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75 1-2 LAWRENCE ST - BUILDING INSPECTION o � � � , The Commonwealth of Mussachusetts 1 Boprd ot Buildmg Regulutwns und$t�ndurds E OR t �4 �� ? Massrchusetts Srnte HuEldmg Cncie 78U CMR 7'h cd�uon , MUNtc tP it 111 _ � , ;; ; USE'. ti` , , ; BuildingPerrnitAppl�cuhonToConstruct, Repair.:RenovutnOrDemulishu R�i�rulhuuar>� One or„TwrrFiiieiil.Y bwe • ' ' ! 'rtt� ' ' Th�s•Sectian;Fnr:O cial: 'se, nly .` r R ;;: ` _, , . , ' ' , <, ; � r �, e -„ . . ,� . � ; ,, . . . ., `Hwldm"Poim�tNum ,r - ,F ., �Signuture ' � � , t„@ucidingCummissronerllns uorufBu�IJm Dute •' r " `" `SECT[ON 1:; TE INFORM _:;; � , „ 5 AT[ON, :' , ':1 t P Address'; -� .i 2 Assesso`rs Mnp&Parcel Numbers :��2. �. 9�i'IJiJJ�`Lfk'tP �'�' r ' `�k tu Is,thm:un uuepted��:�treet�yes''� "na ``� , '�.��P,Number� Purecl Numh�r `;13 Zoning;:[ntormntion 1 A Property Dimeosiqns J'.:i t S.� .�Zoning D�su{it .P.roposed Use�� ` �S:ot Areu(sq;ft) Fron�yge(R) �� 15•,�ulldtng Setbacke`(ft) ` '' r r''; Front Yur'd�� - S�dc Yorde o- t Renr Yard �t Repulredi. , .�ProviJcd, , i :Requlred Provtded � '.!'� Required��,��; -.tiProvtd�il :;i `, , , ' �i '%i �; •16 Water Supply tM O L c 40,§54) 17 Fluud Zane:InPoKmadon : ' 18;5ewage Disposat System � � Zone �_„ ' OulsideFioodZone7 ,�,r " � PubLc,� ;�� Pnvnt�0�; � „��ryeckifyes0_�:�� Mumc�pnl,le� Onsucdispostilsys[nn Q.��: .,: -, ,_ . ` . -,: a .:.. � ; ` ,';'.8EC1'ION`2 PItOPERTY�OWNERSHIP��, � 21 nee'of Hecord.: ' ' �a.��m�f�►� t-��.Y,"i' ' r f�i � �� �z�}f,rJl�e�'3z t� S�'.' , Nome(Pn�� -. Aikiress Cor Servtcc • E � r .. � � -' : : ,; ..- ` r :���""���.:����� .J . .:. ,. .: . . .,,, , ....: _._ . ..:-> ,, . ,,., .:-, „ �. ..; , ,, ` :�� _ ':'Signcture. , ,r<.;;; �Te�ep6ane ,'o `,� „ w , .h .. .. „� ..:. ; . ,., ... : .:. , ` ,. SECTION 3 ;DE$CRIPTtON(OF PROPOSED WORK=(ch;eck oI1 that nPP�Y)'s` ; += ' ' .New Construct�on❑ fEx�stmg Hu�ldmg� OWner Oriupied �t Repwrs�s} O, Alterniion(s) :�AddiUan d :� , .,. :. ; ,.. ,�. . _ � . ,_ Demol�gon�= ❑ Accesso Bld ❑ „ ';Numberof;UnJts r;< Othe��'O`5 dt = � % • :. > Y. . . _.. �Y , $ ,. . _ P� Y � ; BneFDescr�pnon oPPrqposed Wa�k?'3= :�°"' �.�i-' •- t+1.;: f"�f .n � .r:;;"�' _ ,m , �; �.`KtY '�I+:�i�Fs,hS".. �.: �i�' i"�2 = ..< �_'�,�,+. iihty.: r�#: u'Si� Y.: - ,. :�+�,&!t' �"�YML. .�' r�.. � � �e -' . -. . :� -.. . >.., , ,. . , �� . ... '.. . ' ' . ` �SECT[ON4 E5TIMATED;CONSTRU,CTION..COSTS,_,, „ �� ' Y f, Itam , Estiri_yutedCosts,:�� � ` 4 � Of[ic3alUsaOnly t k � ': <� ,. -- .