HomeMy WebLinkAboutBuilding Permit #529-15 - 111 REA STREET 12/8/2014 p►ORT{i
BUILDING PERMIT oF�t�eo ,b�ti
TOWN OF NORTH ANDOVER o? gam''` `-� *°
APPLICATION FOR PLAN EXAMINATIONge
Permit No# Date Received P4oq TED.Pa"��•
`. �SSACHU`S
Date Issu [/
IM ORTANT: 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 ne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: 0 Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District
❑Water/Sewer
_
eESCRIPTION OF WRK TO BE PERFORMED:
Vr\ f� rV-
I ntificati�5 PI -ase Type or Print Clearly
OWNER: Name: t�iA{',t/ '1�, VVUA-V\ Phone:
Address: St-
Contractor
Name:ftV 1 6t-Vkhone'. CO� 40(0y- 0
n
Address: TV�C-f.S
Supervisor's Construction License: 1 / O Exp. Dater
Home Improvement License: 6 J� 1 1 Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ � FEE: $ U'
Check No.: �'� Receipt No.: r �--
NOTE: Persons contracting with unregistered contractors do not have access toAe Juaran un
Signature of Agent/Owner Signature of contractor
'I
Plans Submitted ❑ Plans Waived El. Certified Plot Plan ❑ Stamped Plans ❑
TYPE 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
A
. 1
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
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
r
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 M
❑ Workers Comp Affidavit j
❑ 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
Doe:Building Permit Revised 2014
1� Q
Location
No. �� 1 Date 12-)l
1
. - TOWN OF NORTH ANDOVERAi..
. Certificate of Occupancy $
Building/Frame Permit Fee $ a
a Foundation Permit Fee $
h Other Permit Fee $
TOTAL $ A
h Check#1 3
2- b51)2
Building Inspector
s1O R TFC
Town of y. : _ �6 , ndover
No. o
% h ver Mass iq
� �
COCNICMt WICK
�as R�tEO Pp�,��y
U BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ..........T"..Cj ...... II... ..................... ..................................
BUILDING INSPECTOR
Foundation
has permission to erect .......................... buildings on ...1.1.1...... ... .. ...................
Rough
to be occupied as ........ .e:....A.....re f66f..............................................................
Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning'or Building Regulations Voids this Permit. Rough
Final
2{ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRU N ARTS 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.
O
A&K FOWLER INSURANCE A"
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY1
TW,WE1LrTIFICATE 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 CE$TIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
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 and endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
A&K FOWLER INS LLC PHONE FAX
200 PARK STREET (A1C,No,Ext): (A1C,No):
NORTH READING.MA 01864 E-MAILADDRESS:
29J6 W
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: ACh;AMERICAN'IINSURiUNCE COMP LNY
BAY STATE ROOFERS INC INSURER B:
INSURER C:
110 BOX 189 INSURER D:
INSURER E:
NORTH READING, vt:\ 0I864 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.NOTWITHsrANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TF1 S 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 ADO SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MWDDIYYYY) (MMIDDIYYYY) LIMITS
GENERALLIABILJTY CH OCCURRENCE $
COMMERC IAL GENERAL LIABILITY
CLAIMS MADE M OCCUR. DAMAGE TO RENTED $
REMISES(Ea occurrence)
ED EXP(Anyone person) $
GENTAGGREGATE LIMIT APPLIES PER:
ERSONAL&ADV INJURY $
ENERALAGGREGATE $
POLICY PROJECT F]LOC RODUCTS-COMPIOPAGG $
AUTOMOBILE LIABILITY
ANYAUTO COMBINED SINGLE $
LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIREDAUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIABOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
4 WORK ER'S COMPENSATION AND YJC S`r :CRY UiH
EMPLOYER'S LIABILITY YIN UB-4609PO62-14 04/12/2014 04/12/2015 k _M.IS
9 Y SR ;Y 6. P.0.iNE' ,tin TiVt NIA E.L.EACH ACCIDENT
cLJIC> $ 1,000,000
(Mandatory in NH/ E.L.DISEASE-EA EMPLOYEE $ 1,000,000
1;yes,JeSinbe;,ntle;
CfSCRIRT:ON O• C:�RAP.GrSse':.lw E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIRESTRICTIONSISPECIAL ITEMS
'FHIS REPIA(I�S iLNY PRIOR('ZiR nF1C ATE ISSUED"I'O'IHF:C.ER"1T}7CA'IT?HOI,7JFR AFFF.C11NG WORKERS C'OAQP CO\'7•J110E.
CERTIFICATE HOLDER T CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL DELIVEMM
IN ACCORDANCE WITH THE POLICY PROM
CAUTHORIZED REPRESENTATIVE
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP R n`ghts reserved.
Baystate Roofers, Inc. Proposal
P.O. Box 189
North Reading, MA 01864 Date Estimate#
Tel. 978-664-0668
Fax 978-664-4333 10/28/2014 15718
Name/Address HIC # 137193
Peter Putman CSSL# 99895
111 Rea St.
N.Andover,Ma.01845
Say State I:t.00fers Inc proposes:
Remove approximately 1600 square feet of the existing asphalt shingle roof down to the wood decking.
Install new ice and water shield along the 6' roof edge, valleys and around all the roof penetrations.
Install new 151b felt paper throughout roof area.
Install new white aluminum drip edge along the roof perimeter.
A new Lifetime GAF Architectural asphalt shingle will be installed over the prepared substrate.
All roof penetrations and flashing will be installed according to manufacturers recommendation, specification
and details.
Install new pipe flanges.
Bay State Roofers will properly dispose of all roof debris in our own waste containers.
Any wood decking that needs replacement will be an additional $2.50 per lineal foot.
The back dormer roof will be completely covered with ice and watershield. Build a cricket behind the chimney
on the dormer roof and install new lead flashing. This included in this proposal. Install a ridgevent only on the
bump out gable on the front of the main roof.
New Shingle Roof
Authorized Signatu
Total
$5,980.00
Waste containers supplied by Bay State Roofers, Inc. are for sole purpose of roof debris.
Under no circumstance is the homeowner to use these containers for personal use.
10 Year Workmanship Warranty on all roofs. (Except Repair Jobs)
CONTRACT ACCEPTANCE
The specifications,prices,payment schedule are satisfactory and hereby accepted. Date:
BAY STATE ROOFERS,INC. is authorized toerform work as specified.
P p
Payment will be made as previously outlined. Signature /
All bills over 30 days are subject to 1 1/2%finance charge per month(18% /,,n
annual). Color C,Z ((Z&'
PROVISIONS OF THE AGREEMENT
I.PROJECT PROVISIONS e. Damage to Project: Contractor will not be responsible for any
a.Guideline:The Project will be constructed in strict conformance damage caused by the Owner. or other causes beyond the control of
to the plans and specifications which have been examined and the Contractor.Owner will pay for any restoration work.
approved by the Owner. IV.CONTRACTOR'S RIGHTS AND RESPONSIBILITIES
b.Compliance:The Project will be completed in strict compliance
with all laws, ordinances, rules and regulations of the applicable a. Delay: Contractor will be excused for any delay beyond his
government authorities. reasonable control. These delays may include, but are not limited to
c. Control:The Agreement plans and specifications are intended Acts of God, labor disputes, inclement weather,acts of public authority,
to supplement each other. In case of conflict,the plans will control the acts of the Owner.or other unforeseen contingencies.
specifications and the Agreement provisions will control both. b. Right to Stop Work: If any payment under this Agreement is
d.Charge Orders:As directed by the Owner,construction lender, not made when due,the Contractor may suspend work on the job until
public body or inspector,any alteration or deviation from the specifications such time as all payments due have been made. Any failure to make
that involves extra cost(subcontract, labor, materials)will be executed payment is subject to a claim enforced against the property in
only upon the parties entering into a written change order. Expense accordance with the applicable lien laws.
incurred because of unusual or unanticipated conditions will be paid for c.Substitution of Materials:Contractor may substitute materials
by the Owner. without notice to the Owner in order to allow work to proceed, provided
e. Allowances: If the Agreement price includes allowances, andthat the substituted materials are of no lesser quality than those listed
the cost of performing the work is greater or less than this allowance, 'in the specifications.
then the Agreement price will be adjusted accordingly. d.Salvage:All salvage resulting from work under this Agreement
II.FINANCIAL RIGHTS AND RESPONSIBILITIES is to be retained by the Contractor unless other agreements are
contained in the written specifications.
a. Labor and Material: Contractor will provide and pay for all
labor and materials necessary to complete the Project. Contractor is e. Insurance: Contractor will maintain workers' disability
released from this obligation for expenses incurred when the Owner is compensation insurance for his employees and comprehensive public
in arrears in making progress payments. liability insurance policies.
b. Permits:Contractor will obtain and pay for all required building V.COMPLETION OF PROJECT
permits and licenses. a. Notice: Owner agrees to sign a Notice of Completion within 5
c.Taxes,Assessments and Charges:Taxes.special assessments days after completion of the project. If project passes final inspection
of all descriptions, and charges required by public bodies and utilities and the Owner does not sign the Notice,the Contractor may act as the
will be paid for by the Owner. Owner's agent and sign the Notice.
d. Deposit of Payments: Contractor is required to deposit all b. Clean-up: Contractor is responsible for removing debris and
payments received prior to completion in an escrow account. In lieu of surplus material from the property, and leaving the property in a neat
such a deposit,the Contractor may post a bond or contract of indemnity and orderly condition.
with the Owner guaranteeing the return or proper application of such VI.CONFLICT PROVISIONS
payments to the purposes of the contract. All advanced funds will be a. Arbitration: Any controversy or claim arising out of this
deposited as indicated under Special Provisions. Monies used in Agreement that cannot be resolved, is subject to arbitration, with
escrow become the property of the Contractor when they are applied A arbitrator of mutual agreement,solv , and all parties according to the Agreement payment schedule, when a breach ofp (including
contract by the Owner occurs, or when the Agreement has been Owner, Contractor, Architect and Sub-Contractors) are bound to
substantially performed. this arbitration, If any party does not appear at arbitration
proceedings, the arbitrator is empowered to decide the controversy
e. Bankruptcy: It either party becomes bankrupt. the other party in accordance with whatever evidence is presented by the
has the right to cancel this Agreement. party(ies)that do participate.
Ill.OWNER'S RIGHTS AND RESPONSIBILITIES b. Attorney Fees: If either party becomes invoived in litigation
a. Cancellation: Owner has an unconditional right to cancel the arising out of Agreement, the Court shall award costs/expenses
Agreement, without penalty or obligation, until midnight of the third including attorney fees to the party justly entitled to them.
business day after the Agreement was signed. Cancellation must be c. Limitations: No action related to this Project may be made
done in writing. Upon cancellation, any property traded in, any by either party against the other more than 2 years after the
payments made under this Agreement, and any negotiated instrument completion of work.
executed will be returned within 10 business days following receipt by VII.GENERAL PROVISIONS
the Contractor of cancellation notice.
b. Property Lines: Owner shall locate and point out property a. Notice:Any notice required or permitted under this Agreement
lines to the Contractor.Contractor may,at his option,require the Owner may be given by certified or registered mail at the addresses contained
to provide a licensed land surveyor's map of the property. in the Agreement.
c. Liens: Failure to pay persons supplying materials or services b. Prohibition Assignment: Neither party may assign this
according to the terms of this Agreement may result in the filing of Agreement or paymenntt due under this Agreement without the written
consent of the other party.
mechanic's liens on the affected property. Owner has the right to ask
the Contractor for lien waivers from all persons supplying these c. Qualification:This document constitutes the entire agreement
materials or services. In the event any mechanic's lien is filed through of the parties. No other agreements exist. This Agreement can be
no fault of the Owner, then the Contractor agrees to take all steps modified only by written agreement signed by both parties.
necessary for the release and discharge of such lien.
d.Insurance:Owner will maintain property damage insurance at d.Governance:This Agreement shall be construed in accordance
least equal to the Agreement price. with and governed by, the laws of the state in which the Project is
located.
