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HomeMy WebLinkAboutBuilding Permit #1106-2016 - 11 CAMDEN STREET 4/25/2016 4 RTh BUILDING PERMIT eD TOWN OF NORTH ANDOVER ° ' ` APPLICATION FOR PLAN EXAMINATION - - 11r�� n � Permit NO: \V U _20 Date Received A0'�wieo Date Issued: Z��1 9SSACHUS�� IMPORTANT: Applicant must complete all items on this page LOCATION /J &E&J, 3 Print PROPERTY OWNER °},P. f"Cf 6)1��£ J - Ltfl i✓ Print MAP NO: M_PARCEL:6)7,i_ZONING DISTRICT:. Historic District yes, no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ emolition ❑ Other ❑'Septic El Well ❑ Floodplain ❑Wetlands p Watershed District D Water/Sewer lq nil U/'i��� s/d,06 Identification Please Type or Print Clearly) OWNER: Name: _q,1,TCrn ),`Ibf Phone: UL33�0 Address: CONTRACTOR Name: Phone: Address: .— -----. �m eow Supervisor's Construction License:_ 4 Exp. 'Date: Home improvement License: 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 CT�I : $ Q(ca GCS FEE: $ 1C) Check No.: I I Receipt No.: X2"1'1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner r Signature of contractor E 1r NoRTJ1 BUILDING PERMIT ' 0 '11-ED A�•O r r 6.:,. ..:•4. 6 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION n M 1 Date Received �9°°RAT* Permit No#: gSSACHUs�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER 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 ❑ New Building ❑ One family El Addition ❑Two or more family ❑ Industrial El Alteration No. of units: El Commercial El Repair, replacement ❑Assessory Bldg El Others: E0 Demolition El Other - --�- r ❑.Septic ❑Well ❑ Floodplain El Wetlands ❑ Watershed Dis, net ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email- Address- Su mail: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp: Date: — b 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.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location �!UG - t<c Date �� No. i . . TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ ! Foundation Permit Fee $ Other Permit Fee $-- TOTAL - � f Check# k *� ! Building Inspector c �r Plans Submitted ❑ Plans Waived.❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPF OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming 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 Signature COMMENTS HEALTH Reviewed on Signature COMMENTS x A Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ��F�IRE DEPARvTMENT� = Te�rnpDumpsteronsite dyes =�Ino� \ ;(Locate"da`f 124ManStreet rJ- Fre;Depatments g_ Rn 'K e c.C®'MMENT 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.$10041000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date —Time Contact Name L — — Doc.Building Pennit 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 ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application a Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 NORTH Town of 2 : _ ndover O No. h , ver, Mass, I Z T O LAKE coc"Ic NIWKK S U - BOARD OF HEALTH Food/Kitchen P E IT T D Septic System • THIS CERTIFIES THAT ..........t C�� �1 1� ....,,. BUILDING INSPECTOR .......................................... .......1�. s .,�. ......... . .. .. ...... ... awarw Foundation \\has permission to erect .......................... buildings on ..�.1..... ...SAr.e.e+..t iq_ Rough to be occupied as . -Si1,�.w.. ...�.�..11J... .`..�... �a ... .:` � Chimney provided that the person accepting this rmit shall in very respec conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO RTS Rough Service ............... ...... ... .... ............... ............ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildine 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. OORTh TOWN OF NORTH ANDOVER OFFICE OF ° p BUILDING DEPARTMENT a 1600 Osgood Street Building 20, Suite 2-36 N 471D♦A�,h* North Andover Massachusetts 01845 9's CHUS�� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: �� � lrYCi�I J Nei Number// Street Address Map/Lot HOMEOWNER 2f LL( G� 6),j 7(3�' /' Name Home Phone Work Phone PRESENT MAILING ADDRESS_ bX-yr ,ate lir O/Nr City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of IndustrialAceidents b 1 Congress Street,Suite 100 < Boston,MA 02114-2017 't www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Avvlicant Information Please Print Legibly Name (Business/Organization/Individual): lqehecco Address: (; Qn l�rp City/State/Zip: D(Aki AApT JDg L1Yj'Phone#: Are you an employer?Check the appropriate box: Type of project(required): LE]I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. X Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself t 9. ❑Demolition y [No workers'comp.insurance required.] 10 F�Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other 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;heir workers'compensation policy information. t Homeowners who submit this affidavit 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. I I am an employer tliat isproviding ivoricers'compensation insurance for»ry employees. Below is thepolicy andjob site information. Insurance Company Name: I Policy#or Self-ins.Lic.#: Expiration Date: i Job Site Address: City/State/Zip: j 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 e. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer i»der the pains an nalties of peijuty that the information provided above is true and correct. Si nature: /� Date: Phone#: `19,F'3.3 Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: North Andover MIMAP April 25, 2016 0 9, Q, ' , v G ZA y R b • r Y# , MVPC Bo Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, I Meters Data Sources:The data for this map was produced by Merrimack Planni —SR NORTH Valley ng Commission(MVPC)using data provided by the Town of RoadsOf t`i n 'q1, North Andover.Additional data provided by the Executive Office of < • O Environmental Affairs/MassGIS.The information depicted on this map is i r Easements ? q� O F_1 Parcels i' _ L for planning purposes only.It may not be adequate for legal boundary Oto definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING t THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY * s ^ * OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION ��Ss�cHus�� 1"=55 ft ~�° North Andover MIMAP April 25, 2016 085:0 0045 20CA1NDEN(ST 085'.fl-0024 ,�� X85 O 0004: 1085:.0-0008 1 00885.iO-V007 25 CAMDEN�ST' f0gAiQ4 005' 085iOc0023 �1CAM_DE NDS„f` ,tR X222`f?LEASAt+1T�tST`' I I �O 3 {f85:6=00117' 115(GAAA�MEN1;T 085 0-0014 228CO.LWti ALklftsll '' X22 PRINGEtTON;[ST' tCAMDENtST�\ -0022.2 RTS'-fl-flozs 085.0=fl00 R4OM-0030 ;242(F1E115ANf(ST` 085:.0-0046 005'0-0029 C45(PLEASANT 085 O Ofl32 ti23S(PLEASANT�ST� s�iy 085 0 0043 1; i F ,085 0 00-1A ,.� X085 0 11038, X241 PL'EASAN,�T�ST' ;085",0-0! 06' `254+PLEASA NTtST tp f326,tOSGOOD.r 85';0 0049 `" �'. `` "``S!" 05.fl':QD50 6--d 04.1• 085:0=_0.040 0 } 13 MVPC So Zoning Overlay Zoning Municipal Boundary ®Adult Entertainment Distric Busine s 1 District Machine Shop Village Ove d Busine s 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NA083, — Rail Line ®Watershed Protection Dist 0 Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack Interstates 0 Historic Mill Area O Busine s 4 District NORT►t Valley Planning Commission(MVPC)using data provided by the Town of _I Medical Marijuana 12 Genera Business District OE t`to�•'�� North Andover.Additional data provided by the Executive Office of —SR ®Downtown Overlay District 0 Planne Commercial Dev ? << +�OD Environmental Affairs/MassGIS.The information depicted on this map is 0 Historic District B Corrido Development Dist 3 L for planning purposes only.It may not be adequate for legal boundary Roads U Osgood Smart Growth(40 C Comido Development Dist definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER C,Easements C Hydrographic Features 13 Corrido Development Dist MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Industri I 1 District t - * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ®Parcels -Streams C Industri 2 District - i $ OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Wetlands G Industri 13 District ; 09 �y ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Q Industri I S District °` THIS INFORMATION C Exempt Lands Reside ce 1 District �Jq'��no C Reside ce 2 District S A Rp.qidei ce 3 District SSwC dece 4 District 1"=55 ft de ce 5 Dist ct Ede ce 6 District ,a a esidential District North Andover MIMAP April 25, 2016 085.0-0045 /� 085.0-0024 085.0-0004 085.0-0008 085.0-0005 085.0-0007 25 CAMDEN ST 14 CAMDEN ST 085.0-0023 085.0-0017 de 15 CAMDEN ST 085.0-0014 28 PLEASANT ST 22 PRINCETON ST 11 CAMDEN ST> 085.0-0022 085.0-0021 *ti h4 \ 085.0-0037 085.0-0030 �. 1 242 PLEASANT ST 085.0-0029 e� 246 PLEASANT ST d� Gem° 085.0-0032 9 PRINCETON ST lad 085.0-0043 ti g 085.0-0031 085.0-0038 085.0-0006 0 MVPC Bo 13Municipal Boundary - Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Rail Line Meters Data Sources:The data for this map was produced by Merrimack Interstates pflRT¢S Valley Planning Commission(MVPC)using data provided by the Town of I t North Andover.Additional data provided by the Executive Office of 0 t�sa, —SR � : at �*e�,C Environmental Affairs/MassGIS.The information depicted on this map is 3 e for planning purposes only.It may not be adequate for legal boundary Roads F i A definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER t;r Easements MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING - THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ®Parcels - ;s + OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Trails •o� e • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF O Hydrographic Features THIS INFORMATION Streams _:Wetlands :) Exempt Lands ^=46 ft ` _ Residential Property Record Card Parcel ID: 210/085.0-0021-0000.0 MAP: 085.0 BLOCK: 0021 LOT: 0000.0 Parcel Address: 11 CAMDEN STREET FY; 2016 PARCEL INFORMATION Use-Code: 101 Sale Price: 1 Book: 13571 Road Type: T Inspect Date: 05/16/2011 Owner: Tax Class: T Sale Date: 07/26/2013 Page: 0345 Rd Condition: P Meas Date: 05/16/2011 WILDES,REBECCA,ANN Tot Fin Area: 1477 Sale Type: B Cert/Doc: Traffic: M Entrance: X Address: Tot Land Area: 0.180 Sale Valid: A Water: Collect Id: RRC 11 CAMDEN STREET Sewer: Grantor: ZARZOUR/WILDES Sewer: Inspect Reas: M NORTH ANDOVER MA 01845 Exempt-B/L% 0/0 Resid-B/L% 100/100 Comm-B/L% 0/0 Indust-B/L% 0/0 Open Sp-B/L% 0/0 RESIDENCE INFORMATION LAND INFORMATION Style: CO Tot Rooms: 5 Main Fn Area: 827 Attic: N NBHD CODE: 5 NBHD CLASS: 5 ZONE: R4 Story Height: 1.75 Bedrooms: 2 Up Fn Area: 650 Bsmt Area: 702 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 1 Add Fn Area: Fn Bsmt Area: 1 P 101 S 8000 0.180 N 163,994 Ext Wall: AB Half Baths: 1 Unfin Area: Bsmt Grade: VALUATION INFORMATION Masonry Trim: Ext Bath Fix: Tot Fin Area: 1477 Foundation: CN Current Total: 306,300 Bldg: 142,300 Land: 164,000 MktLnd: 164,000 Bath Qual: T RCNLD: 142336 Kitch Qual: T Eff Yr Built: 1970 Prior Total: 278,900 Bldg: 120,500 Land: 158,400 MktLnd: 158,400 Mkt Adj: Heat Type: HW Ext Kitch: Year Built: 1940 Sound Value: Fuel Type: O Grade: A Cost Bldg: 142,300 Fireplace: Bsmt Gar Cap: Condition: A Att Str Val 1: Central AC: N Bsmt Gar SF: Pct Complete: Att Str Va12: Att Gar SF: %Good P/F/E/R: /100/100/73 Porch Type Porch Area Porch Grade Factor W 192 Sketch Photo 011 192 S4 R I 12 xt R,/FM f B 650 s4 R 12§5%R 11 CAMDEN STREET 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 ❑ Building Permit Application ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ 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 NOTE: 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 ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 BUILDING PERMIT N0RTJ1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION '- ' t2i— IMPORTANT: IPermit No#: Date Received �'�s R..TC us Date Issued: Applicant must complete all items on this page LOCATION �` Pq`VI J rs� Sf 'Print PROPERTY OWNER Rc h ee-C4 w►-le/Y 5 Print 100 Year Structure yesOno MAP _ PARCEL%71 ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg Others: ❑ Demolition ❑ Otherr5 v 1tii i o r„ Main t ©1%Uetland's ® UVa er ed ®s,nc E DESCRIPTION OF WORK TO BE PERFORMED: r}�r'5Tglri�q /977-jC ZInSv/A?