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In accordance with the provisions of the Massachusetts State Building Code,section 105.1
Application for a certificate of use and occupancy permit
Name of Business Parterre Garden Services Phone# (617)492-2230
Type of Business Ecological Restoration/Landscaping EmailIcook@parterregarden.com
Property Address 212 Mid Tech Drive, West Yarmouth Unit# I
*Square Footage to be occupied 934 *attach floor plan Fee: S60
The following department sign offs will be required and will be notified once the application is
entered into the OpenGov permitting system.
X Health Department—508-398-2231 ext. 1241
X Fire Department—Fire Prevention, 96 Old Main Street, 508-398-2212
Other
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ii,, ding owners Signature isk i ,Atr,
A plicant Signature
PleaVe note: this permit is for use and occupancy only. Any work requiring a building permit
will require a licensed contractor to submit an additional application with all the required
information based on the scope of the project.
**Office use only**
Zoning District Proposed Use Change of Use: Yes No
Allowed Use: Yes No APD Waiver: Yes No N/A
Building Officials Signature Date
Updated 6/24
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
!®-y 1 Congress Street, Suite 100
'Ill ,q Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:Parterre Gardening Services,Inc
Address:2 Republic Road, North Billerica MA 01862
City/State/Zip:North Billerica, MA 01862 Phone#:617-492-2230
Are you an employer?Check the appropriate box: Business Type(required):
1.❑✓ I am a employer with 100 employees(full and/ 5. 0 Retail
or part-time).* 6. 0 Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp.insurance required]** 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers, Landscaping
with no employees. [No workers'comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
"If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Continental Casualty Co
Insurer's Address:151 N. Franklin Street
City/State/Zip: Chicago, IL 60606
Policy#or Self-ins.Lic.46S59UB5R96989624 6S59UB5R96989624 Expiration Date:07/25/2025
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 f the DIA for insurance coverage verification.
I do hereby r ' ,under t pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: tL f '(i2 S
Phone#: Y 1,g J v ?'tO
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.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia