Loading...
HomeMy WebLinkAboutBuilding Permit #292 - 156 CHESTNUT STREET 10/28/2008 BUILDING PERMIT N°RrN q TOWN OF NORTH ANDOVER °3�;4~'' APPLICATION FOR PLAN EXAMINATION Permit N0:24 _ Date Received D� ��SSACHUS Date Issued: ` v IMPORTANT:Applicant must complete all items on this page =z LOCATION /{ �� `f 'l Print PROPERTY gWNER 7/_ ° u Print MAP NO:4D CEL ZONING DISTRICT: Historic D70 1istrict: yes no r Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain le#lands Watershed District Water/Sower DESCRIPTION OF WORK TO BE PREFORMED: Mxo Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: , CONTRACTOR Name. i Phone: 7 Address: t+ p Supervisor's Construc#ion Licensee Exp. DatO,:, to-d—/e -Home Improvement,License; ] Exp. Date: _ "!Ile 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: $ JFEE: $__ Check No.: � Receipt No.: I NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund signature of Agent/Owner__ Signature of.confiracfior ;' _ Location ��� � � �/✓T No. _r7D Date o�d %ORTN TOWN OF NORTH ANDOVER a • ; ; Certificate of Occupancy $ y� Building/Frame/Frame Permit Fee $ �I s�cMuse 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # (, `dJ 216 0 b '`-- Building Inspector 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 HEALTH Reviewed on Signature r COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments j Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpsteron site yes no Located at 124 Main Street Fire Department signature/date.c 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 ❑ 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 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 ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 NORTH ONM of 0 No. _- LAK o dovert Mass. —04(!!� COC MICME WICK y1. Aor ATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT 0 '� " BUILDING.INSPECTOR . ..... , ...........�. .............�. s...... ...... ..... ....................................... Foundation has permission to erect................................. buildings on�S C d I1/i ' .t.............. Rough g ..................... to be occupied as........ . . . ........ ...... ......... 1�.................................................................................. Chimney provided that the person acc mg this permit sha 11 in ev aspect conform 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 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 MONTHS UNLESS CONSTRUTARTS ELECTRICAL INSPECTOR C ` Rough ......... ........... ........ Service BUILDING INSPECTO Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. TGLRC Inc. dba Larnbert Roofing C.�orqpany In Business Vince 1 ,32 ' -.n<;_1_; ,: :zr..- Octebely 17,2008 Re,A�dyesso Grey Rock North Aadovei9 MA 01845 l wne3 978-689-9994 &Iespe oao Richard J. Lmnbert 12oofina System Contract for front building 156 and rear$nildin2172 GOLRC Inc. dba Larrahert € o iqQ C y;f H provide " i1 c trg° �, _ � t=u °n_ ti �. ri��t x_6s neeL Amass r Ex n that vile`..are tftffly Knsit red for workers wins- sation, general 1hah-flity,FsatQid^u_obil aip:lblity and al $5,000,0,00.00 Li-nbrella poi icy. its docu entatiopE will be seiyt-Chrough-the US mahl or VIA- " ?IZ� 1 � the above amed-oT if not already provided. Upas i compget O. of the roof s���Td i_a� pay, �e3st �:s��i� ���a� �l`��i�t�Ir�rs wYrar� ti�r e°i��� �°' a_ �F 6a a t ` 9 executed en i 0)3,ear vt;or1'un&,:.ship fJe s" n ye=-ill be sent to tae named pourtye We will pis® include in tliis contrast P.,Cwtainteed(1 5) year rive; St r G ai�°�my. Work to be Performed And Materials to be Utilized 0_y#er,vas� v A S-amidard ten(10)year workmanship vranman-1 a- A es naar -faciurer's Y7Ya7rm °and a 1lve s areru',drnitmld �,.varnmgnt-,'W no extra cost. e Un&r no Circumstance Will ffie-%,a eriggt integni ty ofthe G ,_7*,1 "?nnq,be ill ?H y W���T k {rl f�` ca..,�.y ".s? ?'.,` �F g G dictated 1 wort �� � peF Aory-ne o tae s m aids C x.,vec' ,1�_S)n dicta ted by, he 71h ediltion buh ding code and proper roofing�iacyics founded iqy NCA soo_•( r,overi�g an d waterprc o oing manna Jv 1 u bye -n y? .k aro" -will be executed io obsSr'c�t�a..d�4ocu—���ient any 1�''-m-exis�3L g con, ?itio-as and or any special considerations. 2i Ensuie 1andscko oand d o-1,01ing is and will remain.propedy protected. piea,se take special asole that during demo of the existing?%tsys"ten aft vahareble noo- faestelved apne subfect to frfding duping d'e o'aad de-bras WHI a Y M, �Eye w C so 1riTr9?W v 4 IN 51-05033313 265 ixnter St Haverkpill,miLA MAI Re . a x is "149221 phone(97M 374-9224 ex(978)52145791 A1.4 I ic. %C,S 07E l 330 E-Mail at "Q� ± u Single-Ply-Lie. 4 1711 Please visit-us on the Web at TGLRC Inc. dba Lambert Roofing Company In Business Since 1932 - for this will reduce a disappointment and inconvenient clean up. Lambert hoofing will not be responsible for the above mentioned preparation. 3) Prepare for re-roofing by ensuring all safety measures are taken in accordance with OSTIA and CMR Standards. 4) Remove existing layers of shingles down to the wood roof decking and properly disposed of debris from the jobsite in a legal fashion. 5) Inspect wood roof decking, if we discover any rotted wood,removal and replacement will be performed at an additional cost of- * £• $3.95 per lineal ft. (LF) for up to 1"x 10"rough cut pine stock. • $65.00 per sheet of CDk Plywood (4'x 8' sheet). 6) Inspect Fascia and Rake boards, if we discover rotted wood, removal and replacement will be performed at an additional cost of- 0 $5.00 per lineal foot of Fascia and rake board, pre-primed pine up to 1"x 8"width • Crown and Cornice Molding will be custom quoted depending on the material.required All the work includes removal, disposed and replaceiL If wood roof decking and trim is sound, we will reattach any loose wood to the rafters, sweep deck and prepare for installation. 7) Install 8"wide Aluminum Drip Edge to all rakes and eaves of the roof perimeter as required. The choice of color is to be: White 8) Apply"WINTER GUARD"Ice & `Nater Shield 6'up the roofs transition and/or as per manufacturers' specifications. . 9) Attach "ROOFERS SELECT"premium felt paper to the balance of the wood deck. 10) Furnish and install: • Shingle'Type: 30 Year Traditional style shingle. • Color: Moire Black We use, as our standard, a hurricane nailing system recommended in northeast regions. This means, we install six (6) nails per shingle to reduce the risk of shingles being damaged by high winds and the weather changes we encounter. 11) Roof Flashing: o Re-flash existing chimneys at no extra cost using lead as and if required by good roof practice (masonry not included). If any copper is removed from chimney it will be left on site for owners. If existing copper flashing is sound it will remain in place. .NOTE: During the construction of the front building 4156 we will repair the chimney at building 172. 2 EIAT#, 51-05033313 265 Winter St Haverhill,MA MA Reg. Hie#149221 Phone(978)374-9224 Fax(978)521-5791 i1L4 Lic. # UCS 078130 E-Mail at Single-Pty Lie. 9 1711 Please visit us on the Web at r,�, TGLRC Inc. dba Lambert Roofing Company In Business Since 1932 12) Ridge Vents • Cut back roof decking a minimum of 2"as per manufacturer's specifications if required. • Furnish and install new"Air Vent" Shingle Ment 11 shingle cap over style Ridge Vent System if required. 13) All roof lines will be tarped during demo and we will protect all shrubs to the best of our ability. All debris generated by TGLRC Inc. dba Lambert Roofing Company will be cleaned up and disposed of in a legal fashion. 14) Re-seal large skylight on building 156 as required. Give an existing condition report to owner. 15) Remove existing gutter and replace fascia so that it is prepared for a new gutter to be installed at a later date. No additional cost for fascia work. EXCLUSIONS: Turret roof, pre-existing conditions, flat roofs, skylights and any other trade work. Roofing Warranties: UPON COMPLE'-F ION AND PAYMENT IN FULL A TEN YEAR NON PRO-RATED GAURANTEE ON ALL WORKMANSHIP WILL BE HONERED AND ISSUED BY "T.G.L.R.C. INC". A THIRTY YEAR PRO-RATED WARRANTY WILL BE ISSUED ON SHINGLES BY"Manufacturer". We will also upgrade to a Certainteed"Five Star Warranty" at no extra cost. TGLRC Inc. dba Lambert hoofing Company agrees to: • Commence the described work on or about October 2008 • The described work will be completed in about(5-7)working days • Shall not be held liable for delays due to circumstances beyond our control • Shall not be held liable for any damages to landscape, attics and or fixtures due to circumstances beyond our control • Shall not be held liable and roofs are not covered under the workmanship warranty, for pre-existing conditions including but not limited to: o Mold and or wood rot o Defective, faulty, rotted or worn building counterparts such as, but not limited to: siding, gutters, masonry, plumbing and windows, all of which may jeopardize the watertight integrity of the structure if not in sound condition • Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence 3 EIN#51-05033313 265 Winter St Haverhill,MA MA Reg. Hic#149221 Phone(978)374-9224 Fax(978)521-5791 MA Lic. # UCS 078130 E-Mail atsz_;-v '2'=�� s��� J.'0_ Single-Ply.GiC. 9 1711 Please visit us on the Web at •. ,, ..___:::..�..:.;__,.,_��,� ._ TGLRC Inc. dba Lambert Roofing Company In Business,Since 1932 Required Permits A building and dumpster permit may be required to remove and replace your roof. It is our obligation to secure these permits if required as the homeowner's agent. Note:Homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c, 142A Additional Attached Documents,Agreements or Provisions 9 Insurance Documentation if not already provided i Arbitration Agreement • Contractor Registration Information Notice of Cancellation Form This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inca dba Lambert Roofing Company and the Homeowner Contract Price and Customer Obligations The total cost for all permits, warranty, labor and materials for building 156 to be completed within two weeps is: $26,200.00 The total cost for all permits, warranty, labor and materials for building 172 to be completed in 2009 is: $19,725.00 plus any increases in material costs. Documentation will be produced. Payment Terms: • 1/3 DOWN UPON START, UPON COMPLETION PAYMENT IN FULL LESS 10% TO BE PAID IN FULL UPON ISSUANCE OF FIVE STAR WARRANTY. ® A finance charge of 1.5 %per month(18%per year) will be added to all invoices on the 31 day. All legal and or collection fees will be paid by the binding holder of this contract The law requires that any deposit or down payment required by TGLRC Inc. dba Lambert Roofing Company before the work begins may not exceed the greater of: o 1/3 of the total contract price or: o The actual cost of Special or Custom made materials which must be special ordered in advance to meet the completion schedule 4 EIN 9 51-05033313 265 Winter St Haverhill,MA MA Reg. Hic A 149221 Phone(978)374-9224 Fax(978)521-5791 IIIA Lic. UCS 078130 E-Mail at ' 'ai, c, IKj.cc-''__ SiMzie-Piv Lie. �:1711 Please visit us on the Web at `..,J _. _;_ Od 20 08 08:43p Pat Conroy 97B-8$9-9878 p.2 TGLRC Inc. dba Lambert Roofing Company In Business Since 193.9 Acceptance of the Contract.Proposal DO NOT SIGN THIS COKTRACA'IF THERE ARE ANY DLAMK SPACES OR ANY UNRFS4I,YFD ITEMS NOTE: Duc to volatilo pricing ors building products,this eantmet is valid for 15 days of receipt. You may cancet lids agreement if it has been signed by a party thereto at a place other titan an address of the seller, which maybe the main o,[iccte or branch thereof,provided you trot fy the seller in writing at the mann opice by ordinary!nail posted, by telegram sent or by delivery, not later than midnight of Ike third business day following the signing of the agreement: Becuuce of the three(3)day Notice of Cancellation, work may not commence for a minimum of seven (7) days mer we receive this signed cordract unless the contract is signed at our o ice. d!'l 1 Date- Please sign, keep a copy d return a copy upon acceptafilce f "Quality Workmanship You Can 71rrust" � Thank you for the opportunity to provide you vbith this proal and or contract. Sine er�J,7';f� " 16cfhar J. Lambert President/Quality Control,TGLRC,Inc. dba Lambert Roofing Company 5 BIN#514)5033313 265 Winter St Haverhill,MA t✓M Re.X_jjr(. tV 14921 12honc(978)374-0224 Fnx(078) 52.1-5791 U4 Lic, t}UCS 078130 l:-Mail at l:��tslkrlrtaolitt�Lrr?cx�l.chn' SinKle-Ply 1,ic. #1711 plcsc visit us can rhe Web at www.!titth_r tncxitin .114t The Commonwealth of Massachusetts Department oflndacstrial Accidents Office of Investigations 600 Washington Street Boston,MA 02Ij1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly �. Name ($usiness/Organization/lndividual): Address: J1 City/State/Zip: r7iG Phone Are you an employer?Check the app opriate box: ' 1\,<L_1 am a employer with 4. ❑ I am a general contractor and I Type of project(requ(ed): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.El am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g_ E] Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9• ❑ Building addition required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.El am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or.additions myself. [No workers'comp, right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no 12.0 Roof repairs employees. [No workers' 13.❑ Other 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. (Contractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: . Policy#of Self uis:Lic #. 6� Ekpiratioii Date: 0 .- Job:Site Address / � '�� '• �-�- City/State%Zip Attach a copy of the workerscompensatioir policy declaration page(showing the policy nuniber'and ex iration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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$250 .00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. .I do.hereby certify un thepains and penalties of perjitry that the information provided above is true and correct. Si nature: Date: dw Phone#: Official use only. Do not write in t is area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: eat Boar o Building Regulat ons an tandards One Ashburton Place - Room 1301 Boston. Massachusetts 02105 Home Improvement Contractor Registration Reqistration: 149221 Type: Private Corporation Expiration: 12/6/2009 Tr# 262486 LAMBERT ROOFING CO RICHARD LAMBERT -- - -.. -----_ --__ ----- ------------------ 265 WINTER STREET HAVERHILL, MA 01830 _ _. ------ Update _._Update Address and return card. il1arh reason for change. Address Renewal Employment 1 Lost Car uF CAt e1 AGM-Gifu -PC:8a9G �= \la..ailtu•ctt� - I)��It,ir�uirni ��t f'ul�lii �atct� Bnard of Buildin_ flc ul;tri ni anti '-tandm-(IN Construction Super,sor License License. CS 78130 Restricted to. 00 RICHARD J LAMBERT 95 MAPLE AVE Ott ATKINSON, NH 