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005C DEWEY DRIVE - BPA 14-1902 DECKING JACKET . _ paM- Tom - 1 �l - lQ© 2 c� IcoBl qq The Commonwealth of Massachusetts RECEIVED Board of Building Regulations andStanda�PECTIONAL SE VICf87YOF N u Massachusetts State Building Code, 780 CMR SALEM $evfv Mar2011 Building Permit Application To Construct, Repair,Renovaii l�t(04A a 1f 11 ,ram`40 One-or Two-Family Dwelling 1 ` _ Th:e Seetmn For 0"1"..v5c'illy �.1 Building Perm it Number: Date plied: Bmlding Official(Print Name) Signature Date SECTION 1:SITE INFORMATION v 1.1 Prope Addr ss: 1.2 Assessors Map&Parcel Numbers G [ twi w,_�op-__ 1.1 a is this an accepted street?yes_ no_-_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner'of Record:'/ may/ Name(Print) City,State,Zip �c �twc✓ mod- 47l 3/7- 7791. No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairsil Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Wall /IfJ T SECTION 4:ESTIMATED CONSTRUCTION COSTS Item M Official Use Only I.Building 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing 2. Other Fees: $4.Mechanical (HVAC) List: 5.Mechanical (Fire Su ression Total All Fees:6.Total Project Cost: Check No. Check Amount: Cash Amount: ❑Paid in Full ❑Outstanding Balance Due: sill Ir 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) - D S�fILJ �iQt*�JG�ii J/ icevise Number E irat on ate Name of CSL Holder List CSL Type(see below) No.and Street Type. Description JF-P O/FYI)A:)STe Ar- YI?►7 U Unrestricted(Buildin s up to 35,000 cu.ft. R Restricted M2 Family Dwellin C tylfo - Sate,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 03 HI Registration Number pira ton Date HIC Compan+Nam R gistrarame No.and Street ��A�7 Email address City/Town,State,ZIP -Telephone SECTION 6: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 of the building permit. Signed Affidavit Attached? Yes .......... Q1J No........... SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize S ypuj d tnJy �d� IJr I/i6ht)LY �� to act on my behalf,in all matters relative to work authorized by this building permit appli tion. Print Owner's Name(6leskeiae Sign re) --� • Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurateW the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name ectronic Signature) Date NOTES: 1. 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www,mass.gov//dos 2. When substantial work is planned,provide the information below: Total floor 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 heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" -' CITY OF &VLENl. NWSACHUSETI'S BUILDING DEPART\lENT A�Vo 120 WA.SHNGTON STREET, 3-FLOOR Look (978) 745-9595 KIMBERLEY DRTSCOLL F.Ax(978) 740-9846 MAYOR T HOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BCILDL\G CONMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in 11W (name of aciy) -- (address of f•cility) - i signature of permit applicant dace MOYNIHAN-NORTH READING LUMBER, INC. "QUALITY BACKED BYA DESIRE TO PLEASE" �" 164 Chestnut Street FEIN 04-2261995 North Reading MA 01861 s�sss Contractor Reg No x 978-864t3310/;781 944-8500 , 4 ', 9H: :_g6 Exp Date:_/n"/ "+ a " ';• 3 N 'Salespers6nt(s). HOMEOWNER INFORMATION Name ryr Daytime Phone Stree Address(Not P.O.Box) Evening Phone ���/P�y, Cityrrown State ; Zip pode Mailing Address(if different from Street Address) WORK`TO BE PERFORMED AND. MATERIALS TO BE USED Moynihan-North Reading Lumber, Inc. agrees to perform the work set forth in Exhibit A for Homeowner and to use such materials in connection therewith as set forth also in Exhibit A, attached hereto and made a part hereof. The following schedule shall be adhered to unless circumstances arise beyond Moynihan-North Reading Lumber, Inc.'s control:Work scheduled to begin: _/ /_ Expected date of completion: —/ May be based upon arrival of special order material TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Moynihan-.North Reading Lumber, Inc. agrees to perform the work, and furnish the material and labor set forth in Exhibit A for the Total Contract Price of: $1 /n ILL =�l (which amount includes all finance charges). Payments shall be made by Homeowner according to the following payment schedule: �+ $ X/112 .t 9 Initial deposit upon signing this Contract (the initial deposit shall not exceed the greater of one-third (1/3)of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom Orders as set forth below). $ ?,f 72 by—/ /_or upon completion of delivery of materials $ by—/ / or upon completion of install $ upon completion of the Contract In order to meet the completion schedule set forth above, the following materials/equipment must be special ordered before the Contract work begins, for a Total Cost of Special/Custom Orders of$ $ to be paid for building permit $—6!2 t`� to be paid for'4yNin.w �� r_ Peler ?F"�S' i• Qyb/ c� w $ to be paid for w F - - •"!�"` O NOT SIGN THIS CONTRACT IF THERElARE'D ANY BLANK SPACES f•; • a `(Moynihan-North Reading Lumber,Inc. Homeowner's Signature ' Date Contractor Date J� A 42 By: Dale Fuller Homeowner's Name(Printed) I Installed,Sales Coordinator .You may cancel this Contract if it has been signed by a party thereto at a place other than an address of Contractor,which may be its main office or branch thereof, provided you notify Contractor in writing at its main office or branch by ordinary mail posted,liy telegram sent or by delivery, no later than midnight +!: of the third business day following the signing of this Contract. See attached notice of cancellation.for an explanation of this right. t See reverse side for additional Homeowner Terms and Conditions , 1057-NR 1/11, White-Office Yellow-Sales/Service Pink-Customer , '_Page 1 of 5 HOMEOWNER TERMS AND CONDITIONS The following terms and conditions are an integral part of this Contract between Moynihan-North Reading Lumber,Inc.("Contractor")and Homeowner. 1. All payments are due upon presentation of billing,and a late charge of one and one-half percent(1%%)per month will be applied to past due charges. Homeowner shall pay Contractor court costs,attorneys'and paralegals'fees,and any other expenses incurred in the collection of past due accounts. _ 2. If Homeowner is borrowing money from a construction lender to perform the work,Homeowner represents that the construction loan fund is sufficient to pay Contractor and any other contractors performing work on Homeowner's property. Homeowner irrevocably authorizes Contractor to communicate directly with the construction lender regarding payments and loan balances,and authorizes the construction lender to make payments directly to Contractor. 3. Homeowner shall be in default if it breaches any provision of this Contract;if any warranty or statement to Contractor in connection with this Contract or Contractor's extension of credit to Homeowner is false or misleading when made;if any statement to a lending institution in connection with financing for this Contract is false or misleading when made;or if Homeowner becomes insolvent,makes and assignment for the benefit of its creditors,or files or has filed a petition for bankruptcy. 4. If the Total Contract Price includes allowances,and the cost of performing the work covered by an allowance is either greater or less than the allowance,than the Total Contract Price shall be increased or decreased accordingly without the need for a signed Change Order. Unless otherwise requested by Homeowner,Contractor shall use its judgment in accomplishing work covered by an allowance. 5. If Contractor agrees to do any installation work,Homeowner will procure at its expense and before the commencement of work hereunder"all risk"insurance with construction,theft,vandalism,and mischief endorsements attached,the insurance to be in a sum at least equal to the Total Contract Price. The insurance wi!I name Contractor and any subcontracturs as additional insured. if the project is destroyed or damaged by accident,disaster or calamity such as fire,flood or sto,ms,Homeowner shall pay for work done by Contractor in rebuildirg'of - restoring the project as extra work. 6. If Homeowner defaults under any of its obligations under this Contract,Contractor may: a. Stop work until any payments are received or defaults are otherwise cured. b. Terminate work upon seven(7)days written notice and recover as damages,at its option,either the reasonable value of the work performed through termination,or the balance of the Total Contract Price plus any other damages including reasonable attorneys'and paralegals'fees Contractor suffers as a result of the default. 7. Contractor shall be excused for delay in completion of the Contract caused by contingencies out of its control,including acts or delays of Homeowner or other contractors,acts of God,labor trouble,acts of public agencies or inspectors or public utilities,extra work,breaches of this Contract by Homeowner,problems obtaining materials from suppliers,or other contingencies unforeseen by Contractor. Under no circumstances will Contractor be liable for monetary damages caused by delays as set forth above. 