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164 MARLBOROUGH RD - BUILDING INSPECTION (2) 'rhe Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, T°edition OF SALEM I RevisedJutroury \� F13 Permit Application To Construct, Repair, Renovate Or Demolish a 1. 1onX `O One-or Two-Family Dwelling This Section For Official Use Only Building Permit Numb Date Applied: ­77�!�—dl o Signature: •�7 17i�/�/ Butdio ommissioned Inspector of Buildings Date 'T SECTION I:SITE INFORMATION 1.1 Prro/ppart/y Address: ! f 1,2 Assessors Map& Parcel Numbers I.]a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required provided Required Provided Required Provided 1.6 Water Supply:(M.G.I,c.40.§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if es❑ - Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 caner'of Record• ��. Nd rk �� ley rr,l�,fo Gt 2d. Name(Print) 5 Addrcslr Service: g Signature - Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.ClNumber of Units_ Other ❑ Specify: Brief Description of Proposed Work': F o W SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S S7 Ot3 I. Building Permit Fee:S , Indicate how fee is determined: 2. Electrical S ❑Standard Cityrrown Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (BVAC) S List: 5. Mechanical (Fire S Su ression Total All Fees: S Check No. Check Amount: Cash Amount: 6.Total Project Cost: S /�-Y 66 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 �L/icensed Construction Supervisor(CSL) (�h19 ��7 /✓ ^ (,- l.icenm Number Fxpiration Date N y f l S l Older tr n J�t M List CSL rype(see below)/ r PC Description Address llnreslricteJ a to 33,000 Cu.Ft. Restricted '2 Famil Dwelling Si �7 M Maso Only & rc RC Residential Roolin Coverin relephone WS Residential Window and Siding SF Residential Solid Fuel Burninx Appliance Installation D I Residential Demolition 5.2 Registered HomeI ImP vement ContraSfpor(HIC) /Ud `�S ? &eee-,L - - JfP 'Drt t11L / +�?n �� �r rGCn L� IiIC Comp an Name or HIC Registrant .one Registration Number ZIA Address $?Js Expirfition Date Signuture Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.¢ 2SC(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 of the building permit. Signed Affidavit Attached? Yes ..........d]--' No........... O SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT er_ ®��lti q ¢—�. as Owner of the subject property hereby authorize to Uc's Jf-,"e- 4Vr.O teel`t to act on my behalf,in all matters relative to work authorized by this building permit application. -.9ilmature or Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION /43 eJ 'e !&^e- i Qr ,as Owner or Authorized Agent hereby declare that the statem nts andinformation on the foregoing applica ion are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Autho tiEd Agerli Date (Signed under the pains and penalties of 'u NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will doJ have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and I I0.115, respectively. 2 When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of healing system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" t, INST E0. ES SPECIALI yk; a" fs tyl"`i¢: NUMBE7 "h1• CUSTOMER,,.•Y� £a a � .�.. . r` Y� , 'tF, tc YS r, :;'.:�x ���0 2.5%� ;: ,. .,:: n .r_l r s-e .. :<, � �:: ✓"D��a'_'h t�>; c; m '� l STORE NO.'j x v STREET DRESS ( :.;., � _ STREET ADDRESS r �. ZIP ST �+�A '' v �- x N DITV .,y:, : ATE ZIP CI STATE, n+__x - tea 57+K y"5 s, �pf TELEPHONE.. is t 1 d f k Y DATE yr,'y�K `(k' LOWES HOMECENTgERS INC SMAHIC NO 149688 + H � I � FEIN v B�CMARGE ; r t c R a �MIN r af+,ts� Ncevm�m,m§ennte:a`9�emeo4 © 1 :� .SJ..' I a #i, nd iP .2rf""antanrf amriif '. Qemoatam6aHBdfm herero£=sha'OKes refgFRdtd fithe '`.Ac#lis£`Conertfi` . ,I;Pfi�,F;EA{T. fANi °§I FIS�I,RAC,F,SWQF.A MGAGE" 1QIiE'"5JCISG } NSTREEr ADDRESS i• '.3 +, s y,{e 1 a� T'r £,"_. ;x x, ` C :,_ � �STATE'ti rr aR�'Y rZIP, . r t,� t:. INSTALL j( +t�i•'Y .si.r t, a,k;;+ 8�j{-s'.:p n,r' Ht'." - x. .rA*r£�1`"e Ysz,H „.dam?, t, q. ..%."z# €a�?� 1. 1 ° • r _44ts�"°.g3 u�y a 14, r',•:E, ,� ,z K a "$� 4 ti, e err ♦ s t t .fV � � ', .s`�' �ga"aas a�`. �a^2+°.�Cr+E¢+`'" `�N'4n k•r w a.3,.1 a; � t .. y p F r -. � `C#y '"e'^ 3'v.isra��31 ,? "3•.gh.�£�'�i �g�. � ,�r., �%£bfx r� 4T,a M y"'rPx#'�``S ^x` +'p'r."FuT' !� r;.., 'st�'�fT�t"�v�,�^t T'rwr�H= .U•"'� 6�.4 Z''s' ^' 4F �x *t"'�k �is ,'�z r:'4�,,`"I.Fi i&;?ii� .wn��h'�,�` ' s +Io�@ ems'?+&w� � 's'iz v° ] t 4' is " 5_ �; L a'. w 4:.." 'aµh y`L`'. >.u�3'•'f�l� �c� 'T«�}L � y, x d Y*,r i,k a ry + z .t ' ,taw ~F a£ _ t a v. a Y � h t •tsx «- , } ,rC.�] « L ' yhir3'Sv3PzC'3Yk .s>e.';•�6w*t'7`i rot. w *! ' CO�fltrdCt TOtal ,"°`>{, .1 "' '+ffiy y = n8"ta` y.e&. �,.�a.�� +-nr ...c r vni t:.§ }. �r,r �",. i..rl'rv. . F "applicable tau includedy '> caa�# � . k Are per required fior this mstallattoAnw?w[ J iYeys [ ] No 8 N'y' "Fy gL ' °r-i m.x f•�6::iYsc st}m.T•'.y«" 't,4.awr`s"C..�, �9 „'p f e .? '2A, ; bTict TO CUST©MER.Federol la w recl6keslowe s to provide you with the pamplet Renovate Right Importantleapf Hazzard kfonnatwn fo Famd n T^. es Chdd Care P!ovrdeS and scflools By signing thlsContract,rGustomer acknowledges having.receFved a copyrof thlzs pamphl®t before work beg ,- infomrmgCustomer oftheipotentiavneir�A fthe lead hazard.exposure from renovatwn activrty,to be performed In Customer s dwelling rend. 'g 'r„ p�� �o' %ER&LIEN and ONE YEAR,WARRANTY( 0�BE SIGNERSY INSTALLER +—t SR, N eb drli tlre'undersigned Instaflethridependent Contractor,having been employed by the.Customer whose.name appearvin:1 i[s Contract Uohereby certify thatlhe workreferred to in ' .ConfracYvnlftiepr has beemdompletedto the.Custome`r ssatit fac6on"In'oonside'rationofthereceiptofonedollarand,,othergpod aodwaluable consideratlofi andao.ihe`e>dent permittedby . +>'Maw hereb' vrarve and relingtiish all liens and aIt nghts`antl aims of liepp which 14he cl junderslgned novi have or may hereafter have for Tabor or m2tenal furnish eil`tl The undersigned;certify. " .thffi all e work performed and matenals furnished.fi any,:by any other party or parties upon the order of.the undersigned has been flu lly paid for Putlher I the undersigned'agree to cause . " ,. e=pr'Wfrefease der rnY mechanics lien,which may tie filed agamstthe premises referred tom this Contract by an y subcontractor latidrer mechanic:orrmateriWsuppkei clalmingIheiight to t "A �'glto fisuch`ta Tien thmugh,Work-related to this:Contract 1Ffurtner agree to'hold harmless and mdemndy the Customer,whose name appears in this,Contract and/or, we s iromTand`aggain all ti + _ om aril expenses ansing firm or by reason of such lien qr the release'dr drscharge ofsuch liens Y'y r „ 'I `'?f' ' �*(,f„ " ks�'t�, p `"� .t a°'P W, �.., N7he undersigned an Independent Confrdctor'and/or supplier for the consWchon and'improvemenp ofreal estate pursuant to,this Contract repre nts that any in enals`fuml'hed on saitl r aka ;protect are`fit and appropnate_fodhe purpose for whichthey were used anCihat any labor performed by ilia uridersigneD and/w Its agents or servants was accomplished m a workmanlike} ,. r5 -rtlariner�p ' ,�i , ?.' , „'a,.: �;"r'S tl .,`'Fer�.ii3iab"u#� .fr",a�' a ,'g'`x; `� +�xn. j . p^a In addition tit any warrerenhes specified elsewhere or provided by law theunderslgned for$5 00 and other valuable consideration the receipt and sufficiency of which Is hereby ; acknowledged wananis'thaf all workfumis,eci uncle[Its ctintract shall be,free from defects either ni m9tenal or workmanship and strati be suited m all.respects both for the purposes for T` wnlchr A was specified and for.all other uses for which R Is intended to be used or far whicf'd may be represented m writing by ihe�undersigned to be suited lyk ", 'm+�Vkaf DIY' K ., _" l awry defects immaterial ocworkmanship shall be discovered In the work Tvmished ormatenal used:dunng the course of the work orwifhm one yeah from the date of the cer6ficabon of e, f.`,t^ -;completron or rf such defects are latent withinza reasonable time after which said latent Defects are.discovered the undersigned shall;forthwlth replace or correc�such defective work or r;� ;l „, material hee,from all expense to Lore's m a-manner satisfactory to the'Customer If the undersigned shall fail to replace or cortect any defective or or materials;after reasonable nonce,t ,� t Lowe smay,afits option cause such defective work or matenals to be replaced or corrected and all costs and expenses mcuned m connection therewith'shall be Home by the undersignetl.f` K. r.t,.r E i s ♦ rl t '1"Yh'( 6 bey}.`+/ V 5 •:Rh s Wr � r�i � } Fya^f. ,a^.r".} M. ��g£�+e �� y'f�. R /Lx J�f t�•r;�< .ray'£,4;•e' �'��a.+e _-,�q�' .#2 #� w�;. Instal en z`pr�a. ,. 4x ti� .t.. f'yR '....-rs'�'zk'" s a ', Prmt amen:�. -Sk,-',�''fity '# ' n.� v...,_e',.,r to „i ',A•';' s q•,.pf*°'{ ' - ----------w GATE LOWES HOME CEMERS,INC SMA HIC NO 1486e8T wL ' "-' wy �� � � _ � �` - FEIN M-0748358 >. ^�. cnSH . B NK LLC ` "Efaif,�"T `+�rtrws�'nu�rrrfui" 'd�� , ,`�'Q �aom�ncumv�lru�aean�ag,"a ;antbaan rt+�,e cn �6r, - +y� x 6 F`�riDTagpr �y �YamES.e�deRy@' d'llS�mf�"`h6`[dtb stlglr �'�' „� . Es ,AN fiD{icitt4lMG_�6Es'�E6o sNYtMSif " INS,AL ONSTREE-ADDRESSr x 4s f ,� .AY n y& f �' , °'§"pg8,,��,. 5 Tzi'„�."✓.. 6 �( f t a3.+./.r(J -] r Y� s i P fi t'P e'p £tiySTATE r'01t at „�, ZIP 'd�' ^"'{ ft'M C.i ti, fY1 +. F a • xe a j+ y�.d*.A* dz i f '.ii - �j W e-tS� �' f 'i tt:: £?.f+ 3 0z •i,%.RII�,myp f�. \ ` ' d'k, n p J S 'k 'f�i•i Y P" R'£. k F,9s _ L 4'�'O!` Y L.] ! 0 Y i'"\{WrA �y t r^r3a7 qY ��w` w<r d .Kk t't2 Y3*: 'n++a-L fst"" *4WV,,, :- tn^ .`*Tx*vf'„Y,f ~E •�� a + M1a+.t Mp p 4 4 m tif "k s'rQ n e4 C'F nrcr +. 4 �..k a P x ,r •wFa y,r ct,,s. v"' : sd°9. -ewk 7`� - t K �`• .+t•d r a a °r err '� {vrffix{ wA#"t` l� ,oc. '4 W� I xr� '�d�e Contract Total -d.y. Are perrnrts required1gr this rnstallatton� t 1. Yes''[ ] No 'aPPlrcabletax tY ' uef 'Ih c.'1+ « -�fswd. �.::&' ✓`s9� :C-; ' z a a.ari4°FCCf41 r A NOTICE TAr CUSTOMERS Federal law regwres Lowe s toyrroyrde yoa.with the pamplet Renovate Right•Important Lead Hazard Informal fob aF m ly 14'drn nrmgdCu&Providers and Schools �y srgnrng this Contract Customer acknowledges having recerved,a copy of thrs pamphlet_before woAr,begarr! *4'i^formm9 Customer ofthe potenUat risk of the lead hazardexposure from renovation achy ity to be pertormed m Customer s dwelling unit .,a 4Y. tom, + ..s..M sTa#:s y.Re 9es;.;r v-+ w':-.,s n .t:d a..e !.M1 •t M t }�. # z>-, t. 'f ..A. y�YVA11iER OPrL1ENrand ONE YEAR WARRgNTY(t0 BE SIGNED<dY:iNSTALL`ER `�' • +'� x,`#f §+*nr I c I the undersigned InstIlePflndependenE Cohtractor hawrg been empioyed by,the Customerwrlosa name appears,in-this Contract'do hereby ceAl -` t t�he•ivork.' +3 `*t � Coniradryvi7f be.or has been completed to the`Customer s sahshad(on.In'conslderabon of,ihe receipt of one dollar and other good slid valuable consideration' ^�" + �--- �' (referred to m this` law f here woovaive.afid`teleiqulsh,all hens a ali n tits and,dalms of hensCvihlch I;the undersigned,now'have onmay hereafter fiave for labor or matenal fu and to therextent pertnmed by,,;�-, thatall the wodc;pe`rfortned and-materials famish If an ,b a other party or parties upon the order of the undersigned has been Hilly paid forFuNier I t f Y .Y:any mimed-,f the'undersigned certdy ttieprompt 111,s bl4anjr'th`edhanic s lien which maybe filed against the premises referied;to m this Contfzct by any seboontractor;iaborer me 4 to-ftle such a.herehrough work related tothisContrad I further agree to hotdhartnle"ss and�inderilnifythe Gustomei whose name '` - the undersigned agree to causer•:{ 4 l '<5 costs�"a'rid ezp"crises ansm from or b reason of such lien ot,the release or discharge of such hens:`" chamcpi matenal suppler claiming the right to appears m this Contract and/or Lowas tram and against all a= &r °,g;.The undersigned an inoependent Coritia'ctoi and/or supplier for the,cons(rticbon and improvement of real estate purseanL`to pro fed are fit and�appropnato for the purpose for whch the were used and tnatany IaboT performed by as'ie, neil�and/or'ns a � p + manner ? vP", q.t , ;a y, ptrac�represents That any materials furnished on said�-' e a»'�`t* # - as';� r, ,qy dBfl adara, � S+ _ gents or servantswas accomphened in a workmanlike '„ x In addrition to an warranties y �f~,pitaTa+�^ -f w 'd f'`s h.Ar k c >,••.K f v t e d e va sn Y m :specified a aie[.Z re ar provided b law thevedersigned fot'$5 W and omer val�uab a mn`sidembon the ce t rid$ en whist ackn�owletlgetl`wamants thatall ivodc furnished urMer its confraar shallFbe free,from defects eifhey in rKatenaf-or wodcmanshlp and sfiall be suited m al[res acts botli.I •�`+- "d whic It was specfied and foralfpther uses focitihich d Is intended,to bee used`orfor whlch.d may be represented mvfrlti b the ndersi e�to' � �� y ge . f ° , .f>:, P for the puryoses.for t & .�jdfjany>iefects'in mate of ar vvorkmanship shall be discovered in the work furnished or matenal used'au—d the course.of the workFor',}vithm one a s�ujted � + mate 'hanpw .m It'de ate latent with n a.2$sonable'Ume after which Bald latent defeLls are dI`scoyered .undeisgnedshall±foAhwlth, 'r g p -.,� E. 3 y%r from the date of the certificetion of yr ,',!' , maten It iree"hom aY4'expense fo`-�Lowe s m,a;ma,gaahsfactury to thejCustomer if the urieersignedxshallfadt4 replace or corned ail' `' replace,OP mMect suchbefective woik'.or s+x , Lowe s ay at pgon apu�se E uch defective work or.matedals to be replaced or cem'did andall cost's sand ` _«1 ay .,. ,� y defiedwe wgrk,gmatenals after rea�soliab�le notice hS ,. >n, « $ S1g and dell r `,t is z h f (CJ�' ',tint- ,g,'s ' 'T day of f l y�r ,,d gn on there tli shall be bortie bythe undersigned ` ' r !�wc ✓ � '�]t��nA'rdt' �. , .i Instals r�,, ...• ,,' "I ''tks .nEbs �e`. vf hr `E'-✓s �b." fl' °✓k p�F`'°4Y wfif '�'� r'� �ti.4� a it �*t n r ,+[s9: tt1�S""• � f t,�}` 4 T3�,1#t "{}�`�"f' 'L^F x V r ter '� r'W at+"- wrn� -, � .,} x 'l"°s.•�.T„'2 •+ i. .- 4t'.� g FF y, fS. � ear' r��4 Z 's '.^T. � � -._.. - , :. ..trh `�:Y+„r �faw3�° "R€•'" x'ti-- A.,wd. r .:.w., : ... . _ .".y .x .�y�% � +� � ,�e4.c p'� �r.£�-y `•y�5� " s,:€.t�,� ,� +�''�.`, K 3�`'1'�r .�'��q i '^tf` �td"�fa r',Y��t'�°`,'` s�'+s.,yx+f T u`C p 9,y t�s��'�l,i.y•`.,,-?t++�A' -n'f° Cs6�.;n,�xt.0'�"�e'�li'..a. acY r+'��r+yti�t1 4.z��'tts�'��•ak5m.�',a'a.'o.s`,�.�TdC$"A��r,"63���'tY4 x.,'r�`r.;.gr¢'a4n3�s`f�.r se"'v�rF�t s7t"s'x.'_",f,.�t�v§3 b�a�*".ms.,1W+�}y'y-+yf,-f+"iL`r�al-��a..ts'sesAa/Yf�t'k`'�i+�,,i�^�'t+h sn''$f:F��.:xs,e.,,�s`�t• �w Yklws , � �Xzla� .* a ,i l �, J,* 0, A u- fi +ri. �. t" 'r• a.•{`+1a x g ,'tV rt r+1w ?-.4 si x t TF a • iA^k� rd4 ,e���,�c Mi A .f" i"c'> q- „''l �'t-a .. .............3. .. . av,'c. .. .a�.wa•aai..a..ra+i .v . ....�._ " _..>a,C.t,t$�.t".t'a`+.3k..Y....�sm,�w:::$,,,..eTie�.�ae„t4...w,rE.a..dm..a..-a.,.c.� ..._ _....,'r . �..«>t <. r.. 06/22/2010 14:02 FAX 8173891269 Gl(f! Vl 1Na'lALLAllUlV w - wnno . . -- I t r, n"lunnachuvettr- Department of Public Safet. Board of Buil i �r v d n� R� rulationv • �,. . and . tand,u d. .. Construction Supervisor License License ..CS 61719 Restricted to: 1 G RONALD A GREENE - 10 RITA DRIVE MEDFORD, MA 02155 Expiration: 101Z712011 1 06/22/2010 14:02 FAX 6173891269 Gt{)YNB 1NJTALLAl1VN �u - wn�q , __ - i r .- Otft!Cr asumgr mrairms461PW egP s on VHOME iMPROVEMENTCONTRACTOR Repbatlon:,.�,102957 Type; Expiration; ,�5( 2 Private Corporatiod - -. GJE NSTAl1SP } kfINC. � - Ronald Greene _ 155 Bow Street i k. a Everett.MA 02149 �,. Vadersecremry i i S t t t 06/22/2010 14:01 FAX 6173891269 GREENE INS1'ALLAIUN GU - . LUrr,0 u Inaa Io The CommOnivealtlr ofMacs4chusetts Department of bidustrittl A.Ccldents Office of Jnvestigatians 600 Washington,Street Briton,MA 02111 www.mass.gov/din Workers, Compensation Insurance Affidavit: Builders)COMMCtOYSIElectricians/Plambers n li ant lnf it ation Please Print Legibly oLL� {dN ' iJttlxlC([3usinevslUrgUnixationhndividunl): ;_ �,C/�� S Address:- LLP b'.Q,1ri).��!t✓�— .— .__ . _ — — �:ilylStatelLip._ MtMSrIY �7 Or71'f9 Phoue#: !y/ 9�7- 9,7l-3 — .Are you an employer?Check the appropriate box: Type of project(required): I. i nm'a employer with`16 4. L] 1 ant a genc*al cantractor and 1 6 -n New construction - employees(full antllot•Oart-tune),"' have hired the sub contractors 7. [r t'i;ruodeling ligtcd on the attached sheet. I am a sule.proprietor or partner- se The sub-contractors have ship and have no einployees S. 0 Demolition and have workers' 9 , Building addition working fur me in arty capacity. 00mp.insurance,t iNownrkers'tornp. insuraztee 5 10.r3 F.laearical repairs or additions required.) 5. [-1 We are it u)rporttion and its 3. 1 ens a hnmeovvnx doing;all work offie"have c:cercisrd their 11.[, plumbing repairs or additions FJ I am .nnn workers' comp. right of eatcr aption per MGL 12.❑ Root?rcpa;ts C. 152,$1(4),and we have no insuramc required.)t unployLes.[No workers' 13-© 08icr__ _ camp, itmirance required. — -- — — a.tiny noplignm thin chock,bux Ni mach also fill not rke uaeuon hslew ehowiug their workers'ectnpensation pulicy Infarrnatton,_ T Hnm+owners who submit rhiy ktlidaVil indicahng tltoy are doing tdl work end that hies earaido contm-turo)oust xubmtt a new atflduvii indtealiog such. tl:aalia�r^^Thai chu:k N45 hnK must atradred an wldiPipnal shoot showing,the nnnlo ut Lhc Sub-fAna'aemTe and plats WhGlhar"net those alltirie5 hpvr. cngrlpyca. Irthe suh-cuniraetnm Itavo ampluypear they must provide rhea w rkue'anmp.pOtkY numbut j am an employer that is providing workers'compensation lnsarance fur my employees. Below is the pofrcy and joh.site informattom. �,( / Insurance Company Natne!