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Home My WebLink AboutBuilding Permit # 2/15/2017 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / � s Date Received ` t D-0 17 Date issued: IMPORTANT:Applicant must complete all items on this page _ L®GATION PROPERTY OWNER '� � '� . `� • Prin# 'I OQ Year Old Structure yes rio MAP NO PARCELZONING DISTRICT Fi[stor[c D[str[ct yes no Macli[ria Shop V[Ifage y:.. n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family Ll Industrial ❑Alteration No. of units: ❑ Commercial epair, ,replacement D Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ElSeptic Dwell o Floodplain 11 Wetlands Cl ;,Watershed District. 11 WatPHIS ewer DESCRiPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: l �,C � �{ Phone: Address: 62 ,W f5_2;Z/- , CONTRACTOR. Name:. . Phone: c°.: .. l Address:. f l TI ! ! f Supervisor's Construct[on License '- �' Exp. Date Howie ImpraW�emenf License d/ Exp 17 Date: ' ARCHITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULI)ING PERMIT:$12.00 PER$1000.00 OF THP TOTAL ESTIMATED COST BASED ON$125.00 PER S_F. Total Project COSI: $ `;e' r FEE: $ 9 Check No.: Receipt No.: a~ NOTE: Persons contracting wit registered contractors do not have access to uaranty fund S - ignature.ofAgenfilwner Plans Submitted ❑ Plans Waived ❑ Certified Plot Pian ❑ Sfiamped Plans ❑ c10RT� own �,` 6Andover 0 "" �► No. 26 T b ver, Mass, . ` f ' 0I 7 '1s• Co[.�e[r�l wee« v1' S � BOARD OF HEALTH M AN NNEW r% M It T Food/Kitchen LD Septic System THIS CERTIFIES THAT C! r .... *3..,.... �/. +�� BUILDING INSPECTOR has permission to erect .......................... buildings on .., MMSA.t.A.4..... +J.�.... Foundation .... Rough to be occupied as ...J.x......... �. ! .!! ..� ...... !.� � .......................... 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 MONTHS ELECTRICAL INSPECTOR UNLESS TI .. . Rough ..,....... Service BUILDING INSPECTORS Fina GAS INSPECTOR QeemancE Permit RgqRrred to Occupy BuildinRough 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. Home Improvement Contract * Gary Liss, General Contractor This form satisfies all basic requirements of the state's lJome Improvement contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners.Scek legal advice if necessary.Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement before agreeing to an work on your residence. You may obtain a free copy by call(he Office ofCmrsnmer Afjarrs and Ilnsiness Regulatiwrs's Consumer Irforntation Hotline at 617-973-8787 or 1-888-282- Homeowuer Information Contractor Informatimt Nance : Nicholas Bordeianu Company Name: Gary Liss General Contractor Stn.et Address; 62 Russell Si. Contractor/Salesperson/Owner Name:Gary Liss Cityrfown: North Andover Business Address(must include a street address:13 Stonewall Tcrracre Daytime Phone 978.223.5287 Evening Phone City lrown:Alkiason State:NH zip code:03811 sante Mailing Address(IF I— above) Business Phone 603.362.5185 FederoS Employer ID Nwuber,020386673 I—"i-Mr—k home Hen>c lmpro+'EnerCom.aawaep.number S°eenu T;vmbcr�rvisa impr�t'rmertmmrano�s ha+xawtid R�nn,ion ti cs-051546 nun+bet The Contractor agrees to do the following work for the Homeowner.Supply and install 14 Harvey vinyl double hong "Classic"replacement windows Proposed Start and Completion Schedule-The followingschedulecoill be Required Permits-The following building permits are adhered to unless circumstances beyond the contraclot's control arise required and will be secured by the contractor as the homeowner's agent:(Owners who secure thole own permits 2116/2017__ Date when contactor will begin contracted work will be excluded from the Guaranty Fund provisions of MGL Will be completed within 6 months of start dote chapter 142A.) (Describe in de€ail dre work to be completed,specifying the Eype,brand,and grade of materials to be used,use addiFionol sheets if necessary) Total Contract Price and Payment Schedule The Cont actor agrees to perform the work,furnish the material and labor specified above for the total sum of:$7,600.00 Payments will be made according to die following schedule: 5 7,600.00 due upon completion of installation.