B-19-1218 - 0061 BRIDGE STREET - Building Permit The Commonwealth of Ma49'i6 u � °t +
Department of Public Safety
-� Massachusetts State Building Codeaft� R}
Building Permit Application for any Building other than a One-or Tv oo-1716 i Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1 No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
it
Existing Building❑ Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑/
Is an Independent Structural Engineering Peer Review required? Yes ❑ No @'
Brief Description of Proposed Work: tt-tnHSfN&t F^, �A W_A &26 a "I.J.
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) ❑
Existing Use Group(s): 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.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ i
Private❑ or indentify Zone: or on site system❑ required❑or trench ' or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
R Not Applicable❑ Is Structure within airport approach area? Is their review completed?
f or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
="SECTION 10:`CONSTRUCTION CONTROL(Please fill out Appendix 2)
f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered istered Professional Res onsible for Construction Control
Q,%Grp irll 6e,1'Min, s -_7,j
Name(Registrant) Telephone No. e-mail address Registration Number
Set A dress City/Town State Zip Discipline Expiration Date tre
10.2 General Contractor
�.�I-Q C�v�Gi-r'asc�-.gyp��.C.!'�►�s�
Company Name
n iav8S&II c v1resr-°c a uk —f l2`�W2
Name of Person Respc,Asible for Construction License No. and Type if Applicable
I6A 4VW,*V_ ML_Pt!R Ak-1 icy
Street Address City/Town State Zip
Telephone No. (business) Telephone No. cell e-mail`Gaddress
SECTION.11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with 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 ❑
` SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ /20100Q90 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ N appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note.Minimum fee $ (contact municipality)
11>
5.Mechanical Other $ Enclose check payable to Ct
6.Total Cost $ 2-01000. 00 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my k derstanding.
rA
g /u,,,
Please print and sign name Title Telephone No. Date
<<�r/ial+.c� �"� �,nve►'SAJA 0197_3
Street Address, City/Town State Zip
' Municipal Inspector to fill out this section upon application app11 roval: _
Name Date.
® DATE(MM/DD/YYY1
ACCIRO CERTIFICATE OF LIABILITY INSURANCE
08/26/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject 1
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to tt
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT NAME: Maureen Lashua
WT PHELAN PHONE E (781)641-7228 F� No:
E-MAIL helan.comth l maureen.asua w
ADDRESS: maureen.lashua@wtphelan.com
645 MASSACHUSETTS AVE INSURERS AFFORDING COVERAGE NAIC#
ARLINGTON MA 02476 INSURERA: AIM MUTUAL INS CO 3375E
INSURED INSURER B:
JLP CONSTRUCTION SERVICES LLC INSURERC:
INSURER D:
468 SUMMER STREET INSURER E:
MANCHESTER MA 01944 1 INSURER F:
COVERAGES CERTIFICATE NUMBER: 440990 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIC
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MNVDD/YYY MM/DD/YY Y EFF POLICY P
LTR LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR DAMAGE TO RENTED
PREMISES Ea occurrence) $
MED EXP(Any one person) $
N/A PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY❑ PRO-
POLICY ❑ LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED I I RETENTION$ PER $
WORKERS COMPENSATION X STATUTE ERH
AND EMPLOYERS'LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000
A OFFICER/MEMBEREXCLUDED? wA WA WA VWC10060234532018A 12/12/2018 12/12/2019
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/lwd/workers-compensation/investigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOF
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 1
61 Bridge Street LLC ACCORDANCE WITH THE POLICY PROVISIONS.
1393 Broadway
i AUTHORIZED REPRESENTATIVE
Saugus MA 01906 C�
Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA
a 4000_11me ArnDn rnD0n0ATrnAr Au.o-;%#-...
ACOOREP® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY
08/26/2019
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 Maureen Lashua
NAME:
W.T.Phelan&Company PHONE (781)641-7200 FOX (781)646-2410
A/C No Ext: A/C,No):
645R Massachusetts Avenue E-MAIL maureen.lashua@wtphelan.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Arlington MA 02476 INSURERA: Western World Ins.Co. 13196,
INSURED INSURER B:
JLP Construction Services LLC INSURER C:
468 Summer Street INSURER D:
INSURER E:
Manchester MA 01944 1 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL18121213417 REVISION NUMBER:
THIS IS TO CERTIFY THATTHE 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTE15-
CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 100,000
MED EXP(Any one person) $ 5,000
A NPP1504015 12/12/2018 12/12/2019 PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY JEC LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANYAUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROP RIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? ❑ N/A See WC Certificate
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Re:Location 61 Bridge Street Salem MA 01970
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
61 Bridge Street LLC ACCORDANCE WITH THE POLICY PROVISIONS.
1393 Broadway
AUTHORIZED REPRESENTATIVE
Saugus MA 01906
6N 4noo enee Amon rnennowrinsl en.:..wa... ..
Initial Construction Control Document
To be submitted with the building permit application by a
o d . Registered Design Professional
w` for work per the ninth edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title:Fire Damage Roof and Second Floor Repair Date: October 30,2019
Property Address: 61 Bridge Street Salem MA
Project: Check (x) one or both as applicable: New construction X Existing Construction
Project description: Partial Roofing Replacement and Repair, and Second Floor Repair of Fire Damaged Two
Story Existing Residential and Commercial mixed use builing per submitted drawings
I, Richard Griffin, MA Registration Number: 7814 Expiration date: August 31, 2019 , am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
X Architectural Structural Mechanical
Fire Protection Electrical Other:
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 Construc ' of Document'.
\S�ERED AR
�yi
W. cps TFc�
Enter in the space to the right a"wet" or
0 No.7814 Z
electronic signature and seal: � SALEM,
�0� MA
TN 0 P S
Phone number:978-740-9979 Email:rchard@derbysq.com G
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1.Indicate with an'x'project design plans,computations and specifications that you prepared or directly supervised.If'other'is
chosen,.provide a description.
Version 01 01 2018
Initial Construction. Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the ninth edition of the
Massachusetts State Building.Code, 780 CMR, Sectiorr.107
Project Title:Fire Damage Roof and Second Floor Repair Date: October 30,2019
Property Address: 61 Bridge Street Salem MA
Project: Check (x)one or both as applicable: New construction 'X Existing Construction
Project description: Partial Roofing, Replacement and Repair, and Second Floor Repair of Fire Damaged Two
Story Existing Residential and Commercial mixed use builing per submitted drawings
1, Richard Griffin, MA Registration Number: 7814 Expiration date: August 31, 2019 , am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
X Architectural Structural Mechanical
Fire Protection Electrical Other:
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 iter n 3.).together with pertinent.
comments;in a form acceptable to the,building official.
Upon completion of the work, l shall submit to the building official a 'Final Construc orrCo?ndol Document'.
t -�F
Enter in the space to the right a"wee' or J..
electronic signature and seal: ;s ; ; "°"
Phone number:978-740-9979~ '. AEmail: richard@derbysq.com
Building Official Use:Only .
Buil'dingg Off ctai N6e::v .Permit No.: Date:
Note:l Indu°site witF an x"project ifesign plans,computations and specifications that you prepared or directly supervised. if other'is
chosen,provide a'des.ript'ion..
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CITY OF SALEK MASSAC;ER SE'1"I'S
Buwm DEPARTbaw
120 WAsmNGTON STREET,3m FLoOR
tL.(978)745-9595
FAX(978)740.9846
KDABERLEY DRISOOLL
MAYOR THcmAs STYmRRE
DIRECTOR OF PUBLic PROPERTY/BuaDING 001►MSS CMR
Construction Debris Disposal Affidavit
(required for all demolition & renovation work)
In accordance with the sixth edition of the State Building Code,780 CMR,Section 111.5 Debris,
and the provisions of MGL c40,S54;Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,S350A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
/'A ✓•
(address of facility)
Signature/ a scant
(today's date)
CITY OF S.,UX.IN4 2UNSS.�CHLTSETTS
BUUMLNG Dunn omr
` 120 WASHINGTON STREET,3a°FLOOR
TEL (978)745-9595
FAX(978)740-9846
1CI«BFRi Y DRISCOLL
THO
MAYOR II+NS ST.PIERRB
DIRECTOR OF PI:BLIC PROPERTY/BUILDLNG CONL�13SSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben
Applicant Information Please Print Le 'bl
Name(Business,OrpnizatioNlndividual): v4S 'L P ,
Address: qu v-
City/State/Zip: Atne(rt bi MA 0111y Phone :_ 9 6—
A571
an employer?Check the appropriate box: Type of project(required):
i. am a*employer with 2_ 4. ❑ 1 on a general contractor and 1 6. Q New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑=emofitton
ling
ship and have no employees These sub-contractors have $.
working for me in any capacity. workers'comp.insurance. 9. Q Building addition
(No workers'comp,insurance 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.Q PI bing repairs or additions
myself.[No workers'comp. c. 152, I(4),and we have no 12.[ Raof repairs
insurance required.)t employees.[No workers' 13.❑Other
comp.insurance required.)
Any applicant that checks box#I must also rill uut the section below showing their workers'comnpMUdon policy information.
t I I-neownem who submit this affidavit indicating they am doing all work and then hire outride contractors must submit a new affidavit indicating such.
=Cunimnors that cheek this box must attached an additional shah showing the name of the sub-contractors and their workers'comp.policy information.
I am an emplayer that is providing workers'compensation insurance for my employees Below is the Polley and job site
information.
Insurance Company dame: % lawtua
Policy#or Self-ins.Lic.#:_ St'_� Cet'i;F�CO.tP Expiration Date:
Job Site Address: 6 ] R r**,e <t- _ City/State/Zip:_SeL I e tAA on 1 q'7-o
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 S250.00 a day against the violator. 13e adviwd 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• undo the ns and penalt/es of perjury that the information provided above is true and correct
t tr ' Date- - l—
Ojjcial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/1.1cense#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.Cityll'own Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other ._
Contact Person: Phone#•