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HomeMy WebLinkAboutBuilding Permit #78-12 - 17 STACY DRIVE 7/28/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ' r Date Received Date Issued: _20✓1' IMPORTANT: Applicant must complete all items on this page LOCATION 7 CC-- Print PROPERTY OWNER Bu�) ►.S Unit # Print MAP NO:PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building aOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial aRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic 0 Well ❑Floodplain p Wetlands 0 Watershed District 0 Water/Sewer D SCRIPTION OF WORK TO BE PERFORMED: A i C ±JVSV A( - ►$) k -->V s (Identification Please Type or Print Clearly) - OWNER: Name: PfU�I fJ g6 U+i W Phone: q99S�fa- Address: S�A(—S R• rVJOVe-Y-, CONTRACTOR Name: U I F> (A U Phone: k2 963 9 Address: IA/d I ivG pL, Myelut ULiii� c Dl ��y Supervisor's Construction License: !j Exp. Date: p t,-)— Home ,2Home Improvement License: Exp. Date: /Pv o/a ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. a� Total Project Cost: $ J 2ia� ,' FEE: $ ��b Check No.: /lam Receipt No.: aq q NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Ageritl _. 'Sigp5ture ofcont�actor � � 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 Fpt FFICE USE LY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS DATE APPROVED Reviewed on Signature HEALTH Reviewed on Signature s 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 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 Doc:.Building Permit Revised 2011 June/mi 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.G. And/Or C.S.L. Licenses ❑ Copy of Contract f ❑ Floor Plan Or Proposed Interior Work 00- ❑ Engineering Affidavits for Engineered products 1,1q - NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perrr 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) o 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 Permil 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 .Permi 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 2008mi Location No. Date NORTh TOWN OF NORTH ANDOVER Certificate of Occupancy $ s�CMUs <�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 6 2 I,• c. + 4 14 Building Inspector The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: �, V t di i , (A $[Jy Phone #: Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10.❑ Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.0 Roof repairs 13.W OtherAAjG AIJC41 V��_ y pp a c ec ox 1 must also fill out the section below showing their workers' compensation policy information. 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. Insurance Company Name: --t KA__U C -C Policy # 9 S �; Q �, S — 1 Expiration Date:—IhldXi a. Job Site Address: % `� S�q.Ly I %�% rl ^M A0 t cm 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 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. Ido herebW cert underR pA ains and penalties of perjury that the information provided above is true and correct. Phone #: -7)9 o )— ?4,3 Y Official use only. Do not write in fids 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 M Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sh%et. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp. insurance 5.$4 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.] f employees. [No workers' comp. insurance required.] *An a licant *I, t h ks b# Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10.❑ Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.0 Roof repairs 13.W OtherAAjG AIJC41 V��_ y pp a c ec ox 1 must also fill out the section below showing their workers' compensation policy information. 