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49 LIBERTY HILL AVE - BUILDING INSPECTION (2) 1 The Commonwealth of Massachusetts. Board of Building Regulations and Standards _\7,assachusetts State Building Code, 780 CMR, 7'h edition } Building Permit Application T Co struct, Repair, Renovate Or Demolish a One rTwo arnily welling T 's ecti o fficiafUse Only Building Permit Number:' Date Applied: 1 Signature: Building Commissioner ft pcctor of ildmgs Date .SECTION 1: SITE INFORMATION. 1.1 Pioperty Address: 1.2 Assessors Vlap S Parcel Numbers 1 Ma Number; Parcel Nmnbc, I a L dus an accepted stre t? yes_ no_ p _-. 1.3 Zoning Information: 1.4 Property Dimensions: 7_onins District Proposed Use - Lot Area(sq ft) Frontage(ft) i 1.; Building Setbacks (ft) — i Front Yard Side Yards Rear Yard i Rcqui red Provided Required Provided Required Pro••icc,i _, 1.6 Water Supply: (M G.L c, 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System Zone: _ Outside Flood Zone Puolic ❑ Private ❑ Check if yes[] Municipal ❑ On site disposal - � SECTION 2: PROPERTY ONVNERSHIP' an of eco d: — � A�c (Print Addre� for Service: 2 gg� 97 ff I Sic - Telephone - - -� SECTION 3:DESCRIPTION OF PROPOSED NORK' (check all that apply) 'ew Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Add ;ir:: G Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': I i i SECTION 4 ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only °1 Labor and Materials Building $ 1, Building Permt Fee $ Iodicate how fee is delc:m ❑ Standard GtyrCown Applicatton Fee;; 2. Electrical S a ❑Total Project Cost (Item 6)',x mulnplier x 3. Plumbing S - 2 Other �. Mechanical (HVAC) S List I r 6 Mechanical (Fire Suppression) $ - Total All Fees $' �/�► pp Check No. Check Amount: Cash Amount. 16 Total Project Cost: S /VV~ 11 Paid in Full 0 Outstanding Balance Due: -- SECTION S: CONSTRUCTION SERVICES 51 Licensed Construction Supervisor (CSL) so CPO License Number Expiration Date \'ame of CSL-HoldFr�_ List CSL Type(see below) U t ,.Type Description Address U Unrestricted(u to 35,000 Cu. Ft.) AterA M k' 019' R Restricted 1&2 Family Dwelling Si_et et r ^ M Masonry Only r RC Residential Roofing Covering Telephone ` WS Residential Window and Sidin 9' _7 6 _7 Ll q -7 S`l7 � SF' Residential Solid Fuel Bumin Appliance Installation - - - D Residential Demolition 5.2 Registered Home Improvement Contractor (HIC) It —7 5h� z �✓i 6 7' 7 H!C Com H Re istranta �e Registratn N umber n + a Address) s srale� M�. �j7874g7Sy� . Expiation Date Si_natu 'Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c.,152.§ 25C(6)) Wackers 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 .......... ❑ . No ....:...... ❑ SECTION 7a: OWNER'AUTHORIZATION TO BE COMPLETED WHEN OWNTER'S .AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT �CWC XvA81�� I, $J as wner of the subject property hereby autnorize 5'n .� ' P_r/.. CDiUf\. to act on my behalf, in all matters relativeto work,a,�itho e y this building permit application..' aor•<. y Yn�11C1' Date Sienau!re of Owner SECTIO` 7b: OWN1 ERA OR AUTHORIZED'AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. S fl Sienature of Owner oar Authorized gent Date 1 (Sieved under the ains and penalties of perjury) NOTES: 1. An Owner who obtains a building permit to ado 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 and Construction Supervisor Licensing(CSL) can be found in 780 CMR Regulations I IO.R6 and I IO.R5, respectively. r 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 heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" °ar CITY of SM—EM, NWs.kcHUSETTs •" y a BUILDING DEPARTMENT z 1t: ar 120 WASHNGTON STREET, 3'FLOOR �^• ILL (978) 745-9595 `- RVC(978) 740-9846 )V.%fpFRC RY DRISCOLL MAYOR THObtAs ST.FtiE.iRs D IRECiC R OF PUBLIC PROPERTY/91:ILDL`SG COMMSSION ER Workers' Compensation insurance affidavit: Builders/Contractorv/Electricians/Ptumbers milicant information Please Print Leedbly Vnlne llSwin�wyUrgtnizuietvindividual):1•��?e ll''q\`^ �—tM—� 1�-E-Address: City/State/Zip: � VV-0- PhoneM: Are you an employer?Check the appropriate boat Type of project(required): I. 1 am a employer with 4. 111 am a general contractor and 1 6, (]Now construction employed(full and/or part-time).• have hired the subr:ontractors 2.