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15 WILLOW AVE - BUILDING INSPECTION (2) The Conunonwe;dth Of Ma55;iCI7tlSeltl --� t Board of Building Regulations and Standards I c 712 1 \II NI( IP \I I I ) t :y -tassachusetts State BlAildinc Code. 780 ('!\1R. 7 ' edition Building Permit Application Tc Cunstrt . Rc air. Rem7Vate Or Deinoli.h a /lri n.J Uite- or Tiro-Fuiiile Dt, 'Ili r,� — -i Phis See m For Offici I Use Only Building Permit Numb r: a pli d: Bm lJmg co. . ..i.med 7 or ul 13ud & 0.1c SECTION I: . : INFORMATION 1.1 Property .\drJrys51 1.2 :\ssessors :\lap & Parcel Numbers I -------.-_ .- . 11-L✓,- , I. 1 a IV this un aci'epled sffee Y.' Yes____ no__ :%lap Number P.01CI 1'umber 1.3 Zoning Information: 1.4 Property Dimensions: i I Zoning Dslmt Proposed Use Lot Area(sq it) Frontage (itl -- 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided RrquueJ rJ I 1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone" Municipal ❑ On vtc disposal s m ste ❑ Public ❑ Private❑ Check if yes❑ P SECTION 2: PROPERTY OWNERSHIP' �\ 2.1 Owner Recur Q 6 S ylr1 e L' �� d lit l l('Dfw f l t.��-�---Pj D Name (Print) ^ P n �� Address for Srrviq' �� Signature �p ��N Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New COnstruetion ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) \l teruion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: Brief Description of Proposed Work': / ' SECTION 4: ESTIMATED CONSTRUCTION COSTS Iiem Estimated Costs: Official Use Only (Labor and Materials) 1. 13uilding $ 711 I. Building Permit Fee: $ Indicate how fee Is delel lumcd: ❑ Standard City/Town Application Fee '_. Electrical $ 7 ❑ Total Project G7sr (Item 6) .x multiplier .x 3. Plumbing $ ?. Other Fees: 5 5y- -I. Nfechanical (HVAC) S List: 3. Mechanical (Fire $ TOrd So) resswnl :\II Fees: Check No. —Check Amount: ('ash Amount. o Total Project Cost w ❑ Paid in Full 0 Outst:mdine Balance Uuc: SECTION 5: CONSTRUCTION SERVICES 5.1 Licenser! Construction Supervlsor(CS1.) Lucn.r Xlu --- tai�'� ..\ana•of CSl. Ill •r Z TAI1 1 IJ� 1 1 LI,I l'SLI\pC I,cr hrluw I h\. i. Uc.rl tutu __ WJlrs> /� Re,on,ted 1 ul, l07a.lN1U Cu 11.1 R Re,rnneJ IJc' fanul, I)wil6n_ —� Slellarllle VI Atusonry Unl, __—_— RC Re,l,knual I(IIUIIIIL Co,enng __ ___= Ielrphonle p/M,�L //� \\S Re,I,ieno.d %kwdn„ .old SIJIII_ Z/p�\v1 _� /✓r SF Re,ldclindl Solid I-lie ISul ul n'_ 1 „ LIMO ud.i .11li ni 1 ✓✓✓ ✓✓ VV ✓✓✓ IL------ � D Re,ldenU.d DCIIIolitI nI 5.2 Registere a It i r c •m •unit eWr (MC) MC Con r > Nalne or FI ' Reg . N'nn Reglslrauun Mundt r I :\JJreSs Sig - re ' Telephone _— S CTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(NI.G.L. c. 152. § 2506)) Workers Compensation Insurance affidavit must be completed ;Ind suhmitted with this :lpphCaPon. Failure n, pro,lde this affidavit will result in the denial of(he Issuance of the building permit. Signed Affidavit Attached'? Yes .......... No ... _ ._ ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 _ as Owner of'the subject property hereby authorize .-_____.