Loading...
HomeMy WebLinkAboutBuilding Permit #728-2016 - 129 MOODY STREET 12/14/2015 AJ i !� BUILDING PERMIT NORTHI�rl� O�,tveo TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 4E A T : ti nO OH Permit No#: Date Received rED c5 / gSSACHl1`''�'t Date Issued: 17/ I PORTANT: Applicant must complete all items on this page LOCATION OQ&,L-, S A' Print PROPERTY OWNER tAQ( —,VrC�'h-CA Print 100 Year Structure yes o MAP C)%'b PARCELO��i ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building One family Addition ElTwo or more family ElIndustrial teration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED:(4 sl L�kltg e (�1r StLkl a►�; C��,1vlbSr` to G-yo l. . ( � ► 6� it , h Lacs i n bawlrn C � 1 Identification- Please Type or Print Clearly OWNER: Name:!� Phone: q� ' Address: I LI tkw S Contractor Name: V-J V>r' cW14- d r Phone: CFM 7>F16 • 34 'S 3 Email: i C\-%,,A rbNeL • l7► Address-49 30-t 344 1v� Supervisor's Construction License: ��, 2- Exp. Date: Z� Home Improvement License: VA D 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: $ 1A ��•`l FEE: $ �� 5' Check No.: ?w Receipt No.:,M g 7,0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund nature 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 o 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 �-Ilanning Board Decision: Comments ► Conservation Decision: Comments 6 Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREWbEPARaTMENT Templ®ump-ter-nisite ,yes, Inoue B ► Locatedlaf 1243MainrStieet Firel[be partmentsignature/d'ate COMMLNTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work :>a Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks :4 Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract ;rt 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 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 Doe:Building Permit Revised 2014 Location No. — 2ol�p Dat4 Iti IS •'- TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee $_ ^, TOTAL $ y Check# r Building Inspector NORTH Town of _ ndover O y. t M No. _ * t �- _vh ��� ver, Mass, o COC HICtt!WICKyQ. Pi9s RATED U BOARD OF HEALTH DFood/Kitchen PERT= Septic System THIS CERTIFIES THAT . ok ....�. „ BUILDING INSPECTOR. ...................... u0ij ............... Foundation has permission to erect buildings on........................ ..... . ... .. .. ..... ... ............. Rough • to be occupied as ..... ... .. .l1 .. ..... .. ..................................... Chimney provided that the person accepting this permit s�ia I 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 PERMIT EXPIRES IN 6 MO S ELECTRICAL INSPECTOR UNLESS CONSTRUCTION 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. 10 RISE Engineering ctorRegis�lionNo A drviszoo of Thicisch Engineering G 1 01 No fl b@ S6awm a r C TRACT 3�sa2 RI S E Page 1 i i sy. PROGRAM C= xasDxsnecr4s airosetx AS RMAIN ENGINEERING o TMseuarae�xcoaw Macus t cusrarrmx vmnorrt nAmr cxaerrr wowtoim Mark Bt:the) (978)979-2207 08107/2015 421034 00003 Q I T SERVICE STFUNr r r'm mi¢xrrra Sia r 129 Moody StreetLL j an j 129 Moody Street SEmm zrv.sTAT6.zV 811iaiG amschm iv Nordt Andover,MA O t 845 North Andover,MA 01845- [ JOB DESCRIPTION HEALTH.