7 LORING HILLS AVE - BUILDING INSPECTION Q The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR. 7"edition Building
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One- or Tuo-Fonjdy LisvrlUng
This Section or Office Use Onl
Building Permit Numb . a A lied:
Signature:
Building Commissioner/I for of Buddin ate
SECTION 1: SITE INFORMATION
1.1 Property Address: /t 1.2 Assessors Map& Parcel Numbers
"� L., " t11l/ 1 �Y t' 4" s �I�P Ma Parcel Number
I.1 a Is this an accepted street?yes_ no P Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage III)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required
Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,154) 1.7 Flood Zone Information: "Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 _Owner'of Record: l� N J �N� tK� I f V1 s )j/e
6 r05 V i°N o f r Address for Service:
Name Print)
j� J�_Q D 0
Telephone
Signature
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction FF
❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': n� 0� O
7 17 O(/ D
SECTION 4: ESTIMATED CONSTRUCTION COSTS
7S2.
Offlclal Use Only
Item
I. Building I. Building Permit fee: f Indicate how fee is determined:
Standard City/Town Application Fee
2. Electrical ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 2. OtherFees:4. Mechanical (HVAList:5 Mechanical (Fireotal All Fees: fSu ression
heck No. _Check Amount: Cash Amount:6. Tolal Project CoPaid in Full 0 Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
r.
License Number Expiration Date
N.4n c of CSL- Hylder List CSL Type lace below)
Address T'pe Description
U Unrestricted(uR to 35.000 Cu. Ft.)
Signature R Restricted Ik2 Family Dwelling
.v1 %fasonry Only
RC Revdcnrral Roofin Covering
Telephone WS Residential Window and Siding
SF Revdenual Sohd Fuel Running Appliance Installation
D Residential Demolition
5.2 "lstered Home Impfjavemt Contractor(HIC)
/y /e4)f$ /�3l KL
em f
HIC Com ny Name or HIC Registrant me Registration Number
Ur� �!
A rcs ! ssc _
Expiration Date
Si atyr Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52. 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
[.Signed
his affidavit will result in the denial of the Issuance of the building permit.
ARdavit Attached? Yes.......... N............ 0ECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject� property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
���� SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
2 if 1, �N /C r CP_ ✓`e[ter fi Poi Oeel-+) , 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. 2/Y-4
f ��
Print N
�/col n F
Signatu"f Owner or Authorized Agent Date
(Signed under the pains and penalties of per 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 gf 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.RS, 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 halfbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Protect Syuare Footage" may be suh.ututed for 'Total Project Cost"
IMPORTANT DOCUMENT''@''rJ'cP�f'r1'r1'c'@''�''rl'�''�''�''r�rJ' °
5 C u ern leate of F1an?e Resistarpee 5
S5 ISSUED BY 5
Date of Shipment 5
REGISTRATION 5
5 NUMBER 44
ss Cf10R® 5/13f2008
INDUSTRIES INC.
S r EVANSVILLE, INDIANA 47725 Tent Identification
5 5 p_fZlfp MANUFACTURERS OF THE FINISHED 04629478 5
TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: �5
293200
5 NORTH SHORE RENTAL INC S
5 DBA EVENTS FOR RENT C�
464 LOWELL ST 5
W PEABODY MA 19602741
5 � I
SCertification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 Serial# S
5 8106402(9)
Description of item certified:
5 TENT WALL US2 6'IOX22 WITH
2 CATHEDRAL WINDOW WALLS
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric
JOHN BOYLE STATESVILLE NC Signed:
5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5
O rJ�r Pc PcP�Pr�r1cP�PrJ�rJ�cPcPcPcPcPr PcPcPrJ�cPr�cPEP�PcPc1�rJ�rJ�:2151 312 1J1rJ�rJ�cPcPrgcPcPrJ�cPrJ�i:!li J�rJ�rlc1r�r�cPrJ�cPcPcP�PcPrJ�rJ�cPcPr�cP�Pr1rJLrJ�c fflDL J� �
° `''`''`P-r'rJ'c'@''c'@r'�''�fd'@''c''r''cr'c'l I M P O RTA N T D O C U M E N T'r��PP'���P��r.,PcP�r� o
5 Certificate of FianTe Resistance 5 5 5
5 REGISTRATION ISSUED BY S
rj APPLICATION 'Date of Shipment
s ISR900 5
5 NUMBER iNousTaie iNc s/3v2ooe e
5 EVANSVILLE, INDIANA 47725 Tent Identification
5 Plzl a MANUFACTURERS OF THE FINISHED 04293736
fj TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to:293200
5
5 NORTH SHORE RENTAL INC 5
5 5 DBA EVENTS FOR RENT
464 LOWELL ST 5
5 W PEABODY MA 19602741 5
5 5
5 5
5 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California 5
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 Serial a 8001800(l) 5
5 5 Description of item certified: EIE.ST.4 Toi,20WX30 WHITE.:VINYL 5
5 5
5 Flame Retardant Process Used Will Not Be Removed By S
5 Washing And Is Effective For The Life Of The Fabric C5
5 Signed: 6
Name of Applicator of Flame Resistant Finish
ANCHOR
HOR INDUSTRIES INC.
