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Home My WebLink AboutBuilding Permit # 1/18/2017 fif %AORTN BUILDING PERMIT 0. TOWN OF NORTH ANDOVER N APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received TED CH U Date Issued: I ut , Applicant must con :ms on this page LOCATION PROPERTY OWNER &A Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential [J New Building ( F`One family ;n Addition 0 Two or more family 1.1 Industrial 1teration No. of u-nit-s: ❑1JCqmmercia1------ Ll Repair, replacement 0 Assessory Bldg El Others: 0 Demolition 11 Other 3 DESCRIPTION OF WORK �O BE PERFORMED: ( r,fJ�Q E� Vu-�Q c vssk—W I J r J Identification- Pleas Type or Print Clearly OWNER- Name: J k-,/\" Phone: I Address: LA ej -1— ---------- Contractor Name: VQ V wiv+\ Phone: Email: Address:',-)?o r-1 lk--' Supervisor's Construction License: —Exp. Date-,-9,, L Home Improvement Licenser Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: FEE: $ Check No.: �� 1 0 Receipt Na.: NOTE: Persons contracting with unregistered contractors do not have access to the guar afityfund' 01-01 9677:0011, N®RTH '� own of � s � A. 6 ndover ® 0 o . LAK, h ver, Mas cocnicnewoc� A�'9ATED s u BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System i THIS CERTIFIES THAT ............. BUILDING INSPECTOR has permission to erect buildings on4% Foundation . Rough i. t0 be occupied as ......... :. ....,. .,.... .i..:., ......,�....... ......, . ............................................... Chimney provided that the person accepting this permit sha 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 PERMITEXPIRES I6 MONTHS ELECTRICAL INSPECTOR: UNLESS C T TL T Rough Service .............. ....... :, - ... .,.,......................... Final BUILDING INSPECTOR GAS INSPECTOR ccupancv Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Mall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the wilding Inspector. Burner Street No. Smoke Det. DocuSign Envelope ID.EDC15234-6E91-42E1-9818-AB49D98A073A PermitAuthorization Form m r, r 6Ncr C � 50230371 ('U w�L rr e r. PMHOLAS RAND I NW G(':LAS RAND €`mner of fl"ie property loi°;ated Oat: (d':9wnef`,,Nan,ie,printed) 487 WAVERLEY RD NORTH 1.N ANDOVER (Property Strcmt Address) WitWl hrm, bV aul",horire the Jed ass Save Energy Lic:rvic:c S f ri':rN,;iarn assigned Participating contractor h tc-sd G:rcalravv to act on my lac'at cif and eclat airy rr l"uik inn perrniL tc> la,rrferu,r'rNt irtr,ralratuon and/or we ai:herlraat on work on my propcar,.ty DocuSigueci by: 0rrrrrt(,IMr,1 s Signature, as�,� ta ®atter.... .._.�,,._....._.....__ ..,...._.-.w_ ...._. ._....,.._�... Date,. 10/23/2016 20 46,EDT _... i I F ORN N I''tcerarrr t OFFICE USE ONLY CLEAResult hada assoL;saed the fo kovamrrtt Mass Save l-lrarne ErrAtirgy Service: Participating Contractor tothe above referenced Project: Participating g B Ct trY.1f�.to Date ',, �...$rah Ur7d,Ir W'r 411 P.31 4tin 'fat SOW"r' fngloh SCrOR,St,IlY,P.aC➢00 VV(,"t&'Jr"wYCjugh,MA 011,99 S t�r'��(d•alffi,�C�-7�1?, r�1��mu�� r:til+ Li l 'r;-r !,r Rev. 1.i t9k.