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HomeMy WebLinkAboutBuilding Permit #721 - 21 IRVING ROAD 4/12/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: I 2--J Date Issued: L' / -L,- IMPORTANT: IMPORTANT: Date Received icant must complete all items on this LOCATION 1 O V i N ., '/?0 A b PROPERTY OWNER Cb W' A-(? Print b 14A le -Ai t; v Unit # Print < MAP NO: `j � PARCEL:3 6) ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Su k --V e- 2 2 (,, Q o - OJ f (Y1 G) � 1^ Residential Non- Residential ❑ New Building lone family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ',Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ®}Septics 'O;;,Wei_l) dplain��; ®Wetlands 77-10 4 D Wa er' e�dDistncti P " OWNER: N Address: Li o �.'UK- 11 1N yr w UIluL It-) till rl tCN UF -N4 ll: u (Identification Please Type or Print Clearly) Phone: 9 7� 7 9 q (NF1 U i � q y- CONTRACTOR Name: NS i 2 i ca n -s �C- ? WK I N c:- Phone: 9-A U b 3 3 q a- v Address: Zy i) S(JT'%d o3 ��'F2J- LF Su k --V e- 2 2 (,, Q o - OJ f (Y1 G) � 1^ Supervisor's Construction License: 9 g 3S6 Exp. Date: i Home Improvement License: ARCHITECT/ENGINEER Address Exp. Date: -7 - I - a I a - Phone: Reg. No FEE SCHEDULE: BULDING PERMIT. • $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COSTBASED ON $925.00 PER S.F. Total Project Cost: $ (`o 0 • au FEE: $ d" Check No.: 16-77 Receipt No.: Z�j 1-3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund !Signatu(e , gent/Owne`r Signature `ofAcor ro- Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Flo or/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 (VOTE: 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 (VOTE: 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 2008mi 7 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art E] Swimming Pools El Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature �i COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments 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 Location Y. V n 1 No.--) 2-, DateZ-- Check # 14 })r 25173 TOWN OF NORTH ANDOVER Certificate of Occupancy G Building/Frame Permit Fee $ d "� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector V.9 ) rA W ct oQ 0 <ilu F' Q- A. �/ Q vi c o o v O y O V V n ev m c �= O yr �. _ O `® �Ea o n N C Z ' O O G7 � `�►—'— C (! cc* m cc - O y :CD _m Co O O 3 CD Ey nc� m o :rz o c► d C t m p m :vyZ o +.: c Do CD ` C CL m y..p c �c Q ® ; CCD 0 N p hCD0 Z W C O rL.+ N:5 •VyJ a=LD V CO.c Z ac �LU E h o En C.3 CL g = A . ti C z $nim pl u 0 Z. 0 C/) O U O 4 v .� P4 14-M 2 O O L O O v Z w Ifl. O y CO CM CAI O ca CD ow t O� o co O OL cc o a a Ca ca .o o � Cc v J •� O ca C Z s C..± ca O C tC cc 0. y w° U)w° V, co U � w H w W c�° cn ro w W. w W 44 a cn A oQ 0 <ilu F' Q- A. �/ Q vi c o o v O y O V V n ev m c �= O yr �. _ O `® �Ea o n N C Z ' O O G7 � `�►—'— C (! cc* m cc - O y :CD _m Co O O 3 CD Ey nc� m o :rz o c► d C t m p m :vyZ o +.: c Do CD ` C CL m y..p c �c Q ® ; CCD 0 N p hCD0 Z W C O rL.+ N:5 •VyJ a=LD V CO.c Z ac �LU E h o En C.3 CL g = A . ti C z $nim pl u 0 Z. 0 C/) O U O 4 v .� P4 14-M 2 O O L O O v Z w Ifl. O y CO CM CAI O ca CD ow t O� o co O OL cc o a a Ca ca .o o � Cc v J •� O ca C Z s C..± ca O C tC cc 0. y DAVID CASTRICONE I y /9 -a' CASTRICONE ROOFING & SIDING INC. ` ` ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 In North Andover 978-683-3420 In Boxford 978-887-6147 In HaverhiU 978-374-7314 Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and conditions, on premises o described: Owner's Name...........A,f �'j...........................Ir .......... Tele hone#.....x.1.8...`..2%....N.ta�O q Job Address .... P. 1...2.114 11..................................... City..../.X.G?.i...1.�Y1 a.1(.H ............ State....,M/4 ....... t�.... Specifications: .............................................................................................................................. �} pp.. . .. .......................... . ✓Strip existing shingles. K .. Apply new drip edge to all edges. F x A.) d i� e�y,� rh ........................................................................................................ Apply feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane in valleys and bottom edges of any unheated areas of house. ............................................................................................. ,Kpply felt paper underlayment.-fnstall ridge vent to .................. ...............�...}.........�....- ............. �Reroof using �' g ISH av_,�.�, f ,, �r r shingles with a year warranty. ...................................................................................................................................................................................................................... ,Counterflasb chimney. -New vent pipe flashing. +,egal disposal of all debris. ............................................................................................................................ .................................................................................... Areas) to be worked on: / ..........................................,.l.l....r..z�....G lt.....,.a.t-.... D."'e-✓............................................................... .............. ..............'.........:........................... ......:, a................................................................................................................................ :..� zc� r1 S �a �L......................................................................................... ........................................................................................ 1 s .......................................s.>...�..f....... ...................//.......................................................P..:.:.................................................. Roof board replacement if necessary @ 60 /sheet of °Y'/foot. t ................................................................................................................................................................. ............. Two Year Workmanship Warranty (Not Transferable) 111(anufacturer's Warranty as specif9 by ma ufacturer The c actor agrees to perform the work d ish the materials specified above for the SUM $.... .. �+.c.�(�........ �ayable .....9.i ,0...... on ...�5 � t�........... Payable .......... ................ on ......... .—.................. %balance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability whi a Job is in operation. Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living spaces). Items in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation 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 contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrants) that he is (they aro) the owners(s) of the above mentioned premises and that legal title thereto stands of record in his•(their) names(s). There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108 Tel: 617-727-8598 Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction - related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A. Approximate starting date of work ................................................ Completion date ......................................................... Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation). IN WITNESS WHEREOF, the parties have hereunto signed their names this day of .Af..c.l%........ 20./Il?,. Accepted: . ,GSigned ... lr :... �.............. Owner Signed............................................................................ Owner David Castricone, President 4- The Commonwealth of Massachusetts l 1 Department of Industrial Accidents Office of Investigations # :I.tL 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/Organization/Individual): ('As T R 1 CO N (: Address: ?00 -5u rroI`I 5Tr2F_ger , Su l TE LLQ City/State/Zip: N o, Andy vex- HA 61 kY c Phone #: c{ 7 15 6 % 3 3 U b Are you an employer? Check the appropriate box: 1. © I am a employer with 06 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 sheet. 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 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12,N Roof repairs l3.❑ Other *Any applicant that checks box #t must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid 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�S Policy # or Self -ins. Lic. #: W Cr) Expiration Date: Job Site Address: 01,( I f?V-1 � 6- {\ti fl 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 requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and peenna-ltiiees/of perjury that the information provided above is true and correct. Signature: C"'"-- Date: Phone#: 97 F' 6 L3. Ja?O Official use only. Do not write in this area, to be completed by city or town of -cial. 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 '- ��ia.,::�chusctt.. - Uclt:u-intrnt iil Puhlir �ufctt � Buartl of Builtlin� Rt•ul:ttiun. ,incl 5t:uul:u•tl --- Construction Supervisor Specialty License License: CS SL 99358 Restricted to: RF,WS DAVID CASTRICONE. 31 COURT STREET ,Wx NORTH ANDOVER, MA 01845 Expiration: 12/16/2013 - (uuunissinict• Tr4: 7924 011it'cu1 c( tusu1Intcr)e, 'uiru w� l Q:\I'fairs&1tu�ncss ltcgulaiion HOME IMPROVEMENT CONTRACTOR Registration: 104569 Type: a Expiration: 7/14/2012 Private Corporatio DAFiID1CASTRICONE ROOFING, SIDING 8 David Caslricone 200 SUTTCN ST SUITE 225 NORTH ANDOVER, MA 01845 :� Unticrsccretary A4:�VRCERTIFICATE OF LIABILITY INSURANCE /n9/2' 9/9/201111 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 tM certificate holder Is an ADDITIONAL INSURED, the policy les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, eertaln Policies may require an endorsement. A statement on this eertlflcats dose not confer tights to the certificate holder in lieu of such endo►semen i . PRODUCER OOXTACT HAVE: Willows Insurance Agcy Ko 976 475 3414-1FAX _ �, Hod:•_ -_ 51 Cochichewik Dr AL _ — -_ - North Andover MA 01845 n IN81lRER(9)AFFDR INSURED INSURER A Miden Specia: DAVID CASTRICONE ROOFING 6 SiDn4G INC 1N8URERC: ` 200 Sutton St Suits 226 NORTH ANDOVER MA 01845 GE NAIL r Co GUVERAGES CERTIFICATE NUMBER-.CL119906255 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. OW JR TYPE OF INSURANCE POLICY NUMBER V/O2 EFF P0L1CDOY --- L1MRe GENERAL LJu%rr1 EACH OCCURRENCE _ S 100_0_000 X COMMERCIAL GENER�AL LIABILRY PREM�ISFTO RENTED I s _- - -5000E A = CLAY,CR.MAOE I X I OCCUR 00031600 9/06/2011 /6/2012 MED EXP An we eroen S 100E PER.iONAL d AOV INJURY t 100000C AGGREGATE LIMIT APPUES PER: AUTONOaILF UABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED ALTOS NON -OWNED AUTOS UMBRELLA "AR OCCUR Excess UA! CLAIMS DEDUCTIBLE ANO EMPLOYFRS' UASKM Y / N ANY PROPRIETOWPARTNER/EXECUitVE OFFICERIMEM6EREXDLUDE09 a NIA /....«,.,, E DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE$ (ANUb ACORD 101, Addktonol Remerke sch*dUN, K Ten apace N regUlnrr) GENERAL AGGREGATE S 200000C PRODUCTS - COMP/OP AGG j 100000031 S COMBINED SINGLE LIMIT (Ea KvionU t BODILY INJURY {Per penon) S BODILY INJURY (Per aWdol) $ PROPERTY DAMAGE (Per accluenQ t. S S _ EACIIOCCURRENCE S t AGGREGATE DISEASE • EA EMPLOYE t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Cas tricone ROOPing 61 Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. CastriCOnO Roofing 200 Sutton Street Suite 226 AUTHOMDMP1tnVi7AW4 N Andover, MA 01845 n 'f ACORD 25 (2009109) ` IN502S(zooeoe) The ACORD name and logo are registered marks of 0 ORDORD CORPORATION. All rights reserved. AC`ORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDtYYYY) 9/23/2011 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 n�uT�Twr� �n nn.�nnen •un Ttr APnTlr1l".•Tr �nen IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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 NAME: Eastern Insurance Group LLC - Main PHONE FA No: 233 'West Central Street EMAIL Natick MA 01760 ADDRESS: INSURERS AFFORDING COVERAGE NAIC q NSiURERA:ComTierce insurance Company 34754 INSURED 31969 INSURER B: David Castricone Roofing & Siding Inc INSURER C: 200 Sutton Street #226 INSURER D: North Andover MA 01845 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 91 4 r;aa40-7 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 REpDnUC(�EDF BY PAID CLAIMS. INSR 1--1 i■umocn MA�kL�,Tii ifni'ititiLlr�XF GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F7OCCUn EACHOCCURRENCE $ _ PREMISES (Ea occurrence $ MED EXP (Anyoneperson) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ I GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRa LOC PRODUCTS - COMP/OP AGG $ $ A I AUTOMOBILE % LIABILITY ANYAUTO AOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS X AUTOS BCNGCV /1/2011 /1/2012 (Ea ecckferE 1000000 BODILY INJURY (Per person) $20000 BODILY INJURY (Per accl7enl) $40000 PROPERTY DAMAGE Peraccldenl $ UMBRELLA UAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ g WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORrPARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) 11 yes, describe under DESCRIPTION OF OPERATIONS below N / A WC003999723 9/23/2011 9/23/2012 X W S ATU-O - E.L. EACH ACCIDENT $100000 E.L. DISEASE - EA EMPLOYE $100000 E.L. DISEASE - POLICY LIMIT $.500000 I ---- ......--- _. -- - ..­­­,.,..,,,...,,,,,,, —1,nem.rR Cneouwe,nmore speoeisrequwreo) H Castricone Roofing & Siding Suite 226 200 Sutton Street North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978)688-9545 Fax (978)688-9542 DEBRIS DISPOSAL FORM O '4 O ti D x 1+ a� e .1�<0LHIf IWlth �SSACHU5�� In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit # the debris resulting from the work sliall be disposed sed solid waste d of in a properly licenisposal facility as defined by MCTL c,l 1, s150a.. The debris will be disposed of in /at. - Facility location Signature of Applicant Date NOTE; A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector, 9