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Home My WebLink AboutBuilding Permit #593-12 - 128 JOHNSON STREET 2/8/2012 OWN OF O T NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: o Date Received Date Issued: _ IMPORTANT:Applicant must complete all items on this page LOCATION �� L�n hnSa n 54r re C+ XoJoye-e- HA f( Print - PROPERTY OWNER 4 r i s PrInt MAP NO:gPARCEL: _ZONING DISTRICT: Historic District yes no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial [I Alteration No. of units: ❑Commercial )ff Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other z. p } 0 Watershed�Distrtct.. --=` '�oFlood laui� I}Wetlands £ � Septica F❑}Wella _ � DESCRIPTION OF WORK TO BE PERFORMED: ?e-mo je. &ncl fw e, s) 0 ad�� ►U� Identification Please Type or Print Clearly) OWNER: Name: e..S Phone: D Address: SA 'fee--k At\�dW UI��f �3��a� CONTRACTOR Name: S ; 'i Phone: Address: �� SU oh SU iAI ZZ(o L)0- P 6 Vi- � /A- N `( � Supervisor's Construction License: �'(�� Exp. Date: a- _ 3 Home Improvement License: ( 0 4S 0 Exp. Date: '�- ( 4 -�-o(2 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cosa: $_ U 0. v FEE: $ Check No.: l S b Z Receipt No.: r0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ,- ------- --t.=----- ----- - - ----- ---- -- ---:�__._-- ---- _Si � <_S trac;-t.:s---.r.------ -- ----- <'� t natureo �c` -f/Owner� f. onto .�,� C� ....� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 HEALTH Reviewed on Signature COMMENTS I Y Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wates' & 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 - Date Doc:.Building Permit Revised 2008 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 o Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work o 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/Crossection/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 o 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) o Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perrrlit all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals A the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording ist be submitted with the building application Doe: Doc.Building Permit Revised 2008mi i LocationNo..512 " �"" Date 1 2- TOWN OF NORTH ANDOVER O Certificate of Occupancy $ -: Building/Frame Permit Fee $ o x Foundation Permit Fee $ Other Permit Fee TOTAL $ Check# ;0 Z- c 25016 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (J/9STre/C t) 1V&_ F i li/<r S'/,a/,AJ Address: i:,2 o o c) rn g1E f_r SU/T& 2-2-(- City/State/Zip: LCity/State/Zip: No, A/V bo v,< kA U/ eclf Phone #: 971 6 e3 Are you an employer? Check the appropriate box: Type of project(required): 1.Q I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 132 Other 5 k c�,Vt r\s comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:6 9 TT S Policy#or Self-ins. Lic. #: wCd QJ 9 0 9 2 01.3 Expiration Date: 17 0117 3- Job Site AddressjLt Af 7( City/State/Zip:R0. 7"(l e�, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties k fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under theme pains and penalties of perjury that the information provided above is true and correct. Signature: � - I f�-8- Date: Phone#• 71 k3 .3 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: NORTIy ovm Of Andover .. No. �i3' In _= LAKE of dover, Mass.,_� • � � I Z CO C H IC ME WICK �.e oRAT E D P"? C�2 77 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT....... �/ O d.-r's BUILDING INSPECTOR . ... ........ .. .� ................................................................ Foundation has permission to erec ..................................... buildings on . �. 8... ...610KOA ..... ......P.......... Rough • to be occupied as1KChimney provided that the person accepting this permit shall in every respect conform to the terms of the application file in this office-, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in_the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT' EXPMS IN 5 MONTHS ELECTRICAL INSPECTOR.- E't`+l LESS CONS d'i lJ C S 1 S Rough ................. ........ ......................................... ... ... Service BUILDING INSPECTOR 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 FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE -smoke Det. DAVID CASTRICONE,PRES. CASTRICONE ROOFING& SIDING INC. ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845 In North Andover 978-683-3420 In Boxford 978-887-6147 .In Aaverhil1978-374-7314 I/we the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and conditions,on premises below described: Owner's Name....... .L ..Y.. l'......A.fT.�.I�.I.. ..t l..E',�5.......................................... elephone#..��/. ..-.l.��I..