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HomeMy WebLinkAbout0074 CENTER LANE x� y � �� .,. ;fig, ,,z_, ,: _ ,. .. ,,:. `- ,.,d '.`,t ,i ,. ,: ,. f _. _ .. .. ., ., u , . � . . „ . 1 �. • 2 a1�,�2 5'�� �oF t14*E tom, Town of Barnstable *Permit# 'l'� 6 months Jrom issue date Regulatory Services * BARNSfABLE:, v� MAC' Exp'e i639. Thomas F.Geiler,Director �0 ArED MA't A Building Division Tom Perry,CBO, Building Commissioner Co-Ofs/1 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRES RMIT APPLICATION - RESIDENTIAL ONLY 3 Not Valid without Red X-Press Imprint 7)5 Map/parcel Number /� Property Address � 7 l k 11�r ��n�' ` Qf��Cl�l/ Ile MA 6 Z 63 a Residential Value of Work �a 1031 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Cap -�-vn Q-C'ao r]7 (,yl't Contractor's NameG 4'bkmJ- l�`Sos+h&`n 10 iV iil, wd W it)daz Telephone Number �()�- �7) �y5,0 Home Improvement Contractor License#(if applicable) 173 a L/S Construction Supervisor's License#(if applicable) NWorkman's Compensation Insurance XPRESS PER Check one: 1!/1�� ❑ I am a sole proprietor I am the Homeowner APR 2 4 2013 I have Worker's Compensation Insurance Insurance Company Name i TOWN r� C9 F 13ARNSTA13LE Workman's Comp. Polccy# �C 9 d 7In I - 'Q 3 IV Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to. ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement indow /doors/sliders.U-Value. 0 `3 (maximum .35)#of windows ITJ ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is req e SIGNATURE: C:\Users\decollik\AppDa icrosoft\Windows\Temporary Internet Files\Content:Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 t RenewaC _ e �vAiidersen� 'Iti EWAL BY At NM E�8Si 5wr 26kti& Ran' n ,RI2 �.N, -2.5 _%cad rnrn#izs," 'Phone-F66.56 .2235•Fax 4{i 163�,�¢Q2> � �t - .. ",Fbdo"retTgli'ID Y146rfl566690'- Sn" ,ernNewFmgiandWintlovi,e,FI.Lf1'd Renewal 6Y iluaetaeb'og Soadierp itlew '.t CUSTOM WINDOW AND>DOQR`R>~MODEI;INGAGREEMEIV '. _. �, ., ..a.. _....•.Date d ment ...... a CAA ..: (i);Sseeend,!!est,Gry;sabe�nd.XiP.�?ds>" --... _,�• .�; „-...; , . ' ,s,....- ,,_, � ;:: -�.... �-----•-•• -...: �EMaOi>dE'reii cm _'1{6meT�'oneNwWnF'" - .a<1NoekTtkphonetJuie�bef."- .. :Sa$ Buytf(s)tit="6wi,nntiy ar}4,geverally14gregs torppro*thg products and yor senticRs of Southern Neil England Windows;LLC d/bIa ltenewatx •:by Aitdeiset5 of$Outhern New Engiattd,("Contractor",>o riccoYddn0 with`the Perms and'condttrons=descdbed"on the fra nt and thi;reverse of`, .ttus agreement andon,thte atrachedspeciticauon s}iet( (cbGe cttvrly,t)ysi`AgreemenQ - rt 7oiaf JopAmog,rc�1 t Fawnaud snim�Daffi. � 4 Method of Pdymei�, �_�Cl�ck �h O f(nanced, vepo�t feee,red(33%) �Y� �+ � :�'r �.�tC: *`- "'"` ' �"�'-', •- _ Y , t Credit Cards are aooept�for depos+t b81y�maldmLm 1f3 of die,! t{alane at Start of Job(33@b) 3;Y ( • _Qroiette�ost(t9ease see Credit calf faymtett.Form)Bynfng dui EtdmztedsCompletlon;DatcAV— thatlite 8atbnoeStStarc 6f fob srid die-, k Ba ceton Substaniw 7 y ' r'b"{4 K_..- tfi a on?S+bstanda(Gomplepor,of)0 6 cannot W,tgade`by c►e oh�ple6on C •of)06(33%) ITcard'and muse be trade by peisoro)�teck;'bank rhecic;as lastly' `,j. ('Buye�(s)agrees,and node rstanas.:thttt tots SAgreetiieut oonstitntes the eenhremdetstapding ibetweea k!