(Lubar uhd Mnter3nls) ,s= �:: . .,.:_. ., ' l�Bu4d,ing F;:,_ , ,��.; $ r�"^��; t Bwldmg Permit"Fee $ ��� Tod�caie huw fee istdetermmed; , ❑Stundard CFtylCown Applic�tion Fea . 2;�Iectnc¢I $ �,� �?� r ❑Totpl Project Cos1�Qtem 6)x mulhplier` x' ` ; 3:',Plumbing . ' >.' $ �� �� � Oi6er Fees $` ' ` �� �� , , f , 4`Mecham�al (EIVAG� ; �� `�,.-�`�—�--, s a �.lSL ' ,:. ,�... ... . , ...,. _.� ..s ,_ .. . .. . „ � ... � ' S;Mxhamcnl (Fire" z, $ ` : � ' , �. ; ., .,: Su ress�on ' � . r Tutul Afl Fees $�_ �; ; r v ,� v :• y ' �CheckNq " Cha.kAmuuet i �Cuh Amount 6:Total Project Cost `: 3 ��`";f � � _i ❑po�din Full , ,�Outs,tandmg Bnlunce Due: � .+s. � �; . ��, .; ; ... ,,. .. , ; r ' -�.: .,�q . . �'� �s'. . _� . ., r ,.' ,._ ,. ..: . E ) :.;: 'v'.: ... � �� .,i -.:. .:�5� i { N � . : .i : Y i � r � � ti � 5 � i} b A ,: �'�, 4 .' h y��� .. � > � tt t� t y .. i fi'. } ) Y � '- a !.2 _ �.:, . .. .. � T >Y.,..., .-� ^. �FH St; i t �. _ � u� ,. 1 tt ��� � C�c��.�-���.� ._� . , . . ..... . . �_ t r c: .b.. 2E:. - � � " � � 't y +'�``�,i SECTIOM S CON5TRIICTION SERYICES t � � ` 51 Llcensed Coostruciian 5upervisor(1CS4} s� , ` , }; t7�'�` ; 5 �:��N�ber E� � � ; , �-� : , � , '�r 9t� t .e �r � ,� , '��,�' (�' .� � � � : -�.. pirntiut Dalc; � - z I�U�tlfCSl.f Huldei i s y r i .. �.. , +.� � 4 ' �� CastCSLT �scehelow) �� :� �.,�`�' }1�`'��'� , �.a .: YPe , . . � - n4`t121rcss` ' � - r T ' �: � H .-Descn uon , ' . � ';y�.�yi�=��YiE =Ua"'�lq . -`� � ' � ` U �' Unms[neteJ�u tn3.FWOCu Ft.)s ; � �.,,, : �r- ��g �ryK. i ,e � ' � R � tResFrictedfl�Fumil� Dx'clim -"' F " C�����'7�� ���� % �" x t � st � M ( MIl5U(l ':�if� 5�:i e W� .� s �-,, „ � `" RC. �. `Ru3Jr'n[iul Raofin. �Cuvenn �;: ' � ; T�Icphone � , w tVS.::,' R�s�dintiul Wimh�iV;un�t Sidm r' .M p3 ,:,,: '','. SP �x, H�siticritiul Suti�FuEI Bunun 1""Iwn�� ltutall�u�m . ��� , •ra,D�w:��;ResiQe`atiul'�DembGtTSn 5 2 ttegistered Home(mprovement Cont�actor(HIC) ° :z �y . �-� � z ._ = , � HIQ .mpnnyNarrte'6�H[CRegi5-� tptnmt_�.-.? !-''R�egistratioiiNumhcr ; ': ` Z � � .�"` ra'"' �s� r�/ s�~ ': `� i/ � �l�� Atld � a " .� r - ' " ' 3 w�� ���� Eap3 ion bam %- �` Signature� `- ', ' Telephane ' ��; -. :: -:- ..: .:. ;; .: .., ,; .^ -: rt t ° ;SEC770N 6 WORXER3'COMPENSA'PiON.INSURANCE AF�FIDA VIT(M:G L.c 15'.,�, :§ 25C(6?f s, = " > �:: �:;x ,..�_.. ..,.. . .., „«,._, r.<v. .._..,. >. ,, , ' `���'. Workera��Gampensuvon InsitraiYce u�dnv�tmus`t be completed nntl�,submttted a�th thts nppiicutian„Fuilum ta"pii�vide > ihis uffiluvit wi�l_rtsyic fa tha den7u!of the I`ss�uunce'ofthg bmltlmg permit Signed tit�ffidavlt Atfnched? "�' *Yes � ,,' � � r� �No ❑ � �� < SECTION 7a O,WNEH AUtl'Hf)R77r�T.tON TO 8E'.COMPLETED WHEN � < ' OW1�ERiS'A'�GEN.T'.OR`COIVTRACTOlt`AYP!LIES'FOA BUI1sDING=PEItMIT ., .�' �- '% .` � _ '� , i c .�[•. � 1 �I9 d t .;.(�f x 4 �, Z i' -i� _: .� . T ,.. < Y �: r, ' +'' y ' " ' - as Oivner of the:subject property hereby���� '� ..; ;;, .' �,� . : ��.- . :. t autbonze �' `$t �� �`- -' " to aet on my behn(t (n all mntiers ; rekabve t'o work nuthonzed 6y tHis huitdmg'jierm�t npplicntion. - � � , .� � ° ; . , : 4:,? )' .S) utiiico�O�Vner<=.�. Dute. �� ., .. - .: :� .. ..�. ... , _., - -,.- .` . . .. '.``'� ., .: . � .�. :.;; � �, „=:SECTION:7b OWIVER�,ORAU'PHOR[ZEDAGENT.,DECLARATION ;; +�„ °` ' ` e '. � ` f ,, xI }��#l.�l� �.,�J.3+� ,, � �� � �: ue Qwne%or Authonied Agent hereby declure "� * ; 2hai tha stotements and mformallon oa the fotegomg applicadbn are true nnd nccura[e to tha'best of my_knowledge ttnd �. � ° behalf q � � � # �. ��.1Ptt'ri . �`Cx�LJ r., a , ' Prtnt � ' ' . �`�r.�.�J f� .�'� �t Stghri oPllwnerarAu on gent � O¢[e t '�. 'tSi ed.uni7enthe' inswid. ` nditieeof u - r� ` ' ,�,� ,' ` ' .f.NOTES � .s. �a ` 1 ` AnrtOv3ner`�Yhd obiains n building perniif to do hulher own work,pr an oWner who heres nn unregistered wntru�mr �' ;�. � � (naty,reg�sterbd�in:the$Aoma-ImprovtmeniContrncioi;-(HIC)Progmm) w�11�Rafhave'nci:essto'theurbitranon �: e prugrumnr gunrunfy fund bndeGM il L c I42A.Oiher impocianPinPormahon on the HIC Progrnm:.and + � *,,�;'' � Constructfon Suporv}sor Licert'smg fCSLj cnn be'fov,ed in 780 CMR Re luhons l`t0 R6 and 1 LO R5 res eu�vel <�,. „ �`. .. . . _ , . . p . ....y. , . . .; �';. = 2 45When sub�mnt�al:work is pinnned provrde the mFurmution below � � �! �' '- �'. ��" ,! Totalflooisaren(Sq�F4) `� ���' "V �� "��t(mcludiag�gurnge timshedbasemendntt�cs de�l.surpur�hl �, i :�,,.Gross li�mg uien`tS9.-iFt) � �� �;' f �Habita6le raom wunt ; Ndmberaifireptaees.�� �:IVumherof6edroams '.. <�r Number of b¢throoms Numberut tiulf/bnths ? ��� ` 1 Type oP�heuting syst`em'F ' '�. � ' -NGmberot tle�ka/ponbes a, .;t ' T- e,nf�ooLn system = s .. ,Enclnsed =� Opeq. :,: � , , � :���. ; "YP .;,.;�.�, .r_$., �.,>..,� ._.. -:: � , x:,�.:.: , �.::.:,.. . 3 "['dtol E�ro�xtSquare Foutage mny brsubshtuted fu�'"fumlrPioleet Cast � � � : : � r .° , ` :: c ;: ' r � r„ ., ,r , �.. _: , .: •. _., .. -� x ... :.:�. . .... r _ 7 i� - r> . SCOPE OF WORK FOR Carol & Ray Hunt 75 '/: Lawrence Street Salem, MA 03079 978-745-1239 BUILD WALLS WHERE NOTED: 1. PRESSURE TREATED SHOE 2. METAL STUDS 3. MOLD FREE DRY WALL: (BLUE BOARD) 41 Feet PUT IN DROP CEILING: 556 sq. ft need grid & ceiling tiles ELECTRICAL: 1. 12 RECESS LIGHTS 2. 13 OUTLETS ON NEW WALL 3. 2 DIMMERS 4. 1 CABLE JACKS 5. 1 SMOKE DETECTOR 6. 1 CARBON DETECTOR 7. 1 3 WAY SWITCH 8. Move Dryer Plug, 2 additional lights & plugs HEADER 8� COLUMNS: 1. BOX IN 16' of HEADER 2. Two column wraps WINDOWS & DOORS: 1. INSTALL TRIM OUT 3 WINDOWS 2. (2) NEW DOORS 3. (1) Steel Door PANELS: 1. INSTALL 16 (4'x8') R-13.8 PANELS ON OUTSIDE WALLS CEILING: 1. CEILING HEIGHT 7'2" CARPET: By owner BLUE BOARD: 41LINEAR FEET OF BLUE BOARD (10) BATH: Install small Bath ,-�--�--�---�-�-�-�---�--�- $�- , � - -- - -�--�- ' / - - l��,,�� ��f_����s�¢,�'l� ���� - ,, � � - - .��5 2 �..�-�/����� �`l' - - -%C� -� �� '-� �-`��i���� Y�`'������ - _ _ � _ ----f- � � � ., � , � 1� --�- -„ . .� - �.� ��03��� _ __ �,%���' ��� -� } _ � � � , - - - _ _ - /-�� - - - -- - - . .��� '- �- ��-3� - - - - - - -- � - - �- - � - �-- -� - �---� _ - + - - - - � I - - - �y� T _ __ . ' . _1 �_��C' --- �--�"'�� fi � ' - - � � � - - -a— -�--�--� 1 � _�—�-- ' �-�-�- � �`�r�r.� �� _� � �iv� �i�����,/�� � �_ . _ _. - _ _ � � � � � I � I � � _ �.�. _ ��� .� �_/t���D�� Y, .� I-//) i � � l _ - f I __ - _ w � � , i -.� -,--- �-� �,���/� -�- -�- r, £ . -� � i ( ` — �'�� / _ 1 1 ' - - - +- ` - - - - - - -- �- - _ -�--� -�- E _ � `. , f'�! 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(978)745-9595 Fn.Y(978)740-9&3b (CltfgFRI �Y DRTSCOLL i�RYOR "I�tObf.�s ST.PIEna& DtRECTOR OF PCBLIC PROPERTY/Bl'IIDL1G COSL�IISSIO�iER Workers' Campensation Insurance Afiidavit: Builders/Contractors/Electrictans/Plumbers An�licant Information Ptcase Print Leeiblv / r--� V8l]7C (Busi�.�ss�UrganizalioNindividual): `" ��Cu�Cv/�T, � n G /� ,� " � �i� Address: Y � ��J� `"� 3 y CitylState/Zip: VY� � l� �r�l� Ci UCoy(�7 Phone #: �D— 7 �f 7— 3 i,3 � Are you an employer?C6ec�the yppropriate box: Type ulproject(requlred): L� 1 am a cmployer with 4. ❑ 1 am a general contractor and 1 6. ❑New conytruction employees(fuil and/or part-time).• have hired the sub-contracmrs 2.0 I am a sole prop�emr or p;utner- �isted on�he attached sheet� �• � 2emadeling ship and have no employeex These wbcontrrcmrs have 8. ❑ Demoli[ion working for me in:u�y capaciry, �orkers'eomp. insurance. g, � Duilding addi[ion (No workeri comp. insutance 5. We are n cornoration and its reyuired.] officers have ezercised theu �0.� 6lecrrica!repairs or additions 3.[] I am a homeowner doing aU work �ig[tt of exemption pCr MGL 1 t.Q Plumbing repairs or additions mysclf.(\o worker� comp. c. 152,§I(4),and we have no 12.0 Roof mRairs , insurancereyuired.]t employ�ex. [Noworkors' 13���W, /SRSeMen� rin�s� comQ. in�urance required.j •Any upplic:mllAu[checks box%1 muel uisu fill oui ihe sue�iim below showing thCirurorkas'compenaa�iun�mliey infurmaUon. 