82 LINDEN ST - BUILDING INSPECTION _ --- I'lie C'unnnumcc:dlh of bfassachusclts
Board of Ilkidding Regulations alld SrutdarJs CI'L1. OF
111 s �Lssaehtuetts� Sl;ttc Building).Cute, 790('MR SALEM
I)mllding Permit Applicathill To Construct. Repair. Rcn ate r Demolish a
Onv-or Tuu•fiu ol,' D'velli..
This Section For Olticial Use Onl
Building Permit Number: _ e Applied:
-JlluiiiJing Ulllcial(Print N;une) gnat Dale
SECTION I: SITE INFOR31ATION
L I�rope�y�JQre :YI S 4- QI�I°h 1.2 Assessors mAls dt Parcel Number
"fd1 C7 S
I.la Is this an acce led street? m no \Lip Nunsher I'umel Nmn,Aer
I,J Zoning Information: 1.4 Property Dimensions:
Tiling District 1'ropuseJ ll—.w Lut Areu(s III Y Fmnlagv l ll)
L! Bu11JInE Serbeeks(R)
Front Y:vd Situ YurJs I
Rryuired Provided Required Provided Required Rvar Yard� Isruvidnl
1.6 Witter Supply:111M.G.I.e.40.§34) 1.7 Flood Zone Informatlont 1.11 Sewage Disposal System:
Riblic❑ Privme O Zone: _ Outside Flood'Lunt,?
Chrvk if es❑ Municlpd❑ On site Jispasul system ❑
SECTION2. PROPER,YOWNERSHIPt
2.1 OwnartofReeordt
uq stata,uP
t'Q2 /�n.lon C� rR/-9.5 - poi.
Nu.and Strcrl
felrpAune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ E.risttng Building O Owner•Oceupied ❑ Repairs(s) O Alteratlon(s) O Addition ❑Demolition ❑ Accessory Bldg. ❑ Number of Units
Brief Description of Proposed Worh Other O .Speciry;
SECTION J; ESTI;,1I.ATED CONSTR(ICTION COSTS
hum, Estimated Costs:
11 aborand.\laterials) Official Use Only
I. Building S a I. Building Permit Fee: S _. Indicate how fee is determined:
2. I11 S O Standard Ciry!Tuwn Application Fee
1 I'hunh;ng S ❑Tutal Project C'oslt(lien,6).1 multiplier
_'. Other Fees: S
J. \lah.mic.d ill\ \('1 S List: -
11vch.wical tl'rze
�'„pprvssiunl S fatal \II I''tet: S_ —
r. Filial Project Conk: i �• Chvck Vat. _ __( I,ed .\m.nmt
7 , 3 ❑ P.,iJ In Fall p OutsrmJing Hal.mce Due:
f't)Ntil'RUCIF MISS"VI('F:S
S.I C'onstruction Supentsor Licensr ICtiI.) j \,iralnn Kate
I ietune Nuulher I
�\.lute_u(lr'�SI. Ih:h(k! / 11xt('St. I)Ml:eebeloal.__.__._ ..
�o� 7•t 7 YiJe- _ �La �: - I',pa Ikxripliun
._.---
Nu. .utJ Street It I lmeNlrloeJ 11Luldilt s u to It,Il00 ai. 11.)
R IjO- I Ite.IricleJ IhIl'.Intil D n
+tclli
�( m 00— (C
. 1
l'itpl"mil.Slate./it' µC Hos+lin l',nerin
µg Windou ,utJ,Sidio
SF Solid Fuel Ilorning,\ppliunces
Insululion
D Dmnoliliun
— I'mad address -
t,l< o ► 1 I 1 �3
S,2 Registered It to Improvement U Cunn HIC
ctol ( ) IIIC'lteglsiration Number liy+inuiun Date
IIC Col all) anw or I IN ta{I51ra11{NJltta Iimall uJJrM1 e
No.and Bartel 'oa y
a o v 'rele hone
Ci !ro ,State ZIP
SECTION 61 WORKERS'COM1IPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 157.1 23C( )
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this allldavit will result in the denial of the Issuance of the building permit,
Signed Affidavit Attached? Yes ....,.....
