HomeMy WebLinkAboutBuilding Permit #208-15 - 45 DANA STREET 8/27/2014 BUILDING PERMIT of pORTH
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Date
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Permit NO: (,� � Date Received '1spA�RArEo►rP`45
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Date Issued:
IMP R ANT:Applicant must complete all items on this page
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PRORERTYr.OWNERILL
Print,
"MAF,NO �r/�_-P_ARC°E �J�ZONI G,DIS_ �RICTt,. Historic=District yes nor
lMachinerShop Villages yes? no,
TYPE OF IMPROVEMENT PROPOSED USE
Resid Non- Residential
New Building One famil
Addition Two-or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic) Well Floodplain Wetlands VNatersted ®istrict
Water%Sewer }
DECIRTION OF WORK TO BE PREFORMED:
QIP(
Identification Please Type or Print Clearly)
OWNER: Name: Phone.
Address:
CONTRACT®R' Name: �t�1 �lione
Address Ccm
rSu ervossc uction =Lcense
Exp. Date _ %3:1
ome,Improvement License: /,_ _ Exp: Date ,
ARCHITECT/ENGINEER Phone:
7
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST S ON$125.00 PER S.F.
Total Project Cost: $ h 77 FEE: $
Check No.: 50 � F-U Receipt No.:
NOTE: Persons contracting with unre ' to ontractors do not have access to the guar my f
Signature of Agent/Owner �gnature of contractor
Location
No. ` 'X��-f Date I
. • TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ F
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ r
r
Check# �U
r
`� �' Building Inspector
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
s Conservation Decision: Comments
Water & Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
;FIREDEPARTIIIIENT, TempDumpster onsite eyes � ` hL .' oA H �
Sri T'Tt 'Y ff :
�Located�at�,124fMamStreetF • '� ='- � - � ' �" � � � , '�"'` �� - `` � }
Fire Departinentsignature/dated w _
`' Km' `'�= - ;`-�+ x`c-&. ea:t} 4�'?+'; rc -t,*� YC.'� 'F�.i 't+C W y-• "C.'C` ' '.r�-^ �:,�,� .i
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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)
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❑ Notified for pickup - Date
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Doc.Building Permit Revised 2008
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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
o 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 dumpsterermits require sign off from Fire
p q g Department prior to Issuance of Bldg Permit
i
New Construction (Single and Two Family)
❑ Building Permit Application
o 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. Thea applicant must then. e
PP 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
NORTH
own of 1, Andover
0
Nof 145
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o h ver, Mass,
COCKICAWICK y1.
U BOARD OF HEALTH
Food/Kitchen
PERMI-T T L D Septic System
THIS CERTIFIES THAT ........ ...0. . ...................... BUILDING INSPECTOR
•�.�
has permission to erect .......................... buildings on ...q ........DS./4..r...'$'. ................... Foundation
Rough
to be occupied as ..... r. �1.��L� .� ......r......0111.16r I . . .............................. Chimney
provided that the person accepting this permit shall in every respect conform to the 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
UNLESS CONSTRUC N ARTS Rough
Service
......... .... .. .. .. ............................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises - Do Not Remove Fina'
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
�US/lal y'
0next step LivingTM
This agreement Is made by and among
Next Step Living, Inc.("NSL")
Peter Kalafarski 21 Drydock Avenue,2nd floor
45 Dana St Boston,MA 02210
North Andover, MA 01845 phone: (866)867-8729
Site ID: A178223
03-Jun-14
1. DESCRIPTION OF WORK TO BE PERFORMED
NSL will perform or cause to be performed the following work on the customers 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:
h .� �, Ami .`° + �§ z (� y r > zz ysi-4 'S e
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Work Location: Attic Flat
Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 12 Hr $1,140.00
Attic Floor Open Blow Cellulose 6" 1,439 sgft $1,798.75
Propavent 2'or 4' 10 Each $37.50
Vent bath fan to soffit exhaust 1 Each $115.00
Damming (Not Rebate Eligible) 24 Lnft $44.40
Work Location: Foundation
Insulate Rim Joist with 6.25" Fiberglass Batting 142 Lnft $184.60
6mm Poly Vapor Barrier (Not Rebate Eligible) 286 sqft $234.52
MA Save Weatherization Incentive HoneyWell ($2,741.88)
Estimated Annual Energy Savings from the Above Improvements $163.00
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 1/3 of the total retail costs. (Note:Mastercard,Visa;and Discover accepted)
Additional Payments and Final Invoice: $712.89
-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.
