Loading...
HomeMy WebLinkAboutBuilding Permit #797-2017 - 130 WEYLAND CIRCLE 2/27/2017 I I BUILDING PERMITO� NORTH ,6 ? h��t�eo•„6�6+0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION e Permit No#: 7 ate Received Sys+wreo SACHUS� Date Issued: 1 I IM ORTANT: Applicant must complete all items on this page LOCATION A 3 O UJC� G-+�� i✓C�� Print PROPERTY OWNER SLI C_ ��1� Yh (LS Print 100 Year Structure yesno MAP�PARCEL:�ZONING DISTRICT: Historic District yes no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑ A ition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others.- ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BEP RFORMED: 61 r a4l C, e e s Identifica ion- Please Type or Print Clearly OWNER: Name: �_ i J 6-M ,e—f Phone: 3- S 2319 Address:—L3—C) W Contractor Name: Gv l Phone: 3 7�-o N 93 Email:g;;�i o-J , S _ Addres i �)k 3`.{ SW I kKryij 3 Ts 1 �25(�Z Supervisor's Construction License: Exp. Date: �J -.At,�� �-- Home Improvement License: 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. 4 Total Project Cost: $2L4 ��1. � FEE: $ Check No.: �V ,17a Receipt No.: 17 la1 NOTE: Persons contracting with unregistered contractors do not have access t the guaranty fund 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 a 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 Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit s DPW Town Engineer: Signature: Located _384 Osgood Street I,R DE AP RTMENIT �ITem ®umpster 66, �yes� 4 :ln jL co ated at�t rft- ainf!�-treet4 Fire4D�epart,menus +�C:OMM NTSi___ 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 artmen t 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 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 I New Construction (Single and Two Family) � Building Permit Application 4. 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 Doc:Building Permit Revised 2014 Location e-� No. 7�f 4 U 17 ` Date • TOWN OF NORTH ANDOVER " Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ , Other Permit Fee $ i TOTAL $ �I Check# VVV r r j Building Inspector NORTFt Town of ? _ ., sAndover O 0 No. * _ ,� 117- 7AI * i ti 1 ver, Mass, C O[Hoc Nl WKa 'lf,4S R.�TED P'Pa,`'�5 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System V1' 1LIISWjTHIS CERTIFIES THAT &.14. �TA. 4�r�.............. BUILDING INSPECTOR .......... ii .. Foundation has permission to erect .......................... buildings on .........l...... ... .�!r GodefaiDt RISE Eatgiineertng mcopusewftmmum WA Co rReg Room , �,I .'- Cr ConbracW Rogtstraflon M"120120 SE r 6Q$b%"Wit a4CftWm`MAM2l CONTRACT � FA)L134bQy63�S pap 5 PROGRAM CMA-HES +aorta�trarraut�ie oaaoaroaaaa KeUte laws are Clams oroarteear+r (503)545-2319 01t18tall443634 23902 cattalo etitsae 134 Wry)a�Circle 130 Weyialtd CWe eawtat cm.auak�as — __ ounce a".ank%no Nottll Andover.MA 01F43- Non h Altdover.MA 0 1845- JOB DESCRIPTION liAZ AM LMMOL We neve idenufed that alae err gaoe$etl ligbu plow to your bane.who the reversed he"are artilkd m 0 datrott C61ftd Rood)we vv(0 aeatea l'deetotoe sp=around the faatne by untag 0baghss bit"irodoaion as maeeg4 no insaktion vn'p be madted amort the tap and doted amucs w"toutato tmemcd lWft will tot be $0.00 AIR SEALING:Provide labor and momiak to seal arras of your horneggainst wasteful,escess air tedluW. This work wilt be Pafamod ea aouoat wilt the me of spmW leerier and d is[ars to assure that ym bane we71 be kp with a bcenhfel lour!of air atdhmr®e end indoor air quality.Materials to be used to sad year hamcem indude cmft fomm and outer pm&xts. P46amy toeaa for sealing include air ItAW to adi boanata,attacbed gttrapa and other uatttered ante(windows on not gmeratty addressed.)This will require(10)working boars.A reduction it cubit fat pa mimeo(crm)of dr itrivatton will occur,but the acnmintrrnbaofdm iaaolg�teed. At tht caaptgSorr oftare wemitaSataion wtMh.mhd at no seat W dvrlhonte�a+rahs,atbtol blovra door andfa tomtwatiao safety analyses will be conducted by the sub-contractor to come the slaty oftx indoor eir quality. t t i 5830.00 pAbr€MtNG Provide lobar and materials to install a i7'layer o(R-38 mrsoe d Tibc tmbatts to(30)square fm for damming