No...........G
SECTION lei OWNER AUTHORIZATION TO BE COM1IPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
I,as Owner of the subject property,hereby authorize '
to act on my behalf,in all matters relative tof work authorized by this building permit a plicatll I x
ItA � j QQQC' QlJ / ! Date
I rint uwo is Narne IEkcwnic signature)
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
f perjury that all of informntiun
By entering my name below, i hereby attest under the pains and penalties o
eontaincd in this application is true and accurate to the best of my knowledge and understandin�Lal
Dvl� l � Daw
tte.(I I vtn nw Signature)
lure)
' I'rutlUlsner'sor;\ulluxl/vd,\µat +N,u NO'rESi
hires an u
I Inn registered iubh il's building IproventantermilCu tray urIHICI Prograr l.o do his her own ourk. n flitter +have aceass to thearbitration
program ur guarani)Infomrnon on he Conmialion on the r.M.G.L. C. istruetioe Supers sor t-ialnse can be found asC Prugraln e'an`baI'found at
+ µ bars subsl:uuial,wrk is planneJ, pro�iJe the inl'unnatiun below
I i110uJing garage. finished basement attics. Jerks or perdu
rolal floor.area(ill- 11 . ----.._ Viabilable rounl count -- .- . .. . .
1 g area 15y. Il.l
11n,i; li+m _.... . .. \umherplheJnxnns . . .
\unlherol'tircplaces .. ... _ - -- \unlberol'hall'huths
♦umber of halhnwmt . . - \anther,d'Jecki lior.hes
I\pe al he.11ing i).lent 01'ell
1 I'nclo.cJ
I\pa.,l av,ling i)ueln
1 1 ..l',d•11 1'r„Ihl \,hlafe l',lO1.l4e 1113\ he '11t+dlhdeJ hof'rJLll �'h,jeet Coll"
CITY OF SALEM) �I.ISSACHL'SETTS
3 N • BI:tLDL\G Mt DEPAR- ENT
120 WASHNGTON STREET, 311D FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
ICl\IBERLF-Y DRISCOLL
"MAYOR THo.Nw ST.PIERRs
DIRECTOR of P1:Buc PROPERTY/131:ILDNG COSLMQSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of tPfGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11, S 150A.
The debris will be transported by:
U "/l,dM �P Igh < �
(namc of hauler)
The debris will be disposed of in
name of facility)t
Y)
Jnqq_
( ddress o�facility)
signature of permit applicant
date
dcbri>a17..1o<
08/2E),'2012 20: 42 17815955820 AMBROSE INSURANCE PAGE 01/01
ACOFtD- CERTIFICATE OF LIABILITY INSURANCE DATElmmro 0120
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Ambrose Xnaurance Agy. , Xne. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
56 Cent.1-al Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Lynn, NIIL 01901 INSURERS AFFORDING COVERAGE
:-R2nn
INSURED Delangia, Willi AM INSURER A: '(LBYSCe f Lreyal Fib® Tri„4-„_C$7
AMerican Door, Window & Insula.t:,i3O INSURER B:
:L5 Bailey Ave. INSUIRERc; cylar
:Saugus, MA 01906 INSURER D:
INSURER E:
COVERAGES
THE POLIGIE1 OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REDUIFBiMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAID,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 BVPAID OLAWIS.
