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HomeMy WebLinkAboutBuilding Permit #1251-2016 - 19 ROBINSON COURT 6/1/2016 NORTH 4t LY BUILDING PERMIT o�tt�E� ,actio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION70 1�� zT Permit No#: !// �° Date Received gSSACH0 Date Issued: Ily 1APORTANT: Applicant must complete all items on this page LOCATION '�A1��r1�v►^ CQ d "�- Print PROPERTYOWNER Print 100 Year Structure yesno MAP 2I b PARCEL: COlP ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building BIOSe family Addition ❑Two or more family El Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition _ ❑ Other Septic. O 1Nelf �L �� fFlootlpl_ain ❑1Netlar:ds, "� +R ❑ Watershetl ®istrict_ _^ O'1Nater/Sewer: _ _ _ _ — —_ _ _ DESCRIPTION OF WORK TO BE PERFORMED: C-e 1 lv ow- ,fix�r czr v is Identification- Please Type or Print Clearly OWNER: Name: 5�\wo r-,a„ kzM r`s Phoneq S 3 Address: Contractor Name: \) V/-1- qtr- Phone: CI 3� 3 Email: i Cr ins r NnLtn Add rese PO ;�T-iLi I w� (J-\47ft ()\938 Supervisor's Construction License: 1 °Z S�0 Z Exp. Date: Home Improvement License: 111103 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. - FEE SCHEDULE:BULDING PERMIT.•$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ 3-D Check No.: / Receipt No.: c?qq 2) NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL f Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennaaent Dwupster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes .Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPAR+TMENT -;Tempjpumpster onsite rat ~t L"ocated at>124 MainStreet FireD;epartmentaignatureldatef_ 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) LI Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 I Dug p 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 aBuilding 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 New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 C-t Location No. ,d` Date • TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $_.f_ Other Permit Fee $ TOTAL $ r Check# -7 �j Li. Building Inspector NORTH Town o �� - _ Lndover `+. z kN,6*_. h ver, Mass .,j coc"Ic"t WlcK x,95 RACED PPP�,�S U BOARD OF HEALTH TFood/Kitchen PERM % D Septic System THIS CERTIFIES THAT ......... 1�1BUILDING INSPECTOR S .. .. 14...To .. ................... ................ .... . .... . .... ....... .. Foundation has permission to erect ... .................... building ....... .. �. ... .... .................... Rough to be occupied as ........ .... ....a�,,t.....�.�....M•.� .. ° .. + ..... �5........ Chimney provided that the person accepting this permit shall in every respecconform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO , TARTS Rough ...�........................ Service .................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 0 AOL-OnC, JW MAY - 320116 4' Federal ID r9 05-0406829 RISE En&eering WcontrScWjWSW=Ko8186 \��// MA Contmetor Rogtatwdon No 120979 1 F RISE '� A division of Thielseb Fhgirneedng CTContraetor Registration No 620120 ENGINEERING 69 shaWmat,Canton,MA 02021 CONTRACT 339.602-5197 FAX 339,502.6345 Page 1 PROMAM 908 emtancrm FNS!nED OINBE1WBeN Ime CMA-WS DEs Oa�enaEtn�Div9iEanamraEanaRWORxaB eBsmnnart PnroNE DA9 eutae/ WOMOADER Shauna ROME (978)685-7039 0412'O16 432121 00004 SEMM SWEr sum FIE" 19 Robinson Court 19 Robinson Court SMU CM.S 1E ZP Bum Aur,mr,ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION PHASE ONE-Proposal for this calendar year. $0.00 WALLS:Furnish and install blown