'I l��meuwmar whu submif Ihis aflidavit indieating Ihey are doing oli work and ihen hirc out�ide con�raston must submil n naw a1TiJavit indicating such =Cumrmxon thut ch�•k ihis 6ox mint anached an;xldiliurel charl showing�M nome of�M eub�Contrar.ton and thcir workcTy'cumy.poliry infwm�iion. /um an ra�pl�yer�hat fs providing�vorkers'comprnsadon insuiance for my enfployees. Be%w is tl�e polJcy axd fab s7�a injormu�ion. � Insurance Company Name:�.,�,yy�6�«! b --e ry�uo:::?'�z Yolicy k or Self-ins.Lic.N: Expiration Date: � Jub Si[e Address: Ciry/StatelZip: ,tttach a copy of the workers'compeesation poliey dec(aretlon page(showing the pollcy number and ezpiratlon daRe). Failu[e ro secu[e coverage 0s i'�quired under Scction 25A of MCL c. 132 can lead to the imposition of criminal penalties of a fine up to St,500.Q0 nnd/or onayear imprisonmcnt,as woll;wv civil pennitics in lhe fomi of a STOP WORK ORDER and a fine nf up m S2S0.00 u day against the vioiator. l3e advi.acd that a copy of this statcmcnt may be forwarded�o Ihe Oft ice of Invcstigmiva.uf tlie DIA for insurancc covcraga vcriticution. /da hereby crr7 u�+der t ulns d penal�les ajperjury that the iufurnta(fon pruvidrd ubove Is/rue m�d cairrcG Sinnature:l . .////' . � nnre� Ol�.�J�O Phone�: ��— �`Z 7� J �J y O�cruJ ase ady. Dn im�wriie in tkis ureo,m be cunrpleted by city or lawa nJ�ciuL City ar"1'own: __ Pcrmit/I.icenee# �� IssutngAulhority(circleone): � ^� � ' � l.!iu•rrd of Health 2.Building Depurtment 3.City/fown Cierk a.Etectrical [nspector 5. Plumbing Inspeetor G.O�hcr _ _.._..—.._..____ Cnntact Permn: . _._ Phonc#: ' . . . . . ..... . ... . . .. .. � 6/30/2008 2:3] PM FAOl1: Pe[�uzelo Petn�zelo Insurance TO: il (BfiO) 620-0182 PAG6: 002 OF 003 CO „ CERTIFICATE OF LIABILIT1( INSURANCE o6�o�z°�"ooa ��R (Z03)269-3551 FAX (203)269-7588 THISCERTIFlCATEISISSUEDASAfAATTEROFINFORMATION Petrvzelo Inwrance Agency, Inc. ONLYANDCOtJFERSNORIGHTSUPONTHECERTIFlCATE 4 Research Parkway ALTER THEHCOVERA EAPF ODm BYT EEPOLICIES BELOW. P.a. Box 5050 Wal l ingford, CT 06492-7550 INSURERS AFFORDING COVERAGE NAIC# iNsure�o Liquacoat, Inc �+�+A National Grange Mutual Ins. 14788 PO BOX 434 �++�Re� Acadia lnwrance Co. MILLDALE, CT 06467 �+�� u+su�a v n+sr�a e CO AG THE POUCIES OF INSURANCE LISTED BELOW HI1VE BEEN ISSUED T07HE INSURED NANIED ABOVE FOR THE POLICY PERIOD MDICATED.NOTVVfiHSTANDING ANY REQUIREMINT,TERM OR CONDfT10N OF/W V CONlRA(.T OR O7HER DOCUNENf WITH RESPECT TO WHICH 7HI5 CER'TIFICATE MAV BE i55UED