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HomeMy WebLinkAboutBuilding Permit #842-16 - 101 CROSSBOW LANE 1/27/2016 (3) i NORTH BUILDING PERMIT Q��gyEo 'bs��0 T®WN OF NORTH ANDOVER o , .,.. •, ,� APPLICATION FOR PLAN EXAMINATION _ Permit No#: Date Received 4 0 RA7Eo �SSACHus�t Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 101 ��5� L�� P int PROPERTY OWNER ►rtio �. NA ea Print f 100 Year Structure yes no MAP PARCEL:O CZONING DISTRICT: Historic District yes no Machine Shop Village yes no r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition El Two or more family [I Industrial KAlteration No. of units: El Commercial ❑ Repair, replacement ElAssessory Bldg ❑ Others: ❑ Demolition [] Other P -_.. _ - ?� p Se tic ��Well �F,loodplin 0`Wetlan,ds ,r 1Nateshetl Distract ewesr __� DESCRIPTION OF WORK TO BE PERFO MED: iSb1� boun �r Identification- Please Type or Print Clearly OWNER: Name: mcAV\ d. Phone: . a Address: 101 0 `F�s Crossbow L-ar`e oc r\ °ver Contractor Name: i4t?xusi � 1'�l EeS Phone' `��� Email: k nP— Address: y- �n10Mn c". met 4 19E- Supervisor's Construction License: CS 4-7f> 9I Exp. Date: 4 1-7116 Home Improvement License: i-1i� 129 1—n Exp. Date: 7 11917--- ARCH ITECT/ENGINEER ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost:$ FEE: $ Check No.: Z� Receipt No.:_, NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund - Location No. 2y, Date • - TOWN OF NORTH ANDOVER s-TU1r#ja46 • Certificate of Occupancy $ E. Building/Frame Permit Fee $� . Foundation Permit Fee $ Other Permit Fee $�_a TOTAL w� Check# � Building Inspector jdr � . Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ TanninglMassage/Body Art ❑ SwinIRling Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent DuanP sten on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature w• )90MMENTSIUJ i Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments !bo' -n'servation Decision: Comments X ; ter& Sewer Connection/S nature Date Driveway Permit DPW Town Engineer: Signature: Located Osgood u �Te`r'np Dum''ster,an-site,,.)�..,yes ,F `eet' '"' FIRE�Da PgR,TMEI�Y ��,��;` ��� :� � t r�, Lcaoe 24MainStreet % + R,ym �a artment signature/date„ t. �, �.�' ', ;tz , u f: • ' t COMMENTS _'�'�• ' �� y., h 0-` �rr .� �, ,��. , `, ,;a i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meteir 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 l NOTES and DATA— (For department use) I ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 I 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 Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 4 Floor Plan Or Proposed Interior Work �6 Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit o I Addition Or Decks Building Permit Application Certified Surveyed Plot Plan &6 Workers Comp Affidavit i6 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) 6 Engineering Affidavits for Engineered products riot to issuance of Bldg Permit . OTE: All dumpster permits require sign off from Fire Department p New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses 4, Workers Comp Affidavit 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 Enter construction cost for fee cal - North Andover Fee Cakulatlon Construction Cost $ 28,207.00 m $ - $ 338.48 Plumbing Fee $ 42.31 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 42.31 Total fees collected $ 523.11 101 Crosssbow Lane 842-2016 on 1/27/2016 Basement Finish I NORT1�/ own of No. C, h ver, Mass, ' ' ;L�* • `too CoCNIC44EW1CKAb y1. x.95 a^Teo �Pa��S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT <J. ^.;.Q......... �, , , pool BUILDING INSPECTOR ........... ..............M. ..... ..... . . has permission to erect ................. buildings on ...�. .�. �.� ' � � Foundation ... . ....... ........ Rough to be occupied as ............ ... .w cf%.n...... .!!1. .... -..... ............lo.�f..1............................. Chimney provided that the person accepting this permit shall in every resp ct 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MO HS ELECTRICAL INSPECTOR UNLESS CONSTRUCT .......RTS Rough Service ............. ... . ................................................ Fina BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No-Lath-i.ng or Dry Wall To Be Done - - - - - FIRE DEPARTMENT - Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Page 1 of 5 Nexus H Carpentry and e0y Construction Design e Gv' P.O.Box 2823 Woburn,MA 01888 781760 2031 Fax 978 9751263 mark&nexuscarpentry.com Contract This is a contract between Timothy and Susan Mellody of 101 Crossbow Lane,North Andover MA 01845 (Hereafter referred to as the"owners")and Nexus II Services (hereafter referred to as"Nexus") dated January 22nd 2016. GENERAL SCOPE OF WORK DESCRIPTION WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: work as stated below to your existing basement Scope of work: General details ♦ Meet with local building official and apply for permits ♦ All work will be in accordance with local building code regulations and will be inspected by local officials prior to continuing with the next phase—Nexus will be responsible for arranging and being available for all inspections ♦ Nexus will contact"Dig Safe"prior to commencing any excavation work for their clearance ♦ All work will be coordinated directly between"owners" and Nexus ♦ Nexus confirms that it is fully licensed, insured and ensures any sub-contractors utilized on this site will have the appropriate insurance coverage ♦ Nexus will be responsible for the safe storage of all its property and any materials to be used on the site ♦ Owner is responsible for removal and return of all items of the house in the areas that will be affected and their safe storage prior to our work commencing ♦ Owner will then be responsible for returning all items to these areas of the home after completion of the scope of work SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 2 of 5 • Remove and trash into Nexus supplied dumpster all trash associated with this project NOTE: appliances are not allowed to be put in dumpsters without additional costs "owners" are responsible for removal from site Scope of Work • Make application to the Building department for building permit only • Furnish an onsite dumpster for the duration of the project.NOTE: Dumpster to be placed on boards and located on the grass—"Owner"to specify the day of delivery • Furnish and install plastic protection at the top of the basement stairs and also over any items stored in the existing mechanical area • Furnish and install an egress sliding window to garage framed wall measuring 36"x 72" - $985.00 NOTE: Window to be centered under the existing 1St floor living room window facing Crossbow Lane • Remove and trash the existing sheetrock in the basement stair case—from both walls and ceilings • Furnish and install 2" x 6" wall framing with planned openings to create a living space, a mud room, a mechanical room and access to the existing oil tank from the mechanical room • Furnish and install framing around the electrical/water meter location to create an emergency access through a removable shelf . • Furnish and install "blocking"to allow for a TV bracket wall mounted as noted on drawing • Furnish and install electrics to code inclusive of wall outlets, a TV cable jack with power outlet, six 5" recessed lights to the living space and two 5" recessed lights to the mud room and 1 recessed can at the bottom of the stairs - $0.00 • Furnish and install Batt insulation to the exterior walls only • Furnish and install 1/2" sheetrock with smooth plaster finish to the new wall framing NOTE: rear of framing to remain"open" in the mechanical room and the oil tank location. • Furnish and install sheetrock to the walls and ceiling of the basement stairs—NOTE: smooth finish- $880.00 ♦ Furnish and install sheetrock with smooth plaster finish to the surface of the existing beams in the new living space only • Install tile and grout supplied by you to the mud room area only ♦ Furnish and install 1 interior paint grade louver doors in frames to the mechanical room only.—($310.00 CREDIT) ♦ Furnish and install 1 interior paint grade solid core 6 panel colonial door in frame between the living space and the mud room at bottom of staircase ♦ Furnish and install paint grade trim to baseboards and doors ♦ Furnish and install 1 "pole wrap"to existing lally column in living area- $80.00 • Furnish and install a suspended ceiling system with Armstrong 2'x T the(Part #1205)- $937.00 ♦ Install in the mud room (on the garage wall), a wall hanging system supplied by owners for skis etc. SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 3 of 5 Work not included in this contract Building department fees Engineering or architect costs Permit costs Unseen conditions Painting or staining work Heating or cooling work Carpet flooring Supply of tile or grout Supply of hanging storage for wall opposite new bench seat, installation of TV or any speaker set up Furnish and install custom wood bench seat with 2 separate storage sections underneath and 2 separate hinged seats. Materials will be "faced Plywood" with bull nose router edge detail and a bead board rear wall built in to the framework. Install hooks supplied by owners to rear wall bead board-proposed cost including materials and labor is $3, 850.00 Any other work not specifically noted above PERMITS "Nexus"will accept responsibility to obtain the necessary building permits."Nexus"will act as a GC and work in accordance with fair and reasonable practices,and cooperate fully and under the guidance of the"Owners"and authorized parties.Nexus will pass the cost of the permit directly on to the"Owners''once advised by the Building department. Standard Exclusions: Unless specifically included in the"General Scope of Work"section above,this agreement does not include labor or materials for the following work(any Exclusions in this paragraph which have been lined out and initialed by the parties do not apply to this Agreement): Removal and disposal of any materials containing asbestos or any other hazardous material as defined by the EPA. Custom milling of any wood for use in project. Moving"Owners"property around the site. Labor or materials required repairing or replacing any"Owners"-supplied materials. Repair of concealed underground utilities not located on prints or physically staked out by"Owners",which are damaged during construction. Surveying that may be required to establish accurate property boundaries for setback purposes(fences and old stakes may not be located on actual property lines). Final construction cleaning("Nexus"will leave site in "broom swept"condition). Landscaping and irrigation work of any kind. Temporary sanitation,power,or fencing. Removal of soils under house in order to obtain 18 inches(or code-required height)of clear space between bottom of joists and soil. Removal of filled ground or rock or any other materials not removable by ordinary hand tools(unless heavy equipment is specified in scope of work section above),correction of existing out-of-plumb or out-of-level conditions in existing structure. Correction of concealed substandard framing.Removal and replacement of existing rot or insect infestation. Construction of a continuously level foundation around structure(if lot is sloped more than 6 inches from front to back or side to side,"Nexus"step the foundation in accordance with the slope of the lot). Exact matching of existing finishes. Repair of damage to roadways,sidewalks,or driveways that could occur when construction equipment and vehicles are being used in the normal course of construction. The"Owner"is to enter into contracts for all of the above-mentioned services and provide direct payment to"Nexus" for all of the services we are to provide."Nexus"will be responsible for removing all components and all construction materials relevant to the"scope of work"in this contract.The"Owners"have received a copy of the lead hazard information pamphlet informing them of the potential risk of the lead hazard exposure from renovation activity to be SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 4 of 5 performed in the dwelling unit.This was received before the work began and the"owners"are responsible for informing their tenants of all potential hazards. Dumpsters,trailers and signs "Nexus"will provide as included in the cost of this project,a dumpster for the sole purpose of the removal of trash associated with this project.This dumpster should not be used by any persons for any other waste items or for any purpose outside of the specific use under the scope of work,unless authorization is received from"Nexus".Nexus may have on site for part,or the whole of the project,a trailer containing materials and tools belonging to"Nexus".This trailer will be parked in a position agreed to in coordination with the"Owners"and will be covered under the insurances of"Nexus"at all times.`Nexus''will have on site,a sign,with our contact details,in the event that anyone has a need to contact us directly. Photographs "Nexus"reserves the right to,from time to time,take photographs of the contracted work for use in its general marketing or for production on its web site.At no time will"Nexus"share any personal contact details of the"owner' for any photographs that it may use without seeking authorization from the"owner". Warranties All the components supplied by"Nexus"as part of the original order are covered under the warranty exercised by `'Nexus"and supported by the vendors.All labor and materials purchased from other suppliers to achieve completion of contract are warranted(1)one year from completion of the construction. Expiration of this Agreement: This Agreement will expire 30 days after the date at the top of page one of this agreement if not accepted in writing by "Owners"and returned to"Nexus"along with the necessary deposits within that time frame. Changes in the Work: During the course of the project,"Owners"may order changes in the work(both additions and deletions). "Nexus" will determine the cost of these changes and the cost of this additional work will be added to"Nexus"profit and overhead. People Authorized to Sign Change Orders: The following p o are authorized to sign Change Orders: "N us": Mark Gotobed or Ged White "Client": Timothy-4Susan Mellod Concealed Conditions. This Agreement is based solely on the observations"Nexus"was able to make with the area in its current condition at the time this Agreement was bid. If additional Concealed Conditions are discovered once work has commenced which were not visible at the time this proposal was bid,"Nexus"will stop work and point out these unforeseen Concealed Conditions to"Owners"so that"Owners"and"Nexus"can execute a Change Order for any Additional Work. SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 5 of 5 Schedule of work It is agreed by both parties that this work will be coordinated with the"Owners'and"Nexus"to be undertaken in various stages to avoid complete disruption of the home environment."Nexus"will give"Owners"no less than 2 days notice prior to arriving on site for commencement of any of the agreed stages of work to allow"Owners" to prepare."Owners"commits to have sites identified for construction work available for start at the beginning of the scheduled day so as to avoid any unnecessary delays. Contract Cost and Payment Schedule: Total cost of work description and materials included in the proposal(except materials/work stated)-$28,207.00(Twenty eight thousand two hundred and seven dollars and zero cents) PAYMENT SCHEDULE 1st on Payment due u signing this contract V A g g TOTAL$9,407.00 2nd Payment due upon"rough framing"sign off by inspector TOTAL$8,000.00 3rd Payment due upon sheetrock installation TOTAL$8,000.00 Final payment due upon completion of scope of work TOTAL$2,800.00 Amount due upon signing this contract-$9,407.00 I have read and understand,and I agree to,all the terms and conditions contained in the proposal bove.. Date..... ...:6......."Nexus"Authorization................... .. ............ Date....... .�� �f4?...... "Client"Authorization........ .................. ..... '....... . Date..............................."Client"Authorization...................................................... SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT 9 �as08 "" 0 af.` " do 11:115 ►rig � ,roe' ono n Zc Mato oQ qL oq a „$�y kt\ \ x►,v,E � 2`� Q t W t"r x"•� jj; l�t f fiP F �•rt s �e The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www tnass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name(Business/Organization/Individual) 944U RA C�� Address: ?•© , QR2-3 Ci /State/Zi loq[ O ig& Phone#: -7 o 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* ave hired the sub-contractors 6. ❑New construction 2.[1 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, []Demolition workingfor me in an capacity. employees and have workers' Y A n'• 9. ❑Building addition [No workers' comp.insurance comp,insurance. Me— required.] e?required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 1311 Other comp.insurance required.] *Any applicant that checks box#1 must also f ll out the section below showing their workers'compensation policy information. I Homeowners who submit this afdavit indicating they are doing all work and then 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. lam an employer ilial is providing workers'compensation insurance for my employees. Below is the policy and job site infornation. Insurance Company Name: — Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Ci h/Stot e/Zi P Attach a copy of the workers'compensation 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 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. 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 certify and and penalties of perjury that the information provided above is true and correct. Sitmature: Date 26 Phone#• '7 '760' 263 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: A! ® DATE(MM/DD/YYYY) l CERTIFICATE OF LIABILITY INSURANCE 1/27/2016 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 012 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). PRODUCER CONTACT Lauren Goldman NAME: Cross Insurance-PeabodyPHONE (978)532-5445 ac No:(978)532-2217 139 Lynnfield Street AIL ADDRESS:lgoldman@crossagency.com INSURERS AFFORDING COVERAGE NAIC# Peabody MA 01960 INSURER A:Western World Ins. Co. INSURED INSURERB:Safety Indemnity 33618 Nexus II Services LLC INSURER C: P.O. Box 2823 INSURER D: INSURER E: Woburn MA 01888 INSURER F: COVERAGES CERTIFICATE NUMBER:CL15102253381 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS LTR POLICY NUMBER MM/DD MMIDD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE FlOCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ NPP8290737 8/12/2015 8/12/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PELT LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: Damage to Rented $ 50,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ 500,000 B ALL OWNED SCHEDULED AUTOS rx AUTOS 3116632 11/10/2015 11/10/2016 BODILY INJURY(Peraxident) $ 500,000 NON-OWNED PROPERTY DAMAGEX HIRED AUTOS AUTOS Per accident $ 100,000 Medical payments $ 5,000 UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I IER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Timothy and Susan Mellody THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 101 Crossbow Lane ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Lauren Goldman/MD1 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025Omami °r+� �"' �✓11+G' (���'1✓}llafYllf��rt�'(�h; Q ; �%!�`�hS�CGf.'f�fl��'+Gl� °`` Office of Consumer Affairs and Business Regulation Y 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 ilk 4' Horne Improvement Contractor Registration Registration: 129177 Type: ltWivi" Expiration: 7119/2017Tr# 26M Gerald White Gerald White 23 Glendale Dr Danvers, Ma 01023 Update Address and return card,44ark reason for cftaa ' 0 Address Renewal C Employment. J Lost Card i+:A1 Q �� /rr 1`-�t.Uvi#!d!ll Tkt,� l+ r!lIIXICICII,A,'��1 omee of Comaaser AfTsits&Business Reputation before t or expregiration dstration rand for ind returnae oa1,r HOME IMPRovEMW CONTRACTOR txfore the expiration data 7f found return to: Rep4a#raLion: 129177 Type: office of�Consumer Affairs and Business Regulation Ex;&" w 7/1A12017 Individual 40 Pari Plaza-Suite 5470 Boston..NIA 02116 Gerald While Gerald White 23 Glendale[k - DanveM AAA 01923 Vailtrsetretary Not Valid without signature p.* . . � d s t d lt; 9 �., •• Massachusetts _Department of public Safety _ Board of Building Regulations and Standards C%InNtrurti"la 4uly.:m%or License- OS-073e391 GERALD WIUTE;-� 23 GLEND LE DR DAIRS MA 01923 Expiration 0410`12016 Gosnrtrisstaner I �rrrrrrrrtrrsrrrtrj/I r,/r ltrr;xrt�rraf//. Office of Consumer Aftirs&Bu,ness Regulation Lictnse straticta valid for indiretul use only 1MPROVMENt CONTRAC OR re the expiration date. If found return to: tion: 129177 Type: Office of Consumer Affairs and Business Regulation Indio' 10 Parc plaza-Suite 5170 Expiration. Boston,MA 02116 Gerald White Gerald White + " 23 Glendale �• . Oa 01923 Vnderseeretapv Not valid without signature p