-'. ./..be1�. Job Address...................... . r...... .........................City.. .......State..... ...,t7....... Specifications: ..............i�...................... ............... ................I......... ..................... ....^............................................................ '...��. ,lrµ.......` .l..J.ZS.kt-......u?).....�12.�..:�,t�-f . :.l v1 .... s..... ................................ Q�� .ql..K r....:e�,�s:,1S• �..... . . .. ..... �1 ZL .. ..�.....................- .....r �. .: . ......W. ...5.... 'J ......... ...:............P -. I �.............................................................................................................................................I......... ... .. .... �.. ,.- .. . ......... .......... ` '. f ) ` tttl . ... 1. (eII �. qtr. .... '.c ...Q r.� ....tett�.�..�. :...e. �, n... r. . g s..... . ..r.y............. ...........J. e Q rr 11 a ...' ...'........;..... ..... ...................................... ............................................ ................................. �1 ... ..................................................................... .. 1. /a.n. '. � ��w ....o- ................................ ................................. .---,........._..................... Two Year Workmanship Warran (Not Transferable) Manufacturer's Warranty as spec' y man facIt The contractor agr�s to perform the wor d famish the materials specified above for the of$.....�... J Payable...1P.D.s 7..........on.....�. oSf. ....... Payable....................on.................--........... Balance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability whi�ob is in operation. Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or conditions resulting from application of materials specified above(i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living spaces). Items in attic may need to be covered by homeowner.All materials are property of contractor. Any dumpster placed by contractor is for his use only.Upon completion ofabove work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation as requested by contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable. It is agreed that,if permitted by law,contractor shall be paid by the owner(s)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,that shall be incurred in enforcing the terns and conditions of the contract and/or any lien in connection herewith.Property may be subject to mechanic's lien if unpaid.It is further agreed that this contract may be assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates of the parties.The undersigned warrants)that he is(they are)the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their) names(s).There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to the Office of Consumer Affairs and Business Regulations,Tel.(617)973-8700. Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction- related permit or deals with unregistered contractors is excluded from the Guaranty Fund roo sions of MGL c.142A. Approximate starting date of work.... ........................ Completion date.. = t�l.rlu�t. ...Lt►tr!> .!~rtr �Q_ Z5" Receipt of a copy of this contact is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoirfg provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES This contract may be cancelled,without penalty or obligation,within three business days of the below-referenced date.Mail or deliver a signed and dated notice or send a telegram to Castricone Roofing&Siding Inc,200 Sutton St.,No.Andover,MA 01845. IN WITNESS WHEREOF,the parties have hereunto signed their names this.. .1.?�day of... ......... Accepted: )('Signe _ - ..... ....................... Owner / Signed............................................................................. Owner David Castricone,President NLl„achusett., - Dell.;u•tntu•nt of Puhlir 5afet� wBoard of Builtlinl, Rcul;ttiun, :inti } tantLu tl Construction Supervisor Specialty License License: CS SL 99358 Restricted to: RF,WS DAVID CASTRICONE ` 31 COURT STREET NORTH ANDOVER, MA 01845 r� ------------------- Expiration: 12/16/2013 ( ulnlni..i,ucr Tr#: 7924 Oflirc of Consumer:\fta irs& liu�iucss Itcgultr tion HOME IMPROVEMENT CONTRACTOR I` Registration: 104569 Type: ( -1LF=F°'1,•, :_• ;/ Expiration: 7/14/2012 Private Corporatio DAVID CASTRICONE ROOFING, SIDING& David Castricone 200 SUTTON ST SUITE 225 NORTH ANDOVER, MA 01845 U +Undersecretary rscce Cu•q �la,,athu,ctt•- eclt;trUttcnl nt }'ul iic �:tftti Bll:trtl ui Buililin_ iZr ul;tt;lln. ; tnr; �t:uttlartl, .cense: CS 105611 JONATHAN MACLEAN 33 ERRY ROAD SALISBURY, MA 01952 txplratlon: 4/24/2014 ! :fillll l..jill;l' Tr 105,611 ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 9/23/2011 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(Sy, AUTHORIZED �u.r��iv�nw wnnnrrn�w •uw.rrlr/�rw71r1/ 11Tr rrnr nen IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(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 NAME: Eastern Insurance Group LLC - Main PHONE aCNo: 233 West Central Street EMAINoE 1,508-651-7700 L . 