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HomeMy WebLinkAboutBuilding Permit #508 - 167 CARTER FIELD ROAD 2/10/2010Permit NO: �2L Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this Daize LOCATION k d, ,. brr,A o >µ MA C % OM __,pnot PROPERTY OWNER ' \-lpei n A.nr.p ti,,,-ff Print MAP NO: PARCEL: ZONING DISTRICT: Historic District _ Machine Shop Vil yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Others: Repair, replacement Assessory Bldg Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer - DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) S l E_ - le � v OWNER: Name: t��,ll� �_�� �anrr,czr�e P1( Phone Address l �� CrA-er Ps9 MA Ot�4S CONTRACTOR Name: np-- S(M .o Supervisor's Construction License: _ I(a60(0 Exp. Date: a 1a 5 W 10' ent L 73 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: $�" FEE: $ VF Check No.: 91--y Receipt No.: � _4A 3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature ofAgent/Owner Signature of contracto --- e Location No. Date py1/Ci -1— MORTN TOWN OF NORTH ANDOVER • . • OL Certificate of Occupancy $ �'� s' • MUtBuilding/Frame Permit Fee $ y, ACS Foundation Permit Fee $ Other Permit Fee $ w r> TOTAL $ Check # Bad 22793 Building Inspector i 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 Sianature COMMENTS HEALTH s COMMENTS Reviewed on Signature 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 DPW Town Engineer: Signature: Locatea J64 usgooa Street FIRE DEPARTMENT Temp 'Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS i 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 :r ❑ 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 p' Building Permit Application zal Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ,c�r 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: Doc.Building Permit Revised 2008 S if 011'1l�; The Commons 25 Indian Rock Road Windham, NH 03087 Tel: 603-537-0555 Fax: 603-537-0556 SALES ORDER SO -13296 12/30/2009 Customer Contact Ship To I BILL POWELL BILL POWELL 167 CARTER FIELD RD N ANDOVER MA 01845 UNITED STATES Tel: (782)580-0000,(518)810-3081 I Account Terms Due Date Account Rep Schedule Date 9782580000 Cash 12/30/2009 Eric Holland 12/30/2009 Quotation — PO # Reference Ship VIA nage Printed SQ -14466 Company Delivery 1 12/30/2009 1:56:30PM L Item Description Order Ship Price UM Discount Amount 1JOT350420 OSLO, Wood - Matte Black 1 $2, 246.00 EA $2,246.00 2JOT350074 Leg Kit, Short - Matte Black 1 $62.00 EA $62.00 3Delivery Delivery 1 $216.00 EA $216.00 4IAJHHBGR1248 i I i i I I i I i i I I I I 12x48 - Basic Pad, Gray 1 $99.00 EA $99.00 I i �I I I Our Store Policies are located on the back of this document Tax Details Taxable i $2,407.00 Thank You for your business!! EXEMPT $0.000 MASS STAX-6.25 $150.438 Payment Details Total Tax $150.44 12/30/2009 M XXXXXXXXXXX7635 $2,000.00 Exempt $216.001 Total $2,773.44 X Paid $2,000.001 Balance $773.44 Dep. Avail $2,000.00 I The Commons 25 Indian Rock Road Windham, NH 03087 Tel: 603-537-0555 Fax: 603-537-0556 SALES ORDER SO -13297 12/30/2009 [—customer Contact Ship To BILL POWELL ,BILL POWELL 167 CARTER FIELD RD iN ANDOVER MA 01845 UNITED STATES Tel: (782)580-0000,(518)810-3081 rAccount Terms Due Date- Account Rep Schedule Date 9782580000 - Cash 12/30/2009 Eric Holland 12/30/2009 Quotation PO # Reference Ship VIA Page Printed i' SQ -14467 Installer To Bring 1 12/30/2009 1:57:01PM i_ L Item Description Order Ship Price UM Discount Amount 1LAB25Note Install Wood Insert w/Full Liner 1 $0.00 EA $0.00 2ZFXZFLKIT625 Liner Kit, SS - 6" x 25' 1 $724.73 EA $724.73 3BKPB690 Pipe, 6x90 Adj Elbow - Blk 24GA BM0014 1 $11.50 EA $11.50 9ROC6DP Damper Plate 6" 1 $44.95 EA $44.95 5LAB02 Labor - Install 1 $650.00 EA $650.00 61abnote ********NOTE********** 1 $0.00 EA $0.00 7 These parts represent a typical installation; however other parts may be required or substituted at the time of I I 1 I I installation. Our Store Policies are located, on the back of this document Tax Details Taxable $781.18 Thank You for your business!! EXEMPT $0.000 I MASS STAR -6.25 $48.824 Payment Details Total Tax $48.82 Exempt $650.00 i i Total $1,980.00 X Paid $0.00 Balance $1,980.00 I Dep. Avail $0.00 1 .I Is Jotul F 500 Oslo Heat Output': 70,00o BTU Heating Capacity': up to 2,000 sq. ft. Overall Efficiency 3: 72% Emissions: 3.20 grams/hr. Burn Time: up to 9 hours Log Length: up to 22" Flue Size: 6" Weight: 445 lbs. Mobile Home Approval Optional Accessories • Rear Heat Shield #154332 • Outside Air Kit #154333 • Floor Bracket Kit #750304 • Side Door Lock Kit #155850 • Short Legs (reduces height z 1/4") • Spark Screen #35o169 - • Stovetop Thermometer #5002 Hearth Protection A Bottom Heat Shield is provided with the stove. Follow these guide- lines to form approved hearth pro- tection: • the hearth protection must ex- tend 18" (203 mm) from both the front and side door openings. • any UL, ULC or Warnock -Hersey listed hearth board. (no bottom heat shield required) • any noncombustible material that has a minimum R -value of 1.6 (no bottom heat shield required). • A Bottom Heat Shield is required for alcove installation. �z". 