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. Insurance Company Name: --t KA__U C -C Policy # 9 S �; Q �, S — 1 Expiration Date:—IhldXi a. Job Site Address: % `� S�q.Ly I %�% rl ^M A0 t cm 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 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. Ido herebW cert underR pA ains and penalties of perjury that the information provided above is true and correct. Phone #: -7)9 o )— ?4,3 Y Official use only. Do not write in fids 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 M 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 152, §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 152, §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 burn 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 -MASSA -FE Revised 5-26-05 Fax ## 617-727-7749 www.mass.gov/dia OP ID: SS C>Rc> CERTIFICATE OF .. BIL I SCJ NCE °A�� o3MA111 THIS CERTIFICATE IS ISSUED AS A MATTER OF [NPORMATION ONLY AND CONFERS NO RMTS UPON THE CERTIFICATE HOLDER. TIM CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR AMER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES MDT CONSTRUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHOROED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the polley(ies) asst be endorsed. If SUBROGATION IS WAIVED}, subject to the terms and conditions of the policy, certain Porgy may require an endomement. A statement on this cert does not confer rights m the certificate holder in Neu of such endorsement(s). PRODUCER Durso & Jankowski Iris Agcy LLC 978-688- 198 Avenue 978-68$-7tHI1 North Andover, NIA 01845 Charles S. tiaridoneARR— COKMC7r FAX c� exonucac CUSraMa21D e POLAR P)AE tGCO0W=- i Polar Bear tlmda#ioll Co. IIIc. P O Box 958 Andover, MA 01818 ISA:Perm America 132859 INSURE e:Safety Insurance Ca. 133618 txslRsie: rtssuxsza- INSURER E: INMPER r - ^n MAr r.=Cm=e ATI= M11MQr:P- REVrSIUr4 [quaff iMtt' v •-wv �.,...... .�. ... ._�«.�_... THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED_ NOTvffniSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WFrH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED H0MIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES L M[TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR i rIPE OF 116URANCE POLICY NUMBER Po POLICY ECP i GEMMLLME11UTY I PACti0CGtt USES amarame s �,� 01 A X COVAERCtAL Da4ERALL u1 aelcm AC&864084 03t?�I111 03J29M2 MED EXP 68JV me PeMM) S CLAM 5ADE E y I OCCUR PERSON&AM INJURY S 1.000, L�J j G84EgALAGGREGATIE Is 2,000= PRQDZJcis-COlNP10PACG 5 GEWLAGc�GATELtI TAPPu6Peiz ;—� POLICY i I �Q' ; i toC !!!! s . ArfiONr}i�EL1ABiLGY t ' ((ES i $ 1,tl0fi,00II 1 8 ANY AUTO 1E10926 01104M4 0IMM2 BODLYiN.IflR-0NT fr=) s r Ali QVYtNEO AtFi CSS ! i 1 BODLY ffaW (PW 2MtdMF) I S NiXSMEDUI ED AUTOS I PROFEFaY DAMA s HRMAUTOS (Per2=MIQ i s x MONAwn® Auras LL Is UMBRELLA L(A11 I X OCCUR EACH MC U04CE s 1,000,00 Af ATC s A EXCESS LOW CtAt1 ADE � 1 i AC6864M 03MUll � 03WM 1 's 5 x HD®ucrr�LE RET13�f m s YftORIUMSCOMP13MMON � t � ' �pp _ AC:i ACCM9Si 1$ AISH:IPLOY@iSUABUM YIN ANY PROPRIi 10 tP : e ; ELDSS`-Fh l S DCC<S1DI�? D f A f { f } Ft n-aoLscY LH4ur S >f YeS describe e� DES LEON OF OPERA noNS b--qm 1 t DE iiDN OFOPERA7IOMILOCATIONS/VENKNX5 {A1k30ACORD987.ACM9Mmd c sI is nequoed) G.L.C.A.C., National Grid Corporate Services LLC DBA National Grid, Action Inc, Boston Gas Comparry, Colonial Gas . EssQac Gas Com & Bay State Co.; insured for with respects to work Gas are additional general�a performed on their behalf by the above. C."tt[ i it'i(rA r t tYVL2JCK � - - GL.CAC11 SHOULD AMY Q=TE3E ABOVE DFSCRiBM POLICES BE CATNCELLt33 SEI:DRE LCA.C_ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELMERM IN G. 8 LC State Gas Co ACCORDANCE WITH THE POLICY PROVISIONS - Bay 350 I iONS- 350 Essex Street Lawrence, NIA 01840 AUTHORS R>INUMerrATM ' 01s88 -20o9 ACORD CORPORATION_ All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD : ghtFBx NI_g 1/19/2011 10:14:22 AM PAGE 21002 Fax Server ACORD. CERTIFICATE OF UABJUTY INSURANCE cATfat wmwyi 0111912011 IM CERTWICATEM AS A UATiER OF RIFORK►710N ONLY AND OVERS NO FdCiH15 UPON THE GES1f "Tr f OLOM TM CERMFICATE DOSS NpT AFfWMATIYELY OR Ng*ATIViSLY AUsNo, M !Etat! OR ALTER DW!:OVERAGE AFFORDED BY 11-M POLICIES BELOW 7 S I LATE OF BSANCE DOES Nar CM nUiE A COMPACT RE MrE$BiIiE a=MG II+SS MMWS) AUTL OFA© REPRESWFAMVE OR PRODUCER, AND 111E COMMATE HOLOM UfiPOttTA/N_Brhaeerb5eaorelsoidf►tismADDIIiOtNALftiS1lR306poEeyCmjru>dlseseuloesod B9USROGATION�V7AIVED,mDtaWs E�rmsesslCWMMMSaitlwPaftAcgft'RPS—Y adork'CW TLA on6dswe62adrdoasno�ea nr �8�a PRODWER DURSO A 1ANKOWM TNS NOKrH ANDOV12', MA 01845 22LPT'L. INSURED POLAR SEAR MULAIRON CO INC P.O- BOIL 95& ANDOVM MA 01310 CONTACT maur_- FAX PHONE - (Ar" ftp EA)- FAX {AfC,ito); EMAIL ADDRESS'. PRDDUCER cusmum fD 3t MUREEip AFFORDWG COVERAGE USURER A: TRAVELWS IIVDFMQF[ V tMWANY IHMER E: UdSURER C: RIMER fr. I'RER E: ENS F: COVERAGES CERmRcATENLJ1m3mREYGStOH NLI�IBEE� POJ�OF EUSESELOWHAEBEENSSUEDTOTFOSUREDNAMMABOVEFORTHEPOLICYPERIOD NHC&--M ,6,TQ-�N=P..,,-MMORCOQOFANCONTRA=CROlHM E rWfHREPFiT1aWYJci'D==ERm E IRAYBEESSOEO OR NAY PE RTAOL TMiN%URA M AFFORDED WTHE FOLMM DIEM FtSMNjS SD8J8CTTO ALL E$TRat% MCLUSMM AND COMMONS OFSUf14 POEICtem LUMSHOVM U MAVE Bill REDUCED SY PAID GLA>t#5 R4SR TYPEOFuauRAHcE LTR GENERAL LIABUM coMMEWMALGENEPAL L AE3LITY GOWL AGGREGATE LWT APPLIES P -tit POLICY PROSECT LOC ALTTOWWLE LIAR TfY ANYAUTO ALL CMED AUTOS SCHEDULE AMS HMELI AUMS NON -OWNED AUTOS UI>BFM.LA LEAS OCCUR EXcWSL.iRS CLA944VDB OEDUCMLE RETErnm S ADOLSUSR POLICY EFF DATE POMY 2" DATE ULUM POUCTIrim aZ 1tdl mTrm emw]AYrm mm ttfvo EACH OCCURRED CE S DAMAGE TOR$ViE D S PREASS{Ea ) MED EW (Airy am P0504S p£RSONALSZADVMURY S GENERALAGGREGATE S QRODUCTS-EOI310PAG6 $ LSAT (Ea accident) sODiLYOLKW S (p" +) 80IIILY NV.RIRY S PROPERTY DAMAGE S (Par acddml$ EACH OCCURRENCE $ AGGREGATE $ S 3 NCCSTAitA40RYLr40TS Wof*CE Rt S COMPS "-IROM AND ER11PLaYERS LIAMUiY Val UsagosLomi1 ovow20ii 01MIJ201 E. L EACH E - EA +TC S A� PROP�TOE�PARY�VE Y ELL DISEASE FA BVFPLOY� S O r7ict310 M E.L DISEASE - POLICY LWT S {�2orylrt lO4 hyes,desGlCeuMa< FTf toll aF OPt3blT10ZLS Eotaae DSCRNFT0NOFOPERAiiOrL ASO ECtAtfTB�i 'EEWREPLACESANYPRERCERn 4CA3EISSMTOMp CAIP-HOL MAFBELR' WSVORIMRSCaW CER'EMAM 110113ER GLCAC&DAYSrmGASCB 350 ESSEX SPRY LAWEMUCK WA 01840 ACORa25 (2009/03) MAIO# 1,000 000 1,000.000 7.000.000 CANCELLA7014 SHOULD ANY OFTM ABOVE DFSCRISFD POLICIES BE CAINCEMED CCOI_RE Tfii:FXf�tR TMDATE'fIii, VW.LMMJVi3 %qm THE POUCY PROMOM A Charles I Clark 1988-2008 =ORD CORPORATION. AN rights E—Tve& Partners in Energv r CP zi Gas Account No. Audit Request No. 2M PRELUMNARY-AGREVVIENINT READ THIS AGREEMENT AND.&U-KE SLIME V4U*U-"412 U. UJINDETSTAND IT RUORE SIGNIRNG. NIAKE SMak BLANKS ARE COMPLETED AND ALL pROVjSjaNz THAT W"OT AppL-y _CP % ARE OSSED Of-rr- TF IS AGREEM _T ELAS LEGAL FORCE AND EIFFEC-T AND OLNDS THOSE Wflo S[GzN--.- LN This -Agreement is made ow.; �1_ �n'fflon_e'ywO bf 65 Shawmat Rd, Unit 4, Canton, Massachusetts 02021, (SM247 4114-4creafter called "Administrati've. Co}itr for`' or oji-m-Mvell"and q7* _j (Customer) (Address) Jv (Address coni.