Loading...
0 CLARK AVE - BUILDING INSPECTION (2) MA Lt< *q5 -7L The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling i -Thi s Seohon Fbr Officn Use Only �` r m e Buildmg Permit Number : Dae pplied p "Budding:0fficial(PrintName) . Signature � .:. SECTION L SITE INFORMATION, ].1 Pro erty Address: . CAit; ,L — 1.2 Assessors Map&Parcel NumbersTl �� 1.1 a Is this an accepted street?y,s W no Map MNumyet -- ------- - - - 1.3.ZoningInformat Parcel Number ion: n 1.4 Property Dimensions: Zoning District proposed Use e ---- Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Required -- —'--- _. Rear Yard Provided Required Provided Required Provided - 1.6 Water Supply: (M.G.L c.40,§54) 1.7 IF Zone Information: Public Li Private❑ -- Zone: Outside Flood Zone? 1.8 Sewage Disposal System: .: Check ifyes❑ Municipal❑ On site disposal system ❑ SECTION 2. PROPERTY O 2.1 Owner' WNERSHIPI ecord:un - In, Name(Print) 5 e A 61-9-7c, L C ,In fk ^` _ miry,MlP ate,L No.and Street 7`t -- Q Telephone �S 1 Email Address LECTION 3:DESCRIPTION OF PROPOSED WORK Z(check all thafapply). New Construction❑ Existing Building❑ Owner-Occupied ❑ Re airs s Demolition p O Alteration(s) ❑ Addition ❑ ❑ Accessory Bldg. ❑ Number of Units Brief Description of Proposed Work2: Other 11Specify: - p 1 t SECTION 4.ESTIMATED CONSTRUCTIONCOSTS Item Estimaled Costs: u, Labor and Materials Official Use Only 1.Building $ � �1 BuddingPermtfF,ee $ h � � ? Indicate how fee is deternamed,- 2.Electrical $ ❑Standard Cityrfii Application Fees -3.Plumbing_-_ _ _- $ _ - ❑Total Prgect Cos('-(Item 6)x mulhpher x A _ --.Mechanical (HVAC) $ List: N 5. Mechanical (Fire " �� . �• Su ression) $ Tota hAll Feea 6. Total Project Cost: $ 7 Check N0. Check Amount:` Cash Amount. " b0 .0 Paid in Full,,., 'r ❑Outstanding Balance Due .. .... .. ... .... . SECTIONS: CONS CRUCTION.SERYICES , 5.1 Construction Supervisor License(CSL) HolHol �Ukyrl License Num r Expiration Date Name of CSL der Q(- Ce d G r List CSL Type(see below) U No.and Street Type Descnphon r ' p t _W,D6 v 1'n h)A. Q I, C�a Unrestricted(Buildin s u to 35,000 cm ft.) CIT/Town,State, IP - Restricted I&2 Fami] Dwellin M Maso RC Roofm Coverm WS Window and IT, - 1 SF Solid Fuel Burning Appliances �(Oc� T�mfr,e�.�ra cJrn I Insulation Tele hone Email address_ D Demolition - 5.2 Registered Home Improvement Cn%trector(HIC) IV S. �__ I �— _`ti—�-�z_ HI Coml�Au,v Name or, C.Regis t Name -- HIC Registration Number Expiration Date b cxrJRs elf. obL) n No.and Street ` Y,G sJ v.Ga 7 1 933 y l c�a Email addre s Ct /Town,State,ZIP Tele hone SECTION 6: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 building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE,COMPLETED WHEN OWNER'S AGENT OR CONTRACt�TOR APPLMSrr,,FORBUILDING PERMIT I,as Owner of the subject property,hereby authorize yvCt.J ro V. Gr'ce n L� to act on my behalf,, n all matters relative to work authorized by this building permit. plication. [By rint Owner's Name(Electronic Signature Date SECTION 7b: OWNERr OR A. 11 . UTHO I&D.AGENT DECLARATION—— 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 knowledge and understanding.. Print Owner'sor Autho�t's Name( eetronic Signature — ) Date NOTES:' 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www mass gov/dls 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) _ (including garage,finished basement/attics,decks or porch) — — — -=Gross livin area=s ft --- g ( 9' ) — — -- �_----_ Habitable room count ----------- Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" MA Reg#146589 Contract# CT Reg#0605216 Federal ID#,20-�c625'1L'g'" RI.Reg#26463 Home Improygment5olutlons `J 6 iJ Corporate Headquarters,26 Cedar St,Woburn,MA,(P)800-342-2211 (F)781-933-9626,www.newpro.com (J _ THIS CONTRACT MADE THE ✓6 day of Jif) 20L? between A i -5 /V T, I- .7.4..4/" - % (Home Owners) - (Home Phone) (Bu Ce//P neJ (Address) r (City) (state) (zip) -the"Owner"and NEWPRO