OR MAY PERTAIN,THE INSURANCE AFFOR�ED BY THE POLIGES OESCRIBm MEREIN IS SUBJECT TO ALL THE 7ERAAS,IXCLLISIONS AND CONDITIONS OF SUCH POLIGES.AGCaflEGATE LIMIiS SHONRd NNV HAVE BEEN REDUCEU BY PAID CW MS. MSR TPE�MSURPNGE Pal1LYlIIO@92 PoLILYffFECENE PoIICYE%PWATON � ce�n�uneiutt X5597060 07/07/2008 07/07/2009 �+�+� s 2 000,00 conm�rtcwicer�wv.une2m oxaor�ror�r�o s 500�� anoisnwoe ❑ocam sgor�w(mv�v�) S 10�00 p � av�a nrn�nuar S 2 000 00 �wun�scn� s 4,000,00 ce'nnccaEcn��uurara�esaeu vaoaxrs-coe.�rovacc s 4,000�00 POIICY �� LOC ' . nvraaoei�uneiuTv 81597060 07/07/2008 07/07/2009 ��sux�Eunm = . nan�nuro tEeecaaatl 1 � � PLL OriNED AUIOS BO�ILV ItUFtY X SCt¢oixIDwtos � lPeroe�) S A niaEonuros ' emaruumv rmN�owrtowros ;verec�;eeti) s rrsoa�rzir°°MacE i (vueeanei+l r,a�ueEuaeam nuroarar-EnneeioEerr i Mrvano . o1F�ItlWW EAACC S - � N1fO0PLV. FLG S EXCE83111MBRalALU1B811Y �97�0 �7��7�2� 07��7�2�9 EAQIOCQAiRENCE S 1 ��.� OCClIR �QAQASMlaE Ma('aREG�N� { A s oEoucnei.E - i x �� : lo. : wo�s��,w�+� wcosoeooaaso-oi o�/o�/zoo9 0�/o�/zoio wc�A,u o,w �o`�'"�°'"' E.�.�,��� : soo.00 B �wr�cai�r«avAa,rzwo�amv� a�icrnrt.gnmErsocttuoFm Ei-mgwg-En�xo S 500,00 �c v�aowsi�`asemow E.i.a.s�nse-roueru�.m s 500�00 oTrEx oEscwr�osorawnoru��ocnnm+srveaaFs�ocauswNs noo�eramores�e�nr�svEau rnovisaws E sNoutn nrir ac nE aeNwe oEscrsm�vo�rcgs eE ouvcatEo eso�n� EXPBt11110N O11lET1ElgOF.T/�ISSIIWG Mb�WILL BIFAVOR 70 W1LL 1� WYSYYNI78�NOIICE70TECER161GlEXOLOHtNA1�TOT1IELEFT, BUf iIULURE l0 W1R SUGH NOIILE SW1lL�OSE NO OBLIGATON OR WBRffY :- .. .___ ' _ . . - _\ OF AHY I�IO IIPOi11{IE WAII�,A9 RCBAS OR R�SEIffN7P/QS. _"_ _ " _ _ _ AUfiIOR��SBliAlNE � - Ju ini APPC �� ' ACORD 25(2001lOB) FAX: (860)620-0182 pACORD CORPORATION 1988 ADDENDUM TO PfRMIT APPLICATION OWNER AUTHORIZATION FOR AGENT OR CONTRACTOR: I, ���uh�� . as owner ofthe subject property hereby authorize Liquacoaf, /nc, to act on my behalf, in all matters � relative to work authorized by this building permit application. As owner of the subject property located at �� Z ��4,��� �� , 1 #urther acknowledge and accept the Town of cJ � _ � 03";�7/G : authority to inspect the work performed by the agent/contractor. �, ' � / � - �/G �' Signat e of ner Date ���� � TO BE PART OF THE PERMIT APPLICATIOfd � � `��Boar o uilding�la�ions��ta.ndG�� One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improveme�t;Co�tractor Registration -.