HomeMy WebLinkAboutBuilding Permit # 1/18/2017 OORTH
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
permit No#:
Date Issued-.
IMPOWrANT: Applicant must caznplete all items on this page
MAP �; r�PARCEL.., ZCf�IING�T�ISTRICT r ��,HH�s hoc/O�strlct,, /r� yes ,�/no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
[I New Building Li One family 0 Industrial
0 Addition Li Two or more family 0 Commercial
0 Alteration No. of units-:-
0 Repair, replacement E Assessory Bldg 0 Others:
[I Demolition [I Other
❑ -epfib, 0WbIl
Q Flbo'dpIain Wetlands an,
76Watershed
��WaterlSevuer ,,
DESCRIPTION OF WORK TO BE PERFORMED:
2- Identification- Please Type or Print Clearl
OWNER: Name: C y P h o n e: q-1',S- (Cj CI-I
Y L—
Address:
b-ne.
-tb'r 's
P
Q bhtrac Neim'
Email..
a
pervisors,,:,
Construction;License: P
.......
"n
Hbmo,,,�Improvement
, :License: 05 2�0��
ARCH ITECT/ENGI NEER-- Phone:
Address: Reg. No,
FEE-SCHEDULE:BULDING PERMIT:$1ZOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F.
TotalProject Cost: FEE- $
Check No.: Receipt No.:_
NOTE: Persons contracting with unregistered contractors do not have aceo t guaranty fund
Signature e-of-contractor '- - , ,- J
nnf irp. Anpr-tibwner
RISE60 Shawmut Road,Unit 2 1 Canton,MA 020211339-502-6335
ENGINEERING www.RISEengineering.com
OWNER AUTHORIZATION FORM
Patricia Hamann
(Owner's Name)
owner of the property located at:
67 Raleigh Tavern Lane
(Property Address)
North Andover, MA 01845
(Property Address)
Merrimack Valley insulation
23A Sullivan Rd
Billerica,MA 01862
hereby authorize (Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property.This form Is only valid with a signed contract.
Patricia Hamann
Owner's Signature
12/14/15
Date
........
tAORTf
.Town of ,, 6 ndover
No. -effort,Zat
Y Q L-A. h ver, Mass, . 7
C4CMILN[WIC�[ yot.
BOARD OF HEALTH
mT LD
Food/Kitchen
PER T Septic System
THIS CERTIFIES THAT awoAt 14 MA.�4.!!+ BUILDING INSPECTOR
......................... ... .... ........®........................
Foundation
has permission to erect.......................... buildings on Api... . R llct ........�.. w........ • Rough
to be occupied as ........1. �1�.�........t4..... IL.................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IT S ELECTRICAL INSPECTOR..
UNLESSTI Rough
Service
BUILDING Fina
I CT R
GAS INSPECTOR
Occupancy Permit Required to Occupy PuRough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Fecteral ID it 05-0405629
RISE Engineering 1"11 Contractor Registration No 8186
MA Contractor Registration No 120979
CT Contractor Registration No
RIS ('i0E .5jurivintit Road,Canton,[VIAING' CONTRACT
(401)784-3700 FAX(401)784-3711)
Page
..........
PROGRAM THIS CONTRACT ISENTEREDINTO CIETWNFI
EELSE
CNIA-HES ENG
AND THE COSTOMER FOR 101OHK AS
DNCSCnIBEO BELOW
DATE CLIERti) WORK ORDER
CUSTOMER PHOME
Patricia Hamann (979)697-0298 10/25/2016 437883 35002
SERVICE STFIFIFT IBILLING STREET
a 4-
67 Raleigh Tavern Lane, 67 Maicigh Tavern Lau,
SERVICE CuY,SFATE,ZfP w, BILLING CITY"STATE.,ZIP
North Andover, MA 01845 Nort-h AlIclover, MA 01845
J013 DESCRUPTION
I.IEAI.XH&SArirry: I-Live your heating systen)used up and retested H)he sure that tile undiluted thic gams(10 not cNeccd 100
pairs per million(ppm)carbon,monoxide,Wcatherization work cannot proceed until this is fixed.
$0,00
HAZARD certified
IMMER:We have identified that there are recessed lights present in your home,unless the reeessed lights a
as IC-rated(Insulation Contact Ratc(l)we will create a 3"clearance space around the fixture by using fiberpkiss blanket insulation as
a darinning material,lit)insulation will be installed across the:top and elosF(j cavities which t:oittain recessed lights will not be
insulated.
