HomeMy WebLinkAboutBuilding Permit #527-2016 - 222 BRENTWOOD CIRCLE 10/29/2015Permit NO: �9
Date Issued: P �' st i � 16
\ V%ORTM
1.
a BUILDING PERMIT �f�"Uto 6.6
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION _ a
Date Received
IMPORTANT: ADDlicant must complete all items on this
LOCATION 2-2-6
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Print
PROPERTY OWNER �`�- Q�SA�--►E ���-lt�1Y�T
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MAP NO:O(D PARCEL.0�5 ZONING DISTRICT: Historic District yes rnMachine Shoe Villaae ves
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
F1 Septic r Well
❑ Floodplain Li Wetlands
Watershed District
❑ Water/Sewer
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NLS
OWNER: Name:
Address:
CONTRACTOR
Identification Please Type or Print Clearly)
-Pti.a. -O�At-1 e 0 h N\ -'-Tr Phone: `� ��i-�t���-x{ $10
Phone: `'[ -18— 3 -7 Z--
(VG,C-G(ACL L-AAJ /&A�e11<Iyc�J S Lap >}v
Address: g� �� � f tA\LL , A CA a
Supervisor's Construction License: Exp, Date:
C50L-0"1913$7 3��3%zoJ
Home Improvement License: Z -13
3 (8 Exp. Date: e> %1 IZa1
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 3 14 &--I) FEE: $ J `
Check No.: "<- Receipt No.: 2,
NOTE: Persons contracting kith unregistered contractors do not have accfss to the guaranty fund
contractor lt��.�.
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
77-
ILQCATIONA
PROPERTY+"OWNER.
100'YearStn�ctur� e'er yes no
IMAP il'AR,�EL'� ZONING DISTRLaCT ��HistoncfDistnct` r eyes no:
CMachine Shop;VillageE a Fyes eno
TYPE OF IMPROVEMENT
PROPOSED USE
.
.. -y
Residential
Non- Residential
❑ New Building
❑ One family
[I Addition
❑ Two or more family
❑Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
- ❑ "Septic ❑;Well
�' _1 F_o�dplan;tWet_ #:'�
Watershed ®istrct
'' ❑ Wate /Sewer_ - � ��
<, r _ �
_ � � � _
a
DESGKIP I IUN Ur VVUMtX I u tsc rr-mrunivnr-u.
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
#Contactors}Ne
r�
P —
.
.. -y
7777
;Address.
' Supevlvlsor' '€Consfructio License : '� =-T:__°�`Ep
Date
#
�.. -
-
if�,.�^.Lrm.:ii�iorrmon�I;>o Boz
tExn.. !bate:
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No:: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
SI nature ofA
R91 'S x u".i rY;S
9
1 nat._
ure of°contractor
_ _.v _ _._-_. __�
Location �2�-P�yCX`�-�2 `�-
No. , ' 2z l Date 16 Z
TOWN OF NORTH ANDOVER -
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
* Building Inspector
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TTYPE O'F':SEWERAGEDiSPOSAL"
Public Sewer ❑
Tanning/Massage/Body Art ❑ ..
..Swimming Pools ❑
Well ❑
Tobacco.Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc... ❑ -
.: Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE -APPROVED
❑ ❑
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
Planning Board Decision: Comments
Conservation Decision: Commen
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Rngineer: Signature:
Located 364 Usgooa Street
FIRE D-EPAtiVf_NT - Ternp Durn 'ster on site yes no
Located at 124 Mair, 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-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
j Workers Comp Affidavit
❑ Photo Copy Of HIC, And/Or C.S.L. Licenses
Copy of Contract
❑ Floor Plan Or Proposed Interior Work
Addition Or Decks
❑ Building Permit Application
❑ Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulil
Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.LC. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of
Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and
proof of recording must be submitted with the building application
Doc: 1\SPEC:TIONAL SERVICES DEPAR'I'MENTMFORM05
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C,
SETTER HOMES WINDOW AND SID114G
THE EXCLUSIVE WINDOW AND SIDING CONTRACTOR
978-372-6385 TOLL FREE 1-800-668-3505 MASS REGISTRATION #122318
DATE (9 JOXL4 -LO i "S SOURCE CONSULTANT
HOME TEL. 1i-70'6166tr L[ 8\0 WORK TEL. MR./MRS.
THIS AGREEMENT, made and entered into between EKTER HOMES WINDOWS AND SIDING hereafter referred to as
a contractor AND
ADDRESS/STREET ��'� if�wjW� o CkYGITY Ncc-y$,,, N-n61'%,6TATE AA4 ZIP
hereafter referred to as owner.
THE SAID CONTRACTOR hereby agrees that it will furnish all labor and materials necessary to install the following
described work at premises located at: JOB ADDRESS ' 15
CONTRACTOR agrees to start described work on/or about weeks after final measure and complete described
work in about working days.
In addition to manufacturer's warranty, Better Homes Window and Siding guarantees our workmanship for ten years.
ALL HOME IMPROVEMENT CONTRACTORS AND SUBCONTRACTORS SHALL BE REGISTERED IN MA. INQUIRIES RELATING TO A REGISTRATION SHOULD BE MADE
TO: DIRECTOR, HOME IMPROVEMENT CONTRACTOR REGISTRATION, ONE ASHBURTON PLACE, ROOM 1301, BOSTON, MA 02108, TEL. 617-727-8598.
We hereby submit specifications and estimates for: ( ('
c L 3 t err W c-�,J V CLv,+- -5 o�,-Mr
� Q t�5 %aei i l c��t✓�-r4 v�fJ `�^ l`C{�c5�r�= ao6p
v
� C.cJr'r1'1 •A'lr Prr�?q'��►� tt�J�T Q iz�' �' '\l�'�' �L,
,E. ' G'�t�..ti. ' ��P��-fYri-- �$'N2t^.�►-
t,,-nNqvtrG..ffnb v P Nal, oS A -r- Qz6-f- c3 A�tjP
12OMvp e2 tic `�a� V c W-�
CVt-Tj"W Tew L ,q..{-6,.-tL�<- j F75$ eta\t lClL$ Lfl-�-L<
WE PROPOSE HEREBY TO FURNISH TOTAL INVESTMENT O 6s'i?• ��
MATERIAL AND LABOR (IF SPECIFIED) -
COMPLETE IN FULL ACCORDANCE WITH �� DEPOSIT d
ABOVE SPECIFICATIONS FOR THE SUM OF: BALANCE UPON COMPLETION �'ro
ANY WORK NOT LISTED ON THIS CONTRACT WILL BEAT ADDITIONAL CHARGE. BETTER HOMES WINDOW AND SIDING DOES NOT INCLUDE PAINTING OR STAINING
ON ANY PROJECT UNLESS SPECIFIED ON THIS CONTRACT. J
You may cancel this agreement if it has been signed by a party thereto at a place other than the address of the seller,
provided that you notify the seller in writing at 18 Bates Road, Haverhill, MA 01832, by ordinary mail posted, by telegram
sent, or by delivery, not later than midnight of the third business day following the signing of this agreement.
ALL MATERIAL IS GUARANTEED TO BE AS SPECIFIED. ALL WORK TO BE COMPLETED IN A WORKMANLIKE MANNER ACCORDING TO STANDARD PRACTICES. ANY
ALTERATIONS OR DEVIATION FROM THE ABOVE SPECIFICATIONS INVOLVING EXTRA COSTS WILL BE EXECUTED ONLY UPON WRITTEN WORK ORDER AND WILL
BECOME AN EXTRA CHARGE OVER AND ABOVE THE ESTIMATE, THIS IS TO INCLUDE, BUTS NOT LIMITED T0, HIDDEN DAMAGES THAT ARE UNCOVERED DURING
THE COURSE OF THE JOB AND ADDITIONAL WORK REQUIRED BY LOCAL BUILDING INSP TORS. ALL ELEMENTS OF THIS AGREEMENT ARE CONTINGENT UPON
STRIKES, ACCIDENTS, OR DELAYS BEYOND OUR CONTROL.
NOTE, THIS PROPOSAL MAY BE WLTHDRAWN BY CONTRACTOR
IF NOT ACCEPTED WITHIN -3 C DAYS. AUTHORIZED SIGNATURE DATE
ACCEPTANCE: 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.
AN INTEREST CHARGE OF 1-1/2% PER MONTH (18% PER YEAR) WILL BE ADDED TO ANY AMOUNT U R 30 D OM NV DATE.'
` DO NOT IGN rjH�1S C TRACT IF T ARE ANY S E
SIGNATURE rJ� �ti 1 'f?A SIG ATUR DATE S
L �/Y Z Il
The Commonwealth ofMassachusetts
z Z Department of IndustrialAccidents
I Congress Street, Suite 100
-
Boston, HA 02114-2017
..: ; www massgovldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Individual): V N&
DCA `&
Address: 1 161,= C2,0y h` 0 t 3 "�--
City/State/Zip: CA 8 ) 1 --
C-7
Phone #: T) 8" 3'� Z (o 3 8 D
Are you ane ployer2 Check the appropriate box:
1. am a employez with �!- employees (full and/or part-time).
2. Q I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no, employees. [No workers' comp. insurance required.]
Type of project (required):
7. Q New construction
8. g4t6modelidg
9. ❑ Demolition
10 0 Building addition
11.0 Electrical repairs or additions
12. [] Plumbing repairs or additions
13.0 Roof repairs
14.0 Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit #his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such-
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub-coniraci&s have employees, they must provide their workers' comp. policy number.
Yam an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site
information. �tt�
Insurance Company Name: 1 Vinci C -L-
Policy # or S elf -ins. Lie. #: -7 V jo 13^ Ztr' (% (40 ' 5-1 S Expiration Date:
Job Site Address: 2. Z Z Q"e wiW a d'0 CA 12r—d.0 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cjatify undrmation provided above is true and correct
Si¢nature- \\�er the pains and penalties of perjury that the infoDate: 2 G,' -2-o
Phone 4: l D 3D Z 63 3 8 C
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of liire,
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 maybe 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 bottorn
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. Anew 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.]mass.gov/dia
10/28/2015 03:14 9783747769 RB KIMBALL PAGE 01
ACORD
TM, CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY)
PRODUCER Phan9: (970) 374�38S F9x (979) 37q-7709 1O/28I2015
R. S. KIMBALL INSURANCE AGENCY, INC. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
107 MERRIMACK ST ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HAVER14ILL MA D1830-6208 A.
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
INSURED
LAW $R, MICHAEL J. & MICHAEL II
C/O BETTER HOMES WINDOWS AND SIDING
18 BATES ROAD
HAVERHILL MA 01832-3704
INSURERS AFFORDING COVERAGE
INSURER A'
INSURER 8:
Travelers
INSURER ...., ..,.. -.... Ins
RER C: Encompass Insurance
IN D:
......- . ... .
INSURER E:
NAIC #
IH% POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TNF, INSURED NAMFO ABOVE
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR
FOR THE POLICY PF,P,100 INDICATED, NOTWITHSTANDING
OTHER DOCUMENT WITH RESPECT
MAY PERTAIN, THE INSURANCE AFFORDED SY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
POLICE$. AGGREGATE
TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
THE TERMS, EXCLUSIONS
LIMITS SHOWN MAY HAVE BEEN REDUCED 8Y PAID CLAIM$,
AND CONDITIONS OF SUCH
NSP ADD '.....'..'. ...
TYPE OF INSURANCE
LTR INgR POLICY NUMBER DOLICY EFFECTIVE
_ ... .......--
POLICY E7rPIRATIDN I
I GANF'tQALLIABILITY T MMroD
DATE IMMMONY1 LIMITS
X I COMMERCIAL GENERAL LIABILITY
EACH OCCURRCNCE a
Gnmaae IS •. ,
1 00,000
,••,1,.
'
I
CLAIMS MADE OCCUR
I
To RENTCD
PREMI&Ee IEa orcumn,v)
'
5 00,000
MED. EXP (Any one person) S
„-,
10,000
......
PERSONAL R ADV INJURY ' ¢
._.
000
1.0.1O
GEMLAGGREGATELIMITAPPLIESPER:
GENERAL AGGREGATE Q
2,000,000
POLICY I PRO
PRODUCTS-COMP10PA0G. S
2,0 00,000
AUTOMOBILE LIABILITY 1449253 10/31/16
10131!16
ANYAOTO
COMBINED SINGLE LIMIT
I.
, Me 11.jdant) $
ALL OWNED AUTOS
- -
X SCHEDULED AUTOS I
BODILY INJURY
(Par person) S
C NO
250,000
HIRED AUTOS
.... .
NON•OWNFD AUTOS
BODILY INJURY
(Par eccloent) S
600,000
PROPERTY DAMAGE f 5
250,000
GARAGE LIABILITY
ANY AUTO
I EXCESS / UMMAELLA LIABILITY '
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION S
�IWORKERS COMPENSATION AND 7PJUl32E17880515
'EMPLOYERS' LIABILITY
IR ANY PROPRIETOR/PARTNBR/EXECUTN'E
OFFICER/ATfiMaCR EXCLUDED?
II VON, dAAcdb. "0or
SPECIAL PROVISIONS Dolow
A
AUTO,ONLY -EA ACCIDENT la
OTHER THAN EA ACC S . . . . . ...
:AUTO ONLY: -..... ..............
AGca ..
EACH OCCURRENCE
. .................... .
AGGREGATE S
04/29/16 04/29/16 I we thaw• OTHER --
E"� J.
DENT $ 500,000
C.L.D.8
... .... ......._ .
E,I,.
IEASE•EA EMPLOYEE 5 500,000
E.L. DISEASF•POLICY LIMB I I 600,000
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
JOB LOCATION 222 BRENTWOOD CIRCLE NORTH ANDOVER 01856
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER BUILDING DEPT SHOULD ANY OF THE AEOVF, DESCRIBED POLICIES BE CANCELLED BEFORE THE
1600 OSGOOD STREET EXPIRATION DATE THEREOF. THE ISSUING INAI IRFR mRl I CWhPa\N1rl TO MAIL 90 MAVC
BUILDING 20 SUITE 2035 VVKI I IEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO TME LEFT, BUTFAILURE
TO DOSO SHALL IMPOSE NO NORTH ANDOVER, MA 01845 ITS AGENTS OR REPRESENTATIVES TION OR LIABILITY OF ANY KIND UPON THE INSURER•
FAX: 978-688-9542
Attention: BUILDING DEPARTMENT I
ACORD 25 2001/08 Malcolm D. Kimball Jr.
l ) CertlfiCdte # 3060 0 ACORD CORPORATION 1988
10/28/2015 03:14 9783747769 RB KIMBALL PAGE 02
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s),
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend. extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-S (2001108)
carzmcare *3050
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supen icor Specialty-
License:
pecialtyLicense: CSSL-099887
MICAAEL J LAW :`_
18 Bates Road
Haverhill MA 01$32
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yyr
Expiration
Commissioner 03/03/2016
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Office of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
egistration: x.122318. Type:
Expiration:=-811:130;1fi_ DBA
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BETTER HOMES W).KNUI — V & SID1tdG
MICHAEL LAW t,`,r—'
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18 BATES RD
cty
HAVERHIL.L., MA 01832`
Undersecretary
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