Jun 13, 2014
3tchiridittatutd 3: 11-0- Date
Te e.ca�ce /ycCo•w;Co 3 Jun 2014 Terra nCEAWQp19�iPntier
Name of NSL Representative
The Terms of this Agreement are contained on both sides of this page
Next Step Living 21 Orydock Avenue 2nd floor-Boston,MA 02210,(866)867-8729-inquiry@nextsl:eplivinginc.com.,www.nextstepliviiiR.com
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TERMS OF AGREEMENT
3.PROPOSED START DATE AND COMPLETION SCHEDULE
NSL wil'cart ct customer to schedule:he irviork at a mutually agreeable ime,su�.[ect*o the availahillr}o' rs or`?naterrafs,or to belays attributable to the
weather or other events bevond NSL's co;ural.
4.CONTRACTOR REGISTRATION
Massachusets law reouires horde inprovement contrac a s and s.lbco1ractors Q be reqisocd vi th the Director of ricrac lmproveri Ccirraclel)r Rey:str..Ior. Yo.. nay
squire 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.vvili obtain any necessary peer is as the Clustorror's ager i. Custonners vino secure fila cv n perints or de i r.ith an u.eoistered co ,r°ctor will be excluded=noir tine
Guaranty Fund provisions of the"mc improvement Contractor Lay.
6.PERFORMANCE OF THE WORK AND CHANGES.
6.1 NSL vvil�rat cO�nmen- the`J`Eork,p'or to signirc this Agreement and transmittal of a copy of Ag eement to th„Customer
6.2 1 his Ag eec:ent inay be supplemented,amended,or modified only by the n u ual agreement of the partes.No supplement,ainend,-nert,or modification of 1?is
Agreement shall be binding unless it is in writing and signed by all parties.
6.3 At times.our wea:he;zationa.n tedisc overs situations,n the structure during the dcurse of the Wok that indicates a risk for a health or safety concern for residers,
Such concerns can:nck;de,but are no'limited,o ventlatlor,potentia.,ly hazardous•na,c-.nals such as mole or ashestos,or sir,crural c;ancenns. In the case of health or
safely concerns being identified,NSL reserves the right,per secton 9.2 of:his contra:,t,to coram;nicate concerns:e the Customer Find halt work until such concerns have
been addressed.
6.4 The rebates and incertrves ave fable from the Mass Saver:Hoyle Energy Services Pr^cram and amounts due from the Customer arr.based on the^est estimate of
the Situation in too structure by the NSL tonne ere"gy adviser. ^awe.ver,a.itincs ou.r wcatneri7.at on tear disc'vvers-I:Uations In the home during the xUrse of the t'Jerk
that impact the availability of rebates and incent.vi from the Mass Save P:-caram. In such situarlors,NS:will communicate sucl.,I anges to the C astorner Irl iudnag amu
impact or arlcunt the Custorner.would be expected to pay for the Work. TI?e CtsrOrne:tat have VT..prion to remove from the Contrac,t:e work e'ernents t at need
adjustment,or set up a separate co:,krait for performing t e adios ed'work.
6.5 NSL represents and warrants to the Customer that tai the materials and eca pi.e._unrlisned under this Ac.eerie:t twit be cf cood-L-&' y and e .,,V Ma:[1'e.Wo,
will be free,frorn defects,and(c):flat Cl re 4YOrj vvl II Conform viiia t'?e desoriptior of e IAtio ,descrbet,in Paraq rapt,1.