in Class I Cellulose to(12$9)square feet of virrykided exterior was.Homeowner has received a copy of the EPA's Renovate Right Lead-Safe information guide explairftthe potential risk ofthe lead hazard exposure from the weatherization work to be performed.Your signature is your adamwedgnau of receipt and apamem to proceed. $2,384.65 RISE Er4 ineerin8 will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently,for eligible measures,Columbia Gas offers 750%groeative.not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Scftmm wm up to the first$680 and an additional$340 if savings are justified by the auditor. For the safety and health of your homes indoor air quality,we will be conductinga blower door diagnostic of the available air flow in your home both before the work is bep%and atter the weatherization work is complete.We will also conduct a full assessment of the combustion safety of your heatingsystem mrd water Treater.This has a value of$90 and is at no cost to you Total allowable weatherion incentive is$3.110. $90.00 Total: $2,474.65 Program Incentive: $1,878A9 Customer Total: $586.16 WE AGREE HEREBY M FURNISH SERVICES-COMPLETE IN ACCORDANCE WI1H ABOVE SPECIFICATIONS.FOR THE SUM OF ""*Fare Hundred Ninety-Six&161100 Dollars $596.16 UPON FK&MPECI=tWAAm88MAXT-AM 30SA BEEER D ON SCF E0S=.80MXURILL MM31CP n�ARDECMMACMR tAtE/� 00 WT SIGN THIS CONTRACT IF THERE ARE ANYNK SPACES -wsE EnQheaAeB ammNER 6 MOW:MCDNa ff&%Y BEWrOMRAWN BY US F WEREMMU10IDI MIE OFACCEMOVE gni," ACCEPWUCE OFCONBt a-WE ABOVE ��g,BPECOMI NS AMCONDIU tB ARE BD DAYS 30 SAWA=RYIDBSAAREBEREBYA:PiFA.YOUAREAUO[Oi MIDDOVIEWM . AS SPEARED.PAYNEMIWRLBE U=AS0 MUCEDABOVE a RI E :60 Shawmut Road,Unit 2 1 Canton,MA 02021 339.602.6336 ENGINEERING", . www.RlSEengineering.com c?;"�tienc c�8i�1$ OWNER AUTHORIZATION FORM I Shauna Rollins (Owner's Name) owner of the property located at: 19 Robinson Ct, N. Andover, MA (Property Address) (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. r�LZG� Owneeh Signature z 7 ©/0 Date MAY 3 2016 r The Commonwealth of Massachusetts Department of lndustrialAecidents ` Oice of Inrestigalions �j i Congress Street,Suite 11111 Boston,A/A 02114-2017 www massgorldin l orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information 4 Please Print Legibly Natt3r:($using 5'Ur�nnitatic�n'Indi�idualy: i(tet W\1f.r 1nsQ1& -tq n Y�_t, Address: $0 13ox 314 City;'State!Zip: -1 W ifh 11ft Q1136 Phone;- 9 TQ 3 S_U`34"3._ Are 5-ou an employer"!Check the appropriate box: Type(if project t.required): l. i am a employer with�u [� I am a general contractor and I employees(full and,or art time!.* have hired the sub-contractors ® civ construction _ P 3.� 1 am a ale proprietor or partner- listed an the attached_beet. 1. ®Rctmtdcling ship and have no employers These sub cantractr+r have b. ®Demolition working for me in any ca aciv. .mpimv s and have Workers' P 9. ®Building addition [\o Workers' comp.insurance comp.insurance.' d. rc uirc5. td'c arc a corporation and its 10.[1 Electrical repairs or additions q jf oficers have exercised their 11. Plumbin 3.� !am a homeowner chine all�brk ® 1?rcairs or additions P my7,cif. [No workers'comp. right of exemption per,%1GL [3.®Roof repairs insmrance required.)+ c. 152,Q 1(41.and kve have no employees. [No workers [3.®Other comp.insurance required.] *Any apptican:that che¢ s hn-4=1 m-w-A alw till out thee ioniv:t belvu stlC�it:e l etr a'crker'eortpe s rnon tx91tC}'tntbrtnanea,. ilomeow-nen n to sot+nit this affida�ii indtcatim they°ate doiLe all work a.^.rt then hire m-sidc cin rattan must'uhmq a n tiz a£fiJ t�it:rrdicasia�unh. contlwtors that --i addtnn akheet shoute.E rhe name of the sub-cot::actors am i state'Ahe°.t.er or no:tjtesc Cuitm.hare. employees, t°the sub-coranictcrs have cmplo�c.Garr.mint pre%idc their uvrl erti'oxq.pulisy number. I am an employer that is providing workers'compensation insurance for my cmplvyees. Below is the policy and job site information. [assurance Company Nattte:-A� . InSomfvu t U. . Police#or Self-ins.Lie.`: TI KAIP 30932.'} Expiration Date: tQ130 14 Job Site Address: �-t �t�S Old► Coir City,State;zip:�t►�"� rMcLok/cr r1A U' Attach a copy of the workers'compensation polio declaration page(shove ing the police number and expiration date). Failure to secure coverage as required under Scction 35A of MGL.c. 153 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and'or one-year imprisonment,as well as civit penalties in the fonn of a STOP WORK ORDER and a fine of up to$350.00 a day against the violator. Be advised that a copy of this staternent may be forwarded to the Office of tnvestigations of the DIA for insurance coverage ticrifrcation. 1 do hereby cer#fk under the pain and penalties of perjury that the information provided above is true and correct. lQ l l Sinature. ��`sV` 1�`�t..�,,�.. "..`- Dale: � —r Phone. ' 3�V' 34 3 Official use only. Do not write in this area.to be completed by chy or tox-n Official. City or Town: Permit/License b lscuing Authority(circle one): I.Board of ileatth 2.Building Department 3.Cit ffovk n Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone it: 0 DATE(MWDD/YYYY) ACO CERTIFICATE OF LIABILITY INSURANCE 7/7/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Nancy Usher NAME: y Martin J Clayton Insurance Agency, Inc. acoNto Ext: (413)536-0804 AX No:(413)534-7874 1649 Northampton Street E-MAIL - ADDRESS: P. 0. BOX 989 INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville NATIO INSURED INSURERBAllied World Natl Assurance Co Gauthier Insulation INSURER C: 44 ESSEX ROAD INSURER D: INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER:CL157701379 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AODL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR POLICY NUMBER IMMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ACLAIMS-MADE X❑OCCUR DAMAGE TO RENTED 50,000 PREMISES Ea occurrence $ X GL43487F 7/6/2015 7/6/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- D ❑ X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED Per accidenPROPERTYt DAMAGE $ HIRED AUTOS AUTOS Is X UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ _11000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION BE020792125-194985 10/18/2014 10/18/2015 $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-Fes.EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CSG, NSTAR AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MASS SAVE PROGRAM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICES GROUP, INC. ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET WESTBOROUGH, MA 01581 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD MPIMStbd with pdfFactory trial version www.pdffactory.com r6 CERTIFICATE OF LIABILITY INSURANCE 9+i512D15 TMS CERTIFICATE IS ISSUED AS A NlrTT'ER 0=)JUMY.ATIO:O.+LY 4ND C:lNFERS NO R&5S UflL`N`-±E CEyF TIFICATE HDF..,THIS CERTIFICATE DOES NOT AfFIRY.ATIMY OR tiEGAT:V`ELY AMEN:,,V(TEcND OR ALTER THE COVEP,AGE AF.-CRIDEO CY Tiff:POLICIES BELOW,THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE O CONTRACT B_rTHEE:+'rE ISSUING f%5LJRfR(S)..AuTi DPJZED REPRESENTATIVE OR PRODUCER,AM:)THE CERTIFICATE tf=tq IMPORTANT:It the certlflcate holder is an ADOITIOXAL IwSURED,"so Pdoey(r_s)must be ends del-E`SUBF5GATTON 15 WAIV£D,Wb)--d a the tL'rrs and ccad:t:ons of the policy,cerMr.pcticies may-,-q•jwe a^end�ts-inert.A statetr,-ent en Th.*cert4ki-e loft nts:ccrfer rbgt:ts to the cEr`Z'i[a:E haler in keu of s:xri endoie-'ent(S). R Clayton Martin J Ins Agency Inc :�uv. aerktey Assigned Risk Services 1849 Northampton St PO Box 989 7Z ,f,, (800)634-4588 (666)215-8118 Holyoke MA 01041 ::sss �?Sen�xs(gt+�criey �c- " l4b15fP.'S A�07'als.:,4'�:'EiG:±f Nii,^a w reeA, A=U 3 T 37 1 'n Gauthier Insulation Inc ►+susses PO Box 344 =. Ipswich,MA 01938 eryacsa x R6LRFn c COVER AG S CERTIFICATE NUMBER: REVISION NUM R; TH;S tS TO CERTIFY THAT Th:POLICIES OF t`SUFJ NCE LISTED BELOW?%V-E `J ISSUED TC'T iE INSURED NAMED ABOVE FOR T`j_POLICY PIEZ"OD INDICA'.E3 r+3T MTNSTAt0D,r,M^'R.E y.3s=��SENT.TERMOR CONCATIY.Or ANY:ONTRACT OR OT"M DOC,VENT MTh IZE ECT TO%1 tlCt:THIS CE RTP 4CATIF MAY BE ISSUED OR MAY P'cri'Aix-THE MSURAr CE AcFORDEU BY TSE POLIOES OESMISED!'ERSiN i5 SU3JEC..T TO ALL E TERMS EX'CaMONS AM COa0TTrON8 Oh SL Cr,F'OL<rE5-LOMTS Sri wi MAY t{At'E EicFN REDUCED Sy r-AID G'AP.CS- GEWRAI uAIOJM Y j E {j :4o-osc�aac:�F s E 'C<7ir.*K'Y.GEKAX L44L't- 'r?.+cit.L• t �. I'Q C.AMIu-\•3Jf 1 t yXyat � l E i,'s'CF� 5 S I ffEFart.A2 t Rpt lihlP.Y S GEY%4At A,.(iREW� S k0c 5 Li M.4 K'i1 E:7dLx rv...lev � t�ir a.s_es _ t'.A.yTCZ, �NL�i.v.Vfi_`.' cvR.try?A%__1 _ I hr ax*iin' I- I 1 {5 V40P LLA ton Lj occM EXCESSUAdi1 LJ :AMS-AtAx S .K+att'eGA'E 3F: t---.K-S S 'WOK)�RI COYrE7tSnrrn �r'''' :w.,t.. IN^�I o.'. ANDra11A'r4Ttt UWt,Y 1!. C�1p?T LtC'S ramal E? A+v�q'1�47E'bR�/R:M1Eha Yf^.,^.+.; I' c :L EAc,'r'{rYJ,` S S:1J.X1A t CYTCCUMSLFtxa a ke � WO-P,FYC't'?32i tar3Gwi5 i013622018 iu~.,f%Kir r 4efOrCQ./rgr 'i: AM-EA EWACIt-E ]t SC�'f''10M OF O+GRA r,rJrr�Oa4� Et.YaxAs,-+Cklcy w S SXIW 1 I :,ESC d. t t+^cw,, •l:.CaAiAhS.,Jayt'_S;trx� 4 --y w•.+a ya.x",�.r-�stax szO..i., Elaaar cxmar F«e�r sue. •,V r Ax ry-lrefhxatas.: K f - CERTIFICATE HOLDER CANCELLATION SHOVLDINNYOF THE/LbAXT OESCASEE,YO`_Y:IEE I :..R.YCEL:.e SCrORE Clearesuit TTIE EXPRATiON SATE`HER=CIF.NOTiw WL K?E r+ER?D k1g Contractor Svcs ACC@RCA.NCE WMf TkE PpUCY I-Q'Ot"$O14$ 50 Washington Street Westborough.MA 01581 t '. - J � nature_ AtOFct3 25(2010/05j SPAC 3130 Massachusetts-Department blic Safety Board of Building R g r,OfJorslj," 4+ rona and uStandards C` i�r�e„t tnclflltu License:CSSL-102562 KU- RT R GAOTIF "! P.n Hoz 344 IP-4wich MA, 0191 r .. r ✓��,�/ � !111 Expiration Catnrrrssioner 0&2&2017 :._ (7 l7xw. 11 n 1'UJ1I(>/ltl�(,' `1 11• (,Zj ��l'�(ir:�iC+rC'llGl1�'z/J�� r' {+ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173410 Type: Individual Expiration: 10/1/2016 Tr# 257812 KURT GAUTHIER KURT GAUTHIER P.O. BOX 344 IPSWICH, MA 01938 - Update Address and return card.Mark reason for change. Address ; ? Renewal Employment `: Lost Card SGA 1 0 -10110-05fI+ Omcc of Consumer Affairs&Business Regulation License or registration valid for individul use only NOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: s�il' !Registration: 173410 Type: Office of Consumer Affairs and Business Regulation A 10 Park Plaza-Suite 5170 w` t_xpiratton: 10/1/2016 Individual Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER /J 44 ESSEX RD - IPSWICH,MA 01938 Undersecretary of valid wi out signature