❑ I am a solo proprietor or partner- listed on the attached sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have V. 0 Demolition working for me to any capacity. workers'comp.insurance. 9. 0 Building addition [,No workers'comp.insurance S. 0 we are a corporation and its required.) officers have exercised their 10.0 Electrical rcpaim or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Pl Ong repairs or additions myself.(\'o workers'comp. c. 152,f 1(4),and we have no 12.6aRoof repairs insurance required.)t employ"&(No workers' I5 0 Other sump.insurance required.) •Any appllcunt dca cbwka bra r I must alw nil uul the taxam below showing their watkars'Mompensadon pulley indar alloe. 'I hvavuwrays who suhmit this affidavit indleaing thcy andoing all writ and then hit*outrideeomraurare meat mhmil a new afndavil indlaating such C-umsxwn that check this boa must amahod un addidrwl,hae showing rho none ofthe suh.dmruwn and that,workers'Momµ policy inru floo. wessessew lain un rurplayn chat b provldlne workers'cornpauadan fnruranee jar my ernpluysrx Below/s theivo/ley and Jab site Insurance inurinC n n Company Vmnr. Lc �PPii Policy 4 or Scir-ins. Lic. N: if s t Expiration Date: Job Site Address: CilylStatrJZip: nacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Failunt to sccuru coverage as required under Suction 25A of MGL e. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 antVar one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a tine of up to $230.00 a Jay against the violator. lie advlscd that a copy of This slatcmunt may,but forwarded to the Offices of investigudons ufthd OIA ror insurance coverage wrifieatiun l do/rrrrby cerrljy ror r r/re pains reel ula/t/rs ajprr/ury/flat for GrjurnruNar provided ubwe is true and curreelC pure: Data' - �///( 3 U/jiriul cur rely. Do our write hr Midi arrt4 to be completed by city a,-tawn n/Jlelul ICity or'ruwn: __ _ Permltlf.lccnse-.0 j Iesuing.\uthurily (circlouno): I. ISuarJ of IlcuOh S. Building Ilcpurtntent I.Cilyifnwn Clerk J. Citetrleit inspector i. Plumbing fnspmtor 6.Other Cnnlact i'Mrtnn: _.. __ Phone 1: ACORD„ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/18/2013 PRODUCER (978) 922-4600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARCHER INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 271 CABOT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 13EVERLY MA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A.CONEXCO INSURANCE AGENCY Fitzgerald Construction Inc INSURER B:LIBERTY MUTUAL 5 Planters Street INSURER C: N SURER D: Salem MA 01970- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIRFMENT,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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L - POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MMIDD/YY) LIMITS A GENERAL LIABILITY CPS1284687-1 01/03/2013 01/03/2014 EACH OCCURRENCE $ 300,000 DAMAGE TO RENTED 50,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $_ CLAIMS MADE a OCCUR / / / / MEO EXP(Any one arson) $ 5,000 PERSONAL B ADV INJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 600,000 POLICY JECTPRO- LOC / / / / AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS / / / / BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS / / / / BODILY INJURY $ (Par accident) NON OWNEDAUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EAACCOENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY / / / _ / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE / / / / $ RETENTION $ $ $ WORKERS COMPENSATION AND 1383191-0000 01/11/2013 01/11/2014 X I TORV LIMITS DER EMPLOYERS'LIABILITY ANY PRGPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMSER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ 500,000 It yes,describe under SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT $ 100,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 INS025(0108)US Page 1 of 2 i "yr CITY OF SOUL E. ) >%L.ksSACHUSE-rTS 3i 't� ) .' BL'tLDL\GDEP.iRI'JLEAiT 130 WASHNGTON STREET, 314 FLOOR - TEL (978) 745-9595 FAX(978) 7-W-9346 (UIIBERLEY DRISCOII. AWOR THOSUS ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/gUILD04G COSLLIISSIOYER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CNIR section 1 l 1.5 Debris, and the provisions of tbIGL c 40, S 54; Building Permit 4 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 NIGL c I 11, S 150A. The debris will be transported by: (name of hauler) The debris /will be/I disposed of in (name of facility) (adJress of facility) siy+namrc of permit applicant �,W 13 _- dale Shawn Cell: Page No. of Pages 978-804-8250 FITZGERALD C46NSTRUCTION 5 PLANTERS STREET SALEM, MASSACHUSETTS 01970 978-744-7547 PROPOSAL SrUBMITTED TO PLONE DATE STRE4 / j f Ihi ! JOB NAME tgV CITY,STATE ,ND ZIP CODE f + JOB LOCATION 9ft Aw m� ARCHITECT DATE OF PLANS JOBPHONE E We hereby submit specifications and estimates for: � ... AGt, - o�` ..... ....a!'I.