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Home My WebLink AboutBuilding Permit #240-2017 - 10 COPLEY CIRCLE 9/7/2016 BUILDING PERMIT O NURTN �wtLeo a'9,q, TOWN OF NORTH ANDOVER 32 y�::'` ..:•...•, o APPLICATION FOR PLAN EXAMINATION Permit No#: r �"'(� Date Received '1J9 p�RwZ. SSACHU`�� Date Issued: _ah�l�. --- I IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER `J t a �� t ' o `} 'n Print 100 Year Structure yes no MAP 66 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building VOne family ❑ Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units- ❑ Commercial IIRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: j ccsµ C�,P Identification- Please Type or Print Clearly OWNER: Name: (MA 2CO�. /�V Phone: 4 '1?-(oY( - Address: C (9 I C j`/2 CCC' Contractor Name: \3 6�Ay\ 1P vk hone: Email: Q L �sn2c�c3�c�a��' • 1:;L,/-, Address: A- Z—_ 0{ -r-Tin 4-f Supervisor's Construction License: l 2 Exp. Date: 4 17 Home Improvement License: 3 �7 Exp. Date: t ' 2 I 2—j 6 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED CO`tSTBASED ON$125.00 PER S.F. Total Project Cost: $ 12-OFEE: $ I `7 Check No.: �P-2-10Receipt No.: � NOTE: Persons contracting with registered contractors do not have access to the guaranty fund � t Location No. r G Date /I�/41. • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#' ` r� / Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swunming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4 Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses .� Copy of Contract .� Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks .rr Building Permit Application ,r< Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) .� Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan .� Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit .a. Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) .� Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 NORTIy q Town of ? ? b ndover No. a �_ yj * ; t - ,� , h ver, Mass, V-fogy L KE COCNICNlw1CK AERATE D PPa,`�� S V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT �. ....Q ;(�{1!!.. .. ...... . .................. BUILDING INSPECTOR .......... .. 11!!1......... .... ....... Foundation has permission to erect .......................... buildings on .40... .1 ..... .. ...................... • Rough to be occupied as ....... ....... ...�r . ............ ?! ! ..... ......... Chimney ............... provided that the person acceptilthis permit shall in every re, conform to the term of the appl ation 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 IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TI T Rough Service ' ... ... ....... ..... ....... Final DING INSPE TOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough 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. G F` Fa1MWffV3M= NMI I C imneys Residential & Commercial Roofing CHIMNEYS POINTED-REBUILT-CAPPED All Types Of iding Expert Masonry Work Mass Toll Free *Roof Leaks Experts * Licensed & Insured 1-8010-WAIT-4-US Locally Owned&Operated Since 1976 -------L IKU� G�a�B ?Zo�✓n o� ei,�€ License#034200 (924-8487) /nam i We Work Year Round Proposals To: Jim Groleau Date 8/24/2016 I Street: 110 Copley Circle 978-681-9875 Andover, MA Roof proposal jgroleau@verizon.net Certainteed Landmark 1. Extra caution will be taken to protect house and 12. Removal of all work related debris. Planks will be landscing as best as possible. (tarps etc.) placed under dumpster to prevent any damage to Magnel s run at final clean up. driveway. 2. Remov all shingles from entire house. 13. Building permit included. 3. Inspect and re-nail any loose or lifted plywood. 14.Contractor workmanship warranty: 10 years under Any co promised plywood will be replaced at an normal wind and rain conditions. additio al cost of$65.00 per sheet of 1/2"CDX. Total roof cost: $119800.00 4. Install heavy gauge 8" aluminum drip edge to all eaves and rakes. White,brown or mill finish upgraclU. $1,000 5. Install g' of Certainteed Winter Guard ice and Chimney cap: �+ water shield along all eaves and top to bottom in all (Stainless steel) valleys; Install double coverage of ice and water (E shield in rear valley"catch all"area. . Skylight optio : Install(2)new Velux S06 ES \ 6. Install C-ertainteed Diamond Deck synthetic fixed skylight d flashi kits. $875.00 underl�yment to remaining sheathing up to ridge. additional cost p r uni nstall factory AsMaHed 7. Install '11 new pipe boots. light block blinds. 22 .00 additional cost per 8. Install Certainteed starter shingles to all eaves. unit. Please be advi : Some minor cosmetic 9. Install ertainteed Landmark Limited Lifetime interior finish trim be needed. architectural shingles to entire house. 