pYeR TYPE OF INSURANCE POLICY NUMBER D LICY EFP I E EXPI o TION LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 0
COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any ene VM) 5
DL AIMS MADE DOCCUR MED EXP(AMY WOP111=) $5,900
A CFP0055334-00 5/28/12 S/28/13 PERSONA-S ADV INJURY 91 ,000 ()00
GENERALAGOREOATE 02,000,000
GEN'L AQW:EGATE LIMrT APPLIES PER PRODUCTS.COmPIOP AGO 82,000-000
POLK.2 PEO- LOC
AUTOmOBILELIABILITY COMBINED tSINGLE LIMIT s1,000,000
ANY AL TO _—
ALL OUINED AUTOS BODILY INJURY S
8CHEOJtFD AUTOS (Par pemn)
g HIRED WTOS 47635400001 8/17/12 8/17/13 BODILY INJURY s
NON.)'WIFD AUTOS (Por=ddnnt)
—. - (PPRPO cA GdongAMHGE $
GARAGE LIABILITY AUTO ONLY•EA ACCIDENT e
ANY AL TO OTHER THAN EA ACC $
AUTO ONLY: AGO E
EXCRBSUASIUYY EACH OCCURRENCE S
OCCL* CLABAS MADE AGGREGATE llu
S -
OEDIiC TIBLE S
RETF.N Will S S
WORKERS tDMPENSATON AND r ER
EMPLOYENIPLIABILIi EL EACH ACCIDENT 3
C 001606573. 2/11/12 2/11/13 E.L DISEASE-FA EMPLOYEE 4 A
E,L DISEASE-POLICY LWri i
OTHER
TESCRIPTION O�OPERATKYNWLCCATWNSfuE t.ESIELCLUSICN9ADDED BY ENDORSEMENTMprCIAL PROVISIONS
Carpetitcy & Insulation
:ERTIFICATE HOLDER ADOYYICNAL INSURED;INSURER LETYIOt: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED pOUCE S BE CANCELLED BEFORE THE EXPIRATION
city Of Salem DAYS THEREOF,THE ISSUING M9URER WILL ENIOVOR TO MAIL.1 p_DAYS NmrTTEN
1Lt:t:n. : Building Dept. NwICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURETO DO EO SHALL
City Hall
IMPOSE NO OBLIGAnON OR LIABILITY OF D UPDN THE INSURER,ITS AGENTS OR
fialem, MA 01970 REPRESENTA
AUTHORRED PAP 05
L O ACfSR0 CORPORATION 1988
LCORD 2E-Ei
7 Massachusetts - De;aart rant of""poi c Saiei y
Board of Building ReguiaVons and Stat dards
Construction Supen isor specialty
W ELLIAM J DELAiYGIS
15 BAILEY STREET _
SAUGUSMA 01906 _
VUVJfLviT
fd_ :_ ..cc F!`nrtatimPr Affairs and Business Re6'-1at1UTi
10 Park Plaza-Suite 5170 j
Boston,Massao}� setts 02116 �.
o .;erratinYl
Home Improvement
Type: DBA
Expiration: 11/2512012 Tr# 218111 j
AMERICAN DOOR WINDOW & IKWE- M _
wiLLIAM DeLANGIS ---
15 BAILEY AVE I
w n4 nr%A
SAUGUS, IVIA v
Update Address and return card.Mark reason for change. It
Address l Renewal ❑ Emptoymeut Lost Card
I
nocrat � gnt,4pe;pa.G1a7276 `'� :-e„ nJe of `7(RddaeltUdEb
V tot
Laden License or registration vaUd for individat eye a:1
Oifice of Coasvmer Affairs a Basins Aegt before the expirmti0n date. If found return.
HWiE"ppg48AEMT 1-014 CTo" Tvue: office of Cousumer Affairs and Business Regulation
nn
Boston,M 4 gM10
AtiAER7CAN 6CQR p��1NSULATICN
WILLIAM OelANG1S ;.
it BAILEY AVE -------F e'er" ',.r,... I.,;without st¢namu .