7.INSURANCE AND REGISTRATION
NSL represents and,.tarr nts to the Customer:hat t has a wal d Home Improvement:.Cor:'r.ctor Registrat on(No, 62'11)and the neces.,a: nv,su�ance re, y
applicable favi and norma rty!Tint"tamed by prudel`•(Cantrac{OrS in NSL'&fleiii,i CIG.,:'lg,b.,,not lin?IieG to,ArOrkerS Comber rSatlOr?:i'...stlra!nCe for ail°r'play'Peb..:?.r..il
perform tine Work.
8.QUALITY OF WORK.
NSL agrees t'iat the Work will be performed in a dead and workrla^i,ke mane._rlc that NSL vi ll r I air and repla;e. at its o,vr expense,and p O pt y jpon Cus o!n&s
re
cuesIt any de`ects of wcrkmansh,p arid materials provided by NSL,vhich appeal up ie f1;year aftercompleiiar,o'the Work or vaithir ariv orl period as„ern ed or
required under applicable lave,provided NSL h,as received final;ayn?en as provided herein.
9.PRE-EXISTING CONDITIONS&PROPERTY PROTECTION
°A NSL shall rot be respo.:sibic for any damages as a consequence of the'A,ori.performed in the"o."1e u e to Pte-existlrig Conditens. These cenditionS include but are
not limited to poo!1y fastened or broi on d"i!all,moisture dam@ce,ror-code cv s.roc::ail.cracked or fraoile siding or shin cles..old p.:)-.s and fttires rot:ina.good.etc.
9.2 NSL reserves the r'ght not to pe.o l Work upon the n.scoverr of asocs:os,meld or,it}otter potential health risk to the Customs'. In this cvcn:,;he C:astomer is
responsible fol;emedyirc the at-risk situation including any necessary removal of hazardous materials and all b'lis for services to date shatbe pa,I irr led lately. 'v'lork
cannot resume until-emec ation is comolcte.
+.3 Willile NS,_will ir:ake best effo:s to prated any propr ,o`the C.s.omer, its tie Customer's responsi.",lity to remove oar protect,including dust protection.any
personal property iri ding:he norl,,itso f. NSL i of be rcistuns:ll.,for carriages to or losses of anv of*he above inert c ne p,)pit: no-;xc p;,n,p ate ted pnor to ITle
com-lencement of the!;Fork.
10.GENERAL PROVISIONS.
'C,1 NSL reserves the nyt':, the exte permitted by applicable la.4•,to have °de or mair,ta rl a meet an c s r material mer's lien,or to file a no+,ce of intention to fell.and
to take asp'ether steps t0 per an e afcrce such a tie^ Custe.n° :'alis to pay NSL as pro sided herein.
'0.2 This Agreement shall be bonst.,r-i in accordance';.::1 the la.+,s of the rGornrron x,eiat h o`klassa&userts.
1C.3 This Aoreerl fo rns'he con.,l.,te .e.g a ed agreement betv;eeh NSL acid Custo ler. Tie parties e;,resent and wa rant that n execAino this Agree li„r t,:hey:are
rat relying on any rep-ese:tatiorts warranties or tears other than as expressly curtained herein, This Agreement supersedes all prior agreements between.the Customer
end Contractor and m.ay not ce altered absent a subsequent vrritten agreemerisigned^y both parties.
You^lay can-1 this Agreement i':t ha.been sicned at a place otnor than the NSL's normal piece of business,prov ma you notify NSL in ovrit l at its slain office or
branch office by ord'nar}m:.i posted by telegram sent or by deliver,,not later.ha rnkinight of the third business;:ay fallowing the signing of this,Aareeme i. See::ie
attached not ce of can elia.ior form for an explarat'on of this right.
11.ENERGY BENEFITS.
