HomeMy WebLinkAboutBuilding Permit #282 - 337 PLEASANT STREET 10/6/2009 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received �0
Date Issued: PS
IMPORTANT:Applicant must complete all items on this page
LOCATION p d�
Print
PROPERTYOWNER I�
� bn
Print
MAP NO: LM 0 PARCEL: ZONING DISTRICT: Historic District yes no
'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 PERFORMED:
/y0 Saiwc-k(rr.&/ lg
S
Identificatio Please� Type o�rint Clearly)
OWNER: Name: 1A "'i
Phone:
Address: PLca3_a-io-
CONTRACTOR
Name: 8 <pf,) n11-50 LJ Phone:
Address: X(4 iA;
Supervisor's Construction License:_q Exp. Date:
Home Improvement License: 1 Exp. Date: bqI16
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: $ FEE:
Check No.: O,�(Oob Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
--
Sign ature of Agent/Ownerat m Signature of contractor_�„�
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEW DISa fv
Public Sewer Tanning/Massage/Body Art Swimming Bools
Well �
Tobacco Sales Food Packaging/Sales
Private(septic tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
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
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
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/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)
❑ 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
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: Doc.Building Permit Revised 2008
I
Location �-�-
No. �� ' � Date
MORTM TOWN OF NORTH ANDOVER
3:'��j�•o!•�'4,
9
• i
Certificate of Occupancy $
ITS
Building/Frame Permit Fee $
sCHus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # �
r r
22507
Building Inspee{or
Date.. ............................
NORTH
• °`t"`°:•�"� TOWN OF NORTH ANDOVER
' PERMIT FOR WIRING
SUSE�
This certifies that ..^ - ; -c.<
has permission to perform .....:..........— - ........ ......f ..!%'............................
......... .. .
wiring in the building of -= - - ter, --- ........
,�
..............................._............................
at.. ... .....�:..._. �- -�:, ...... .,North Andover,Mass.
Fee.. ........... Lic.Nof ......... '...-....` -`-" max- .........
ELECTRICAL INSPECTOjt i�
' Check # -� 1///
i
,C-\ Commonwealth of Massachusetts Official Use Only
Pen-nit No. Q ? Z�
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: I/, ,l,J,, 34�e
_,t, To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street&Number) .337 P S �,, , j_ T 4 .
Owner or Tenant f�q,.7 RC2 Ge� -,, ,y " Telephone No.
Owner's Address N -
Is this permit in conjunction with a building permit? Yes ❑ No Fr] (Check Appropriate Box)
Purpose of Building xfe. S we, �,� X Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Ze
Completion of thefollowing table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KV A
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
p No.of Luminaires Swimming Pool Above ❑ In- 1:1o.o Emergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. / Tons TotNo.of Alerting Devices
No.of Waste Disposers Heat Pump Number__ Tons KW No.of Self-Contained
Totals: etection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
�No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
00 Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: G- p — O G Inspections to be requested in accordance with MEC Rule 10,and upo,r completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
tmdersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE � BOND ❑ OTHER ❑ ecif S :
( p Y)
I certify, ander the pains and penalties of petjtuy, that the information on this application is true and complete.
FIRM NAME: e-ti n � LIC.NO.:c 37 L
Licensee: �= 1a'a —r;i 1%Ue,-L Signature LIC.NO.: L
(If applicable, enter "exempt"in the license number line.) Bus.Tel.Wo? 7 7 7- 72.8 Z
Address: Alt.Tel.No.:
*Security System Contractor License required for this work; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally -
required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
NORTH
® of : t 4Andover
0
No. a z
_ - _
C' 'i
.== A K E = dover, Mass., �� •
A_ COCHICHEWICK ��
7,e ADRATED
7`S BOARD OF HEALTH
PERM T T D Food/Kitchen
Septic System
Lqev�..::.7
BUILDING INSPECTOR
THISCERTIFIES THAT................ ......................................... .................................................. Foundation
has permission to erect........................................ buildings on .jllp........ Rough
to be occupied as..........1 ... Chimney
.
provided that the person accepting this permit shall in every respect conform to the terms of 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
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIONT
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.
