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HomeMy WebLinkAboutBuilding Permit #207-15 - 177 ROSEMONT DRIVE 8/27/2014 BUILDING PERMIT O` NORTH q �TLlG xb TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 'k Date Received �•9 p�Rw7eo r S SgcHuss Date Issued: IM 0114T ANT:Applicant must complete all items on this page .gl'p`rMr° it` a t:: ""y' �` �rr$ ,; r+ au t�' ROPE-RTA,111WN R a b MAPNO,�1� ARC uP _ `Z NINGDISTRI T �' yH stonctDist�ict ` Yes o y..�,T:_»:�..�.,;:� .-..�..,, :-.��..�.',.�. � Y�,��..�� •_,x4'��:j, - � ,alVlachne�Sh�op,'Village��Y�e, �.n �� ' TYPE OF IMPROVEMENT PROPOSED USE tial Non- Residential New Building Onefamily Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: bemolition Other �� �. Septics Well 'Floodp n #4 We_ glands €� �Z f7 Watershed ®ism , f 1lUater/Se_ ` - 4.�'_F...d,_ ..a_._ ....... :-....ne,.Y ±�:_ -sT�.:�za--.—. —°*•?— 7.a.�Q a.r-w+wE:`=�..... +.-_i_—_..���A,>=Y�.t«.e "�3K��nF-�a DES RIPTION OF WORK TO BE PREFORMED: d dentificati n fle a Type or Print Clearly) OWNER: Name: Phone:0-0 690 01a:� Address: C301)4TR�►CT®RNarneh®nes x ; x21 -..r ,• F6� `�rta =c �c f af;..a p �`..�,�:-w rA ;•. €. i+a. r' > ��'.t"�'� . Addie s - x` . e}3°'"m'i--'moi'= rr�:�.x-•� r77 Supervis©Ott CC'®, coon License ;,f -- k' i 14p ra+ 4 Fri y i. Home lmprovernentLicense j�. tw. Exr®ate,r/ 3- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $t3nl € FEE: $ �� Check No.: Receipt No.: NOTE: Persons contracting with unr ' te' ontractors do not have access to the f d 5ignaturelofAgent/Owner= ^ . ., i _. tgnaturexofcontractor ,�;� t i 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 i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature 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 DPW Town Engineer: Signature: Located 384 Osgood Street r'c±. ti� :�'°""ra"`�"r�*g FIREDEPARTMEN�T " TempDumpster�on�siteyes� �no .. �-v C ME 3"`�,amiStr � `a ` FaireDepartment'signature/date����" €�¢ ,I 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 foricku Date p p - � Doc.Building Permit Revised 2008 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 l ❑ Building Permit Application , 1 ❑ 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o 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 E3 Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report o 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 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location �^N No, Date o - TOWN OF NORTH ANDOVER • fx' Dj;Sts• • Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1. t Check# 27953 Building Inspector 'L NORTH Town of ndover 0000, N®. soh ver, Mass, A.) cocNictiewrcw �1. L) BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ........................................................................ ......................... ..................... . . . has permission to erect ... ...... buildings on ..�... eC Foundation Rough to be occupied as ........ ... lr.... A.�l ..........'.�`.....�,.j .�1�1.�i.� . ..................... Chimney provided that the person accepting this permit shallYn 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 L4 UNLESS CONSTRUCTI ST L.. Rough Service ................ ....... ..... .. ............... Final ILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to 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. A t �116�io 1'f next step. Livi ngTM phis agree` nt is majiebykAd among- ^ « y Next Step Living,Inc.("NSL") Shobha Patel f 21 Drydock Avenue,2nd floor t B, on,MA 02210 177 Rosemont Dr phone 866)867-8729 North Andover, MA 01845 Site ID: A353825 02-Aug-14 1. DESCRIPTION OF WORK TO BE PERFORMED NSL will perform or cause to be performed the following work on the customer's address above,in a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: e• a Work Location: Attic Flat Hatch:Thermal Barrier Polyiso 2 inch(Attic) 1 Each 200.1 Lnft. $410.00 Attic Floor Open Blow Cellulose 4" 1,558 sgft $1,682.64 Perform:Air..Sealing at Estimated 62.5 CFM50 Per Hour.: 1.4 ` Hr 411050-00 ~ MA Save CMA`Weathenzation.Incentive $2;551.98 Total Net Investment: $650.66 ;estimated Annual Energy Savings trom.the Above Improvements $131.00 1 - 2. PAYMENT: CUSTOMER agrees to pay NSL for the work as follows: Payment#1: $100.00 -Credit Card or E•check deposit is due at the time the Work Is scheduled. Required payment information will be collected over the phone by a customer service representative at the time of scheduling. Deposit is not to exceed W of the total retail costs. (Note:Mastercard,Visa,and Discover accepted) Additional Payments and Final Invoice: $550.66 Additional Payments for the Work shall be due upon completion of the Work. If the final invoice is being paid by check,credit card information will still be required at the time of scheduling. Notify the customer service representative that you are paying by check and your card will not be charged unless we fail to receive payment within 5 days of invoice. Customer Signature Date -- 2 Aug 2014 Willi Aquino Sig t e Date Name of NSL Representative The Terms of this Agreement are contained on both sides of this page Next Step Living^21 Drydock Avenue"2nd floor.Boston,MA 02210"(866)867-8729"inquiry@nextsteplivinginc.com www nextsteplivint corn TERMS OF AGREEMENT A353825 3.PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work ata mutually agreeable time,subject to the availability of subcontractors or materials,or to delays attributable to the weather or other events beyond NSL's control. 4.CONTRACTOR REGISTRATION Massachusetts law requires home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to: Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170,Boston,MA 02116.617.973.8700. 5.PERMITS NSL will obtain any necessary permits as the Customers agent. Customers who secure.their own permits or deal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor taw. 6.PERFORMANCE OF THE WORK AND CHANGES 6.1 NSL will not commence tlie'Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer 6.2 This Agreement may be supplemented,amended,or modified only by the mutual agreement of the parties.No supplement,amendment,or modification of this Agreement shall be binding unless it is in writing and signed by all parties. 6.3 At times,our weatherization team discovers situations in the structure during the course of the Work that indicates a risk for a health or safety concern for residents.Such concerns can include but are not limited to ventilation,potentially hazardous materials such as mold or asbestos,or structural concerns. In the case of health or safety concerns being identified, NSL reserves the right,per section 9.2 of this contract,to communicate concerns to the Customer and haft work until such concerns have been addressed. 6.4 The rebates and incentives available from the Mass Save®Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However,at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. in such situations,NSL will communicate such changes to the Customer,including.any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment,or set up a separate contract for performing the adjusted work. 6.5 NSL represents and warrants to the Customer that(a)the materials and equipment furnished under this Agreement will be of good quality and new,(b)that the Work will be free from defects,and(c)that the Work will conform with the description of the Work described in Paragraph 1. 7.INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration(No:162111)and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field,including,but not limited to,Workers Compensation Insurance for all employees who will perforin the Work. 8.QUALITY OF WORK NSL agrees that the Work will be performed in a good and workmanlike manner,and that NSL will repair and replace,at its own expense,and promptly upon Customers request,any defects in workmanship and materials provided by NSL which appear up to(1)year after completion of the Work or within any longer period as permitted or required under applicable law,provided NSL has received final payment as provided herein. 9.PRE-EXISTING CONDITIONS&PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to preexisting conditions. These conditions include but are not limited to poorly fastened or broken drywall,moisture damage,non-code construction,cracked or fragile siding or shingles,old pipes and fittings,rotting wood,etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos,mold,or any other potential health risk to the Customer. In this event,the Customer is responsible for remedying the at-risk situation,including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customers responsibility to remove or protect,including dust protection,any personal property including the home Itself.NSL will not be responsible for damages to or tosses of any of the above mentioned roe n p p rty of properly protected prior to the commencement of the Work. 10.GENERAL PROVISIONS. p; 10.1 NSL reserves the right, the extent permitted by applicable law,to have,file or maintain a mechanic's or material men's lien,or to file a notice of intention to lien,and to take any other steps to perfect and enforce such a lien,if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. 