Loading...
HomeMy WebLinkAboutBuilding Permit #1186-2016 - 926 FOREST STREET 5/12/2016 �✓ v �?'��(CP �"C"���v1 NORTH 01 BUILDING PERMIT 0 J y TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ! ^O oyry* ilk .w . . Permit No#: Date Received 74p�RAr&o ov gSSACHUs�t Date Issued: IM ORTANT:Applicant must complete all items on this page j LOCATION 42- 2- 6 a/� 'T, rint PROPERTY OWNER- 1,0 L,t��. Ll e/e /' 1, Print 100 Year Structure yes (no MAP �� U PARCEL: ZONING DISTRICT: Historic District yesno Machine Shop Village yesno TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Xpne family 0 Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain El Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: dentificatio - Please Type or Print Clearly OWNER: Name: Phone: b /-Z Address: Contractor Name: A 2-'7 t � Phone: 2 4 Email: l .�a�� �' �` .eh.✓r' f;�;A;A� .i ., Address: Supervisor's Construction License: Z J Exp. Date: Home Improvement License: / J' 2 Exp. Date: 'v �,l ARCHITECT/ENGINEER Phone: Address: Reg. 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: $��, T Check No.: ` ��Z✓' Receipt No.: 3Z/ NOTE: Persons contra istered contractors do not have acces to -guaranty and Signature of Agent/Owner S gnature of contractor C -i= Locatio In No. + + lr r }�j° Date `-7 1,-z-1 I ! ' • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 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. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ 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 Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes _ no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 a Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 NORTH Town of �� . : _ : 1.. . Andover o No. h ver, Mass COCNICMl W.0 �.95 RATED P-P�,�qS U BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT ...........PERNA, .. BUILDING INSPECTOR........ �......KIK. .............. ......... ........... f......... Foundation has permission to erect .......................... buildings on .. ��,.. . . ... r. Rough to be occupied as ........... . ... ...�`....... ............................................................................................. Chimney rt;�X provided that the person accepting this permit shall in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough 21,444, . Service ................. �. �s.................................... Final BUILDING 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. Proposal AB Carnes Roofing,Inc. Page 1 of 1 30 Arrowhead farm Rd Boxford,Ma.01921 978.887.1431 MA.CS-000230 and HIC Reg.176928 Proposal Submitted To: JOHN&BEVERLY MAE LONGUEIL Date April 24,2016 926 FOREST ST Project Name NORTH ANDOVER,MA 01845 Address 603-512-2197 We propose to furnish material and labor-in accordance with the specifications below: Seventeen Thousand Nine Hundred Dollars($17,900.00) Payment to be made as follows:$300.00 Balance Upon Completion Notice:All home improvement contractors and subcontractors engaged in home improvement contracting,unless specifically exempt from registration by provisions of Chapter 142A of the General Laws,must be registered with the Commonwealth of Massachusetts.Inquiries about registration and status should be made to the Mass.govlllcenses website. ROOF PROPOSAL ® STRIP ROOF OF UP TO TWO LAYERS OF ASPHALT SHINGLES.COVER ROOF DECK WITH THE UPGRADED RHINOROOF TITANIUM U20 HIGH PERFORMANCE SYNTHETIC UNDERLAYMENT MEMBRANE.COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ® ICE DAM PROTECTION:INSTALL CARLISLE HIGH PERFORMANCE ICE&WATER BARRIER OVER ALL HEATED AREAS FEET WIDE AT THE LEADING EDGE OF ROOF AND THREE FEET IN ALL VALLEYS.WRAP THE CHIMNEY(S)AND SKYLIGHT CURBS WITH ICE A D WATER BARRIER. ® COVERALL PERIMETERS WITH EIGHT INCH PREFORMED ALUMINUM DRIP EDGE. ® INSTALL GAF COBRA RIDGE VDIT AND/OR❑ ROOF LOUVERS FOR ADDED ATTIC VENTILATION. ® COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS AND FLANGE. ® REPLACE WALL FLASHING(S)AS NEEDED WITH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF$25.00PLFT.WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK AND YOU MAY NEED TO HAVE A CARPENTER REINSTALL OR REPLACE THE SIDING THAT WAS REMOVED. ® CHIIM14EY FLASHING,REMOVE EXISTING FLASHING FROM CHIMNEYS.CUT NEW REGLET INTO THE BRICK AND SECURE THEN LEAD WITH METAL ANCHORS AND SEAL. PLEASE ADD$500.00 T VEP (BLACK TAR USED BY OTHERS IS NOT FLASHING) ® COVER ROOF SURFACE WITHCERTAINTEED LANDMARK 24 LIFETIM RRANTY DESIGNER SHINGLES. ® REPLACE DEFECTIVE ROOF DECK AS NEEDED WITH SIMILAR AT AN ADDITIONAL COST OF$4.00PSQFTIPLFT. ❑ COVER ROOF DECK WITH CDX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING,AT AN ADDITIONAL COST OF ® NAILMG: SECURE SHINGLES WITH EIGHT IN TOTAL COATED ROOFING NAILS AS PER CERTAINTEED SPECIFICATIONS. ❑ SKYLIGHTSI REPLACE EXISTING SKYLIGHTS WITH NEW VELUX OR WASCO UNITS.WE WILL PROVIDE THE SKYLIGHTS&FLASHING KITS AT OUR EXACT COST FROM OUR SUPPLIER.OUR LABOR CHARGE IS$90.00 EACH IF THEY ARE THE SAME SIZE.INTERIOR WORK IS EXCLUDED. ElREPLACE DEFECTIVE TRIM BOARDS WITH CUSTOMERS APPROVAL USING NO.2 PRIMED PINE,ADD$15.00PLFT TO THE ABOVE PROPOS CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK AREA. THE PROPERTY OWNER AUTHORIZES AB CARNES TO OBTAIN THE ROOFING PERMIT.WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC AREAS. CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE STRUCTURE AND FOLIAGE.HOWEVER,SOME MARRING AND OR MINOR DAMAGE COULD OCCUR. IN ADDITION,WE CANNOT BE RESPONSIBLE FOR ITEMS FALLING FROM WALLS,SHELVES OR CEILINGS DURING THE ROOFING PROCESS. SPECIAL INSTRUCTIONS; THE ABOVE PROPOSAL INCLUDES SHINGLED ROOF SECTIONS OF THE HOUSE,BARN AND CABANA. 10 UPGRADE SHINGLES TO THE LANDMARK 300LB HIGH DEF PREMIUMS,ADD$2945.00 TO THE ABOVE PRICE.YES( )THIS IS OUR EXACT COST WARRANTY UPGRADE:THE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM 110 MPH TO 130 MPH WITq M UPGRADE TO THE CERTAINTEED HIGH PERFORMANCE HIP&RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL CHARGE.YESVI -05u�,'I �Go��c�.� 11 EMAIL ADDRESS Sm,4L4L Warranty:All work warranted against installation defects for 5 years;this warranty is limited to the installed item(s)and its repair only.Material is warranted by the manufacturer against defects for 50 years;see the manufacturer's warranty for exact warranty performance. Cancellation:Customer has legal right under federal law to cancel this contract without penalty or obligation within three business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side. Dispute Resolution:All parties agree that any and all disputes relating to this proposal shall be settled by arbitration as provided by the AAA.This forum is user friendly and does not require lawyers.Please see reverse side. Signing this Proposal mean ,you have accepted all the terms as stated on the front and back of this a,eement. Please see reverse side. *Date of Acceptan �� �� Signatui. i 1 *Signatur Signature �✓ O er,Barry Carnes L PLEASE SEE REVERSE SIDE TOWN OF NORTH ANDOVER WASTE AFFIDAVIT As a result of the provisions of MGL Ch.40-s54, I acknowledge that as a condition of building permit# all debris resulting from the construction activity governed by this building permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL Ch.111-s150A. Waste Disposal or Solid Waste Facility: ALLIED WASTE Address: 300 FOREST ST Town/City, State, Zip: PEABODY, MA 01960 NAME OF HAULER: AB CARNES ROOFING, INC. DUMP TRUCKS DATE: 5-12-2016 SIGNATURE OF APPLICANT: Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-000230 Construction Supervisor t . BARRY S CARNES 30 ARROWHEAD FARM RD BOXFORD MA 01921 r-jZ7 C'�— Expiration Commissioner 03/07/2018 _ Ill'GG' � Q�jyG/'JGQ��TiLUP.LrilI'1, ��: C�i���1JC�'C;I'GGI.I�'rfJ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 176928 Type: Corporation Expiration: 10/10/2017 Tr# 269957 AB CARNES ROOFING, INC. BARRY CARNES 30 ARROWHEAD FARM RD BOXFORD, MA 01921 - Update Address and return card.Mark reason for change. SCA 1 Ci 20M-05/11 Address Renewal Employment Lost Card The Commonwealth of Massachusetts Department of Industrial Accidents i I Congress Street,Suite 100 Boston,MA 02114-2017 wwn:mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ihly Name(Business/Organization/individual):AB CARNES ROOFING INC Address:30 ARROWHEAD FARM RD City/State/Zip:BOXFORD, MA 01921 Phone#:978-887-1431 Are you an employer?Check the appropriate box: Type of project(required): k6 am a employer with Some employees(full and/or port-tune).'" 