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Home My WebLink AboutBuilding Permit #358-12 - 598 SALEM STREET 10/26/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ' Date Received Date Issued: ° IMPORTANT:Applicant must complete all items on this page LO CATION Print PROPERTY OWNER f S Print MAP NO:() PARCELS ZONING DISTRICT: I-listoric District yes no Machine Shop Village yes no t TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential [iNew Building [I One family ❑Addition ❑Two or more family ❑ Industrial [aeration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑Demolition ❑ Other ®,Se ml `AN � t ' '•s.°' . ®y-' F R ? `� i 'S2y�'(V ?.- Floodp W6te'•r9Ts4 he ticcel ;' • i ®�Water♦/tiS ewer"� _ �.k- _:�-'�� -:_��i. �-- - - --"---. .�_s._��._ _ DESCRIPTION OF WORK TO BE PERFORMED: °t "7 enz Identification Please e Type or Print Clearly) OWNER: Name: ��e Phone: G/-7 Address: CONTRACTOR Name: buv()' 40 i �-� Phone: Address: R) 106 6237 NO TvP �I Ila Af9 ;Sgqu-z Supervisor's Construction License: Exp. Date: `c9//t1/ I/ Home Improvement License: 1 I,, --)33 R-- Exp. Date: c7h d ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 7Sy FEE: $ ,'r,0a Check No. Receipt No.: -�2 NOT e ns ntractin wit unregistered contrgcprs do not have access to the guaranty fund ;.. — S -_ - - Si' �afiai=e::of,a�L —- � Building Department The following is a list of the required forms to be filled outfor 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 Permi Addition Or Decks ❑ Building Permit Application Y ❑ Certified Surveyed Plot Plan - ❑ Workers Comp Affidavit o 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 Ener Compliance gY 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 JCDTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i -all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals is t the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording It St be submitted with the building application Doc: Doc.Building permit Revised 2008mi I 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature li COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments mater& Sewer Connection/signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dempster on site yes no Located at 124 Main Street Fire Department signature/date CON34ENTS 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 2008 Location S,-X*` T� ' No. /2 Date r r AORTN TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ CMUstt�' Building/Frame Permit Fee $ r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �� 748 4p Building Inspector �.1®RTIy ® oAndover . No. 0 * 0 o , lover, Mass., A_ COCKIC EWICK i �7ae ADRA T E D P`'P IT BOARD OF HEALTH En� MIT T D Food/Kitchen Septic System BUILDING INSPECTOR /'S 4 S THIS CERTIFIES THAT.............�.....G .................................................................................................................................... Foundation has permission to erect........................................ buildings on..... S- cP ..SG/ ? ......... ................................... Rough //� to be occupied as /'r ......./••••r \G'.A....� Chimney p 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 7 y- ELECTRICAL INSPECTOR. UNLESS CONSTRUCTION SW 1 S Rough ...................................... ................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy .wilding 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. SEE REVERSE SIDE smoke Det. ,i Page No. of Pages r Builders License # 58443 Home Construction Reg. # 109288 alsle (781)944-1994 (978)664-2557 "The Areas Oldest and Most Reputable Roofing Company" P.O. Box 637, North Reading, MA 01864 i PROFt�7L� BMITTEDTO S0 n S P ONS � DATE q c2 3 STREET, r � — C/ JOBNN/AME f "a 1f�i CITY,STATE) D IP CODEg JOB LOCATION C4 A/I o v r We hereby submit specifications and estimates for: Entre Roof � !e� Rip& Remove all shingle debris from roof&job site with our own disposal truck: ❑ 1 layer d2 layers ❑3 layers or more d Repair/or Replace any roof decking; not to exceed 50sq.ft. (additional at$1.70 per ft.) Install 8"aluminum drip-edge/and rake-edge along entire perimeter. Choice of mil white r brown Install ICE&WATER underlayment along horizontal eaves,valleys,sidewalls, sky-lights and chimneys C� Install premium base sheet underlayment between roof deck and roofing shingles UK Install your choice of Tamko/GAF or IKO Lifetime architectural roof,shingles See manufacturer warranty policy for more details '� ,• 4 � Install new aluminum flange i vent- e s PP 9 ( ) Chimney(s)-counter-flash and re-step existing flashing" �w ❑Cut& Install new lead flashing -vent with low profile design, hidden by shingle caps Cd Continuous Ridge F ❑Soffit-ventilation ❑ Roof louver; ents ❑ Seamless aluminum gutters-custom fabricated at job site by our own gutter machine ❑Downspouts ❑Leaf gutter guards Other `Please Note:All items in roof attic should be removed or covered due to falling roof particles,at time of roof tear-off Price includes all items above that are checked only/others may be priced separately upon request. �r Propase hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: 5 Total price not including options. dollars($ ). Payment to be made as follows: L-11 ! / 30%deposit required before ordering materials.Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Late charges of$50 per week for all outstanding bills due upon day of Authorized ✓' completion. Signature /�� -Accepting proposal means agreeing to the terms of the enclosed binder Note:This proposal may be j contract. withdrawn by us if not accepted within :?o days The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, 114A 02111 -- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractoi-s/ElectriciaDs/Plumbers Applicaut Information Please Print Le ibl Nalne (Business/Organization/individual): P® Box 637 Address: No. Reading, MA 01664 City/State/Zip: Phone Ar��, 2n employer? Check the appropriate box: Typeof project (required): 1. g ral contractor and i - a emnloytr uvith 4. `J I am a general _ loyco ff it _ai,.