10.3 This Agreement forms the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement,they are not retying on any representations,warranties or terms other than as expressly contained herein. This Agreement supersedes all prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both parties. You may cancel this Agreement if it has been signed at a place other than the NSL's normal place of business,provided you notify NSL in writing at its main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this Agreement. See the attached notice of cancellation form for an explanation of this right. 11.ENERGY BENEFITS. The Sponsoring Utility Company(the Utility)is entitled to 100%of the energy benefits associated with all Energy Conservation Measures,excluding the value of energy cost savings by the Customer,but including all rights to all associated ISO=NE Energy,Cape*and Reserves Products.NSL agrees to provide the Utility with such further documentation as the I.Mli may request to confirm the Utility's ownership of such benefits and Products. ty ty cts 12.NOTICE CONCERNING SPONSORSHIP Customer understands and acknowledges that NSL is not an agent,vendor or sub-vendor of The Sponsoring Utility Company(the Utility)with respect to the installation of an energy efficiency measures.In the event of the failure of an energy conservation device to perform as expected,Customers sole recourse is to Contractor and not to RISE Engineering(RISE) or to the Utility.The Utility and its operating companies shall not maintain,remove or perform any work whatsoever on the energy conservation measures installed. Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. Customer agrees that it shall not hold RISE,the Utility,their affiliates or operating companies liable for Contractors to perform its obligations under this agreement,for failure of the energy conservation measures to function,for any damage to Customers Premises caused by Contractor or for any and all damages to property or injury to persons caused by the energy conservation measures. 13.LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14.CONTRACT CANCELLATION Under Massachusetts law,you may cancel this agreement If it has been signed by a party thereto at a place other than an address of the seller,which may be his main office or a branch thereof,provided you notify the seller in writing at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not hater than midnight of the third business day following the signing of this agreement. V Planview Diagram Customer , Advisor Name: I Address ROSf OY)- " DY Advisor Phone #: Town N61+ + A hJC V-tr p I JL4 1�7 Any limitations to access by truck? Site ID35?J� NOTES Any work scoped outside of Best Practices? Approved by: pa1� iso L4'1 o dC +n AkbC �5s8a e),rls `n C1/10 Iyhrs 6 09 3 2� 1 q,u, +3 � Z 3+' co ukj nd* S�►n elder :�t ,n t '-mmtyly . /fes �j�!%(/F.il`�"J'C.IF�//'C/C•'E''J"Y/fr'f ®ffice of Consumer Affairs d Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration — Registration: 162111 - Type: supplement Card NEXT STEP LIVING INC. Expiration: 1/14/2015 ROGER OUELLETTE 21 DRYDOCK AVE. 2TH FL BOSTON, MA 02210 Update Address and return card.rylark reason for change. SCA 1 20M-05111 Address Ej Renewal E] Employment F� Lost Card �le c;�aT�zi�ear:u�uc�.tl af':/��a�:�uc�'ccvclCi ff'ice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration 162111 Office of Consume"'airs and Business Regulation Type' Expiration10 Park Plaza- ytite 5170 _ 1/,181201;5. Supplement.;ani NEXT STEP LIVING INC; _• _ - Boston,,nA" y16 - 9" ROGER OUELLETTE fl 21 DRYDOCKAVE.2TH.FLi� BOSTON,MA 02210. Undersecretary of valid without signature Massachusetts - Department of Public Safety I Board of Building Regulations and Standards Conktructit►n Supen'Nor 5pecialt% License: CSSL-103811 I ROGER A OVELLETT 55 1S7A ® ROAD " ' WM' rv* Ac k IRIS 028g ` : Expiration I Commissioner 09/1313014 Restricted To: CSSLAC e insulation Contractor I . 6 Failure t® possess a current edition ®$the Massachusetts State Building Code as cause for revocation of this licensee For®PS Licensing Information valuta www.M@SS.GOv/DPS ,I i NFfTS4 OIC IIS,HS CERTIFICATE OF LIABILITY INSURANCE 1==13 "'' 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 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACTEN THE E ISSUING INSURERS AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certlff W holder k an ADDITIONAL INSURED,the po ft(In)merit be endomsd, N SUBROGATION IS WAIVED,stlD)ect to the terns and conditions of the policy,certain policlas nmy re quIm an endorsement A Statement on this cufficabe does not confer rim to the certificate holder in lieu of such endoMggm a. PRODUhlin hmmmnce Agency Phorasa 781a655�2775 S26 Lynn Foils Parkway F=751 5.0255 WL EdL. � Melrsso MA 02176 John E.