51 m m 8" 203 mm Q Min. 50.1/2" 1283 mm 457 mm 457 mm Min. 541/4" 1378 mm Figure 44. Minimum Hearth Dimensions. 281/4' 718 mm Figure 45. F 500 Oslo dimensions. See clearance chart on page 27for flue collar centerline positions. Alcove Installation Requirements M • This side load door must be locked closed unless a 36" clearance can be maintained to that side. • Chimney connection requires listed double-wall pipe. • Optional Bottom Heat Shield must be installed. • UL/ULC or WH listed hearth pad or a noncombustible material having a minimum R value of 1.6. • If used, wall protection must extend 48" (122 cm) from the floor, including bottom air space. • Min. Ceiling & Connector Clearance, Fig. 49. A: Top or Rear Exit from hearth Unprotected: 691/2" (176.5 cm) Protected: 431/2" (110.5 cm) Fireplace Clearances A: Stove to Mantel, max. depth 12": 30" 762 mm B: Stove to Top Trim, 1" thick or less: 16" 4o6 mm C: Stove to Side Trim,1"thick or less: 12" 305 mm llr_� 161/4" 4 3 mm i 271/4" 692 mm —r ? Top Exit �9" 737 mm 25" Rear Exit 635 mm 281/4" 717 mm mm 118""-� 4466oQra_m=-- TMax. Depth 4g..1220 mm 14 14, 1355 mm 355 mml� _- 561/2" — 1435 mm Figure 47. Alcove with no wall protection. 12" '300 mm 1 Max. Depth 48" E 1220 mm _-E F� 401/2" 1015 mm Figure 48. Alcove w/ wall protection. Figure 46. Mantel & Trim Clearances. ' Maximum Heat Output based on kg of dry hardwood burned per hour. ' Heating Capacity and Burn Time will vary depending on home construction, climate, fuel type, and operation. 3 Overall Efficiency is based on a burn rate of.75 kg hardwood per hour. 20 _ Max. Depth — If — 48,. 1220 mm Min. Wall Shield Height q8„ 1220 mm Figure 49. Alcove Ceiling and Double-wall Connector Clearances. Stove Clearance Diagrams / Top & Rear Exit. p %A ,,-PN PROTECTED WALLS PROTECTED WALLS O 21 OR - PER NFPA CAN/CSA-B365-M93, 281/8 51/2" 1. 5mm 0 j 6 mml• •_. j 715 mm ~� 1 2 3mm i j4 0 -0"� 8 211/8" 13., u" o mm —� i' 457 mm 330 mm I 201/2" 3 5 1p/8" 9 zzg mm I 161/z"LL N C 537 mm 5z3 mm 38q mm 421 mm ++ V m 5Lmm 55 5/8" rn ti } 14F+rPl, � 1438 mm�O C a59 3/4' 116.'9 33om ,�-•. ' 3 Z to .1518 mm 0� v 1518 mm a L♦w 281/8" • 161/2" 201/8" 161/2" O �l 715 mm I'� z1mml•� c j 12% f j 421mml�� � l 10" 254 mm 131/8" 9" zzg mm —� az'!1 334 mm 16 Uz" 10' 254 mm 131/8" 9' zzg mm 161/z.. b C — -�. 421 mm 335 mm 421 mm H 3 +y4r E 48 5/8" ° y 1 1 m ti $ 238 mm O F9r d 1 48 ?2 C! z's,14" 138 mm - Y ^3 rrs ;4 553/4" I 513/4"m I 11-6. 3 in 3HEARTH EXT HEARTH 1315 m I :.:• ... R..,a,...;.'`Y�. a.;......'. w 0 Oa 281/8" is 5 1201/8" 13 5/8 715 MM -� �j-'422mm1.c j -51zmm I'-� �i-•345mm�-I u? 5 2921 mm zzg mm f 7-a2_MM 91/8" 6" 1 z mm 6' 1 z m m R Gat �' ` ._,... _ 3 16 5/8" 5 13 5/8" _ _ ./345 mm O_\n, ti - - - F to ?R ro 346 5/8"d3 - ti d n8q mm y 1q" ss6,A -' } 3 = y \ 356 mm~ �8 3 �� 3 OA 0: J 51 3/4" 'a'-'• 3 I �H T b696" 1 3 d C` 4-1 18 mm 3 i`, 1 513/4 a I :D: � a HEARTH EXT. 5 �111j �/ HEARTH EXT. 1315 Note: i) Hearth Extension calculations include the protection requirement measured outward from the side and front door openings. •2) Corner and Alcove installations require use of Side Door Lock Kit i5585o• Left side hearth protection may also be reduced to 8" with use of the door lock kit. Mobile Home Installation The F 500 Oslo is approved for instal - Chimney Connector lation into mobile homes in the US. UNPROTECTED PROTECTED and Canada. Clearances SURFACE SURFACE • The stove must be secured to the per NFPA 211 or floor•of the mobile home. Use O CAN/CSA B -365-M93 Floor Bracket Kit 750304. OSingle Wall 18" / 46o mm 12" / 300 mm 54333 P Use Outside Air Kit 1 to pro- DoubleWall . 