Operating, LLC, "NEWPRO". b (E-Ma//)forproprietary use on/y NEWPRO hereby agwpss that it will for.the consideration hereinafter mentioned,furnish all labor and material necessary to install the following described work at the premises located at: The job address is a condominium. (✓ob Address) TOTAL# - NEWPRO WINDOW OPTIONS: WINDOWS I SERIES# Grids:LJ YES LJ NO ❑CONTOUR LJSDL LJEURO rJ DIAMOND Window color CITY I Window color QTY OBSrrMP:(Locibon) ❑TOP [J BOTTOM Int: Int: Screens: (Exterior color Full Screen Standard) ❑HALF ❑FULL Ed: Ext: Vent latches: ❑YES ❑ NO Capping Color:?WtJrT( l SI771 UDOOR$ MODEL CITY P/ease/n/t/a/-• PVC Smooth LJ Noll LJ No Cap Irl Sliding Glass Door T­7 77 MODEL NAME MODEL# QTY Color InJ() Out Double Hung / Active: jeftl Center Right Customer understands that NEWPROO 2 Lite Slider / HDWR: SN B BGE WH does not do any painting or staining. , ' 3 Lite Slider (1/4,112,114) Entry Door Style.yl{7 �-XP I. lie:when removing or replacing interior 3 Lite Slider (M,113,1/3) f Color In. )9(7-koutJ rff stops or trim). NEWPROO is not respo- Casement(Hinged Right) f Fiberglass Steel risible for conditions or circumstances bey- Casement(Hinged Left) f HDWR: SN © AGB AB ORB and its control including condensation resu- Twin Casement / sldentss style I I / lting from or due to pre-existing conditions Stationary Casement / Color IrV ' --Out: /7-,� a(ciicie one): Triple Casement (1/4,1/2,114) j Storm Door S Io. 7 CASH - Triple Casement (113,13,1)3) f Color In pl7z—Out"7 t5oe e, Balance paid toinstaller at completion Picture Window / HDWR: SN BB AGB AB Sash Only / Left Hinge Right Hinge FINANCE Hopper f Em Door$tyle Bank completion form signed at installation Awning f Color In: _'AOt: Garden Window Fiberglass Steel TOTAL Bay Window(Roof/Soffit),f HDWR: SN" BB AGB AB ORB CASH Bow Window(Roof fSofft6 Other'Door$tyle PRICE o Other Color In_,i�_ Out: DEPOSIT= h Other HDWR: /' WITH ( 000) -. DESCRIBE WORK&PROMOr/ONSAPPL/ED"rfjteG( ," 6 f rl'y/y' `ORDER S4, /V//,)t:;, V0M' W/ O W1 S_—i Yl 4,?r 17 P ) L-b UU TOTAL Q67 �7f'I/.- .� 1 :7 1 �f/U � � Ue✓T�l�/}"✓C'' fI/ .0 DUE AT 7 l7L? 1�J J 714 S r 0tf M r10,07r, -T-0-0 J/7.x' C /i INSTALL %V rZ.I t'1 L "d 07 n L 7-14,4,- Al 2p/-" /.�5,6� Est Stat Date.`Z -� `a/�Est Comp.Date: '1' p /.,J" 'f.� Customer understands this is an"estimated date" Owner has read and agrees,to the terms and conditions on the front and the reverse of this Agreement. Owner specifically agrees to the(1)Total.Cash Price; (2)work being performed; and (3)work not being performed. Owner understands that this Agreement and any attachments contain all of the promises made by NEWPRO. Owner has been orally advised of his right to cancel this transaction at any time prior to midnight of the third business day after the date of this transaction and Owner was provided with two(2)copies of a cancellation form explaining this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Rhode Island Sales Only): Notice to buyer: (1) Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of then available Information are left blank. (2)You are entitled to a copy of this Agreement at the time you sign it. (3)You may at any time pay off the full unpaid balance due under this Agreement, and In so doing you may be entitled to receive a partial rebate of the finance and insurance charges. (4)The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement. (5)You may cancel this Agreement if it has not been signed at the main office or branch office of --� the seller, provided you notify the seller at his or her main office or branch office shown In the Agreement by registered or certified mall,which shall be posted not later than midnight of the third calendar day after the day on which"the buyer signs the'Agreement, excluding Sunday and any holiday on which regular mail deliveries are not made. See the'"accompanying notice of cancellation form for an explanation of.buyer's