{Law rorbids demanding full payment until contract is completed to both party's satisfaction} NOfFS:(8)Including all 6nana charges(a e)Law requirus that any depositor doivi"yment required by lheconuactorberore wndcbeg nsmay aterof(a)one-thirdoftlicW lcontractpriceor(b)dreactualcastofmyspecialequiprrtentorcostommadematenial notrxoordthegre which must be special ordered in advance to reel the completion schedule. Ex ressWarrant -Is onex rw warranty king providedl thecontraetor?Eb,-No OYes(All terms gf%cwaaiant must he attached to the contract Subcontractors-The contactor agrees 10 be solely responsible for comp]elion ofihe work described regardless oflhe actions of any third partyl subcontractvi utilized by the contactar.'rhe contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under ibis agreement Contract Aceeptanee-Upon signing,this document becomes a binding contact under law.Unless otherwise noted within tlris document, the contract shall not imply that any lien or other security interest tins been placed on the residence.Review the following cautions and notices carefully before signing this contract. Don't be pressured into signing We contract-'fake tune to read and fully understand it.Ask questious if something is unclear. r has a valid Home Im vement Contractor tic islmtion.The Inv requires most home improvement contractors and Make sura the contracto subcontmctors to be registered with the Director of Elome hnprovement Contactor Rcgisuat on.You may inquire about contractor registration by writing to the Director at le Park Playa,Room 5170,Boston,MA 02116 or by catling 617-973-8787 or Sas-283-3757. Does the contactor have insurance?Ask the Contractor for his insurce company htfatmatian so that you can confirm coverage,or ask to sec a copy an of a"proof of insurance"document. Know your rights mid responsibilities.Read the Important Infor,nation on the reverse sideofdris form and get a copy ofthe Consumer Guide to the Home Improvement Contactor Law. You may cancel this ago emeat if it Inas been signed at a place oilier Bran the contractor's aerial place of business,provided you notify the contactor in writu;g at his/her main office or branch office by ordinary mall posted,by telegram sent or by delivery,not later than midnight ofthe third business day foliawing die signing of this agreement.See the attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE P Y BLANK SPACES! Tao idenbinr copies efrhe b—.Ti adand sipyed,enneopy tbwdd go m ehC he[0r1_—. 4rr,tr epi byl4caomrarW Homeowaves Signature Cop� cto s sigrMute Date:216117 Date:2!6117 Contractor Arbitration 'rile Holne Improvement Contractor Law provides homeowners with the light to initiatcan arbitration action(as an alternative to court action)ifilloy have a dispute with a contactor.The same right is not automatically of to a contractor,however. '['lie cournictor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below,This clause would give the contractor the,same right to arbitration as is afforded to the homeowner by the Home Improvement Couti-delor Law. 1,11c c by mutually agree in advance that in the event the contractor has a dispute concerning this contractor and the homeowner here 'co n contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary ofthe fixeclifive officoffice ofConsumerAffairs and Business Regulntion and the consumer shall be requ red to% I III to such arbitration as provided In e -0 r Massachusetts General Laws,chapter 142A. ture Sig�5it",re ..... Honleowner's Signature Contractor's Sip NOTICE:`Elie signatures ofthe parties above apply only to the agrectrient ofthe parties toultenudive dispute resolution initiated by the contractor.'Hie homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A honicowner's rights under the Home Improvement Contractor I.aw(MGI,chapter 142A)turd other C011SUrner protection laws(i.e. MGL chapter 93A)may not be waived in any way,even by agreement.However,homeowners may be excluded from ewaill rights if the conn-actor they choose is not properly registered as prescribed by law.i-lumeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions ofthe home Improvement Contractor Law.'rhe contractor is responsible to,•completing the work as described,in a timely and workmanlike manner.Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty far workmanship or materials.In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose.An enumeration of other alatteis on which the homeowner and contractor lawltilly agree may be added to the terms ofthe contract as long as they do not restrict a homeowner's basic consumer rights.Ifyou have questions about your consunier/honicowner rights,contact lite Consumer Information Hotline(fisted below). Execution Of Contract -onced documents have 'file contract most be executeddica in dul , _to and should not be signed until a copy of all exhibits and refer been attached.Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted,or not applicable.One original signed copy ofthe contract with attachments is to be given to the owner and the other kept by the contractor.Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received fully executed copy ofthe contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance ofthe dates specified on the payment schedule In cases where the homeowner deems Mm/herselfto be financially insecure,However,in instances where a contractor deems hini1herselfto be financially insecure,the contractor may require that the balance offends not yet due be placed in a joint escrow account as a Prerequisite to continuing the contracted work.Withdrawal offunds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Homo Improvement ContractorLawor other consumer rights,or if you wish to obtain a free copy of"'A Massachusetts Consumer Guide to Homo Improvement"contact: Consumer information Hotline Off Ce OfC011SUrner Aflhirs and Business Regulation 10 Park Plaza,Rouni 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at If you want to verify the registration of contractor or ifyou have questions or need additional information specifically about the contractor regi,,qlafloa component of the Rome Improvement Contractor Law,contact: Director of Home improvement Contractor Registration office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the IIIC website at liflf ://%v\vw.t �Ls!..&AMIOaAlrl V 01' Go online to view Qac status ofaHome Improvement Contractor'sRegistuation: In p.Ydb.sta Go,o i a m,sIL)i n Out 12ISLY—e 11!00-icUllsee,I i St-'p ySp. For assistance with informal mediation ordispuacs or to register forrual complaints against business,calk Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Boreaut 508-6524800,508-755-2518 or 413-734-3114 Version 2.1-11/220.010 Insurance Solutions Corporation - Page 1 of 1 DATE(MMIDDIYYYY) LHIS CERTIFICATE OF LIABILITY INSURANCE 2/3-5/2017 ERTIFICATE 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 HOLO>ER, IMI'CYRTANT: If the cartificata holder is an A�DDITt 1NAL.INSURED,the o the ptlllcy(ias)moat he endorse - If SUBROGATION IS WAIVED, sof jest to the terms and conditions of the Policy,certain policies may requira an andorsement. A statement*0 this certificate does not confer rights t 00.4'ie into hnlder in[lou 0f SUCh end01rsOMWIt 9 • CONTACT PRODUCER N 2: I,5.z1$$ FLOG, [ia.rtODJ$C'. PHONE ((jQ3y�e2^4 (10 FAX (603)3132�2034 Insurance Sol[.7ti9ns Garpaaatian A A . .1ind b@ie Cmins3uralToe,com 60 Wast:vi,11a 1 INSURER S APrtlRDENa3 COVERAGE NATO tl plaiatow NH 03865 INSURERA-MG Insurance, Com an 15997 INSUREn N RS :�:NorGU11 tnsvrsnc� Oosn ori 31470 Y Lp88 INSURER c; DBA GARX LIES GENERAL CONTRACT INSURERD: 7.3 STONEWALL FEEL �� e ATKIN80N NX 03811-2149 Ns7utd�ftF COVERAGE$ CERTIFICATE NUM)BER:CL166282 &70 REVISION NUMBER: 'PHIS IS To Cm5y TI1AT THE 101_1010S OF INSURANCC LISTFO SELOW HAVE BEEN SUREt7 iVAMCL7 Ai3UVE T Uig'I"hiE i3C7i ICY Pr t�1f7I� INDICATED. I,iOTWITHSTANMNG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCl1MENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUr;;D OR MAY PERTAIN, THE. INSURANCE AFFORDED BY THE PC I,IC(ES DE50RI13F_o HEREIN 15 SUBJECT TO AU,THE TERMS, "CLLIS10N$AND CONDITIONS Or SUCH POLICILS.LIMITS SHOWN MAY HAVE BLEN ReDUC180 8Y PAID CIA IMS. POLICY MBLR N1 Y i.IMITS TYPE OF INSURANCE 1,000,000 FTACLAWS,MAQ ERCIAL GENERAL LIARIUTY EAL'H OCCURRENCE $ �! (JAMA k ) EN bD � 254,QOQ E t7ccule 5,000 SCI2244770 5/15/201E 5/7.3/2011 MPC)EXP Anyr>no AWUAa 8 PER.dONAL&ADV INJURY $ 1+000,000 GENCRAL AGCRCGATE S 2,00(),000 GEN'L AGGREGATE LIMIT APPLIES PCR: '�,004 040 7C P(71.1GY PRO, I,UG PEtC)t)UGTS•COMP7GP Al C $ + ,1 G7 ASBOX S OTHER: N N 1,400,409 AUTCIVQB;LI~LIABILITY BODILY INJURY(Pat persoh) 5 ANY AUTO ALI,OWNED X SCtiEDULED 5/15/2016 5/15/2017 pODILYINdURY(Nf uadant) AUTOS AUTOS S NON-OWNED P OPE,RTY PAMArr X Hiker)AUTO' X AUTOS 5 Mul[i)clic crudil EACH OCM)RRENCE $ UMBRELLA LIAR ( [CUR AGGREGATE S EXCE 66 LIAR CLAIMS.MADE S r I4FT NTIO $ OTH• WORMIwR5 CQMP9N$AUQN PTT[ P (= AND EMPLOYERS'LIABILITY YIN E.L.EACH A(:C:IiDENT $ 7.00 000 ANY �N A "/15/2p16 . . . . , EAFMP,pYE $ 100.000 OFFICEIRIMEMftizEX0,UOF07 Lyj CANCIOD434 .. (Mandolary In NHp H yqs,elv�crihu un[Srr NM y ylA lintmd in 3A G.L.DISEASE•i-'()LI(=Y LIMIT S 500 040 (1Fgl;R1PTI0N qF gPFAATION81,011w DESCRIPTION OF QF ERATIDNS!LOCA'ri0N6 I V HIGLE& (ACORD 101,AdditEonal Rwnki,ks SCIIOdul4,may b(t attaqwd it 1„ore owl"o IS roquirod) CERTIFICATIE HOLDER CANCELLATION —9642 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELL,I30 BEFOREtMK Cltr x THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCO Town G, RDANCE WITH THE POLICY PROVISIONS, 120 Main St N Andover, MA 01845 AUTHOREPEDREPREWNTATIVE 54 Y��iLh C�ac�.lia/LJ13 .... 5:,.-....:° (�1988-2014 ACORD CORPORATION. All rights reserved ACORD 25(2014103) The ACORD name and logo are registered marks of ACO€ZI) INS025 r,man,) AL DATB(MMIDDIYYYY} 4.�CCPRV CERTIFICATE OF LIABILITY INSURANCE 6/28I2016 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(ies)must be endorsed. If SUBROGATION 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). CONTACT Linda BOCJCtc'i710wicz PRODUCER NAME: -' Insurance Solutions Corporation JA[C' NE No.FXt. (603)382-4600 FAX No_(603)382 zU34 60 Westville Rd ADDRIESS,lindab@isc--insurance.com INSURER 5 Ai FFOROING COVERAGE _ NAIC# Plaistow NA 03865 INSURERA34MIG Insurance Company_- 15997 _ _---_.._ _.-T_____. ____._.__.__.__ INSURERBNorGUARD Insurance Company__ 31470 GARY LISS INSUR9Rc. _ — DBA GARY LISS GENERAL CONTRACT INSURER D: 13 STONEWALL TER INSURER E ATKINSON NH 03811-2148 INSURER F! COVERAGES CERTIFICATE NUMBER:CL1662827670 REVISION NUMBER: THIS 15 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. IN5RADOL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDDNYYY }( COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 r� DAMAGs=TO Rl=1JTED 250,000i A CLAIMS-MADE I n I OCCUR PREMISESiEeoccurreace $ SCi2299770 5/15/2016 5/15/2017 MED EXP{Any one 5,000 PERSONAL&AOV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO LOC PRODUCTS_COMPIOP AGG $ 2,000,000 JECT ASBBX S OTHER: COMBINED SINGLY DMIT AUTOMOBILE LIABILITY Ea acGdenS $ 1,000,000 BODILY INJURY(Per person) $ ANY AUTO u ALL OWNED X SCHEDULED 22gg770 5/15/2016 5/15/2017 e0D1LYINJURY(Peraccklenl) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-0WNE0 Per accldenl X HIRED AUTOS X AUTO& MvHi otic credil 5 UMBRELLA LAB OCCUR CLAIMS-MADE OCCURRENCE 5 EXCESS LIAB CLAIM5•MAGGREGATE 5 0l13 RETENTiON3 PER OTH- WORKERS COMPENSATION STATUTE ER,,,_ AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORWARTNEWEXECUTIVE E.L.EACH ACCIDENT — S 100,000 OFFICERIMEMBER EXCLUDEDI NIA 13 [Mandatary In NH} GAWC700434 6/15/2016 6/15/2017 E.L.DISEASE-EAEMPLOYE 5 100 000 IIyes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS be€nw DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) 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. AUTHORIZED REPRESENTATIVE / ... - Keith Maglia/LJB — (D 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014104) The ACORD name and logo are registered marks of ACORD INS025onuni) --•-•----»,�.