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HomeMy WebLinkAboutBuilding Permit #821-2017 - 27 MAIN STREET 3/2/2017BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received %� l pate Issued: d ' ORTANT: Applicant must complete all items on this page - z •. ' _" Print Q `Y x . r PROPERTY OWNER ' Pnnt ` t1 D0 Year�Structure yes no MAP PARCELS ZONING'DISTRICT._­ 'Historic District.: yes ng Machine Shop Village yes no 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 ElAssessory Bldg ❑ Others: emolition ❑ Other TT_❑Septic 1Nell ❑ Floodpla{n Wetlands m Watershed District .Water/Sewer, D SCRIPTI®N. OF W KK .10 kit FtK1-uK1u1ty: ti d' i d I" 's V m / r 1 w e-!- & C i. "oi''+4l f? OWNER: Name: Address: �l ry Yf' 1x % 644 li - Please Type or Print Clearly Al Al q6 e: -73P Contractor NaPhone: Address:f . c r� ��`- Ae a �S- G 'Supervisors Construction License:..._ X2- '9 _. _ `� _. Exp. Date: Home Im rovement License: /w �_ 7 _ .. _ [Exp., bate.", p n� .-_ ARCHITECT/ENG[NEER t? Phone: Address: L,5- 014'te Son Z9i'�K& , r'/j%KO eg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COSTBASED ON $925.00 PER S.F. ,_ ,Total Project Cost: $ FEE: $ Check No.: C S Receipt No,,- � NOTE: Persons contracting with unregistered contractors do not have: s to the u ty fund Signatia�e_of_Agent(Owner Signature of contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPB'Z�F SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/MassageBody 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 Reviewed On Signature. CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Boarci of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r, 9 Planning Board Decision: Comments s LS Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT'- Temp Dumpster on site Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street yes no z -)imension 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 2014 M 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 ❑ 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 NOTE: 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 DOTE: 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 Location,? 7 t No.P� ,/',tat C< � Check # /J _l,i ,-mv �%,eA M I Date � _ �L - d-0 / J7 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL A / Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ '55,000.00 m $ 60.00 Plumbing Fee $ 7.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 7.50 Total fees collected $ 175.00 27 Main Street 821-2017 on 3/2/2017 interior demo a 0 SAL* JO 2 O O m r S� Em v N U O_ w N �d c O 1 9 "O O O LL L 7 O K T N c L U r=' O Lr W ,0 O~LU LLJ Z Z J a o (o c LL SNL -C p C wz i(p N C 11 0 V LL wCL Z H Q (7 O C LL JO 2 O O m YI u Y \ O O LL Em v N U O_ w N 9L N Z Z c O 1 9 "O O O LL L 7 O K T N c L U (o LL O~LU LLJ Z Z J a Lcu p O LL' (o c LL o CL N Z u J -C p C wz i(p N C 11 0 V LL wCL Z H Q (7 p K C LL w F- a. w LU O_ LL p j C� O N aj ( j r N 0 Y 0 (n �. 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K'3: 1i xu¢x'L'i 0L I'' 0.91 1 zLm. z,io tL+ OOH dLl^2 Loot xaL NZ¢xuu XZ �C, u�3 uO�oLr aL Q u<u � ZJoo}3 :Gide J2 u 9L >>K.oLzL a1.L aL >1 ' oua L . �Joor$ z3arc z rd�p 3dez 0 Kua L vQ J >9) L 1 O T Ur i X> F C K N uozo.2 >Ua LI J u <i W<Z uu¢u C3dKJz` f t -_� ZOQ 4 01 a d XNo ud-. � OFC L J {�jWU COL. }� IR 7�'w opu z Q X00 LN L>s • 1-ZN u ll- uQw XMa Ili<1 !� 7 K z O z CSN.. >2y. J �aZQ Jp� tip. J1L >z D^J. K'3: 1i xu¢x'L'i 0L I'' dLl^2 Loot ua I ul Ku uozQaz � ZJoo}3 :Gide J2 u 9L j I uo<L OJ 00 H L x E �Joor$ z3arc z ,UZ >9) L 1 { II O T Ur i X> F C K N uozo.2 >Ua LI J u <i W<Z uu¢u C3dKJz` -_� ZOQ 4 rai a d XNo ud-. � OFC L J {�jWU COL. °The commonwealth of Massachusetts Department of IndustrialAccidents X Congress Street, 5l.e 100 " : d Boston, MA 82114 2017 dim sy�o www mass.govldia TJVarkers' Compensatiouhsuxanee A da =Builders/CouLxaciorslElecirSciansl'l hers. TO BE FILED Wl'?I'H TM PKnnTl�NO ABTilol' CL`Y. Laine (BusinesslOigabizaiion/Ivtlividual): 1 Address: / «�I l i' -C 1' 01 City/State/Zip-, �d %el M Are you an employer? Gheckiiie appropriate box: R1 Phone 4. <6 � v 73 1.Q I am a employer with employees (full and/or part time)•" 2_❑ I am. a sole proprietor or parfnershrp andhave no employees VVD"eng forme in any capacftty. [90-Mrkm' comp. insurance required.] 3.01 mahomeownerdoingEUWork myself [Nd workers' comp. iasurancerequired] 4-F]I am a homeowner a adwill be hag contractors to conduct all work onmy property. Iwill ens ethat all coutractois eitherhave workers' compensation insurance or are sole t- t. pr rietorswith.noempi6yees. 5. am a general contractor and shave hiredihe sub -contractors listed onthe attached sheet These sub -contractors have employees andhaveworkers' camp. insurance.; 6.❑ We are a corporation. and its, offic6LshaYe exercisedtheir right of exemption per MGL e. 1 4 and vee have no employees. [No workers' comp. insurance required ] Type oproject 7. ❑ N6-N'do`nstrir Hon 8. El R..emod0. 9 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs o7 additions 1—U plwnbing repairs ox additions 13'.�]Roof zeparzs 14.n Other a hca i HomePoPw ners wthhaotcsbubecld;bbox #It atta ed'an additional sheeshowingtheuame ofl rsob°oniract°rs and sfiate�ae pensatonpolo n3hsttiouiihesectionbeloursbnwmgtieirworkes'Gomtmbrftew �_ ��e mgoutside con1ractors �en� tConiractors that check c oHe n�ber. .. .._ _ . - • _ employees. Ifthe sub -contractors have employees, they must provide then workers' omp- P Y . X arrt an employer• tiiatisp�ovidingivo�ker^s' compensation insur�ancefor° my employees. Bela7v is tliepolicy aradjob site znfornaaiion. . insurance CompanyNMe:. policy # or Sel-f-ins. Lic. Expiration Date, Clip/StaielZip: .. Job Site Address, Attach a copy of theWQ4kers' cO. pensaL on policy declaration page (showkagthepo"cynumber andexpiraiiozi date)- Failure to 8eCUX0 coverage as required and r MGL estin the f na o f OViolation °WORK ORDERIand a fine of up to $250.00 a and/or one-year Imprisonment; as well P day against the violator. A copy of this statement may' be folwarded to the Of6 ce of7nvestigations of the DIA fox insurance 1-, PrP UPve- i-Hration. c dcorrecf Xd hm'-abby certify the pains and nal f ofperyury that tlye inforMaiaon prov aoa above , true / _/,'7 Sv 81— yov -73 a official use only. Do not-Wite in t7zis area, to be cor,�pleted by city or'to�vn official. permit/Licease # City or Town - Issuing .A.uthoxity (circle one):Xnector 5. plumbing hTector 1. Board of [eaith 2• BuSiding peparbuent 3. CiiylZ o vvn Clerk 4. Electrical sp 6. Other Phone #: Contact Person' 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 empkoyer is d'ef'un6d as "an individual; partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferprho, and including the legal representatives of a deceased employer, or the receiver` "or trustde cif 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, constnietion or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment b6 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 applicazttw1w has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(�) 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 neeessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their cerdf cate(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, apolicy is required. Be advised that this affdavitmaybe submittedto the Department of Industrial Accidents for confirmation ofinsurance 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 orlicense is being requested, not the Department of IudustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a ivorkers' 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 PIease 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 •"alt locations in (city or town!)" A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filed 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 I Congress Street, Suite 100 Boston, MA 02114•-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE Fax ## 617-727--7749 Revised 02-23-15 www.mass.gov/dia ACORO' MODER4 OP ID: RC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 endorsements). PRODUCER CONTACT Durfee Buffinton Ins. Agcy,Inc NAME: Chrlst0 her E. Brown 77 Second Street PHONENo• Ext1.508-679-6486 a No Fall River, MA 02721 E-MAIL Christopher E. Brown ADDRESS: _ INSURERA: I raVelers Insurance Co. INSURED Modern Construction Services 91 Elmcrest Road INSURERS: No Andover, MA 01845 INSURER C: E: F: 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. I TR ADOL S e POUCY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD UMiTS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 CLAIMS -MADE OCCUR I 1680-7C295143-17-42 01/21/2017101/21/2018 �o�,,,�E TO NT . %An A. GENIL AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC wicu cAr (Any one person) I S 5,UUUI PERSONAL 8 ADV INJURY Is 1.000-00 GENERAL DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) TOWNONO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of No Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. No Andover, MA 01845 AUTHORIZED REPRESENTATIVE i Christopher E. Brown ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD OTHERS a - l.U4ar1Ur AGG 3 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED SINGLE LIMITt S PDSINGL JURY (Per person) S AUTOS AUTOS HIRED AUTOS NON-OWNEDAUTOS URY (Per axident) S DAMAGE S n1) S UMBRELLA UAB EXCESS LIAR OCCUR CLAIMS-MADET EACH OCCURRENCE $ AGGREGATE $ DED RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N / A S $TATUTE OR H E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE $ H as, describe under DESCRIPTION OF OPERATIONS below E.L. DISFARF _ an' icv iuiT e DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) TOWNONO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of No Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. No Andover, MA 01845 AUTHORIZED REPRESENTATIVE i Christopher E. Brown ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ACORO® CERTIFICATE OF LIABILITY INSURANCEF DATE (MWDDNYYY) 03/02/2017 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 CONTANAME: Kathleen Carvalho Pte" o Ext: (508) 679 sass ; No: DURFEE BUFFINGTON INSURANCE AGENCY INC. E-MAIL ADDRESS: kcarvalh0@durfee-Ins.com INSURER(S) AFFORDING COVERAGE NAICS 377 SECOND ST. INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 FALL RIVER MA 02722 INSURED INSURER B: MODERN CONSTRUCTION SERVICES LLC INSURER C: INSURER D INSURER E : 91 ELMCREST ROAD 1 INSURER F: NO ANDOVER MA 01845 COVERAGES CERTIFICATE NUMBER: 131130 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 JUM WVD SUBR POLICY NUMBER MMIDPOLICY EFF MM//DD EXP LIMITS COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE FIOCCUR DAMAGETO PREMISES Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑PRO ❑ JECT LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per axident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED I I RETENTION $ $ WORKERS COMPENSATION X OERH AND EMPLOYERS'LIABILITY Y / N STATUTE E.L. EACH ACCIDENT $ 1001000 A ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? WA WA WA 7PJUB4330P98A16 07/23/2016 07/23/2017 E.L. DISEASE - EA EMPLOYEE $ 100,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT I $ 500,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. %,GR 1 Irwrk I r- nvILUMM GANGtLL.A I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of No Andover I ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street AUTHORIZED REPRESENTATIVE No Andover MA 01845 �- ,6 C�_/1_ Daniel M. Cr y, CPCU, Vice President — Residual Market — WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD G . rr n N n 0 5 rt n G rt G �i cD 0 0 a N• (t r� rt w b 0 n b N d O O R. W o G � CO r C CD K ~ ` . P CD r (D CD Fj o G� �v) CD Fl. m.�,aryi�p ?I o p• G O y s• ID ru Ln CO "h G o � rt y o y a o = N r+ a tp i N• � d ; 0 `r7 0° i Ln Cn C I rt rt G ! Fj i cu ®, Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -092297 Construction Supervisor p � DAVID W PAUL ' 91 ELMCREST ROAD , NORTH ANDOVER MA 01845,' = Expiration: ' Commissioner 09/24/2018 �., C���ie �paoivwaasr.�cec��� a�C� �lc�eaac�craeCld .\ Office of Consumer Affairs & Business Regulation VEIMPROVEMENT CONTRACTORration: :-63647 Type: tion: _-%8fl17==_ LLC -._ MODERN CONSTRUCTION SERVICES '6 —a DAVID PAUL 91 ELMCREST RD. ,s NORTH ANDOVER, MA 0184 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 v Ii ithout signature