S
WAP Work Order
`forth Shore Community Action Programs.,Inc. Job Number:25126
,.18 Main Stre.It Work Order Date: 11/8/2012
Peabody,MA.014611 Ownership:Owner
Phone: 978-531-8810
American Door,'Almdow,&Iusulation Auditor:Brandon Dorrington
1.5 Bailey Avonue Email:bdorrington@nscap.org
rlaugus MA 01906 Cell: 781-540-8569
Email:wdelangisC4 comeast.net Phone: 978-531-0767 x121
!'hone: 781-2 ill-6244
!`vlaria Lee-M caulifie NGRID Gas $7,250.83
rt2 Linden St Total $7,250.83
Apt. 1
Salem MA 01970
'181-956-1126
Safety lssue(s): Vermiculite Present/Knob&Tube Wiring
'—.-j7 Llll�
I III'III.� "��'i11 I'1 l! I,11I III:I � , i1;L 1, I III IUUI II.I {Il {I ! . i � ?I° � (��I'
a� I�I II�� ` .i IIII��IIIIi.
1 IIt:L:G111 I. �IIItI,!!II�I�i 1 i?_e
Atfic/h r eevvall Floor Tr ansi ion 63 $2.52 $158.76
Dense I'IcL w/cellulose
R-10-1..�restricted-slopes/floored 252 $130 5327.60 Finish slopes
fill w/e, I lulose
R-11 F R in open rafters/walls/ 189 $1.31 $247.59
kneewl Its
R-18-2 i:restricted-slop es/toored 2,12 $1.42 $343.64 KWF
till w/r.rl fill
R-30 u I eesrrieted-settled cellulose 880 $1.37 $1,205.60
Sub-at is roof cavity fill v 33 $1.65 $54A5 -
-•_ TTT1,p: I I,,I! .i!'I Ilv " :1,1111 a 1 'II III " ,i,ry_ I { (..I . III1 'I I 'll t'i li !III{I'{,4"(hi G{EiI 11 ii�1i'iN:,III, III I'III II,iNt'i
11 I' t I. ! r !i ,i{ I IIII I:I II�!I 11:I I Ir I I i� �II�I L,I ,. �I fly{ 'I I'I,IN:.n1, I Ii9iII �IlYlffllf{ill�l'I�IIIY�I f'1.-!uns
ICI{tldll4(I!!,a,A� 1�� 19t1 !,IIIIIi!'II:bIU1:1��� iG�liPiIIII,��J��I�Inllill�ll!I;ICI±,Il11li{II�I�dhl�il?�IGIIIII�II�IIII��11�!611N�??!� IIt11!�III,ti�IIIIN� ,,l?,IH�IIIII� �!����lallllll„Ill��,ln �,�afi,
Roof v:it S65(A sq it NFV)small 6 $80.00 $480.00
It lino y,r.,It•.Ig"71'2!Gl��t (I I.�l . 1ill'� IPIII�1 111 N'ni p' n111 „ III. ,.{.I !I I11{I'1 I ICI,It Ingle' {i I,�i' II,' 1l
Kiln p �3as ! ,, , �I, 14au A 1 i, l l i Ali; ii,�, l : l'Ih,I{ li ' �, Ilh�,�III IcrJ�I�!!!!{II.a!i�I �II!7�IIIG���GI�!1+t,I +lr �� tih"�iN ��1�� +0111
1 �lI !..rlti Nn'!xll l �nlit!�,m 111111b111:111;I�hIJ!Iltllll GIIII�I�� 1111�111.1i1!III IIli�fli�:,u.,CItII. 0� �
Sill tw I pa rt foam w/fit.,ergiass batt 79 $2.20 $173.8.0
?!I-
(81�"N�{�� ? ry I h ?! 1R lR!�I11i
2 $15.75F Ifsi�l�j"yryffllil l �,(ulhll1{{�,�I!'I I�I.N^Nk:'l'lIth,.1{1h1„I.lIi l I'Y1,$31.50
Page 1
Date: I I/i'2012
WAIF Work Ordler: Job Number: 25126
R-5 Dn r.[wrap or R-maa.on door 1 $51.00 $51.00
Repair:I:ef'it Door _ 1 �I $52.00 $52.00
Weaths+strip s/Q-lon or equal 3 $45.50 $136.50