°i DocuSign Envelope ID:3BDE8B5B-9087-45E8-901 O-A97D65000A97 CLEAResult CONTRACT FOR PRODUCTS I SERME WORK This service is brought to you through support from your local Lititit This Agreement is made by and among and GLBAResult Rd, A -1ES 1.1n: I X 50 Wzohijigton Street, S'Ili: te Westborough, MA 01581 FoderLt ID No-222457170 ct,to addre-qsabov ('Mail eompleied(wintra 0 I. DESCRIPTION OF WORK TO BE PERFORMED Coli(lvokw will pol-romi orem IS(-.in N!performed Clip follow-hkg Work on these,'Prellil"es"ill a proft'-.1;i0lial llinfillerand in act-ordallco with slit,imuls of thiS C0111HIC.1,ill(AlUffilg the attadwo revoituvendation.Wwork Order desclibilig the.Work ill(10ail(t1w-WorkC)wilich are illcol-po'.-ah-A hurebE 1lv lvferejlc(`: q).24'�"r'�' Y N. PAYMENT Cvsl.ollwr 11grevs to]?"ky(..'ontrat.-Lor fril,the WoTk.the Calstamer'Shart.(if(1w Colitrart ptic-""as f(Ahm-'s:11 111val,�l ------ 113, m;a DqjwAt payable to CLEAResivit.upon sfll txixig the 01(d.t(l!='XV.qd 112'4-flle toll1-Mail cosk)�Mall cheek&Contract to CLEAllesult,Attu:RES,50'Washington St., 3000,WCStV*)70VKq11,NM'015BI.F111"d payilllIlt: -t—_asthe rima payment f(w tji(!Work shall bt:vayabIe to the ludk:1mudent -it.110/she 1011 liol be 1-mitilroot I o Ply tilt'[1ifity 111centive histallation.Contractor("ITC") upon qatisfactol-1,conkpletion othe f Work,clistonlor lulderstands tit, sh.-H-0 ortile Contract plieo ill lboamnind ofS (711,111gl's1)illoiVidit'111111t,ilems—AnWor p1j,viom inormse.ordevremse the size,or the Wifify hice-litive Share. III, DISPUTE RESOLUTION ']'I%L-TIC and Cu5tow1'r 3;nxfo hiadvmce 13m Jill[he 4ve111 flull 1110 l](' nti a Lli-plite('o1wc-nong tlil'R Conkrilo,flit-11C ffl41y boblllil dbij)MV 10 a idbitnfflr)ll SOITH11 Whidl iiytiw CitstollivrShidl 1v wqWird W stiblidLif) v 142L1- You may cancel this agreement it it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third 0? L K SPACES. bqr;su§iaqitp1lowjng the signing of this agreement. DO NOT SIGN TH15 CONTRACT IF THERE ARE 12/27/2016 1 09:17 EST 0 4- 11 TIC here,if applicable Initial here uyrat wall the Progwall)to asmign n Par(R-ilvioing Cottiractor DaW Nam(,of("LE Vlovl'OSOE v,Ti.I k�itlt(s(o IT)tMS AND CONRYMONS WPEAR ON TINE REVE ME, DocuSign Envelope ID:EDC15234-6E91-42E1-9818-AB49D98A073A l CLEAResu CONTRACT FOR PRODUCTS / SERVICE WORK VIN SPNICP K t}r00g[1d ro ym thratigh sllppof( (rola yotlr 10CM utilit rh1i Agreernent is made by and among and :`��t'1it31115 l"6f3f1(� [�11��.,Pes11It Norl h t' ndf)ver,M. A 013 ,5-f#213 0 Washii)gton Street, suito:3100 1 Site M S0005913037i Westborough, NIA 01581 P role{:t IF7:1*100050264214 I'ef.leral 11) No.222. 571.70 C}isri3Encx ID:00005023199c (A-fail coillPIOU'l('ollteart to address ahov?) Contract TTS:201008%5 ASE-A1_ 1. DESCRIPTION OF WORK 70 BE PERFORMED UM(rxrLur%',ill 111•rrOrin fir['Alt'At to he perfurJtlod flit:following wod� fill these"Yl'crtl:7rs"hl a p rufrssianat manner and ill aixord<uly Wilk fhet('37)l5 of HIN Coal€tart,illchidillg the a l(ached reconlltlendal i0iily/41orl(ttr(le€'de�rxil)illg the work in detidl(flit`")Voile"I Which{lir incor]}J.nnitt d hertila by l-vf6('t3('l': I?e��vl�tl�rl "�)ls€.st41�y t.l:�u�loi��l Pe Dorm,Air Scialing at E:stirna ed.52.5 Ct=vl-5il Pw Hour 6 Living Space x505.92 Boer sw'-;P 3 NkA S69-54 +�rlor Door It/QaYnar Si ipping 1 sNIA X82.77 Sub fossil: aa58.2-1 Uiility lncc;atit'c Share W5.23 'tl�rsnfel fore€tltaJ:Yioll 0.00 3 ell'offlice vse c sll,r i-drited.,-If Iaw-2M6 Page 2 M a 11. PAYMENT _ ['t>st.nnx r l�rr.1 s lo]Jay Crituraclor for Clic-Work..the C'€s tFJnt r Sl>lir of the contraeT Pt-ice a.5 hills" s:paynivni 41—.�_ _,..._._...._.__.__... is'l l.Ieposil 1jayaLle to CL R"lllt.tlporl sigill"l-the��olArac.t.knot i£1 s�'m't'd 1 i1-131'€lle.Soo d 1-4.