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HomeMy WebLinkAboutBuilding Permit # 9/6/2016 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NoM Date Received ED Date Issued: I PORTANT: Applicant must complete all items on this page In / ,/ 1/ //% x4m ro/0% // rri /„ / // / / // r r 11115,1011/1 It/m/na r itOn., ;,a.......... -------------- TYPE OF IMPROVEMENT PROPOSED USE --------------- Resigential Non- Residential Ei New Building pf)ne family ri A ition I,] Two or more family El Industrial 11 Iteration No. of units: El Commercial Repair, replacement E]Assessory Bldg F.1 Others.- El Demolition El Other ........... t j M, .11i'l 11/m/N DESCRIPTION OF WORK TO BE PERFORMED: 04 ------------ Identification - Pleaselyz rPrint I arl OWNER: Name: 0, hone., A"7 Xvo#"J� Address: ui ////k i0i'�1'50111110 4'msig W"-M-­' V 00 ....... >;//.. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ -7 x-;If, FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acc__ g arai yfitnd Signature ofAgeqVOwner Siqnature of contracto toRT� Town of s _ �� 6 ndover O ti. 6A No. ao 11 Wit. p C, u,KF h ver, Mass, CUxkxv SA�'l db CMKHewK. AFF ORAre n Aea,e�y � U BOARD OF HEALTH Food/Kitchen PER T D Septic System THIS CERTIFIES THAT ...,.. � ' ,. r b BUILDING INSPECTOR has permission to erect .... ................. buildings on .... . ,,......,.... .���... 7---W. - Foundation "' � � Rough to be occupied as ....... . .....�. .................................................................... chimney provided that the person acceptln this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 'PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS ST CTI S Rough Service ... .... ........ ...... "' Final BUILDING I PECTOR GAS INSPECTOR Occupancy Permit.Required t® Occupy„l;uzlding Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Mall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the wilding Inspector. Burner Street No. Smoke Det. Proposal AB Carnes Roofing,Inc. Pagel of 1 30 Arrowhead farm Rd Boxford,Ma.01921 978.887-1431 MA.CS-000230 and HIC Rog,17G92$ Proposal submitted To: MOHAIMMADALI KHORRAMI D August 21,5,2016 460 RIVER RD,,APT 323 P I ct Name 105 AUTRAIN ANDOVER,MA 01810 A ress NO ANDOVER,MA 01845 781-437-1750 1 1/7 1) We propose to furnish material and labor-in accordance with the specifications below: Sixty Four Hundred Dollars($6,400.00) Payment to be made as follows:$300.00 Deposit,Balance Upon Completion Notice:All honor Improvement contractors and subcontractors engaged in home improverrunitcortracting,unless specifically exempt from registrafort by provisions of Chapter 142A of the General Laws,must be registered with the Commonwealth of Massachusetts. Inquldes about registration and status should be made to the Mass.govAloenseswebsite. ROOF PROPOSAL 0 STRIP ROOF OF UP TO TWO LAYERS OF ASPHALT SHINGLES,COVER ROOF DECK WITH THE UPGRADED RHINOROOF TITANIUM U20 HIGH PERFORMANCE SYNTHETIC UNDERLAYMENT MEMBRANE.COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. 0 ICE DAM PROTECTIONS INSTALL CARLISLE HIGH PERFORMANCE ICE&WATER BARRIER OVER ALL HEATED AREAS SIX FEET WIDE AT THE LEADING EDGE OF ROOF AND THREE FEET IN ALL VALLEYS.WRAP THE CHIMNEY(S)AND SKYLIGHT CURBS WITH ICE AND WATER BARRIER. f,q COVER ALL PERIMETERS WITH EIGHT INCH PREFORMED ALUMINUM DRIP EDGE. F1 INSTALL GAP COBRA RWQE VENT AND/OR ROOF LOUVERS FOR ADDED ATTIC VENTILATION. COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS AND FLANGE. REPLACE WALL FLASHING(S)AS NEEDED WiTH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF$25.00PILFT.WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK AND YOU MAY NEED TO HAVE A CARPENTER REINSTALL OR REPLACE THE SIDING THAT WAS REMOVED, M- CHIMNEY FWHING�REMOVE EXISTING FLASHING FROM lF ANY CHIMNEY(S).CUT NEW REGLET INTO THE BRICK AND SECURE THE NEW LEAD WITH METAL ANCHORS AND SEAL, PLEASE ADD TOAWVE'PR]Ct`BLACK TAR USED BY OTHERS ISNOT FLASHING) M COVER ROOF SURFACE WITHCERTAlNTEED LANDMARK 235 �RRANTY DESlGNER SHINGLES. 0 REPLACE DEFECTIVE ROOF DECK AS NEEDED WITH SIMIAR AT`ANADDITK)NAL COST OF$4,00i1S0FTfPLFT. 