03811 i E t r),r,{tion: 6/2/2010 nilni••l n i Tr= 27762 I f 8 / 25 / 2008 3 : 07 : 46 PM 8740 02 /02 s tt V tom't hl1'1�\NS� lf4\\ 4lillt�144 c��f \'4e"t"�'�r� e4 � t st ¢" e Cf JS S L1 E A Tl;D, 081,2.5''0013 THIS CERTIFICATF IS ISSUED AS A MATTER OF INFORMATION ONLY ANIS \IImI InsurulL rlgcncy 1nG CONFERS NO RIGHT'S UPON THE CERTIFICATE HOLDER.T'H1,"s L ERTMICATE* IP O Pix 511 I DOES NOT AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED ICY THE POLICIES BELOW. Salem,N4A 0 19 70 _ I COMPANIES AFFORDING COVERAGE IIN S IJRED — -------- i CTGLRCbic clba Lambert Roofing Co. COMPANY A A.I.M. Mutual Insurance Co 1265\Venter Street LETTER 1Haverfi 1,MA 01330 ts: ,Y"'n,.- '•f.c:'k:`'tai.$s;'f'w�2}44''kk.4:,'ttt�t43 + e ,n f�.' SRI ka tlK aq'ta "k,x <•yf;tf'> f)'�.fe,.`r4S:i ,`3x,42 C 1 ;. }„ sr•..y y t a, �, t: >r+. ,,. s 1 t ,f .,qs,t... 7��s`;t'.'tds'',��i7}, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AJ3(VE FOR THE K LIC�- PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF.ANY CONTRACTOR OTHER DOCUMENT WITH RFSPEC' TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.IhC 'I'()ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CI..A1IvIS. 40 TR Tl'PE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION I' DATE(Ir1 M/DG/YY) DATE(MMIDO/YY/ LI NUTS I I GENERAL LIABILITY I GFHFRP.L A,A'RE-__.ATL ISI --- _J - PRi-1D!IC"I'SI":I:I In P/i iP II I:':t,11'+I f.F-;CIAL GENERAL LIABILITY i PER:'Or IAL 8AG:' IIIA:'•' fl i _ f ! LAINIS MADEF_ IrCCI.IR EAI.H URREHI'E l J-.'4'lNEF;S,.'C':!NTRP.CT!iF:'S PR'_iT _... .... __. .. _ I FIRE DArnA-.--.L r;,o,••:­ I =--- - -'-'-- MEG EXPE7J:E(W. AUTOMOBILE LIABILITY -------- -----_. !:OMFINED SINGLE LIMIT MAFI'' ALIT,-- ALL:'WII ED A UTI IS 111,1DIL`r INJIJE,' J I -'HEDULED AUTOS (Per p'-"I) I AIRED AUTOS 11-:'Ii.•:AWI ED AI ITCIS BODILY INJUR'1' _ARPAE LIABILITY (Par."Hd 0 I i PROPERTY DAMAI-,F. EXCESS LIA13ILlT\' EACH iCCU RF ENCS - -—_ =HKIFP.ELL.A FORM AGGREGATE r —___----- - JTHER TFIAN UMBRELLA FORM (rdf�.r+ypr WORKERS COMPENSATION AND STATLJTORI'LIMITS+ OTHER 1 EAIPLOYERS LIABILITY X HE PROPRIETOR/ EI,EACH A --- — A PARNERS\E-4ECUTIVE ACCIDENT $ 1,000,000 UFFICIEP,SARE MCI- F.:riCL 6009966012005 08/28/2008 08/28/2009 EL DISEASE--POLICY LIMIT $ l,000,OOO EL DISEASE--EACH EMPLOYEE ' N'IMENTS!DESCRIPTION OF OPERATIONS OR LOCATIONS: WORKERS' COMPENSATION COVERAGE APPLIES TO MASSACHUSETTS EMPLOYEES ONLY i ' - ,._ ..-,s,>,;. :k6:'!i'L le ft x�s<41� �A 4e.'k''�r 4`•<ss�0,l\44, ~���. ; t.,+. �,4 a t yr it k 4 HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DA rE HEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 WRITTEN NOTICE TO TIB:C'ERTM.('AT OLDER NAMED TO THE LEFT.BLrr FAIl,LIRE T 1 - O MAII.SL CH NOTICE SHALL I1,7POSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESEN'I'A I'IVES. LrrHORIZED REPRESENTATIVE 4791 ,yam The Commonwealth of Massachusetts Department of Fire Services a Office of the State Fire Marshal .P.O.Box 1025 Srite Road,Stow,MA 01775 PERMIT Date: Norah Andover Permit No Dig SafeNnm er (City of Town) (1f Applicable) In accordance with the provisions of NLG.L..l4 8 Chapter_j_(Z as provided in section 5-7 C;MR 34 Stan Dam This Permit is granted to:. /..,g Full name of person,Firm or Corporation Permissionto locate dumpster for construction/renovation/demolition of "building. Comments: dumpster. must be . 25 ` from structure if unable to place with required Restrictions:clearance dumpster must be covered with plywood or tarp end of work -day � at .— S lJ (Give location by street and no. or d cnb in such m s prov d%dequate Iden V cation of location) Fee Paid$ 50.00 ���^��/�� Fire Chief This Permit will expire- (Signature of offical granting permit) Offical granting permit (Title)