10 year Not included in pr osa materi MFG. warranty. (See extended wananty) . (1) extra bundle of shingles included. All shigles will be installed and fastened . All work to be completed within 1-3 days accords g to mfg. specs. weather permitting. 10. Install i iew GAF Cobra ridge vent and cap with color rr atched Certainteed Shadow hip and ridge shingles. (MA code) Certainteed 3Star extended direct MFG warranty 11. Counter flash chimney lead, wall connections and A fully transferable 100% coverage against all roof protrusions with ice and water shield, tie material defects for a fully non pro rated period of into new shingles and seal with clear Geo-Cel 20 years. Please refer to pamphlet left in estimate sealant folder. Offered to our neighborhood referrals and included in this proposal at no additional cost. *Note*: Please be advised if applicable,valuables in the attic sh�uld be moved or covered due to minor Balance due upon completion,no deposit required debris, dus and asphalt particles that will accumulate References available upon request during the tripping process. All Under One Roof not HiEW rated member of the accredited BBB and responsibl for any damage or clean up that may occur Annie's List in attic. Thank you! i �\ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization/lMividual): /�n 1 A U h 0'e2 Address: J-,> TGi+ Ac— 0/ tN City/State/Zip: -0,C\S-e^' Ll M) Phone#: Are you as employer!Cbeck the appropriate box: Type of project(required): 1.[—)1 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Q 1 am a sole proprietor orpartnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance requited.] 3.[:]l am a homeowner doing all work myself[No workers'comp.insurance required.]r 9. Demolition 10 Q Building addition 4.D 1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sok 11.E]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions Sam a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14. Other /Z-01- 6.E]We aa corporation and its ofFicers have exercised their right of exemption per MGL c. are or 152,§1(4),and we have no employees.[No workers'comp.insurance required.] •Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information- 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors 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. )f the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: opL t �-i t2CC�� City/StatetZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 and/or one-year imprisonment,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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the paraaides ofprjuthat he information provided above Soveis true and correct r Si ature: Date: 6 Phone#: 91Y —92;_ — 73- 3 1 Q lwial use only. Do not write in this area,to be completed by city or town ofj'ieial. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency sbaU withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. if an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax #617-727-7749 Revised 02-23-15 www.mass.gov/dia ACQRD® CERTIFICATE 4F ► DATE �.... F _ LIABILITY INSUROANCE (MMIDDNYYY) THIS CERTIFICATE IS ISSUED R A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT16 S UPON THE CERTIFICATE HOLDER.0 00 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 BE REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, TWEEN THE ISSUING INSURER(S), AUTHORIZED IMPORTANT: c the policy,the certificate holder Is an ADDITIONAL INSURED,the p o11Cy(le3)must be endorsed. If SUBROGATION IS WAIVED,subject to certificate holder in lieu of the terms and conditions of such endorsea rtaln policies may require an endorsemen ment(s). t. A statement on this certificate does not confer rights to the PRODUCER 02051-001 Per Insurance Agency LLC PRAJACT Branch 2051-1 822 Chickering Rd M (978)685-7690 A/C.No: (978)687-0149 North Andover,MA 0045 BASS: INSURED A.I.M.Mutual Insurance Company All Under one Roof C/O John Lanza=ame 30 Temple Drive Methuen, MA 01844 COVERAGES CERTIFICATE NUMBER: THIS Is To CERTIFY THAT THE POLIEVISION NUMBER. CIES 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 IS SUBJECT TO ALL THE TERMS, �gEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCEyP POLICY NUMBER j ^'�M �r LIMITS GENERAL LIABILITY COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ MAMM CLAIMS-MADE 1:1 OCCUR $ MED EXP(Any one person) $ PERSONAL 6 ADV INJURY $ EN'LAGGREGATE LIMIT APPLIES PER. GEN ERALAGGREGATE $ OUCY RO' OC PRODUCre.COMPIOPAGG $ AUTOMOBILE LIABILITY ANY AUTO S_ ALL OWNED SCHEDULED BODILY INJURY(Per person) S AUTOS AUTOS HIRED AUTOS NONgYYNED BODILY INJURY(Par accident) S AUTO$ a UMBRELLA LIAB OCCUR S EXCESS LIAB EACH OCCURRENCE S CLAIMS MADE DEO RETENTION $ AGGREGATE S 0�S�{1RF�RipRS��7ps�€Cpp►RaTSI?Efigr�E ARM, TH s A 9FFICER/M Vs% EXC UB9 c1mvE x Y IMITB °ER I'(rrmandAdatory in NH) L-'J NIA AWC400-7009464-2015A 11/9/2015 11/9/2016 E.L.EACH ACCIDENT S 100 000.00 eCiiiPTlOi�OF�PERATIONSbelow E.L.DISEASE-EA EMPLOYEE S O 00000.00 E.L.DISEASE.POLICY UMIr S 500,000.00 DESCRIPTION OF OPERATIONS!LOCATION8/VEHICLES(Attach ACORD 101,Adoitlonsl Remarks Schedule,Ir more space is required) The workers compensation policy does not provide coverage for John Lanzafame 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 close-2010 CORD CORPORATION.All g to reserveq. e registered marks of ACORD From:Universal Insurance To:19769750461 07/15/2016 14:45 #715 P. 02/002 AC CERTIFICATE OF LIABILITY INSURANCEDATE( HIDDNM) THIS CERTIFICATE iS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO ER.ITHIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY TH POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),A ORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the cartiflcate holder Is sn ADDITIONAL INSURED,the polley(los)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 i:srtiflcate does not cooter r ghts to the certificate holder in lieu of such endorseman s). PRODUCER GUNTA UNIVERSAL INSURANCE AGENCY PHONE Leandro GuimarBea (508)752-9333 F 374 BELMONT ST. leandrouniversaliesa en .com WORCESTER INSURERS AFFORDMOCOVERAOe NAlce INSURED MA 01604 DISURERA: ACADIA INS CO 31325 MGG CONSTRUCTION INC INSURERS INSURER C I 12 WATER STREET APT 1 INSURER D INSURER E: MILFORD MA 01757 -INSURER F: COVERAGES CERTIFICATE NUMBER: 69377 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL PERIOD { INDICATED- NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO I HCH THIS ? CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL I je TERMS, f EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY ADD SUGN INSR TYPE OF INSURANCE HAVE BEEN REDUCED BY PAID CLAIMS. i P EF P l POLI D yr ! COYYERCULGENERAL LIABILrrY YNUMIOI LOW$ Sj 1i1C11000URRENCE s CWMS•1IME OCCUR I s LIED EXP we s WA PERSONALaAOV*WRV s pENOTHER LAGGREGATEUNITA1:1PPUESPEM GENERAL AGGREGATE s POLICY 0 JECT Lac PRODUCTS•COMPR)P AGO Z AUTOMOBILE LIABILITYCO : BIN Me S AALLNYAUTO GODLY INJURY(Per pa:on) t owNEo W�HHpEgog�LEo wa NON-0WNED BODILYIMMY(pWONWene a Hues oAUTos AUTOS 0 ER f UMaR[CLALS1a a OCCUR [XC[SSUAB EACH URRENCE s CLAIMS•MADE N/AC�� OM I I RETENTIONS WORKERS COMPENSATION ANDEMPLOYERS'UASILI Y YIN X AANYWROPRIETOR)PARTHaRlEXECUTIvs IWA NIA NIA ELEACHACCIDENT S 1 1000 R# In NN) MAARP301454 05/20!2016 05120/2017uoriaunda E.I.DISEASE-EAEMPLOYEE s 1 ,000 IPrI OFOPERATIO MI EL.DISEASE-POUCYLSAT s 100 ,000 NIA DESCRIPTION OF OPERATIONS/LOCATIONS i V[HICus(ACORD ICI,AddlUonu Rmwrks SehsduU,wry be suachy N mw.@P&m A"ked) Workers'Compensation benefits wis be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 OS OB B.nD authoriza0on is give to pay I claims for benefits to employees in states other than Msssachusstta if the insured hires,or has hired those employees outside of Massachusetts. S This Certificate of Insurance Showa the policy in force on the date that this certificate was Issued(unless the expiration date on the above policy pro as the Issue date of this certificate of insurance). The status of this coverage can be monitored darty by accessing the Proof of Coverage_Coverage V Cation Search tool at www mau.govhwd/workers-CompenssponArwOSUgationa/. i CERTIFICATE HOLDER CANCELLATION r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELL 0 BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DE 0 IN ALL UNDER ONE ROOF ACCORDANCE WITH THE POLICY PROVISIONS. 30 TEMPLE DR AUTHORMft REFREbENTATIVE METHUF.N MA 01844 L. Daniel M C Y•CPCU,Vice President—Residual Market—W DRIBMA ACORD 23(2014/01) The ACORD name and logo are registered arks of ACORD RD CORPORATION, All righ a reserved. I I , i Massacllusetts -De;:,irr hent or Boyd of 3usidiny tcgw;ari;^; z :,a .... >L„niti'uCtiull Supervisor License: CS-069120 JOHN W LANZA,AME,,— 30 TEMPLE DR METHUMN MA D1844 i,7- h i �.�..•.�.f cam.. �, t„��• _ .: •3: . �E>�'zmsssioi1 04/03/2017 ' I Click on the registration number to view complaint history.You can also%clew arbitration and QWgranty Fund h iStOry. The list Is current as of Wednesday, October 8, 2014, Search Results REGISTRANT RESPCWStBLE RIEMTRATtON ADDRESS EXPIRATION S�IATUS NAME INDNIDUAL HUM113+R BATE I ALLUNDERONE ROOF LANZAFAUE• 137 7 166 A MERRIMACK ST 10/02/2015 Current .JOHN METHF-N .MA 01844 y"" 1 02W Commonwealth of Massachusetts. Mass.GovO Is a registered service mark of the Commonweafih'of Massachusetts. I i i i