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HomeMy WebLinkAbout0024 HANNAH CIRCLE 1. .,�� f ��ccn n ��% C�rc.� P r-� � �, � nEC-���-1998 12:40 C]ALMOUIT�H 5084570649 P.01!01 r.E9ocore rMVOVCANB-UIvl� - �,4 20-Minute Insulated Steel Door MA UME E.OHIO �•uoo•63r.eex� SIZES AND RESTRICTIONS (refer also to Genera.!Informalion,section"FIRE 1."): • Models and size maximum: Any Therma-Tru insulated steel door,either Prernium or Construction Series, in sues up to a maximum of 3/0 x 7/0, may be labeled with a 20-minute label. Models and sizes not shown in the price list sr,ould be inquired as special orders. • Handing: Doors are not hwWed. A bjnge-prepped slab makes either a kI-I.or LH door. • Hardware reinforcement: Constriction Series doors are not built with loekblocks. No reinforcerne.at blocking will be edded to Construction Series doors. Premium.Steel doors have stan&ard lockblocks. If additional nonstandard blocking is required,request quotations for doors as Premium Steel doors. Refer to Product Manual, section.SHOP 3,DOOR PREPARATION, for block sizes, locations, and availability. • Peep si.gbts: Rated viewers are allowed. A maximum of two are allowed per slab and must be located a minimum of 12 inches from door edges and each other. • No Iftes permitted: Any lite cutouts will Void the fire rating, • Smoke barrier requires spring binges: Smoke barrier, doors must be installed with self.-closing binges. Positive latching hardware is not required. • No louvers: Louvers are not.all.owed. • Decorative plates: Brass and other decorative plates may be located in,the bottom sixteen inches of either or both sides of the door. Screws must be located every six inches. FEATURES AND CONSTRUCTION DETAILS. FALMOUTH :.UMBER INC. • 24- or 25-Ga. Electrogalvani.Zed Steel 670 Teatleket Highway „ East Falmouth, MA 02536 • Solid Insulating Core T9L.548-6868 • Primcred Steel.Surface ARCHIBALD REALTY TRUST Wm. Chas. Place , 9 Parker Road Osterville; MA 02655 I (508) 428-8721 FAX (508) 420-1956 Technical Manual IE:suoo: Noy 95 FIRE 2 Page Product Details C�`�ma`4�i•Ti tn°�a`"v"0'rnoorwk of tMm.,sTw Co'p. � T --- `-vt, TOWN OF BARNSTABLE 4 3 . CERTIFICATE OF OCCUPANCY .PARCEL ID 022 134 .002 GEOBASE ID 36686 ADDRESS 24 HANNAH CIRCLE PHONE COTUIT ZIP - LOT 22 & 22 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT CT i PERMIT 35134 DESCRIPTION SINGLE FAMILY DWELLING (PMT.#30356 PERMIT TYPE BCOO TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES - DIME CONSTRUCTION COSTS $.00 � Q� 756 CERTIFICATE OF OCCUPANCY sAwvsrABI.E. MAS& 1639. FD MA'I BUIL NG IVI N j BY DATE ISSUED 12/03/1998 EXPIRATION DATE TOWN OF BARNSTABLE -• ,e'.,�� y ;- �= BUILDING PERMIT PARCEL ID 022 134 002 GEOBASE ID 36686 ADDRESS 24 HANNAH CIRCLE PHONE COTUIT ZIP - x LOT 22 & 22 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT CT M'. PERMIT 30356 DESCRIPTION NEW 2 BDRM HOME SEW.PT-#98-227 PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BLDG PMT CONTRACTORS: ARCHIBALD, WILLIAM Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: $620.00 Oar BOND $.00 CONSTRUCTION COSTS $200,000.00 Q� 101 SINGLE FAM HOME DETACHED 1 PRIVATE P ftAB14 MASS. 039. BUILDING DIVI�ON w-� DATE ISSUED 04/23/1998 EXPIRATION DATE. THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN— a CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS i PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS.MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS .ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- (READY TO LATH). PANCY IS,REQUIRED,SUCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH- 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. ANICAL INSTALLATIONS. 4.FINAL INSPECTION BEFORE OCCUPANCY. BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS �� I ► 6 2 2 2 i3�� i2�z9� 3 rl �j� �;2� 1 HEATING INSPECTION APPROVALS ,'..: ENGINEERING DEPARTMENT L� 2 BOARD OF HEALTH ram' �9% XY OTHER: rG�C SITE PLAN REVIEW APPROVAL / sf WORK SHAY NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON INSPECTIONS INDICATED ON THIS ' THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION, Cd 3S1 3 t The Town of Barnstable BARASS- E. MASS. • , ,Department of Health Safety and Environmental Services 0, Foy Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-790-6227 Rap rossen Fax: 508-790-6230 Building- issioner Inspection Correction No ce 'Type of Inspection Location 4aln-Vv A-L t Permit Number � Owner Builder 1 x. One notice to remain on jobsite, one notice on file in Building Department. � i The following items need correcting: w '1 �►� L -,mac'-��� ao� i 1 Please call: 508-790-6227 for re-inspection. Inspected by . S Date �� 2C?�-dlcall i Engineering Dept. (3rd floor) Map Oc;�11 Parcel ,eO o;2% Permit# Ouse# {?a C , Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) r �. Fee c%.q. r/0 coy �62 O Conservation Office(4th floor)(8:30-9:30/1:00-2:00) ZAf � ® AIc�f'� �o� Planning Dept.(1st floor/School Admin. Bldg.) ®�� ' ®�'P4/4� �.77 ' e Definitive Plan Approved by Planning Board /19 �6too -�7 �I 111 BARNSTAMASS.&E 2,, 'r�'e I L CS "� --'�-� - ft MAN�`� ; 1� TOWN OF BANSTABLE .Building Permit<A plicatio Project Street Address Q� 14C-P1kVaA,Village-('. OMIT— Owner _�(�, li- '.� �!1 F ( I Address /�� 66 _ C9 Y Telephone 0;AF r Permit Request k L4:c First Floor �,C�-73-(� square feet Second Floor square feet Construction Type Estimated Project Cost $ _ j� Zoning District Flood Plain Wafer Protection- Lot Size �C C-�- Grandfathered ❑Yes 14wO Dwelling Type: Single Family Two Family ❑ Multi-Family units) l Age of Existing Structure Historic House ❑Yes or On Old King's Highway ❑Yes o Basement Type: 611 ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) ,/�� Basement Unfinished Area(sq.ft) �` `� LID Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New 0­1 --t- is*- _ Total Room Count(nFNo g baths): Existing ® New First Floor Room Count 1 Heat Type and Fue ❑Oil ❑Electric ❑Other Central Air es Fireplaces: Existing New Existing wood/coal stove ❑Yes Garage: ❑ tached(size) Other Detached Structures: ❑Pool(size) , Attached(size) p��Cx `— ❑Barn(size) ❑None ,�� ❑Shed(size) ❑Other(size) , Zoning Board of Appeal;�rf • ation ❑ Appeal# Recorded❑ Commercial ❑Yes yes, site plan review# Current Use Proposed Use lle)ll / Builde Information Name 1 e 6?JkV&qL- Telephone Number Address 15, 11 , License# C,5 Home Improvement Contractor# Worker's Compensation# 0/r 6 92 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ,�4!1 ae4iz�� SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING RE ASON(S) FOR OFFICIAL USE ONLY 3 to { PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER r 4 DATE OF INSPECTION: FOUNDATION - r FRAME l��' 1"'� !�:� �� 2�✓ INSULATION FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL (� / GAS:,,- ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION.PLAN NO. t ' i f CB/oH S 54 02'12"E Fnd 242.67' REFERENCES: Assessors Map: 22 O Parcel: 134-2 91.3' N _ ZONE: RF Setbacks: 44,600t SF Front: 30' Side: 15' Rear: 7 5' z NJ U V (.a Concrete 16.0' Foun da t ion A� c m ti A� o 2.5' � o b h 4.3' 54.8' .JS., 2.0' �6 J'. 21.5' N V 16.5' 3.0' 4 Concrete o Foundotion 7.0' o 87.0' N 11.s' Aso 1 N 4.6 15.7' 0 1. 0 y CB/DH 24.0' Fnd W O1 h 00 t N O /�� «l�`1 �N Of I certify that the foundation z R = 25.00' c RICHARD y am✓ shown hereon conforms to the ' = 21.74 �0 c R. setback requirements of the ce/OH Fnd �+ LHEUREUX H No. �� Q Zoning Bylaws of the town °fGISTi E° +- of Barnstable. 5 — Ce1DH Professional Land Surveyor Date Fnd PLOT PLAN IN r n �G=J�IIV�UIr,I�L-�9 MA ISO. NOTES: DATE: 19/MAY/98 SCALE: 1"=40' 0 FEET 1.) The structures shown were located on the ground by conventional survey methods on May 78, 1998. PREPARED FOR: Archibald Realty Trust 2.) The property information shown hereon was 9 Parker Road compiled from available record information and Osterville MA does not represent on actual on the ground survey. PREPARED BY: capesury PO Box 718 Hyannis MA 02601-0778 DWG # C305PP1 FIELD BY: JCM/RJM (508) 790-7902 / 790-7905fox ,�- 7 q Lca'>r VL 'S,:R. LoT T A ,> sa,�.•• .a �" ...-•,�'"/ cabµ e , < ,�.. ,� V. /c�7 id X is n• . :. '�/ �„� ;; 54• / „ *as s654 j / " . L cT 41�T 2 o f 2 .00' � LaCAT�� G�LLi ITS M A�S, r cE tzr P-1 Tt +AT i-riDATM S fi caN u f••E E:2�a CG�M?1.:1� W I"T�( � V o �.�, T)-I c. S i D E[.. N E ArraO "3/ = PL:AJ...1 Q. F'�•P.E;1.Jc E :. r�Eon ? c•--a.�rs of TOS li=w,j ' raA-0.•..+•rr�s�.g l c ems.+�r•1: M A 45.. : �r.��t Arm-0 W I T?•h w T H5 PGAn lJ. _ (.o Ja . e 4.1 aAwne Ti-i 5 r�C..1 L+ I NO r31'4S c��.+ Acs.l ems,.ISTF�2Efl G:Iir�0 SuQ�,IE�/o 2 I�S'TC.:�Mi�►J'r C'�l /4Nd±..�1�? Q•V 1..4a�r.. �... M A O FF-t-.0 T t)�E•o 'i'o D�T��M �I.rE l.o'r LINE��• . > PLICs'�1-+7 : ARc,+,r.��o_P�Acrr,rr i MAScheck COMPLIANCE REPORT Massachusetts Energy Code Permit # MAScheck Software Version 2.0 Checked b /Date CITY: Hyannis STATE: Massachusetts HDD: 5973 CONSTRUCTION TYPE: 1 or 2 family, detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 4-23-1998 DATE OF PLANS: TITLE: COMPLIANCE: PASSES Required UA = 352 Your Home = 318 Area or Insul Sheath Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 1547 30.0 0.0 55 WALLS: Wood Frame, 16" O.C. 1600 19.0 3.0 86 GLAZING: Windows or Doors 260 0.400 104 FLOORS: Over Unconditioned Space 1547 19.0 73 ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in sections 780CMR 1310 and J4.4. Builder/Designer Date i MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck Software Version 2.0 DATE: 4-23-1998 Bldg. Dept. Use CEILINGS: [ ] 1. R-30 Comments/Location WALLS: [ ] 1. Wood Frame, 16" O.C. , R-19 + R-3 Comments/Location WINDOWS AND GLASS DOORS: [ ] 1. U-value: 0.40 For windows without labeled U-values, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments/Location FLOORS: [ ] 1. Over Unconditioned Space, R-19 Comments/Location AIR LEAKAGE: [ ] Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. Recessed lights must be type IC rated and installed with no penetrations