-. to act un lily heh:Jf, in all matters relative to work authorized by this building permit application. Sienature of Owner -- ---- Uate S TION 7b: OWNER) OR AUTHORIZED AGENT DECLARATION I 1 llu R, - , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application :re true and Accurate, to the best of my knoMed,ge and behalf. y� Sign ire of wner or Authorized Agent Date (Si ned and r the aine and ,,hies if e(u ) NOTES: 1. An Owner who obtains a building permit to Jo his/her own work or an owner who hires :In unregistered conmictor (not registered in the Hume Improvement Contractor (HIC) Program), will not ha.e access to the arburauon program or guaranty fund under M.G.L. c. 11'_A. Other important information on the HIC Program and Construction Supervisor Licensing (CSl_) can be found in 780 CMR Regulau :ons I IU.R6 nd 1 R 105, ICNpcctively. I When ,uhstartnal work a planned, provide the mtormatiun below' Total floors area(Sq. Ft.) (including garage. finished basement/attics. decks or porch! Grohs living area I Sy. Ft.) Hahitahle room count Number rf tneplaces Number of hedruont, - -----_--- -. - Number of hathruums Number„t halt'h:uhs --_--__-- ---_- -- fNpe of heating system Number of decks/ poi,hes -..---_-- Type of cooling S)stem _.- i 'Total Project Square Foolage'• may he ,ubStituted tii "fotul Project Co,i" _ __J �="" ,Yl aesach usefts- llc 1:u'gnent ei'Pu111ic C;dct� I 4 Beard of 13dildin!_ Re,'tdations and Standards Construction Supervisor Specialty License License: CS SL 99699 ' Restricted to::WS, E, ROBERT POCZOBUT - 17 BEACH ROAD APT. 45�, LYNN, MA 01902 _ (: Expiration: 2/8/2012 "k aunn Tr➢4: 99699 �_ _ TN � - CERTIFIED (l(, VINYL SIDING INSTALLER t; ASTM D4756 '. t #800004816 Stnroaed by the varyt Sidmg'testiarte Poczobut, Robert Expires. 07/01/111 _. 17 Beach Road Apt 45 Adminlstered By. Lynn,Maseacbeseda 01902 Amapect..1 Testing Inc �� d f c PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Devld E ZellerIna Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 370 Lynn my ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Lynn, MA 01901 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Roblcco Inc 17 Beach Rd Unk 45 Lynn, MA 01902-0000 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING 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 THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. g LTR TTE OF INSURANCE POLICY NUMBER FOLICTIFFEUMDATI FOUCTEDIFIRATKINDATIll A KKfKs D EMPLOYERI'LNBILrrY -lum LIMITS - .. E PROPRM'rORI PAKTNERSR7KECUTNE OF ARE: ATITORY LIMITS IN 0 OWL❑ 7431459 7/23/2006 7/23/2009 _ Caw pAppll=toMAOp"w*OHy. HACCmENT 5 1,000,00 ISEASE POLICY LIMIT 5 1,000,00 rI SE E11 X EMPLOYEE s 1,000100 DI9SCPjPTION OF OPERATION HR7LESBPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION THD AT HOME SERVICES INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATTN; DARLENE EXPIRATION DATE THEREOF,THE IBSUNG COMPANY WILL ENDEAVOR TO MAID 3200 COBB GALLERIA PKWY 020 DAYS WRnTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT ATLANTA,GA 30330 FAILURETO MAIL SUCH NOTICE$HALL IMPOSENO OBLIGATION OR LNBILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 08-2T-2008 1408 FRNFTRD HOMIG IMr� READ TIDSa:v�.. a"lmbllcd by. g, Sold, pt-llomc Sc[e Sw Inc. dlela TheH J tAD uA 0�160 �; /_�_ WotcestM. BtyDeh Name: Bootee 345AGMM ( 657-5162:Fax(SOR)75fr1627 Tall FreehD?.l.k a C p2439%RI Coal lJch if427 �¢rsw� Number. Feaard ID a75-Z68�1.0"aapatconuadw Rea.M 126893 -- 33 QSow&31 CC Liao 365522: O, 7 state zip city 1R0b11aden Addreva: Ramerhaaa% rboaat Waeh twoaa [ 3 CRY Home Addrett l7 scede � I tl� Addtde) yes>:/]ls,dlS� (mactive 0o fim RTheeHw tDNM - V address.a8rc�mbuy. ❑t DO NOT-W.m Aveeae am mmkeuaC tb fe PaP )ocated et cite Defoe the installation taBatlon'7� �^Customet'�,me owners ofdfh&AsP 'liver and et:an8e 6v*d'c'md I'm t is Ids � At- feO° ys�Oe.