<a patt�e9;kaad that# +,thererare no'sterhal ttnderhtandfngs chattg ng any 4of tLe�ttrms of this Agretatent.Bt,yer(s�'p clmRsvlgt�ges Visit Bnger(s) a.(1)has aead thts:Agseetneatf nndeistands the ferias of tfits geeeinent,and Gas nt slued A completed,,sego-d,;land dated:r copy of ihts Agreement,iaclttdtng the two aRtacbed Ngbeces$i Cancellatfioa,oo"ihe date'Sesf tvs[tt�above sad(2)_t:as aril y' .»tformed of Bnyera s t�eghtw cancel dus Agseemert,DO NOTcSIGN THIS C0N_Tlj ACT,�IF TfU=AUAM BIsANK$PA(`E$ jl tJwde!eland Stiles Only)No6cx to iluyer: 1)'Do sot: foie`Agreement tf am of the'epaces fat e»ded torltlte areet� raris •to the esteat of;then available tnfa:mateoa are left l�laait'(2)`,Xtit1 are`eaodetdttn:a copy of t6ts Age eementattbe'tie yonsn (s),Yott may`att time pay o8'the fail uapatd balance duc under tots Agreemment,and ad a6 lmag you may be catatLed tag receive a partial"rehpte of•the Saasce sad iosuraace ohat'ges`-*(4)Tb'de -U--bars tto ag tto unlawfovy eattr yonrpremise_s oa oamnut say breach e3 the peat a to repos`sees goods pnrcl�ased wader this Agteemetit (S)Yonmay caueEi thta Agreement? .fit et has:aot been sagged at�e male office.or a braatlt office of the seIIer,provided yen notify the tceiler;at fits qr.fier'matn t. t gBioe or branch office shown tai the Agfieep►ent by rsgistered;or cet•ttfiied mail,which shall be posted ttot`Jater thee anaddaght • ;of the hied caletiilar daqalbdr the;tlaq onhvfiach the`buyer gt,�1°e the Agreement,eaclndiag Satriday and guy>to�iday on which= ',tegaWr;m;aldelirenegascaotti de Bee _eacootnpattysugaotsoeoftxitceBationform,[crane Isaatsoaofbn ;s A 7; <:;Buyer(sj`recervel:iF{econsutifeteducabon matena:Lspmv,+dLd'bytheRhodeItla:Sid'Cohiracto_rs"RegistrauoHBoaid (lJuy�'s'ImhrtLrJs Renewal:'byrMd«sea of Stitdr era New England.; .( $uyee(sj t�' f #Si$dyer(s)' a" � A 51 (nteof uc�.Aq er i r Si 'ture� ":5tgrtatute,"' •Pnnti�lameof Prq�iuct�fanag6r-� _ � <Pruit,NamC�' F`' t'Rrultl�afne:• �- ;YQIT, TI�tBUYER(S), MAY CJlSN,(:EI.THIS TR4NSAC7'iONrAT ANY TIME'PRlfglt T0,r h D111i6j Ole TIB T__*Ds t BUSI11TS5S DA'Y AFTEIt'THE DATE O(F�T�H�IS TBANS_ACTION.SEE THE ATTACIISD NOITCE OF CAN _BLLATI©lii FDRMS" OI3 AN Eli PLAIVAI iOA1 Ue TARS Ri�I.,.+ `Dale of Transaction t .;You maim t en'cgi' ' Dal ':Wrl'ansactlon 7tiu;irisq eanceti 4 +.,this tr`ansaetion;_Yvttito y,, shy or o`bligatlon,wittrtn, this ttansaedon,yvithout arty pmal_y orz,#lgadon,wttliiR.'• •;i lit�ee baseness days from the above date Jf you cancel,any.#ii r tht+ee;lrt)siness troin the above elate:N you cancel,ei►re ifroperty traded::in,any payrttertts:made bjr yo{r under tlte.'i tpropeety trade,arryrtiapatymerits made by you under ttte Contract or'Sale,and arty negodaible rrtseriaRtertt,e#iecu$ed';7 Contract,d f SAIe�aml ar►Jr,negodabin instrumenf"exeatEed'€ .;bli you rr`rtl be,retitmed within ten badness day'409"- fir ,S "l*,YO will be rmturned wWp;ten b.Usirrcss days+folloWlog + receipt:b)r the Seller of`your Wceilation notite.gird any,i,receipt¢lr FSellgr of your eancellatitin ttodce rand airy security'tnten'sta Ondng:orrt of ithe tranractront will W-s.' secuHt mberest at isir g flout of the franssc4oit wilF.be; •:canceled Hyou tanceh y-ou must mates agalbble to,the Seller',ii'cancel ed If yoU caneel,you must;make arailablegto the Seller .,at ypuv ieside m;m�ubsta,ttallr-is good condition'asij n►hen;=##s at your rsslcitncE,in stibsta2tially,as gaol toridkltin as w)ten.i recehred;any goods deliyeied to yisu under thl>i COetrad or,;1 ,received,atly}goode deltWaMe d w:yoi,order this Contractor+ a5ale;or)rotr mayhif you wish,comply with the instructions of Y i t Sale,or you may,if yogi wisb,comply wrtli,tfie tnstruc6ons.of the Seller regardi�tg fire r ewt7r#shipme fit of•NteYgoods At the ",+tl Seller;agarding ells rearm shtprpar+li,of the goods at the (Selier'a a",xpertse and risk.ll"yop do#ivalte Ike�dda�avertable Sall r% nee atrtd ri31c H do3make.the s availeble #lto the Seller arnd the Seller does not plcktitem up wicltin ` I tfie, rand the`Setler d�nofip)ckrtlt�tip within? +�twelity d of the date,ofacaniellatiorr.yowl . )m r i tvrei►ty days.of the date of rcariceliation,,.you`mat+:retain ore+` dispose " �re goods wkhout any#errtKer,obt ont f u l i dispose of the goods without any further obligation'H,�rou, *:fail toj make the gtwds available to the Seller,or lftiyou agree j i fail`1ti maims the goodsva3labte:to the Seller,or if.i!ou agree t "to r�eClrr7r,the goods bo;the Seller,ands fall to do so,,then •p to metum the".goods 6A)ie Viler and,tiail to,do so,tlien .;yqu remain(table for,performanrc of aN abpgat;olis under; qou iTmain!table for performance of ail obligatiats under,. the Contract.To•cancel rthls Oaiisactton mall or•deliver F'I the Contract To"ranieel this teansabton, m9ilr delliret ?a si and eo ,of thls wnrellatlon notice.`or I a s W and dated t:o of this eaneelW- b notice or geed. dated py arty Mother wNtten lto�cb,or seed a tel4sgratTi, to Renewal ley .I othier YvWtteneilfobt�e; send a teiegttitrrr tooJne0.walgi . +And n Soutltem Nevv1Englarid at 1137'Park East Dr, i tMdeesen oGSouchem.New E and ati1137 Parii East tDr.,; tuW 01895,N0T MIDNIGHT OF,.j f Woorisoeket,Pt102895i NOTrLAA ERTHAN MIDNIGHT�OF` (Data , 91 WRY tl,ilHleREBYClliGE1:TFliSRA1+iSAG7'ION, Maw— • s •• .RbFr'Co�While'�+8uyer�CttrpygYelkw'l , Buyer.-Copy Pink% � '; i i I i i I . Renewal ; �P�r-: byAndersen4 '- WINDOW REPLACEMENT en An!:-.,wt,,.-mpt ny y Wool Composite IF l ettestCaticra Dual• Argon Low E } Rahng�oun �'' Double Hung f 100-00390547-005 ENERGY PERFORMANCE RATINGS U-Factor(U.S)/I-P Solar Heat Gain Coefficient 0- m3.0 0 . 31 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0m53 Manulcaturerstlpuletes that these ratings oonfonn toappllcacle NFRC pmceduma for uetennining whole product pertonnance.NFRC ratings are datermined fora fixed set of environmental conditions and a specific product size. NFRO does not mcornmend any product and does not warrant the suitability of any product for any specule use. Consuk manufacturers fitamfure for other product partonnence Information. _ ww iArc.org. SEA-( This product meets Gre t I Seal's environmental ' ? �► standards governing ,;' c• � energy efficiency,heavy � • :......;` G metals in the frame and i 4V sash materials, i ,. `�1 packaging,and consum r CrI education materials. "'" DESIGN PRESSURE(PSF) t s Window m Msruifncenpx Atwsanm t ll n. �•Y;', H - LC � ,. • �" � 25 RbA b6 Sloped Sill DH IN •` `+���`� ; ��`�'� I -r.:. :xnr'w•��,- e<'! r�!;'t^ ''Y�,i,y;y�%;::'•aiy;` Tmed to NAfB4)2or AAMAAVDMAnA I01/6/A740-05. Msou[acmta sti ulntrs mafO�MRID teaA gcabla staodaras . __.. re - + r't•flryy i4u.