508-653-8089 Natick NAA 01760 ADDRESS: INSURERS AFFORDING COVERAGE NAIC N a INSURER A:Coinnerce Insurance Coinpany 34754 INSURED 31969 INSURER B: David Castricone Roofing & Siding Inc INSURER C: 200 Sutton Street #226 INSURER D: North Andover MA 01845 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2141633407 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. INSRADDLSUBR ��hl�Y EFF P ltirGY t F1rP �.u�ri•umocn rrtt mi ir GENERAL LIABIUTY EACHOCCURRENCE M $ _ COMMERCIAL GENERAL LIABILITY DAMAGE 10 HENTET- PREMI S a occurrence)s $ CLAIMS-MADE D OCCUR MED EXP(Any one arson) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY 7 PRO- LOC $ AUTOMOBILE LIABILITY BCNGCV /1/2011 /1/2012 Ea aocklera 1000000 ANY AUTO BODILY INJURY(Per person) $20000 ALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Peracctdent) $40000 X NON-OWNED HIREDAUTOS AUTOS DAMAGEPROPt $ $ UMBRELLA UAB HOCCUR EACH OCCURRENCE $ 1H EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ B WORKERS COMPENSATION C003999723 9/23/2011 9/23/2012 X WCSTATU• O - AND EMPLOYERS'LIABILITY ANY PROPRIETORPECUTIVE Y/N TORY LIMITS ER OFFICER/MEMBER EXCLUDED? � NIA E.L.EACH ACCIDENT $100000 i (Mandatory in h yes,describe under E.L.DISEASE-EA EMPLOYE $100000 nd DESCRIPTION OF OPERATIONS belaw E.L.DISEASE-POLICY LIMIT $500000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION Castricone Roofing 81 Siding SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 9 g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Suite 226 ACCORDANCE WITH THE POLICY PROVISIONS. 200 Sutton Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 ®1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I Atm 9/9/2CERTIFICATE OF LIABILITY INSURANCE /9/2"°°011 1 tY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate holder Is an ADDITIONAL INSURED, the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condMons of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such sndorseman s. PRODUCER CONTACT HANE: Willows Insurance -•_..._..._.._475 p►gcy .U�MV.�N, 978 475 3414 51 Cochichewik Dr EMAIL PR YCER North Andover MA 01845 — _ N_A_I_C0 INSURE 191 AFFORDING COVERAGE INSURED IN$uRER A Aiden Specialty Ins Co DAVID CABTRICON>r, ROOFING 6 BIDING INC I RN t+_•INeuRERD: •----.._i�— _...—... ..-- ' 200 Sutton St Suite 226 _.._ NORTH ANDOVER MA 01945 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:CL119906255 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 SP CERTIFICATE MAY BE IS RESPECT TO WHICH THIS ISSUED U 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. LTR TYPE OF INSURANCE .+...__ 01 SUER _.-.__.. ppm FIF MIDDY EXP --- -.--•—.—. POLICY NUMBER W LIMITS GENERAL LIABII TY EACH OCCURRENCE S 1000000 X COMMERCIAL GENERAL LIABILITY — -- – – -- � PREMI0._��SCvegeunanoe� S 50000 A = CLAIM34AADE I X I OCCUR DO031600 9/06/2011 /6/2012 MED EXP An one on S 1000 _PER,40NAL&ADV INJURY 6 1000000 GENERAL AGGREGATE S 200000_0 GEKL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 100000 POLICY 7 A"C'T F7 LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMB ANY AUTO IRS scOdanl) S ALL OWNED AUTOS BODILY INJURY(FW penon) S SCHEDULED AUTOS BODILY INJURY(Per accident) g HIRED ALTOS PROPERTY DAMAGE (Per ecdoenl) i. I_ NON-OWNED AUTOS ' S UMBRELLAUAS EEC CUR $ LIXCES,S Luc EACH OCCURRENCE S IM$.MADE DEDUCTIBLE AGGREGATE i RETENTION S _-- WORIt6R8 COMPENSATION S ANO EMPLOYERS'UABILM Y/N WC STATU. OTI 1 ANY PROPRIETOWPARTNFR/E)fE0Ui1VE - .. T1DAX.LIMIT.S..._�R_ _ OFFICERMEMBER EXCLUDED7N/A E.L.EACH ACCIDENT S (Mandalay In NN) a It Yes.deieriba under E.L. DESCRIPTION OF OPERATIONS blow —'DISEASE.EA EMPLOYE j E.L.nISEASE-POLICV UMT L:::— — I DESCRIPTION OF OPERATIONS 1 LOCATI10081 VEHICLES (ANICh ACO$tD 1(7,AddNlonN aelnwke Sehodule,N n►en apses M roqulN,d) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Castricone Roofing ; Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. CastriC.One Roofing 200 Sutton Street Suite 226 AUTHOMDNlPR!leNYATWB N Andover, MA 01845 /� "f ACORD 25(2009109) INS025(2ooaoe) The ACORD name and logo are reQlstered marks of 0 p CORD CORPORATION. All rights reserved, I Town of North Andover0� 14O rh Building Department o 27 Charles Street '' A North Andover, Massachusetts 01845 (978) 688-9545 Fax ( / 9542 A 978\) 688- ° .w°°, j`h *. .. . �SSHCNUS�� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting ting from the work shall of in a properly licensed be disposed soli P P Y d waste disposal facility as defined by MGL cl l s15Oa. The debris will be disposed of in/at.- ZN(f, ' Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project th ough the Office of the Building Inspector,