-MADE X OCCUR CPA3158728 01/0112017 01/01/2018 DAMAGETO RENTED 300,000 PREMISES(Ea ocvmence) S MED EXP(Any one person) 5 5,000 I PERSONAL&ADV INJURY 5 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000 X I POLICY I JECoT I I LOC V n LealI2,000,000 .3ya PRODUCTS-COMP/OP AGG 5 I I OTHER: / y EBL AGGREGATE s 2,000,000 A AUTOMOBILE LIABILITY ,I 1'� (Ea OMaBBINNED ent)SINGLE LIMIT S 1,000,000 X ANY AUTO CPA3158728 `j 01/01/2017 01/01/2018 BODILY INJURY(Per person) S — OWNED SCHEDULED _ AUTOS ONLY AUTOS • BODILY INJURY(Per accident) 5 _ AUTOS ONLY _ NON-OWNEDUTS N (Per PROPERTY 5 S A X UMBRELLALIAB X OCCUR 1,000,000 EACH OCCURRENCE 5 EXCESS LIAR CLAIMS-MADE CPA3158728 01/01/2017 01/01/2018 AGGREGATE S DED X RETENTIONS 0 Aggregate $ 1,000,000 B AND EMPLOY RS'LIAATION BILITY YIN X ISTATUTE EROTH- ANYq� PROPRIETOR/PARTNER/EXECUTIVE WCA3158729-20 01/01/2017 01/01/2018 1,000,000 OFaFACCE En BER)EXCLUDED? N/A EL EAQ,-(ACCIDENT S 1,000,000 lM EL DISEASE-EA EMPLOYEE S If yes,desutbe under 1,000,000 DESCRIPTION OF OPERATIONS below '' EL DISEASE-POUCYOMIT S 'B Worker's Compensatio WCA3158730-20 01/0112017 01/01/2018 1,000,000 C Pollution Liability TIEDE654299117 01/01/2017 01/01/2018 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS f VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached inner.space is required) 17-18 Workers Compesnation Includes-All states except ND,OH,WA,WV,WY CERTIFICATE HOLDER - CANCELLATION 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 FOR Informational Purnoses `f ACORD 25(2016103) ©1988-2015 ACORD CORPORATION_ All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts rtp Department of Industrial Accidents ixi) = 1 Congress Street, Suite 100 Boston, jt1,4 02114-2017 • \,/ "' www-mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH !BE PERMITTING AUTHORITY. Applicant Information [ �j G / Please Print Legibly Name (Business/Organizalion'Individual): SLA-TPFeRd A J e cO E- //yit4 1,01 b CiOw-S Address: 2(c, 4Ussco lt4 City/State/Zip: P Phone #: tit( - 2>-8'— 7 Are you an employer?Cheek the appropriate box: Type of project(required): I.II am a employer with 20 temployees(full and/or part-time).' 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity. [No workers'comp.insurance required.] 9. ❑Demolition 3.0I am a homeowner doing all work myself [No workers'comp.insurance required]' 10 ❑ Building addition . 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions :.Q I am a general contractor�,�t a,!�d in„ hirede the sub-contractors listed on the attached sheet. 1 g.❑Roof repairs These db eo�ra hamv 'J.,�r3 aye workers'comp.insurance.:- �J 1 I 14.[ Cher Ali n �2 o.J 5.❑We area corpotah@ dr& lc' av -xercised their right of exemption per MGL c. lit c ah,and we have noemployees_[No workers'comp.insurance requited] n#40 itez €R-1/j *Any applicant that checks box#11 must also fill out the section below showing their workers'compensation policy inform non. -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. Ifthe 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. //]� ,1 Insurance Company Name: fire if12 f S (p 5. I..fJf'1� f Policy#or Self-ins.Lic.#: t,(�tA.3 E8'7 /Z q_ — Z'0 f Expiration Date: i/i h K n Job Site Address: 2 34 n5le 1S(Qn d (._t r. City/State/Zip: l r1Mov f 4 M A 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 the ains and penalties of perjury that the information provided above is true and correct. Signature: Date: 81' 3 —1 7 Phone#: 40 1- 2-1 T et?) 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#: oe o o 0 0 0 0 o V o o e e 00 0 0 0 0 do 0 b N V N ti 1(� Vl N tri tit Q ti.N. N V .�i 10 M N :, y ;y e C B, O 5 yyy .y H m e C O0 tl N p '.7 IJw y L. vii N el � '� C p. - 2q " a. j O W A _ . c�00etc F R. �., �� z m ,u, o o e �'.. 0o e w .a q NN c ," pj'tioo m r3 VN ee A rUoo �... o e j P. .0V' rNn vFj o0 0,0°+ Ly. R}Q.79y� F + r- v x ze ) N'> — d �oa —o h d C m y 0.. 'Ea cTo A U� o -- _ IQ i Ly .o -ci .o m v > F U A —i ee ecoC v \ Um m Td L L. a W, :2P. 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