8. If Contractor encounters unforeseen conditions that were not reasonably anticipated by Contractor,Contractor shall call the conditions to the attention of Homeowner and the Total Contract Price and schedule will be adjusted by the extra work necessitated thereby. No installation, plumbing,electrical,flooring,decorating or other construction work is to be provided unless specifically set forth herein. In the event Contractor is to perform the installation,it is understood that the price agreed upon herein does not include possible expenses incurred in addressing hidden or unknown contingencies found at the jobsite. In the event such contingencies arse and Contractor is required to furnish labor or materials or otherwise perform work not provided for or contemplated by Contractor,the actual cost of such additional unexpected work plus fifteen percent(15%)thereof will be paid by Homeowner. Contingencies include but are not limited to:inability to reuse existing water,vent and water pipes,air shafts,ducts,grilles,louvers and registers;the relocation of concealed pipes,riser,wiring or conduits,the presence of which cannot be determined until the work has started;or imperfections,rotting or decay in the structure or parts thereof necessitating replacement. 9. Homeowner shall be responsible for the coordination of any work performed by itself or other contractors,and shall be responsible to have the work site ready for contractor to proceed. If installation is involved,with its work through the completion date.Any work performed by Homeowner or other contractors shall not hinder Contractor's schedule. Contractor does not warrant any work performed by Homeowner or other contractors not working for Contractor as its subcontractor. 10. Homeowner understands that some products described in this Contract may be specially designed and custom built,and as such Contractor will take immediate steps upon execution of this Contract to design,order and construct those items as set forth herein. Except as provided on page one of tf:s Contract,,this Contract is not subject to canceiiationby Homeowner. 11. The delivery date,when given,shall be deemed approximate and performance is subject to delays caused by strikes,fires,weather conditions,acts of God or other reasons not under the control of Contractor,as well as the availability of the product at the time of delivery. Once the delivery date is determined,Homeowner agrees to accept delivery of the product(s)within one(1)week. 12. The risk of loss,damage or destruction,shall be upon Homeowner upon the delivery and receipt of the product. If Homeowner is not ready to accept the product,the delivery payment will by made as agreed upon and an extra storage fee of Fifty Dollars($50)per week will be charged. 1 13. Title to the items sold pursuant to this Contract shall not pass to Homeowner until the full price as set forth in this Contract is paid to Contractor. 14. Contractor agrees that it will perform this Contract in conformity with customary industry practices. Homeowner agrees-that.any claim for adjustment shall not be reason or cause for failure to make payment of the purchase price in full. 11 15. This Contract sets forth the entire understanding of the parties. Any and all prior contracts,agreements,warranties or representations made by either party are superseded by this Contract. NOTWITHSTANDING PARAGRAPH 4 NO CHANGES SHALL BE MADE TO THE WORK DESCRIBED OR TO THE CONTRACT PRICE UNLESS AND UNTIL HOMEOWNER AND CONTRACTOR SIGN A WRITTEN CHANGE 1057-NR 1/11 White-Office Yellow-Sales/Service Pink-Customer Page 2 of 5 American Properties Team, Inc. 0,0 � TO: 5C Dewey Drive FROM: Jennifer Pappas, Property Manager RE: Deck Replacement DATE: December 4, 2014 tax****•*****�***•a*xs**r**•�*s�*z**rx*x*x*ass**�**r•***xsx***•*r*tssss* Please be advised that the Board of Trustees for Pickman Park has approved the replacement of your deck at the above referenced unit. This approval is contingent upon it matching the existing deck in size/construction. Composite materials can be used. The Board will not allow any other design alterations. In addition, the deck must be built in accordance with the attached specifications and all drawings that were provided. We also require that permits be pulled in advance (regardless of what your contractor may tell you), and then a copy of the final approved permit once completed must be sent to APT for the unit file as well. You will need to bring a copy of this letter to the Salem Building Department in order to receive your permit. Should you have any questions or require additional information, please feel free to call me directly at(781) 569-2675. cc: Unit File 500 WEST CUMMINGS PARK-SUITE 6050. WOBURN •MA .01801-781-932-9229 •FAX 781-9354289 II �e tporizv........eal!� Z'�/faaeae✓urael I Office of Consumer Affairs&Business Regulation j p� MEIMPROVEMENTCONTRACTOR 4y3 - egistration: 171474 Type: xpiration: .:312112016.,:. I ndividu al SHAWN ARSENAULT - SHAWN ARSENAULT� , - 24 GRAHAM ST - LEOMINSTER,MA 01453 '' Undersecretary - I JIf Paassacr asva _ Ue a.., 'i,e:i W-V Soaca of Building 2 gu Cns i d a:a^.ds ds -- = Construction SuP iJcegs, CSFA 106031 SHAWN ARSENAHLT Io5 HANIILTON STREET Leominster MA O144533 Crmmissicn e! O8l2412016 - � 78 - �i �/ - 1 �1 ARSEN-2 OP ID: NB ,acoRO" CERTIFICATE OF LIABILITY INSURANCE DATE IMMlDD YYYY) �i. 08/01114 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(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(s). rurarr PRODUCER rltOOe: br G-5J4-5'S J3 NApME: Anderson,Bagley&Mayo PHONE F Insurance Agency,Inc. Fax: 978-534-9385 AIC No Ext: FAX N.: 44 Main Street,P.O. Box 360 E-MAIL Leominster,MA 01453 ADDRESS: Richard M.Bagley INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Charter Oak Fire Ins Company 25615 INSURED Shawn Arsenault& INSURER e:Travelers Indemnity of America 25666 Eric Arsenault INSURER C:Travelers Arsenault Brothers Constructio 105 Hamilton St 1st FL INSURER D: Leominster, MA 01453 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE POLICY NUMBER MMIt)OYIYYYV MMIDDYIYYYY LIMITS TR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 B X COMMERCIAL GENERAL LIABILITY 16605563M546ACJ14 08/Ot/14 O8/01/15 PREMISES Ea occurrence E 300,00 CLAIMS-MADE FXI OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY S 1,o00,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 3 2,000,00 POLICY F7 PRO- LOC $ COMBINED SINGLE LIMIT 50D,00 AUTOMOBILE LABILITY Ea accident E A ANY AUTO BA-8672A678-14-SEL 08/26/14 08/26/15 BODILY INJURY(Per person) S ALL OWNED X SCHEDULED BODILY INJURY(Peraccidenl) S AUTOS AUTOS NON-OWNED PROPERTYtDAMAGE E HIRED AUTOS AUTOS Peracaden E UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR Ld CLAIMS-MADE AGGREGATE $ DED RETENTION$ _ S WORKERS COMPENSATION rE.L ORSLMIT ER AND EMPLOYERS'LIABILITY G ANY PROPRIETOR/PARTNER/EXECUTIVEY� IHUB6690675714 04/02114 04102N5 EACH AccIDENr 8 100,00 OFFICER/MEMBER EXC WDED9 NIA (Mantlatory In NH) DI SEASE-EA EMPLOYEES 1oO,O0It yes,descnhe under DI SEASE-POLICY LIMIT S 50D,00 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ABach ACORD 101,Additional Remarks schedule,H more space is required) Fax 978-664-0872 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Moynihan Lumber Co. 164 Chestnut Street North Reading, MA 01864 AUTHORIZED REPRESENTATIVE Richard M.Bagley rights reserved. O 1988.2010 ACORD CORPORATION. All ri 9 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UIV www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciaus/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Shawn Arsenault & Eric Arsenault d/b/a Arsenault Brothers Construction Address: 105 Hamilton Street, 1st Floor City/State/Zip: Leominster, MA 01453 Phone.#: 978-514-4848 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 3 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8, ❑ Demolition workingfor me hr an capacity. employees and have workers' - Y P r5' 9. ❑ Building addition [No workers' comp. insurance - comp. insurance.# required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof 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 anew 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: Travelers Policy#or Self-ins. Lic. #: IHUB6B90875713 Expiration Date: 04/02/15 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 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 in 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 certi under the pains andpenalties of perjury that the information provided above is true and correct. Si nature. Date: OY-.0 Z - Phone k 978-514-4848 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: Phone#: &,&A ff MOYNINAN LUMBER BEVERLY NORTH READING PLAISTOW 82 River Street 764 Chestnut Street 12 Old Road -P.O.Box 509 P.O.Box 128 P.O.Box 1160 Beverly.MA 01915 North Reading,MA 01864-0128 Plaistow,NH 03865 (978)664-3310•(781)944.8500 (603)382-1535 (978) FAX:(9788))92727-8201 FAX:(978)864.0872 FAX:(603)382-1935 Subcontractor Workers' Compensation Waiver I Shawn Arsenault , hereby acknowledge that I, as an independent contractor, have been asked by Moynihan Lumber Company to provide it with a certificate of Worker's Compensation Insurance coverage for myself. Based on the exemption provided by the Worker's Compensation Insurance coverage for myself because I am a sole proprietor without employees. Therefore, 1 hold Moynihan Lumber Company and it's related organizations and the Arcadia Insurance and or Self Insured Lumber Business Association, Inc. totally harmless for any injuries or cost of injuries incurred by myself because I have voluntarily chosen to exclude myself from coverage by engaging the exemption provided under the Worker's Compensation Laws- 1 have taken this option of my own free will. j_-%,� Witness4- ---� Sign Date: y- Z t! — /M "QUALITY BACKED BY A DESIRE TO PLEASE" �/ /VY/ )V' t{�J/ ��'VVV✓' Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02-116- _— Home Improvement Contractor Registration Registration: 136860 - Type: Private Corporation Expiration: 9/6/2016 Tr# 255814 MOYNIHAN NORTH READING LUMBER-J,N I`° ' DALE FULLER PO BOX 128 _ _—y N. READING, MA 01864 .�;$ - ;_� Update Address and return card.Mark reason for change. Address 7 Renewal n Employment 7 Lost Card