•1.1}11[:rrAs).31L11 L'lIC£l &con ra<'t to(:C,1 AReslElt,�1f91: 5,-3©(Q13;11dJ1;�tUIR�€., Ste.301)(1,W(!stborougil,MA 01,591.lZinal ll.syn its:� :{'—: _ _;Js ilw Rrlal payll"Vilt for the•Worl(shail he paynill(,to tlln 3�rtepellcient installation Contrart.or("1101")upon sa ti ditetot-,•completion of file 1's'ol ic.C:rlslorlleJ.uttdtl si{tnd c than lu 6slltl%Vill not I1P.1 a=]unerl ttJ]�a�`illi'. 11 t'llifj llx nnli°r S1latLY of tl{E'.{'o€1T13ci.]'rii('e lit tllrt>atnlelil€li.C7f _�,�;:"" Ulullgvs ILL irlltll'ldnal lilw itc-Ills iiil(vt)]'[)I.0Vi0l1ri 1LIC 11(hT,11 ilial\'jucrL ww or timi—ealse IIIc size ofthe t-�dl l,y lncnulit°e"ham. III. DISPUTE RESOLU' lON Ttlt'll(")nd O>_slonier lwrlY!y mukli<dh-atrtke in aarl''Iuvv lltrt i1i itlt'r sunt that tl:a 110 has a d spwk. -olwk-lleLq{0&t•taalr d,Ill('TIC rlt}e submit mi rh tif�tlocr fes;l plivak,,tt})h l-liul fif�11'I(:1'4\'hJ(:)7 ii.Ls lJ('.lkJ 7111]LL'nLt'd lay t1aC l}113('h 1-1f t'onsUllleJ';1.fftu.t�anlel]lGsnie'S's)il'�lllltl{rin.iJ1ll(�11tilr SJnt'1'tihnll lY`1'r:f]ilJl 1111?813}311'!11 tU�SIC'.ti:lJ'i)11.l.iflrlll ils})Y(?tnclt'fl 111 A1.(i.].t.142A. YOU May cancel this agreement if it has been signed by a party at a place other than an address of the seller, provldecl you notify the seller in writing by ordinary mail posted, by telegrar:a sent or by delivery, not later th bllrlidnight of the third busi esT ' 761f6wing the signing o7 this agreement. UO NOT SIGN THIS CONTRACT IF THERE. A NY BLARK SPACES. 10/23/2016 120,46 EDT Cststo{i r r — _ Dar( hldic:rllc y(lnrt r lct.r.rfl ITC herr.it arr]�lfrnhir 11 I ltailial IlHlr i!'vc,t€ttntll �_�" � the 1'rohl'alll trj:tsslnz)a flirt l('ipathig Cont ('l,t•.r11"tt�stJll SJ�tati�r-e l�ajr• avanir�tr# (:I.f,;�1,r.4tlll ite111cscitll.alav(>fPriJairrlj TERNS AND COFaTHH&`9`1i1CbNS"PEAR R dAN ULM u1'"YVI116'SE, 2'?titl-1?-131.1(3 The Commonwealth of Massachusetts Department of IndustrialAccidents Qpe of Investigations I Cong;ress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aafi . Name (Business/organization/Individual): Address: -34q IN A 11,11, 11,otate/Zbo: Vmwi UN 61013 Phone Are you an employer Check the appropriate box: Type of project(required): 4. [] I am a general contractor and I i,MrI am a employer with have hired the sub-contractors 6. New construction employees (full and/or part-time).* listed on the attached sheet. 7. Remodeling 2.0 1 am a sole proprietor or partner- These sub-contractors have 8. Demolition ship and have no employees employees and have workers, working for me in any capacity. comp.insurance.t 9� [3 Building addition [No workers' comp. insurance $. IJ We are a corporation and its 10.[)Electrical repairs or additions required.] officers have exercised their 11.[)Plumbing repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL myself. [Na workers' comp. 12.0 Roof repairs I insurance required.] c. 152, §1(4),and we have no 13.[] Other employees. [No workers' comp.insurance Leq Ted, IPAny applicautthat checks box#1 must also fill out the section below showing their workers'compensation policy inibnuRii0n. f Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. TContractors 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. Iaman employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site iqfbimation. it I rvw a Insurance Company Name: Policy 4 or Self-ins. Lic. Expiration Date: A Ll + City/State/Zip: A-v (All ilt�s�N\ � Job Site Address: Attach a copy of the workers' corapendlation 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 irnprisoninent, 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 cerqy under the pains and penalties of perjury that the b4•ormation provided above is true and correct. 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 S.Plumbing inspector 6.other Phone T DATE(MMOWYM) ACS CERTIFICATE OF LIABILITY INSURANCE 10/18/2016 THI TIFICATE IS ISSUED A5 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS AFFORDED BY CERTIFICATE DOES NOT AFFIRMATIVE INSURANCE DOES NOTLY OR LCONSTI PUY AMEND�TExTEND A CONTRACT BETWENa AGE HEOR ALTER THE CR ISSUING NSURER(S),rHE AUT OR ZIED BELOW. THIS CERTIFICATE REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les) must be endorsed. It SUBRQGATION 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). o ACT PRODUCER NAME: Meg Munroe MARTEN J. CLAYTON INSURANCE=AGENCY INC PRONE 413)536-0804 w Na E-MAIL ADDRESS: mmunroe@m'cla ton,eom INSURERS AFFORDING COVERAGE MAIC# 1649 NORTHAMPTON ST.,RTE 5 31325 HOLYOKE MA 01041 INSURER A: ACADIA kN5 CO INSURED INSURER B: GAUTHIER INSULATION INC INSURER 0: INSURER D: PO BOX 344 INSURER E IMA 01938 IPSWICH INSURER F COVERAGES CERTIFICATE NUMBER: 94521 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDL SUER POLICY EFF POLICY EXP LIMITS 9 ITR TYPEOFINBURANCE POLICY NUMBER MMID W MMlDD YV COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ A GETOR T 0 $ P EMMES Ea occurrence CLAWS-MADE OCCUR MED EXP Any one erson) $ NIA PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: pROpUCTS-COMPIOP AGG $ POLICY❑JEo El LOC $ OTHER: COMBINED SIN LE LIMIT $ AUTOMOBILE LIABILITY Ea ac dant BODILY INJURY(Per person) $ ANY AUTO BODILY INJURY{Pet accdent) $ ALLOrED AUT NIA NON•OVMI D PROPERTYDAMAGE $ Per accident HIRED AUTOS AUTOS $ EACH OCCURRENCE $ UMBRELLALIAB OCCUR EXCESS LIAR CLAiMS-MADE NIA AGGREGATE $ DED RETENTION$ X STATUTE ERH WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 546,004 ANYPROPRiETORfPARTNERIEXECUTIVE NIA NIA NIA MAARP300327 10/30/2016 10/3012017 A OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 540,400 (Mandatory In NH) If y63,describe under E.L.DISEASE-POLICY LIMIT $ 544 040 pESCRIPTION OF OPERATIONS below NIA DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD lot,Additional Remarks Schedule,maybe attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts€f the insured hires,or has hired those employees outside of Massachusetts, This certificate of insurance shows the policy in force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass,govllwdlworkers-compensationlinvestigations/. 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. TOWN OF NORTH ANDOVER 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORN name and logo are registered marks of ACORD aA^m(MkA7i3W7TTi1 R CERTIFICATE OF LIABILITY INSURANCE 7/14/201 HIs NEGATIVELY AMEND, EXTEND OR ALTER THE ISSUING NSURER(S),TAUTHORIZED TF1IS CERTIFICATE IS ISSUED AS A MATTALTERINFORMATION ONLY AND CONFERS NO RIHETSN COVERAGE AFFORDED BY CERTIFICATELICIES CER'1'1FICATE DOES NOT AFFIRMATIVELY Q BELOW. THIS IE TIFPRArE OF I SU THE E. DOES NOT C R13 rICA E HOLDI ROTE A CONTRACT BETW N REPRESENTATIVE require an endorsement A statement on this certificate does not canter rights to the IMP it the c®rtlficate holder Is an ADDITIONALa'NSURED, the pollcy(!es) must be endorsed. If SUBROGATION IS WAIVE!?, subject o Chet terms at holder ditlO ons f ch endorsement se policy,certain po!lcles may NAM Nancy il8tler (413)534-7874 PRODUCER PHONE . (413)536-0804 arc Martin j Clayton Insuranae Agency, Inc. E•MAlL D EBS: MAIC 0 1649 Northampton Street INSURER 8 AFFORDING COVERAGE P. O. Sox 989sNATIO_ � 0104].