�MlcLaughlin Jr. AFwRoaao covERAOE Naec K INSURER A:Na0lu9 Ineurence INSURED NwdSbp LJving,Inc. INSurme:Commerce Insurance ComMily 34754 Jeff Ussack INSURSRc:Indian Harbor Insurance Comp. 3 40 29 Drydock Avenue,2nd Floor Ian,FAA 02290 INSURERD:AIM WNW Insurance Co. INSURER E° 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 VIRTH 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. TYPE OF INBURAm rJUR POUMNUMM LrAm A X ooELIABIurY SOUND lining M4 um'3ETORRENCE s S arRa �D 900 mmms raAm X OCCUR MW EXP(Inv crm „) 8 10,0 PERSONAL i ADV INJURY S 1,090,000 GENERAL AGGREGATE $ %mlow GEN1 AGOREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAW S 2x000 POLICYPRO- LOC I I S A UABLI" I lS ]ANyAUTO OUND 11911615 11911914 SDDILYINJuRY(Perpeman) sAlLOnM T X A�pg�DBODILY INJURY(Pera�d2H) S HIREDAUTOS AUTOS RrY GE g s $ X WHIRSUA LUISOCCUR EACH OCCURRENCE C 0110ESSUAS HCiAM"ADE BOUND 11911912 0193®914 AGGREGATE $ 5,000,09 X RerEwnoN & YYC STATLL I ER ANDEVIRAMWLIJUMM 0 ANYPROPRIETOWPART114M IECUTIVEYrN RIOAWCMGIGMRG12 11611613 0II930At4 E.LEACH ACCIDENT S , OFROERNMEM13ER EXCLU W El n E.L.DISEASE-EA EM S , I MIMPnoN IO bet" E.L.DISEASE-POLICY LIMIT S SOO E nsteR Float UUmm 11/11915 11611914 Ilmft 50, E Equlpment r -T UUI15603 11911913 .11911PI4 Ofmft TrDrJ OF OPU R Rx r LOA�TrONSe lA ru Ao> 9er, asl�n .0 ss raffia, Off1cm CERTIFICATE HOLDER CANCELLATION INF0=01 SHOULD ANY OF TM ASM DWCNBE®POUCM BE CANCELLED BEFOM For ITi�rIrIBUDrI Only ACCORDANCE EXPIRATION LATE THLRNF, NOTICE BE IN ACCORDANCE THE POLICY PROVIBIONL AUnaD�® ATME 011166-2010 ACORD CORPORATION. All difts rimmed. ACORD 25(2010905) The ACORD name and logo are mgMgmd marks of ACORD f The Commonwealth ofMaossachugetts Dela meat oflndustriaf Accidents ® ke o,�Invesdga�taons FF) 1 Congress Street, Suite 100 Boston,MA 02114-2019 wwwomass gov/dia Workers'Compensation Insurance Affidavit.- Builders/Contractors/Electricians/Plumbers Applicant Information T_ Please Print Legibly Nar9"dP (Busi.sass/Orgatw.ixmtioeo/lx+aiavidual): Next Step Living Address.. 29 DryDock Ave city/state/zip: 80ston, MA 02210 phone#a (566)557-8729 Are you an employer?Check the appropriate toxo Type of project(required): 1.0 1 am a employer with 750 4. ® I am a general contractor and 1 employees Mull and/or part-time).* have hired the sub-contractors 5. ®New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. [3 Remodeling ship and have no employees These sub-contractors have q. E]Demolition working for me in any capacity. employees and have workers' 9. ®wilding addition [No workers' comp.insurance comp. insurance.f required.] 5. ® We are a corporation and its 10,®Electrical repairs or additions 3.® 1 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.]f c. 152, §1(4),and we have no Insulationemployees. [No workers' 13,09 Other comp. insurance required.] e-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infoamation. f homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. £E'r'a:?('r���k I i. �i�rr'."•e F.i3^t Okadb(,O ar,a idl ra +! 1(-jrt ubP„ Jze��,iFar r )i_�::.Fth ..P::1"-ro tr c.Wrs rd Gtro7w :`R�'1'(:�t l not CAt:?a„rri f*46^ W employees. If the scab-contractors have employees,they must provide their workers'comp.policy number. dam an employer?hag is purrovimY ngP workers'com penasmadona in smraunaceforr my employees. Below h the puoficy man d job ske inform, � Insurance Company Name: A.LM Mutual Insurance Company Policy#or Self-ins. Lic. #: AWC7026153012012 Expiration Date: 00/30/94 i Job Site Address: City/State/Zip: 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 MOL 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 W®1K 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 cove. verification. 8 do hereby cera Yy m ader t'fae p. ides obi periggy Mae She informarlon peon Med 01boV b gr" and co#'Feeg. Si tore: - / � Date: Phone Official use only. Do not v riee in this area,go be completed by efy or grown official City or Town- FermltA.icense# ` Issuing Authority(circle one)- A.Board of Health 20 Building Deportment 3.City/Tovm CIlerlk, 4.ElectRical Inspector S.Flum. bft Inspector 6.Other Contact Person. Phone#a �