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HomeMy WebLinkAbout0065 LOUIS STREET l�� �' I Cape Save Inc. TOVY'tl Or BARNSIA NI: 7-D Huntington Avenue South Yarmouth, MA 02664 7E #{F , ,4 Tel: 508-398-0398 Fax: 508-398-0399DIVISH AV 4 1-18-12 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St.Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 65 Louis street,Hyannis has been inspected by a certified Building Performance Institute (BPI)Inspector. Ceiling: R-38 Cellulose& R-19 cellulose(slopes) Foundation Perimeter: R-5 fiberglass All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey r TOWN OF BARNSTABLE,BUILDING PERMIT APPLICATION Map pp 3 7 Parcel �� Application # �: 6 Health Division Date Issued f Conservation Division Application Fee Planning Dept. _ Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis l �;< C Project Street Address 6 5 L 0 U,IS �-t - Village 1 testa-A ,,J Owner P" Address S km e Telephone $ 2L5 ePermit Request �;r pal -��� Sa®e- o� ,n s ��� w► , R-49 ✓1� DC�esk +6 V-IS tosr- i ar- Do6:5i D`P Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 45,OM Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Q Two Family ❑ Multi-Family (# units) Age of Existing Structure 7 _ Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft.) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: _ existing _new Total Room Count (not including baths): existing _ new First Floor Room Count Heat Type and Fuel: ❑ Gas 1.0il ❑ Electric ❑ Other Central Air: ❑Yes XNo Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # _ Recorded ❑ Commercial ❑Yes W'No If yes, site plan review # _ Current Use Proposed Use APPLICANT INFORMATION p_ (BUILDER OR HOMEOWNER) 4 Name W� 1 hl �rCIKS64 / �� &v e, Telephone Number ' 3 0 - 0 3 9� Address � �-u.n �A4�f �� License # �C so(AA �Mlrnow+k �� Home Improvement Contractor# 6� 3 d-• Worker's Compensation # —1 fill G 9� / d� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO�a rnnBU,� h DATE SIGNATURE ) 2 3� �► 1 F FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED ' MAP/PARCEL NO. '- ADDRESS VILLAGE ` OWNER ` DATE OF INSPECTION: FRAME -INSULATION' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ;t 'GAS: ." ROUGH FINAL ' FINAL BUILDING`; gl DATE CLOSED OUT ASSOCIAI'I0N PLAN NO. ` [4 x r ' 460 West Main Street OUS ING Hyannis, MA 02601-3698 ASSISTANCE ENERGY & HOME RE-PAIR T (508) 790-7106 F (508) 790- ORPORAT ION 2425 HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: UT-AN-D-Sl-GN T H-I-S-FO-RM--IfF-Y�t _- THEAPPLICANT HOMEOWNER. I i�'c�..�•P, �-� _ hereby consent to and agreethat weatherization work may be done by the Weatherizationt Program of Housing Assistance Corporation (herein after referred as Agency") on the property located at: � L"' The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of thefollowing measures: Weather-stripping& caulking of windows and doors, insulation of attics, sidewalls& basements, attic and other ventilation measures and possbly replacement of badly deteriorated windows. In consideration of the weatherization work to be done at my home agree to the followi ng: 1. I give permission to the"Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The HousingAsdstanceCorporation reserves the right to inspect thefuel or utility bill for the weatherized unit on an ongoing basisfor no morethan five(5) years after theweatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent. 4 Home Owner: (Signature) Date: __..........-- -- .__._..................._ _ r' Agent: (signature) . Date HAC approved Weatherization Company : __ = = 5 PP P Y � _ ��e 'L`r.e ._.. All Cape Energy, Caliber Building&Remodeling, Cape Cod Insulation, j ape Save, Creswell Construction, Frontier Energy Solutions, Lohr&Sons, Peter Smith, Resolution Energy, Rock:Solid Construction Cape Save 7 Huntington Avenue Suite C, South Yarmouth, MA 02664 t y� a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass govMdi:a orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aunlicant Information Please Print Let�l& Name(Business/organizatiowbdividual): 1[4.14.A Ei L As is 'a�.