&SAFETY:WcOhann6on work cmmat pn=W tmtit the insuffteiod daft issat ss fixed.BOUMt SPH.0 FLUE GAS/ 8ouu AM SEALM:Provide labor and maiaialsto seal Thiswok wilt be performed in concent with rhe ase of special-tools=4 diagnostic tests to assum that your homewill be left va,a heatthJui level of air exchange and,indoor*quality.Materials to be used to seal your home can include caulks,foams mad other products.Primly areas fafing seainclude air lealm3cto attics;basemamts,attached garages and other unheated areas(windows arenct gcomally addtcsstd.) This will mgdhv(8)working homy.A reduction in cubic feet per minute(cfim)of airmnfiltration will occur,butthe actual natDbeT of cfin i5 not At the completion of the wamherizaticm weak,and at no additional cost to the hmneowmea;a front bto%tr door and(or combustion safety .analysis will be rsmadocted by the sub-w�to ensure the safety oftlie indw air quality. $680.00 ATR SEALING ADDER:(2)wmkhng hours. 5170:00 DAMMING:Pmidelaborand materials to install a 12"layerofR 39 unf sed fiberglass.bans to(20)spume feed fardammning p $41.00 ,ATTIC FL.A.T:Pmvirlalaborand materials to install an 8"Myer of R-28 Class l Cellulose added to(1120)square feet of open attic spamBOB.ER SPILLS FLUE GAS/THE TOP 3"LAYER OF ATTIC IBSULATEDN HAS THE VAPOR BARRIOR FACING UP, THE HOME OWNER HAS SLAHEU TM'VAPOR DARRIOR/ SI,�34:9fI KNEEWALLS:Provide labor and materials to install 2" FSK fii=d semi-rigid fiberglass board insulation to(28)square fed of IMWNWI area.TWS IS GABLE ENDS OF VAULT. $98.00 VENTILATION:Provide labor•and materials to install(2)insulated=hung hose with soffit mounted flapper vent to exhaust existing butlroon Ws).ANE IS A KITCHEN VENT. SM7,50 VENTILATION:Providt labor and materials to install ventilation chutes in(29)rafter bays to maintain air flow. $56.00 BASEMENT CEILING,Provide labor and materials to install(28)liner fcx t of R-19 unfmcd fiberglass insulation to the perimeter ofthe basement ceiling at the house sill. $49.00 RISE Engineering will apply all applicable,eligible incentives to this contract_You will only be billed the Net amoonL Cutremly, for eligible measures,Columbia Gas ofTes 759'o incentive,not to aecxed$2,000 per calendar year,and an incentive of 100%for the Air Scaling measures up to the first$fast and an additional$340 if savings are justified by the auditor, For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the wmk is begin,and after the weatherbtation work is cormpletm We will also conduct a full assessment of the combustion safely of your heating system and water heater.This has a valueofS90 and is at no cost to you. Told allowable weatherintion incentive is E1,110. $90.00 Federal u? RLSE Engineering Ri Con"Mr ReShMAon No A division orThietich Engined ing CTConlradorRogloballooNo 60 sbawourt uait A Canton,KA 01.521 CONTRACT 71 339�5t1-LW FAX 339.511244 RISE PROGRAM Ti10 MMINACFiBmenmeaEDpa2w H RWo r�AE ENGINEERINC CMA-INS rTgEtNl6TDN tKDNwoNKAa CUSTOMER PKM DATA CLM# YWW CRM Mark Bethel (918)974-2207 08/0V2015 421034 00W3 stRRa. 129 Moody Street 129 Moody Street Saw=crMnATS„aP o"M CrMSTATE.ap Worth Andover,MA 01845- North Andover,MA 01845- JOB DESCWTION Total: $2,9500 Program incentive: $2;451.93 Customer Total: $5113.98 WEAL MHMUWTOPpR1W8EKMM-COW TEINACCORDAUMVEMAWWSP€CWA•ttOHS.FMIMSlMOF ***P"nre Hundred Three&981900 Dollars $583.98 UPON F9NL�AND APPADVAL BY Rtt�ENffi,,tU8Tt�1AHi AGW�S TCi EEANf ANCUNT�Ni ittLt-DJrPNE.ST OFl7C NAt.HE 8C3tYwX ON AHY MPMBUAVWAFM=WMSMfMVMMFGRWWAWWaMAUMOI GVANAVXI ".F.p36HTS DP-NEdSIgN.B AHDCONrNAEIORNEflRTNATION. DO Nt3T'SIMI THS CONiRACr IF WEMAM ANY OL4NK`5FAM RoheriGiven(Aug P .204 { AUnD,585MATilAa.WSEEAgMMl�g CU4TOMSt HDM TM CCUTR=VAYSE VWNMtO 88YtA W WTEXECURDWIM 0020E ACCEPTANM ACCk71'At#CE�CKSN11WC7-TNEAaWFiPNdQE5,9PEGtTCAiiDNB AHD CCMDiT(pNg pp�T 30 „AIM SlRWFACfONYTCS AHDARE}i$ffBYAGCEr1ED.Y677 ADTii D'r4DQ71tE NtCRIC AS.SPECrR M FAYiV3trWU8EU"AS ounXeDABCME OWNER AUTHORIZATION FORM ' (ownees Name) owner of the property kwated at (Property Add ) �. a (Property ddress) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineedng,to