$0.00
AIR SEALING:Provide labor and materials to sea[areas of your home,against wastchilexcess air I(Nikaj;e. This Work will be
performed in concert Witt'tile use ofspecial tools and diagnostic tests to assure that your]ionic will be left Witt,a healthful level of
air exchange and indoor air quality.Materials to be used to Wal your home can inchitle caulks,loans and other products. Primary
areas for sealing include air leakage to attics,basements,attached garages and other unheated area,-,(windows are not generally,
adtlressed.) This will require(12)working hours.A reduction it,collie fee,per routine(efin)()fair infiltration will occur,but the
actual number of e:fm is not guaranteed.
At the crialpictiott()(tile weitherization wok and m no additional cost to the llomemvaer,a final blower door and/or eonlb istion
-actor to ensure tile safety of tile indoor air quality.
safely analyNis will be condumcd by the sub-conti
$1,020.00
DAMMING:Provide labor and materials to install it 12"layer of R-38 unlaced fiberglass baits to(92)square feet for damming
purposes.
$IMM
ATTIC M.,AT:Provide labor and materials I(.)install an 8"layer of R-28 Class I Cellulose,added to(432)square feet of Open attic
space,
$591.84
AT`NC FLATProvide labor and materials to install an 8"layer of R-28 Class I Cel Ili lose added to(384)square feet GNP-Ifflic
space,
$526.09
STORAGE BARRIER:Homeowner is responsible,liar the removal of the stored hems blocking the installation ofweatherization
work in the attic, Removal must occur prior to the.scheduled work start,SPECIFICL
ALY 111'?,MOVI-1 ITIE STORAGE AND
FLOORING TEMPORARILY FROM BOTH ATTICS.THE FLOORING AND STORAGE CAN BE m.0 BACK IN THE AREAS
IN WHICH THE INSUALTION WILL NOT BE ADDED.
$0M0
ATHCACCESS:Provide labor and I back of the kneewall hatch with 2"rigidTherniax board,and seal(lie
c(lge of the hatch with weatherstripping.
$60.00
[� Federal In#05.005629
! RISE Engineering RI Contractor Registration No 8186
MA Contractor Registration No 120879
CT Contractor Registration No
RISE60 shawmnl Road,Canton,MA CONTRACT
ENGINEERING'
(401)784-3700 FAX(401)784-3710 Page 2
PROGRAM T%S CONTRACT IS ENTERED[Nr0 BETWEEN RISE
CMA-HES ENa1NEERING AKOTM CnSTOmS FOR WORK AS
DESCRIB€:0 BELOW
PHONE DATE eLtENr4 woRK ORDER
cusrouaR
(978)697-0298 10/25/2016 437883 35002
Patricia Hamann
SILt.1N0 STREET
P67Rat
STREET
igh Tavern Lane 67 Raleigh Tavt rn Lane
OILUKCa Wy.STATE,ZIP
WV.STATE.ZIP
Andover,MA Ol$45 North Andover,MA 01845
JOB DESCRIPTION
ATTiC ACCESS:Provide labor and materials to install(1) easily moved,insulating cover for the attic access folding stair. A
small flat surface of plywood will be created around the opening within the attic. 'Rus will allow the cover's integral Weather-
stripping to restrict air leakage.
$237.65
VEI ITQ ATION:Provide labor and materials to install(2)insulated exhaust hose with roof mounted flapper vent to exhaust
existing bathroom fan(€).
$237.50
vENTILATION:Provide labor and materials to install ventilation chutes in(60)rafter bays to maintain air flow-
$)20.00
gASFNIENT CEII I1qG:provide labor and materials to install(92)linear Feet of R-l9 unfaced ftbergtass insulation to the perimeter
of the basement ceiling at the house sill.
V61.00
i
1—_
Federal 101E 05.0405629
RISE Engineering RI Contractor Registration No$186
MA Contractor Registration No 120979
CT Contractor Registration No
RISE
Ib0 Shawmul Read,Canton,MAENGCONTRACT
(401)784.3700 FAX(401)784-3710 1� 1� V
Page 3
PROGRAM
THIS CONTRAG71SEHrERED INTO BETWEEN RISE
CMA-Figs ENGINEERINOAND THECUSTOMER FOR WORK AS
DESCRIBED BELOW
CUSTOMER PHONE DATE CLIENTP WORKORDER
Patricia Hamann (978)697-0298 10/25/2016 437883 35002
SERVICE STREET BILLING STREET
67 Raleigh Tavern Lane 67 Raleigh Tavern Lane
SERVICE CITY,STATE,IIP BIWNO CITY,STATE,ZIP
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRH TION
RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Not amount. Currently,
for eligible measures.Columbia Gras offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for
the Air Scaling measures up to the first$680 and an additional$340 if savings are justified by the auditor.
For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow
in your home both before the work is begun,and after the weatherization work is complete.We will also conduct a full assessment
of the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you. Total
allowable weatherization incentive is$3,110.
$90.00
Total: $3,232.67
Program Incentive: $2,702.00
Customer Total. $530.67
r We AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
�j
'Five Hundred Thirty&671100 Collars $530.67
UNPAID BALANCE AFTER 30 PAYS.BEE REVERSE F R IMPtlRTANT INFORMATION ONUPON FINAL INSPECTION AND APPOVALRY RISE ENGINEERING,CMOUGF1STO GUARANNTEES,RIG S OF RECISIOAMOUNT DUE IN FULL N SCHED11UNG,AND CONTRACTOR EST OF 1%VALL 06CREOISTRATO�
DO NOT SIGN THIS CONTRACT IF THERE ARE LANK SPACES
Nathan Weiss
AUTHORI7,EO SIGNATURE-RISEEngf Ming CtlSTOAt ACCEPTANCE
HOTS:THIS CONTRACT MAY BB WITHRRAWN 6Y US U NOT EXECUTED WITHIN DATE OF ACCEPTANCE
ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AHD CONDITIONS ARE
I� 30SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK
I' GAYS. AS SPECIFIED,PAYMENT WILL BE MADE AS OUTLINED ABOVE
ii
��"[� { (� / �j ( {�/�( [J �I [ �{ (� �}J ( MERRVAL-03 WEJE
CL�ll\STi3�l#CA tl E l F L[7/r�LJ U 1! Y ���14�11IQA17V�'-'J 'L� flA'S'E[IhthiDDfYYY'!J
6/13/2046
THIS CERTIFICATE 15 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 POLICIUS
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURFR(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IR PORTANT: It the certificate holder is an ADDITIONAL INSUPED, the pDlicy{ies) must be endorsed. If SUBROGATION IS IAIAIVFD,subject to
the terms and conditions of file policy,certain policies may require an endors(?ment. A statement on this certificate does not Confer rights to the
certificate holder in lieu of such endGrsement(s).
CONTAGT
9RODUCER
Automatic Data Processing Insurance Agency,Inc PHONE — 1 FAx
fAfc.Nn.Ext}:_ I RlC,Na
I ADP Boulevard e-rtAIL
Roseland,Nd 07066 ADDRess:
_ fNSURER(S)AFFORDING COVERAGE
INsuRskA:5StarV3AAIG AmericalTAlferrlativelnsuran —
MSURED l)Ilerdimck Valley lns"lanon Cori rtasusr.Re:
._..
23a Sullivan Rd UrSURERC:
North lNlerica,MA 01862 INSURER D.-
INSURER
:INSURER F
COVERAGES CERTIFICATE NUMBER, REVISION NUMBER:
Tt m M TO CERTIFY THAT T"a POLICIES OF INSURANCZ 1,15TF-D BELOW VARVE BEES}ISSUED TO THE INSURED NXj1ED ABOVE FOR THE POLICY PMO})
INDICATED- PEOWJ1THSTANDING ANY REQUIREMENT,TERM OR CONDIT10N OF ANY CONTRACT OR G-s HER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE Pj)AY BE ISSUED OR MAY PEP.TAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEPON IS SUBJECT TO ALL THE TERMS,
EXGi_USIONS ANIS VW!DITIONS OF SUCH POLIGiES.LINNTS SHOWN MAY HAVE 13EEN REDUCED BY PAID CLAIMS.
