24A-166 (3) 319 PROSPECT ST BP-2016-1541
GIS6: COMMONWEALTH OF MASSACHUSETTS
Map:slock: 24A- 166 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: Door Replacement BUILDING PERMIT
PermitBP-2016-1541
Project# JS-2016-002631
Est. Cost:$10354.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): 12588.84 Owner: BIXBY GEORGE W&NATALIE A
Zoning: URA(I0O)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 319 PROSPECT ST
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401) 935-2633 O
NORTH PROVIDENCERI02904 ISSUED ON:6/27/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:Replace 4 exterior doors in the existing openings
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 tt Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature: FeeType:
Date Paid: Amount:
Building 6/27/2016 0:00:00 S40.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
Department use only
F r - - City of Northampton Status of Permit: .
Building Department Club CUHDriveway Permit
N 2'� 212 Main Street Sewer/Septic Availability
( Room 100
�LWater/Well Availability
`cr;oa 'port ampton, MA 01060 Two Sets of Structural Plans
°NOrnamT rn:++a ' - :7-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
///��1 �J � Map Lot Unit
.'9 yY]„�L.Y ��a Zone Overlay District
"-V/Y " v/ ' Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
kirT 1-443- ail'Y get ere 9217e1/7747:
O o noil NMfiv
Name(Print) Current Mailing As IND-
.
. - LV�/. 04-7 {
Telephone
Signature
2.2 Authorize-at Age : 0-41121-,
IIIP
Name(Print) / Current Mailing Address: y'' o 215
,�09409-"S�-13-5"2---
Signature
�5� oX�
Signature' T Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /0, --3971.b0 (a) Building Permit Fee
2. Electrical / (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee /y'
4. Mechanical(HVAC) /
5. Fire Protection
6Total=(1 +2+3+4+5) ,(/ ?;31.-Pli Check Number I /6677
This Section For Official Use Only
Building Permit Number'. Date
Issued:
Signature.
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R:i.
Rear
Building Height
Bldg. Square Footage %
Open Space Footage V
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location) _. . . .
A. Has a Speciat Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW Q YES 0
IF YES, date issued:'..
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW O YES O
IF YES: enter Book Page: and/or Document N
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (3 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES
Q NO O
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,grading,excavation,or tilling)over l acre or is it part of a common plan
that will disturb over 1 acre? YES O NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement indows Alteration(s) n Roofing n
Or Doors Jq
Accessory Bldg. ❑ Demolition
❑ New Signs [C] Decks fq Siding [C] Other[DI
Work: escrip]i n f Prosed 1 / A. 1 , T .. E:Ha ✓��{'l o.Y
Alteration of existing bedroom Yes /�N000 Adding newbedroomYes /` No
G/�!
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 rooms in each family unit Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stones?
E Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. NJ?T�j09- p-- , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relat e to work authorized by this building permit application.
ent.T L - 6
Signature of Owner Date
•
---Th
a'/rYea". /Mw/ as Owner/Authorized
Agent hereby dec are that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the .- san/.enalties of perur
�� ,.,: > -
Print Name
Signature oiorner/Agent
— L Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:/ � isw yJ {/� /� Not(* 5L
Applicable)£/�/j'7�
Name or License Holder: ViApievg4 '/ �" � ( 5 r// 992af
/fro v A /Y!9 r, License Number
d�-�l �2 / Date l7
Address -5 ALL, r� 'l Expiration
Yh(4- � N/p3!/
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable £
—Fitt ))o D pY' )2#1.93
Company Name (�,� ��' Registrabo Number
/94 /rn et3 /1
AddressJyExpiration Date
irylide , // riµ. 0/62K—Telephon2lk2
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
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 ilding permit.
Signed Affidavit Attac No £
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Definition of 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.
Such"homeowner"shall submit to the Building Official,on a Conn 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 ofthe 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)ofthe Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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 definedfibybMGL c 111 , S 150A.
Address of the work: Se 1/Z65rrii/ -" 7
The debris will be transported by: 1(119--Z- �h/31
The debris will be received by: k41/2-Zt i /inn—
Building
i '—
Building permit number:
Name of Permit Applicant gi T�/t
-
Date Signature of Permit Applicant
May 23 16 06:38a p2
HOME IMPRO'EMENI CONTRACT ( ,1
PLEASE READ THIS C
/ Sold.Furnished ane Installed by:
Branch Name:New Englbed Date: /1 S C, CRD At-Home Services,Inc.