The Sparson g utility Company;the Uti.tv is entitled to 1?C,�of the energy be is it&associaTec:vita all Enerc;Conserlanor Measures,e xcludinq inn-value of encagv
cost savings by t-Cus Omer but i`cluaing al;mints to all associated ISO-NE Energy.Capacity and Reserves Products.NS agrees to provide the Utr:,,v,i fi such.further
daCumertatiotl as the Utility'nav request to conf rm the U lit,s ownelsh o*such benefits and Products.
12.NOTICE CONCERNING SPONSORSHIP.
Customer understands and acknowleoges tnat NSt_is not an agent vendor or sub-vendor of The Sponsoring Utility Compary,the Jt ty)write respect to'he installation of
arr energy e`f G envy measures,Ir the evei"it or the failure,of an energy CGnseri stion device to perform as expected,CustGmer's sole recourse Is to Contractor and:.tot to
i,U tSe;1'rilG...J..rtiICeS Graup "S ;a: .0 the Utility.The,.HVy,and-.s operatig coral i.,S.hal:riot'1 car..:ta,.'i,remove or perform Fri ..(irk whatsoever on the energy
conservation measures insta'led.
Customer understands and acknowleades tea,tl eir oarticipatien in ale Mass Save Hoyle Energy Services Program is voluntary arc that they have consented for
Conractar to nstall the proposed proposed energy conserva+ion measures.
Customer agrees that it s a l not eta d CSG tre Ut lity.treir afar:ia.es or operating ,ompanies liable to-Comractor s to perform is obligations Linde this aareament for
fa lure of the energy copse vaton meast,res t.,f-niton,for any uamage to Ctis.Omer's Premises cause by Contractor or fol any ar?d all damages to prope }or .l;ury to
13.LIMITED TIME OFFER.
The pr ces and i centive offered in this Contract are subject to change in accorca ice vi th T'le Soonsor:g Utility Company'class Save Hoine Enerc Sev ces Proorafrl
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 later than midnight of the third business day following the signing of this agreement.
Office of Consumer° Affairs d Business Regulation
gu on
10 Park Plaza - Suite 5170
Boston, Massachusetts 0211.6
Home Improvement Contractor Registration
Registration: 162911
Type: Supplement Card
NEXT STEP LIVING INC. Expiration: 1/14/2015
ROGER OUELLETTE
21 DRYDOCK AVE. 2TI-I FL
BOSTON, MA 02210
Update Address and return card.Mark reason for change.
scn i " zo"`'o�" E] Address [j Renewal [:] Employment Yost Card
,fes
''�~\ ft'ice of Consumer Affairs&Business Regulation License or registration valid for individul use only
MIMPROVEMENT CONTRACTOR before the expiration date. If found return to:
W7Ex1pIratjdn-:-,�
istration: 162111 Office of ConsumeXrffairs and Business Regulation
Typ@' 10 Park Plaza-S `ite 5170
14%2015 Supplement;and
NEXT STEP LIVING INC. Boston,. A }'1(
ROGER OUELLETTE <`
21 DRYDOCK AVE.2TH FL
BOSTON,MA 02210
Undersecretary of valid without signature
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1 Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction 5uper%tgor Specialty
License, CSSL-102811
ROGER A OVE LUTTE
55 STORE ROAD ;.
Wan'lck RI 02
E.-piration
Comrnissioner
NIW84 OP ID:DS
CERTIFICATE OF LIABILITY INSURANCE °AN" °°1"
11/08113
SUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIOHTB UPON THE CERTIFICATE HOLDER.THIS
SOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
44 IFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sj AUTHORRED
eNE OR PRODUCER,AND THE CERTIFICATE HOLDER,
.� IT the cwdftde hokbr b an ADDITIONAL INSURED,the pd4s")mist be endor" N SUBROGATION IS WAIVED,abject to
,,w and cmdidm of the policy,rsrfaln poflola mmy em*ft an ondm ment. A ataW III11t on this owliflcate doss not coofbr rlghta to the
.d"troller In doer of such m
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John I-I aagf iln Jr.