----- - ---...—..---'----- -- ---- _
SIIDR -- I 3��L1CY CFF Pl7LIGYEXP UrATIs
L TYPE OFRISURANCE IfplSall`N>3� POLICYNUtiBER t f.I?;Woo)yYN)I MMInDI'MYII
GENERAL LIABILITY I I EACH CCCURRSNCE j 5
r— 4 DAn�E WHENI
I CO1dtSERCIALGENi7HALL1.4BILCTY = PREMISESIEaaccumpc3)_.,r
j�� :GIAIFhS-;7ABE pCGUR !' I 1-iAFD EXP[r%ny wilGeoscnl _.-
t �
i I � GFNCRALAGGREC!`t
GEta'LhGGREGkiPLlSt;TFPPEJESFER: 1 PRODUCTS-COMMOPAGG IS
e � I—,PRC-
POCKY i : RY LOC 1 4
E I AUrOLip81LEL1A81LIrY I � � l CORi8IMED5INGLELI[:ttr —
ra Ell
idnnl S
AtaYAUTO 1 i BOGILYINJURYI'll pefson}
! ALLC74:'NEO $CH6DULED l apgtLYlN]URY[Farecc:denl)I5 -
----..
3 AUTOS ,4iTi'D5 I I i PRPERTY DAMAGE g
i NON-OWNED
HIRFA t.UTQS f,UT05 l
-.. U'daR6LL4[JRS �^ j EACH OCCURRENCE
GCCUR
Ei{CE{55 L1AF CLAY,ciS MADE I AGGRECi,TE-__--.
P,eTENifOiV
VdORILERSCOAfPENSATIDN �r WCSTATU-
! I IAND Et:1PLDYERS'LIABILITY YIN /� TCRYLIAiSTS E??---_._.....-_ ._.... . ...._--
i Ear F'10FRIETORIPARRE-WEXECI.III IV19WC7491113 61't8120.16 61'18)2097 EL IACH AGCI6EPST 'F�CWCED? NrR __r.__..____EL.DISEASE-EA EYEIryesdescfih=undsr e,I 015 SE
S 9,QOL3,17QQ
{OeSCFiIP�G.IOFaFER:tTiO:iSf�grp:+
nGS`CrilPilePJ OF OPERATIONS!LOCATIONS!tlEHSCLES [Attach AG(]Rn 104,Additiun.i Remarks Scheflul%it more space is required)
1
it
i
i
_CERTIFICATE HOLDER CANGELLATION
SH013LD ANY OF THE ABOVE DESCRIBED POLICIES 13E CAi3CELLED BEFORE
TWIT EXPII7ATIGIN DATE TiIEREOE, NOTICE WILL SE DELLVERET3 IN
{ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Norlh Andot,er,M8SS8Clii15eiIS
120 Main Street
ITHDR12ED REPRESENTATIVE
North Andmer,MA 01845 i
— 1
p•1958-2(I'l0�;COl2D CQft?DRAT lC]N. All riLUlits reserved.
ACORD 25(2090105) The ACORD dame and logo are registered manes of ACORD
`0 CERTIFICATE OF LIABILITY INSURANCE nAT1110712016 )
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(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS VVAIVED,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).
�PRODUCER NA1�IE�CT CarOIynACOUghlin
j Charles J Coughlin Insurance
PHONE (g78)957-3588
14 DinleyStreCt E4AINC N t.
1 P.O,Box 10 ADORE ..... oughlinins.com
.
Dracut,M A 01826
_ INSURER A, Northland Insurance Company 24015
INsuRED MerrimackValley lnsulalion Corporation Joseph A.Ryan.Jr. INSURER D, Safety Standard _ 39454
23A Sullivan Road 1NSISRERc: Torus Specialty Insurance Company A0159
N. Billerica,MA01862 INSURER D:
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 PER1013
E 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.
C TYPE OF ILTR ...__ WSURANCE ADDL SUERYEFF Y E%P _
INSD ❑ POLICYNUMBER M ❑ P�❑ LIMITS
A MNWERCIAL GENERAL UASILIfY W8274182 01121!2016 01/2112017 EACH OCCURRENCE 5 1,000,000
�_— oAr,+Act=fn(tE7J1EC) 100,000
CLA1t08-.IAOR OCCUR PREWSESI£aoccuaortcel
MED EXP(Any one person) 5 5,000
PERS011ALa AOV INJURY $ 1,000,000
caENLAGGREGAIFUMTAPPISESP8R GENERALAGGRcGATE $ 2,000,000
PGLICY I
JEn LOC PROi'WIM-CCkIlPlGPAGG 5 2,00{),000...
OTI-EER I s
B AUTOM091LELMIIITY 6205006 1112512015 1112512016 CDrLRINEO SINaLE LIMIT s 1,000,000
{Ea accident) _
ANYAU10 BOOILYINJURY(Per person) S
�'.
OWNED SCHEMED SCOLY INJURY(Per acctdDnI) $
ADDS GNLY AUr05 -- T
AHIRMUTO _ / hi.`]I`40WiJE0 PROPERTY DAiM,GE T' S
AUTOS ONLY V AUT05 aNLY
1 5
C ✓Iurm3REL+AMAU _ ex.eUR 87593L161ALI 01/2112016 01121/2017 EACHCCCURREtcE S � 1,000,000
EXCESS L[AU .. _CLAIrAs-A1ADEf AGC�`IEGATE s 1,O00,o0d
1 CEO RETENTION S [{ ----- S
1 W0RKERSCOMPENSATION PER I D1Tt-
?. AND EWLOYERS'LIABILITY
YIN STATtJ1E___I__-.
ANYPROPRIETOR PARTNERrEXECUTNVF NIR E€_EACH ACCIDENT S
3 tlFFiCER1t:E41pFJt EXCLUUE07 —...._—.�._-
IMa,tdatory in NH1 1E.1_.DISEASE-EA EMPLOYEE $
3 It yes,describe urde� EL(DISEASE LlrydT 5
OrSCRIPRON GF O.ERAl1ONS below _
i�
DESCRIPTION OF OPERATIONS f LOCATIONS VE11101-;S(ACORO 161,Additional Remarks Schedule,may be attached kl more spgco is required)
Insuiation Installation
i
CE=RTIFICATE HOLDER CANCEL[ATiON
SHOULD ASSY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN
i
Town of North Andaler,M assachusetls ACCORDANCE WITH THE POLICY PROVISIONS.
120 Main Street
NorthAndOaer,MA 01845 AUTHORIZED REPRESENTATIVE
I
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
:l/ie Ct1 r rlr�rw'flrrXrrft/z r� ' tas �cYd cr, c� t,
1
Department gjIndusli-iti'Acei(lents
Qf
'lr4, �a fly f "rz, �i z gon Street
ui rBoston, MA 021'11
btr Wft7.mirls,V.go 111(thl
t rkers" ;cfmpeifsafion Insurance
11fidvit-
,pLIt ,illlformation p�le �s�eaPr/in� 'sf �a Irr
l�
aainc,(tirisiiiess/oi-purrrir,;rtis`rnllndivi(Itial): 11 eirii-nark Valley 1175UIation Corp.
Address: 23 A Sttliivan Rd.
(..A 1 �J la�atu/i�,i a: I illeric MA 01,862 . . -_.._. __.. _. Phoma U.: 978-888-3495
Are you sear cnalrlovar? Chock the approl>a-kite box: hype of aro ect req uit-e�c�l
r1. 1 am a general contractor and 1 1� J �".t ��
q 1,� l acct is envloycr with 1�3 �� �� �fc,w carr trua�.lrol�a
c.na�lr> ees full and/or arta have hired the sula-crania ac;;tor,s �'
1 Jr (' {� _t t n�ac� �;. �.�
l:ama scric;proprietor car pa�artne.r listed on the attac'l-led sheet. 7. _ I�csraaocle lira
These sub-colatr∾tors have
"hit)and havc, nc'a'naployees 8, ❑ Demolition
1 workinat for inn in ally ea acil:', employees and haveworkers,
1 t'ee uitc;cl. � .� l � `'. [� Wa77ar.cr t+5ccarlarrr<rti<an anci its 10.
. � l.itri'Iclrrat�;telcfrticrrr
F to wear ccs c;ota°rla. insurance I ' 0.(] l;lec;la ic,al repairs tsar addilions
1 ]
3.El
I am ruyselal(aINoeowner doin-wv rker�•s' cotnr�llworl<�. rightoffiwcrs have ofexe ptionclerNl(Kl-, 12.� C`tic>rrf`ling rcpair�claairscar additionsrnsuraanc,e rcacturred.J r c. 1 S2, x,1(1), sand weh have no
employees. [No workers` s
13.X Other.–Insulation
i _._._.._._ _.