0 COVER ROOF DECK WITH CDX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING,AT AN ADDITIONAL COST OF 0 NAILING: SECURE SHINGLES WITH EIGHT IN TOTAL COATED ROOFING NAILS AS PER CERTAINTEED SPECIFICATIONS. 1-1 SKYLIGHTS:REPLACE EXISTING SKYLIGHTS WITH NEW VELUX OR WASCO UNITS.WE WILL PROVIDE THE SKYLIGHTS&FLASHING KITS AT OUR EXACT COST FROM OUR SUPPLIER.OUR LABOR CHARGE IS$90.00 EACH IF THEY ARE THE SAME SIZE.INTERIOR WORK IS EXCLUDED. D REPLACE DEFECTIVE TRIM BOARDS WITH CUSTOMERS APPROVAL USING NO.2 PRIMED PINE,ADD$15,0OPLFT TO THE ABOVE PROPOSAL. CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK AREA. THE PROPERTY OWNER AUTHORIZES AS CARNES TO OBTAIN THE ROOFING PERWIl".WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC AREAS. CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE STRUCTURE AND FOLIAGE.HOWEVER,SOME MARRING AND OR MINOR DAMAGE COULD OCCUR, IN ADDITION,WE CANNOT BE RESPONSIBLE FOR ITEMS FALLING FROM WALLS,SHELVES OR CEILINGS DURING THE ROOFING PROCESS, SPECIAL INSTRUCTIONS- THE ABOVE PROPOSAL INCLUDES ALL SHINGLED ROOF SECTIONS OF THE HOUSE UPGRADE SHINGLES TO THE LANDMARK 300LB HIGH DEF PREMIUMS,ADD$935.00 TO THE ABOVE PRICE.YES THIS IS OUR EXACT COST WARRANTY UPGRADEJHE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM 110 MPH TO 130 MPH WITH UPGRADE TO THE CERTAINTEED HIGH PE FORMANCE HIP&RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL YES EMAILADDRESS: Warranty:All work warranted against Installation defects for 5 years;this warranty is limited to the installed item(a)and Its repair only.Material is warranted by the manufacturer against defects for 50 years;see the manufacturer's warranty for exact warranty performance. Cancellatiow Customer has legal right under federal law to cancel this contract without penalty or obligation within three business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side. Dispute Resoluflon:All parties agree that any and all disputes relating to this proposal shall be settled by arbitratton as provided by the AAA.This forurn is user friendly and does not requir lawyers.Please see reverse side. Signing this Proposal means you have accepted all the terms as stated on the front and back of this agreement. Please see reverse side. *Dale of Acceptance Signature__ Signature ............ Nvner,Barry Carnes PLEASE SEE REVERSE SIDE TOWN OF NORTH ANDOVER WASTE AFFIDAVIT As a result of the provisions of MGL Ch.40-s54, I acknowledge that as a condition of building permit# all debris resulting from the construction activity governed by this building permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL Ch.111-s150A. Waste Disposal or Solid Waste Facility: ALLIED WASTE Address: 300 FOREST ST Town/City, State, Zip: PEABODY, MA 01960 NAME OF HAULER: AB CARNES ROOFING, INC. DUMP TRUCKS DATE: 9-06-2016 SIGNATURE OF APPLICANT: ft The Commonwealth of 1Viassachusetts r Uepartlnent of Industrial Accltlents I Congress Street,Suite 100 : Boston, MA 02114-2017 mVI,P.tnass.go v/ilia %ut•Icers'Cont,pensatioal Insurance Affidavit.Built(et'slCtautractats/Ci lectriciartslPlutnllers. '1'O BE C+ILE'D wa •rim PERMITTING AUTHORITY. ApplicaaatInformatiolt _ __..___._...._ Please I'aloot I ct�ibl NaI e(BisincssiOi-ganixtatioti/Indivi(lunl):AB CARNES ROOFING INC Address:30 ARROWHEAD FARM RD City/State/Zip:BOXFORD, MA 01921 Phone#l:070-887-1431 Are you art ealpaoyer7 Check the appropriate box: `type of Project(a°c(lula•ed); t,o Irun aemployerwith some ._employees(full und/orpart-liunc).* 7. El New construction 2.[:]1 alis u sole propriewr or partnership and have no employees walking for me in 8. Reanodoling any capatoity.[No workers'comp.instimoce required.) 9. L Demolition 2.LJ l moa a hunleowitcr doing all wart;niyscll'.[Na wurkars'cramp.insurance rectuirwd.l' 4.01 out a hmneowner and will be hiring caMactars to conduct till work oil my property. twill 10 Building addition unsure that all contractors either have workers'compensation insurance ar are sole I I. Electrical repair's of additions plxrprieols will)na employees. 12, Plumbing repairs or additions 1 lull a gunerat contractor turd I luive hired the sub-conaaactuls listed on die attached sheet. These sub-cuntractors have employees turd htave workers'cuillp.iusurance.a 13.0 Roof repairs 6.EjWe tare a corlamulion and its officers have exercised their right of exemption per MCIL c. 14. Other 1 S2,�t(4),and we have no employees.[Na wurkcrs'ctrinp,hisurtllace required,] s'Auy upplicluat that checks box III must also till out the section tsclow showing their workers,conrpcnsation policy information. i ftomeowneis who submit(]its affidavit indicating they are doing all work and then hire outside contractors must submit it oew Aftdavit indicating such. tCoatraetors that check Ibis box must attached tarn additional slicer Shawurg 111011111110 al the rmb-conlnletois aild state whether or not()lost:entities have employees. Ilthe sub-coott"aetors!nava empluyccs,dlcy most pl'ovide dwir warkets'cutup,policy slumber. !am an emidoyesr'that rsPr'ovidixg workers,corrrpensatiorl iusuranc'e.Jbr toy eruployees. Below is the policy uud Jail site - — infurolation. Insurance Company Narnv (RAVEL ERS INDEMNITY CO OF AMERICA Policy 0 or Self'-t1{s. Lir It.6HUB OG36156-6 '15 Expiration Date: 10/15/2016 a Job Site Address:.. _. __. _. Cily/State/'hip:._- Attach u Copy of fake workers' C0111pensation policy declaration page(Showing the policy aaumber and expiration date). h'ailure to secure:coverage its required under N1131..c. 152,§25A is a criminal violation punishable by it line up to$1,500.00 and/or one--year ilrtprisonnaent,as well tis Civil penaltietr in the torte of it STOP WORK Old)ER and a line of up to$250.00 n day against like:violator.A copy of this statement may he forwarded to the Office of Investigations of the DIA liar insurance coverage verification. I ala hereby certify trrr � .tl:e�y'ttlrrs arrrl lrcrrteltic.ti of"iminra,tint the iufuraratlmipi°uvlded above Jv titers and correct. Phone rr:9/8-881-1 31 Official use only.o not write ill this arca,to be completed by city or tome of ficial. City u1•"Town: ,.__ ., Permil/License It Issuing Authority(circle onc): 1.hoard of health 2.llatllding Department 3.City/'Town Clerk 4.13ectrical Inspector 5.Plumbing Inspector 6.Other Ctrulact l'erseu; I'laoate 1t: YVYY}E(MMIDDI A Rte . .CERTIFICATE OF.LIABILITY INSURANCE GATE(MMID 16 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(les)must be endorsed. If SUBROGATION 15 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 holdern lieu of such en orsement s. PRODUCERCONT NAME:CT BRIAN L- (� _ PRESCOTT&SONS INS PHONE 1)`(781)322-2350 --�LLC,l4oL - --- 963 EASTERN AVE E-MAIL — MALDEN,MA 02148 INSURER S AFFORDING COVERAGE NAIL p INSURER A INSURED - - INSURER 6; Travelers IndemniN_ggTpany of America. - AS CARNES ROOFING INC -- - INSURER C 30 ARROWHEAD FARM RD – - — -- - - .BOXFORD,MA 01921 INSURER D: T_- . 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 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 Y PAID CLAIMS. INSR SUBRTYPE OF INSURANCE - PO !C P POLICY EXP - - - - LIMITS POLICY NUMBER GENERAL LIABILITYtin EACH OCCURRENCES COMMERCIAL GENERAL LIABILITY �� PREMISES Ea accunence — $__------- CLAIMS-MADE OCCUR ' - _ PERSONAL&AOV INJURY $ GENERAL AGGREGATE _ $ �— GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG b POLICY .. PRO- LOC g AECI AUTOMOBILE LIABILITY COMaINPO SINGLE LIMIT ANY AUTO - rrl - BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Peraccldenl) $ -- AUTOS AUTOS' —� NON-OWNED PROPERTY DAMAGE --._..._ HIgEOAUT05 AUTOS UMBRELLA LIAE OCCUR EACH OCCURRENCE $ F FJ EXCESS LIAE HCLAJMS-MLRE - - - j AGGREGATE $ DEO RETENTION$ - - - ............. .. ... - $ WORKERS COMPENSATION X WC STATU- I OTH- AND EMPLOYERS'LIABILITY Y 1 N B ANY PROPRIETORIPARTNERIEXECUT€VEI E.L,EACH ACCIDENT $ 10O000 OFFICEIMEMBER EXCLUDED? � N I A 6HUB-OG361 b6-6-15 10/15/2815 10/15/2016 (Mandatory in NH) .... .. - If yesdesc=undE.L.DISEASE-EA EMPLOYE $ 1001000--......._,.,.,._._. , er - PFBAii--s w. r ! E.L.DISEASE-POLICY LIMIT ..$ 500,000 1 . DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 161,Additional Remarks Schedule,if more space Is required) ROOFING CONTRACTOR CERTIFICATE HOLDER . . . CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE- EXPIRATION DATE THEREOF, 'NOTICE WILL BE DELIVERED IN 1600 OSGOOD ST ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE Brian N.Leary,PRESCOTT&SONS INS ©1988-2010 ACORD CORPORATION: All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD LOO/L00'd 0£O# L TO:90 9 W/90/60 EV969999L6 V01 MOU- c"R"0 CERTIFICATE IFICATE OF LIABILITY Y INSURANCE DATE 9IO6I2O16YYi /'^t 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 NAME: BRIAN L. j PRESCOTT&SONS INS PHONE FAX Arc.,Nph_... ._................_._ 963 EASTERN AVEE-MAIL aaDREss: MALDEN,MA 02148 _...._ ......... ....... .. INSURER(S)AFFORDING COVERAGE NAIC# __.. ....__ ...._............ ................. ......._ • INSURER A INSURED 1 1 INSURER 8: Travelers.Indemnity CompanyOf America AB CARNES ROOFING INC 30 ARROWHEAD FARM RD INSURER C BOXFORD,MA 01921 INSURER D: ' 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 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. !LTR TYPE OF INSURANCE a DL S B POLICY NUMBER MM/DDNYYY MMIDDNYYY LIMITS GENERAL LIABILITY EACHOCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITYPREMOSES.(ra occurrence) $._. CLAIMS-MADE 1:1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMP/OP AGG $ 1 F-1PRO- _................ POLICY LOC $ AUTOMOBILE LIABILITY ( COMBINED 81N,LE.LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNEDPROPERTY DAMAGE _... ._.. HIRED AUTOS AUTOS Peraccident_ _......e $ $ UMBRELLA UAB OCCUR �,.�.. ...,.. EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ .,,,. $ WORKERS COMPENSATION C STATU= OTH. AND EMPLOYERS'LIABILITY r`Y U� ER B ANY PROPRIETO OFFICE/MEMBER EXCLUDEU?PARTNER/EXECUTI N IN/A 6HU6-QG36156-6-15 10I15l2015 10/15/2016 E.L E CHACCIDENT _....$_,�000QQ..-_ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,000 if yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) ROOFING CONTRACTOR CERTIFICATE HOLDER­ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE d' MOHAMMADALI KHORRAMI b, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN / 105 AUTRAN AVE ACCORDANCE WITH THE POLICY PROVISIONS. NO ANDOVER,MA 01845 / AUTHORIZED REPRESENTATIVE Brian N.Leary,PRESCOTT&SONS INS O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD NOTICE z NOTICE TOrn > TO 0 EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS I Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — httP://www.state.nia.us/dia As rC(]Llircd by MassachuScUs General Law, Chapter 152, Sections 21, 22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.D. BOX 1450 MTnni i7pnpn — 0-- - - -1450 .. OMPANY (6HUB-OG36156-6-1 15 ADDRESS OF INSURANCE C 1 10-15-15 TO 10-1 1 5-16 k POLICY NUMB FIR EFFECTIVE DA'I;t-,,S PRESCOTT & SON INS 963 EASTERN AVE MALDEN MA 02148 NAME,OFINSl,)RANCEAGEN-I' ADDRESS PIIONE# /, AB CARNES ROOFING INC 30 ARROWHEAD FARM RD o BOXFORD MA 01921 EMPLOYER ADDRESS h. O EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above name(] insurer is I-C(lUired in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions ol' the Workers' Compensation Act. A copy ol' the First Report ol'Injuty must be given tot the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, it' the, treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for Such attention at the NAME OFI-I0SPI'I'AL ADDRESS 000849 W20P1G16 TO BE POSTED BY EMPLOYER assaCht,rsa tts C:bepaitn ent aai Public Safety Board of BuIldmg Raaftawrl;atwns and Standards t..ir, ruse CS-000230 , Construction stq)L�rvrsw wa BARRY S CARNES 30 ARROWHEAD FARM RD BOXFORD MA 01921 a nn')s ,tia>ne6 03/07/2018 l�f�''c Office of Consumer Affairs and Business Regulation 10 Park Flaw - Suite 5170 Boston, Massachusetts 0211.6 :Nome Improvement Contractor Registration Registration: 176928 Type: Corporation Expiration: 10/10/2017 Tr# 269957 AB CARNES ROOFING, INC. BARRY CARNES 30 ARROWHEAD FARM RD BOXFORD, MA 01921 Update Address and return card.Mark rertson for change. ,SCA I Address Renewal I k;tnployment Lost Caird