or installed inside an appropriate air-tight assembly with a 0.5" clearance from combustible materials and 3" clearance from insulation. VAPOR RETARDER: [ ] Required on the warm-in-winter side of all non-vented framed ceilings, walls, and floors. MATERIALS IDENTIFICATION: [ ] Materials and equipment must be identified so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. Insulation R-values and glazing U-values must be clearly marked on the building plans or specifications. DUCT INSULATION: [ ) Ducts in unconditioned spaces must be insulated to R-5. Ducts outside the building must be insulated to R-8.0. DUCT CONSTRUCTION: [ ] All ducts must be sealed with mastic and fibrous backing tape. Pressure-sensitive tape may be used for fibrous ducts. ' The HVAC system must provide a means for balancing air and water systems. TEMPERATURE CONTROLS: [ ] Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. HVAC EQUIPMENT SIZING: [ ] Rated output capacity of the heating/cooling system is not greater than 125% of the design load as specified in sections 780CMR 1310 and J4 .4 . MISC REQUIREMENTS: [ ] Refer to 780 CMR, Appendix J for requirements relating to swimming pools, HVAC piping conveying fluids above 120 F or chilled fluids below 55 F, and circulating hot water systems. ' ----NOTES TO FIELD (Building Department Use Only) ------------------------- i MAScheck COMPLIANCE REPORT Massachusetts Energy Code Permit # MAScheck Software Version 2.0 Checke by/ ate CITY: Hyannis STATE: Massachusetts HDD: 5973 CONSTRUCTION TYPE: 1 or 2 family, detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 4-23-1998 DATE OF PLANS: TITLE: COMPLIANCE: PASSES Required UA = 352 Your Home = 318 Area or Insul Sheath Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 1547 30.0 0.0 55 WALLS: Wood Frame, 16" O.C. 1600 19.0 3.0 86 GLAZING: Windows or Doors 260 0.400 104 FLOORS: Over Unconditioned Space 1547 19.0 73 ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in sections 780CMR 1310 and J4.4 . Builder/Designer Date i ARCHIBALD REALTY TRUST Realtors- Builders- Designers 9 Parker Rd. Osterville, Mass. 02655 Phone 428.8721 .I DEPAITMENT OF FI SL IC SAFETY 'CONSTp )LyBuPERVISOII LICENSE EYpUur Blrtldatla '• _ ite�tlfea = _ Wt92ll •• err�l OSTERVILLE, MA llW5 108772 ! Restricted Tot SA ISS - None i to - Masonry Only 16 - i d 2 Fully Noses Failure to possess a current edition of the Massachusetts State Building Code Is cause for reYocatloa of this license. ------------- rlr � • �f,y it J,�j)i�b J y�l• rt AY ' K 1 sTk• -710 �JgrO' 1/INI� � Y\ S11L j qI& i 5to OF- K ° 15'0' S t YL i - 7D. ,•-6.a I z sz IS 52 mak ZE13BA1 Fl S:Z. 9 a C 3`} �• - *� b�! I sc� i —— �\ 18310 ¢ I CIN•' 24!0"11'0• �i' I 120'2 ^0 9'•V .I,` _b o. OK_?� ►4{ -'IL6 - � L 4— �1'S�oH C7 2942- R —. — Q I z-oue - I4-io• -- �."1•--* ._. I�+-�o� H� ZOS.z r# � � NN�� i 2gSL i 5 2- 4Z_ ._s• .;Q .i ta yx. LeI� r•.xc, ..._ .. ir Iz = ,:.....-:_....._..-.�.�_..._......_ .,.;,_tea:.� .�....� , ELV�E.-GOTIlL'C_.�JA E- _,.ANNAN _ R.4 RS. WARREN ICKERSoN=. ROrKLZ7Nr s r }a ti Ti�ESII)Ewe F- +v��T-U� L.NCt , ANNAH. CIP,CL.�_T DPAWN POP, VIARREN N fCKER50N1-bR��l-)'V' 0.0 b0 Rill -_--- I�I_I I - -: CLA4bTAR�3'.h.�•TY! ...� "1 LpAR -S"rW - _ - P.O T I E yj #?i F�ISF�.� a•� �/a y/gs fZ f ' y r I T-o• ,...,. I 21 1 , ?S'o•7,11 . 93', T — C1L0 I 1 I ! , I , vv il �-�- � �F- i i I .'1w. Ito_- 7co.- _7'-�• Ow 0 I .aA �- rs 9 SlD T AQ F- AN Mt,P n�[rrr 2K I _ _ 4-t -t--. _ -.____ -. �-. ,. �- , Iir �.•Q. _' L�NC`3000 ' I Z•O ! 4 z5' - iz 1417 LCQutv'DATiON I � .Zq.'.98'REVIScJ-FINAL I v ' e s:. I , M ' ,Y• LOCA t BL`b' + q. Ib'� ►� 4 4 . Tc Is-0 ►IM' I' zoo IpA i 1 4,0 � �,_,,. 3C•o _� I i _ moo' ,Y o. 14 4:0/�+— --13-'� -._... ----{lab--. .►I� ...- --- i ---—I�fi I lo=� 1 .n Ito S t7l L yea 1 H, OAK, � 5-0 j 1 1Trw Ls I o y20 -t amc. C 3`} GiazSG .__ _bco... 7�6. -1L1. 2�{42 - _ iy 14=10' ZOMG 3ba� g H/ • Zpc ZO IT :34S2- K 305Z_ 1 I =-- _ , --R��- r- 77 4 'PS{K 416. � L s l i r� 1 - -:r tw _ - � �SHIp[1►P.��NE_ - - - TF -DR.+ . ARREN ICKER50N=- RO-Ci » , I� E511�ENCL= v0rUrl-'LACE NNAH IPcL_- DPA%(IN �bR P.4 MR;, \X/ARPEN NXXPR50N43R•OWION, i E0 jq _. --.. -:.:_--:. .__. -_ IF PO P,00 (OUT. T2 � i ZX IZ ! 0•-0• 1-4 e•-o• id -114- `ice �0 w,or t i IV-0 A tiw i 1 - -- -- - -- 1 771 r - -- — 1 ; . y4'i I 1 i -jF bA �15�'-b'-0• - .I ' -ILO--F>F '710- i ih•w+ _ -r _ I :I Idjj• - gyp• - i_ - 1 10 iI I , I -- * ��• -+f IL P�l xz zy'o •JI J 51D= 191H1T �r-z�a I wA• •I � �rd9' I - O�rRwN ftrz -- - - 15-0- M je-0-a�1 15 O i SP 1 A.il �ODNC 3000 1 - - I �1� n.i2o ffin:'3AFseSsoNcL �Z.Z.' 7 LCQUNDATION I / .Z4'92'REVISED-FINAL ~i:Fes` 3 � • } ��.. h t v i / .. I ----- y� Z X b- 5'4" • rr � E- 11 W 44 10`0• •io 1�-0 24 MULL I I - ,. EL �� %,.-o IN— era--rnnri<- . - _ - N, I ass.I Jl� dft The Commonwealth of.4fastiachuticit Department of Industrial Accidems It i l - office ofinyeafg-911ons (llp II ashitr-toit Street Briton, Afuu. 02111 Workers' Compensation Insurance Affidavit ;3;7 -�,Ivq m • Ilea C t V l i L\ .� '# I am a homeowner petforming all work myself. I am a s roprietor and have no one working In any capacity Y _ L� .r ._.._ .. ro.r.n. ..w.cscr-....m.�s7+°r:rt�r:rt+.^R!��r........u�w... .�+..�� ..-r^...^^..•..ems-- �_—_� am an employer providing workers' compensation for my employees orking on this job. comm,iny na e: add itv: nhone 0, — insurance co. t am a sole proprietor, general contractor, or homeowner(circle ate)and have hired the contractors listed below who have the following workers' con sation polices: cnm any name: address: ✓ U t hut/ phone �� — gin•: #• 7 insurance co. Volicy# - - •t-.. .yR - :;e•-.,.... ..._- _ .:.ram-T-c:r�?.��iT'rr�.w-...yy:gf•t_ '.-T4'vc.: --.-..•.v,..,...:.s.,...._ - cnm an name: �n addre5s: city � one#: ✓ "v �� �� i su ince c �� !"� ��6 v �i # Attach additional sheet if neceisar---- _' t -.i..� ice..v._... ��`._�.«.,, » .p.1y�,•. .. . :awe. .. ...su. .�.n 1. Failure to secure coverage as required under Section 25A of h1GL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 andiur unc s cars' imprisonment as%%ell as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement man be formyarded to the Orrice of Investigations of the DIA for eoycragc verification. 1 do herehv certif•under the pains and p tics of perjure Ili tl information provided above is true and correct. Si^_naturci Date Print name Phone# official use unly do not write in this area to be cumplctcd by city or town official city or tms n: permit/license q riBuilding Department Licensing Board check if iminediate respunse is required 0selectmen's Office r: C]Ilealth Department contact person: phone q; rJ0lhcr S.