COMp. insurance rccluired.J
rinw°applicant tfaar chedt ,",lynx tt l rrrttst.also till out tho Section below showinp,their workers'compensation policy int61-111aalion.
itonrc rbwarexul wYlta',r suhnwit this affidavit indivar.inl,thay are during all wvoik and that hil-,011kik c0artr,'ICt0a:c must subrnit.a rr€�wr;rM'fitlarvit inelicatin�sucar.
:contractors actors that check this hcs.e mural attsaclaccl aan�ulditiarwal sheel a,dlowhrt;the name of the Sub-eont.a act or"trnd statte wylrether ol,not those ea'ar:itict,have
rnpfoycca. Il'thes Still-cont e aelaara have employees,they must provide their eworkcrs'comp.policy number.
— 1 rrrrr carr clh lcl,that rs lro idht,-ivorhers eom eosrtiora insll rrccrr•eray errrplr%tcdw. Below islle lo--C_i._ y
arrrtjCrlr site
ire formation.
insurance Company warrc : 7sir V3 AAIAmerican Alternative Insurance
---------------
Colicv lel or Self ins. lsic. it: V9WC7491.1.8 .. � _- -._ l xpiraation 1)atc 6/18/2017_
Job Site Address: C',ityl8tate%.Ii1a:t� odd ,:-� ll� P1(
;<t
tt:�ach it copy of the�w or
` 1 �` � •lccrs' coraalacrrsaatirtaa policy clec°laaratic.,u page. (showing„ the peliey raaaraaber•and expiration c4 rata*.).
l";ai'lure to set,ure coverage ars rectatired render Section 2:5A of MCi1.,c. 152 carry lead to the in�rlaosition o1"criminal penalties ora
fine;uta to$1,5(10.CO and/or orae-year inatarisonrnent,as well ars civil penalties in the "orm o�laa STOP WORK C)ftl:)E"R and a 1iucs
of t.r1a tea`250.00 as dray against file^ violator. Be advised thart a coley of this sl aternent may lac; forwarded to that:,011-we of
Mica stigations ofthe DIA for insurance covcraafe verification.
I(to hereki,eerl4j?under the tacrirn rind lac ntilties ty,l e jrrr,lr tlrrrt the irry'«r°rrrati err 1rr'craxr'ded above is tr•r e and coal eet.
o
17Me-
.
lrwrra bf..._ /8 88£3 34,3.;r
c
ficial itve r u/r. Do nol ra>4le in l/riv ger-ea,to be completed by ally ojr horn of
ficitrl
City or':l'oawra; w .w.._.._ _.._...._. _ .....
Rssoiar zullrcarity(circle orre);
i. Board ofHealth 2. Building h)elaatrtment 3. City/Town Clerk 4. Electrical Inspector, 5.PiraInsimrten•
6. Career
Contact Person: _ __...__ _ I'lrone,il;_�________,
s
e
Office of Consumer Aff;~lirs and BILISiness RegUlatiari
?Q Dark Plaza- Scrito 5,1701
Foston, Massachusetts 012116
Home Improvenier4t.Contrac:tor Registration
Type; Corporation
Registration: 180506
Merrimack Valley Instflation Corp Expiration. 11/23/2018
23 A Sullivan Rd
Billerica, ISA 01862
Update,address and return card. Mark reason for change.
rr, rrrrrrnaarrrrr//f n�`E ✓C�rr.,rrrfrrrc,f�t
-. office of C;onsurnur Affairs Business Regulation
ROME IMPROVEMENT CONTRACTOR Registration valid for individual use only
Type. Corporation before the expiration date. If found return to:
sOffice of Consumer Affairs and Business Regulation
FieRitr atLq EMT,tic>rt
,r�u It3 rztJfi I'p/131 Cr16 10 Park,Plaza-5uite5176
Boston,MA 02116
Morrirtlaok Valley Insulation Carp
Joseph Ryan
23 A Sullivan Rd
Billerica,MSA 01862 �Undcrsccrctary��_ .d CTt�Vr�dt)w�
i hout signature
'p,
j
pS r' G..,l-0/5541
j,
JOSS'VE A RYAN,.- � i���J�
00 f�:lar:,c+ait [l✓J ,✓.a