i purposes. $61.50 ATTIC ACCESS:Provide labs and ma rials to insulate the back of(1)Wft hatch wish rigid board at R-10 or greater wish the required the going Wedhersuip the Paimcter. $60.00 ATTIC ACCESS:Provide labor and metaiats to landate(l)had of de Lneaaaii batcb with rigid hoard to R-10 or grcma with the rcqu"ecd the rsaiug,and sell the adgc*fee ketch with weohershippin& $60.00 t ATTIC ACCESS:Provide labor and mammals to mekc(i)tertP Y *w an actio tea The apcnWgv4 be closed with uWamb similar to arose eaating Finish sanding and pending is not indu" i r 583.00 r Vbf nATION:Provide tabor and ma=ids to imWI(3)insulated tahm=hose witb mof momtttd clapper matt to o&aust j botuoam telt).Namaudd 0 636 or ageivd=L t � 5356.23 COMMON WALLS:Provide tabor awl materials to iasmil rigid board at R-10 or gloater with the reQUkW fee rating to(270) squat fat orom mm wet!arse. 5847AO 4 f. RBF �mt•Osoaw ISE ar p�xs C©Nmclr ftip------------ _ . o,�ar.oecw iGeille]ami mm"- a QIW. Immo aw GIRR 17 #qhs �faa ,a CIMIC 130 Waylwd C&de Noll Anbm.MA 01845- _ . mm°664 a w'- - 1�andoMer.1MA Olt4S- JOB DB.SCiZ�P1'iOAi Awcoaft IFI000alMeeoaQ�aootoal.Ym�{ao�0a6�00�eMltlaooc�t q �� medsruesuPlomaB4ti�8omedsaaetdittoexl ��o�►adevQ�rymsraAea�laoami�eatla0lir arEq�aasloaWled8Yl6ea� 6 ivQaoratr VOWMkiml ds awdoar kat�ea+ml�IestrAlar of fi d ma loasftqtyabmftm .� -ee--sMe.Blalroo►doaatagmx�e�¢ OWAIMCoaiaeeaaheil0. asd+�c6ae 'Ihislmsawtroad990aed[smaoaaeteoyan lbtd tGaR�nittvmeoaoema0blyda: amtraeeor.ataysOd�aWam6abAaboa�oowaOAnagpo�t8pitoduosase3b Oft bl�aaamalaattietrmaaleireElp�otf6aa�eo�plafma[�bMa�k, ll�000 Tam ftoloom TW* iSBTr04 we�me�rte dS�FSe�BQ,oOaes �38T.44 aueraoa as aio�eaa�araa: aa�seroe111041�eajwwWonaaawaiu. ev+swuoew�a000reruaaiarrn unwoa�tNc�oraaata�samaaa�n aoadumoaa►aaoma bOMplm01171dSC0lilitllt:Ti!'ll�llMlNIIfBL/�ptpo '-- Pd I --,�,�,�°'as aeevpaoeasa°mm°r' ;�aorspo►oo�rea raaieooaa: rncat�roamon spuooumwooa 1 ENGINE}ERING so*O*r"R04 Unit 2 E Callon,MA OM,13M.024M OWNER AUTHORIZATION FORM Al OwWs No") owner of the property bcated at 0 Ad ) Ol�' gkopft "ewj hereby auemem C uww �'�; C r an authorized sW=nbacW for RISE&Ckweft to ad on my behalf tD obWn a b admg permit and to perform work on my ply This farm is only valid with a signed oorftct. The Permit will be severed by the iraulWn •�m��� h� m thcsworks cesporWbNity to dose out taus pemdt by cm* *V O�e1's 'cite s.sos ' The Commonwealth of Massachusetts Department of Industrial'Accidents a Office of Investigations r I Congress Street,Suite 100 Boston,MA 02114-2017 www.massg;ovldza Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A h tion PI se i 1 ibl Name (Businessoganizatioa/Individual): ►� +�� 11'1SV�A.�10Y1► ,V`R--- Address: Com•0 BOX '34q Ci /State/Zi : l QlWi U\ rl tot 11M Phone#: • 1 Su •��B Am Pu an employer Check the appropriate box: Type of project(required): 1.; I am a employer with __ 4. [, I am a general contractor and I S ®New construction employees (full and/or part-time).* have hired the sub-contractors 2.[3 I am a sale proprietor or partner- listed on the attached sheet. 7. [3 Remodeling ship and have no employees These sub-contractors have $, ®Demolition d have workers' employees an P Y working forme in any capacity. ees ,� 9. (1 Building addition [No workers' comp.insurance comp.insurance. 10.[3Electrical repairs or additions required.] 5. [3 We are a corporation and its 3. doin I am a homeowner all work officers have exercised their 1 l.®Plumbing repairs or additions ® g myself. [No workers' comp. right of exemption per MGL 12•['Roof repairs insurance required.] t c. 152, §1(4),and we have no I3 ®ether employees. [No workers' comp.insurance required.} *.Any applicant that checks box#I must also fill out the section below showing their workers°compeasation policq!*flnadon. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employee& 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 f ob site information. Insurance Company Name-- N f n d ►tL Policy#or Self-ins.Lic.