HomeMy WebLinkAboutBuilding Permit #685 - 12 MIFFLIN DRIVE 5/10/2010 BUILDING PERMIT Ofr10RTh
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TOWN OF NORTH ANDOVER 0 *°
APPLICATION FOR PLAN EXAMINATION
Permit NO: d Date Received
SACHUS��
Date Issued: _w
IMPORTANT: Applicant must complete all items on this page
LOCATION. A
PROPERTY OWNER l Vt
Print
MAP 210 - PARCEL:_._n ZONING DISTRICT: Historic District yes
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Res' Non- Residential
New Building
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District,
Water/Sewer
DESCRIPTION(OF WORK TO BE PREFORMED:
dentification Please Type or Print Clearly) R
OWNER: Name: �C) \-vLyt,y fat Phone ��'�'�3"
Address:
p
CONTRACTOR Name: Phone: O
Address: 21
Supervisor's Construction License: 9cl S Exp. Date: "2-9—
Home Improvement.License: _ 1, I` 1 Exp. Date: L ""
ARCHITECT/ENGINEER Phone: t
Address: Reg. No.
FEE SCHEDULE:BULDINGERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost. $ ���� �� FEE. $
Check No.: 3I ZU Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have accesto he uaran n
Signature of Agent/Owner Signature of contractor _..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
❑ 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 issuc, nce 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/Crossection/Elevation Plan Of Proposed Work With Spri ikler 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 2008 .
i
Plans Submitted Plans Waived 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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
t
I
HEALTH Reviewed on Signature
COMMENTS
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 924"Main Street
Fire Department signature/date
COMMENTS
C
Dimension
Number of Stories: Total square feet of floor area, based on E terior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop req ires 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)
i
i
❑ Notified for pickup - Date
.........................._..._...._..........................._.................................._......................._................................................................................._...................._......................................._.................................................................._.._................... ..............................-.........................................................................................
Doc.Building Permit Revised 2010
Location
No. U� ,� Date
TOWN OF NORTH ANDOVER
" Certificate of Occupancy $
+ �
s -TS^cNus''••°'Eta Building/Frame Permit Fee $
Foundation Permit Fee $ ;—
Other Permit Fee $
F TOTAL $
Check # O
t
f` Building Inspector
i
T40RT H
TONNM
No. � w"
L A dover, Mass.,
COCMICKEWICK
AO
RATED P'P �C:)
S BOARD OF HEALTH
Food/Kitchen
PERM .IT T D Septic System
�� A G BUILDING INSPECTOR
THIS CERTIFIES THAT....... ........ 1�....................................................`!.:.:. ....
Foundation
has permission to erect........................................ buildings on .....s.L........w1i......
.
........ Rough
to be occupied as............"ac6ep� i
' ............ ... .. .....
provided that the arsonhis arm' .. .....""'.""""""""""" Chimney
P permit shall in every respect con to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the nspection, Alteration and Construction of
Buildings in the Town of North Andover.
PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTR ®N S ELECTRICAL INSPECTOR.
�S Rough
...... ..................................:.......................... Service
BUILD ECTOR
Final
Occupancy 'Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done
Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT
[Burner
Street No.
IL—SEE REVERSE SIDE Smoke Det.
. i
PROVISIONS OF THE AGREEMENT
1.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 a. Delay: Contrackor will.be excused for any delay beyond his
with all laws, ordinances, rules and regulations of the applicable reasonable control.These delays may include, but are.not limited to
government authorities. Acts of God,labor disputes.inclement weather.ads of public authority,
c. Control:The Agreement plans and specifications ate intended acts ofthe own
d or other unforeseen contingencies.
to supplement each other.In case of confficL the plans will control the b.Right to Stop Worfc If.arty payment under this Agreement is:
specifications and the Agreement provisions win.control both. not made.when due.the Contractor may suspend work on the job until
d. Charge Orders:As directed by the Owner, lender. such time as all payrttents due have been made.Any failure to make
public body or inspedw,arty alteration or deviation from the specifications payment is subject to a claim enforced against the property in
ken laws.
that involves extra cost(subconbact,�labor,materials)will be executed accordance withe
only upon the parties entering into a written change order.Expense- c. Substitution of Materials:Contractor may substitute materials
Incurred because of unusual or unanticipated co ndilions win be paid for -without notice to the Owner in order to allow work to proceed.provided
by the Owner. that the str4piituted materials are of no lesser cpality than those listed
e. Atlawances..:lime Agreement price irKAales allowwices,and in the tions-
the cost of performing the watt is greater or less than this allowance, d.Salvage:AN salvage resulting from work under this Agreement
then the Agreement price wig be adjusted accordingly. s to be retained by the Contractor unless other agreements are
IL FINANCIAL RIGHTS AND RESPONSIBILITIES contained in the written specificatioris..
a. Labor and Material- Contractor.will provide and pay for all e. Insurance: Contractor will maintain workers' disability
labor and materials necessary to complete the Project. Contractor is compensation insurance for•his employees and comprehensive public
released from this obligation for expenses incurred when the Owner is liability insurance policies.
in arrears in making progress payments. V.COMPLETION OF PROJECT
b. Permits:Contractor will obtain and pay for all required.building a. Notice:Owner agrees to sign a Notice of Completion within 5
permits and licenses. days after completion of the project. If project passes final inspection
c. Taxes,Assessments and Charges-Taxes,special assessments and the Owner does not sign the Notice,the Contractor may act as the
of all descriptions, and charges required by public bodies and utilities Owners agent and sign the Notice.
will be paid for by the Owner.._ b.Clean-up:Contractor is responsible for removing debris and
d. Deposit of Payments: Contractor is requiredto deposit all surplus material from the property, and leaving the property in a neat
payments received prior.to completion in an escrow account In lieu of and orderly condition.
such a deposit,the Contractor may post a bond or contract of indemnity VI.CONFLICT PROVISIONS
with the Owner guaranteeing the return or proper application of such
a. Arbitration: Any controversy or claim arising out of.this
payments to the purposes of the contract_All advanced funds will be
Agreement that cannot be resolved,is subject to arbitration,with
.deposited as indicated under Special Provisions. Monies used in an arbitrator of mutual agreement, and all parties (including.
escrow become the.property of the Contractor when they are applied Owner, Contractor,Architect and Sub-Contractors)are bound to
according to the:Agreement payment schedule, when a breach of this arbitration: It any party does.not appear at arbitration
contract by the Owner occurs, or when the Agreement has been
substantially performed. proceedings,the arbitrator is empowered to decide the controversy
in accordance with whatever evidence is presented by the
e. Bankruptcy: if either party becomes bankrupt,the other party party(ies)that do participate.
has the right to cancel this Agreement.
b.Attorney Fees:It either party becomes involved in litigation
ill.OWNER'S RIGHTS AND RESPONSIBILITIES arising out of Agreement,the Court shall award costs/exoenses
a. Cancellation: Owner has an unconditional right to cancel the
including attorney fees to the party justly entitled to them.
Agreement, without penalty or obligation, until midnight of the.thirdc. Limitations:No action related to this Project may be made
business day after the Agreement was signed. Cancellation must be by either party against the other more than 2 years after the
done in writing. upon cancellation, any property traded in, any completion of work.
payments made under this Agreement,and any negotiated instrument VII.GENERAL PROVISIONS
executed will be returned within,0 business days following receipt by
the Contractor of cancellation notice_ a. Notice:Any notice required or permitted under this Agreement
b. Property Lines Owner shall locate and point out property may be given by certified or registered mail at the addresses contained
in the Agreement-
fines to the Contractor.Contractor may,at his option,require the Owner
to provide a licensed land surveyor's map of the property. b.Prohibition of Assignment: Neither party may.assign this
cAgreement or payment due under this Agreement without the written
. Liens: Failure to pay persons supplying materials or services
consent of the other party.
according to the terms of this Agreement may result in the filing of
mechanic's liens on the affected property. Owner has the right to ask c. Qualification:This document constitutes the entire agreement
the Contractor for Hen waivers from all persons supplying theseof the parties. No other agreements exist. This Agreement can be
materials or services.In the event any mechanic's lien is filed through modified only by written agreement signed by both parties.
no fault Of the Owner, then the Contractor agrees to take all steps d.Governance-This Agreement shall be construed in accordance
necessary for the release and discharge of such lien. with and governed by, he taws of the,state in which the Project is
d. Insurance:Owner will maintain property damage insurance at located•
least equal to the Agreement price.
a
a .
Baystate Roofers, Inc. Proposal
P.O. Box 189
North Reading, MA 01864 Date Estimate#
Tel. 978-664-0668
Fax 978-664-4333 3/25/2010 10042
Name/Address
John McKenna
12 Mifflin Drive
North Andover,MA 01845
Bay State Roofers Inc proposes:
Remove approximately 1400 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 30 Year-GAF Architectural asphalt shingle will be installed over the prepared substrate.
A new ridge vent will be installed to ensure the proper roof ventilation.
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 square foot.
New Shingle Roof
Authorized Signator .
Tota 1 54,350.00
`--- ,� Deposit Required $1450.
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 refurse.
10 Year Workmanship Warranty on all roofs. (Except Repair Jobs)
CONTRACT ACCEPTANCE
The specifications,prices,payment schedule are satisfactory and hereby accepted. Date: ago l o
BAY STATE ROOFERS,INC.is authorized to perform work as specified.
Payment will be made as previously outlined. Signature
All bills over 30 days are subject to 1 1/2%finance charge per month(18%
annual). Color r e W
x a/ -� t,a.S e_ -f` y_ c el f APP--6 ve.J j
o�ll Leslo�
P 7P-
.
54—
The Commonwe¢lth of Massachusetts
Department o f fndustriul Accidents
Office of Investigations
600 Krashing ton Street
Boston, MA 02111
w►y►+?•nzassgov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/P'lumbers
Applicant Infor><nation
Please Print Leapbl
Name(Business/OrganiiztionMdividual
):
Address: 0
4 +
City/State/Zip: � � Phone#:
Are yo employer?Check the appropriate box:
1• I am a employer with 4. lam a Q Type of project(required):
❑ general contractor and I
❑ employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction
I am a sole
proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
shipand
have no employees These sub-contractors have
working for mein any capacity, workers com ,insurance. 8 ❑Demolition
[No workers'comp. ' P
P insurance 5. ❑ We are a corporation and its 9. Building addition
3.❑ required] officers have exercised their 10•❑Electrical repairs or additions
I am a homeowner doing all work right of exemptionMyself Per MGL' 1 -0 Plumbing repairs or additions
y [No workers' comp. c_ 152,§1(4),and we have no
insurance required.] t employees. [No workers' 12-❑Roof repairs
comp.insurance required.] 13.[] Other
`�n} =?hcznt that check-.box iul must also EU out the section meow show n19 th _
'homeowners who submit this affidavit indicating they are doing aL'work-and tn®hire fl�ide on c"oc.must s: c
:Contractors that check this box must attached an additional sheet showing aOtOia dtheir
submit a new affidavit indicting such.
e the name of the sub-ontractors and their workers'Iam comp.policy information.
information.an employer that is providing workers'compensation insurance for my employees- Below,is the policy rend job site-747==
Insurance Company Name: A-C
Policy#or Selff ins.Lic.
AN Expiration.Date:
Job Site Address:__ I z �• w�,
City/State/Zip:
Attach a copy of the workers'compensation policy declaration ans
F be( hawing the policy number and expiration date).
Failure to secure coverage as required un )
q under Section 25
A of C. 152 c
fine u to an lead to the
p $1,500.00 and/or one-year imposition of criminal
_ ne year imprisonment,as well as civil penalties in P normal Penalties of a
of up to$200.00 a day against the violator. n advised that a c P the form of a STOP WORK ORDER and a fine
Investigations of py of this statement may be forwarded g the DIA for insurance coverage verification. y ru'arded the Office of
I do herebyr* �er,17eai
pxeft�pe °fPe ju7'tfirat the information provided above is true and correct
Si store:
( Date.:..--- 77—tO
Phone#:
FOther
only. Do not write in this area, to be completed bJ'citj,or town official
n• Permit/License#
hority(circle one):
Health 2.Buildinb Department 3. City/ own Clerk 4.Electrical Inspector E]lnsp
son:
Phone#:
Information an_ d Instructions
Massachusetts General Laws chapter 152 requires all mPtoY�rs
to provide workers
compensation. employees.for their
P
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association ox-other legal entity,employing employees. However the
owner of a dwelling house having not more than three aparhlzents and who resides therein,or the occupant of the
dwelling house of another who employs persons to do mainte3nance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such.employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensingagency shall withhold the issuance or
renewal of a license or permit to operate a business or to monstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=mpliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the.performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es) and phone number(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 not required to carry workers' comp ensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. The affidavit should
be.rets-ned to the city or town that the application for the pertuit or license is being requested,not the.D�artment.of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pemiit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under`.`Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future peimiits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to than 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-...
The Commonweal& Gf Massachusetts.
Department of Industrial Accidents
Office of Investigations
600 Washing-bn Street
Boston,MA 02111
Tel. # 617-727-4900 ext40.6 or 1-877-MASSAFE
Revised 5-26-05
Fw. #617-727-7749
izfrVirw.mass-gov/dl a.
EIG Fax Server 5/5/2010 10 : 23 : 10 AM PAGE 2/003 Fax Server
TE(MMIDDNY
ACORP, CERTIFICATE OF LIABILITY INSURANCE 1 05/05/2010
PRODUCER (800)782-0251 FAX (781)261-2099 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
77 Accord Park Drive HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Unit B1
Norwell, MA 02061 INSURERS AFFORDING COVERAGE NAIC#
INSURED Bay State Roofers. Inc. INSURER A: Gemini Insurance Company
Po Box 189 INSURERS: Commerce Insurance Company 34754
North Reading, MA 01864 INSURER C: ACE USA
INSURER D:
INSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILT R D'R NEU TYPE OF INSURANCE POLICY NUMBER POLICY MIDD YIVE POLITE EXPIRATION p TION LIMITS
GENERAL LIABILITY TBA40546 06/15/2009 06/15/2010 EACH OCCURRENCE $ 10000
X. COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 1000
CLAIMSMADE M OCCUR MED EXP(Anyone person) $ 1000
A PERSONAL&ADV INJURY $ 1000000
n
GENERAL AGGREGATE $ 200000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 200000
FX—]POLICYF—j jEQ LOC
AUTOMOBILE LIABILITY 08MMBCCXKR 06/15/2009 06/15/2010 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
100000
ALL OWNED AUTOS - BODILY INJURY
X SCHEDULED AUTOS (Per person) $
B
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR E-1 CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND C46281135 04/03/2010 04/03/2011X ITORyLM5WC STATT• X O R
EMPLOYERS'LIABILITY
C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 50000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 500.00
It yes,desalbe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ 500.00
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Evidence of Insurance rAUTHORIZEDREPRESENTATIVE
onald Cleaves/JML ��
ACORD 25(2001108) OACORD CORPORATION 1988
i
T 13oarfofri�fng�eegulatio'nsd� Stan ar s9' .
lugHOME IMPROVEMENT CONTRACTOR
Registration: 137193
Expiration;,,10/15/2010 Tr# 276696
}Y.14_1' Type: Private Corporation
BAY STATE ROOFER INCA .;_
WILLIAM LORD a
240 PARK ST Y`' ,;3" `f �,.
N. READING, MA 01864 >`''' ,administrator .I
I
4
/ 5-
7- Nlassacitusctt tai'Public 5afch
Board of Building Rc,,ulatiuns and standat.ds
Construction Supervisor Specialty License
License: CS SL 99895 '
Restricted to: RF
ROBERT OKEEFE
2.1 FRANCIS STREET
NORTH READING, MA 01864 r
Expiration: 9/29/2011
('nnuuis,innrr
Tr#: 99895 .
I