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IIMRED NLISSB6N E,Inc. a vm@•Commerce Irmurance Cord 34784
Jeff21 Dr7dock Avenue,2nd Floor msum :lndbn Harbor Insurance Com 36900
Boston,MA 02310 B1s D:A.I.M.Mutual Insurance Co.
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER°
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED HAM ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERRA OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT VNTH 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 SEEN REDUCED BY PAID CLAIMS. �
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PERSONALAADVIMURY S 1,000,
GENERALAGGREGATE $ 4,ON,
GENLAGOREGATELIMIT APPLIESFEd: PRODUCTS-00e1PIDPAGG $ 41
POLICY LOC IS
AUTCHOW LIANUM EINoWNnB I S 1,000,
I3 ANYAUTO BOUND 1181181a 11011114 BODII-YINJURY(Parp"W) $
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CERTIFICATE 6IOI.,DER CANCELLATION
INF�1
SNOUI.D ANY OF THE ABOW DESCRIBE®POLL BE CANCHJJW B
For lOrdAnAGO ®r9 M EXPIRATION DATE THERIIDF, NOTICE MILLI IN
ACMWAM WM INS PC=PROVISIONS.
ASD REPREaHr1A71Nes
AP
®10 ACORD CORPORATION. All eight Teed.
ACORD a5 0101 Mw ACORD now and logo am m9latuad matt of ACORD
dDePaH ment of industrial Aeead'ents
®ice ofIftves'hkadons �
1Congress Sgreei,suite 106
Boston.,MA 021142017
wwmass.govldla
Workers'Canmpensafloin Ansur eta Affidavit.Bufldelrs/Contractor/EIleetidans/Plumbe s
APPLICaent Information _ Fleale Print Ledbly
Nairne Next Step Living
A, ddress: 29 DryDock Ave
City/State/Zi : Boston, MA 02290 Phoale#e (866)867-8729
Are you in employer?Check the approprfatce bozo Type of pro�ec�t(rcegm�fred): s
1.M i am a employer with 750 4. ® 1 am a general contractor and i
employees Mull and/or part-time).* have hired the saibacontiactors 6. ®New construction
2.[3 1 am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling
'these sub-contractors have
ship and have no employees 3. [1 Demolition
working for me in any capacity. employees and have workers' 9. ®Building addition
[No workers' comp.insurance comp.insurance.t 141. Electricafl repairs
required.] 5. E] We are a corporation and its ® ep 'rs or additions j
officers have exercised their
3.® i am a homeowner doing all work 11.®plumbing repairs or additions
myself: [No workers' comp. right of exemption per MGL 12.®&hoof repairs a
insurance required.) f c. 152,§1(4),and we have no ;
employees. [No workers' 13.@ Other Insulation
comp.insurance required.]
'$Any applicant that checks bots#I must also fill out the section below showing their workers'compensation policy information.
1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
i"i+�*.�r7i`.tF1�tdG—��.✓ti cid�'9":i'. Lpi(-.'.,rrq:;VJj-':d;i''�'1�P'."� 'tl':fii?`�•{;:�i't♦. c c
employees. If the sub-contractors have employees,they roust provide their workers'comp.policy number.
11 am en enaulployer Met 18providing workers'CoMpefflSdjon dWWra§1 ce j 0?nosy eMp loyeeg. BOJOW is tthepoll ey gadjob.ruse
ififorrmmdom j
insurance Company Name: A.LM Mutual Insurance Company
Policy#or Self-ins. lLic.#: A149 C7025953®92012 ]Expiration Date: 09/30/94
Job Site Address: City/State/Zip:
Attach a copy of the workers'compemsatuom policy dleclaradom Page(showing the polncy number and expfratfom date).
Failure to seem 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 once-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.041 a day against the violator. Be advised that a copy of this statement away be forwarded to the Office of
investigations of the DIA for insurance covTage verification.
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City or Town: Perrmuut/ILncensce 0
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