rights. (Rhode Island Sales Only): Owner acknowledges receipt of required Contractor's Registration and Licensing Board consumer education materials. (Owner's Initials) \ By: I �ft�oC �� `" �L EIN# Signed: ` ��`.J*.,, Product SSppeclallsirPr/ntedNama) Owner u By: , .,� ' �� Signed: NEWPRO Operating,LLC(S/gnature) Owner -�; a' US-15 ;„ .WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy Ro714, _,.,t ADDITIONAL TERMS AND CONDITIONS Warranties: Any product warranties are provided by the manufacturers of the products that Owner is purchasing. NEWPRO is also, providing Owner with a labor warranty, which covers NEWPRO's labor. Owner understands that Owner should read all the written warranties for complete details of warranty coverage and that warranties are available for complete review before signing this Agreement. Late Cancellation: Owner understands that Owner has three (3) business days to cancel this Agreement. Owner understands that if Owner wants to cancel this Agreement after those three (3) days, NEWPRO does not have to allow that. Owner understands that if NEWPRO does let Owner cancel, however, that Owner will have to pay to NEWPRO a late cancellation fee equal to 33.3% of the purchase price in order to cover NEWPRO's labor,administrative,and material costs. Delay/Unknown Conditions/Damages: Owner understands that if NEWPRO determines within thirty(30)days of the date of this Agreement that it cannot perform the work according to NEWPRO's professional standards,NEWPRO can cancel this Agreement,notify Owner of cancellation,and promptly return Owner's money.Owner understands that issues that may cause NEWPRO to cancel this Agreement include incorrect pricing or unknown pre-existing conditions to the property. Owner understands that NEWPRO is not responsible for structural or other defects in the proPerty,and that NEWPRO's products do not cure these problems. Owner understands that the work could be delayed by events that NEWPRO does not control. Owner understands that NEWPRO is not responsible for(a) damages due to causes beyond NEWPRO's control,(b)damages arising from a delay in NEWPRO performing under this Agreement,or (c)unintentional damage to Owner's personal property,it being understood that it is Owner's responsibility to remove/secure his personal property prior to commencement of work. When Money Is Due: Owner agrees that when the work is "substantially complete", Owner will pay the balance due on this Agreement. Owner understands that "substantially complete" means the work has been materially finished, functional as intended, and a final inspection,permit, or occupancy certificate, if required,has been obtained. Owner agrees that once Owner has paid the purchase price, if Owner believes any of the work performed by NEWPRO is defective or incomplete, NEWPRO will inspect the work and perform any service Owner is entitled to under this Agreement and/or any warranty. Owner agrees that if Owner does not pay any of the money when it is due, Owner can be charged a late fee of 1.5%on the amount owed for each month the money is not paid. Owner agrees that if Owner defaults on any promises under this Agreement,and NEWPRO hires an attorney to enforce this Agreement,Owner will pay NEWPRO its reasonable legal fees and related costs or expenses,as long as it is legal for Owner to do that. Other Understandings: Owner agrees that Owner will assert a dispute,claim,or controversy (hereafter referred to as a "Claim") arising under or relating to this Agreement only on behalf of Owner's own self and that Owner will not assert a Claim on behalf of,or as a member of,a class or group in either an arbitration proceeding,a private attorney general action or in any other forum or action. If a court determines that this.specifrc paragraph is not fully enforceable, the court's determination shall be subject to appeal. This paragraph does not apply to any lawsuit or administrative proceeding filed against NEWPRO by a state or federal government agency even when such agency is seeking relief on behalf of a class of buyers. Owner agrees and understand that if Owner finances the work, Owner's separately provided financing documents will include the number of monthly payments and the amount of each payment, including any finance charge. Owner promises that he will provide NEWPRO with access to the work area, including access to electrical outlets. Owner understands that this Agreement and any attachments make up the entire understanding between the parties. Owner agrees that any change to this Agreement must be in writing and signed by both parties. (Massachusetts Sales Only): All contractors and subcontractors must be registered by the administrator of the Board of Building Regulations and Standards and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170, Boston,Massachusetts 02116 Telephone: (617)973-8700. It shall be the obligation of NEWPRO to obtain any and all permits necessary under this agreement,as the Owner's Agent.NEWPRO shall advise Owner of any necessary permits. The Owners who secure their own construction-related permits or deal with unregistered Contractors will be excluded from the guaranty fund provisions of MGLC, 142A. Any deposit required under this Agreement to be paid in advance of the commencement of work shall not exceed the greater of one-third of the total contract price or the actual cost of any materials or equipment of a special order or custom-made nature,which must be ordered in advance of the commencement of work,in order to assure that the project will proceed on schedule.No final payment shall be demanded until the contract is completed to the satisfaction of the parties. (Rhode Island Sales Only): THIS IS A NON-NEGOTIABLE CONSUMER NOTE. During the term of this Agreement,NEWPRO shall maintain public liability and property damage insurance covering the work of not less than$500,000 combined single limit,bodily injury and property damage and workers' compensation insurance as required under chapter 29 of title 28_NEWPRO and/or subcontractors or material persons may file a lien in accordance with Rhode Island Mechanics Lien Act,chapter 28 of title 34. (Maine Sales Only): Consumers are strongly advised to visit the Attorney General's publicly accessible website (www.maine.gov/ag) to gather current information on how to enforce their rights when constructing or repairing their homes. The Attorney General can be contacted by telephone at 207-626-8800. Any alteration or deviation from the above contractual,specifications that results in a revision of the contract price will be executed only upon the parties entering into a written change order. In addition to any additional warranties agreed to by the parties, NEWPRO warrants that the work will be free from faulty materials; constructed according to the standards of the building code applicable for this location; constructed in a skillful manner and fit for habitation or appropriate use. The warranty rights and remedies set forth in the Maine Uniform Commercial Code apply to this Agreement. If a dispute arises concerning the provisions of this contract or the performance by the parties that may not be resolved through a small claims action, then the parties agree to settle this dispute by jointly paying for one of the following: ❑ Binding arbitration as regulated by the Maine Uniform Arbitration Act, with the parties agreeing to accept as final the arbitrator's decision; ❑ Nonbinding arbitration, with the parties free to not accept the arbitrator's decision and to seek satisfaction through other means, including a lawsuit; or x❑ Mediation, with the parties agreeing to enter into good faith negotiations through a neutral mediator in order to attempt to resolve their differences. (Connecticut Sales Only): THIS INSTRUMENT IS BASED UPON A HOME