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HomeMy WebLinkAboutBuilding Permit #433 - 104 MAIN STREET 12/18/2007 BUILDING PERMIT of pORt%ORTF1,b�tio TOWN OF NORTH ANDOVER or '° °� APPLICATION FOR PLAN EXAMINATION '' 3 Permit NO: Date Received �SSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION /6' ,+ Print PROPERTY OWNER � �c�C��c.��,ll k » C Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESC 1P ION OF WORK TO.BEPREFORMED: ��s�c�11 1��.� ��1� �c�1v\ 1� � c1\ � ��n - ' eat- '• 1 , Jdentifi atiop�Please Type or Print Clearly) (, OWNER: Name: �6 -!r� � � ' Phone: I6-- �t Address: �� `-� Llti �� � � ��L�k� �`� �ZS C• I�14 S� � CONTRACTOR Name: f t�( r�Ck f-Q Phone: Y 7� Address: .v�-('7 ` SCE' ��%��c c� ��c'(� j Aocw<; Supervisor's Construction License: `%- 2 5 Exp. Date: Home Improvement License: /6-*)--'W5 Exp. Date:,,,,,,,, -12� ARCHITECT/ENGINEERC�, 1r'1.2 j(� ✓( C . Phone: Address: `;�C- A•k1 l c1 (N Reg. No. c/ FEE SCHEDULE:BOLDING PERMIT: 12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_ �cc . y U FEE: $ '* 0 — Check No.: CQ �3 Receipt No.: Ddb NOTE: Persons contracting wt unregistered contractors do not have access toee uaranty fund Si nature of A ent/Owne� g_ _�__ _ 9__ _ _ ___ Signature of contracts Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales !, Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature&Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Dor.INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location No. Date 1a2 lel D--•- 011ORTh TOWN OF NORTH ANDOVER N.ao Certificate of Occupancy $ '��s'•^ Eco Building/Frame Permit Fee $ Q AC MUS Foundation Permit Fee $ Other Permit Fee $ , TOTAL $ Check # 2067 Building Inspector NORTIy t 01" 0Andover CA © dover, Mass.,--AQ-10 - o �-'- T COC MIC KE WICK A. WIC 7�ARRA7ED PPS` `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System Il BUILDING INSPECTOR THIS CERTIFIES THAT.... .r��G.. ... � O�.. —�1Sv V ..... ......... ...l�........ ..........................J........... ' .._ .......... Foundation I has permission to erect........................................ buildings on .....to..`f.........rV7101.r.'l.... ................................ Rough tobe occupied as......C�l? !..r......oc:.? ...�r........................................................................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 70 — ELECTRICAL INSPECTOR UNLESS CONSTRU S TS Rough .......... ............. .................-....�... ........................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. IFSEE REVERSE SIDE Smoke Det. ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE 12/18/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NORTH ANDOVER INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 WAVERLY ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NORTH ANDOVER MA 01845-2415 INSURERS AFFORDING COVERAGE INSURED INSURER A:CITIZENS INSURANCE CO Michael Rodden INSURER B:HANVOER INSURANCE 47 Prescott Street INSURER C:AMERICAN INTERNATIONAL GROUP INSURER D: North Andover MA 01845— INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE MM/DDIYY DATE MM/DD/YY GENERAL LIABILITY 'a' EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ 300,000 CLAIMS MADE OCCUR ZBN 8605683 02/01/2007 02/01/2008 MEDEXP(Anyoneperson) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JECT LOC B AUTOMOBILE LIABILITY ADN 8336670 07/16/2007 07/16/2008 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY X SCHEDULED AUTOS (Per person) $ 100,000 HIRED AUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per accident) $ 300,000 PROPERTY DAMAGE (Per accident) $ 100,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE / / / / $ RETENTION $ $ EMPLOYERS'WORKERS OMABLSn ON AND / / / / X TORY LIMITS R E.L.EACH ACCIDENT $ 100,000 C WC1760133 01/01/2007 01/01/2008 E.L.DISEASE-EA EMPLOYEE$ 100,000 E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER:_ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT TOWN OF NORTH ANDOVER FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845- � - ACORD 25-S(7197) ©ACORD CORPORATION 1988 INS026S(9910).01 ELECTRONIC LASER FORMS,INC.-$00)327-0545 Page 1 of 2 Page No. of Pages Proposal R1CY1 L Ra-ZaN I'KJ D�'1.,1 - C C X 7 U.I" W C i 47 Prescott Street FORTH ANDOVER, MASSACHUSETTS 01845 Phone (978) 687-2934 Uc. #028538 PROPOSAL SUBMITTED TO PHONE DATE Panaione & Macdonald Insurance Agency December 3 , 2007 STREET JOB NAME 104 Main Street CITY,STATE and ZIP CODE JOB LOCATION Horth Andover RIa 01845 ARCHITECT DATE OF PLANS JOB PHONE We propUr hereby to furnish material and labor—complete in accordance with specifications below,for the sum of: I I Payment to be made as follows: dollars($ 7, 5 O n_f) I rn ca' o f i njioi dc-%q All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from specifications be- Authorized low involving extra costs will be executed only upon written orders, and will become an Signature extra charge over and above the estimate. All agreements contingent upon strikes, acci- dents or delays beyond our control. Owner to carry fire, tornado and other necessary Note:This proposal may be insurance.Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days. We hereby submit specifications and estimates for: i Supply lahor and materials to complete the basement project as described in the plans and specfications submitted. Work will be done on a time and ,material plus 10% basis. Rough grade existing floor material including possible removal of some. Install new footings, posts, and concrete floor as speced. Remove some existing board partitions. The estimated cost is olus or Minus $7, 500.00 and does not include any electrical, plumbing or duct work. Carpentry rates are as follows: 'like Rodden - 0,49.00 per hour Paul Goad - $49.00 oer hour James Savage - $39 .00 per hour i Arreptattre of Proposal —The above prices,specifications A4441 !::�- and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified./Payment will be made as outlined above. Date of Acceptance: ( �{�/r d� Signature ' • i i Board of giiildiiig Regulations and$tari lards C.onstrycfiorr St+pervi�"or License I Lig • C-S 2853'.8 da 5/1948 2947 . "�t N AND'O`i%ER,MA 01845 ioner o� auaelta `-- C' ward otS'nng 4� Fln{fiEpRflv�1 ..,, Q AID* f�NfFhae4 Rcidri��• ��4 _f�f 4r ,r-�-� ;a�,� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Tie ibl Name (Business/Organization/Individual): Address: JLJ_f7 City/State/Zip:iLal�t ` ? . C (S� Phone.#: Are you an employer?Check the appropriate box: ,.�/ Type of project(required):, 1.LJ I am a employer with ! 4. ❑ I am a general contractor and I employees(full an part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [3-Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. $ required.] 5. ❑ We are a corporation and its 10,❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised.their 11-❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑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. $Contractors 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: Policy#or Self-ins. Lic.#:�l� c�—�I-r;—��� ! Expiration Date: Job Site Address: I C ,1-G r �CZ ti 7 �' City/State/Zip: p: Ci /State/Zi 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. Ido hereby certifymi di er r a'ns-a d penalties of perjury that the information provided above is true and correct Si atur`e: Date: I ll O _ Phone#: 972 7DI 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 5.Plumbing Inspector 6.Other Contact.Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the.occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to,opera'te.a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25CM states""Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contiactor(s)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-7274900 ext.406 or 1-877-NIASSAFE Fax# 617-727-7749 Revised 1122-06 www.mass.gov/dia ,„ CERTIFICATE OF LIABILITY INSURANCE DATE ACORD12/18/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NORTH ANDOVER INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 WAVERLY ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NORTH ANDOVER MA 01845-2415 INSURED INSURER A:CITIZENS INSURANCE CO Michael Rodden INSURER B:HANVOER INSURANCE 47 Prescott Street INSURER c:AMERICAN INTERNATIONAL GROUP INSURER D: North Andover MA 01845— INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE MMIDD DATE MMIDD/YY A GENERAL LIABILITY / / EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ 300,000 CLAIMS MADE ®OCCUR ZBN 8605683 02/01/2007 02/01/2008 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 $ 2,000,000 POLICY JECOT LOC B AUTOMOBILE LIABILITY ADN 8336670 07/16/2007 07/16/2008 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY X SCHEDULED AUTOS (Per person) $ 100,000 HIRED AUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per accident) $ 300,000 PROPERTY DAMAGE (Per accident) $ 100,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE / / / / $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU OTH- EMPLOYERS'LIABILITY / / / / X I TORY LIMITS ER E.L.EACH ACCIDENT $ 100,000 C WC1760133 01/01/2007 01/01/2008 E.L.DISEASE-EA EMPLOYEE$ 100,000 E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSA/EHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT TOWN OF NORTH ANDOVER FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Ir��~ „ NORTH ANDOVER MA 01845- ACORD 25S(7197) ©ACORD CORPORATION 1988 *,,;INS025S(9910).01 ELECTRONIC LASER FORMS,INC.-(800)327-0545 Page 1 of 2