a �
Renewal —L V EWAL BY 1 °�1V DERSET MA License Felderal Tax ID#res 83-0404201'
1\
bvAAnderserl: '=
WINDOW REPLACEMENT OF GREATER NIASSACHUSETTS AND NEW ILAMPSHIRE
104 Otis Street•Northborough,NIA 01532
Phone 508.919.0900•Fax 508.919.0903
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s)Name Date of Agreement -
le
Buyer(s)Street Address,City,State,and Zip Code
33r7 n aver A,4
d g�
E-Mail Address II I Home Telephone Number Work Telephone Number
C\\AA alum.mskedu q7$- (01-3 -�3q -�yS �65�
Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.dba Renewal by Andersen of Greater
Massachusetts and New Hampshire("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this
agreement and on the attached specification sheet(s)(collectively,this`Agreement").Buyer(s)hereby agrees to sign a completion certificate after
Contractor has completed all work under this Agreement.
Method of Pymnt:❑Cash ❑Check ❑Mastercard ElVISA
Total Job Amount:Z �Y Estimated Starting Date:
O Discover ❑Financed,App#:
Deposit Received(33%):
Name on Credit Card:
Balance at Start of Job(33%): �—
Estimated Completion Date: Credit Card#:
Balance on Substantial z deyS
Completion of Job(33%): FCCxp.Date: CC Security Code:
By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion
Buyer Initials of Job cannot be made by credit card and must be made by personal check,bank check,or cash.
Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that
there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation
from,this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby
acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a
completed,signgd,and dated copy of this Agreement,including the two attached Notices,,of Cancellation,on the date first y
written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF
THERE ARE ANY BLANK SPACES.
Renewa�by Andersen of Gr r and NH Buyers) Buyers)By; � — Z2 rtii t eU it �6�71
Signature of Pr ct nager gipature Signature
/��` 'f�l�irzsu Mt- i k3 n cA
Print Name of Product M(-ager Print Name r Print Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT.
- - — — — — — — — — — — — — —�<- — — — — — — - - - -gc— — — — — — — — — — — — — — —
�
NOTICE OF CANCELLATION NOTICE OF CANCELLATION
Date of Transaction f-/''7-Of . You may cancel Date of Transaction �-/'%-O9 .You may cancel
this transaction without any penalty or obligation,within I this transaction,without any penalty or obligation,within
three business go from the above ate.If you cancel,any three business days from the above date.If you cancel,any
property traded in,any payments made by you under the I eroperty traded in,any payments made by you under the
Contract of Sale,and any negotiable instrument executed Contract of Sale,and any negotiable instrument executed
by you will be returned within 10 days following receipt by you will be returned within 10 days following receipt
by the Seller of your cancellation notice,and any security by the Seller of your cancellation notice,and any security
interest arising out of the transaction will be canceled. interest arising out of the transaction will be canceled.
If you cancel,you must make available to the Seller at If you cancel,you must make available to the Seller at
your residence, in substantially' as good condition as your residence, in substantially as good condition as
when received, any goods delivered to you under this when received, any goods delivered to you under this
Contract or Sale;or you may,.if you wish,comply with the I Contract or Sale;or you may,if you wish,comply with the
instructions of the Seller regarding the return shipment of instructions of the Seller regarding the return shipment of
the goods at the Seller's expense and risk.If you do make the goods at the Seller's expense and risk.If you do make
the goods available to the Seller and the Seller does not the goods available to the Seller and the Seller does not
pick them up within 20 days of the date of your Notice pick them up within 20 days of the date of your Notice
of Cancellation,you ma yy retain or dispose of the goods of Cancellation,you may retain or dispose of the goods
without any further obGgction. If you fail to make the I without any further obligation. if you fail to make the
goods available to the Seller,or if you agree to return the I goods available to the Seller,or if you agree to return the
goods to the Seller and fail to do so,then you remain liable goods to the Seller and fail to do so,then you remain liable
for performance of all obligations under the Contract. for performance of all obligations under the Contract.