o cnu�rJ-r1rJr�rJ�u�u�cnu�rJ�rJ�u�u�cPcn�nr�crrJ�rJ�rJ�cl�rJ�cnr�rJ�cPr�rJ�cncru�u�rJ�cPrJr�cPu�cnrJ�rJ�rJcPrPcPrJ�cnr_r-u�cPc,n�nrJ�rsr_r-rJ�u�u�cPJ�u�u�crr.nrrrJ�u�cPcPc.r� �
Ubl Ul/2UUy 14:1U bt73--yb4-141d4 4Y-LtbiwYr enanl wcr r-r-w.z u�
ACORN CERTIFICATE OF LIABILITY INSURANCE
H� ATE 9 AARATFIBIR OFINIP0RUAfP-0jT—
Frank VenutD ONLY A1t0 CONFERS NO FEOE{Fg UPON THE CERTIFICATE
c/oASIA, Inc, al'Fa��T11E COC AQE�AF ORDEQ BYwrTHEaPODLICI�END OWR.
M Main Sheet;Suite 808
Boston,MA0212g NSURE'RSAFFORDINOCOVERAGE �NAiC$
women NaUR91A: bolch•ArnaHcan ImaurenceCompany
Allep ant Management Corp, M671
30D Lafayette Rd.
Rye,NH 03870.000 USURER
WWRER D:
E
COV LIES
THE POLQIESOP INSURANCE LISTED BBLCW HAVE BEEN ISSUED TOTHE INSURED WAEDABOVE FORTHE POLICYPEFVOD INDICATED,NOTWRK9TANOIN0
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS OWnFICATE MAY BE ISSUED OF
MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO At,LTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,AGOREQATE UMfTS SHOWN MAY MOVE BEEN REDUCED BY PAID CLAIMS.
I
GIRMALUABIL" EAw000umPmx a
+ OOATM1IEROMt OP,NENALLNELITY + � a
CLARsaMAD MEDE]XP(ADrenopPeani S
tf'7� i PERSONAi,FADVOWRY 'S
Aee S
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PoLloy P O LOC
DOMOMEDSR,rOIEIMn
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ALL OYMEO AUTOS i I I(P�sa1
ACHEDULEDAUTOe I ( t
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A
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A ORF�r�E7XCjilH1�07 Ea1tME WC$0-90.735.00 �10118,PZ008 11J01/2009 E.L.rAwmOroBur $ 1,000,000
P.4 Da -EA EMPIovEe a 1,000,000
f admpge br bMav E.L.DISEASE-P0. MIT a 1,0001000
OrNER
Location Coverage Pariocit 10/18/8008 11101l2009 Cortllketw. �NHOQ2780396
Cllww: B21
plSdtlPTgNOFaP®IATIDNerLOCAYbNervER0.�rEl[QLalerasMO®eYENDORMFENTIO 44PROUMIM
Courage Is provided far orgy North Shore Rental,Inc.dba:Evers to Rent
time employees leased to 464 Lowell St
bui not subccr*aclors of: Peabody,MA 01960
CERTIFICATE HOLDS CANCELLATION
aHOIAa ANYaFTNEA00VEePOYGW BE CM109A@I aFJQR6Tf6P1fpRlATieM
DAIS THEREOF.TIP.IaMItM a16U{FR PALL ErioaavaR TO NAM 80 DAYe WaNTTDt
North Shore Rental,Inc. NOnce to the CSMFICTTE tKKAIM RUMS)TO TIE LAST,SLIT PAIWRE To DO 50 BHALL
dba'Events for Rem N/POea so WLIdTTIBN M slAe OF ANY MD UPON THR RMMn IN Aa O aR
464 Lowell St
Peabody,MA01900 R AmEs.
ASrniO�RerlleeEfYaTiYe ��
ACORD 25(2001/OB) 9ACOAD CORPORATION 1958
610537 6/5/2009 1 :08 : 49 PM PAGE 2/003 Fax Server
li n :419242 9900099
DATE(MMIDOfM
ACORDr CERTIFICATE OF LIABILITY INSURANCE 06/05109
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Pao
PRO Rental Specialties ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
USI HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O.BOX 53310 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
5
Irvine,CA 92619 jINSURERS AFFORDING COVERAGE
800 854.3298
INSURED INSURER A: St Pad Marine Insurance Co
North Shore Rental,Ina INSURER B:
dba:Events For Rent INSURERC:
464 Lowell Street INSURER D:
Peabody,MA D1960 INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWOHSTANDING
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POUCYEFFECTIVE MUCYEIIPIRATN)N LIMITS
LTR YPE
INSR TOFINSURANCE POLICY NUMBER DAT MDD TE MMW
A GENERAL LIABILITY CK00220071 04/01/09 04/01110 EACH OCCURRENCE $1000000
FIRE DAMAGE(Any oneTve) $100000
X COMM ERCIALGENERALLIABILRY
CLAIMS MADE .a]OCCUR NED E (Anyone penton) $5 000
PERSONAL&ADV INJURY $1 000 000
GENERALAGGREGATE $2 000 000
CENL AGGREGATE LIM TAPPLIES PER: PRODUCTS-COMPIOPAGG $1 DOD 000
X POLICY PRO. WC
A AUTOMOBILELMBILITY MA00200332 04101/09 04/01/10 COMWNEDSINGLELIMIT $1,000,000
(Fa accldem)
X ANY AUTO
ALL OWNED AUTOS r@ f ODILYIN URT $
SCHEDULED AUTOS �^'y
HIRED AUTOS I { ' t�•� BODILY INJURY $
e a 1 (Peraaltlent)
NON-OWNED AUTOS
PROPERTY DAMAGE $
(Peraaitlent)
AUTOONLY-EAACCIDENT $
GARAGE LIABILITY
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGO S
A ExcEssumiuTr 502XA8914 04/01109 04101110 EACH OCCURRENCE $1000000
X OCCUR Ej CIMMSMADE AGGREGATE $1 000 000
S
DEDUCTIBLE
X RETENTION $10000 $
WC 3TATLL OTH-
wORKERB COMPENSATION AND
EMPLOYERS LIABILITY EL.EACH ACCIDENT $
E1.01SEASE-EA EMPLOYEE$
E.L.DISEASE-POLICY LIMIT $
A OTHER CK0022D071 04101109 04/01110
quipment Floater 5,0 D Limit
2.
ecial Form $2 500 Deductible
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIE IICLUSIONS ADDED BY ENDORSEMENTMPEC WL PROVISIONS
This certificate Is issued as a matter of proof only.•Except 10 days
notice of cancellation for non-payment
CERTIFICATE HOLDER ADDITIONAL INSU RED;INSURERLETTER: CANCELLATION
l- - SHOUIDANYOFTHEABOVEDESCRIBED POMCIESBECANCELLEDBEFORETHEExRRATION
DATE THEREOF,THE ISSUNG INSURER WILL ENDEAVOR TO MAILAD!DAYSWRITEN
NOTICETOT,IE CERTIFICATE HOLDER NAMED TOTH ELEFT,BUTFAIWRE TODOSOSHALL
IMPOSE NOOBLIGATION OR LIABILITYOF ANYMND UPON TH E INSURERITS AGENTS OR
REPRESENTATNES.
AU�T�°RQE REPRESENTATIVE
- c7 �A/
ACORD 25S(7197)1 of 2 #S3873256IM3873253 AXLlG O ACORD CORPORATION 1988
Events For Rent Page 1 of 2
Status: Reservation
464 Lowell Street 978-535-5035 phone Contract#: 211923
Peabody, MA 01960 978-535-4561 fax Reserved Date: Wed 8/26/2009 9:OOAM
www.eventsforrent.com Operator: KEITH R.
Customer# 5269
GROSVENOR PARK NURSING HOME 978 741-5700 FAX 978 745-8888
7 LORING HILLS AVE
Salem, MA 01970
Qty Key Items Rented Status Event End Date Rental Fee
1 1900330 ( 745) TENT FRAME 20X30 Reserved 8127109 5:00pm $480.00
1Day$480.00 3Dys$480.00 1Week$960.00 4Wks$2,880.00
8 180012000 ( 685) TABLE BANQUET 30X96 Reserved 8127109 5:00pm $64.00
t Day$8.00 3Dys$8.00 1Week$16.00 4Wks$48.00
TABLES MUST BE PROTECTED FROM WEATHER AT ALL TIMES
TABLES RETURNED DAMAGED ARE SUBJECT TO REPAIR COSTS
PLEASE DO NOT STAPLE INTO TABLES FOR THE SAFETY OF OUR CLIENTS AND STAFF
1 060018000 ( 242) CHAIR SAM FLDG BLACK Reserved 8/27109 5:00pm $1.10
1Day$1.10 3Dys$1.10 1 Week$2.20 4Wks$6.60
TO MAINTAIN QUALITY.PLEASE REFRAIN FROM APPLYING STICKER-LIKE MATERIALS OR
OTHER SUBSTANCES TO CHAIRS
30 060018000 ( 242) CHAIR SAM FLDG BLACK Reserved 8127/09 5:00pm $33.00
10ay$1.10 3Dys$1.10 1Week$2.20 4Wks$6.60
TO MAINTAIN QUALITY,PLEASE REFRAIN FROM APPLYING STICKER-LIKE MATERIALS OR
OTHER SUBSTANCES TO CHAIRS
Qty Key Items Sold Price Each Price
1 650025000 ( 956) LABOR CHARGE Selling 50.00 $50.00
1 650025000 ( 956) PERMIT FEES Selling 150.00 $150.00
1 101970 ( 1027) DELIVERY&P/U SALEM, MA Selling 50.00 $50.00
DELIVERY AND PICKUP
Delivery Date: Wed 8/26/09 Contact: LOIS
Pickup Date: Thu 8/27/09 Phone:
ORDER WAS PLACED BY LOIS ON 8/18/09
DELIVERY WILL BE ON WEDNESDAY MORN. BY 9:30AM
PICK UP WILL BE ON THURSDAY MORN 8127/09
TENT WILL BE STAKED IN PARKING LOT
CUSTOMER WILL CALL WITH DIGSAFE TICKET#20093404314
***$150.00 LABOR CHARGE IS FOR EVENTS FOR RENT OBTAINING BUILDING PERMIT AND FIRE PERMIT ***
***$50.00 LABOR FEE IS FOR DRILLING AND PLUGGING STAKE HOLES ***
***NON-REFUNDABLE RESERVATION FEE OF $430.00 WAS RUN ON CARD#**** **** ***5 001 EX 02/13 ****
*** NAME ON CARD: NANCY ESCALADA****
*** BALANCE OF RENTAL WILL GO ON CARD BEFORE DELIVERY****
Reservation fees are non-refundable
Payments made on this contract:
Rental/Sale Paid $430.00 on 18-Aug-2009 3:33 pm Credit Card Amex xxxx-xxxxx-25001 Auth:169094
Total Paid $430.00
1 agree to pay the above amount according to the card issuer agreement. SIGNATURE:
Printed on 8/20/2009 8:11,54 am Modification#3
Software by Point-of-Rental Systems WWW.POINT-OF-RENTALCOM
Contract#: 211923 GROSVENOR PARK
Events For Rent Page 2 of 2
NURSING HOME
RENTAL CONTRACT Rental: $578.10
This is a contract.The back of this contract contains important terms&conditions including lessor's disclaimer from all liability for Damage Waiver: $0.00
injury or damage&details of customers obligations. These terms and conditions are a part of this CONTRACT! Sales: $200.00
"If equipment does not function properly notify lessor within 30 minutes of occurrence or no refund or allowance will be made.
'RESERVATION FEES are NON-REFUNDABLE if cancelled. Delivery Charge: $50.00
'ALL rental items should be considered USED unless otherwise noted.
'ALL deliveries are strictly TAILGATE deliveries unless otherwise arranged.'EFR is not responsible for and will not secure rental items inlon customer vehicle upon pickup of items-customer is responsible Misc.Charges: $0.00
for securing items to his/her vehicle for safe transport to&from Events For Rent. Subtotal: $828.10
'Unless declined.I agree to the Damage Waiver charges for the rental items for which Damage Waiver is offered. D W.C.is
offered on only selected items.
`Events For Rent reserves the right to apply appropriate charges to Master Card,
Visa,Discover or American Express for late,lost or damaged items. Massachusetts $36.13
"Upon receiving rental items,I acknowledge receipt in good order of the items rented, u
"I certify that I have read and agree to all terms of this contract. TOTAL: $$64.23
PAID: $430.00
SIGNATURE: AMOUNT DUE: $434.23
GROSVENOR PARK NURSING HOME
Modification#3
Printed on 8/20/2009 8:11:54 am
Software by PoinMof-Rental Systems W W W.POINT-OF-RENTALCOM
-� CITY OF S.uEms AxSSACHUSETTS
BLIIDNG DEPARTMENT
w.=v, �e�a•l2,0n\w��/.►SHNGTON STREET. )aa FtoOR
TEL (978) 74S•959S
F.ut(978) 740-9846
KI.%l3ERLEY DIUSCOLL
�1YOR IliOhtAi ST.PDaRRs
DIRECTOR OF PLBLIC PROPERTY/BL•QDNG CONOUSSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
>nnllcant Information // Please Print Legibly
Naine 1Busirwss.Organrrafiomindtvidual): ✓e/Z�S F r ee lz 6±14e�/ 4N7/ s�ONo i�IPK < ra,,O,
Address: ybLl LDw11c/� 54—;
City/StatdZip: ea b0 T dw DI�60 PhoneN:
,ire yo as employer!Check the Appropriate box: Type of project(required):
I 1 am a employer with � m 4. ❑ 1 a a general contractor and t
e have hired the subcontractors 6. ❑New construction
employees(full and/or p -time). 7. Remodeling
2.❑ 1 am a sole proprietor ar partner- I isted on the attached sheet. : ❑
ship and have no employees These subcontractors have It. ❑ Demolition
workingfor me in an capacity. worker'comp.insurance
Y P tY• 9. ❑ Building addition
No workers'core insurance 5. ❑ We are a corporation and its
l F 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing mpain or additions
myself.(No workers*comp. c. 152.41(41 and we have no 12.❑Roof repairs
insurance required.)t employees. LNG workers' 13.❑Other
comp. insurance required.)
-Any applicant that chocks boa el MUM aim fill uw tie seatie baler shoeing their workm'cwnp nsaitn policy infurmatlos.
'i ianaueran who sul adl this affidavit indicting they an doing all work and the him outside coam"on,nmO1 sulanit a nee amdavil indic edno suck
:r,m1ra9on that chnk his box mua aaaattd an additival Jhart.hewing the nose of the abawmnrctan and thck woskas'corny.policy inf x"aso a.
/as an employer that fir providing workers'compensaden/nsaraace for my emplaryeas. edow/s the pulley onsirm slkr
information. n T
2
Insurance Company Name:
Policy N or Self-ins. Lie.N/: LtJC — , S�_ g L9 — 7 3S —2O Expiration Date:
Job Sire Address: -2 /� �r/rkr5 /-/, //5 City/Stawizip: Se. levee fi/6/ Dl 970
,\ttack a copy of the workers'compensation policy decla albs page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a. 152 can lead to the imposition of criminal penalties of
fine up to S 1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a Jay against the violator. Ile advi.Axl that a copy of this statement may be forwarded to the Office of
Inccaugationa ui the DIA for insurance coverage veritieation. -
/do hereby certify under rah its mad penahles ojperjury that the iteformadoa provided above is true and correct
Dole,
Q
tyfcirl use otdy. Da not write in.this area, to be.arnpleted by cify or town it/�la•iaL
City or ruw•n: Permit/lAcenseN___.
Iuuintl Aulhonly (circle nne)c - ----
I. Ituard of Ileullh 2. Rudding Department 3.City/rows Clark 4. Eltctrical lotpector 5. Plumbing Impector
6. Other
l„ntaet Perion: _ ._ _. __ ...Phone N: _.-