___� have b"'d the cnh_CnntroCt�-S I I 6. ❑ New conStTUCtlOr] i-�i.��JlVy�-�.,$ 11 usi ni3W V3 X31 L-L1i 11C�.' .. 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g- ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp-insurance.t 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. oof 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: k?0_i Q2e /S Policy #.or .Self-ins. Lic. #:'7 P. ( Expiration Date: L l Job Sitc Address: Ctry/Jtate/Z,p 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 m 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signa ` Date: Phone #: 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: Informati®n 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 enuty,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 repau.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 1 S2, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate 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, §25C(7)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-contractor(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 he 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 be 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 obit in the event the Office.ofInvestigations has to contact you regarding[he applicant. Please be sifre.to fill in.the permit/license number which will'be used as a reference number,.In addition aiiapplicant that.]aust submit multiple peiirfitLhcense applicatfons.in any.given.year, need.only:stibirut one affidavit indicating cut7ent. policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (cityor town)."A copy of the affidavit that has been officially stamped or marked by the city or#ov✓n 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 perrrut not related to any business or commercial venture (i.e_ a dog license or permit to burn 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. # 617-727-4900 ext 406 or 1-877-N ASSAFE Fax # 617-727-7749 Revised 4-24-07 Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information araeC.Wimy Name 'popStreet Address(do not use a Post Office Box address) Contractor/Salesperson/Owner.Name Iscl� City/Town State Zip Code Busiluess A&kess(must include a street address) Daytime Phone Evening Phone City/TownState Zip Code e /4A d 6 e Mailing Address(It different from above) Business Pbo& Federal Employer ID or S.S.Number Home Impmv -Cemmp¢r Reg.Number Eaph¢timde, pmaeme¢t a¢melon have ..w;e rego,r uo¢¢¢inner The Contractor agrees to do the following work for the Homeowner: (Describe eiinn+detail ttthhee work to completed,specifying the type,brandhnd grade of materials to be used,use additional sbeets if necessaiv.) j Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be �y{,t �✓J excluded from the Guaranty Fund provisions of ate when contractor will begin contracted work. MGL chapter 142A.) 3cl —Date we.mracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: Payments will be made according to the following schedule: $ L upon signing contract(not to exceed 1/3 of the total contract price 2E the cost of special order items,whichever is greater) $ by / /_or upon completion of $ by_/_/_or upon completion of $L `/�upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(--) $ to be paid for NOTES:(-)Including all finance charges(•*)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-thud of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty beine Provided by the contractor? ❑No Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor.The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. ¢ Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most 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 the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her 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. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical coP9 of the contract t be completed signed.One copy should go tor_.The other copy should be kept by the contractor. H wner's Signature Contractor's Signature 011oll [ lf�Ja-2 l� Date Date Contractor Arbitration >� The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by t e Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required t submit to such itrati as provide In Massachusetts General Laws,chapter 142A. Tmeowner's Signa a 'Contractor's Signature OTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: I I Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at h_pt ://www.mass.izov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at httt://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: htM:Hdb.state.ma.us/homei=rovement/licenseelist.asl2 For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 Massachusetts- Department of Public Safety A UNIBoard Of Building Regulations and Standards Construction Supervisor License License: CS 58443 Restricted to: 00 KENNETH P DUVAL PO BOX 190/72 NORTH ST N READING, MA 01864 Expiration: 12/10/2011 ('ununissi"O/i' Tr#: 10475 Office of Consumer Affairs&B siness Regulation HOME IMPROVEMENT CONTRACTOR Registration:.--::x,.167338 Type: Expiration: W-1012012 LLC w D AL ROOFING;:LLC ' KENNETH 72 NORTH ST kk- NO.READING, MA 01864 Undersecretary NOTICE z NOTICE TO TO V o EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21,22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P .O. BOX 1 450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-023ON91 -9-11 ) o3-1i -ii TO 03-11 -12 POLICY NUMBER EFFECTIVE DATES m— GILBERT INS AGCY 137 MAIN ST m READING MA 01867 ® NAME OF INSURANCE AGENT ADDRESS PHONE# DUVAL ROOFING LLC 184 PARK STREET NORTH READING MA 01864 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS =638 W20P1G02 TO BE POSTED BY EMPLOYER