��, _ ---_ _=_ -__ � _ -y Regisfration: 160440 �-- [ Type: Private Corporation �3�� ��"' �~ ���� 6cPiration: 7292010 TAF 272093 LIQUACOAT INC. ; � :�r �", CRISTANO FIGUEIROA �., 4_ �'_ , , �=-� ''; P.O. BOX 434 °c'�p �� =� MILLDALE, CT 06467 � �.l ' 1 E : � ` Update Address and retum card.Mark reason for change. - 4 �� -�f�� � � Address � Renewal � Employment � Los[Card DPS�CA1 c7 50M-0�/07-PC8690 . e �� �m„�����o�v o�✓6�.�/� _ '�;�,.,� 6oard o(6uilding Regulations and StaodaNs � � "_ NOME IMPROVEMENT CONTRACYOR �. � RegistraUon: 123626 .� ExpireUon: 3/19/2009 TrN 127254 -� Type: Individual . i Paul J.OToole _. Paul O'Toole ' 25 CHERYL DR. d�`Q'0u""�' � MIITON,MA 02186 Administramr � �\ . . . ._.—_. . ✓/ee 'Pio�nmxoozurea�l� o�✓��,a�wacliueella - BOARD OF BUILDING REGULATIONS . �� �.�' License: CONSTRUCTIUNSUPERVISOR " � � � � Number. CS 078157 . � �� '��' �*���. BiRhdat�:�10/30H968 z �r� ' Expires: '10/30l2008 Tr.no: 3228.0 . Restricted: 00 - PAULJ OTOOLE 25 CHERYL DR ��� MILTON, MA 02186 � �mmissioner MUTUAL POLICY CONDTTIONS ENDORSEMENT MASSACHUSE'I"I'S WORKERS COMPENSATION ASSIGNED RISK POOL This policy is issued by Associated Industries of Massachusetts Mutual Insurance Company as a designated insurance carrier of the Massachusetts Workers Compensation Assigned Risk Pool. The Massachusetts Workers Compensation Assigned Risk Pool was created by statute to provide a means for Massachusetts employers who could not obtain coverage in the voluntary market to satisfy their obligations under Massachusetts General Law (M.G.L.) Chapter 152. The Workers Compensation Rating and Inspection Bureau of Massachusetts has been ' designated by the Commissioner of Insurance, in accordance with Sec6ons 65A and 65C of M.G.L. Chapter 152, to administer the Pooi. This policy is issued utilizing forms and in consideration of premiums, additional fees (if any) and chazges as prescribed by the Pool Administrator and approved by the Commonwealth of Massachusetts. It is understood and agreed that the "Mutual Policy Conditions" of this policy jacket are amended as follows: MUTUAL POLICY CONDITIONS THIS POLICY IS NON-ASSESSABLE. NO PERSON OR ORGANIZATION WHICH IS AN INSURED NAMED IN THIS POLICY SHALL BE A MEMBER OF THE ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY (THE CORPORATIOl� OR BE ENTITLED TO ANY OF THE RIGHTS OR BENEFITS OF MEMBERSHIP IN THE CORPORATION. SUCH INSURED ALSO NEED NOT BE A MEMBER IN GOOD STANDING OF ASSOCIATED INDUSTRIES OF MASSACHUSETTS. IN WITNESS WIIEREOF,the issuing Company has caused this policy to be signed by its president at Burlington, Massachusetts, and countersigned on the Information Page by a duly authorized representative of the Company. � I 71�Ls eMorsemenl6 altaNatl to Ilrepo0cy IMkatetl hebw enA Lv eHecOve an