�:ri�;,.-mss.-�.. . ' �'Ite Co,rrr,rvnsnealth of'lllassar�)rust�lis Al t�lJFr,'1„r(:iil fif 1ptrdi,sp,°i R!/t[°t'itit',rIS Office of Irrryesfigations 600 iVashingfvx Sir-ref no.vtort, .AM 02111 ..�` tt�lt�►tr.,►ttrss.gor/dirt �Wol$tt~1s' Ceii{{ 1�{t5:1{1)bll iisiitailee A[lacihvit: 131liltlerslC:ontr-a tors/i�Sectridans/1"lltstt hers A�r'sliehtt i�iiitt{>Yii{��ibid ['lesise Print }Legibly Address: L ..-_._.._.. ._._....... .__-_.._ City/staletzip;/�TQW/ GN 11LI 03g-// Phone lf: -La3 Aft yo0:til t'fiiiiiifgi'{•7 dld'til box: Type of liroject(rerluire-d): I.❑'! ani a eiil�r69a With 4. ❑ 1 atn a genctal cotitractor and 1 6. ❑ New constructiotl crnlilayecs(tutl aiidloir lAtt-iitlic).* have hired the sub-Culillactors rr--�� 7. Remodeling 2.Ll l atil a SoiC irtoprrelor Or itarlller- 11SECd oil 1110 altachccl;I1Cel.j ship and have ffo employees 'These sub-contractors have 8. �-1 Ucntoiilian wotking tot life ih any capacity. workers' comp. insurance. 9. ❑ Duilding additiolt [No workcts' coitip. institaiice 5. ElWe Wear.. corporation and its I ❑ l;lcctricai rcllairs or atltiilious requited.] officers have exercised tlicir 3'.❑ l am a liofiieowhet doitlg all work right of exemption per MGL t 1•❑ Plumbing repairs or additions myself.Wb workers' coitip. c. l S2,§1(4),and we have no 12_❑ Roof repairs itisutaitca r" lliteci. fi employees.[No workers' l j 111 Other of%/1`i17G4,,S _ Collip.insurance minimi.] — — *Any nllrrlicnnl khat diecksbux lit must also rill out the scctian below showing llltir wulhels'cpnllicn,-,ntiorr hcilicy irlfirrntntinn: t ito,mowncrs who subi nil this at'Novil Wtdicating Macy are doing all work mtlt then bite auisidc conhacl<irs must sulmnit n new ntlidnvil initicnt ing such. tcontractots plot chemic tiillitux nlusi ultneil-A in Rdditlonat shect shawhig nim unme urthc sutl"corIITlIetOIS 8111](heli 14Dr1iC15'cuntll,policy iuf'ortnsilion. A lull mr crrtptrijici•AW is,phoilitliiig 11,01-kCts'conspertsaiiorr iusru-arrce f ire-11r•1-employees. Beloit,is tire patios arrd joie silt irtfurnrtrtirrri. Insurance Company Name: /1/G96-1M-2 17 Policy 11 of Wr m.Uk h: 15Akl �� —__ - I;xpirnlion Date: /57 / -- .. Job Site Address:a1z If1/SS_o�GL -V Cily/Slalc/Zip: hllpnk''p5'pl A Attach n cony nt{6 i oi•ltel•s'ttlifffeilsaltioil policy declaratiotl tragi(sltowirig the policy nusirber Ind evii-atimi time). Cailnte to secure coverage a5 tetjttired under Section 25A of MCL c. 152 can lead Io llic imposition of criminal penalties ora Cnc up to$1,500.00 atid/or otic-year imprisoliment,as well as civil pcnallics in the form of a STOP WORK Oland a tine of tip to$250.00 a[lay Against isle violator. tic advised that,'i copy of this statement may be forwardccl to the O€[ice of limstigaliolls eCdtb NA for hisuratice coverage verification. ,l do hereby rCi•i j-it er the pairis and jrerialdes of jrerjut3,Ihnl the itt frtnitation provided above is idle and cor)-C(1 ' Sigrnalttre: T7;ttc: Z�6�f, Uffirirri rise utri'ir, bn iroi i+rile in this area,In be rnrirpleled by city or totsrr u1fcirri. City ol-Tbivli: 1551t�11�,�.1l��tt3l'1Iy 1,C14'C,@ 0111'.): 1.tltim-d 41$es#1Nt 2.oulWtllg 0eparimenl 3.Cilyfrown C luk d_Elvdi-iral lnspeetor PTuluhiuR luspeetor G.btiref — Cnittacl4'ei'soia: l'hnne.11: %�e`{cruuuo�rrtrr+nl(�o��•fl<r:f:It�c�rr�c((.= Y ez Office of Consumer Affairs&Business Regulation i WWHOME IMPROVEMENT CONTRACTOR l � �egistration: 1'12595 Type: �� Expiratign: 41912017;; Individual GARY E.LISS GARY.LISS 13 STONEWALL TER =t.._,._ •�. .- __ ATKINSON,NH 03811 Undersecretary Massachusetts -Department of Public Safety Board Of Building Regulations and Standards Y1}I1.9i r774f1{Ili,]li lllF I ISiiI License: CS-053506 GARY E LISS 13 STONEWALLTE ; Atldnson NH 03541 ^Oilr Expiration Commissioner 03/30/2017