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HomeMy WebLinkAboutBLD-23-002817 • nJ oti Jed j02-1e1 z �' E r _ :—ONE 4 TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department " ' 1 146 Route 28, South Yarmouth,MA 02664-4492 _linQV212022508-398-2231 ext. 1261 Fax 508-398-0836 , I Massachusetts State Building Code,780 CMR s.� BVIL.ING DEPA�r 'ernzitApplication To Construct, Repair, Renovate Or Demolish By. -- — a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: ; . 3-0tA811 Date Applied-, i _JM leA(S - /1-) - 4 Building Official(Print Name) • Signature Date SECTION 1:SITE INFORMATION 1. cop rty, /�re � 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes __ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required I Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? _ Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 O ner'of Recerd: 3 , iair-y ()----IN rtm, 6-,s--(0 ),(/ ame(P 'nt) 11 City,State,ZIP 5159- " 7 /*C)c 6 i col 0 n,,w/ e vethbo.co-rf-- No.and Street Telephone Email Addrqks SECTION 3:DESCRIPTION OF PROPOSED WORK2(ch k all that apply) New Construction 0 I Existing Building l Owner-Occupies Repairs(s�,, Alteration(s) 0 I Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Descriptiono Proposed ork2: ^ SI- ,ti �� �(E A•�-h ,5f\ ( u n ik Su rv.61,1 (k) cith fii/f utio,ik, watV SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and laterals) I.Building $ I v l e�i\ 1. Building Permit Fee:S I 1-0 Indicate how fee is determined: 2.Electrical $ EdStandard City/Town Application Fee 0 Total Project Cost3_Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ -' -S c 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ ._ , Suppression) Total •All Fees:$ i Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ( `1 U(p a ❑Paid in Full at Outstanding Balance Due: 11 cA n✓ \ 1\� \ SECTION 5: CONSTRUCTION SERVICES 5.1 CoCopsfrructiin Supervisor License(CSL) ( 1 7(, Name of qa.Ho License Number Expiration Date (a I 0,cL 1 `tkt, ek List CSL Type(see below) City d Street Type Description SI�i�b/l O _ U Unrestricted(Buildings up to 35,000 cu.ft) City/To ,State,ZIP R Restricted 1&2 Family Dwelling M ci Masonry 1 ���� `� AA i vita�'C . Gawk, RC Roofing Covering ) y� WS Window and Siding 1 • �(��' d U SF Solid Fuel Burning Appliances Telephone I Insulation Email address D ' Demolition 5.2�tered Home Improvement Contractor(HIC) I 1 L�/, /� _ Y1 `- "1 s•y' fi3 ° m ly et a oA. gistrarit Name HIC Registration Number Expiration Date Hfcyty" (t`1 1 '`k (/lVU • '"17 • U1• Emaildd r"�•(� ' City/Town,State,ZIP IIIph Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(ibI.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 A/Q No 0 . SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTORl�, APPLIES FOR BUILDING PERMITI,as Owner of the subject property,hereby authorize " "4 C6 p 1)OY5 to act on ray behalf,in all matters relative to work authorized by this building permit application. /QYIn cSa ( ltb `V--- Print Owner's Name(Electronic ignature) Date • SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this plication is true and accurate to the best of my knowledge and understanding. .....,e44 nna-r5 , , 0 ' -)--Y Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtain¢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 nor 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.ttov/fps 2. When substantial work is planned,provide the information below_ Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) 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" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext.-1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at I 5Aikgc 6yook IZ Work Address Is to be disposedfollowing of oat the location: R kL 'A 00-11-'1W4 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. S. '�..' re of Application Date Permit No. Page 1 of 11 CT Reg#0605216 MA Reg#146589 r RI Reg#913463 NrEel HOME SOLUTIONS 26 Cedar St Woburn, MA 01801 800-242-9974 Federal ID#20-2625129 Luxury Contract Customer Information Ann Savery (508) 737-0905 0 Date: 10/11/2022 73 Swift Brook Rd annmsav@yahoo.com Rep: Joshua Moss South Yarmouth MA 02664 Office#800-242-9974 Location Agreement NEWPRO hereby agrees that it will, for the consideration hereinafter mentioned, furnish all labor and material necessary to install the goods purchased by Owner in accordance with the terms described on the following pages of this agreement (collectively, this "Agreement") at the premises located at: 73 Swift Brook Rd South Yarmouth MA 02664 Custom Shower Details