SOLICITATION SALE, WHICH SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT. THIS INSTRUMENT IS NOT NEGOTIABLE. The owner(s) of NEWPRO is or has been a shareholder, member, partner, or owner of the following corporations, limited liability companies, partnerships, sole proprietorships or other legal entities that have been a home improvement contractor during the previous five years: NONE A p ) ® DATE(MM/DDMYY) CERTIFICATE OF LIABILITY INSURANCE 1 1/6/2015 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 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 endomement(s). PRODUCER CONTACT Melissa Pflug g Mackintire Insurance Agency Inc PHDNE (508)366-6161 AAC No: (508)366-5202 11 West Main Street ADDRESS:melissap@mackintire.com INSURER(S)AFFORDING COVERAGE NAIC If Westborough MA 01581-1931 INSURER A Netherlands 24171 INSURED INSURER B:Libert Mutual/Peerless 24198 Newpro Operating LLC INSURERCAcadia Insurance Co. 26 Cedar St. INSURER O: INSURER E: Woburn MA 01801 1 INSURER F: COVERAGES CERTIFICATE NUMBERMs ter 14-15 - 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. INSR TYPE OF INSURANCE ADDL UBR POLICY NUMBER MMIDDY/YYYY MM/DDEFF V EXP TR NYYY LIMITS GENERAL LIABILITY y EACH OCCURRENCE $ 1,000,000 DAMAGE TOR NTED 100,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A 7 CLAIMS MADE OCCUR CBP 8589577 2/31/2014 2/31/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 8584174 2/31/201412/31/2015 BODILY INJURY(Per accident) $ X HI/REOSAUT S AUTOS X AUTOS�ED - PROPERTY DAMAGE $ Per accident Uninsured motorist Blsplit limit $ 250,0001 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X RETENTION$ 10,00 U 8582578 12/31/2014 12/31/2015 $ C WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNEWEXECUTIVE Y/N E.L.EACH ACCIDENT $ 500'000 OFFICER/MEMBER EXCLUDED? N/AC-20-20-003506-02 5/01/2014 05/01/2015 (Mandatoryin NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below, E L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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. To Whom It May Concern AUTHORIZED REPRESENTATIVE T Moynagh/KRISTI ACORD 25(2010/05) - ©1988-2010 ACORD CORPORATION. All rights reserved. INR025 r?mnns m Th.Arman..or.,o....+lnnn pro•nnl=fnr=d mnr4=of ACr1Bn The Commonwealth of Massachusetts - Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): /`�pr, ;-�(.-a ,� rte.f-I n-, /LL Address: a(,' Ceda c S r City/State/Zip: (�!�,rr) t rng (�)/ a p r Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.� I am a employer with SO 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. R Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself [No workers' comp, a 152, §1(4), and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.0 Other *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Iota an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: hgoC JC w)6-e, 145C.rX,y Policy#or Self-ins.Lic.#: Expiration Date:�� f ' Job Site Address:-6 CIG.-k -t t T ty p: ��e M1� �( Ci /State/Zi 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 under the pains and penalties ofperjury that the information provided above is true and correct. Signature ���ZB?'I'LQ,�f �� ' / Date- Phone# atePhone# Official use only. Do not write in this area,to be comple7by7Electrical icialCity or Town: Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk Inspector 5.Plumbing Inspector().Other Contact Person: rice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 146589 Office of Consumer Affairs and Business Regulation lww" Type' 10 Park Plaza-Suite 5170 Expiration: LLC. 15 Supplement Card NEWPRO OPERATING, LLC. Boston,MA 02116 THOMAS FOXON 26 CEDAR ST. g ������ WOBURN, MA 01801 — ��4'�L�—"ir'—"— Undersecretary Not valid without 5igry c®r, � Massachusetts.- Department of Public Safety Board of Building Regulations and Standards Cmetrucnnn Supen'isur _+cense CS-029090 THOMAS P FOXCIN - ' - 230 WALNUT ST - READING MA >;ommissioner 11/19/2015 -