I'� IIII II � lllI,ll IIIII'i�lINiIIl',�,iliil!IIIIiI!,!�ll��:I�i�+[[nI!'!l�lI!I�,IiI IIBItIlr!,!f1�6i1t1�I1i I(IIII II�IIIII IIII'III I iII'IlIlI�'itIII,�IIVIlI'I III �II IIIlIluI llfl! Nl!lfltl!1'I1I11111J� ,Illalli l!IIU�N�II y['I�a6�1"Iliihllf1,IC rlu��llSl,l�lil l�( IIIIIiII1'In „nI�V { II�L"" I GIII11!1- � l
IINI"� :��{Il11 Iil'l Clothes fryer vent including; '1 1 $89.00 $89.00
EXhaw t Duct
-r':alll Ilxnl"-I 11
ti a I:.�II.I l:r'.ii!'+!illaiy'llI;+l,�I,l!!!!.IJ I.y:.4Il�,1I uI1IhII�II!III III lIII;�,!'i! IIII Ii
FnllU
I t:I(� !,1!II�Ii�t II In'I'IiVlll;lIiI I111 1 IIlL�IIr I,.I I,Ij'L,:IpI!!IqI Il.l: I,IIry:,. 11111
1It,1
Domes)i water pipe wrap $2.63 $15.78
a1� 1�CI!'�I!!II,G;IGIIIlIIIiIlII"Al,(fII;IiI1�;V�I1IIGI:d�l1N1I.Lll[il�i"I1I+1I,,'IiI�l1`1f1l�'�'�1n!„n7GiElI+"�:;ifI.'II I'fl�l I'htI'l UL,l,if,t�lIl tl�ryd!li!I�,'(IIIlIf,'IGlIIf�aII�!!IIII!;,lh,1Ii�ll{��ItuIh"I'�i�'�I'1�HIIF1l4,1l1'1!I1 1�",N n1NI1!faHll;!I,L{I1lL!,1I V,1I�;G!-!1tIi,
6J!Cill::�:Ohl:�IJlinl,lll�llllihllu.ilull,I!I.,L:,kip.Ihl:ilil�,l,,�161��iII,I�I!!11�I111, I
Attic st a Ilia;with two-part Ibam 4 $75.00 $300.00
Basem, I rt sealing with b,vo-paA 3 r $75.00 $225.00
foam
Cut/cicsv t-ctic-kneewa!l.acceis 3 � $78.75 $236.25
Slide b ,•I 1 v $22.00 $22.00
Weatt �su,ip(Q-lon or equal)attic 1 $31.50 $31.50
a
hatch
h!:1I�I1I�'1�I�IPL::::;,,:!�II.IIIII Ih�",�tlI hI�l,►;�lula-�.�tl,ilIl,l l 6+I,,1 I1�i1I:I.II1 11iI11I I.ii:lII:l):J Gi,Il,''—'I III+,1 I i!1IiI 4l 1II'!II InI'I�I'1.1.1 q!iIl!:k l'llg{,l illl•l ullll!+I�II ii ill,lI�ll iLI"lI�'I„Itll,Ih!I ll:l!IlIuI Il,l�!;I,I1 I1 !f�l'III�III ,L,,I I.�.LI',+I IIIrII!.1 hilt ra��� 4,I7�+!,,IliI 11�CIIf1I.�I,�I�� 3IrilI II�raiaIi!,ni I,{ll,ltI�llI)l N,IInu 11,'N!�[g�IllL�lllpil!1,I1,1I,�111i 1�1',I1I,'9�:.'IIII_I.IN��LICIC:LIIIII
Buildit 1;Pormit 1 $100.00 $100.00
IIII ' ip
III , I_�I�r�I�!iliilil!IIIIIIIII�III�I!IPr'P,I�11!IIII�I�:�I!I��!IIVIIi�II�IdIuGlll�ffnll�ll!+I�IH;�IhI���!��I.NIiIN41111�(I!�.I�I�I�IIi,r�i�11�1�6Ni!fI�1fII�INull�lul�llJ�II�!IIII1191n��EI��I�I!G��I�I��!��1,,,71111�I.��Pr�It��i!�1111!I,I�>�I,
Wood � board/shake:,/shingso 1 r e534 $1.79 $2,924.86 Vinyl
_
vinyl(, :nse pack)
Date: ! ,/5..2012 Page 2
WAP Work Order: Job Number: 25126
I•! I�II����������'I������������������
Glass r+placement to 64 Lai 1 $44.00 ;W4.00
Total -� —_� ;37,250.83 -
Contractor Instructions:
Before;ti ._i a the Job: During Job:
1.Please uoiiry us 24 hours beiole starting or scheduling a.job. 1. Incorporate lead safe practices as applicable.
