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HomeMy WebLinkAboutBuilding Permit # 1/12/2017 . 4 ZyORTfy . BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION r1.� Permit No#. ' Date Received 'Jy �R.TEb 14F SRC HU Date Issued: 1 1 IlVIPORTANT:Applicant must complete all items on this page LOCATION �.°� s Pnn - - — PROPM WY ®WNER --1 - -� - - Pnnt '(WYeaP,., TW11 yes no MAP _ PARCEL ZON(NG T_IP Historic Distract` yeso N_ 1 i5 [Vlacl�irie,Shop;Village, yes- ne TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building7ne family [IAddition ElTwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement E Assessory Bldg ❑ Others: ❑Demolition ❑ Other C7 Sepfiie, 0 11Ve[l 0. Flao plain we"i:Iar cis ' M lJt�atershed Dtst�ict - - - - DESCRIPTION OF WORK TO BE PERFORMED: 1AI v-9, 6077 Identification - Phase Type or Print Clearly' OWNER: Name: Phone: Address: `Contractar Name: Address - �uperv�sbr's.Consfrtacticrilcise = - 6� 1 Exp Dae Hame,Irn rovemert License ! �-_ Exp; Dai �- l?...� .._- - - ARCHITECTIENGINEER Phone: Address: Reg. Pio. FEE SCHEDULE_BULDfNG PERMIT.$12.00 PER$160f.00 OF THE TOTAL.ESTIMATED COSTBASED ON$125.00 PER S F, oal P ®fie $ Oost: f c ! 3 FEE: $ r Check No.: �7 Receipt Na:: NOTF,o Persons contracting with unregistered contractors do not have_access to the gua arty fusel' 14®WTH Towno ndover 0 :. T 0 No. (Z 2.0 rl _ i ti Y O LAME h ver, Mass, Co[MIS MEw.CK y�. p04AYIE0 jspa���J S BOARD OF HEALTH Food/Kitchen PERMIT. T D Septic System THIS CERTIFIES THAT J,e fpSe �� BUILDING INSPECTOR ................................ . ... 9..ln..1�dV..,........................................................ has permission to erect .......................... buildings on .......,rFoundation Rough . ... to be occupied as ....... ............ IN.DAIII!!�. ...................................................................... Chimney provided that the person accepting 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 EXPIRESI c T ELECTRICAL INSPECTOR UNLESS ....... Rough Service ..... ...................,., Final BUILDING INSPECTOR GAS INSPECTOR _ ce 2ancy Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. - ; Coastal Inures Inc• Home r®�e � contract Rrd�r,rlr�l t MCL chapter 142A), but does not include standard Improvement Contractor l,aw rovements should first obtain a copy oalli ti g the Pelson planning home imp obtain a free copy Y This form sakisfies all basic rcquiremcnts of kilo stakes i fo ee Tmp to any work on}'our residence•You may lattgnag eta protect 1lonteowners.Seek legal advice if necessarygTt Consumer Ciuidc in 13ome improvement"before agreeing Information efts ,'s Consumer Information 13otiine at 617-973-am or 1 $$8-283-3757 or on otir we st e. Massachus Contractor office of Consumer Affairs and Business Regulation's Homeowner Information Name Camp�l,Y __.--- Name Coastal Industries,Ince _ _ . -------- -- _ john Toto �__._ _ -- ------ � Contraatorl salesperson!Owner Name ox a — Street Address(do not use a Post Office 13ddress) Jesse 3 Hilernan 50 'Deer Meadow Road — Gip Code J —___— nes 77 Newark,Street Busis Address(crust include a street address} —� J mm—�_ CiryCl'a,vn state MA 01845 _ _ ___�— 7ipGude State N Andover ____,_______.__--- -_— Cityrrown MA oIH32 _ _ _ ___ —Evening Phone Haverhill __ _ _ 5,lytlme Phone 978-505-7043 —� ��— — J__ Cederal Employer lt7 or 5.5.Num>ter 04-2517938 37 4543 Expirationdate ___ — = Business Ph one 978- 8Jt012017 li dtfferent from above) li.,w tmprovernenr Copntractor rieg Number Mailing Address( Law restores that mnsl hoa+e HIC 182968 4120/2017 inrprnvc+ncnl rantracrMber a CC— 661 X13 a valid rewstralton number S V 1 i I ! c brand,and grade of materials to be used,use additional sbeels if necessa . '1'hc Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the tYP'> g Remove&Replace 20 Double Hung Windows & l Picture Window with Low E & MA Argon Windows to be manufactured by Coastal Industries,Inc 71 Newark Street Haverhill, Series 3550 U value .27 dule-The i; II rMGLchaptear its-'Che fotlawint;building permits are required be°adhe d to nate d Completion circumstances beyond the contractor'scontrol arisetll I red by the contractor as the homeowner's ager who secure their own hermits will be nt the Guara��ty Fund provisions of 1212 1/2016D ate when contractor will begin contracted work. r 142A.) 1/11/2017 Date when contracted work will be substantially comptcicd. "Total Contract Price and Payment Schedule � ) 'rhe Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: , 9.773.94 Payments will be made according to the following schedule: whichever is greater) $ 4,500,00 Upon signing contract(not to exceed 113 of the total contract price or the cost of special order items, $ by 11 or upon completion of $ by 1 I or upon completion of $ 5,473.94 upon completion oftbc contract. (l.,aw forbids demanding full payment until contract is completed to both party's satisfaction) The following materia!/equipment must be special $ to be paid for ordered before the contracted work begins in order to rnect the completion schedule.(*'*) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third or the lwal contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advartce to meet the compielionschedule. Homeowner's Rights A homeowner's rights under the!-tome Improvement Contractor Law(MGL chapter 142A)and other consumer be waived in any way,even by agreement. However,homeowners protection laws(i.e.MGL chapter 93A)may not may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law- Homeowners who secure their own building permits are automatically excluded from all Guaranty Bund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below) Execution of Contract The contract must be executed in duplicate_and should not be signed until a copy of all exhibits and referenced advised not to sign the document until all blank sections have been documents have been attached. Parties are also filled in or marked as void,deleted,or not applicable. One or signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor.Any modification to the oj'iginal contract must be in writing tracted work may not begin until both parties have received a fully executed copy of and agreed to by both parties. Con the contract, and the three day rescission period has expired. B Accelerated Payments gA contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the B homeowner deems hien/herself to be financially insecure.However,in instances where a contractor deems him/herself r to be financially insecure,the contractor may requite that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of A Massachusetts Consumer Guide tQ Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170,Boston, MA 02316 617-973-8787, 88$-283-3757 or visit the OCABR website at lsit�;11�F t�1 _.t� srt>vlc c1e! If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contaot: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at i)UfLleti t v -ii�� ��ti'..Ic�� <f l Go online to view the status of a Home Improvement Contractor's Registration: t,ii.t3 llci$�,,t _._t�<t tis/1ot it I4g111Cc7�n, i,zSli,!.�..�1 cclis For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE, ABOVE DATE. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller], AT [Address of Seller's Place of Business] NOT LATER THAN MIDNIGHT OF (date). 114EREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: -------------- ............ ...............- -------------------- e 6eg ula ti o Business Office of Consumer"kffairs CIOR —IjOMEIMpROVEMENTCONRTyPe- Registration: 1-829-58 I nd hAdu a l ExpirattomSM012017 JESSE j.HILEWIAN JESSE HILEMAN 22 BRANDY BROWN RD. HAVERHILL,M-"w830 ijdersecret"y tary TVBoard 0; Rea s Con+truction Super\istir — Ce'se CS-066103 JESSE J RMF MAN P.O.BOX#5344 - Haverhill M 01835 04/2012017 1/12/2017 12:55 PM FROM: Journeay Insurance Journeay Insurance Agency TO: 1-9'78-688-9592 PAGE: 002 oF 002 AC RO oz CERTIFICATE OF LIABILITY INSURANCE DATE ;mmoonyrYl 01/12/2017 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 policylies) 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 9 certificate holder in lieu of such endorsement(s). PRODUCER Phone: 978-34"161 Fax: 978-346-9620 CONTACT Journeay Insurance Agency Inc NRae: JOURNEAY INSURANCE AGENCY INC PrtcNE rAx 978-346-9620 8 WEST MAIN STREET Ac No Ea 978-346-87fi1 Ac No E-hIA1L MERRIMAC MA 01860 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURFRA National Grange Mutual Insurance Ce 14788 INSURED INSURER E r JESSE HILEMAN DBA NEW ENGLAND BUILDING SOLUTIONS INSURERC PO BOX 5344 INSURER D: HAVERHILL MA 01835 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 12285 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 ALLTHE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD'L SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LIR _- .-....._ 1NSR VIVO _..__.. ..._...,. _MM DDfYYYY MWO N-MY .._._..._ .- .-- A GENERAL LIABILITY MPT8337L 11101/16 11/01/17 EACH OCCURRENCE $ 300,000 X COMMERCIAL GENERAL LIABILfTY OR TOR re $ 500,000 PREMMISIS ESEa oN ccurence) CLAIMS-MADE 1-1 OCCUR MED.EXP(Any ono person) $ 10,000 PERSONAL&ADV INJURY $ 300,000 GENERALAGGREGATE $ fi00,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 600,000 POLICY p,COT LOC $ AVTOMOB[LE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL ED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PRCPERiYDAnWGE $ AUTOS (peraccident) UMBRELLA {IAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-FADE AGGREGATE $ DED I RETENTION$ $ TH WORISbRs COMPENSATION TORY LEhQTS OR$ AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOWPARTNEEXECUTIVE E.L.E.4CHACCIDENT $ R/ OFFICER/MEMBER EXCLUOED9 NIA E.L.DISEASE-EAI-MPLOYEE $ (Mandatary in NH) V If yes,describe under EL.DISEASE-POLICY LIMIT $ iI DESCRIPTION OF OPERAWNS below 9 u 0 tl DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(Attach ACORD 401,Additional Remarks Schedule,if more space is required) I u CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,Ma. ACCORDANCE WITH THE POLICY PROVISIONS. AUTIIOAZEO REPRESENTATIVE Attention: (x:978-688-9542 Derek Journeay ACORD 25(2010/05) 1988-2010 ACORD CORPORATION. All rights reserved. i The ACORD name and logo are registered marks of ACORD R l �.--� COASIND-01 CATHYL ,d►coRL7" CERTIFICATE 4F LIABILITY INSURANCE DATE(MMlDD1YY1fY) `,...� 12/08/2016 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 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 endorsements). PRODUCER TACT cONCathryn L.Llscombe Charles F.Murphy Inc. arc°°,No,Ext):229C,No; 14 Storrs Ave Braintree,MA 02184 I" Lss:cathy murphyinsgroup.com INSURERS AFFORDING COVERAGE NAIC# INSURER A-Arbella Protection Ins Co 41360 INSURED INSURERB:ATbella Indemnity Ins.Co. Coastal Industries,Inc INSURERC: 77 Newark Street INSURER D: Haverhill,MA 01832 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. ILSR TR TYPE OF INSURANCE ADDINSDL SUap POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1'000'000 Qg CLAIMS-MADE 0 OCCUR 8500064020 04/30120/6 04/3012017 pREFAA€SESOERENcu a ce $ 100,000 MED EXP IAny oneperson) $ 5'000 PERSONAL&ADV INJURY 1000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000'000 X POLICY❑j T E-1LOC PRODUCTS-COMPIOP AGG $ 2'000'000 OTHER: $ COMNED SINGLE LIMIT 1,000000 AUTOMOBILE LIABILITY Ea c BI $ ANY AUTO 1020018388 0510512016 0510512017 BODILY INJURY Perperson) $ OWNED Ix SCHEDULED AUTOS ONLY AUTOOSy�N BODILY