�C be HoInc DM^t'�88 Seeed+). all of wbicb We i �g,�tt.ciuccdvelY. an,.�-ao•"ieiod m tba blow �o and PaYttrsot Samanny a¢echcd harem and any referenm along with any aPPuab1e Amfwt •Contract"): ieb W pee..aamawn R"a* S own lmalatiea ram/b/,o a S ( f �� 3 �f 7f� f7�r Cww o l7Sa u Dmn C7 lib S fia8 vYmdowa Ifauletaie ODeamsr Cov= Many Dose S a atwmdo" bmobawn d0utlenr Covem(]EeaY Dose C]- _ wima.e Inwwtee pCwoererCovaa O8a¢yDose O .dCeaaaMAmoaatd�uoPamtadea fdammusa. Ter dContract Amount s 7 /91 Maine Porelemara amy act dgadt mere men an+Yf td K art CosrrMAmwmC of the work for each Product.Cam will esectue a Completion CertificateO.av�.r a�aaa d ay' an fodivldnal SPae Sbat)add pay any balmtca doe. As OPea6lc.emob Q Order� (One ft m � sfted c sally obligated and liable hrammdOt- individuni P—Wea(s)included hannol at She Home Vapor msert'ra me rigid ro issue a Change Order or provider 4 W�6?��,ot Perform its Ob(Ige�ns due b a saocnaal is diacat ,if The Home Depot or its authorized service old.ub an or 1-d Pam4 errors Ot be"_m; dal hazard[mcb m mo]d,Mbearoa OdWr saffip'CfneetOE.PDrmP problem with me home,eavlronmea wink required to eomPI the job wan not bcluded f¢din ConDacr. eam fads the total t SraammY# t78sa.S3 . included as Pats at this Conaact. Pa rnee, nme nary_ 'ILe Pay��*0��and final pry cu sby Product(as appliable). Correct amwnt and paymcam nary . NOTICE TO CUSTOMER not atYa a' ompletion Certificate(note: You are entitled n a eompletvlY fBled-ln ropy of the Contract at ffie time you s1go. 9 Sb�)before work on am Product there is Due Cnopkd1 n CatAAcare for aaeh tlsted Product as defined by latdkAddal lsec is Complete. tatoner agraea pay The Home the coati of materlab,labor.espensea /n she event of hrmWetloa of title ConitaM.Gti � to cero ffer tiro the data o!terminstlon.Wes a Mho and serviCr+pcovlded by The ldome DepM err Amkosiaaqyd L71 amotmb act forth In thfa ppeemeat or a �arpEP05 ibPAYMEN OR OTHER PAYMENTS MADO E. �ONT T OWITA TO THE ROME DEPOT SROM THE TES FOR RECOVEltV OF gUCILAMOUNr9• 1.tMPPING THE![OTtdE DEpOT'S OTHER REhIED is tic arum agreement batamoa Crammer p nd Avidsdd : Coemmc apneas sad undersmnds fiM this A$Cmaem pftOY d�ssnOas and agrarnentk euhur ea a t)tpOr wrm tcpad eD ma}?soducta acid(ppmllauan saviaa e¢d a ed or emeadttd elaCept bg n writing signed g m eeitl Prods �icla�wwledgesisem a5"�'rba rag read,undamteads.voluntarily accepts the �Lbstome�efdxStlhen Hoare U�oi v�.mm of add Iran raeivad a copy of this Apemomc �. ®� . Sat s rent• Deco a gi�aatnra Ta No. caswm 's Signore Data Sales Comelad feat eNo. <s+ePptla3b) AGREE .t.AT1ONa CUSTOMER MAY CANCEL THIS pimvvaalyriuT WITHOUT PENALTY OR OBLIGATION BY mirvERDHG WRITTEN NOTICE TO THE HOME . . DEPOT BY MIDNIGHT ON THE THIRD BUSIINESS DAY AFTER SIGNING THIS AGRERKEN THE o W STATE SUpP18.eam ATTACFRD 00-20-06 PO4:03 IN CONTAINS A FORM TO USE 1F ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. rTjONSAM 6rAT9D ON T=RRVSRTR I®SAND ARn PART OFTHL%C.ONTRACr N=C'fi:AbMrrONAL TERM AND COND