+j!..... .. .. ... . ..... ...... ........ ........ .... .... ................. .. ..... ... ..... .. ........... ..... .............. ...... ................... ........... ..... ........................ ............. lore �:- � '.. �3 + +�{�' ... .:. .. .. . ... .. .... .... ... .... ..... ....... .. .. ..... . ...... .................... ........... �?�.1!,ct-..... ... ... T. , ......... cx.1�-......................................................................................................................... Z.....St .cti! ..... .... ...... ....... ............ ..... .. .. ..... ........ .............. ......... ............. . ........ ... . ... ... -` �iv4 {! .... 7 .C� . ..r ...iZ Shf�:-(Lc ... .. .. ..... ......... . . .... .... ... .. .. . � j. 1� ..... Av L.... ?vlt._ ? d ►+ha... .. ........ .ss. .. .. .. .. .. ................. ........ .................. ........ . .. ..... ...... .. .... . ........rf . . . . wt[ w �106.... sad,.. .. .....b t. .`Et�otau.c -. u C��.�-......u�t).... ..... ........ .......................... ... ..... . ................................................................................................................................................................................................................................................... ...:.....................................................................................................................................................................................................................I......................... .............................................................................................................................................................................................................................................. ................................................................................................................................................................................................................................................... ............................................................................................................................................................................................_..................................................... .......................................................................................................................................................................................................................................I........... ................................................................................................................................................................................................................................................... y� ,, �r.,,,Ve 3prop05e hereby to furnish material and labor—complete in accordance with above specifications/for the sum o I tAl4fN f LIMA- tr AWJ+'y`o'f . dollars 6 t)t./ 6V" ). Payment to be mad_as follows: �� 41Y�f�trti�- yl i ✓I� titihActn [��W All material is guaranteed to be al as specified. All work be completed in workmanlike manner according to standard practices.Any alteration or deviation Authorized = from above specifications involving extra costs will be executed only uponwritten Signature orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry Note:This proposal may be fire, tornado and other necessary insurance. Our workers are fully covered by withdrawn by us if not accepted within .""V days. Workmen's Compensation Insurance. 