#: � 3 O Expiration Date:_ Job Site Address: 3 0 W i�� City/State/Zip:W n t 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 of a - imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine P fine u to$1,500.00 and/or one year im P 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 cen*under the pains andpenalties of perjury that the information provided above is true and correct. S.en e• L- csh PhoneCk-;r • 3 5l0•"3`��i 3 [6. cial use only. Do not write in this area,to be completed by city or town official. y or Town: Permit/License# uing Authority(circle one): Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Other ntact Person: Phone#: AC R® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDJYYYI� 41..� 1 10/18/2016 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). PRODUCERONTACT NAME: Meg Munroe MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE : (413)536-0804 a No E-MAIL ADDRESS: mmunroe@mjciayton.com 1649 NORTHAMPTON ST.,RTE 5 INSURER(S)AFFORDING COVERAGE NAIC# HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325 INSURED INSURER B. GAUTHIER INSULATION INC INSURER C: INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 94521 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 UBR POLICY EFF POLICY EXP TR TYPE OF INSURANCE POLICY NUMBER MMIDONYM (MMOIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE �OCCUR A D PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS AUTOS N/A N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE N/A AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION PERTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE OR — ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICERIM EMBER EXCLUDED? WA WA WA MAARP300327 10/30/2016 10/30/2017 — (Mandatory In HH) E.L.DISEASE-EA EMPLOYFF-1$ 500,000 if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only,Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel M.CrainriBy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD AC<>R0 CERTIFICATE OF LIABILITY INSURANCE r s/a� rn 2o 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 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 NAME:ONTACT Nancy Usher Martin J Clayton insurance Agency, Inc. PHNEON (413)536-0804 ALQ No):(413)534-7874 1649 Northampton Street ADDRESS: P 0. BOX 989 INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURER A:Nationwide Mutual-Harleysville NATzo INSURED INSURERB:Allied World Natl Assurance Co Gauthier Insulation INSURER C: P.O. BOX 344 INSURER D INSURER E; IPSWICH MA 01938 INSURER F. v COVERAGES CERTIFICATE NUMBER:CL1663001850 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. INSDL" SUR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE Fx�OCCUR I DAMAG TO RENTE PREMISES Ea qccuTq_n_c;qI $ 50,000 GL43487F 7/6/2016 7/6/2017 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 LU\B OCCUR EACH OCCURRENCE $ 1 000,000 B EXCESS LIAB HCLAIMS.MADE AGGREGATE $ 1,000,000 DED RETENTION 1 nU028251970 10/18/2016 10/18/2017 $ WORKERS COMPENSATIONR 7 - AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) tFE.L.DISEASE-EA EMPLOYE $ yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1200 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEGA y - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/)1) The ACORD name and logo are registered marks of ACORD MPtA -d with pdfFactory trial version www.odffactorv.com LL _ office of Consumer Affairs and Business Regulation 10 park Plaza - Suite 5170 Boston, Massac tls 02116 Home hnprovement qplbclor Registration Registration: 173410 Type: Individual M Expiration: 10/1/2818 Trf 291320 KURT GAUTHIER KURT GAUTHIER o 119 COUNTY ROAD IPSWICH, MA 01938 . Update Address and return Bard.Marls reason for change. (� Address Renewal [] Employment 13 host Card gG11 p 20N1.05H1 �Pomzmo �deo�'C�aaad�vaekd Office of Consumer Affairs&Business Regt&don Registration valid for individual use only before tire HOME IMP ENT CONTRACTOR exphadoa data ufound return to: j r 3410 Type: Office of Consumer Affalrs and Business Regulation Errpiratl B lnd vidu8l 10 Park Plaza-Suite 8170 Boston,MA 02116 KURT GAUTHIER --- KURT GAUTHIER t�t ��:#a:s�,�t#� Cle�par#►eteaes#cw#��st�trr.�.�:�let#y SOON of Puliding 'Ina Standards t. :eo-%ee GSSL-102$0 r KURD"RGAltT"" s4 � !!Q*1"34 1pswkh MA #I v Ikuwl fi:t2rrwn►� +c7itl;+ OWSW17