act on my behalf to obtain a budding permit and to perform work on my property. &4k �' . atdwf Owner's Signature - Date The Cananran aea kh of.A&vsaehusetts Deparhnent of Industrial Accents t)Twe of amvestiga ans I Congress Street,Suite 100 Halton, A 021142017 wwwjnass.gov1dia WorkerV Compensat an Insurance Affidavit- Bui)derstCo ntracttr lectr ciat3Vl'Ittmbers Appligmt Information Please Print Uffibly Name Cir ,'State/Z : 3 6 Phone M 9 Yfa I S o.34 S 3 Are you an cmployye r*Check the appropriate box Type of pro*t{requireatlt- _ d,X I am a employer with S — 4. tj 1 am a gmeral contractor and 1 emptows(fill and/or part-time)-* have hired the sub-L tractors 6. [ c�co qtr ect�€�� 2.0 1 am a sale proprietor or Ser- listed on the attached sheet €x 0 Remodeling odeling Ship and have no employees Thew have & [3 Dernolition working for me in any capacity. employees and haveworkers' Comp-insurance'-, ' Building addition [;�o wa:ork °cow.insurance �. rNuir 5. 'e are a corporations and its 1t1.()Electrical repairs or additions ;�. �i 1 air€a d°atatnawtt doing all work officers have exercised their 11.D I'lur€a€aing repairs or additions myself LNo wtttkers'c right of exemption per MGL ]2,[3 hoof repairs irtsurance required-1 t c. 152,§l(4).and we have no employces-I.No workers' 13.0 Other comp.insurance required.j ° ny applimahaOccksbm it)r iia al fill out the wcrs+an Wkf*' awiewg+-,wr work ca mpcamfim,iaoiicy trfornmics R, H. _ submit this Affidavit ittd ati g sra doing all wok ind Amhire cjattgdc cxa madsus mpat�,rwhwt a affidavit davit indicatiz; h. tContimzm that choc*nais bn mwuaftrbrdzn ad&iurml t�hma showarm the tunte of she 5Ub-Centra:tars MW state whedler of ax Vic:Mrilks have wtaloytm if the sub-cw&a=n ruavv cies must pru-i;ek tip rti serer - t c u`us ee. I am an empkgw that aT pry° ii workem"compensation manaaun for my€mp bees. Bolan,is the pnliq andjob site inforAwdon. lnsurarite C' ally 2w1 t t - -._..____......... _ Policy#or Self-ins.l.ic, ;.. '" ft.P 0 Expiration date; Job SiteAddress-. lZq �l)ll��s�� t irlFsta ,2tp:NV�'tfll'1�(�y��VI ut ��Q Attach a copy of the waarkers'easaWnsation polipy declaration page(showing the policy number and eVirat n elate). ailure to seemeoverage as required muker Section 25A of MGL c. 152 can lead to the imposition of criminal perialties of a title up to$1,-M.00 and/or carte-y r imprisonment,as well as civil penalties in the Porta of a STOP WORK ORDER and a fine of up tea '>50.00l a day against the violator. Be advised that a copy of this state meat may be- forwarded m fire Office of Investigations of the DLA fear innmcr coverage verification. I do Eby c>dntaj y under the pains and ponaMesof pedur y that the information wed above is out and com rc ljqoatu _ 1 phone q A's 'S'Ls� 3 Ofy1cial use only. Do not wry in this area,to he complete=d by rity or town offuiaL City or Town: P+ xltlLttse Itomsing Authority(circle one): 1.Board of Health 2.Building rtnretat 3.City/Tow o Clerk 4.Electrical Inspector 5.Pluntift IMIa dor d.Other C aaatact Person: Ilton d. . R O CERTIFICATE OF LIABILITY INSURANCE r THIS CERT E TE t5 ISSUED AS A itATT C'F WfMMATION OW AND OWERS NO RICHT5 UPON THE CERTIFICATE MOLDER.TMIS CE MFICATE DOES NOT APr^1 OATWZF Y .ut-GAMELY 04ENO,tMND OR ALTER T'-fE covsp CE AFVDKoW ey THE POLICMS BELOW T*"CEi TIRCATE Or 06JURANCE Does NOT C3td5TTTUTE A CONTRACT BMVEEM TME ISSUING INSURER(S),A€lT?iCHR EO REPRESENTATTW OR PRODUCM ANO THE CEATIFICATE HOLDER, i!!MRTAWT-u Fie toarwk e P okw r&;;;Ba MEWAL[f65VR`f5,5FP0h 1 ;;5 7;z;;t be wftrSeT If M-055TION IS WANED.kjbjed t0 tP WTAS&Md :'ibiom tftfae Vo4c',,""aim pekies fray require an: - Mint.A=te'r*M ops M*cenjkdte does r,ot..oww Fights to am Owtfkate harder in Reo of such Clayton Marlin J Ins Agency Inc zSe7w Assig ns iM Suers is"Noortitatr4t"St POBox"s ereg r 0 $ 4 ar,�g�B&b 215 E116 COVERAGE Gauthier Insulation kc +aR ac$ 00 Box 3" &Saxa c: I{VwtC k,MA 0183E V �a S, C CERW CAT'E WVIM- Hi P#AT TPS'I Cs E59 TSE POLICY IND C:AT ED,NOTiMTt4rANMW AW REt3L'd3TRE 'T_TEE OR CONDITION C3'Ali Y CONTRACT OR 077. 'kR DOCJ3 RT VATH RESptot TO WP t TH CERTIFICATE MAY 6E fSSueoOkwAy PERT^w,TPSE'.t WRANCE AFFORDED BY TPtE POLSOMS tPLSWISED KRE d IS SUBJECT TO Ms_THE TERM& fXWJWW AND COWITKAS OFSUCH P OUCTS_LEI'S MAY HA%lt BVt-W REC.'a; £Q8Y t°AM CLARA& e®+ota2 cwwtArsr at«t $ c 0 a�ax�aedxa a�cnrtvkmr A lksacor 17 aec S AuTowcattLablM L Uti All . p^ st Et'AL I .......... S arta! beam.. U Uiw>40WL ' E. t' E' SB La7d5 $ S „ €a aw'r oa!xtt�4w. rnza €ar z t Eat Aa:Srw _ S ► tea £aa,C1. �s � arx [� WARP-300327, `:it�'�f+ �5 t�t3fsktfi t+E Cra•SJ �+Sx?aw�frs {r�q; E a.L'�5€.. •+'� Y S S9G,+ i E C •:.,a:, + :...3.: ,k»:'AC'&Y r;�sA?.fC..�'+�4'i 43fCE x°4 4iil 1{ . ACS aRaart �". EIRTMEATEMM Ciaar+rsutt TNS Ex��aeTer ATE Tt�Rf G�,?i6kT Yrs. e CQ nta�Ctar Svcs ACOOMM4T VMX THE POLs£Y T'RaR . 50 woshblotoat Shoat * � Was t4 MA 01$01 3' Signature: f AMAD 25(2010110S) 8PAC 3139 TE ACS V CERTIFICATE OF LIABILITY INSURANCE DA7i(7i2015YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Nancy Usher Martin J Clayton Insurance Agency, Inc. PAHONri Ext):. (413)536-0804 A�:(413)534-7874 1649 Northampton Street E-MAADDRESS: IL P. 0. BOX 989 INSURER,AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville NATIO INSURED INSURERB:Allied World Natl Assurance Co Gauthier Insulation INSURER C: _ - 44 ESSEX ROAD INSURER D: INSURER E: IPSWICH MA 01938 1 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MOLICY EFF POLICY EXP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED SO,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/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident X UMBRELLA LIAB OCCUR EACH OCCURRENCE _ _$ 1,000000 B EXCESS LIAB CLAIMS-MADE AGGREGATE _ $ 1,000,000 __ - H DED RETENTION BE020792125-194985 10/18/2014 10/18/2015 $ WORKERS COMPENSATION I PEROTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? N/A -- ---- (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under ----- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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/MEGA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Mrrdr69tbd with pdfFactory trial version www.pdffactory.com « me"t of Public saf0ty � ... B*Ofd Of BUJIM09 Regulations and Standards Li L»1 +gyp 4 X11 GAi3■p M � P OL flax 341 ` bmkb MA 01901 x Expiration Office of Consumer Affairs and Busyness Regulation 10 Park Plaza- Suite 5170 Basten, Massachusetts 02116 Horne Improvement Contractor Registration Registration: 173410 Type: individual Expiration: 10!1/2018 Tr# 257812 KURT"GAUTHIER KURT GAUTHIER ' — P.O. BOX 344 IPSWICH, MA 01938 ... _...................._._ ___. Update Address and return card.Mark reason for change. [7, Address Renewal Employment Lost Card $CA i G 200,06.15 ._ .. ��t �r'rrrxras+rrrrr�rrf�r�C:^,t'�r<,'urr��rtx�I; 1 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only fIOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: registration- 173410 Type'. Office of Consumer Affairs and Business Regulation expiration: 1011f2016: Individual 10 Park Plaza-suite 5174 Boston,MA 02116 KURT GAUTHIER ". KURT GAUTHIER 44 ESSEX ROS- IPSWICH,MA 01938 � _ ��� _ __.. ..e.... Understrretary of valid wi ant signature