2. Obtaii. lei.lmred buildinl;pet in 2.Total for Heath&Safety and Repairs cannot exceed$2500.00.
3.Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form W H-347.
Additiol+it Contractor Instructions:
Certificate+ r Insulation post erl? Yes NO (CircleOne) Attic Inspection form attached? Yes N/A (Circle One)
Date: WAP Auditor. _Date:
Contra��.iOr ___. __— —
Date: Fiscal Officer: Date: -
Energy Inir+actor:__.___. ._—. —
Page 3
Date: It,",/2012
CITY OF ScU2II$ \/L-XS&ALCHL'SETTS
BUILDING DEPARTSI NT
• ) ' r• 120 WASHIINGTON STREET, 3"FLOOR
TEI- (978) 745-9595
F.1x(978) 7404846
KINEBFRLEY DRSSCOLL
MAYOR THOMAS ST.PIERRS
DIRECTOR OF PU13LIC PROPERTY/BUMMING CONNISSIONER
Workers' Compensation insurance Affidavit: Builders!Contractors/Electricians/Plumbers
Antslleant information / J Please Print Legibly
Name tousiixss.OrgtnizatioruindiOOvidual): /�//P202ZII X .7/�..ro 6244allLr�
Address: �� l even eA izz
City/State/Zip: Phone!!:
Are you an employer?Check the appropriate box: Type of project(required):
1.CE fam a employer with 3 4• 0 i am a general contractor and 1 6. 0 Now construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'camp. insurance. 9, 0 Building addition
(No workers'comp.insurance S. 0 We are a corporation and its
required.)
otTkers have exercised their 10.0 Electrical repairs or additions
3.0 i am a homeowner doing all work right of exemption per MGL 114:1 Plumbing repairs or additions
myself.(No workers'comp. c. 152,J I M,and we have no 12.0 Roof repairs
insurance required.)t - employees.[No workers' 13.0 Other
camp.insurance required.)
•Any applicant that chrxks boa 91 must alms rill out the section balow showing their worken'Mmpenmdon policy information.
r I hweownc»who rubmir this affidavit indicating they am doing all work and then biro outside contraatom true/Submit a txw afedavil indirning such.
:Gmtmtors that chmil this box mast anachad an additional sheet showing the time of the nub<ontraeton and their worker'Monti.policy infomution•
/rem an employer that Is providing workers'compensadoa insurance foamy employees. Below Is the polley and Job slit
itnjortnarlon.
Insurance Company Name:
Policy#or Scl6im. Lie. d: Q O /��o 0 —1 Expiration Date: lF 3 '
!ub Site Address: /l Li 2 l n d P e, �r 7. SO .P a1' 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 Section23A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonmen%as well as civil penalties in the farm of a STOP WORK ORDER and a fine
of up to$2X00 a day against the violator. 13e advised that a copy of this statement may be rurwardud to the Office of
Investigations of the DIA for insurance coverage vcriticulior
I do hereby certify tinder the palms Surd penaldes of pedury that the ill/brinaillon provided above is IrU7 and correc6
Phone d:
(Viciul use only. Oo not write in thIs area,to be comryleled by city at town ofpc101
City or Town: PermittLicemre
Issuing Aulharily(circle one): _
1. Board of llcalth 2. Building Department 3.Cityfrown Clerk 3. Electrical Inspector 5. Plumbing Inspector
6.Other _.
Contact Persno: Phone M: