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HomeMy WebLinkAboutBuilding Permit #867-11 - 20 HOLBROOK ROAD 6/17/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO. Date Received Date Issued:_ ' I1v ORTANT: Applicant must complete all items on this page LOCA -TION 2s�, Flo l VC � Print PROPERTY OWNER � Print MAP NO: �pARCEL:� ZONING DISTRICT:. Historic District yes no Mit Machine Shop Village yes no TYPE OF IMPROVEMENT PROP O D USE Res! ntial Non- Residential i ❑ New B 'ding One family ❑ Ad ' on ❑ Two or more family D eration ❑Industrial No. of units: ❑ Commercial j Repair, replacement ❑ AssessorY Bldg 11 Demolition g ❑ Others: _-__ 0 Other Wateir�shedDistnct� ;..' }=' DESClUpj10 N ®iy WORi� TO -01!, Zr r -'^ °--'a• .�.. . Liui OZ iD. OWNER: Name: 0,, (Identiflcation Please Type or Print Clearly) Phone: Zg Address: zet. 14 CONTRACTOR Name: , j Phone: Address: , ���` 0 Supervisor's Construction License: f o 7Z!5( Exp. Date: Home Improvement License: �G C G C / Exp. Date: ARCHITECT/ENGINEER Phone: ®rir'Ircc�• Keg. No. FEESCHEDULE: BOLDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COSTBASED ON$925.00 PER S.F, o Total Project Cost: $_ 0gc�e�c> FEE: $ 9r. ® ° Check No.: 3f5? NOTE:Persons contracting with unregistered contractors do not have access to th Sinnati►rariif.'dna:;+in;;;:��->_�:_::-;7777,7:-.7,.,..�---�---_— �antYfund S Plans Submitted F]Plans Waived ElCertified Plot Plan ❑ tamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Swimming SW1mg POO1S Public Sewer ❑ Tanning/Massage/Body Art well ❑ Tobacco Sales I Food Packaging/Sales E] 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 COMMENTS HEALTH COMMENTS, Reviewed on Signature Reviewed on Si nature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board'Decision: Comments Conservation Decision: Comments Water & Sewer Con nection/si nature & Date Driveway Permit DPW Town Engineer: Located 384 Osgood no FIRE DEPAR.TNMNT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date co TS. 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 or Electrical Inspector Yes No DANGER ZORIE LITERATURE: Yes No MGL Chapter 166 Section 21A–t- and G min.$100-$1000 fine Doc:.Building Permit Revised 2008mi v 1— 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 ❑ 'nJorkers 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 Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Con-I.r ac- ❑ 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 Td®TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg P 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 .P ermi In all cases if a variance or special permit was required the Town CIerks 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 L No. 9�6 7 Date TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ CHU S Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3 2 42. 7 9 euilding inspector • t—urnisn and Install all necessary ma-ierlals LO COrT1ple Le ulC t.11V)cUL. • Provide a thorough clean-up and disposal of all debris generated during project. Edmunds General Contracting LLC agrees to commence work on/or about and described work will be completed in about l days. Product Upgrade7'. Product Upgrade 2: ira . - i - Contractor's employees are fully covered by workmen's compensation and liability insurance. Upon completion of the above work, all undersigned agree to execute and deliver to the contractor, their joint note in accordance with his (their) above obligations as requested by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees, and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by the contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. Edmunds General Contracting LLC guarantees all workmanship performed for years. We will register �Vt, 143 %jj factory enhanced warranty providing � t Ye of material defect coverage and Y years of workmanship def 6 coverage through GAF Materials Corporation for: Ino charge. �.� K the additional cost of X 'Edmunds General Contracting LLC will provide the materials, labor and disppsal to replace up to 64 sq. ft. of o t dephntj and 20 tt Any additional materials including labor and disposal will be replaced at 'D per sheet or % linear nal cost. c NN All material is gu�r�a�teed as sp�o�fdonn e. Al work to be completed in a workmanlike manner according to standard Edmunds General Contracting, LLC agrees to furnish the material and practice A yyralerationord isrspecifcationsinvolvingexlracostswillbeexecutedonlyuponwritten orde44SS �a11d will become an ex1iover and above the stated contract price. Contractor is not responsible for labor complete in accordance with the above pecificatio s, for the sum daiq�geduetohighwinds,tornadoes, hurricanes, fire orotherhazards.Owner(s)agree tocarry fire tornado and other 1 j� 0 �> j �ritecessary insurance. Contractor is considerng ate of owner's landscaping and and lwiillenot beto eheld responsible nature of the f any O f t �°�f�a�r,P a" . �uu I$ installation some damage may occur. We attempt to minimize any damage, i t:a damage occurs. Contractor is not responsible for any damage to the interior of property, Includingpre-existing PaymeotTerms:,. _... _. - - . - ; _ — nddwns i.e waters ai s cruor_ g, taste_ .. - g t 'n ; blin .p " r expose " di ions resulting lrom application of materia s s tl palls) or cph a not to exceed 1'/3 of the total confrac � orT" ^ 'specified above Items in the attic may need to be covered by tht owner. c Contractor is not responsible for damage •'A deposit of ­ Y ( caused by ice dam build-up. All agreements are contingent upon strikes, accidents, or delays beyond our control. start of work. The balance of is due when work is completed to the o xa satisfaction of all parties. �$' Authorized Signature: • For your convenience we offer financing and accept all major credit cards. E�m ds eneral Contracting LLC If you elect one of these options we will add an additional 5% to the contract Note: This proposal may be withdrawn by us if not accepted within price stated above to cover dealer/merchant fees. • A finance charge of 1.5% per month 08% per year) will be charged on past due days. accounts over 30 days ZiCCeptallce Of 4121ropozaf - The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of acceptance: I DO NOT SIGN T A CONTRACT IF T . ERE ARE ANY BLANK SPACES. Authorized Signature: Authorized Signature: All home improvement contractors shall be registered. Any inquiries wibout a contractor contrau1bcontr II berexaclud t are access to the Guaranteedirected Fund provisions fofnsumer Affairs and Business Regulation, 10 Park Plaza-5uite 5170, Boston, MA 02116 (Phone: 617-973-8700). rom Owners who secure their own construction—related permits Rev. 04/11 The owner will receive a signed copy of this contract before work will commence. The owner has three (3) business days to cancel this contract and incur no penalty. Correspondence should be directed to Edmunds Gienerzl,Cbntracting LLC at the above address. 4N-771=771 plii;C7 Fully Licensed and Insured rDDn Member of MA Better Business Bureau Member of NH Better Business Bureau GAF Cert. ME # 20212 Y HIC Reg # 166661 EIN # 26-1081508 r r— r,ir--% MA CSL # 014728 ' m•BHB _r General Contracting, LLc ,� � Ma�C�iElite 51 S. Broadway #2214 Salem, NH 03079 (603) 890-0084 10 Stevens Street #141 Andover, MA 01810 • (978) 475-0095 P OPOSAL SUBMITTED TO i��-, PHONE `1-7� DATE c1 i d STREET Zo I, R6 _ E-MAIL ' CITY, E, AND Z JOOCATION JOB Kd .1) ovf-© Completely protectthe home with tarps to catch falling debris. Respect and protect shrubbery and flower beds. Strip off B layers of roofing material down to the bare roof deck. Inspect the roof deck for structural defects. Determine the condition of the underlying plywood or boards, and repair and replace as necessary*. Inspect roof ridge for proper 11/2", spacing on either side of ridge for maximum exhaust ventilation. Cut in if necessary. Aim Install new heavy gaug (A )Yl IK (col( ) drip edge at roof eaves. Install -IA )CLA�-"W��V\ ice and water shield to meet manufacturer's specifications (i.e. 6 feet from roof edge, 3 feet centered in valleys, around all skylights, chimney bases, roof penetrations and at all sidewall transitions). Install ILPsGh` A.V-W k)\r- breathable roof deck protection to remainder of the roof deck. Install new heavy gauge Ln)k1P- (color) k)%)yh drip edge at roof rakes. Install Pircco (�-t�h- V starter strip at roof eaves and rakes. Install SAT Tl1rAC.ti'-,ryy_ L;4(_VlM-k kA desired color. _MZ3 (color) Install,nevv flashings to meet manufacturer's specifications. (i.e. sidewalls, chimneys, skylights and roof penetrations). Install �f (feet) of CiA w—lu ( e>ov\�. .4 ridge vent at roof ridge to allow maximum ventilation. Hand nail to ensure proper fastening. _tyVA2(Ara-t ( Install Ja (feet) of distinctive hip and ridge cap. Hand nail to ensure proper fastening. Thoroughly clean up and dispose of allroofing debris on property. Magnetically sweep property for nails. Notes: T,nAtl lntLv at,�-�tl C G tv\-1, Ab �,� c- sr�_CC , nvI Pi1C,1lVIAV(.l, Ick /SktAn C71(t {(.1171I tTJ'lc>o_� V Edmunds General Contracting will: • Obtain all necessary construction -related permits to complete this project. • Perform work as efficiently as possible without sacrificing quality. • Furnish and install all necessary materials to complete the project. • Provide a thorough clean-up and disposal of all debris generated during project. Edmunds General Contracting LLC agrees to commence work on/or about /� I and described work will be completed in about days. Product Upgrade �.t�f� t �" T " VC`3t�_1 t1 's Pel e_ -' Product Upgrade 2: �-FT k v\ c; Contractor's employees are fully covered by workmen's compensation and liability insurance. Upon completion of the above work, all undersigned agree to execute and deliver to the contractor, their joint note in accordance with his (their) above obligations as requested by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees, and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by the contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. Edmunds General Contracting LLC guarantees all workmanship performed for `years. We will registerfactory enhanced warranty providing _, O ye rs of rKaterial defect coverage and Y years of workmanship def Lrf coverage through GAF Materials Corporation for: no charge. _� K the additional cost of X Edmunds General Contracting LLC will provide the materials, latioi and dispsalto replace up to 64 sq. ft. ofof gf �ecnp and 20 tt Any additional materials including labor and disposal will be replaced at C"i � per sheet or (� ! linear nal cost. Edmunds General Contracting, LLC agrees to furnish the material and Al aterialis,guli t ed a3fspg�f/ed.�woktohecompleted inaworkmanlike manner according tostandard practice. Aeyralteiation or ilevia on from bove to involving extra costs will be executed only upon written lahnr emmnlata in,acrorrfanra with the shove lssnar.ifir.atinns. for tha sl Im ordeSS,W will become an extrr -char a over and above the stated contract price. Contractor is not responsible for wi td �A O U w Fj a W 0 co Z 43 Q. 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CO2 LLI W W �c W U) From:Julie Dortona FaxID:Santo Insurance Page 2 of 2 Date:611IW2011 08:28 AM Page:2 of 2 OP ID: JD ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/17/11 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 603-890-6439 PlanrightInsurance-Salem 603-890-6521 224 Main Street Suite 3C Salem, NH 03079 James ASanto CONTACT NAME: PHONE A/C,No: AIC No Ext ADDRESS: PRODUCER EDMUN-1 CUSTOMER ID #: v INSURER(S) AFFORDING COVERAGE NAIC # INSURED Edmunds General INSURER A:St Paul Surplus Lines Ins Co INSURERB:RIVer ort Insurance Company Contractor LLC INSURER C: PO Box 2214 Salem, NH 03079 INSURER D INSURER E: INSURER F 11/11/10 rn��oAr-ce CERTIFICATE 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 LTR TYPE OF INSURANCE DDL INS UB VJVD POLICY NUMBER MM/DDYYYY OLICY EXP MM/DD/YYYY LIMITS 1600 Osgood St North Andover, MA 01845 GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CP572203 11/11/10 11/11/11 DAMAGE TO PREMISES Ea occu RENTED nce $ 50,000 MED EXP (Any one person) $ 5,000 CLAIMS -MADE a OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $ 2,000,000 $ X POLICY J CT LOC AUTOMOBILE LIABILITY CO MBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ ANY AUTO ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULEDAUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident) $ $ NON -OWNED AUTOS UMBRELLA LAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB HCLAIMS-MADE DEDUCTIBLE $ $ RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N (Mandatory in H) EXCLUDED? (Mandatory in NH) N / A WC288300042503 - NH 0288300042503 04/03/10 04/03/11 04/03/11 04/03/12 X WC LIM OTH- TO LIMITS ER E.L. EACH ACCIDENTOFFICERIM$ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMfr $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) WC: 3A:NH 81 MA / David Edmunds has elected to be excluded from coverage on the NH policy. Job location: 20 Holbrook Road N Andover MA 11/11 nrre f CE I ANATIAN I.GR 1 IrII.M 1 C nv L✓Gn - --- - TOWNNAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 1600 Osgood St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25 (2009109) ©1988-2009 ACOIRD CORPORATION. Au rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � ---,A A ir-,J (fir,. Address: l- -66. n� City/State/Zip: Or-V4„� ,,,`�J$L 0� _ bPhone #: Are y,@Can employer? Check the appropriate box: 1. I am a employer with i 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 shget. # ship and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other f- - v ..rN...,a a aL uux tri must also run 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: Policy # or Self -ins. Lic. #:_ p�,1 S Expiration Date: Job Site Address: 2_jc> (,\a 6Z .1 City/State/Zip:j 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. I do hereby certifv under the pains and penalties ofperjury that the information provided above is true and correct. Phone #: ., (� A G 11 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector 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 152, §25C(6) also states that "everystate 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 bb 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 isi 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 Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Massachusetts - Delmitme it ot• Public SafetN Board of Building Re<-ulations mid Standard Construction Supervisor License License: CS 104728 DAVID EDMUNDS'. P.O. BOX 2214 SALEM, NH 03079 Expiration: 10/3/2013 ('unnnissi, Tr#: 104728 . ' ✓ize U� o�n��caiu�rect�i o���czc1 uoeit Offfee of Consuma Affairs & B sines Regulation s i HOME:JMPROVEMENT CONTRACTOR Rergistration: ,O,1Y66661 Type: Expiration: --6/21%2012.._ Corporatipn ED UNDS GENE=RAL�-CONTRACTI'NG, LLC. ., _ !L DAVID EDMUNDS�.rtYy` 1 SHAKER LN HAMPSTEAD, NH 0384;:.,'`' . y- Undersecretary