—,.C7�F}Ll+, C�_ q -- - _ Expiration Date; — Jo6 Rlte Address v`1� �t••t Lf $i'met'� �,�city'I:icate/`/sp:��'r7B���'7yY ptlaeh a mpy of the workers'compensation policy declaration page(showing the policy number and expiration date). haihue to secure coverage as rego1red under-suctio 25A or MOL c. 152 can lead to the imposition Uf criminal penalties or a tint:up to S1,500.00 andlor one,yearimprisoument,as well as civil penalties in the form of a ST()p WORK ORDER and a fine oft u>�250.00 a day against the violator. Be tldviscd that a copy orthis statemenc may be forwarded to the Office of Invesri aAans of the DIA for insurance co ern c verification. 1 do hereby certify under the pains and penaltles of perjury that the In on pruvided shops lr erne and correct. Phnnell; �. of lclal nee un y. 1M not wait in that aria,to becolnp7by crty or town official L or-Town: permlt/LiecustsM hority(circle one):Health Z: Hutkllnl peparlMcnt 3.CityfCown Clet), 4.Electrical inspetor S. Plumbing inspectorrson:_ Phanc#: t ZJZ d 'MO L11148U1 200 099 8L6 9Z: LL ZZ-90.OLOZ 05/24/2010 12:26 FAX 6173891269 GREENE INSTALLATION CO - Y LOWES D INST [A 001 05/04/2010 15:32 #131 P.001/001 IS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT$UPON THE ET7TIF(CA7E HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTENT OR ALTER THE COVERAGE AFFORDED Y THE POLICIES BELOW,THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A COVERAGE E ISSUING INSi1RER AUTHORIXED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER, 8 WWAJJ NT: If the Certifieste holder is an AOTITIONAL INSURED, the LDER, S WAIVED, aut>jact to the twrma and conditions of the Parcyob )must ba andoreed ItSUBROGq pON Nis caAificsta does not confer to!a the policy, cwrtain Pottciee may require and andOMSMlent. A atatemeM PRODUCER certificate holder in lieu Of such andorsemanC Now Eng tend Haftge Ins Agency Stonaherm mA2180 COMPANY A COMPANIES AFFOROIIIIO INSURANCE INSURED GRANITE STATE INSURANCE COMPANY Gnane 6etettatton Co Ina lag nowstmet Evama, MA02140-COM rws t5 ro t�RTIPY rtwr rr�POLIgES'�INBUNAHCE USl'Fb BELOW"AVE TF6 PbUCY PER(OO INdICATEO.NOT WRH$TwNbit AIW REO BEEN Wet ED TO TFa:INBUWX NAMED ABOVE FOR OOCt1MEMr WITH RESPECT TO t18REAAEIVr,TERM OR CONDITION OF'AIW CONTRACT OR OTHER WHICH TrrT C'="CATE MAY BE"Lqf OR MAY PERTAIN,THE MLOIANCE APPO�gp THE POIJCIEB Deffm8E0 FlH IN{g BUaJEC1'TO ALL THE TERMS, MAY HAVE MEEK RB E7fCLU8iONa ANP Cbf�TT'IONS OF SUCH POLIGEg.UMTre SHOWN tAJCEf]BY PAID ClIU1d8. Po Trr A P el MeglAMgE PCLFWIIUNEM rmuwtgtTQnYa PAR A DEMp4OreRa'LWRITY OftcjwPRMNA7Me1 PAR "OPHEiraw TMERP,EAEwrtie 41NpTs FICERp ARE aaoEa o 4613213 3/04/2010 I AntaRr�s,ae KMdmMA 3ro'0/2017 W+�vm.vq AetweNr a ODD.00 wPTwN oP dt>EtuTlo Pa er`wIr s Na/VE�111CLRataPk7CIAL TTReM eeworpe 88 ao CERTIFICATE HOLDER ANCELLATION LOW3S COMPANIES ATIN:ISINSuRANCE sMaud,wvCFTHE+aays025CRUDPlXc""ECANCEU&DWweruE PO Box 1111 9WRATION DATE THEREOF.NOY'U Wy.M MrWE 1Ed a ACCOPOANCE NORTH WILKESBORO.NC 28888 WNTE THE"My PROyaoNC AVTHORILED REPRESENTATIVE