Ihe d�e stated herem,et t201 AM..stantlartl tima et Ne etldre�s of Ne InsureE as desm'hed In Ne infomallon page. - Popcy No. Group ExpireUon Oate of Policy ERecBve Date of E�dorsement Endorsement No. AWC 7012452012008 03/21/2009 03/21l2008 Issued W Additional Premium Retum Premium Paui 1 O'Toole dba Milltown Contractin ISSUEA BY: ASSOCIATED INDUSTR[ES OF MASSACHUSETTS MUTUAL iNSURANCE COMPANY . camtersigned �'��'�^ AIM-2 6/96 RA ^"�O1�d��"m'"s 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY I INFORMATION PAGE A�sociated Industries of Massachusetts Mutual Insurance Company ' � Burli�gton, Massachusetts NCCI NO 26'158 (800) 876-2765 POIICY N0. AWC 7012452012008 PRfOR N0. AWC 7012452012007 ITEM t. The Insured Paul J OToole dba Mill[own CoMrading � Mailing Address: 25 Cheryl Drive Milton MA 02186 Qao. 5treet rown m caYy _ CoumY S�ate Zm Com � Individual ❑ Partnership Q CorporeUon ❑ Other FEIN 01-4602425 Other workplaces not shown above: . - 2. The policy period is hom�2�n008 �03/2112009 �p;01 a.m.standard tlme at tlie insured's mailing address. 3. A. Workers Compensetion Insurance: Part One of the poliq applies to fhe Workers Compensadon Law of the states listed here; 'I MA B. Employers Liabiliry Insurance: Part Txro of tAe policy applies fo work in each sfate listed in item 3A ThelimitsofourliabilityunderPartTwoare: BoditylnjurybyAccident$ 1,000,000 eachaccident � BoditylnjurybyDisease $ 1,000,000 poRqlimit BoditylnjurybyDisease $ 1,000,000 eachempbyee C. Other States Insurance:Coverage Replaced By Endoreement WC 20 03 06A D. This policy indudes fhese endnrsements and schedules: SEE SCHEDULE � 4. The premium for this poNcy will be detertnined by our Manuals of Rules,Classfications,Rates and RaGng plans. �� All iniormatbn required bebw is subjad to vedfication and change by audit - GassificaUons � Premium Basis Rates C� �y��� PerEtaO Fs4mated . Taal Mmial o! Mnuel . No. ��� Remuneralu�� PreMum iNTRA 068873 �I SEE NSION OF INFOR TION PAGE Minimum.premi�m$ 500.00 � Total Estlmated Mnual Premium $ 575.00 As indfcated,interim adjustmeMs oi p2mium sha0 be made: Deposit Premium S 575.00 � a,n�ly ❑ semi,oMuanY ❑ Q�ey ❑ nnonmry MA Assessment Chg. , . � $295.00 x 5.5000% $0.00 This poli�y,induding all endorsemen4s,is hereby coun[ersigned by � `-�-CYa. 02/13/2008 auu�s�y�me � GOV GOV KIND PLACING CIAiM NAME SAFETY � STATE CLASS AUDIT OFflCE OFFICE CHECK GROUP A[tantic Insurance Gmup Mp yyp3 �p� Agency Inc 530 AdamsStrea � WC 00 00 01 A(11-88) Milton,MA OZ l86 Intlutlz mPY�ted materiel dtlre Nalmnal Camca m Campense�o^��aa�se. �eE v�its pvmisian.