�pl% ('/�fc SA Address: I -C.., to u n9 it t teab c3 City/State/Zip: • ��i2Mogt�T� UNione t 3 g' employer?Are}rou e n Check the appropriate box: Tv project' r 4. I am a '�of p (required): ) I.[a I am a employer with 1.y ❑ general contractor and I� w employees * have hired the sub-contractors 6 [3 New construction (full and/or part-time). 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. [3 Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'coiiip. insurance comp.insurance.* required.] S. [] We arc a corporation and its 10.C] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 l.[3 Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.0 P Roof repairs insurance required.) + c. 152,§1(4),and we have no 13.®OthcrTtW�a'�ltm employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 subcontractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I ace an employer that is providing workers'conepensadon insurance for trey employees. Below is thepoGcy and job site information. Insurance Company Name: I P.G k n e o to V -In S U 0.�CE o m p a,n Policy#or Self-ins.Lie.#: —rw C. 3 3,, 9 --9 Expiration Date: 0 a 1 a.0 a, Job Site Address- tU5 L owls S'� � city/state/zip: n Attach a copy of the workers'compensation policy declaration page(showing the policy numb 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 D1A for insurance coverage verification. 1 do hereby cerafy under the pains MdRena4des erjury that the informadon providedn above isct true and corre Si a e• r Date: d� d. P #: - i - Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector g.Plumbing Inspector 6.Other Contact Person: Phone#: aco CERTIFICATE OF LIABILITY I °0/20/°°011 INSURANCE 10�20�2011 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 endorsement(s). PRODUCER CONTACT AME CT Shannon Sperrazza Risk Strategies Company PHONE (7B1)986-4400 o (781)963-4420 15 Pacella Park DriveE-MAILADDR :ssperrazza@risk-strategies.com Suite 240 INSURERS AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURERA:Selective Insurance INSURED INSURERB:Safety Insurance Company 3618 Michael McCluskey, DBA: Cape Save INSURER C:Technolociv Insurance Company 7 C Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02644 INSURERF: COVERAGES CERTIFICATE NUMBER-CL11102041451 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 I ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 100,000 A CLAIMS-MADE Ex—J OCCUR 2PPS1994480 0/16/2011 0/16/2012 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,0001 X POLICY JECT PRO LOC $ AUTOMOBILE LIABILITY Ea BINEDtSINGLE LIMIT 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OS SCHEDULED 6208200 1/6/2011 1/6/2012 BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ X Underinsured motorist BI split $100000 300000 X UMBRELLA LIAB X OCCUR CPPS1994480 0/16/2011 0/16/2012 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,OOO DED RETENTION$ $ C WORKERS COMPENSATION Executive excluded WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X I TOY ANY PROPRIETOR/PARTNERIEXECUTIVE rom coverage E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? N!A (Mandatory In NH) C3297972. 0/21/2011 0/21/2012 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required)) Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a National Grid, d/b/a Boston Gas Company, d/b/a Essex Gas Company, Action Inc., and Housing Assistance Corporation are listed as additional insureds as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS. 484 Main Street Hyannis, MA 02601-3698 AUTHORIZED REPRESENTATIVE Michael Christian/SM3 '°% -��` ACORD 26(2010106) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25roninmint Tho Af_nan nnma anril Inn^nra•aniefarari mcbrire^f OrtnRrl Office of Consumer Affairs and usiness Regulation _ - 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration i i Registration: 164432 Type: DBA CAPE SAVE Expiration: 10/6/2013 Tr# 217656 MICHAEL MCCLUSKEY - 7C HUNTING