-0989 INSUREIaA:Nationwide Mutual-Hada v'ille Holyoke INSURERBAl.lied World Natl Aasnrance Co INSURED INSURER C Gauthier Insulation INSURER D P.O. BOX 344 INSURER E'. MA 01938 INsu FREVISION Nt3MBER: IPSWICH 01,1563001850 COVERAGES CERTIFit;ATE NUMBER: TERM OR CONDITION OF ANY CONTRACT OR CHEREIN 5 SUBJECT TO ALL THE TERMS. CH TH' THIS IS TO CERTIFY THAT TME POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE OTHER DOCUMENT NAMED ABOVE FOR THE POLICY INDICATED, NOTWITHSTANDING ANY REQUIREMI;N , CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED IClESR POLI Y FF POLICY EXP LtMrrB EXCLUSIONS AND CONDITIONS OF SUCH AO� ,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM 1,000,004 SSR PO ICY U BE EACH OCCURRENCE TYPE OF INSURANCE 50 r 000 �[ COMMERCIAL GENERAL LIABILITY PAEIA a e § 5,000 A CLAIMS-MAOE 53 OCCUR 7/6/2016 7/6/2017 MMD EXP(An one arson $ 1,000,000 (iL43487F x PERSONAL&ADV INJURY $ $,000,000 GENERAL AGGRIEGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES pER; PRODUCTS-COMPIOP AGG $ A POLICY❑JEGT 11 LOC S $ O ER E acclde i AUT0140BILE LIABSLITY BODILY INJURY(Per Person) $ BODILY INJURY(Per accident)s ANY AUTO PROPERTY DAMAGE $ ALLOVVNED SCHEDULED eccIsn AUTOS AUTOS $ NON-OWNED HIRED AUTOS H AUTOS 1000 000, EACH OCCURRENCE $ AGGREGATE $ 1 00 aO0 g UMBRELLA LIAR OCCUR $ EXCESS LIAR CLAIMS-MADE $SOD792125�194955 10/18/2016 10/1g/2p16 O p R TENTI N STA E B WORKERS COMPENSATION E,L.EACHACCIDEN7 $ AND EMPLOYERS`LIABILITY Y r N E,L.DISEASE-EA EMPLOYE S ANY PROPRIETOR/PARTNERlEXECUTIVE ❑ WA pFFSCERlMEMBER EXCLUDeD7 E,L.DISEASE-POLICY LIMIT $ (Mandat4rY in NH) If yyes describe under DESUiRIPTI N 0 OP RATS S below GRID AItE yIgT4PTi A8 ADpI'SIONAL IN3UREA8 ON A PRIMARY NON—CONTRIBUTORY DEBCRiPTtON OF OPEpAnON81 LOCATIONgrVEHIGLESQIiAI�ioi,Add[tlansl Remarks Schedule,may be sltbCl<ed if mare space le raqulrad) CLEARBSt7I+T► RVER5OURCL PAit) NAT BASIS CANCELLATION >CERTIFIGATE HOLDER IELLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES WILCDELIVERED IN THE EXPIRATION DATE THEREOF, L BE CLFAttB$13LT ACCORDA AICNCE WITHTHE POLICY PFlpViSEI]NS. ATTN: COIRTR `1'OR SERVICES DEPT AUTHORIZEDREPRESENTATIVrs 50 WASNINIGTON STRt11581 WESTBOROU011 s r Daniel Sullivan/MEG ®1988- 14 ACMD CARPAiIA'IION. Alt rights reserved. The AGORD Warne and logo are registered manta of ACORD ACORp 2S(�pt41t11) s.;..I .z�mminn v&uvW.$DdffaC1C7 D LC—OM Office of Consumer Affairs and Business Regdation 10 park plaza- Suite 5170 Boston,NWsac efts 02116 HomeImprovement or Registration RegistMWn: 173410 TWe: (n"duai EWW110n: 10!1/2018 ?.91320 x KURT GAUTHIER , KURT GAUTHIER, ° 't 19 COUNTY ROAD . IpsWCH, MA 01938 �,� Updat®Address said rotorQ card.Msrkreseon for chsnge. ❑ Ad&ew ❑ Itmevnd ❑ Imployment ❑ Lot Card �{ ae�nmuvQa 1eod4g&0 Re 'atioo valid for individual nee only before the Baexgirstiou date. if fomad return ta: Office of Coa�mer At1~aairs do sine�s dou and Busintss ��° HOME IMPROVEMENT CONTRACTOR Office of Consume'Affairs ry. 3410 10 PsrhPleas-Smit®5170 Explra8 g individual tea,NA 02116 KURT GAUTHIER KURT GAUTHIER --