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself.[No wo[kers'comp.insurance required.]1 9. ❑Demolition 4.❑1 am a homeowner and will be hiring contractors cont to conduct all work on m 10❑ Building addition y property. I will ensure that all contractors either have workers'compensation insurance of are sole l LQ Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5b1 am a general contractor and I have hired the sub-contractors listed on lite attached sheet. These sub-contractors have employees and have workers'comp.insurance.= 13. Roof repairs 6.❑We are a corporation and its officers have exercised their tight of exemption per MGL C. 14.Q Other 152,g 1(4),and we have no employees.[No workers'comp,insurance required.] "Any applicant that checks box#1 must also till 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 u new affidavit indicating such. lCont actors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or lot those entities have employees. if the sub-contractors have empluyees,they must provide their workers'Gump.policy number. 1 cue an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. TRAVELERS INDEMNITY CO OF AMERICA Insurance Company Name: � Policy#or Self-in Li' c.#:CHUB-OG36156-6-15 Lxpirat Date:10/15/2016 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 MGL c. 152,§25A is a criminal violation punishable by a tine 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.A copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby certify an rre plllns and pen !ties of perjury that the iuforuiation provided above is true and /correct. Si nature: ��- --e:5 Qate:_T I- T-- - — Phone#:978-887-1 31 Offcial 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.O Wer Contact Person: Phone#: ,Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `� 1 04/11/2016 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 BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Fausto Pina ACE INSURANCE SERVICES INC PHONE (508)584-5900 FAX Alc No): E-MAIL aceinsuranceservices@yahoo.com ADDRESS: @Y 675 WARREN AVE INSURERS AFFORDING COVERAGE NAIC# BROCKTON MA 02301 INSURER A: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED INSURER B APC CONSTRUCTION INC INSURERC: ° INSURER D: 51 FORD STREET UNIT 1 INSURERE: BROCKTON �� MA 02301 INSURER F: COVERAGES _ CERTIFICATE NUMBER: 43555 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 WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurtence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOSr accident $ Pe UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MAD NIA AGGREGATE $ DED I I RETENTION$ �,/ $ WORKERS COMPENSATION /� STATUTE ETH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECU VE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? NIA N/A N/A 6ZZUB9F53382616 03/08/2016 03/08/2017 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L./DISEASE-POLICY LIMIT 1$ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AB CARNES ROOFING INC ACCORDANCE WITH THE POLICY PROVISIONS. 30 ARROWHEAD FARM RD AUTHORIZED REPRESENTATIVE -BOXFORD MA 10921 Daniel M.Crc�ky,CPCU,Vice President-Residual Market-WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD NOTICE z W NOTICE � r TO W a TO EMPLOYEES r �� EMPLOYEES 7�/ y0W 0,1M S�6 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/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 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY _ 1�7 6HUB-OG36156-6-15) �0-15-15 TO 10-15-16OLICY NUMBER _ ` EFFECTIVE DATES PRESCOTT & SON INS 963 EASTERN AVE - - MALDEN MA 02148 CAB E OF—INSURANCE AGENT ADDRESS PHONE# ° RNES ROOFING INC 30 ARROWHEAD FARM RD BOXFORD MA 01921 `OYER 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 000849 W20P1G16 TO BE POSTED BY EMPLOYER