0(CCeptance Of Propo6al —The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized to do Signature J 1 `��+�_—���✓✓✓"`" f the work as specified.Payment will be made as outlined above. Date of Acceptance Signature t You may cancel this Agreement if it has not been consummated by a party thereto at a place other than an address of the Seller,which may be his main office or a branch thereof,provided you notify seller in writing at his main office or branch by ordinary mail posted,by telegram sent,or by delivery,not later than midnight of the third business day following the signing of this agreement. Boston; Massachusetts 021 16 Home Improvement Contractor Registration • Registration: 117699 Type: Individual Expiration: 11/6/2014 Tr# 233360 SHAWN D FITZGERALD _ ---- - --- -- SHAWN FITZGERALD - - - PLANTERS __..-.-__ ..---------- ----____._-- SALEM, MA 01970 Update Address and return card. Mark reason for change. - Address _ Renewal Employment Lost Card SCA I o 20M 05`1 r "...... � `����"""�""�7 License or registration valid for individul use only ' Office of Consumer Affairs& Business Regulation before the expiration date. If found return to: V_QME IMPROVEMENT CONTRACTOR Office of Consumer Affair's and Business Regulation Type'grration: 117699 Individual 10 Park Plaza-Suite 5170 pir-tion: 1 1/612 0 1 4 Boston,MA 02116 SHAWN D FITZGERALD . SHAWN FITZGERALD l PLANTERS gam-- -- — — SALEM, MA 01970 Undersecretary —S—Nt valid without sign- -___ 36-0035,202%% 1 Massachusetts - Department of Public Safety �I I © u•..Ww - - Board of Building Regulations and Standards 01 1 Construction Supervisor Tis card ackno edges that the rc o p ie h hae sjn T aes License: CS 103060 10 rour O tu Soea Construction s nc com'.e Safely and Heakh 5 pLA jAWN D FITZC� -} 5 PLANTERS ST&EE s SALEM MA 01940 i _ Expiration 03/27/2015 (Trainer name-pory commissioner --- - _ w Pr NSA Submitted TO: j. Lob Location: " - Richard Barbau � 19 Beacon Street 383ftu)Lowell Street, Suite 2G,Wakefield.NIA 01880 19 Beacon Street Salem,MA 01970 ivlvw.RyanAndSouRooftng.coni Salem. MA 01970 J Tel: 617571-9056 Enuiil:RvstnAndSons@,NIE.com Prepesaidetw April3,2013 We are pleased to hereby submitthis proposal to furnish materials and labor,cempletell in eccordeoce with the below specid cadens: (Additional charges may apply for any change's not included below in proposal either by request ofowner,or if Ryan and Son Roofingftnds unforeseen circumstances that will affect the performance,quality or integrity of this job).In the event legal action is taken to enforce any provision of this agreement,the prevailing party shall be entitled to all its reasonable costs,.including reasonable in-house or outside attorney's fees. Not responsible for debris in attic. 'r1J, I!Boyd(�(I'RI�(�'I4(130 11Itstallidimsidbto: $10.000.110 • Remove existing siding on house • Prepare existing walls of house for installation of vinyl siding Install Tyvek house wrap on entire house .� . Ittstg�vinyl siding on house BBB. . liist'�11 J-channel to match siding color around all windows and doors,to receive siding Install all outside comers to match siding color Install white vinyl soffit Wrap all soffit,fascia and rakes in coil stock of your choice Clan Up: • Will cover area with tarps to minimize debris • Remove debris related to work- - • NOTE: Please cover any belongings in the attic,as they will get dusty,if applicable Cost details: Includes cost of permit,labor,dump&material pall etdScbednl . -- V payment due upon signing: $2,000.00 Total Cost: Total balance due upon completion: $8,000.00 Kindly remit payment to "Peter Ryan". Thank you! Respecdoll➢Snbmittedb➢: 4Thanrkyou ✓/ acceptedby�i0V tar / All work is 100%guaranteed for craftsm t 11 other warrantees are through the manufacturer.All warrantees will be null&void if job is not paid in fullr left' serve you!!! Ryan And Son Roofing,Inc.is fully licensed(#159797)&insured. CC: Peter o Licensure Information , —X�o�. oG,IH >y�lRcm)Lowell S� pFIH t. Suite 26, Wakelieid,N4A 01880 www.RvanAndSonRooring.com Tel: 617-571-9056 - i,?moiL Ryan.anr5ons(ajNiT:.com Nome Improvement Contractor license: SCAT e ✓/e'�onenrAft,in&(f el �loan<lrraalGr f / ¢ Ofrtt otCgvsvmnr Affairs&B mess RegvWNov reaom...... �r ffri:;.rc/ /1 +� ,x HOME IMPROVEMENT CONTRACTOR Off$r of Consumer Affairs& I•usiness Regulation Registration: 1695M 8pME IMPROVEMENT CON!RACTOR ' -' Expiration: 7/1,2013 Type., i�l-el Private Co gistration. 