tl CSC Vrhae—detain Flb YGRW-Outtamar Wlk-Salea Comaama ACORfl_" CERTIFICATE OF LIABILITY INSURANCE 7EXTEND 100/YYYY) OB PRODUCER 1-404-995-3000 THIS CERTIFICATE 1S ISSUED AS A MATTMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPOIFICATE HOLDER. THIS CERTIFICATE DOES NOT END ORhomedepot.certrequestOmarsh.com ALTER THE COVERAGE AFFORDED BY TBELOW.3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE #INSURED INSURERA:Steadfast Ins CO 7 Home Depot U.S.A., Inc. - The Home Depot, Inc. INSURERS:Zurich American Ins Cc 16535 2455 Paces Ferry Road INSURERC:Illinois Natl Ins Co 23817 Building C-8 Atlanta, GA 30339 INSURERD:American Home Assur Co 19380 INSURERS Hampshire Ins Co 23841 COVERAGES - 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDI pOLICYNUMBER POUCYMEFFECIIVE POLICY EXPIRATION LIMBS DDATEA GENERAL LIABILITY IPA 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE S4,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS PREMISES Ea ccurenee $1,000,000 CLAIMS WOE a]OCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Any one parson) $EXCLUDED PERSONAL B ADV INJURY $4,000,000 k GENERALAGGREGATE - S4,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $4,000,.000 X POLICY PRO. LOC B AUTOMOBILE LIABILITY BAP 2938863-05 03/01/08 03/01/09 COMBINED SINGLE LIMIT X ANYAUTO (Ea accident) $1,000,000 ALLOWNEDAUTOS BODILY INJURY $ - SCHEDULED AUTOS (Per peman) HIRED AUTOS BODILY INJURY $ NON-OWNEDAUTOS (Peraodden0 X SELF INSURED AUTO ... ... PROPERTY DAMAGE ,S PHYSICAL DAMAGE - (Persmident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN EAACC S AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACHOCCURRENCE _ $5.000,000 X I OCCUR CLAIMSMADE AGGREGATE S5,000,000 E DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION AND 1928757 (FL) 03/01/08 03/01/09 X TORY WCSTATT OTH- EMPLOYERS'LIABILITY S ER D 1928756 (CA) 03/01/08 03/01/09 E.L.EACH ACCIDENT $1,000,000 ANYPROPRIETORIPARTNERIE%ECUTIVE - - E OPFICERIMEMBER ExCLU0E07 1928755(ADS) 03/01/08 03/01/09 E.L.DISEASE-FA EMPLOYEE $1,000,000 Has,describe under SPECIALPROVISIONSbelow E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER F TX Employers Excess TNS-C45197967 (TX) 03/01/08 03/01/09 ccurrence/SIR 25M/2M D Workers Compensation 1928759 (QSI) 03/01/08 03/01/09 E Workers Compensation 1928758 (KY, MO, NY, WI) 03/01/08 03/01/09 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS -FOR EVIDENCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2455 PACES FERRY RD., N.W. BUILDING C-8 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA *419-7 ACORD 25(2001/08)datkinson ©ACORD CORPORATION 1988 8213215 063-A-a79 43-43 DR VI-a y VLnilo NPRC . 5100 Product Do..101¢-Man1 I Vautana da dobl¢ gaillotina Argon/Prosalar I Arg6n/Pro9olar Netlond Fenestration 3/32" Glass 1 2.38 amt Vidrio - RaftC=dls No Laninatad Class 191n vidrio lamLnido ® No Grids I Sin rajillas ENERGY PERFORMANCE RATINGS eOLUACMDEPOMMOMBOROMM U-Factor Solar Heat GainCoefltdent fxaorU - CoeedwomGmands de Energla Solar 0 . 32 1 . 6 0 . 29 ADDITIONAL PERFORMANCE RATINGS MrAULACWNSUpU n MAMDErm DIMIENro VfsibleTiansmittance TmnsmBmnde(01" 0 . 