&tore The Home Depot At-Home Services
Branch Number 33 90S Boston Tumpika Unit 1,Shrewsbury,MA 01545
Tog Free 377-9113-3766
Federal IDE 75-2698460:ME Lc HC 0241910 Cont LCF 15421
.{y CT I iu O IOC 0565S22;t44 Hi bnpmueme:a Cont-torReg.le 125393
Installation Address: 3 tC1 P,, c is lr ale 6›.1 044
City Stem Zip 6
Pur°fnser(sl' Mork Pim Home Piton: Ceti Them:
[ 1 E [ 1 I [ 1
_A,- • _ G '. [ ] _ ] l [ 1
Home Address:
(If different from Install Address( --_.�_... Cita _--_-- Sum Zip
E-mail Address Eo receive protect cmr•mnnice tion;and!lame Ocwt updates): -
IOONOT wash tcr. m_ keiirg entail:from The Hong Depot
Project Information: [In receive
CCus er"),die - of the property lorded rt the above installation Caere,warns to buy,
arta TED Ar-Homo Sen c Inc. "The Home Depot")og<en to furnish,deliver and arrange for the installation*Installation'I o`
ell materials described on he rc!oav and on the m@raics Spec S heeds),all of which arc inconoratdl tele this Contract by Ors
re thenen,along with any appllcble Stam Supplement and Payment Summary attached hereto and any Change Orders(atllcaiveiv.
'Co tract
lobi oo' Itieducts, SpeeSkregsi e: Project Amount •
LO I s ❑Statin_ IJ Windows ❑ set tion 337 b�
2 I Wally
' I)S1 ❑a ;ewers r r1 -- 3. .3 [G�3.5
❑a 1JSidir O w a ❑In inahan
❑c -
C Demo Doors ILL_ _ d
E1100;102 DSidiM wicd,ws ❑lsalsson __ _— '7
5 )(Clow OEM-6 Mors❑ i
•
craTif g USlifirm Itibobris inralaiin5 �(y
L.Goorst Covers Egtotry Dors El
Minimum La%Depc4dCmnaet Amor dMrgrW earnbonMmb mmrrt
Maim Purchaser may ort deposit mertthanonedhirddtleCnnhmtAmoun Total Contract Amount $ � rV 25'j
Customer agate'Rat, immediately upon completion of the work for each Product,Customer will execute a Completion CO-ANZIO
(one acoca Product as dcCned by an in ividtml Spec Short)end pay any Whom due. As applicable.each Customer under:his
( otner agrees to he Jointly and severally chbgamd and liable hereunder.
The Horne Depot n, r es the tight to issue a Change Order or terminate this Conrad or any Intlindual Products)included herein,at
its discretion,if The Home Depot or ds authorized service provider determines that it cannot perform its elongations due to a structural
prablcei with the Lome,environmental hazards sr ch as amid.asbestos or lead a • concerns.pricing en-ors or became
work required to complete[belch was eta inclrided!n the CoContract_
in.other safety e ncer n
Payment Summary: lite Payment Summers s 136lJ' nemded a; nail of this Contract, se:s forth she total
Contract amount ar payments required for deposits and Anal palmers m Product(aa appbcile;.
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time von sign. Do nor sign a Completion Certificate(note:
there is rare Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete.
In The event or termination of this Contract Customer agrees to pay The Home Depot the costs of materials,labor.expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth In ibis Aon etnuv or allowed under applicable Ins. THE HOME DEPOT MAY WITHHOLD A MOL NTS
OWED TO THE HOVE DEPOT FROM THE DEPOSIT RATME\T OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPO P'S OTHER REMEDIES FOR RECOVERY OF SACH AMOUNTS.
Acceptance and Authorization; Cc g understands LINO his Agreement is the en lin:agomEco bettitiot f 1-et
HI me.Dom:with retail mite Products and Instal atb ..s and si des all pun discussions and aay.Fncds..aa
h
:oral or o Mien,relatingd Prod .b :id Install tior.Th Agreement(-an b igred amended P by totting signed
'yC d Thd D.le-C ,mi I {ges ant agrees that �ylo has reed.iadcs ad opts the
'nm received and has rec ,eJ p of pis Ogr :man 1 ariiv
Ac •.taihn- Subn c. _ C
Inter,Signature Joie tae
alm .It s Signature Oa-c
J: Telephone No.
Customers Signature _-_- time --
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS cm:MI mon
AGREEMENT\V1THOLT 1'E\ALT'OR OBLIGATION 0
BY DELIVERING WRITTEN NOTICE TO THE . I / �� Z�
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS G /C�/
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO ESE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
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p 9 Office of Consumer Affairs and Business Regulation
rat' i0 Park_PinTa e Suite 5170
Roston,Massachusetts 02116
Home Improvement"Contractor Registration
R>Fgiaitpton: 125893
Type Supplemeni Card
Expiration: Br32016
THD AT HOME SERVICES, INC.
RICHARD TROIA
2690 CUMBERLAND PARKWAY SUITE 360
AT1A NTA, GA30_3:;9
- Update l,ddrosi and return eard.Matt Mason ror chant_
sots .; anti of Vt Address r:Renewal ..matey-eat `_' tan. a:v
- OTc:ct Cunsutu r affiirs o Rastness?4gulatioa License or rodis'tra6Un valid for indtvidul ust only
-tie u bd c she tapir-flaw dart. If found retard to:
.hCifECdPP.OYc£R.r-sVT CONTRACTORRWine o`Cancvmar ArTirs and R
Bitstnessegulation
:'.gw98trScre i2&"ue3 Typ:: i62eric 4=aa-Suitca3lC
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ACR:e CERTIFICATE OF LIABILITY INSURANCE :-02!1 ,6°
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 INSURERIS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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$).
PRODUCER CONTACT
USA. MRON
TWOMERSAA 1JANC IG ' FAZ
PRONE j pJQNeI:
3 O EIO NRaaC.u.° JAIL Nn_EA1:_
3.9GO LSVPA ROAD.Sly Z$G EMAIL
AD_ANTA GA :G<0 ADDRESS:
__ UISURERISI AFFORDING COVERAGE 1 PAW
ICC4 Z.uomeGGAYi':}i% _ _ INSURER A:61141125131W919ITECAII@MY !r203(17 _
INSURED INSURER 9:Zonal American Insurance Co '16535
THD AT-NOME SERVICES,INC.
DBA THE HOME DEPOT 4-HCHE SERVICES INSURER C:New Hampshire IR Co !73647
2830 CUMBERLAND PARKWAY.SUIT 2311 INSURER D:IRnois National Insurance Company IZ3617
ATLANTA.GA 30335
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATLW3746646-14 REVISION NUMBER:8
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 CONDmON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OP 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.
N15R 'ADDZ'SURR. POLICY EFF POLICY EXP R
LTR TYPE OF INSURANCE paw50.qPOLICY NUFIBER I(AIM'DDHYTY).IMAYDDYYDO I LIMITS
A .. COMMERCIAL GENERAL LIABILITY ' GLDIEBT714416 110311010316 -B3101/71317 !EACH OCCURRENCE IS 9000,000
DAMAGE TO RENTED
F ^ .._ni PP MISES(Ea occurrence) 15 LOAM
:LIMITS OF POLICY XS :
HED EXPIAnv me Persam 3
5:CLUBEO
_-- OF SIR.51M PER CCC PERSONAL&ADV INJURY ''5 9'000.000
. Ov-PE^AT=u _c:.I:T,,Pe( _ e_... • GENERAL AGGREGATE 9.090,000
.:EilF.C,0LrY Jc.d -1- PRODUCTS-COMP/OP AGC S 9.000.000
5
auroMMOBILEtIABILITY BAP 253Ee0113 .03)0112018 03101;2017 COMMIED SINGLE LMIT ,S 1090.000
1E53,ti0Hu1
:( ANY AUTO. I BODILY INJURY(Per pawn) j 5
xxL UL=D 'SELF INSURED AUTO PHY HMG - won:,INJURY(Per acain)-,5
M EC `:L- ._AATOS
AUTO'SNN C I I POPERW DAMAGE I-
UMBRELLA LAB _ OCCUR i-acciEsA5
.I ' EACH OCCURRENCE i5
EXCESS LIA2 CLAIMS-MACE ' •
AGGREGATE
GED RETENTIONS I 115
r WORKERS COMPENSRION !NCB155519215(ADS) '0310112016 090112017 I X RE I 10TH- '
-ANOOMLDYERs w.eNLm Y Y �Wco15519211 A:(,I(Y,Ns'NJ! 1 !09012016 03D1120R 1.W0,000
.PRO OYERSFAPIERt XECUrnr f �) EL EACH ACCIDENT
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DESCRIPTION OPERATIONS �COnilnuEa on Additional pace I EL.DISFARF-POLICY LIMIT 1 S 1'�
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DESCRIPTOR OF OPERATIONS I LOCATORS VEHICLES IACORD 101.Additional Remarks SthedW4 may be attached if mere spate's rtMJR5I
EJIDEi9CE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-NCME SERVICES.RIO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
OBA THE HOME DEPOT AT-HOME SERACES THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi MMMeTIee _Mnnao--s SAM/ca ..-'-
CO 1988-2014 ACORD CORPORATION. All rights reserved.
A CORD 25(2014101) The ACORD name and logo are registered marks of ACORD
The Comrzonweciitlz ofMassecleusefts
^�—/ Depotneat of Inhdust ficci
deats
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Office of inleSugaioae
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Ah-'tae=tIstf._1.nfna ?lease Print Lez-bia-
l Li lr
Name Bvsin�xlOnT. -.oa(�varidu=�): ad!'] ,��Jsvp i };% /1 yiL ..---
Ir e—
ll', n"� ,;---
Address: F-
-"02 0:9411Tsl..` I onui 'ff
Cityi.:zca/[ip_ . - - 1 • r
an'_ faIs1t..:; , ,, , .11 !I1Aa - r
Are you an employer? Check thea r!opriateboe 1—Type of project(remzed): .
1.❑ - a ern,layer with 4. •J I es ageueral contactor anal ert6. ❑New coushmctitm
employees (fuil.nid/orp-°-rt- redhaste bired se sub-contractors
2.n I we a sola uroodetnr or Farmer- listed on the attached sheet 7. ❑Remodeling
ship cad have no employees These sob-contractors have S. 0 Demolltion
wod4Ma for met-.any capacity. employees ped have-workers' 9 ❑B� ad �
[io"'arks-en' comp.vsrn ca comp.Maumee,
nquired.1 5. ❑ We 2=e a corporation ad._its I0.0 Mectrial repairs urzddidens
3.❑ I am ahomeownar dots all work ofcer have ezecoisedtheir Il.❑Plumbing repairs oraddidons
myself. i r n waders' come. right of exempdoupes MGL I2.❑ ofraPas
=S=ane req±e&]1 G.152,§1(4),endure have no
,..,r yp
emdmyees.No step-Byre' 13_LM Other Ic-%
comp.Swaim required.]
1pry_epec=thar ettec 3 beret moseelso L9 arc thescvGon bdcw shoninathdr micas'®opuaaimnnofa'iotonoadeo.
1 lionu.o*m zs who setrmi[bus"affidavit inticuio;ive an dote=-ob war::mitten him outside=talc=mut mbmdt anent acadVRmdieatingsaeh
`eonirctenate check irishecmuse attached=addidomt shttshove:me thcnwso etc sob mtaetors=debt whnhcrornattete enti5es hers
cmplaycs.If tau sae-con.zrsa bore cmp!oycce,they r,yr pmvidc tltc'n wericm'comp.palter ovmht
Lon eh employer ilia ityrnatdoig workers'cornpmzsallwt insi1rancejar my employees_ Below it the porky acad./oh site •�
iin:onnL^ari /J
». trwmce Cam➢ N 't I. I" L 0 _
Camay 1 amp: .�1.'(J.ter 7/5.'l y:J i!✓ �iUS -
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Policy g orSelf-is.Liu.': (A yv w J O b :f �%2!:� BxpimtoaDate: 3 ! 1 /i .7
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Job Site Address: '9L 6 'I itJ t`� City/5'mmiZip: .a e/i�I !eil I E/ PP'
Attach 2 copy ci the workers' compensation policy declaration page(showing the policy number and expire:In date).
Failure es senutG coverage as respired under Set 25A of MGT,c.152 can load to the imposition of orimioal penalties of a
me up to$1,500/70 md/or one-year mmprisoffieat,aswell as civilpenalties in the feta of a STOP WORKORDM mad afore
of up to 5250.00 a an What the violator. Be advised That a copy Of LYS statement may hefornazded to the Office of
Mvesdgadons of the DIB.2mr1,.r t 'I a coverage verification_
do Irerehy rnit ;ctb,
jldEr tat•t Oyes of '!!at 2•e freforneconprovided above is Ince and eorrect
-17- 16
Simatie- d �/ :we
///( U� Date:
Phone et S-7,0 '- v G 7 /ice
-,-
.—.._____.—.—
Official ase only. Do not Atte he this area,to be completed by city or!own official.
City or Town: ?e_"air/Licease
Issuing Authority(circle one)_
?.Board Of;Beath J.Balla-kg Department 3.City/own Clerk 4.Llectriczl Inspector S.Plumbing Inspector
S.Other ]
Contact Persons Phone m: