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HomeMy WebLinkAboutBuilding Permit #170-2017 - 31 UPLAND STREET 8/18/2016 O� t%ORTH q Tt � � BUILDING PERMIT ��gLED 6i6�� TOWN OF NORTH ANDOVER 32 y.:."' . _ APPLICATION FOR PLAN EXAMINATION _ X7,,4 i Permit No#: d" Date Received l �ySS,7ED P.. CHU51 Date Issued: l IM ORTANT: Applicant must complete all items on this page LOCATION 3 i PZ—?1 C1,D S U C� 6, ov Print PROPERTY OWNER t Vr` i Print 100 Year Structure yes Ono MAP PARCEL: ZONING DISTRICT: Historic District yesMachine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building >9-One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial X'Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other = Septic \Nell. ❑ Floodplain ❑Wetlands;, ❑ V1/atrrtshed'District; 0 Wates/Sewe:r DESCRIPTION OF WORK TO BE PERFORMED: 1pC�d©F5 s� Identification- Please Type or Print Clearly OWNER: Name: i_(QQIICC GOU Phone: P ?4S% t/O�T7/_/' c% Address: 3� C G Contractor Name:i�V/C Y Phone: `?7',9- 879—.-0z(-809- Email: Address: 7 6(e_L 1QA Supervisor's Construction License: 09 ?C boExp. Date: 11z,311-e Home Improvement License: 7S0 26 Exp. Date: 1� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 00 FEE: $ /64 Check No.: � Receipt No.: 1,5M 1+1 NOTE: Persons contracting with unregistered contractors do not have access to nd tur -n L _ - J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ 1 Swimmin Poc�1s'':_ ' l0 Tanning/Massage/Body Art ❑ g Well ❑ Tobacco Sales ❑ Food Packaging/Sale4 ,1 11 Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY 1 INTERDEPARTMENTAL SIGN OFF ® U FORM a PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS i CONSERVATION Reviewed on Signature i COMMENTS HEALTH Reviewed on Signature a COMMENTS —L Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Panning Board Decision: Comments &nservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: _ Located 384 Osgood Street }ARE DEPAP! dTnIIENTg Tern Dumpster=onisitew= 3 a S. x�.+'*ern �� e�&�(w t i A , n t,Located t 124 MaiN treet• �• .° ,; `��• *+� kFl�reDepartmerIt�S�gnatur�e%ate��� � . z'`. : } i' `�� � .R `a5 . , " k U Vit .r. a1 T+'qftrt, �x 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) I I' I I II r ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. I Roofing, Siding, Interior Rehabilitation Permits 4, 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 OTE: 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 OTE: 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 2012 I ECC Energy code 4, Engineering Affidavits for Engineered products OTE: 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 P ✓y— No. Dateil�G,a , . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ACA)-, ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# .� c 7 ..9 '' Building Inspector NORTH Town of t s ndover O No. I �_ b1 � :t �� � akel It IA - ZZA - 0 % .�K. h ver, Mass, CO[MK Ml wKw y1' S fJ BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT .............1&t*.bj..LA6.................................................... ............................. BUILDING INSPECTOR ...4 ..... . .' �� ...'.,.... Foundation has permission to erect .......................... buildings on ....... .... . ......................................................... Rough to be occupied as ....... .. . .......4J.M.W............... Chimney provided that the person accepti this permit shall in every respect conform to the terms of the application Final on file in 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 ELECTRICAL INSPECTOR UNLESS CONS.VMqIO S Rough Service ...... .. ..... ... ..... Final BUILDIN SPE TOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. Dempsey Roofing LLC P.O.BOX 383 Billerica, MA, 01821 Phone: 978-670-8904 -www.dempsey-roofing.com Fax: 978-362-3102 8/17/16 Contract Customer Name: E U lU s CC O lJ Address: 31 Upland St. City: North Andover State: MA Zip: 01845 Description: • Install tarp from roof to ground to protect siding & landscape • Strip existing 1 layer down to roof deck. Inspect&re-nail where necessary. Any broken or rotten plywood will be replaced up to 1 sheet '/2" CDX. Any extra replacement will be at an additional cost of time and material. • Install 6' of ice and water shield underlayment along all eves, 1.5'under cheek wall flashing and 3' in valleys • Install 151b paper on remainder • Install 8"white aluminum drip edge around entire perimeter • Install LTD Lifetime GAF Timberline HD or CertainTeed Landmark architect p roofing shingles (color& manufacture chosen by homeowner) • Install one new 3"pipe flange • Will use current step and roll flashing • Install cap shingles over ridge vent to ensure proper ventilation • Remove all roofing debris • Material, labor, permit and dump fee included i Total: $8800 Ten year warranty on all workmanship .Signature of acceptance 6a Lt, Dempsey Roofing LLC �U G The Commonwealth of Massachusetts z . T. DepaytMent ofindustrialAccidents _ _ M I Congress Street,Suite 100 .Boston,MA.02114-20X7 -` www mass govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/EIgctricians/Plumbers. TO BE FMED WITH THE PERARTTING AUTHORITY. Ap licant Information Please Print Legibly Name,(Business/(>rgamzationfkdmdual): Address: City/State/zip: Phone#: Are you an employer?Check. e appitopriafe box: Type of project(xequired): 1.g i am a employer with. •� s employees(full and/or part-time).* 7.- New colisttuetion 2.r]1 am a sole proprietor or partnership and have no employees working for me in 8. Remo delirig any capacity.[No workers'comp.insurance required.] 9_ ❑Demolition IQ l am a homeownerdoing all workmyself[No workers'comp.-insumce required.]t 10 FJ$ g addition 4.❑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 11.❑Electrical repairs or additions proprietors withno employees. 12:C]Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.'�Roof repairs These sub-contractorsliave employees andhav-workers'comp.insivance.1 14.[]Other 6.Q We are a corporation and ifs of�cers have exercised their right of exemption per MCTL c. 152,§1(4),and wehave no-,employees.[No workers'comp.insurance required] `Any applicaotthat checks b6x#1 must also fill out the section below showingtheirworkers'compensation policy information. t Homeowners who saEif flys affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tConiractors that check this box must•aftac�ied an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-coniracfors have employees, ey must pro-videthes workers'comp.policy number. I ain an employer that is pr*ovidingworkers'compensation insurancefor my employees'Below is•theponcy acid job site information. Insurance Company Name: l v4 Z- 1&3 C'o C 00702748720t6 4 Expiration Date: 7/0/ //7 Policy#or Self-ins.I�ic.#:-�}(.� �f' Job Site Address- 3 U PL 11 I-1P -S r City/State/Zip:V Attach a copy oftbewohckers' compensationpolicy declarationpage(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 tine 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 cerci er a andpenalties ofpetjary that the information provided above its tr e/and correct Si ature: Date: d5 An, Phone#: ��' — 66 78 Official use only. Do not write in this area,to he completed by city or town official City or Town: Permit/License# Issuing Authorial(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �I Information and Instructions Massachusetts General Laws chapter 7.52 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 contra6t of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,asso ciation,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 vvho Lias 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=he boxes that apply to your situation and,if necessary, supply sub=contractors)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. l§e advised that this affidavit may be submitted to the Department of•Industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. the affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you.'are.required to obtain a workers' compensation.policy,please call the Department at the number listed below. Self-insured.companies should'enter their' self-insurance license number on the appropriate line. City or Town.Officials Please be sure that the affidavit is complete and printed legibly_ The Department hao 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 areference 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 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-MASSAFE Fax#617-7277749 Revised 02-23-15 www.mass.gov/dia DATE(MMIDDIYYYY) ACOR& CERTIFICATE OF LIABILITY INSURANCE `.