X .The Commonwealth of Massachr�setts -
- Department of IndustriglAccidents
Office of Investigations
600 Washington Street
.Boston,MA.0211.1
www.massgov/dia
Workers' Compensation insurance Affidavit: Baders/Contrcactors/ElePc�We p���umb r
Agglicant Information
Name(BusinesslorganizationUdRivi
.Address: 2'4n
Ciwstafezzip- V °7�C' Phone#:
6-6-'10"
Are yo Atremployer?Check the appropria a box: Type orproject(required):
am a employer. with 4. ❑ I am a general contractor and I 6. ❑New construction
z. --
� have hired the sub-contractors
employees(fall and/or pax ane)•' listed on the attached sheet." 7• ❑Remodeling
2111 I am a sole proprietor Orpaxtner-
Thesesub-contractors have 8. El Demolition
ship and'have no employees
working forme in any capacity. workers'comp.insurance. g, ❑Building addition
[No workers' comp.insurance 5• ❑ We are a corporation and its officers have exercised their 10.E]Electrical repairs or additions
required.] 11. airs or additions
3.❑ X am a homeowner doing all work right of exemption per MGL ❑Plumbing repairs
myself.LNo workers' comp. c. 152,§1(4),and we have no ME].Roofrepairs
employees.[No workers'
insurance required>]" 13.❑Other
comp.insurance required.]
-Any applicant that checks box#1 must also fill outthe section below showing their workers'compensation policy information.
T-Homeowners who submit this affidavit indicatiagthey ore doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContraetors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
X am an employer that is providing workers,compensation insurance for my employees. Below is the policy and jah site
A
information.
Insurance Company Name:. At C°`��`
Policy#or Self-Ins.Lic.#: U
4 l Expiration Date: L442-, S
Job Site Address: City/State/Zip: 4 U
Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section25A ofMGL o.152 can lead to the imposition of criminal penalties of
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
ofup to$250.00 a day against the violator. De advised that a copy of this statement may be forwarded to the Office-of
Investigations of the DIA insurance coverage verification.
X do Hereby certi u der e pa' an pe o Yjury t at the information provided above is true and correct. -
� Date• .-
Si ature•
Phone i#-
Official use only. Do not write in this area,to he completed by city or town official.
City or Town: Permit/License 0
issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbingfuspector
6.Other -
Phone#:
Contact Person:
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 ofhire,-
express or implied,oral or written. .
An employes is defined as"an individual,partnership,association,corporation or other legal entity,or any two ormore
of the foregoing engaged in a joint enterprise,and including the legal representatives of a:deceased employer,or the
receiver or trustee of an indiiidual,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 shalt not because of such employment be deemed to bean employes."
MGL chapter 152,§25C(6)also states that"every state or local lie-easing agency shall 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 1.52,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shalt
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 phonenumber(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are notrequired to carry workers'compensation insurance. If an LLC or LLP does have
employees,apolicy is required. De advised that this affidavit maybe.submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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 Depaxtmenthasprovided aspace atthebottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till 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(ifnecessary)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 p ermits or licenses. Anew affidavit must be tilled out each
year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture
(i.e.a dog license orpermit to burn leaves etc)said person is NOTrequiredto complete this affidavit.
The Office off Investigations would no to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
no COMIAO.Uwalth ofMus achmotts
Dopa eat ofWwWal Accidents
Qfco ofIRVesiigatkna
6.00 Waft. gtaa fteQt
Boston,MA. 021.11
Tel#617..`Z217_4900 QA 406 ox x-8.77-MI ASSAFF,
Revised 5-26-05 Fax#617-727-7749
WWW- .amov/dia
✓fie -Poryninaruuecz�Zo���°°czc�au6el�6
Office of Consumer Affairs&Business Regulation
HOME IMPROV,,WENT CONTRACTOR
i
Reg istratio n:-jj�37193
k = Supplement 1
Expiration:W 1901:6 16
�I BAY STATE
i ROBERT O'KEEFE :_:
PO BOX 189
N.READING,MA 01864`>' Undersecretary
P
AL
Massachusetts -Department of Public Safety
Board of Building uildmg Regulations and Standards'
Construction Supen'isor Specialty
License: CSSL-099895
ROBERT E OKEEFE
21 FRANCIS STREET:
NORTH READING 1VIA 01864
Expiration
Commissioner 09/29/2015
I