To cancel this transaction, mail or deliver a signed and To cancel this transaction, mail or deliver a signed and
dated copy of this cancellation notice or any other written dated copy of this cancellation notice or any other written
notice, or send a telegram to Renewal by Andersen notice, or send a telegram to Renewal by Andersen ;
of Greater Massachusetts and New Hampshire, 104 I of Greater Massachusetts and New`Hampshire, 104
Otis Street,Northborough,MA 01532,NOT LATER THAN I Otis Street,Northborh,MA 01532,NOT LATER THAN
MIDNIGHT OF -2D L15 .(Date) MIDNIGHT OF Y-0-3-6�.(Date)
I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION.
Consumer's Signature - Date I Consumer's Signature Date
RbA Copy- White Customer Copy-Yellow Customer Copy-Pink
�����' MA License (expires� `rFederal Tax ID# 83-0404201 dersen.
OF GREATER MASSACHUSETTS AND NEW HAMPSHIRE
WINDOW REPLACEMENT .Mdmencom,Nny
104 Otis Street•Northborough,Massachusetts 01532
Phone 508.919.0900•Fax 508.919.0903
SPECIFICATION SHEET
Buyer(s)Name Date of Agreement
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices
and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR
REMODELING AGREEMENT,of which this Specification Sheet is a part.
WINDOW DETAILS
1. Contractor will Install a total of /_3 windows in Owner's home,using the following individual quantities:
_Double Hung(DB)X Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom)
Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle
Double Casement(CDW) ❑ Standard handle ❑ Metro handle
Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle
2 Lite Gliding Window(GW)
Glider/Picture/Glider(GFW) ❑ 1:1:1 or ❑ 1:2:1
Awning Window(AW)
Picture Window(PW) 3�0y Q }� �P
Bay or Bow Window — / to lade- c! z D� i/t
Patio Doors(see separate Door Specification Sheet)
2. Yes ❑ No Qty of Windows to be Custom Fit Replacement: Z
3. 9 Yes ❑ No Qty of Sills to be replaced by Contractor:
4. ❑ YesK No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings)
Exterior casings: ❑ Pine ❑ maintenance-free material ❑ Factory applied 908 Fibrex brickmold
5. Glazing to be:X HP Low-E®SmartSunTM (Tax Credit Eligible) ❑ Other If other,please specify:
6. Exterior color to be:,g White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean
7. Interior color to be:X White ❑ Sand ❑ Canvas ❑ Terratone❑ Pine ❑ Maple ❑ Oak
Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner.
8. Hardware:.gr White ❑ Stone ❑ Canvas ❑ Brass Double Hung:
9. ❑ YesX No Install Lifts with Double Hung Windows
10. Screens: windows to have: ❑ Half 1
1,9 Full screens Screens to be:X Fiberglass n Aluminum ❑ TruScene
a
t GRIM DETAILS
11.Windows have grilles:-0 Yes ❑ No If yes:5e Grille Between Glass(GSG)❑ Removable Interior Wood aNTwi❑ Full Divided Light(FDL) .
Qty:& Qty: Qty: Qty: Qty: Qty: Qty:
I'l
ZI
EI.
ILL]
OH ."i. Glider I ICPW.,GPVY
Draw grille patterns above "Use additional sheet if needed Owner approved(initials):
ADDITIONAL WORK DETAE S
12.❑ Yes X No Contractor will remove metal frames of windows. Qty of Units:
13.M Yes F-1NoContractor will install new paint-ready or stain-ready casings.
Interior casing qty of openings: Exterior casings qty of openings: 1Z ❑ Pine Maintenance-free material
14.❑ Yes No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings:
Interior stops qty of openings: Exterior stops qty of enings: ❑ Pine ❑ Maintenance-free material
15. Owner is-aware that Contractor does not do any painting. ( 1 Owner Initials
16.❑ Yes XNo Contractor will wrap exterior casings with aluminum coil stock of color.
Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing.
17 Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.
187K Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full.
19`X Yes ❑ No Building Permit--Contractor will secure any and all necessary permits. The fee for the permit(s)is not
included in the Contract Price and a separate check is required at the time of sale for this fee.
20. Additional job details:
21. Yes,❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment.
!No final payment shall be demanded until the contract is completed to the satisfaction of all parties.
It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR
REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or
modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are
in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet.