� 07/08/2016 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 CONTACT NAME: Richard Beecoff FIRST INSURANCE SERVICE, LLC PH�NE Ext): (978)531-4461 AAlc No: E-MAIL ADDRESS: @ info firstinsuranceservice.net 11 WHITNEY DRIVE INSURER(S)AFFORDING COVERAGE NAIC# PEABODY MA 01960 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: DEMPSEY ROOFING LLC INSURERC: INSURER D: P O BOX 383 INSURER E: BILLERICA MA 01821 INSURER F: COVERAGES CERTIFICATE NUMBER: 67431 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM DD//YYYY MLICY EFF MI ICY EXP LTR DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 71OCCUR DAMAGES O RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F PRO ❑LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED _SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED 1 1 RETENTION$ $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? NIA NIA NIA AWC40070274872016A 07/01/2016 07/01/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I 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/. CERTIFICAT CANCELLATION 4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Dempsey Roofing LLC ACCORDANCE WITH THE POLICY PROVISIONS. O Box 383 AUTHORIZED REPRESENTATIVE 'llerica MA 01821 Daniel M.Crc�+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 AC"R" CERTIFICATE OF LIABILITY INSURANCEP3/18/2016 ATE(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 endorsement(s). PRODUCER CONTANAME: Commercial Lines Prescott and Son Insurance Agency,Inc. PHON o,Ext) (781)322-2350 SAX 963 Eastern Avenue E-MAIL ADDRESS: + INSURER(S)AFFORDING COVERAGE j NAIC If Malden MA 02148 INSURERA:Endurance American Ins Co INSURED INSURER B: Dempsey Roofing LLC INSURER C: 7 RICHARDSON ST INSURER D: �^ INSURER E: w Billerica MA 01821 INSURER F COVERAGES CERTIFICATE NUMBER:CL1631822656 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 AODL SWVDUBR� POLICY NUMBER �^MM/DDIVYY M/DD/YYYY LIMITS LTR I TYPE OF INSURANCE POLICY EFF POLICY EXP $ COMMERCIAL GENERAL LIABILITY I 'EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE OAMAGETO RENTED C,OCCUR (_ 1 PREMISES(Ea occurred100,000 _ S CBC20000050401 9/3/2015 9/3/2016 3f MED EXP(Any one person) E S 5,000 f PERSONAL&ADV INJURY 1$ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,,000,000 POLICY PRO- 0 LOC JECT � I �PRODUCTS-COMP/OP AGG �5 1,000,000 X OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident) _. ANY AUTOBODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS i BODILY INJURY(Per accident)'5 NON-OWNED PROPERTY DAMAGE _ HIRED AUTOS AUTOS � pa_ er c_cidenl 5�� $ UMBRELLA LIAB OCCUR I EACH OCCURRENCE !S EXCESS LIAB CLAIMS-MADE) I AGGREGATE ��5 DED I RETENTIONS 1 {5 WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA ,E.L EACH ACCIDENT S (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 5 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE­-POLICY LIMIT 1$ 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) RE: 59 Salem Road, North Andover, Ma 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. Building 20 Suite 2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 J S Scholnick/PJR �"''�"'�-�--'�-'�--�""�s•-�� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) ry Massachusetts Department of Public Safety a Board of Building Regulations and Standards License: CSSL-099681 Construction Supervisor Specialty fit ERIC DEMPSEY P.O. BOX 3831 BILLERICA MA 01821 fir ti ..ten Expiration: Commissioner 05/23/2018 r t '- U/2P. C/�oo��ir�aoa�cuelrr�a a�C%UGudJac�.c��el,�iJ- Office of Consuiiwr Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR ;Registration: 178026 Type: a � ;F, Expiration:=--�-3/6%2bt LLC0:1-8, DEMPSEY ROOFING ERIC DEMPSEY , f 7RICHARD ST BILLERICA, MA 01821 Undersecretary � Q t