� �#„ Meets or exceeds M.E.C.,C•E.C,&I.E.C.C.Ar lnfilltretlon requirements WDMA Helhaik Wi 0lication program. r l Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-042926 ```mot:"1 1♦-�,,� � v. PAUL H THMEAVi,T 26 LESTER ST Q N SNEITHIF ELD ki 02 Expiration Commissioner 02/16/2015 ug Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 y Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 113245 Type: LLC Expiration: 9/19/2014 Tr# 231545 SOUTHERN NEW ENGLAND WINbOWS LL I MATTHEW ESLER ,T( 1 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 } •z Update Address and return card.Mark reason for change. Address U Renewal I]Employment Lost Card OPS-CAI 0 5%1-04/04-61 01 21 8 OfOceSfP�ods67/if?f= d $f(Sid�e9'4 ° License or registration valid for individul use only . HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration 173245 Type: Office of Consumer Affairs and Business Regulation Expiration: 9/19/2014 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 LYERN NEW:ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON� MATTHEW ESLER I i 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 -� Undersecretary Not valid without signature &17fConsumer Affairs TBAus1nWes4sefg-(/uElation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW EN GLAND WINDOWS LL Expiration: 9/19/2014 PAUL THIBEAULT 1137 PARK EAST DRIVE W OONSOCKET R1028 95 Update Address and return card.Mark reason for change. SCA 1 0 20M•05/11 Address Renewal R Employment Lost Card (� r . � v/ee ��o,rier�uyr[[aeal/�o`C�1WaJJac1[cJefl9 _ Mee of Consumer Affairs&Business Regulation License or registration valid for individul use only before the ex iration date. If found return to: a —_ ME IMPROVEMENT CONTRACTOR P ,{ Office of Consumer Affairs and Business Regulation Registration: 173245 TypF: 10 Park Plaza-Suite 5170 Expiration: 9/19/2014 Supplement 4'ard Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON PAUL THIBEAULT 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 Undersecretary Not vali without signature II Client#: 30124 SOUTNEW AGORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1/02/2013 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 pollcy(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 endorsement(s). PRODUCER CONIT "Anita Little - NAME: Willis of New Jersey,Inc. PHv INN Ext:856 914-4660 F 856 914-1881 1015 Briggs Road EMAIL A/c No PO Box 5005 ADDRESS: Anita.Little@willis.com INSURER(S)AFFORDING COVERAGE NAIC# Mount Laurel,NJ 08054 A INSURER :Selective Insurance Co of the S 39926 INSURED INSURER B:Argonaut Insurance Co. 19601 Southern New England Windows LLC INSURER c:Beacon Mutual Ins.Co. 24017 D/B/A Renewal by Andersen . INSURER D: 1137 Park East Drive Woonsocket,RI 02895 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. LTRR TYPE OF INSURANCE NSRADDLSUBR WVD POLICY NUMBER MM%DDY� POLICY LIMITS A GENERAL LIABILITY Y S202945900 8/10/2012 08/10/2013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $SO OOO CLAIMS-MADE 7 OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- JECT LOC $ A AUTOMOBILE LIABILITY S202945900 8/10/2012 08/10/201 COMBINED SINGLE LIMIT Ea accident 1,000,000 X ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED J SCHEDULED AUTOS AUTOS (Per accident)BODILY INJURY Pidt $ 1 X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident A X UMBRELLA LIAB OCCUR S202945900 - 8110/2012 08/10/2013 EACH OCCURRENCE s5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $S 00O 000 DED RETENTION$ $ B WORKERS COMPENSATION AIC927698352394 8/21/2012 08121/201 We sraru- oTH- AND EMPLOYERS'LIABILITY C ANY PROPRIETOR/PARTNEPJEXECUTIVE Y/N 68028 8/21/2012 08/21/201 E.L.EACH ACCIDENT $1 OOO OOO OFFICER/MEMBER EXCLUDED? ® N I A (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 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Cert holder is included as additional insured regarding work performed by the named insured. 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. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S213748/M213024 AXE The Commonwealth ofmassaachwsetts I rt Department of Industrial Acciden ts Office of Investigations 600 Washington Street lostol,MA 02111 ! WWW-Massygov/diet Workers' Compensation fusurInce At'fidevits Builders/Contractors/Electricia®s/Plumbers AvpUcant Information - - Ple>tse Print LeFibli Name (Busiaess ftuizadontbdivi&W): Address: /3 7 Par V'e-1 City/State/Zip: Wtat �SBr-�� �, -oa,84s Phone#: Are you an employer?Check the appropriate box: I. I am a employer with o` 0 4. ® I am a general contractor and I Type of project(required): 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. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ®Demolition working for me in any capacity. employees and have workers` [No workers'comp. insurance comp. insurance.t 9. ®Building addition required;] S. ® We are a corporation and its 10.0 Electrical r 3.® I am a homeowner doing all work officers have exercised their repairs or additions myself 11.0 Plumbing repairs or additions y [No workers'comp. right of exemption per MGL Ms1.rrance required.]t c. 152, §1(4),and we have no 12. Roof repairs 3a.0 1 am a homeowner acting as a employees.(No workers' MER Other F�,P IqCA_ ¢A }- general contractor(refer to#4) comp.insurance required.] t t7 �ldow--r °.any applicant that checks box#1 must d"fill out the section below showing their wodm,compensadad t Homeowner$who submit this affidavit it dieating they are doing all work and then him outside eoatractors�soyffi new affidavit indicating such, �ttact 1 `1 that check this box must attached an additional sheet showing the name of the sub-cant wtm ad sum why or 1q those entities have empjoyeee. If the sub-contractors have employees,theymust !provide their workers comip.policy number. � i am an eatployeP!lead u pravrdr�a�tvoP era'C®aepa°►csatrora hour=ce for a¢y employees. Below is the pope}►and job site IltfaPAeati0l$ Insurance Company Name: D (> f�S U2Awc Policy#or Self-ins. Lie.#:Al !9 7 6 9 9 3 A-d 37.41 Expiration Date: Job Site Address: C o t1 `,a r La y)-P, City/State/Zip: rlvn%� ( Vt Attach€ 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 pe fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK nalties ORDER and a of 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. = r do he76 eeriri !!order a pains wnd penalties of perJur}'that flee�inf�Orlmnao�d=lfflprm�v=dedbove is tr'rrc and correct Ofj9cial use only. Do not write in this area,to be completed by city olP town 0i iciai . City or Town: Permit/License# Issutag Authority(circle;one): I.Board of health 2.Building Depr;rtment 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: P6nna ft•