} Hereinafter called "Customer-" The Customer is the 0- wneL;/ Tenant of the above mentioned Premises. DESCRLMON OF WORK TO HE PERFORMED Inconsideration of the Administrative Contractor's agreement workmanlike manner all work (',the Work") se to Select a qualified Installation Contractor to Perform in a good conditions of ihis Agreement. k' t forth in the attached Work Order(s), the Customer agrees to the' -berms and No work may be performed without the written consent of Owner. Customer understands that calculated energy savings are estimates only and are not guaranteed. PRJCE For. the Work desc!jbed in the Work Order(s) and shown, on the accepted Offer Sheet, attached hereto, the Total Estimated Cost is $ The Total Due at the time of Installation from the Customer for: Insulation Measures Heating System Measures S Other S Total Customer Cost for the Work to be performed is S If the lAst97ahoft Conhwetor determmes that the Work canivor be providedfor the Price quoied above, call parties Wiff have the right to termiffate this Agreement- Price quoted is valid for 90 Amy& 13 Owner of the Premises agrees to pay, priortothe comalenceinent of the Work, and Administrative in full satisfaction for the Work the PriceContractor accepts, .set forth above. 0 Tenant agrees to pay, prior lo, .the Commencement of -the Work, and Administrative contractor 'acce^ in satisfaction for -the Work the Rice set forth above.--, -RIPHT To CANCEL THE CUSMmER C&NCEL THIS AGREEKWT IF IT HAS BEEN SIGINIM AT A PLACE -OTHER THA?, AN % -ADDRESS OF TjjE APNIMSTRA-nVE camrRACTOk WMCU MAY -BE rM'1-AMN OFRCE OR UPLANiM. THEREOF pROVWED � -NOTWUS THE ANNUNWrRATME COVrRACTok IN WR_qlN(; AT fr-S -MAI N 10IFFICT, TDR EA&,qCH_,gy - THATTRECMrOMER NT_ SEr OR by DEM'ERV- --0 LATEWTHA9 MWIVGHT OF Tj& T"nW *MNT - ATELFGItAM SIEN onx)PtAgy MArL POSI", BY CREME Ep _SS .%o-RCEOFC�4N .4rE) ANNEXM FOR IDAY FOLLOWING TIM SIGMNG OF TIUS AN _1�01AXAITON 01? TIM RIGffr. IMPORTANT. ADDMONAL TERMS AND CONNDMONS ARE By signing below You, the Customer, represents that (1) Beni read and ON THE REVERSE SWE 1111&179� both' before You signed it; (2) You agree to be rides of this Agreement bound by the terms and 00ndiflonS set forth on the front and back of this Agreement; (3) The Administrative Contractor (directly or indirectly) has made *no representations or warrant' ties regarding the Work other than -those contained in this Agreement; (4) That at the time Y(rd Signed the Ag'reem=4 has been sig.ned by the Administrative Contractor or its administrative it representative, them were no blanks -that had not been completed and that the A. `ark you requested Was properl described above. HoneywoU Signature Date Owner Signature Date H Tenant signature Date oneywell —White Installation Contractor — Yellow Cust6mer -Pink 1/09 Office of Consumer Affairs and Ifusiness Regulation 10 Park Plaza - Suite 5170 n Boston, Massachusetts 02116 Home Improvement Contractor Registration. POLAR BEAR INSULATION CO Vincent LeBlanc P.O. BOX 958 ANDOVER, MA 01810 DPS -CAI 0 50M -04104-G101216 C Officeoffoiume'r�' W. -W B si (11*9egu� HOME IMPROVEMENT CONTRACTOR Registration: ,102726 Type: Expiration: '712/2012 DBA !P1d'BEAR INSULATION COP,-. Vincent LeBlanc 51 SO. CANAL ST..,,.. - _- LAWRENCE, MA 01'41 Undersecretary Registration: 102726 T e- DBA Expiration: 7/2/2012 Tr# 298090 w; Update Address and return card. Mark reason for change. Address F', Renewal 1-1 Employment Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite.5170 Boston, MA 02116 Not valid without signature s1 ri *•, ches.ctT - Depa: tiilear 1)f Paltlic jai"t t; B1s 3rd cif Builll#n,, RC�nrtll(iJ]s and :fit tndal1lti i- Onstruction Supervison'• its Lisa s1 ,kens = CS Si. 99352 Restricted to: WS VINCENT LEBLANC 24 LANDING DRIVE METHUEN, MA 01844 = f .. , .. Expiration: 1/30/2012 ( a�nai> �uncr it : 99352