�evJ Identification- Please Type or Print Clearly OWNER: Name: Q r� erm t v 0 of-e S Phone: Address: /r CA a4d rm S%fr« Contractor Name: pr-?r r- i z-A(a KC Phone:_ Y02 G?� Email: Address: 5 7- ;N t 5T Supervisor's Construction License: /VGoi> Exp. Date:. . Home Improvement. License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 300_ © o FEE: $ • Check No.: �r Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have acces o th guaranty fund . •. x:tea:F^..a,,�.---..,R-;^Es':y�+,•.^'.+�r.. _,: +' - ��^.-w- -• �'{- 2Z �V Location 4 , _A �1 cX � m ' No. — Date - . • TOWN OF NORTH ANDOVER a- Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 'e Checkrz—D #� 1 29985 Building Inspector z i Plans Submitted ❑ Plans Waived,El Certified Plot Plan ❑ Stamped Plans ❑ TYpF OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming 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 Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 1 I Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street e ^ {FT' Temp Dumpsteronsite �ye,�s2 tno i a aLocatetlta124 Ma"iriStr eet � 4 Fire; epartmenignatur d fe e } I. eF NORT!j Town of ndover O No. h , ver, Mass, co�M��M.w�cL; ■ �1 �qS R^reo 11 BOARD OF HEALTH Food/Kitchen PERMLD Septic System lit• THIS CERTIFIES THAT ......................... GeCie ..................�� .... ................................. BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ... ........GiA.1i%P. .......................... Rough • to be occupied as ........ .+ .�.� ...........! ...... .. . . :. .. ..��.................. Chimney n ever ....... provided that the pers ccepting this permitihall in respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR • UNLESS CONSTRUCTI SRTS Rough Service .............. .... ... .... ............................................ Final BUILDING INSPECTOR 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. Federal ID#0"405629 RISE.Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 RIS A division ofThielseh Engineering p/� ENGINEERING 60 Shawmul Unit#2,Canton,MA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 Page 1 PROGRAM THIS CONTRACT i8 ENTERED INTO BETWEEN RISE CNIA-14E'S ENGINEERIUO AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENTS WORK ORDER Rebecca Wildes (978)258-1998 10/30/2015 424670 00002 SERVICE STREET L BILLING STREET 11 Camden Street i I 1 Camden Street SERVICE CITY,STATE.ZIP BIWNG CITY,STATE.ZIP North Andover,MA 018 0 North Andover,MA 01845 �---� JOB DESCRIPTION 4 BARRIER:A Blower Door'rest v'll not h cted or home,due to the presense of asbestos. $0.00 BARRIER:Wc have identified a moisture issue in your home that needs to be addressed.Homeowner is responsible for correcting this moisture concern,prior to the installation of any weathcrivation work. $0.00 BARRIER:We have discovered what appears to be a mold/mildew-like substance in your home.This is being brought to your attention to identify it as a pre-existing condition to the insulation and air sealing work planned for your home.Your signature is your acknowledgement of these conditions and agreement to proceed. $0.00 AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use ofspecial tools and diagnostic tests to assure that your home will be tell with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) This will require(6)working hours.A reduction in cubic feet per minute(cfm)of air infiltration%vial occur,but the actual number of cfm is not guaranteed. At the completion of the weadierixation work,and at no additional cost to die homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $510.00 ATTIC FLAT:Provide labor and materials to install a 10"layer of R-35 Class 1 Cellulose added to(288)square feet of open attic space. $423.36 ATTIC FLAT:Provide labor and materials to install a 14"layer of 1149 Class 1 Cellulose added to(144)square feet of open attic space. $243.36 ATfIC ACCESS:Provide labor and materials to insulate the back of(2)attic hatch with 2"rigid Thermax board.Weatherstrip die perimeter. $120.00 VENTILATION:Provide labor and materials to install(2)12"X 12"aluminum gable end attic vent. $229.00 VENTILATION:Provide labor and materials to install(3)8"diameter roof vcnt(s)to increase ventilation in attic areas. The vent can be supplied in(circle color)black,broom,gray or mill finish. $256.50 VENTILATION:Provide labor and materials to install ventilation chutes in(24)rafter bays to maintain air flow. $49.00 BASEMENT CEILING:Provide labor and materials to install(98)linear feet ofR-19 unlaced fiberglass insulation to the perimeter ofthe basement ceiling at the house sill $171.50 Federal ID d 05.0405929 RISE Engineering RI Contractor Registration No SIN RISE - �A Contractor Registration No 120979 A division ofThtelsch Engineering ENGINEERING 60 Sbawmat Unit 42,Canton.MA 02021 CONTRACT 339-SO2-035 FAX 339_502.63as Page 2 PROGRAM THIS CONTRACT IS ENTERED WTO BETWEEN RISE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBIENBMM CUSTOM PHONE DATE CLENTA WORKORDER Rebecca Wildes (978)258-1998 10/30/2015 424670 00002 SERVICE STREET' --- BMUNG STREET I 1 Camden Street I I Camden Street SERVICE CRY,STATE,MP 6"M CRI;STATE,IIP - North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION CRAWLSPACE:Provide labor and materials to install(144)square feet of R-19 unlaced fiberglass insulation to the cmwlspace ceiling to be in contact with the subiloor and completely filling the joist cavity to be flush with the joist bottoms. Then install I" polyisocyanurwc foam board insulation. Seal all seams with FSK tape. $554.40 CRAWLSPACE:Provide labor and materials to install(428)square feet of 6 ml polyethylene over open ground in designated crawlspacdearthen basement areas. 5329.56 CRAWLSPACE:Provide labor and materials to install (90)square feet of R-10 rigid Theenax insulation to the crawlspace perimeter wall up to the sill and against the band joist. 5333.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures,Columbia Gas offers 75%incentive,not to exceed 52,000 per calendar year,and an incentive of 100%for the Air Scaling measures up to the first$680 and an additional$340 if savings are justifled by the auditor. For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in Your home both before the work is begun,and after the weatheRiaation work is complete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has a value of 590 and is at no cost to you. Total allowable weatherization incentive is$3,110. $90.00 Total: $3,307.68 Program Incentive: $2,600.00 Customer Total: $707.68 WE AGREE HEREBY TO FURNIS'FI SERVICES-CONPWFE W ACCORDANCE IMTH ABOVE SPMMATIONS.FOR THE Sum OF ""Seven Hundred Seven&681900 Dollars $707.68 UPON FWAL WSPECTION AND APPROVAL BY RISE ENCOMERINt- AGREES TO REMTTAMOUNT DUE IN FULL INTEREST OF IS WALL BE CHARGED MOUTKY ON AVIV UNPAMaNABCE IDDAVS.SEEREVMMFOR DAPORT RMTION ON OWWANTEES.RIOHTS OF RECURCK8LYIEDUAM AHD CONTRACTOR REOMTRATKIIL DO SIGN THIS CONTRACT IF TH=ARF—AWbPA SIGNATURE-RISE ---- NOTE THIS CONTRACT MAYBE WATNDRAWN BY US IF NOTE)MCUTED WITHIN BATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPEMCATIONS AM CONDmONS ARE 30 SATISFACTORY TO US AND ARE NERM ACCE VM3L YW ARE AVURWMTO Do THE WORK DAYS. AS SPECW=PAYMENT WD.L BE MADE AS OURAIEDABOVE e OWNER AUTHORIZATION FORM t, z?, (OWes e) owner of the property located at l CQ A,01 cz—r i>, ' (Property Address) Ah &zgg ) g oci G r zL4 L (Property Address) hereby authorize (Subcontractor) an authorized subwntractor for RISE Eng'cneering,to act on my behalf to obtain a building permit and to perform work on my pmperty. I !' Owner's Signature M) T he Corssanoraraei dtda of Massachusem Dep aaleerat of Industrial ACCU IS I Congress Streeg Suite 100 Bosiors 02_1_1.4-2017 ra:mas&g&Y1darn UT— Comp=ensation Insurance Affidavit:$uildess/Con€ractor-JEIecuidaaslPlumber,- TO BE��ID WIT,Ffr--PER]v lT•lriG AU-ITI()Rl�l- AiDpHcant Information Nease Print Name (BusincsslOrpnizatiowindividua!): Address: C It�//StaTTYp: �� �;. :i 7 L..it % i s%(�/v pl]OIIe#: l `f" ` �i'� Am yore no employer?Cbech the apomprivte bos: Typ=e of project("quired)= I.Q I am a employe With i_ _copkQr=(full snftr part-time)_' ?_ 1-1 New construction 2-0 I am a sole proprietor or p ip turd bac no cmployom working for roe in 8- t"""I IZCIIIOdel1I1� 211Y-432citY-(No tt rkc s'comp_inst==required.] 3.0 I am a bomarwaer doing nit wont my=IL(No°rockers'cotttp_insurance -j t 4. 0 l=nolition 10 4 I am a hom=9vner aad cvtlt lx hiring contractors to conduct all work.ort my property-I Will li ��Building addition ensure that all contractors cithcr have workers'oampMsation insurance or are sole 11-1-1 Electrical Fairs or additions proprietors with no employees, 12_0 Plumbing repairs or additions 5�I am a gmeat Contractor arid I bave birr d the sub-coutractors listed on the attached shod 13-E]Roof repair s ?hese sub-contractors have c mpleyecs and have workers'comp_iastaancef 6_0 We are a cozporation and its odI'iecs have exacisod their right of uempaoo per rtitGL t 14.d=t Other 152,§I(4).and we have no emplpyom[No workci comp-ms-ram--Virt&I `Any applicant that=heeler box t:I midst oho field Cts the sccIIon 1>`Iow showing[heir workers txasateon polity info tmatioa t Homeowners who submit this affidavit Wksting they arc doing all work attd dxn hire outside oontmaors must submit a new affidavit indicating such- tCoonactors that check this box mast attached as additional she=shawiag the name of the sub-coa a=lms and sate whctbcr or not tbo5e=Mitt=s have employes_ If the sub-contractors have cmpioyccs,thY an, provik their worktrs'comp.policy nttmb`r_ f air an employer that is providing Workers'compensation insurance for my employees. Below is there policy and job site infomrataor� � Lasurance Company Name: t C3 "1C i Policy#or Self-ins-Lic_ Expiration Date-- J%%rv��012 lob Site Address: �� �5 1YId'°� /' City/Statt�Gip:� . (f�/-I�pV..eK- Attach s copy of the workers'compensation policy decim-stion page(showing the gouty number and egp$rataoal date). Failure to secure coverage as required under-MGL c- 152,§2511 is a criminal violation punishable by a fine up to 51500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a lay against the violator-A copy of this statement may be forwarded to the office of investigations of the DIA for:r:a. — ;overage vcsifieadon. t do hereby cern•fy*aerate ruler=pairs and Fearaldes-o.fPgfury rhae doe injormadon proy Med above is true and correct ii ertature: �� 4.r' j y:,; ti' '; Date: "hone 2-2 --7 Gf C— Ofj'icaal use only. Do not write in this area.to be completed by cifor tow o;�zeiaL City Or'f'owrn_ PermiuLkense# Issuing Authority(circle one). 1.Board of Health L Building Department 3.Ci'rYf'ovm Clerk 4.F+leetr'ic8l lnspec$oi- Plumbing juspedor• 6-Other- Contact Person: phone#: POL ABEA-01 JONEILL ,a►CORO CERTIFICATE OF LIABILITY INSURANCE DAT1/6/2 D/YYY1� 1/6/2016 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 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). PRODUCER CONTACT NAME: Durso&Jankowski Insurance Agency PHONE 978 688-7000 FAX 11 Saunders Street Arc No Ext: ) (ac,No):(978)688-70.0_1_ North Andover,MA 01845 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE I NAIC>/ _INSURER A:Nautilus Insurance Co. 17370 INSURED _ INSURER B:Safety Insurance Company .33618 Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc P 0 Box 958 INSURER D Andover,MA 01810 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD I POLICY NUMBER MM/DD MM(DD LIMITS A X I COMMERCIA GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000 I ____1 INN538691 03/24/2015 03/24!2016 DAMAGE TO RENT ti'--_-- CLAIMS MADE U OCCUR PREMISES(Ea occurrence $ 50e600 MED EXP(Any one person) $ 5,000 I I _ PERSONAL&ADV INJURY $ V 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I i GENER_A_I AGGREGATE $ 2,000,000 POLICY 0 JEu LOC f PRODUCTS-COMP/OP AGG $ 1,000,000 E OTHER: I$ AUTOMOBILE LIABILITYI O BINEDISINGLE LIMIT $ 1,000,000 B 12100926 01/04/2016 01/04/2017 BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS i X AUTOS BODILY INJURY(Per accident) $ X NON-OWNED PROPERTY DAMAGE 1$ X HIRED AUTOS i AUTOS ( (Per ac' an ------- $-.___-$ !UMBRELLA LIAM X "OCCUR i I ( EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB_ CLAIMS MADE I IAN019284 03/24/2015 03/24/2016 I AGGREGATE $ I DED RETENTION$ ( $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITYSTATUTE ER_ ANY PROPRIETOR/PARTNER/EXECUTIVE YE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L DISEASE-EA EMPLOYEE$ _ if yes,describe under E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insulation Work-Mineral Insulation Work-Mineral;Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf by the above insured is Thielsch Engineering CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g g ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE (11000 401A AI%Ann/1/1nnr1n A"e%U Ail-...L.�w-......-....d IIW2016 Preview:Certificates of Insurance AC©® CERTIFICATE OF LIABILITY {NURAINC 7TE(MMODYYYY) `64� 0110412016 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). PRODUCER CONTACT NAME: PHONE Automatic Data Processing Insurance Agency,Inc. c. 1 .Extl: (ANot 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC 9 INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER O: INSURER E: INSURER F: _ COVERAGES CERTIFICATE NUMBER- 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOIA HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTA11THSTANDING ANY REOUiRELIENT.TER&i OR CONDITION OF ANY CONTRACT OR OTHER DOCUtaENT.'.11TH RESPECT TO''WHICH THIS CERTIFICATE NIAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN:S SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.0,11TS SHOV.'N I.!AY HAIfE BEEN REDUCED BY PAID CLAILIS �R SR TYPE OF INSURANCE INSD VNO POLICY NUMBER IMIXOD/YYYY) (MRI+DD YYYY)POLICY EFF POLICY EXP I LUSTS COMMERCIAL GENERAL LIABILITY EACH QCCUNRE1.CE S CLAINS-NAUEEl IOc-culi FIiEF11SES IEa xa:cerc^I 5 TIED E}:f•ri,r:;ra p_rsar.! PERSCNAL`.AUV IIJUH'! GENLAGGREC'.fli LH-111 APPLIES PER: GENE:KAL AGGREQ--,I E S PCLIC': EC I LCC I'RUCtti Is-C-0IJP CI'AGG S F-1,EC UTr:Ei: S AUTOMOBILE LIABILITY Ui.1 Ir:EUSR.LL ET � AN'AUf0 BCUIL*,INJURY 5F-pss:mu S eat L`:a:El �CHEL'•ULEO ALV Cs AUI CS BCUIL''II:JUIi iPr.�c^.reml 5 livli-0'ia:Ell ALA G H11 EUAUICS AUT Qs il'�r;+:_�_�uI S VR=LALIAB OCCUR`. -RICH C'CCUFRENCE E%CESS UAB CLAIL1S LVJ)E AGMEGAIE S DEO IiE1El:I IOI:S WORKERS COMPENSATION X I•t[ u H AND EMPLOYERS'LIABILITY sri,lUlE EI Y,N 1,000,000 ',NY f9a:PIaE 1rE:P,1H TF VEDi C-CUT'n1E EL E;,CH:,CgUEt:I 5 A cf nd.!, ¢r.tBE(Ek Lt Gti Q NIA N POtNC772258 01101:2016 01/01,2017 (RSandalory in NH) E.L.L•ISEASE-EA ELIPLCYEE 5 1,000,000 1,000,000 CESCRIPIICt:CP CPEIiA fICRS bco;: E.L.UISEiSE I°COC!wall 5 DESCRIPTION OF OPERATIONS!LOCATIONS(VEHICLES(ACORO 101.Additional Re—le,Schedule.may be attached it mwe 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 TheHsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE AC 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Regdefion -c - of onsumer��� Office lU ParkPlaza-S�-w 5170 acht�Se 0211b Boston, = tor on xome moment COIltr�_'- Reg i- 1026 - ` Types- DBA Tt# 259 7i?120�5 Co- POLAR BEAR[NSI Vincent LeBlancOak_ for P.Q.BOX 958 g'i0 _ _= _ - amtcemcn�s n ioCiw n ANDOVER, NIA 0'i _o�aAaa, - � ❑ Rewwal ;-J Addrm ❑ - - �p1gi6 Opg.CA1 ss -Zs�Zs_.. 71��I)n SuPe`T,25131 JrfiL'�3:3� �a3 r ' \iSSLIUW pigj pW IK welts