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23A-105 (14) 143 SOUTH MAIN ST BP-2019-0996 GIs#: COMMONWEALTH OF MASSACHUSETTS Mavillock:23A-toy CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT P ,i # BP-2019-0996 Proiect# JS-2019-001641 Est.Cost.$25600.00 Fee:$166.40 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group VALLEY HOME IMPROVEMENT INC 112166 Lot Size(sp.ft.): 7710.12 Owner: MCMURRICK TIM Zoning: URB(100)/ Applicant. VALLEY HOME IMPROVEMENT INC AT: 143 SOUTH MAIN ST Applicant Address: Phone: Insurance. P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:3/1912019 0.00:00 TO PERFORM THE FOLLOWING WORK:RELOCATE LAUNDRY, NEW BATH VANITY, NEW CLOSET & DOORS IN BEDROOM CONVERTED FROM KITCHENETTE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Fieal: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of OacuDancy Signature: FeeTvve: Date Paid: Amount: Building 3/19/20190:00:00 $166.40 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-09% APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE (413)594-7522 PROPERTY LOCATION 143 SOUTH MAIN ST MAP 23A PARCEL 105 001 ZONE URB(100 THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENC)�ED REQUIRED DATE ZONING FORM FILLED OUT t Fee Paid Q JAW Building Permit Filled out \ Fee Paid Twcof Construction, RELOCATE LAUNDRY.NEW BATH VANITY,NEW CLOSET&DOORS IN BEDROOM CONVERTED FROM KITCHENETTE New Construction Non Stmchual interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 112166 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPI " INPORMATION PRESENTED: � fog" Approved_Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ (UL�i IOY7 Rt�D Intermediate Project: Site Plan AND/OR Sp Major Project: Site Plan AND/OR Six �� �J(/Q✓7 Nntz,�� ZONING BOARD PERMIT REQUIRED UNDER:§ Finding Special Permit Va Received&Recorded at Registry of Deeds Proof Enclo _Other Permits Required: _Curb Cut from DPW Water Availability _Septic Approval Board of Health Well Water l caro of Health Permit from Conservation Commission Permit from CB Architecture Committee _Permit from Elm Street Commission Permit DPW Storn Water Management _Demolition Delay Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. Variances me granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. Department use only City of North s of P rmit Building Dep rtm ECEIV M.�cw veway Permit (, 212 Main feet Sew rlSep'c Availability ` Room 1 0 NAR 12 201 at Nell Availability \ Northampton, O1 60 Two etso Structural Plans \ phone 413-587-1240 F ) 41587- ❑nn its PI ns, Dr¢'T DparatDING"', }gne 6Pec1 !' RTIUA1PTOtL Mq. APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: `y. This section to.be completed by office I%{?J S. 1 �a-L.{'1 fT Map�`Z_ Lau /n6— Unit ?'1O(G 3C�i Zone Oyeday District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: T1rnh,-S0.ru rn,1 4yey-LcA tow Name�nqQ Currem Mailing Address: 413— 12731 - _1 Telephone Signature 2.2 Authorized Anent: Rachel R0,C)I5 r5 PO Box t'W91 1=laencc d tt3 oloto2 Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oficial Use Only completed bpermit applicant 1. Building Z 2 Y50 (a) Building Permit Fee 2. Electrical X650 (b)Estimated Total Cost of D Consbuction from 6 3. Plumbing /SDD Building Permit Fee. //q/. co 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) ZS(g00 Check Number J. This Section For Official Use Only Date Building Permit Number. Issued' Signature: Building Commisslonedlnspector of Buildings Dale EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Most Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Thia column to be filledm by auddmg Deparmat Lot Size 1 � Frontage -� Setbacks Front Side L:= RO L:C R:= Rear Building Height O o 0 Bldg.Square Footage O Open Space Footage / (Wtuee miewbWg&pavd #ofFaxidnit Spaces Fill: - mi me&I.ocatiov A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW © YES Q IF YES, date issued:[ IF YES: Was the permit recorded at the Registry of Deeds?NO 0 DONT KNOW O YES IF YES: enter Book F Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: IF —� D. Are there any proposed changes to or additions of signs Intended for the property? YES © NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,Men a Northampton Storm Water Management Permit from the DPW is required. SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteratlon)s) Roollng ❑ Or Doors O Accessory Bldg. ❑ Demolition El New Signs [0) Decks Ill Siding 10) Other[0) Brief Descripti n of Prop sed yyr(L SmokeA (0s l // Work: Od(r..d�2 /LUn0/..o 6n.Y�Nai✓ny row claOf-Irsaya Ip r�ufordeK�.UneW k��/Myi(cr Alteration of existing bedroom_Yes—No Adding new bedroom�)C Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a, If New house and or addition to existing housing, complete the following: a. Use of building. One Family Two Family Other b. Number of roans in each family unit Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? In. Type of construction I. Is construction within 100 R of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No J. Depth of basement or cellar gear below finished grace k. Will building conform to the Building and Zoning regulations? Yes No. I. SepticTank_ City Sewer_ Private well_ City water Supply ' SECTION 7a-OWNER AUTHORIZATION.-TO BE COMPLETED WHEN OWNERS'.AGENT OR CONTRACTOR APPLIES.FOR BUILDING PERMIT * I, llm3 erx.. Rckurrio-N as Owner of the subject property (7 hereby ooze N4-C f�(Aalet Rjsbe,4s to act m in C matters relative to work uthorized by this build PZ application. Signature of Owner Oaate 9 I,� r KVN-r1G f��32✓� as OwnerfAuthonzed Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. �&0h V4b&4% Print Name VM, 031,Vl9 Signature of OwrxedAgent Date . J SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction__Su__o11eMJJeor: (J `_,, Not Applicable ❑ Name of License Holder: 1�Q KbbCA-5 11D 1 IO(O License Number \Q Ch"NA n SV, EA%41a_rn42b[k:jMR otoad (oft 121 Address Expiration Date ti rr�-s84��aa. Signinure Telephone 9.Real stered Home Imorovement Contractor:T.y;�,; :,�"Q�L�t„t _f J„i, i,� w: Not Applicable ❑ �GI..Q.QeL�I k}omG orzi.TPmen+ 105543 CiMe Na Registration Number QA -11 )1, 126 Address Expiration Date Telephone U12L �5a SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(N.G.L c.152,§25C(e)) Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result in the denial of the issuance of the building permit Signed Affidavit Attached Yes....... pyNo...... ❑ City of Northampton Massachusetts DRNT OF BOILDING INSPECTIONS 212 Kn i 212 lLin 8a Bu • Municipal iltling Northihrmpeon, . 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR')regulates the registration of contractors and' subcontractors performing improvements or renovations on detached one to four family homes.Prim to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("ITIC'). M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair,modernization, conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owner- cupied building containing at least one but not more than four dwelling units....ar to structures which are adjacent to such residence arbuildirgr'be done by registered contractors. Note:IJthe homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work 1Fee/e'orr tliw SI all —,;AV4Ire 4e4#13st.Cost S 60V Address of Work: 14-5 S. ►-ta Lr1 r.4- Date of Permit Application: I hereby certify that: Registration is not required fm the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury. I hereby apply for a building permit as the agent of the owner: a11111f \o-usu""' �m orc)rerncnf Ln� to ski 3 Date Con ctor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property. Date Owner Name and Signature City of Northampton "��, Massachusetts '.e YI �-" '�, •' DEPARTNENT OF HDILDING INSPECTIONS \ " 210 Nsin strBBt • NunicipBl Building Q\ Northampton, M 01060 Massachusetts Residential Building Code Section 110.R5.12 Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section 110.R513.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5,provided that if a homeowner engages a person(s) for hire to do such work,then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Official,on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. City of Northampton s' Massachusetts ) ➢EPARTMtT]T OF BpILOZNG INSPECTIONS �t u 212 Main Strut apynicipal Suiltlin9 ®({� '.rthupton, e 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the 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 c 111, S 150A. The debris from construction work being performed at: ILA5 c7(]>t4' H& Ln Ln &ry-ePJ4-- (Please print house number and street name) Is to be disposed of at: �n U16. �C L . printnE dlciCIUSk!ftaMf C* Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Slg&M&of Permit Applicant or er Date If,for any reason, the debris will not be disposed of as indicated,the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth ofMassachttsetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A Eceut Information Please Print Le 'bl Name(Busmess/OrgaabaoovIndlvidua]): -� Address: Q-m Wit, (90(pa—1 840 (Z\,Jcits .1e —Dr City/State/Zip: "F10�er-xe Ft'Pr aob-2- Phone#: Ulmer'584-'15a�- Are you an employer?Cherk the appropriate box: Type of project(required): 1.0 t am a employer with employe ,(full sod/or pan rose)` 7. ❑New construction 2.❑Iamasok pmpnctmmparmmhip aodhavemempbyw wodmg 6umem 8. Remodeling sey capacity.Ma wothrsm•.,iemramr required I In I an a bommwaer domgaa work myml4[No workem'comp.insurance tagwrM.]t 9. ❑Demolition 4.❑Iamahomwwovmdw beb4wgeootractontocoeductaawotmmypropmy. Iwia - 10❑Building addition mane that au coatracmrs tuber be.c wmkers'comp enation insmmoe m are aok 11.❑Electrical repairs or additions pmpnatm withno emph yeo' 12.[]Plumbing repairs or additions 501.o ,smal rontractarandI how,brood the sebrnntncton lirYdon doanacheasbast. 13. ROOfr aIIS Thne aubcontracmrs hart employee mod have workm'mmp..0 ❑ � . 6❑Weamawrpanaooandibofficershaveurni rotitightofcx®prionpm MGLc. 14.❑Other 152,§1(4),aedwe have so employees.