INJURY Per accident $ X AUTOS ONLY ATOSONLDY Parr;c.tlenDAMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS UAS CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X PIAT TE OTH- AND EMPLOYERS'LABILITY 422005453301 04130/2016 04130/2017 500,000 ANY PROPRIETORIPARTNERIEXECUTIVE YN NIA E.L.EACH ACCIDENT $ {RFILERIMEMB1W EXCLUDED? endatory En NH] E.L.DISEASE-EA EMPLOYE $ 500,D00 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below L L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace is required) CERTIFICAT LDER CANCELLATION \ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE (Evidence of insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN / ACCORDANCE WITH THE POLICY PROVISIONS. 1 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �y Ae Commonwealth o,f Hassachuseft Department offx�r�t�,stdaZAccz ezats M Z Congress,S`tY Eet, s4u100 d dos oxo _VA 02114 20 7 w� www.massgovIdia lEi ectr%ciar�sl' ers, s " �''y9 e3zsatiox� n� x c6��.�tda'git;:Bui%derWCoufraetoxs ,. yakers' Co1�xp A( $fll - flEES;� ' � YER1Y4 G Pleass?�'xn� � 'bI A ''lican��ormatiton. N`d,117O(iiTsinessA Kg ny�fl�I077�I1�T91[ila r e �1V Address, C r�• � . Phoned: L�1 tato 3 Tpe ofpxoiect(VoT Orl)e ' sepon arr emplopex?G eckr the appropria#ebox: , art time d constriic�Zon emplayoes(trill axullnr p )•` A 7. El Nd .[ am aamptayer v+itb — 8. L]RemodeNg Xamasoleproprietor orpa,I MbipondhaYenoemployeesworkingfozmein ed.1 9. QDeanoliti94 any capanity LAO Workers'Pomp.insurerca ze tP'ir allwarkznyself.(Toworkw?comp.insoranceze�ed.I i i4 F1 BuUding addititJn 3,��am ahozneownez cluing zn xvrili behiriugcorr=irffatorstnoondu,,tallYTozlrorcznyp p Y• ��n 7 eCtriGi[I ep3lTSD7C d[itio q.� am a hazneoruner aad i11 eom ensation insarauce or aro sole ensure that all cnntxac ors erther have workers' p PSiap�In .re ad.'s o�additions is` a ees. i2_l'"1:� g p pzapriefoxs withna erapoy 5.� RbQfrepahs I am a general eonizaetor and have hiredthe sai�-canfractovs licked on the attached sheet plrese sub-oontraafiors Tuve employees sndbavevrarkers'comp.insuzance i�. Other 1 ot�eerslraysexercisedtheir�gT�ot�xemptiar�.pezMGLG• � I����� `� ;�� - �❑Wearcacorporatig�iandz#s, _ r 152,§1(4),mod av&no employees.�Navtarkers'comp.S�suzanoerecp�sred atian_` ax$#1 snusE also fill out a seationbelo�u sho v�gtheirvvorkers'campensatiozrpoTrcyintarrz>a p,�rapplioa'tthatchenks a i t ozneawners vvTrQ submit this aMfl indicating they are doing all vrorkPBdtha e ofthe sub cankractars and siaYe ether oz$o a nttla h Ye tcontractazs that check this Homtaus�atlacli d'au addifio sh r °�it wozlzers'aamp-pohay n }eT Il employccs. 7£thesub-coniXactnrshaveexpa3' p e z Zo ees. joelo�uisateporreyartdyohsite u, d X ama�2 ernplayex treat isprovidir2g�vorers'compensation izsu. artce for rtzy p y infonnation. Tnsurame CovapaayNamg: . ExpirationDate' pol oy ff or 80ifins.Lia.#:_ City/State/dip: x r • rob iteAddsess: e sho gthepolicypu�bexande pzt'a ioxrdale). AtlacTz a copy o Sze�v4xke s' compensaU01a)PPORey declaxationpag t e as re uized�derZY1GL o.x52,§25Ais a cxiva?nae olatP SER and �of4to $250.00 a Failure to Src€ Ce coverag q enaTties v�the-form of a STOR FORK and/or or<.e-yeax iaprIsonm eu as we71 as ca vel p e violator'.A copy o-f-�is statement may be forwarded to t�.a O-ffica of�vestigat�.oxLs of the DTA for ixas�.xrance day against th a coverage-Verfcation. ees " rxrxc et triep its r�penalties of etlat3'Mat the ioxformation p?avaderl above is t�rye and cox�ect. I do ltere�y Date: 81 ature: ' T'7aove#: official use oxt�y. Do notvrite In tTiis area,to 7�e corj2pleted�y city 01,town official F n7ni t/Licexse# City or ToNm-- �ssning.A-ftfhority circle one): ` ecto�r 5.T'Zum�inglnspeeEor 3.CztylTo �,.T3oaxd o-fff�=al-�h 2.��.ciirrgDepa�:t�.en� �.Cork d•.Execl::rzcal.�sp 6,Other Rj.oj:%a#: ("nri:ac Rerama