HomeMy WebLinkAboutBuilding Permit #935 - 170 ROSEMONT DRIVE 6/27/2012BUILDING PERMIT
TOWN OF NORTH ANDOVER
10,
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Argo
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteratb��
No. of units:
Commercial
Assessory Bldg
Others:
Demolition
Other
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DESCRIPTION QF WORK TO BE PREFORMED:
Please Type or Print Clearly)
OWNER: Name: 16kAJ
9- ---Z/ 7 �,
ARCHITECT/ENG I NEER
Address:
Phone:
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: $ FEE: $ bo -M .
e q
Check No.: ZY3/ ReceiptNo.: �L
NOTE: Persons contracting with unregistered contractors do not have access to the guq�lan fund,
ty
Plans Submitted
Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tannin : g/Massage/Body Art
Swimming Pools
Well.
Tobacco Sales
Food Packaging/Sales
Private (septiclank'
'etc.
Permanent Dumpstei.on -Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATEAPPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition- No: -Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments I
Water & Sewer Connection/signature & Date Driveway Permit . . f.
DPW Town Engineer: Signature:
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 21 A —F and G min.$100-$l 000 fine
NOTES and DATA — (For department use)
El Notified for pickup - Date
Doe.Building Permit Revised 20 10
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
L3 Building Permit Application
Li Certified Surveyed Plot Plan
• Workers Comp Affidavit
• Photo.Copy of H.I.C. And C.S.L. Licenses
Li Copy Of Contract
u Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Mass check Energy Compliance Report (if Applicable)
a 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)
L3 Building Permit Application
a Certified Proposed Plot Plan
Ej. Photo of H.I.C. And C.S.L. Licenses
u Workers Comp Affidavit
El 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
(3 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
Doe: Building Permit Revised 2008
Location �k>r-
No.- Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 66
Foundation Permit Fee
'q, "n
- C - 4$
'71 �* Other Permit Fee
I Trtm- TOTAL $
Check #14,� 1
25461
Building Inspector
MOYNIHAN-NORTH READING LUMBER, INC.
"QUALITY BACKED BY A DESIRE TO PLEASE'
164 Chestnut Street FEIN:04-2261995
North Reading, MA 01861 "AA Contractor Reg No.: I
978-864-3310 / 781-944-8500 W W Exp. Date: _/_/_
Salesperson(s):
HOMEOWNER INFORMATION
Y\ rx- yv\ r,�, K)
Name Daytime Phone
2)
Street Address (Not P.O. )x) Evening Phone
,�) 6 �A\ B, V,.,L4
Y\ MA
Cityrrown State Zip Code Mailing Address (if different from Street Address) 4.. cd
WORK TO BE PERFORMED AND MATERIALS TO BE USE6, � -f ' V,
Moynihan -North Reading Lumber, Inc. agrees to perform the work set.forth in Exhibit A fo� Homeowner and to
use such materials in connection therewith as set forth also in Exhibit A, attached hereto and made a part
hereof.
The following schedule shall t�e adhered to unlegs cir'cum"stances arise beyond Moynihan -North Reading
Lumber, Inc.'s control: Work scheduled to begin: — Expected date of completion:
May be based upon arrival 6i special order material
TOTAL CONTRA BICkAND PAYMENT SCHEDULE
Moynihan- North Reading Lumber, Inc. ��ees� pe or he work, and furnish the material and labor set forth in
Exhibit A for the Total Contract Price of- amount includes all finance charges).
Payments shall be made by Homeowner ccording to the ollowing payment schedule:
$17 2615"5 Initial deposit upon sign�hg��ract (the initial deposit shall not exceed the greater of
one-third (1/3) of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom
Orders as set forth below).
$ INb,-aa by -1 4 or upon completion of delivery of materials
$11160,AO by—L-4—or upon completion of install
$_ upon completion of the Contract
In order to meet the completion schedule set forth above, the following materials/equipment must be special
ordered before the Contract work begins, for a Total Cost of Special/Custom Orders of
to be paid for building permit
to be paid for
to be paid for
D(? NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACMES
rV\
han-North Readi
Moyn ng Lumber, Inc.
IH16rnW�VhJr's Signature- V Dat& Contractor Date
A -*Ij U1 1 #1/ t/ tA Vr_r , I T-1 ft I f3y: Dale Fuller
r4meowner's 'Name (Printed) Installed Sales Coordinator
Y�u may cancel this Contract if it has been signed by a party thereto at a place other than an address of
Contractor, which may be its main office or branch thereof, provided you notify Contractor in writing at
its main office or branch by ordinary mail posted, by telegram sent or by delivery, no later than midnight
of the third business day following the signing of this Contract. See attached notice of cancellation for
an explanation of this right.