159797 Type: RYAN AND SON ROOFING ING xprration: 5/29/2014 Private Corporation " - CLINTON GALVIN - RYAN AND SON ROOFING INC.. 93 NEW SALEM ST;: 'WAKEFIELD,MA 01880 PETER RYAN - Und<rsecrefsrp 93 NEW SALEM ST - WAKEFIELD, MA 01880 L_ Undersecretary Construction Supervisor License: 11 �-+ 11a.•Tchu,ett.- pepa:vnent of 'ulrlfic S;r!'rt�.� Sn trtl �J 3uildi '�c mlannn, inQ �I:Uu1:ut7. License: CS 1046M CLINTON GALVIN 102 DEL MONT AVE APT 2 LOWELL, MA 01852 �"`�--"-'%•"'`-'�i'K-'� Expiration: 711MO14 CITY of S:UEml,umsakcxc;sETTs yy BUILDING DEMTMENT 130 WASHINGTON STREET, Ya ROOR T EL (978) 745-9595 F.kX(978) 740.9846 Kt.%f13ERLHY DRISCOLL T MAYOR 1 toit�►s ST.PtE.alts DIRECTOR OF PUBLIC PROPERTY/Bt:B,mG COJ@IISSIONER Workers' Compensation InsuranceAff7davit: Builders/Contractory/Electricfans/Plumbers A s Ilicant Information _El ease Print Legibly Naint:(Ousio4in0eganizatiory Individual): -44 Address: f C City/State/Zip: ga Phone hl: 61i 7-J'9/ q0n; ,tire you an employer?Check the appropriate boss 'Type of pro)eet(required): I. I am a employer with_� 4. 0 1 am a general contractor and 1 6, 0 New construction employees(ILll and/or part-time).• have hired the suMe:ontractors 2.0 lain a sole proprietor or partner. listed on the attached.rheut,t 7. ❑Remodeling ship and have no employees These subcontractors have V. 0 Demolition working fur ma in any capacity. workers'comp.Insurance. 9. 0 Building addition (No workers'comp,insurance 5. 0 We ace a corporation and its required.) ofRccn have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing ropairs or additions myself.(No workers'camp. c. 152,§1(4),and we have no 12. Roof tvpairs insuranea required.1 r employees.(No workers' rump. insurancerequired.1 IJ.�Other �f -Arty applicant mot Omits bar ll must alws All owl the sectiuo blow ahawine their waken'mmpensadon paltry inlumlellan r I herreuwnwe who sul,nttt this anitGva mdleatne they an dame all work and thus Alro outride camnetan mrW auMntt a now affidavit indlatlne cock :C,mtmenn that cheek this box mustmachadm adult.nal•henahowine the nano Drib•nttvomnctan and their w rimn'ramp policy inromuaoo. !ut»an ernp/uyer rhur l►provldln,y lvorken'romprntodaa Guuronee jot my emp/uyses Below/at/he Palley and job sus injorurullaa / ,, Insurunce Company Nmne: !OG f %l- policy 4 or Sclf-ios. Lic, naW__�.. —e�I a Expiration Date• fd / Job Site Address: I9 &J c i9 h t4 City/Statr/2ip: d o-1� Altacb a Copy of the Ivorkers'compensation pulley declaration page(showing the policy number and expiration data). Failure to sccuru coverage as required under Section 2Ja\of NIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a line Of up to 5250.00 a day against ilia violator. Ile advised that a copy of this statement may be furwurded to the Orlica of Llvestigutimts ul'the DIA for inmrmua cowraga verilicaliun. /do hdreby ratify dr ns Ad r es ujpdr/ury tuNas providda above ii's ime and curreei P n f f Ya7 6 D/jic•iul ase Duly. Do our write he r64 afea,ro be cunsplNad by city ur town aIjIelal ! I I City or Town: ._ ._ Pefmlt/I.Iccnlej Issuing Auliwrily (circla una): i1. Iloard of Iivillh 2. Iluildlnq OCportnrmtt .l.Citylfn,vo Clerk 4. Cteetrical Lupectur 5. 1'lunlbing Llepector i b.Other Contact ACORP, CERTIFICATE OF LIABILITY INSURANCE �I—P - - iss'J�6 As)cm�'c�- FIFF'W!"Dis 7FR OF INFORMAI ION ONLY,;Nrl CONrERS NO PlGHTS UPON THE (:FRTIFICAIE HOLDFR.THIS :HRTIFIC A 1'E DUES Nor A F514MATIVCL- OR N&,(.-,AT!VH Y AIALND, ExTFNU OR AL f;R-,I* COVILRA01- AFFORDED Py mr, PC)Lirtr..-,- 3F: uw 'iii!9 1-,ELRfIri,,;A1L OF INS ORANCE DOE'S Nb r ':0NS,1-1T0TE,h is ON IRACr f3CT%A(kLN'T1,If- ISSUING INSURERS},AUTHOR17Fn ,0KfANT ff1hpr, fti"V"IIVtwirler'iO lTT-f1ATI —ji� " 67TL' i 77,0, —1 n'0 k f-,r-o I A ,�m Wi I-T-$t R §GTAti6-N-RWA WEI.i UJ—jo—ot t ....... kl,t M '�rl Telsmrance Agency, rtic, Fql� 181 5 1 -1, 0-.- 7-81, 593./26() 17' 6r4�adway AD:NeSh NAU'E�(U)AFF09.01NI-i:'XWCRALCIF NAP; MA 01904 260� MWJRw A Liberty Mutual Insurafire Gf-oup 0032 Fmp I F,e Home lLmDrw.(jqnon�,1 9r Audubon Rood f APT W; IPd. MA (j,'I 48t) JL NLIMBLP: (-,Oonidl REVfSION NUMSCR: L" vi '7111 p oJc ;P i r All Hrt":p! o T, LL ; + " JN 1. 0 t h I I, iAA M:'� r"llif 11 VOW 'o v vo L`J(;� �UMfit K • 1 rV;)(P Mylly; JAO�L,." :AGM 'Ll "WIX, 11.� WT rV`13 OIL i(l"It y V010Y LF"., "'o'-w r 1!11 N', wc� .11s Iw�' 'AB�Lfr I : -012.1X08112012 "v um- iL' 00 -211 L L I'T1FK;ArE HOLULP LANCE-I J.,,,TICIN �m'rm-"N ny 17 :)Ni Y rw .Ikl M ACURID