52 NaodaWrtr dlRoides smt emee row ardamt m eppksift Nim pamdaas tar cid nnir"Mmla padmt permrmmma•w1C rowareddmnhedmratemdeetorerrvhausmnmlca111edmmpdasped9e110",3m0IFFEdoesnotiewtur ndarypadd addmnotwwWft aWlaNBy AanypmdactNanYVedli:aee.0¢¢ultnmadeaOoeYs MOO foram po0xtparbmm= -- ` hhonroa awwvj*CM - ------ ---------------==-=---- --------- :._. 6bteplmMeesdPdagAedoeve101 curiplam con bsprocaft adoseptaNmdeWCpmademrahadras@dertamteldel poaslatos I maampor WW=det ..kmdaeporunm ftflode amb Yun4enan depoMM vi NRICnoromnderdedrpwpaductoYmgeradfa9tadpoduo0o 0188dKINKIDIMMUnnsour M ,cormtboond ftft dal Winuft loss drmoepopladodo Nis p oluchwwwrdteag UnLt gaalLlias tov ENERGY 9TAR r¢Qion(¢) : North¢rn, North Cant+ai, South Cnntral, Southern. La anidaa oaliSioa pars LAW SNERSYSTFR r¢71en(se) ENERGY STAR: Norte, -Noma C¢ntral, Sur Caettral, gar. •� IND: R¢in OG/Class 3/32"/B-R43 T¢sL¢a-91za: 36" x 63" IND: Essfs rro GG/VLdrio 2.38 sea/B-R43 - DP " +45/-45 Taseatlo grobado: 91.4 en x 160 Con Efi9fi09fi1a1 4G773 B9 Norman 2951120 KeepftI W for po%bEiER6TSWl°m6maLTo loan nmmvilewN.easVIapw Grade esm gnfmm pool pagbs reemholms EI[R6Y SW Pao mnocamds owto do mt.vkh wwNievot4oL ----- 0 >oarxrxoaaaeala�✓l�ooaaa4aaelO Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registr•.�cl!L� 126893 Ekffilfx�/2010 a 6—plement card The Home Depot^Apae id'e = y RICHARD FALLO. 3200 COBB GALLS 1W #20 �` 1 RTLANTA,GA 30339~-`` The Commonwealth of Massachusetts Department of Industrial Accidents , Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aipplicant Information Please Print Legibly Name (Business/Organvation/Individuai): Address: City/State/Zip: Phone#: A;re an employer?Check the appropriate box: Type of project(required): 4. Q I am a general contractor and I 1. I am a employer with_ _ 6. ❑New construction employees(full and/or part-time) have hired the subcontractors listed on the attached sheet.: 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have g. Demolition ship and have'no employees employees and have workers' working for me in any capacity. 9. ❑Building addition [No workers' comp.insurance comp.insurance.t 5. Q We are a corporation and its 10.❑Electrical repairs or additions 3. I required.] h homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12 ❑ repars insurance required.]t C. 152,§1(4),and we have no 13. Othe$ 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: t Homeowners who submit this affidavit indicating they am doing all work and then him outside connectors trust submit a new affidavit indicting such. 1Contractors that check this box must attached an additional sheet showing the nam of the subcontractors and state whether or not those entities have etrmloyees, if the subcontractors have ettployees,they most provide their workers'.wrnp.policy number. I am an employer that is providing workers'compensation hrsarance jar my employees Below is the policy and job site information. r— Insurance Company Name: � Expiration Date: Policy#or Self-ins.Lic.#:__I t.��r- Job Site Address: 6 M 110 A) i V— 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. 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 n er e p ' s and penalties of perjury that the information provided abov is i and correct Si ature Date: Phone#: o fficial only. Do not write in this area,to be completed by city or town official, n: Permit/License# 11 hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5:Plumbing Inspector son: Phone#: