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HomeMy WebLinkAboutBuilding Permit #1252-2016 - 125 COACHMANS LANE 6/1/2016 If NORTH A[>'Y Qj BUILDING PERMIT ow- STyED +bt O TOWN OF NORTH ANDOVER - APPLICATION FOR PLAN EXAMINATION Permit No#: '1"6, Date Received ZZs CHUS��,`� Date Issued: --& I PORTANT: Applicant must complete all items on this page LOCATION � _�G.�Mar� S LC^-� Print PROPERTY OWNER CV0J (-S O' Cbnr\e,l I Print 100 Year Structure yes o MAP Z O PARCEL: 0 % " ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential ❑ New Building ertne family ❑6ddition ❑ Two or more family ❑ Industrial ri"Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑}Septic Er til T Flootll"ain; ®-UV�etlands � ❑Waterhecii i®istnctt VW DESCRIPTION OF WORK TO BE PERFORMED: CeIN 1& i rl Ob u) Identification- Please Type or Print Clearly OWNER: Name: Ch,o.Al—% U430nnL11 Phone:G �'�2► �' �91O� 3 Address: 11 S Cao v S -�-^-�- Contractor Name: IGv�' C;u� � t� Phone: c� Yl�3 M' 3A 6 3 Email: GI-r,+-i nSvt tir o c� ,,,!� .�,•.� Address: P p 3`tL1 �Vswv 14 d 19 3 FJ Supervisor's Construction License: L S�0 Z Exp. Date: � � 3�1 �0 Home Improvement License: Exp. Date: lks) 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: $ 3 Z `l 4 FEE: $ Check No.: Receipt No.: b � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location �_) U 1%,_4 , No.J Z Z" 2-0t Date • • TOWN OF NORTH ANDOVER • ' Certificate of Occupancy $ + Building/Frame Permit Fee $ -Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#2 30444 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL r Public Sewer ❑ Swimming Pools ❑ Taming/Massage/Body Art ❑ 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 Zoning'Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments a Conservation Decision: Comments Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpsfer on'siteq ,y*es,�. , ;� ,� - �, ot i�fo atec at 124 Main Street t 1 , ;• i4 pj {r ks, ►zty t € Ayj �' °�� 4 4 . µ c ` lt` X R'� 47'Yt� f tf' 1 w"yi+ = :: e.., '�'►1 ' . . <iFire Depa nt signature/date . ��ur , � ; `#� w .. . �. sC° i..'F+,' ai'F x r -�. a'f 'i 'i#1 '^- ;• ` , .-+.;„n?”," ''tij °C.E�7� k?�Yr�iti�.'us�ri4'r'�<' r�+`y,,v"�d'�'�;,�t�'t7��,�$i '�? :���j1"�i �+�•�,: �`'�`��,"�-'fiic�.`S` a'at 'n.r� •XI:c a <.�.+' rse.�.:�.,t.s-,c.'�cs. 7n.s w`. ,1{�r�ir '..K } � 1 err _ e c t/„ c } �aL�S .. ��".►s'''a�'�''�'�• COMMENTS`skjµ}�'F�y,�1�`�^N����"� f �`.s, y•.tc• 'r,7 l;''�:S f1 S i flab'+� �mtJ'ix�J.��.. -�� d � spy ;.kt�thX• 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.Bnilding Pennit Revised 2014 I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses 4, Copy of Contract 4 Floor Plan Or Proposed Interior Work � Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products I OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 t40 R TFl Town of �� _ ndover ,. .�.. , to No. � �cja_ �d� � _Y �_ _ _ ver, Mass, 1►�'i �„QCOCHIC"IWIC. S R�TEo �Pa��S 11 BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT .......... ..... � ...... , , �,', ......; BUILDING INSPECTOR .........................................nn has permission to erect .......................... buildings on ...Ir�:�... .. .. . r!!11 '.!:! ...LAM.... Foundation + Rough to be occupied as ...&-rw;r�.. . ., .. .. .�1� ....,,�.�t. ... .�. .� �!�-... Chimney provided that the person accepting thisermit 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 INSPECTOP Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTLQU STARTS Rough Service ....... 1.71. ... ~ ............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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#064)406629 RISE Engineering R1 Contractor Reglatradon No 8186 Adivisian of'Ihiclsch Engineering MAContractor Registration No 120876 RISE ENGINEERING' 60 Sdawmot Unit#2,Canton,MA 02021 CONTRACT rT 339-502-6335 FAS 339-5 -6345 V I�fw Page 1 �p PROGRAM uCASA-HIES fiEnanes iwoxs"�o INM umFOR WORK OEscraaEo BELOW CU310 ER PHONE DAM cugnrr Wan ORDER Charles O donnellVM \,U\2016 (978)777-6653 W22/2016 434388 00003 su:ntnce suREEr SUM 125 Coachmans Lane Coachrnans lane sEMM cmr.sUtE.aP mumcrw,s1XV_MP North Andover,MA 0 5 North Andover,MA 01845 JOB DESCRIPTION PHASE ONE-Proposal for this calendar year. $0.00 HAZARD BARRIER We have identified that there are recessed lights present in your home.unless the recessed lights are certified as 1C-rated(Insulation Contact Rated)we Mill create a 3"clearance space around the fixture by using fiberglass blanket insulation as a damming material,no insulation will be installed across the top and closed cavities which contain recessed lights will not be insulated $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 Kill be left with a healthful level of air exchange and indoor air quality.Materials to be used to scat your home can include caulks,foams and other products. Primary areas for scaling include air leakage to all ics,bawments,attached garages and other unhealed areas(uvindouus are not generally addressed) This will require(12)working hours A reduction in cubic feet per mintae(cfm)of air infiltration trill occur,bit the actual number of cfm is not guaranteed. At the completion of the mtherization work.and at no additional cost to the 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. $1,020.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 umfaccd fiberglass balls to(114)square feet for damming purposes $233.70 KNEEWALLS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(128)square feet of kneewall arca. $448.00 KNEEWALL FLOOR Provide labor and materials to install a 12"layer of R-42 Class 1 Cellulose added to(256)square feet of open kncc%%Wl floor.OFF10E ROOM.I COULD NOT ACCESS $373.76 ATTIC ACCESS Provide labor and materials to insulate the back of the attic door with 2"rigid Thermax board and seal the door's edge with weatherstripping to restrict air leakage. $72.22 ATTIC ACCESS:Provide labor and materials to make(1) temporary access to an attic area. The opening will be closed with materials similar to those existing Finish sanding and painting is not included. $85.00 VENTILATION:Provide labor and materials to install(2)insulated exhaust hose with roof mounted flapper vent to exhaust existing bathroom fan(s). $237.50 VENTILATION:Provide labor and materials to install ventilation chutes in(66)rafter bays to maintain air flow. $132.00 Federal ID N 05-MS629 RISE Engineering RI Contractor Registration No 8186 MAContractor Registration No 120979 RISE A division of7tlielsch Engineering 60 Shawmut Unit N2,Canton,1114 02021 �� ENGINEERING' y Iv!a RA 339-502-6335 fAX339-502-6345 CD#�.t.�A Page 2 PROGRAM RIS CNIA-11ENGINEERINDGAND�cCU810I&RFOORROM WORKAS OESCRISEDBELOW CU3XM°1t PHONE OAE CLIMB WORK ORDER Charles 0 donnell (978)777-6653 0412212016 434388 00003 SERVICE BSIEET MWHD STiW 125 Coachnians lane 125 Coachtttans Lane SERVICE CrIY.SW$ZIP MUM CrtY,STAIE.MP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION VENTILATION:Provide labor and materials to install ventilation chutes in(66)rafter bays to maintain air flow. $132.00 VENTILATION:Provide labor and materials to install( 17)4"X 16"rectangular aluminum soffit vents to increase ventilation in attic areas.Specify color.White or Gray. $425.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currcntty, for eligible measures,Columbia Cas offers 75°x6 incentive,not to exceed$2,000 per calendar year,and an incentive Of 100%for the Air Sealing measures up to the first$680 and an additional$340 if savings are justified by the auditor. For the safety and health of your homes indoor air quality,we will be conducting blo-.wr door diagnostic of the available air flow in your home both berore the work is begun,and Biller the%catheriwtion work is complete.We will also conduct a fall assessment of the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you Total allowable mcatherization incentive is$3,110. $90.00 ,D � 2 5 2p16 air Total: $3,249.18 Program Incentive: $2,714.39 Customer Total: $534.79 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECtFICATtONS.FOR THE SUM OF ";"Five Hundred Thirty-Four&791100 Dollars $634.79 UPON FaU1L E APPRWAL BY E ENmNEERMQ CUSIMAER AGREES IOREWTAM7UNTOUE m FULL DERESTCFI%WUSECIIARGEOMMILYONANY UNPARI DAYS.SEE E FOR B,PgCCWTDIPoRigH7N CH GtAMMES.RKRIAOF RECWM SCHEDULING,AND CONIRACM REGIS1RA'WK DO NOT SIGN THIS CONTRACT IF TNERE'P9tMY BLANK SP A S.ONAWK-RISE rft RACCEP NOE:lfl8 CONFACTNAY BE WnIORAWN BY US IF NOrEXECUEO WIHM DALE OF ACCEPTANCE ACCEPWrCE 0FCOH1RACT.1HE ABOVE PRICES.SPECIRCASONS AND CCNMONS ARE 30 SAISFAC10RY W US AND ARE HEREBY ACCEPED.YOU ARE AUHORIZED 10 DO IRE WORK GAYS. AS SPECIRED.PAYNEHTWILL BE MWE AS OUIUNEO ABOVE RISE60 Shawmut Road, Unit 2 1 Canton, MA 020211339-502-6335 ENGINEERING" www.RISEengineering.com OWNER AUTHORIZATION FORM I, C kci r l eS G 'd '?e' / /_ (Owner's Name) owner of the property located at: (Property Address) (Property Address) hereby authorize , (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. Owne 9 Signat p16 � 2 Date Vlad Tire Commonweaitit t)f ifas.sacitusetts Department of Industrial Accidents C)ffiee of Investigations I Congress Street,Suite 100 Boston,VLA 02114-2017 wa►w.mas+.gc w'dia N orkers'Compensation Insurance Affidavit:Builders,('ontractors:Electricians?Plumtrers :applicant Information Please Print Legibly a9TnC s tau u€ sN t :r#a13cp;1;it;€71(rr isEl a tt: (U-1 C%Y f �t'i 4t_��• f 1 ,—1`=— C°itd;State1ip:.... wiQI Phone y: 9 'T` 3 ALO. 34S 3 Are you an emplr;Trec'Check the appropriate box: i rpe(if project t required.)l 1,� 1.am a emplo cr x i h_S _ tad [ams'p,mrTJ c.T tact€+ Z11t1 I t f t,, 0 No% �E=NSMWfiM1 empit7vczs I ttf aTzl or part-tan c p.` h c Fired tit sub cont,actors s .'..� I am a�cyii i?resprTctt7r itI partner'. hstial on Lite.attachvi'i sheet. e . 9 Rct7`iodelin+- ti.?3i1sI}'s;i4` iltl ?11pli'�' ti i hose stit7-t:oviracaora iLivee ��3a<.nZc t'on %vori-m- Iter me m 111tc ip.acitl. emplo.+ ces and hate workers' i `/, ttiliii_�t<.:at�c�j;itrrl [`i7�i'fstkixs, :ofnp. 111.,,t�Lllc`e ct rnp Fis.t'.':3'rW ®i� "" Q �N t arc a Ct r-pur'ti n and ids 10.0 a_l>~cvica!a4pairs or aMiTion s ?,tti t t am a hointitwner doing exet.Scii th,.,r !i.[]pfunfbvv. rcrnirs(7r addilions s ri hk o excin Tics 1 sts VIGL i Taticit t`f7 i�7ti er'< iC Tip. 1, tbt�t rCpnitS Insurance rGc'�ilmt d_l� c. i Si .It`tl-IltT{� 5��is3i> +t(� - `, 41i {t iti�33Y:itis'i;7i:..;.c h.t ?ttLL-?.�,}S .',S:4•t'{ .'S".`El'R. tx. -:.t'.i{ tS L�6..i'a'k `A :s:s, }, t{_. F {`h�:.T-§..s(+1 {t.�F{•' ,..5'Ft.:a;fL-17. t lriL'{ `'iJ°S ttt311,ttt f:. ;.=j..`.4*St a'.klCf.'»..+,.�l�S.tt':,3F�a1 e><':.u�:iiCC.:}F1it'lF S;it:s:#31154 I i.;....Elft el'1,..eS,S,...1>;i:S?.C,:C+i k..s::f lsf€i�• :t!l`:F6 Y,IT'l*t'i(8< �.;t+P:�,�c; �::�r Duh cap#r34, :fr•,•€: -r,.s.:.:.�e�. '.c+trs;. {+r,t _,t:s?7et, ,au.��r �vst:it.t=- i��c�€as,r??t;f. t am ata emptcis r that is praltidin�n«rkcr cnanprarEataan rn:xurunrc fear ant cnatticra ecz Bdow is the patic_y ant!job rtte inftrmatiom } fnasuraticc Colrjpall \xIte: Policy tyr scif ill$, Lig:. ', ri fy A (] � Expiration Date: �a Joie Site Address 12S (zpL km&j-%_s La jt- city State Zi K10 4% vi A-dv e 4T Attach a copy of thr workers'compensation pol ev declaration papE ishowina the point number and expiration date). Vaikire,0 Secure cover ge as req tired lander Si:cti(m o ?4,'f(Ll_C. 152'can lead w tilt juipositicui of c antnit;l p'lal'u-_IX.9 r{itc up to S1.HXJ,00 atk'i•41-()rte 4YC,1r iinpra,OTi;n�;n,,&s%VIII as,r n,zi P_en hies in the 'srin a:a41(CJI'WORK ORDER anti a nac of4m, it,5250..00 ra.°Il y raPai twT 0u ti allator. Be advised tha a copy of't11i5>t tc:Ttta;it lyla�, b.:4+rwinjeu to the€0ic.c of {mesf€Ie:it-ons ofthe[DIA fity irrs r''ancc vo%craygx 1cr1 ,Mvn1. �r I do hereby certify under thr pains and pearatt es of parjurat that Me infcirttmation protided above is true and correct. turr: 1J ^ t Phone,k`et Official use only. IN)not write in dais ares.to be cntttplttM by cin,or town official. City or Town: Permit/License# I%ruing.Authority icircle one: 1.Board of health ;.Building Department 3.Citp'l'oon(Aerk a.Electrical Inspector 5.Mumbing Inspector 6.Other Contact Yersc►n: Pbont�: ACORO® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 7/7/2015 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(les)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 Nancy Usher Martin J Clayton Insurance Agency, Inc. PHONE (413)536-0804(413)536-0804(AIC.NoF Na:(413)534-7874 1649 Northampton Street ADDRESS: P. 0. BOX 989 INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville NATIO INSURED INSURERBAllied World Natl Assurance Co Gauthier Insulation INSURERC: 44 ESSEX ROAD INSURERD: INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER:CL157701379 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE thign wyn POLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE FX]OCCUR DAMAGE TO RENTED 50,000 PREMISES Ea occurrence $ X GL43487F 7/6/2015 7/6/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑PRO- JECT ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION SE020792125-194985 10/18/2014 10/18/2015 $ WORKERS COMPENSATION PER 0TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CSG, NSTAR AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MASS SAVE PROGRAM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICES GROUP, INC. ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET WESTBOROUGH, MA 01581 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG ` ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD MPIMStbd with pdfFactory trial version www.pdffactory.com c. CERTIFICATE OF LIABILITY INSURANCE .' �..•r- Vrtbrrtyt5 THIS CEl?TIrCATE IS ISSUED AS A NATTER 0 ):-;l-Y+CT ON ONLY"D CON*ERS'40 P}G?CS u:'CN M CERT1,1CAiE HQDEF.THIS { CERTIFICATE DOES NOT AfrIPM&TWEcY OR 1EGATIL'ELY AMEIe3,SND IIP ALTER TSE COvEPAGE AFt'CiRDEv 8Y TrIE POLICIES It BELOW.THIS CER11FICAT£OF IIiSUF-kVCf 00=_5 NOT COUSTFUTE A CONTRACT B-rTW EEN`,"S£ISa1JIM3 INSVR€RiS),ALFr40FIZED PEPRESEMTATIVE OR PRODUCER,AWD THE C:ERTFICATE 24OLG ER IMPORTANT:If the Certificate NDIder is an AOOTTSO."L p S4REv.we pot.c�jmst must he end rsftt.If SU ROGATION IS WAIVED,kibj- to:he te±rrrls and ccoditrons of the potiu:;r,certx,n pefkties may reg;we,A e^odon .;ent.A statecr'eri on t us certsR•yte dohs rpt cuTifer rjWs to,h-- cerfrcate tode.r in lieu off s4r erKjorsementlsi- Clayton Main J fns Agency Inc Usem- 5crVley Ass tried Risk Services 1649 Northampton St PO Box 989 (800 634-458£1 1 �£�h:t8e5p 215 EIIf Holyoke MA 01041 +c mss cdi�c Se^riCeSjybert 1eyl sit tb P iMS;t'��_S.dt�Fr/�Yaa SCIYEF.A�L IQiY'..7 Gauthier Insulation lnc ul£vs£a a PO Box 344 IpsiNIch6 MA 01938 NSUIF;= y 4d54f.:'n' - COVERAGES CERTIFICATE NUMBER. 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CERTIFICATE H6000 CANCELLAtIGN SXXIL.;Aw or,.14C Ai t?l Epi:CANCE1-'E:8Cf7DRC Clearesutt T#IE EXF,RA,TrOk^ATE'HE°�Of,SIX izp w't-t BE W—NVEIK.ETJ IN Contractor Svcs ACCOcRDA:YCE4X:Ta TH POU YIPRGt?SiONS 50 Washington Street Westborough,MA 01581 ianature: :CURD 25(201€10S) MAC 3139 Massachusetts .De !S rt►nent of Public Safety Boartt of Budding Regulations anti Stan daw,ds C'r��rkt r�t«ija s� rc it:,w Vj*, rlA3 License:CSSt._902582 KURT11GA1 tft 7k P. Bos 344 IPswkh MA 0193a r M art o` CO"Wrlisslooer 05/251 17 s Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173410 Type: Individual Expiration: 10/1/2016 Tr# 257812 KURT GAUTHIER KURT GAUTHIER _._._. P.O. BOX 344 IPSWICH, MA 01938 Update Address and return card.Mark reason for change. i Address f Renewal �;i Employment - -, Lost Card SGA 1 0 20M•05/11 /C `(`"c.nur..: Office of Consumer Affairs&Business Regulation License or registration valid for individul use only "OMEIMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 173410 Type: Office of Consumer Affairs and Business Regulation expiration: 10/1/2016 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER // 44 ESSEX RD fCfi`uv� IPSWICH,MA 01938 �— - _.___ Undersecretary of valid wi aut signature