[Ne workers•romp.weuranm mmrbeL] *A y eppbemt thetcheoks box#1 mum also fill out the section below showing bekwurkers'eompensatioepolicy infom mon. t Homcow1 whotbmit Wer offidavit outcome dory am doing all workandthm hoe omNecontracmn must submit a new afdavh indicamg such. ICmurar on that ch,tkmts box most atnche lan additional sheet showing the home of the sub-metracmn and state whether m not ebbe tomes have emplmyen. pokry mmber. lam"employer that is providing workers'compensation insurance for my employem Below is the policy and job site information. ff�� _ I /' Insurance Company Name: HY`-eWL �� Y) G r QCrynr anq qhs Policy#or Self-ins.Lia Expiration Date: 1 Job Site Address: City/Slatemp_ lsaeCnee 1, o1ooZ Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date). Failure to secure coverage as required under MGL a 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify un airs and alfies o attire information provided abo77"e7correct Signature Date: Phone#: 21. it 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 ofHeakh 2.Building Department 3.Citylfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employer is defined as"...every person in the service of another under any contract of hive, express or implied,oral or written." An emph yer is defined as"an individual,partnership,association,corporation or other legal entity,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 repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed on be an employer." MGL chapter 152,§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'Weither the commonwealth nor my of its political subdivisions shall enter into my 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)Daniels),address(es)and phone number(s)along with thew certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or parmers,are not required to cavy workers'compensation insurance. If anLLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 my 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 One. 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 out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in my given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that bas been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on fie 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 permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves eta)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MAO2114-2017 Tel.#617-727-4900 ext 7406 or 1-877-MASSAFE Fax#617-727.7749 Revised 02-23-15 vv w.mass.gov/dia Information 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 mother miter any contract of hire, express or implied,oral or written." An employer is defined as"m individual,partnership,association,corporation or other legal entity,or my two or mom 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 dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of mother who employs persons to do maintenance,construction or repair 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 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a[teens.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 sur any of its political subdivisions shall enter into my 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 your insurance company's time,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the 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 Deparunent 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 my 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 out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/liceuse number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in my given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be providedto the applicant as proof that a valid affidavit ism file for future permits or licenses. A new affidavit musk be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to my business or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fm number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1.877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Furor aevtad r1-23.15 I{c ( Commonwealth of M a ssachusatls `V Division of Professional Licensure �./ Board of Building RegQulations an Standards Cons 'rliSIUPT'isor CS-112166 � spires: 0610112021 r RACHELK10 AERTS VE EASTHAMPTON hJq 07087 ' >� trl/CcTdOy7�� ..e. s: Commissioner Cj— Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Mchusetts 02108 Home ImprovemRtractor Registration Type Corporation W Reglstrabon: 105543 VALLEY HOME IMPROVEMENT INC = Expiration: 07/16/2020 P.O.BOX 60627 FLORENCE,I 01062 y 'o �Y 7� Update Address and Rehm Card. iGl O WlaDV17 .J�.e �invnonrceat7iPo�.�ouar.>uunelG OMica ME IMPRer Aedn TCONTR ReOulatien HOMEIMPROVEMENTalrat CTOq before the expiratforlate. Nual ouseoNy 7strAWnaroora0m Office of Coteau.., Affairs and Bu reeRn to: Reaistratlon, ExcinEN ,07116 tl20 OneA Ashburton re Suite 13 business Regulation 1L6 _ 0]/162020 One Ashburton Place Suite 1301 VALLEY HOME(1(``1tyty�N�.� RiNC Boston,MA 02100 STEVENRSIOED 340 NORTHAMsTONE, -- MA`'S1'6b2" Undersecretary Not valid without signature