Package: Tub to Shower(Custom Acrylic/Spray Foam) Wall Color: Othello Size - Drain: 60"L x 30"W - Left Wall Style: Cobblestone Impressions Base Color: White Walls To Ceiling: Yes Threshold: Single Fixtures Align Valve&Trim ONLY QTY 1 Chrome 5' Straight Shower Rod QTY 1 Chrome 18"Grab Bar QTY 1 Chrome Liquid Accents 24" Grab Bar QTY 1 Chrome Liquid Accents Teak Seat QTY 1 Gray Metal Moen Single Function Hand Shower w/Slide Bar&Elbow QTY 1 Chrome Moen This space intentionally left blank leaptodigital.corn 2.11.2 Accessories Page 2 of 11 Single Tier Corner Shelf Smooth QTY 2 White Window Kit(51"x 6") Smooth QTY 1 White Luxury Labor Wall Repair(As Needed) QTY 3 Remove Cast Iron or Steel Tub QTY 1 Tub will NOT be removed in one piece Installation & Promotion Details Newpro will remove any demoed or installation debris from the property in relation to this contract. All promotions were applied at the time of purchase and can not be combined with any future offers. Payment Total Price: $19,064 Deposit: $5,000 Due Upon Completion: $14,064 Payment Method: Finance Estimated Start&Completion Estimated Start: 14 to 16 weeks Estimated Completion: 1 to 3 days Customer understands they will be contacted to set a firm installation date once all product is received. State MA Year Home was Built 1968 LSWP NO This space intentionally left blank Page 4 of 11 Plumbing Disclaimer If during the installation phase, NEWPRO discovers that unforeseen repairs (plumbing, etc.) related to the project are required, additional charges will apply and Owner will be advised of the conditions. NEWPRO is not responsible for unforeseen damage to plumbing below or behind the tub, including shut-off valves or faulty plumbing. In some instances due to the age of the plumbing, repairs may be required to meet current code at the additional expense of Owner. By initialing, I acknowledge that I have read, understand and agree to the above conditions. Demolition /Dama•e Disclaimer When a replacement tub/shower is purchased, NEWPRO is required to remove the existing tub/shower. In rare instances during the demolition process the bordering wall and/or floor tile may be damaged. NEWPRO is not responsible for this damage as in most instances damage is due to the age of the existing material and the method used for removing the existing unit. The replacement material may no longer be available for repair NEWPRO is not responsible for repainting or restaining as a result of demolition damage. In some cases, due to pre-existing conditions Newpro may be forced to add a Filler Strip to cover a void between your new Tub/ Shower and your finished floor. Customer agrees to hold Newpro harmless and understands that Newpro will not be responsible to tile or complete this area other than add a filler strip. By initialing, I acknowledge that I have read, understand and agree to the above conditions. Install Disclaimer It is our mission at NEWPRO to give our customers the ultimate experience in their bathroom remodeling project. In fact, most of our customers really appreciate knowing that their bath can be completed in just one day. At times, we run into unforeseen conditions when doing a bath remodeling project and because our first priority is ensuring you have a quality job, there are times when a bath remodel goes beyond one day. When these situations occur, rest assured that your project is our top priority and takes scheduling precedence over any other project in the works. Flooring is the responsibility of the customer. By initialing, I acknowledge that I have read, understand and agree to the above conditions. Custom Shower/Tub Door and Payment Disclaimer Customer acknowledges the custom shower/tub door will be measured after the base and walls are installed to insure proper fit. Manufacturing lead times for custom doors average 2 to 4 weeks and sometimes longer depending on material availability and design requests by customer. Customer acknowledges custom door will not be installed on the same day as the base and walls. This will require a second visit to complete the door installation. Customer acknowledges and agrees to a$500 hold back on all cash orders and finance order where the finance company allows a partial payment until the custom door is installed. Finance completion form to be signed when base&walls are installed. NEWPRO will expedite delivery and installation of custom door. By initialing, I acknowledge that I have read, understand and agree to the above conditions. This space intentionally left blank leaptodigital.com 2.11.2 Page 1 of 16 CREATE A 5 STAR EXPERIENCE FOR EVERY CUSTOMER ASK FOR A REVIEWw w W HOME SOLUTIONS Luxury Work Order Customer Information Ann Savery (508) 737-0905 0 Date: 10/11/2022 73 Swift Brook Rd annrnsav@yahoo.com Rep: Joshua Moss South Yarmouth MA 02664 Rep# 800-242-9974 Bathroom 1 Details None Package Includes Selected Base, 3 Walls, 1 Corner Trim, Floor Repair if needed Shower Measurements Package Tub to Shower(Custom Acrylic/Spray Foam) Wall Color Othello Size - Drain 60"L x 30"W - Left Wall Style Cobblestone Impressions Threshold Single Walls to Ceiling - Room Height Yes - 88 Base Color White Left Side Wall Width 60 Opening Length x Existing Base Width 60" x 30" Left Surround Width 32 Trim Skirt YES Right Side Wall Width 60 Right Surround Width 32 Fixtures Align Valve&Trim ONLY QTY 1 Chrome TRM-M-2191-C 5' Straight Shower Rod OTY 1 Chrome SRS-60-C 18"Grab Bar QTY 1 Chrome Liquid Accents LAGB-18-C 24" Grab Bar QTY 1 Chrome Liquid Accents LAGB-24-C Teak Seat OTY 1 Gray Metal Moen MOE-DN7110 This space intentionally left blank Page 2 of 16 Single Function Hand Shower w/Slide Bar&Elbow QTY 1 Chrome Moen MHS-3868EP-C - I Accessories Single Tier Corner Shelf Smooth QTY 2 White CC-ST-W Window Kit(51"x 6") Smooth QTY 1 White Luxury WK'W Labor Wall Repair(As Needed) QTY 3 Remove Cast Iron or Steel Tub QTY 1 Tub will NOT be removed in one piece Installation Instructions Left Wall Valve -Shower Fixture- Drop Ell - Wall Repair- 2 Corner Shelves Back Wall Wall Repair- 24" Grab Bar-Window Kit Right Wall Wall Repair- 18" Grab Bar Pre-install Checklist Variance Required NO Property Type Single Family Parking Options Large Driveway Fixture Install Handheld w/Drop Ell (No Shower Head) Curtain Rod or Glass Doors to be Installed Straight Curtain Rod Bath Location 1st Floor Existing Base Type Cast Iron/Steel Existing Walls Tile Is there access behind wet wall or below base? YES Below Base Ceiling Panel/Soffit NO Window Within Wet Area YES - Window Kit Ordered Wainscoting/Accessories NO Second Full Bath NO Additional Items to be Installed None Are there any existing problems with the plumbing? NO This space intentionally left blank leaptodigital.com 2.11.2 Page 3 of 16 Image: 1.1 ,g �,Qr p l ,, f "k X{ �y T5 �`ryy `F� ft'., �fm sµ% 6_Y a rc• . "�� .q K as .': ' ---',! '7.g'''..4' ':%t'"' -;:.41'::---',::s nc' ' ' .# '''''•,,,,::'4::4-4,- k �o i t tT wn _ x leaptodigital.com 2.11.2 Page 13 of 16 Imaie: 1.11 )1111111* ''',,,: ' ._.' 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A/71 ;URN.c;A 01801 UndersecretaryNsif •without signature Commonwealth of • hi Division of Occupational _, :,era Board of Building Regulations and Standards Cons�tfIet on S Adervisor CS-110763 • spires:05/0512024 JEFFREY CC3i11NORS . 64 OLD FIELH RD SOUTH BERRY_JCK ME 03908 iggirtlee Commissioner 044 .. Page 4 of 11 Plumbin Disclaimer If dur:-1g the installation phase, NEWPRO discovers that unforeseen repairs (plumbing, etc.) related to the project are required, additional charges will apply and Owner will be advised of the conditions. NEWPRO is not responsible for unforeseen damage to plumbing below or behind the tub, including shut-off valves or faulty plumbing. In some instances due to the age of the plumbing, repairs may be required to meet current code at the additional expense of Owner. By initialing, I acknowledge that I rave read, understand and agree to the above conditions. Demolition/Dama•e Disclaimer When a replacement tub/shower is purchased, NEWPRO is required to remove the existing tub/shower. In rare instances during the demolition process the bordering wall and/or floor tile may be damaged. NEWPRO is not responsible for this damage as in most instances damage is due to the age of the existing material and the method used for removing the existing unit. The replacement material may no longer be available for repair. NEWPRO is not responsible for repainting or restaining as a result of demolition damage. In some cases, due to pre-existing conditions Newpro may oe forced to add a Filler Strip to cover a void between your new Tub/ Shower and your finished floor. Customer agrees to hold Newpro harmless and understands that Newpro will not be responsible to tile or complete this area other than add a filler strip. By initialing, I acknowledge that I have read, understand and agree to the above conditions. Install Disclaimer It is our mission at NEWPRO to give our customers the ultimate experience in their bathroom remodeling project. In fact, most of our customers really appreciate knowing that their bath can be completed in just one day. At times, we run into unforeseen conditions when doing a bath remodeling project and because our first priority is ensuring you have a quality job, there are times when a bath remodel goes beyond one day. When these situations occur, rest assured that your project is our top priority and takes scheduling precedence over any other project in the works. Flooring is the responsibility of the customer. By initialing, I acknowledge that I have read, understand and agree to the above conditions. Custom Shower/Tub Door and Payment Disclaimer Customer acknowledges the custom shower/tub door will be measured after the base and walls are installed to insure proper fit. Manufacturing lead times for custom doors average 2 to 4 weeks and sometimes longer depending on material availability and design requests by customer. Customer acknowledges custom door will not be installed on the same day as the base and walls. This will require a second visit to complete the door installation. Customer acknowledges and agrees to a$500 hold back on all cash orders and finance order where the finance company allows a partial payment until the custom door is installed. Finance completion form to be signed when base&walls are installed. NEWPRO will expedite delivery and installation of custom door. By initialing, I acknowledge that I have read, understand and agree to the above conditions. This space intentionally left blank leaptodigitai.com 2.11.2 ACORD> CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/30/2022 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 have ADDITIONAL INSURED provisions or 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 NAME: Marsh Affinity PHONE FAX Marsh Affinity (NC,No,Ext): 866-237-4079 (A/C,No): a division of Marsh USA Inc. ADDRESS: DDRESS: ADPTotalSource@marsh.com PO Box 14404 Des Moines.IA 50306.9686 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: New Hampshire Insurance Co. 23841 INSURED INSURER B: ADP TotalSource CO XXII,Inc. INSURER C: 5800 Windward Parkway INSURER D: Alpharetta,GA 30005 Alternate Employer: INSURER E: Newpro Operating LLC INSURER F: 26 CEDAR ST Woburn,MA 018010000 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 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 7YPEOFINSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LTR INSD WWI (MM/DD /YYYY)/YYYY) (MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS MADE OCCUR DAMAGE TO PREMISES(Ea RENTED MED EXP(Any one person) S PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S PRO POLICY JECT LOC PRODUCTS-COMP/OP AGG S OTHER. S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY _AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _AUTOS ONLY (Per accident) S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RblhNTION5 5 WORKERS COMPENSATION —PER OTH- ANDEMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 2,000,000 iOFFICERMIEMBER EXCLUDED,' NIA WC 024509800 MA 07/01/2022 07/01/2023 pl (Mandatory in NH) E.L.DISEASE-LA EMPLOYEE 5 2,000,000 f yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) All worksite employees working for NEWPRO OPERATING LLC,paid under ADP TOTALSOURCE,INC's payroll,are covered under the above stated policy.NEWPRO OPERATING LLC is an alternate employer under this policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Newpro Operating LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 26 Cedar St Woburn,MA 01801 AUTHORIZED REPRESENTATIVE ACORD 25 2016/03 ( ) ©1988-2015 ACORD CORPO ION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents . —�! Office of Investigations ,J) Lafayette City Center i 2 Avenue de Lafayette, Boston,MA 02111-1750 `-c >s� www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): NEWPRO OPERATING INC Address:26 CEDAR ST City/State/Zip:WOBURN MA 01801 Phone#:401-475-2849 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.* required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *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. ttontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: NEW HAMPSHIRE INSURANCE CO Policy#or Self-ins. Lic.#:WCO24509800 Expiration Date:07//01/2023 Job Site Address: 00 [ City/State/Zip:31 V r�` �' , - 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 d e ins and penalties of perjuiy that the information provided above is correct.rue and corrrec Signature: Date: l ' b v Phone#: 401-47 2 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3tCity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.QOther Contact Person: Phone#: