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HomeMy WebLinkAboutBuilding Permit #37 - 300 SUMMER STREET 7/8/2010 BUILDING PERMIT "°oT"qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ' w 1• ��SSACHUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION � �6 d �S'U m me. Sir e�.f- �� /�ZTint PROPERTY OWNER 6/"i L � Print MAP NO: /67 PARCEL: 151 ZONING DISTRICT: Historic District yes o 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 Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: S-h o 6r) � Identification Please Type or Print Clearly) r OWNER: Name: g_ r i c_ Sko l+Z Phone: q )� 6k3 00 Address---,I()d S U no tel-. ✓1uve✓ HA o t b '-}- CONTRACTOR Name: �D O�I(()ne . Phone: 9-) 3 • 13 q{ -o Address: Zoe Sut�DA STree t S(i & 2Z.(,0 �)o ,u\lu Hjl - ()( f* Supervisor's Construction License: ci Exp. Date: ! (o- Home Improvement License: 1 d`��� Exp. Date: - ( 4-�� I 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: $ cQ4 ho ° FEE: $ Check No.: 13 Receipt No.: os NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund -- - c� ignature of Agent/Owner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED H EALT.H COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit Located at 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 2 1 A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Building Department I 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 I ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) i ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o 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 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location • (' _ No. Date —-�9, ^`�. � NORTN TOWN OF NORTH ANDOVER 3 o< � A Certificate of Occupancy $ Ms<�a Building/Frame Permit Fee $ AU Foundation Permit Fee $ { Other Permit Fee $ TOTAL Check # O Building Inspector f 09898 ,� Date . . !4' � . . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . GA'L . . . . . . . . has permission to perform . � ���,- dt�.�. 2�sz��� 1 plumbing in the buildings of. . . J�kA4 7 . . . . . . . . . . . . . . . . . . . . `,at . . �O(D. . la.tnn sn, . n ' . . . . ,North Andover, Mass. Fee'.`",; . . . Lic. No. l+'�J. . . . . . ('3 . . . . . . . . . . . . . . Y PLUMBING INSPECTOR Check 4 �2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CIN _ I MA DATE ' 1 Cq 'L _ PERMIT## U JOBSITE ADDRESS 5i OWNER'S NAME `mac _6 u P OWNER ADDRESS L TEL -- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: R RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES NO[�( FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ( _......___( ! ( __...___' .TT.__( __ _ .-_.( --j __._..._( _._..__:.( DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ( _...r___( ___J ------- INTERCEPTOR ___INTERCEPTOR INTERIOR f _.__.._( .__._..i _..... KITCHEN SINK __( _..-.-___.d _--._.__d ---------! LAVATORY ! _._._J ._._..._...1 __.-_--_1 ROOF DRAIN SHOWER STALL l __I ____._( -___ ___._( ,____.f ____l -__1 SERVICE I MOP SINK TOILET URINAL _...... ....... .__.._.__I .-..-._.J WASHING MACHINE CONNECTION WATER HEATER ALL TYPESWATER PIPING OTHER -� - - . � -_ ____f _d i =77j INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO �1 BIYOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND Q OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT �] SIGNATURE OF OWNER OR AGENT C hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge aoyi that all plumbing work and installations performed under the permit issued for this application will be in c pliance with alZeent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws FrLUMBER'S NAMEi 5C4 SIGNATURE IVIP JP CORPORATION 0# jPARTNERSHIP # _ LLC COMPANY NAME vici'o2 r�� fruu�i�c Lv ; ADDRESS CITYvT _...._____....... STATE /Z( ZIP ©fri �' TEL FAX — _ A CELL MAIL y/a e- �-'�Sc�/ + .N......_ ►2�.... dyt._ _..((J ,-i- -... - ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r t ' 1! The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Dame(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ` 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, [J Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie 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. lam 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.#: Expiration Date: Job Site Address: 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 requiredunder 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 penalties of perjury that the information provided above is true and correct. Signature: Date: Phone M Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 9- 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#: a 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 bean 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 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 he. 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 be 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 bum leaves etc.)said person is 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: Tho Commnwalth of Massachusetts Department ofIndustrial Accidents Office of Iavestigatioas 600 Washington Stroet Boston,MA,02111 Tei,#617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax#617-727-7749 www.m.ass,gov/dia °.COMMONWEALTH OF MASSACHUSETTS ul SESTEIPL+ LICENSED MARUMBER " ISSUES THE ABOVE LICENSE TO: VICTOR FISCHBACH JR d° PO BOX 7,27 ROWLEY MA ' 01969-3727 9454 05,'71/14 16498 `t • COMMONWEALTH OF MASSACHUSETTS,' PLUMBERS AND GASFITTERS ' LICENSED AS A JOURNEYMAN PLUMB ISSUES THE ABOVE LICENSE TO: vICTOR A FISCHBACH JR PO BOX 727 - ' ROWi_EY MA '01969-3727 17978 • 05/01/14 164982 f ' I All• i F ORTH Tovm of oAndover TONo. - �` A dover, Mass., goo? t o COCKICMEWICK V �d ADRATED SS BOARD OF HEALTH PERMI,.T T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..........E. `. ................45............................Z. ............................................................. ............... Foundation has permission to erect........................................ buildings on ....34;!.........SV��!! .....`... ►... Rough to be occupied as M. ... C.�i� ................. s......... �........ ...... (LO Chimney p' ........... . provided that the person accept! this permit shall in every respect conform to the ter sof the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations'Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRU ON TS ELECTRICAL INSPECTOR Rough .......... ............................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the-Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. I DAVID CASTRICONE '7!6 r!!0 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 Haverhill 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 below described: M 3�6—/Q6 o�p Owner's Name......-1`.1.C,......Is.. 2;,...........................................................T phone#...1. t .`...f r.�U ®........... Job Address....10.()...... .......V...V.................City... L..V.e-J...................State.....1.'1. .... Specifications: .............................................. .............................. ............. .............. ... .......................................... ..... • � ........5.1. ..1.rA. ........ l..t'L.✓A!�"........ D. ....:17.k'�171..L'.L'................... DI ...:..,JL C.I.a ....... ... a f..... . .a/-...— r . r..ytrt...... .....C..n: ..l .. .Le%...........1`1.xw ..... ....... ... .................... l"..... ..... .1 1. a e:e........Q., .....1040...,;-n ..3............... r .....•1••••l•,X�,.......t.►a..1••�..1.�. .. - ...,...�?.�..�.yd'..ke..t�.�....1.`..eyut.v..t� ....�..K..t.,rkt�x�.c� .....�;,L.I/.,�d::..a,.,/...,gnt*a ./. P-A a.0 z�....cS..F ..yet. ..... Y. d'......1.zrr.....ktaal,.c.tL:...... �. . . ............................... r .....` h�.d.1.1'....... d. .... ^: .......�?'l.Q:.,c.at..r.....C..l1.t.ryr>�„t�yr..r............................................................. 1.5 .. .......fz. ...... .l Jd . ................................................................................................................................. ............................................................................................................................................... - Two Year Workmanship Warranty(Not Transferable) Manufacturer's Warranty as specifi y ma ufacturer The coutractor agrees to perform the workar@�u i h the materials specified above for the SUM $... .8..D..0..... Payable...,9:3,(70..........on Payable...YJAi.2Q............on.. 3�alance payable on corn igtion of _ _ Owne or Owners are not responsible for Property Damage or iiability whilejoS is in operauon. 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 waranks)that he is(they are) 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....6.YE....day of..S/.t..t t,�..........,20...ID Accepted: �� J Signed— .... :............ ................................... Owner Signed............................................................................. Owner David Castricone,President ., , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 v wwru mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (BusuiessJOrganization/Individual): �A� I CAST C 0 J� R 0�F (T `! S I�1 N�r I N L Address: 20f) Se :!tT7L J S—vCZ��-t- City/State/Zip: N N bQ J>E(, M 0 I NS Phone #: 9I )9 (P 3 4 2,0 Are,you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with `$ 4. ❑ I am a general contractor and I employees (full and/or part-tune). * have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees Those sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp. insurance comp. insurance. 10.El Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12,E] Roof repairs insurance required.] I c. 152, S 1(4), and we have no employees. [No workers' 13.N Other 3 t t7 11. e comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating the; are doing all work and then hire outside contractors must submit a new affidavit indicating such. ,Contractors that check this box must attached an addi'.ional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors h,:ve employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjob site information. Insurance Company Name:7\()e_ K� t1 �_ to (20 MD f-11 V. 6 Policy #or Self-ins. Lic. #: \N C 9 95 a` 4 (o Expiration Date:\ 9 %A-3- �0 l 0 Job Site Address: �OC7 YV►I►'1Pe City/State/Zip: N-) VW6� NA 60 it 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the(p�ains and penalties ofperjury that the information provided above is true and correct. Signature: .�J.�►�./ C Date: ! �Q bo _ Phone#: 10 Official use only. Do not write in.this area,to he completed by city or'town official City or Town: Permit/License# Issuing Authority (circle one):' 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Town. of North Andover e4 Try JRuddiiag D e1- , �i`� a... a - lent 27 C.1-4ules Street North Audove:r, Massachusetts 0.18q'S -9545(978) 688 �) 8-9542 `'ACEIt.15�' D Mss DISPOSAL FO1W In accordance with 111e provisions of MCrL c 40 s 54, and a condition of. Buildiag perinil. # the debris re-,,.ilarng from the work shill. be disposed of in a properly licensed solid waste disposal facilil) as defined by MGL, cl1, s150a. The debris will be disposed of 5igaawr-e of Applio"ant Date NOTE: A demolition permit from the Town ofNort.h Andover inu.st be obtained :fur this project tluougli tht Office of the Building Inspector. ✓I_1A.► LL-1 I e ss+a..r�nrl`"Aa.�a...t_ _09/21;/2009 I . 1508.7651-7-DO` ' 11 ' FAX 5118-6 3+8D89e��� PHIS CERTIFICATE IS ISSUED AS A MATTER OF INF=ORMATION PRODUCER i Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 West Central Street HOLDER,THIS CERTIFICATE DOC$ NOT AMEND,EXTEND OR ALTER T� .HE CQV -,F_AFFORDED BY THE POLICIES BELOK Natick, MA 01.760 — --- Select Ext.53389 INSURERS AFFORDING COVERAGE NAIL# INBUREp Pavid Castri cone Roo l ng ng Inc- INSURER A: The In5urance Co or State PA 200 Sutton St INSURE R B'. tate to 226 INSURER C, North Andover, MA 01845 INSURER D: INSURER E. COVERAGES THE POLIGIE5 OF INSURANCE LI5-I-E0 BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TI'if POLICY PERIOD INDICATED.NOTWITHSTANDING ANY 118OUIREM51NIT,T01V!OR CONDITION Or ANY CONYR,ACY OR OTHGr1 bOCUMEni r WIYH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM$.EXCLUSIONS AND CONDITIONS OF$UCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE DEEN REDUCED BY PAID CLAIMS. INSR DD'I yo TYPE OF INSURANCE POLICY NUMBER POLICY F_FFFCTIVF POLICY EXPIRATION DAYF.�MIAROLY LIMITS GENERAL LIABILITY f:AC,H pCCLIRRFNGI; $ COMMERCIAL.GCNERAI_LIABILITY DAMAGE TO RLNTFU —�CLAIMS MADE JJJ OCCUR .C51L-a.ticcuconGnL__NICD CXr(Any one Raruvnj S PCRSONAL 6 ADV INJURY $ Qt:rO RAI AGC9011GArc $ GtN'L AFJOREGATE LIMIT APPLIC9 P[R. r'HUVUC I S-CUMp10I'A00 POLICY 'R(' LOC IECT AUTOMOBILE LIABILITY COM91MLD SINGLE LIMIT $ ANY AUTO (1-a ncadrm) ALL OWnIFq AUTOS BODILY INJURY SCHEDULED AUTOS (flotneraon) $ HIRED AUT05 - BODILY INJURY $ NON-OWNED AUTOS (Pnr aict:idertl) Pr;Or1'.gYV fSAMAt'f! $ (Por v0denr) GARAGE LIABILITY AUTO ONLY•EA ACCIDENT $ ANY AUTO PA ACU $ OTNEIT 7NAN AUTO ONLY: AGO $ EXCESSIUMBREL-LA LIABILITY •• CACI I OCCURR=NCE 3; OCCUR CLAIMS MADE AGCHL CAT[ U y 1711?VC1'll9ll: - ^^ T S ni CTENTION WORNF_RS COMPF_NRATIDN AND WC9752746 09/23/2009 09/23/20I(1 X( I WCSTATU I OTR EMPLOYERS'LIABILITY fly_LIMLT _ A ANY PROPRIF.'r()PIPAR'fNFRIE•KFCIJ'rlvF E.L.EACH ACCIDENT $ 100,000 OFFICFRIMfMIPER EY,CI-UDFD^ If E.L.UISr11SE-IJA EMPLOYE $ 100,000 yyoob,doscnbc Vndw vPEOIAt.PROVIMONS blow F.I„DI$FASF-P'O ICY I,IMIT $ 500,000 OTHER -- ——— OESCRIPYION OF OPERA'fION9 I LOCATIONS I VFHICLE9 1[XCLI.I$ION3 ADDED BY FNDOR9FMENT I SPECIAL_PROVISIONS CERTIFICATF.1-JOLDL-R.. David Castricone Roofing & Siding SHOULCI ANY Or YIIE ADOVC':t SCR19ED POLICIES I.TE CANCEI.1.0 OLFORE YHE EXPIRATION DATE THEREOF ',I IE 19BUING INSURER WILL ENDEAVOR To MAIL 200 SuttOn Street 10 DAYS WRITTEN NOl hlf!TO THF CERTIFICATE HOLDER NAMED TO THE LEFT, Suite 226 BUT FAILURE TO MAIL SUCH!JC'rIC6 SMALL IMPOSP NO OBLIGAYION OR LIADILITY North Andover , MA 01845 OF ANY KIND IJPON THE IN%,. i'i,IYS ArtNT$OR«EPRESENYAYIYES. AUTHORIZED REPRESENTATIVE State_Brice/PKC ACORD 25(2001108) CJACORD CORPORATION 1988 1 s Office of Consumer Affairs&Business Regulation o' HOME IMPROVEMENT CONTRACTOR t�I Registration: 104569 Type: ^ 4 =... Expiration: 711412012 Private Corporatio ' DAVID CASTRICO.NE ROOFING,SIDING& David Castricone ' 200 SUTTON ST SUITE 226: NORTH ANDOVER, MA 01845 Undersecretary \I;u�achusctt, i epal'lrucut of Public -safm + t3uartl of Buil(lin;; Rc'-nilations ant/ "ltantlar'tl� Construction Supervisor Specialty License License: CS SL 99358 Restricted to: RF,WS "" ! ir DAVID CASTRICONE 31 COURT STREET NORTH ANDOVER, MA 01845 Expiration: 1211612011 ( un4nii.�i4 nrr Trg: 99358 ,?v'