See reverse side for additional Ho'meowner Terms and Conditions
1057 -NR 1/11 White - Office
Yellow - Sales/Service Pink - Customer
N
Page I of 5
t, � * -I I0, �_
HOMEOWNER TERMS AND CONDITIONS
The following terms and conditions are an integral part of this Contract between
Moynihan -North Reading Lumber, Inc. C'Contractor") and Homeowner.
1 All payments are due upon presentation of billing, and a late charge of one and one-half percent (11%%) per month will be applied to past due
charges. Homeowner shall pay Contractor court costs, attomeys'and paralegals' fees, and any other expenses incurred in the collection of
past due accounts.
2. If Homeowner is borrowing money from a construction lender to perform the work, Homeowner represents that the construction loan fund is
sufficient to pay Contractor and any other contractors performing work on Homeowner's property. Homeowner irrevocably authorizes
Contractor to communicate directly with the construction lender regarding payments and loan balances, and authorizes the construction lender
to make payments directly to Contractor.
3. Homeowner shall be in default if it breaches any provision of this Contract; if any warranty or statement to Contractor in connection with this
Contract or Contractor's extension of credit to Homeowner is false or misleading when made; if any statement to a lending institution in
connection with financing for this Contract is false or misleading when made; or if Homeowner becomes insolvent, makes and assignment for
the benefit of its creditors, or files or has filed a petition for bankruptcy.
4. If the Total Contract Price includes allowances, and the cost of performing the work covered by an allowance is either greater or less than the
allowance, then the Total Contract Price shall be increased or decreased accordingly without the need for a signed Change Order. Unless
otherwise requested by Homeowner, Contractor shall use its judgment in accomplishing work covered by an allowance.
5. If Contractor agrees to do any installation work, Homeowner will procure at its expense and before the commencement of work hereunder "all
risk" insurance with construction, theft, vandalism, and mischief endorsements attached, the insurance to be in a sum at least equal to the
Total Contract Price. The insurance will name Contractor and any subcontractors as additional insured. If the project is destroyed or
damaged by accident, disaster or calamity such as fire, flood or storms, Homeowner shall pay for work done by Contractor in rebuilding of
restoring the project as extra work.
6. If Homeowner defaults under any of its obligations under this Contract, Contractor may:
Stop work until any payments are received or defaults are otherwise cured.
Terminate work upon seven (7) days written notice and recover as damages, at its option, either the reasonable value of
the work performed through termination, or the balance of the Total Contract Price plus any other damages including
reasonable attorneys' and paralegals' fees Contractor suffers as a result of the default.
7. Contractor shall be excused for delay in completion of the Contract caused by contingencies out of its control, including acts or delays of
Homeowner or other contractors, acts of God, labor trouble, acts of public agencies or inspectors or public utilities, extra work, breaches of this
Contract by Homeowner, problems obtaining materials from suppliers, or other contingencies unforeseen by Contractor. Under no
circumstances will Contractor be liable for monetary damages caused by delays as set forth above.
8. If Contractor encounters unforeseen conditions that were not reasonably anticipated by Contractor, Contractor shall call the conditions to the
attention of Homeowner and the Total Contract Price and schedule will be adjusted by the extra work necessitated thereby. No installation,
plumbing, electrical, flooring, decorating or other construction work is to be provided unless specifically set forth herein. In the event
Contractor is to perform the installation, it is understood that the price agreed upon herein does not include possible expenses incurred in
addressing hidden or unknown contingencies found at the jobsite. In the event such contingencies arise and Contractor is required to furnish
labor or materials or otherwise perform work not provided for or contemplated by Contractor, the actual cost of such additional unexpected
work plus fifteen percent (15%) thereof will be paid by Homeowner. Contingencies include but are not limited to: inability to reuse existing
water, vent and water pipes, air shafts, ducts, grilles, louvers and registers; the relocation of concealed pipes, riser, wiring or conduits, the
presence of which cannot be determined until the work has started; or imperfections, rotting or decay in the structure or parts thereof
necessitating replacement.
9. Homeowner shall be responsible for the coordination of any work performed by itself or other contractors, and shall be responsible to have the
work site ready for contractor to proceed. If installation is involved, with its work through the completion date. Any work performed by
Homeowner or other contractors shall not hinder Contractor's schedule. Contractor does not warrant any work performed by Homeowner or
other contractors not working for Contractor as its subcontractor.
10. Homeowner understands that some products described in this Contract may be specially designed and custom built, and as such Contractor
will take immediate steps upon execution of this Contract to design, order and construct those items as set forth herein. Except as provided
on page one of this Contract, this Contract is not subject to cancellation by Homeowner
11. The delivery date, when given, shall be deemed approximate and performance is subject to delays caused by strikes, fires, weather
conditions, acts of God or other reasons not under the control of Contractor, as well as the availability of the product at the time of delivery.
Once the delivery date is determined, Homeowner agrees to accept delivery of the product(s) within one (1) week.
12. The risk of loss, damage or destruction, shall be upon Homeowner upon the delivery and receipt of the product. If Homeowner is not ready to
accept the product, the delivery payment will by made as agreed upon and an extra storage fee of Fifty Dollars ($50) per week will be
charged.
13. Title to the items sold pursuant to this Contract shall not pass to Homeowner until the full price as set forth in this Contract is paid to
Contractor.
14. Contractor agrees that it will perform this Contract in conformity with customary industry practices. Homeowner agrees that any claim for
adjustment shall not be reason or cause for failure to make payment of the purchase price in full.
15. This Contract sets forth the entire understanding of the parties. Any and all prior contracts, agreements, warranties or representations made
by either party are superseded by this Contract. NOTWITHSTANDING PARAGRAPH 4 NO CHANGES SHALL BE MADE TO THE WORK
DESCRIBED OR TO THE CONTRACT PRICE UNLESS AND UNTIL HOMEOWNER AND CONTRACTOR SIGN A WRITTEN CHANGE
1057 -NR 1/11 White - Office Yellow - Sales/Service Pink - Customer Page 2 of 5
AC"Ilspa. ED, BILLJ-1 OP ID:
1:�_j CATE jMM1CDNYYy)
kb� CERTIFICATE OF LIABILITY INSURANCE 06104112
EBELOTHIS CERTIFICATE IS ISSUED AS A 7,
TII MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BEL W . CON
W. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A TRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER
IMPORTA—NT: If the certificate holder Is an )DITIONAL INSURED, the POlicY(les) must be endorsed. If SUBROGATION TS—WAIVED, �subje.t to
L the terms and conditions of the policy, certain Policies may require an endorsement, A statement on this certificate does not confer rights to the
_.SSq!ES!!t.!�)Ider In lieu of runh 3nj_6t_
PRODUCER 781-598470 0ONTAC
A James Lynch Insurance Agency I NAME!
297 Broadway 781-599-05 PH r FAX
Lynn, MA W90,4 80 (AIRNN,, Exit;
10
Thomas R Ross L-IWAIL
I ADDRESS;
----- ------ -- ----- INSURERA:Safety Insurance
INSURED Bill J21rii �ka Carpentry
2.5 Paquot Street INSURER 8:
Billerica, MIA 01821 INSURER C:
INSURER D:
INSURER E:
THIS IS TO CERTIFY THAT THIF POLIC111 - OF INSURANCE LIS . TED BELOW HAVE B R —ISSUED To TP "'VISION NUMBER: _�O
E INSURED NAMED ABOVE FOR THE LICY PERIOD
INDICATED, *NOlWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIrICATIE 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 13Y PAID CLAJMS.
IN-1 - �_______,___ ----------------
LTR TYPE OF INS URIANCS POLICY EPF P L
POLICY NUMBER MP41DDrYYYY MMIDDIYYYY
GENERMAL LIABILITY LIMITS
COM . FiCi LL EACH OCCURRENCE —1,000,0
A X COMMERCIAL r3ENERAL LIABILITY OPOD000478 05104112 06/04113
CLAMS-MADEFx_1OCCUR — ISES (Ea Occurrence) . $ 100,0
MSO EXP (Anv ona nartnn) T A(II
GE:
IABILITY
ANY AUTO
A ALL OWNED SCHEDULCO
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AUTOS UTOS
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UMBRELLA LIAO OCCUR
EXCESS LIAO
WORKERS COMPLNSA N
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ANY PROPRIETORIPARINERIEXECUTIVE
OFFICERWEMBER EXCLUDED? n NIA
(Mandotory in N141 07
DESCRIPTION oF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additi.no, Rcrharl(a Schadislo, If morcVP040 Ib roctuhrod)
Carpentry/ interior
&AOV INJURY S I
GGREGATE $
- COMP/OP AGG $
'i -
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) s
PROPffkT-Y DAMAGE
[Peraccident) $
S
E. L. EACH ACCIDENT $
E.L DISEASE - EA EMPLOYEE e$:
El DISFARF - PnI WV I MAIT e
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Rloynihan Lumber ACCORDANCE WITH THE POLICY PROVISIONS.
164 Chestnut St
North Reading, MA 01864 AUTHORIZED REPRESENTATIVE
I Y
0 1988-2010 ACORD CORPOiiATION. Ali —rights resared,
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
-W
BEVERLY
NORTH READING
PLAISTOW
82 River Street
164 Chestnut Street
12 Old Road
P.O. Box 509
P.O. Box 128
P.O. Box 1160
Beverly, MA 0 1915
North Reading, MA 01864-0128
Plaistow, NH 03865
(978) 927-0032
(978) 664-3310 - (781) 944-8500
(603) 382-1535
FAX: (978) 927-8201
FAX: (978) 664-0872
FAX: (603) 382-1935
Subcontractor Workers' Compensation Waiver
1, William Jarzynka , hereby acknowledge that 1, as an
independent contractor, have been asked by Moynihan Lumber
Company to provide it with a certificate of Worker's Compensation
Insurance coverage for myself. Based on the exemption provided by
the Worker's Compensation Insurance coverage for myself because I
am a sole proprietor without employees. Therefore, I hold Moynihan
Lumber Company and it's related organizations and the Arcadia
Insurance and or Self Insured Lumber Business Association, Inc.
totally harmless for any injuries or cost of injuries incurred by myself
because I have voluntarily chosen to exclude myself from coverage
by engaging the exemption provided under the Worker's
Compensation Laws.
I have taken this option of my own free will.
Witn'
Date: /OZ/
Signature
"QUALITY BACKED BY A DESIRE TO PLEASE"
J
Are you an employer? Check the appropriate box:
LEI I am a employer with _ employees (full and/
or part-time).*
2.Z I am a sole proprietor or partnership and have no
employees working for me in an;y capacity.
[No workers' comp. insurance required]
3. We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1 (4), and we have
- no employees. [No workers' comp. insurance required]*
4. We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Business Type (required):
5. F1 Retail
6. E] Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto., etc.)
8. Non-profit
9. F1 Entertainment
10. [] Manufacturing
11.0 Health Care
12. D Other
�Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
"Ifthe 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 I comPensation insurancefor m employees. Below is the policy inforination.
Insurance Company Name: James Lynch
Insurer's Address: 297 Broadway
City/State/Zip: Lynn, MA 01904
Policy 4 or Self -ins. Lic. # BP00000478 Expiration Date: 05/04/12
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 Tnay be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under thepains andpenaldes ofperjury that the information provided above is true and correct.
Sip_,nature: Date: 10/03/2011
4: 978-670-0627
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:
www.mass.gov/dia
Phone 9:
The Commonwealth of Massachusetts Print Form,
Department of Industrial Accidents
6
Office of Investigations
I Congress Street, Suite 100
Boston, AL4 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: General Businesses
Apj2licant Information
Please PriaLLegibly
Business/Organization Name:
WilliamJarzynka
Address:
25 Pequot St
City/State/Zip:
Billerica Ma 01821 Phone #: 978-670-0627
Are you an employer? Check the appropriate box:
LEI I am a employer with _ employees (full and/
or part-time).*
2.Z I am a sole proprietor or partnership and have no
employees working for me in an;y capacity.
[No workers' comp. insurance required]
3. We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1 (4), and we have
- no employees. [No workers' comp. insurance required]*
4. We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Business Type (required):
5. F1 Retail
6. E] Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto., etc.)
8. Non-profit
9. F1 Entertainment
10. [] Manufacturing
11.0 Health Care
12. D Other
�Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
"Ifthe 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 I comPensation insurancefor m employees. Below is the policy inforination.
Insurance Company Name: James Lynch
Insurer's Address: 297 Broadway
City/State/Zip: Lynn, MA 01904
Policy 4 or Self -ins. Lic. # BP00000478 Expiration Date: 05/04/12
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 Tnay be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under thepains andpenaldes ofperjury that the information provided above is true and correct.
Sip_,nature: Date: 10/03/2011
4: 978-670-0627
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:
www.mass.gov/dia
Phone 9:
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Details
Licensee Details
Demographic Information
�Full Name: WILLIAM C JARZYNKA
ender:
wner Name:
License Address Information
Page I of I
Address:
25 PEQUOT ST
Address 2:
Construction Supervisor
City:
N BILLERICA
State:
MA
Zipcode:
01862
lCountry:
United States
License Information
License No:
CS -037120
License Type:
Construction Supervisor
Profession:
Building Licenses
Date of Last Renewal:
4/20/2012
Issue Date:
4/28/2010
Expiration Date:
4/17/2014
License Status:
Active
Today's Date:
6/26/2012
Secondary License:
Doing Business As:
Ptatus Change:
18
Prere si on
I No Prerequisite Information
Discipline
I No Discipline Information
Documentum
http://elicense.chs.state.ma.usNerification/Details.aspx?agencyjd=l&license—id=228093& 6/26/2012
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