AVE. -_.. _.. ... S. YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. DPS-t Al 0 50AA04104 p101216 Address Renewal J Employment i- Lost Card —� i._.; t _ L!i2(J4Ll(�P.CL/.CdL Oy�: _ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: yRegistration: 164432 Type: Office of Consumer Affairs and Business Regulation c Expiration: 10/612013 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 I CAS SAVE MICHAEL MCCLUSKEY 8201 S.HOURD CT CHAPEL HILL,NC 27516 / _ Undersecretary of valid without signature �Iassuchusctts- Department of Public Safeth Board or Building Regulations and Standards 1� Construction Supervisor Specialty License License: CS SL 102776 � re fi Restricted to: IC W►LLIAM MC CLUSKY 37 NAUSET ROAD WEST YARMOUTH, MA 02673 5 �� v-- ��" Expiration: 6/2&M13 ( nnnu� irner Tr#• 102776 08.125:201 a 09:23 919K12955 PAGE 01 i 01 CAPE* 7SAW Weatherization 508-398 398 August 22, 2010 To Whom It May Concern: William J. McCluskey is are employee of Cape Save. He is authorized to negotiate contracts and building permits for our.company. '0 Michael McCluskey Cape Satre—owner 919-593-5939 cell TC Huntington-Avenue,South Yarmouth,MA 02664 0'r- fin The Town of Barnstable. Department of Health, Safety and Environmental ervices > AiM t Building Division KAM 639. 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Home Occupation Registra on Date: 1 I Name: Address: Village:—�I �amm S Type of Business: S Map/Lot: INTENT: It is the intent of this section to allow the res' ents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to Fe provisions of Section 4-1.4 of the Zoning ordinance, provided that the activity shall not be discernible fro outside the dwelling: there shall be no increase in noise or odor; no visual alteration to the premises which w d suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no' crease in air or groundwater pollution. After registration with the Building Inspector, customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by permanent resident of a single family residential dwelling unit, located within that dwelling it. • Such use occupies no mo than 400 square feet of space. • There are no external al rations to the dwelling which are not customary in residential buildings, and there is no outsid evidence of such use. • No traffic will be erated in excess of normal residential volumes. • The use does not' olve the production of offensive noise,vibration,smoke,dust or other particular matter,odors, ectrical disturbance,heat,glare,humidity or other objectionable effects. • There is no rage or use of toxic or hazardous materials,or flammable or explosive materials,in excess-of� rural household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • Th a is no commercial vehicles related to the Customary Home Occupation,other than one van or o e pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and of to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • o sign shall be displayed indicating the Customary Home Occupation. • ifthe Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the dersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant: 1'` Dater �. Assessor's Office(1st floor) Map Lot Permit# _ /O_�O, Conservation Office(4th floor) - Date Issued Board of Health(3rd floor)(8:30-9:30/1:00- 2:00) c- v v SPFvegee- d,5'0 O o, Engineering Dept."(3rd floor) House#1 rJ' Planning Dept.(1st floor/School Admin.Bldg.) RARNSPARLE. • - Definitive PI p veal by Planning Board 19 E 01M� TOWN OF.BARNSTABLE , Building Permit Application Projec ress e0 3- Village -Owner ,,� ,�f.� ��.eo W/✓ Address `Telephone 7 7/ Permit Request ZAI-S�r-A2-t- I1G�L,0 00oc Gt/in/A�al /2:U - L Z k szi �S'�'1Z�� �-•- �?E�i�d>= i`�t'ic Xoy� ate/ olfi2G.c�-�/��= rci �r�gS.v/�LT' Total 1 Story Area(include 1 story'garages&decks) square feet Total 2 Story Area(total of 1st&2nd stories) /YO square feet Estimated Project Cost;:$ Zoning District ' Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway O Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached. Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name ��jt//� /� 'J��`3 Telephone Number Address License# O 4/4 Home Improvement Contractor# /007410 O L 7— Worker's Compensation# OF Gc/Ef3kJ `33* 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 SIGNATURE d� DATE -- 7 ys— BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) - FOR OFFICIAL USE ONLY PERMIT NO. 102031 DATE ISSUED 9/7,/9 5 MAP/PARCEL NO. 309 207 c x , ADDRESS 65 Louis Street VILLAG-t Hyannis OWNER Walter & Rafael A. Perez DATE OF INSPECTION: _ FOUNDATION r FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH .FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r ✓fie (� o����GaGQ,zGliuQe4 : HOME IMPROVEMENT CONTRACTORS REGISTRATION oard of Building Regulations and Standards 1 One Ashburton Place — Room .1301 1 Boston, Massachusetts :02108 1 I . I HOME IMPROVEMENT CONTRACTOR --------- Registration 100740 Expiration 06/23/96 r Type — PRIVATE CORPORATION HOKE 1MPROVElIEN1 COHIRACIOR..•_ ' .gavistratiom A00740 I Capizzi Home Improvement , Inc . I Type -..PRIVATE CORPORATION- II Thomas Capizzi , Sr . I ENpirmtion 46/23/96 1 1645 Newton Rd . Cmplzzi Home I1�provememt, Inc Cotuit MA 02635. j Thomas CAPizli, Sr. �View,"- f!24M Newton -Rd. ADMMSTRAMA Cotuit MA 02635 Restricted To: 10 DEPARTMENT Of PUBLIC SAFETY lug [ONSTRUCIION SUPERVISOR LICENSE 10 — Role Rxober: . .Expires: tirlldile: I 11 - Nuoiry oily CS 146189 10/29/1996 10/29/1148 16 - 1 a 1 Fioily Holes Restricted To: 10 �1..L. 9AVI8 H NEBB commas,oNm '100 PLUM HOLLOW RD ' E FALNOUTH, NA 12536 r 1' The Town of Barnstable N"& Department of Health Safety and Environmental Services 1 Building Division 367 Main Sltcet.Hyamtis MA 02601 Ranh C Office: 508-790.6227 B € F= 508 775 3344 For office use only . Permit no. Date AFFIDAVIT HOME n"ROVEMMT CONTRACTOR LAW SUPPLEMENT TO PF.RI 'T APPLICATION MGL c- 142A requires that the"reconstruction,aitaadmz =0radon+mpa'r' cow imprvve:rteat, remcn-4 demolition. or coon of an addition to any per' owner = building containingat least one but not more than four dwelling units or to stIm"r s which zc a4 to such resid=cc or building be done by registered contractors,with certain cooepd=M along with mgaixe:nents. Type of Waric:,/[���Gt/�NmcJ-�-/►aQ� i{1GwEst.Cost — Address of Woric �1— /—I"—t s Oa-ner.Nan= 'J Date of Permit Application: I hembr certify that: Registration is not required for the following rrason(s): Work exanded by law >abunder=000 Bniiding not eowrter occupied Owner pulling own P ' Notice is hereby given,that- OWNERS OWNERS pULI,ING T1D3R OWN PERMIT G DO NOT HAVE ACCESS TO VOR APPLICABLE HOME I PA WCMK ARBITRATION PROGRAM OR GUARANTY FWD UNDER MGL c 142A SIGNED UNDER PENALTIES OF PE LWRY I hercby apply for a permit as the agent of the a mw. Vem RegisUad= No. Date OR —`--_ The Commonwealth of Massachusetts Department of Industrial Accidents F 600 Washington Street i Boston,Mass. 02111 Workers' Compensation Insurance Affidavit al Z G G�� ciSv [ /�— i!I /� d ZG3s� phone I am a homeowner performing all work myself. I am al sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. company name- ' address: city: ....- insurance co. AoY# am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: _ address: ctty. pjlone#.: Insurance co. -,L _7. .✓� :: Ro�tcY# U� " �F� g � company name: address: city: phone# insurance co. policy#:.. tat: �a tfiona� et=f:>necessa_ .,:..; Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under t s an penaltiesgriury that the information provided above is true and correct Signature Date Print name Phone# 412X 9J-1 <: official use only do not write in this area to be completed by city or town oRcial i� ►. t* [.: city or town: permit/license# nBuilding Department L Licensing Board C]check if immediate response is required [3Selectmen's Office i. i; [31iealth Department contact person: phone#; r•tOther fj (revised 319c PIA) ne re and n- 1 r 2 b, ,prior oof , ty. e ::re .�Y do 3 4 y 5b )Y ; con .dor n de S s de �I s :our 5 6 a fin et 4 � �. et n. z{ v pJ � to >' ° /ous i et rtes 9ui �s z , A