6" / 18o mm 6" / 18o mm vide outside combustion air. B Use only listed double-wall pipe ❑ © Single Wall 18" / 46o mm 12" / 300 mm for the chimney connection. Double Wall 6" / 15o mm 6" / 150 mm The stove must be grounded to the mobile home chassis. • The stove must otherwise be in- stalled in accordance with 24CRR, Part 328o (HUD). Consult your local building in- spector or fire officials about restric- tions and requirements in your area prior to installation. 21 ACORN CERTIFICATE OF LIABILITY INSURANCE DATE MM 12/29/2 91 PRODUCER (603)432-3666 FAX (603)432-6076 Lakeside Insurance Agency, Inc. One Wall Street Windham, NR 03087 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Fences Unlimited Inc, Mis-Bec of NH DBA The Stove Shoppe The Commons 25 Indian Rock Road Route 111 Windham, NR 03087 INSURERA: Acadia Insurance 31325 INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. II T R R DD' INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY CPA0311123-10 01/01/2010 01/01/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 350,00 EE "ES-IE4 urence CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5,00) r 00 A PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 POLICY PRjE O- LOC AUTOMOBILE LIABILITY CAA0311124-10 01/01/2010 01/01/2011 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,00 BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per person) $ A BODILY INJURY HIRED AUTOS - NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ 1 ANY AUTO H AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY CUA0311125-10 01/01/2010 01/01/2011 EACH OCCURRENCE $ 5,000,00 X OCCUR FICLAIMSMADEAGGREGATE $ 5,000,00 A $ $ DEDUCTIBLE 1XI RETENTION $ Q $ WORKERS COMPENSATION AND WCA0311126-10 01/01/2010 01/01/2011 X WC TORY IIMIT FIR A EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ SOO, OO E.L. DISEASE - EA EMPLOYE $ 500,00 OFFICER/MEMBER EXCLUDED? If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Covering fence, installation, and other retail operations of the.named insured. WC statutory coverage is provided for New Hampshire and Massachusetts. No Executive Officers are excluded from coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. FOR INFORMATION ONLY AUTHORIZED REPRESENTATIVE / Edwin Duvall/PAULI Ar— zf`;A ACORD 25 (2001/08) ©ACORD CORPORATION 1988 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/Orgz Address: 4� City/State/Zip: a\ 4 Qt Phone #: (,03 — 53 _- ,, Ar you an employer? Check the appropriate box: 1. I am a employer with 4. ❑ I am a general contractor and I _ mployees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp, C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other clay appacam mar ene%Y.s Dox tt! must also i'll 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. It Insurance Company Name: Policy # or Self -ins. Lic. #: W r,,4 Q 3 1 r1 � b l (� Expiration Date: Job Site Address: City/State/Zip: 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 fine up to $1,500.00 and/or one-year impnso , 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 viola Bea ised that a copy of this statement may be forwarded to the Office of Investigations of the)A�i'or i4suranCovera verification. I do hereby and pAalties of, information provided 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other is true and correct /), io Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 15.2, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 15Z, -§25C(7) states "Neither the commonwealth nor any of its political subdivisions shall " enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or 'License is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 www.mass_gov/dia +., oard of Building Regulations and Standards Construction Supervisor License Lice se: CS 96606 Blrlhdate , 2/25/1971 31 01Expr_'ra n •y/2010 Tr# 96606 KEN SZYMANSK4 rl f 27 TICKLEFANCY LA14f SALEM, NH 03079 Commissioner 91te Board o ul m#egulalons an tan ar sg One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Cntractor Registration Registration: 154473 - Type: Private Corporation `f Expiration: 3/14/2011 Tr# 281037 MIS—BEC OF N.H. INC. KEN SZYMANSKY �! ; q 25 INDIAN ROCK RD. SUITE 19� 4 s WINDHAM, NH 03087 << ~ a _ Update Address and return card. Mark reason for change. Address n Renewal ❑ Employment ❑ Lost Card DPS-CA1 0 40M-08/08-DBSLIFORMCA108212008 T1ze �a��yreoauvea,�Cli a� �%%aaac�ciu�aelCa Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 154473 Expiration: 3/14/2011 Tr# 281037 t s Type Private Corporation MIS -BEC OF N.H'>.INC KEN SZYMANSKY 25 INDIAN ROCK RD 66ITE"1'9,� WINDHAM, NH 03087 Administrator License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rot 1301