Renewal by Ander_ G het and NH Bu/y/err((ss)) Buye, (s 0�)Aj1(� /f�\ y
Signature ofGct tager Signature {' / Signature
• �, ,$C�--•���_r.� �l��+r'�y til- C�i�l.c�rl
Print Name of Product Mandger Print Name Print Name
RbA Copy- White Customer Copy-Yellow
C The Coinrnonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgakdolls
600 17ashington Street ,
Boston,M 02111
wwrv.=ss.gav/dip a
Workers' Compensation Insurance Aicldavit: Builders/Colitractors/Electricialms/pgumbers
Applicant Information Tease Print Legibly
Name(3usiness/Organizationllnditidual):
'Re f,e)r, /64 :�Ylr e�-Sr?i1
.Address:_
City/Sfate/Zip:. Alof-"q ba 1,0 o1KJ-)_ Phone-
-A.re'you an employer?Check the appropriate box: Type of project (required):
LE'I.am a employer with J Q 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 pa tner. listed on the attached sheet # 7.� modelirc g
ship and have no employees These sub-contractors have 8. f Demolition
working for me in any capacity. workers'comp.insurance'`�:' g, ❑Building addition
[No workers' comp.insurance d. ❑ We are a corporation and its
required.] o5cers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself. [No workers'comp, c.152, x.1(4),and we have no 12.7Roof repairs
insurance required.]t employees.[No workers' I.D. Other
comp.insurance required.]
`Amy a plicant that checks box rl must also fIl out the sw tion below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all worIt 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 isprovidin;workers'compensation insurance for my employees. below is the policy and job site
information. )
Insu:ance.Company Name: K»o;j- �`1 CL't2 f1C y
Policy or Self-ins. ic.= J E:piration Date �.1�
Job Site Address:_ �11'�-- City/State/Zip: (_
Attach a copy of the workers'compensation policy.declara.tion page(shoving the policy rumber and expiration date).
Failure to secure coverage as required under Section 2A,of MGL c. 152 can lead to the imposition of criminal penalties of a,
:ane up to$.1; 00.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP'VVOI_K ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy_of this statement may be forwarded to he Office of
Investigations of the DLA,for insurance coverage verification.
Ido hereby cert under the pains andpenaIties.ofperjury that the informaiionprovided abov is true and correct
t,
Signature: \_._. Date: 1
Phone=
Official use only. -Do not write in this area,to be completed by city or town official
r_
CIL)-nr T'own: PermitI.-LcWnSe f
sig�utk ort5 (crce ona : °
F
1.Board of PTezlth 2s.-Dun-ldins DepzrtFnent 3.Cit57/To«'n Clerk: 4.Electr cal Inspector 5.Bl -nl ink Ipspectnr
o.Other
Contact person: Phone_:
Board of Building FeguIations and$tazdar ds
'Ccnstr:ction.SupenrisorLicenS2•
,'_� -�_ _ • .. Licesise;,CS •95707 . .' •
� '��..�"� 5i�thaase�_'g/871962 • •• � .
1.=dpi^afippQ.9020 0 Tt T 95701 ,
BRIAN DENNISOCI
8o CREST CIRCLE
WOP,CESTEF' -,'MA 01603"' . Comm sinner;
EN?EWAL Y AItiDERSON
BRIAN..DENN. ISON
104 OTIS STREET
N!ORTHBOROUGH, MA.0.1532
DPS-CA7 0 5oN-IDlo7-PC8420
.�. . . ..:.. .. .• J�.������� �f�¢d�!�-.ice _ - ...
board of Euilding Regulations and Standards
HOIVI_INIPr'OVEMENT CONTPFiCTOR
L•; R
i. -gist=aio1c, 149501
E .DL=ni:1_Ofl_=_{-%7-412010
,~i' ,iement Card
1= ,
RENEWAL BY AgD=-R80-t - i.:;
BRIAN DENNISd; ` ^ri
1 D4 OT1S STREP
NORTHSOROUGH,MA 61532Administrator
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PROOUC '"MS CE�; !FiCA-!= 'as
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FB:'iewal ty Anderson IKISURER A: H= 'ford Insuranca Conjran.y
%.AJIndcws,.Inc, INSURER E: I`I'e.,M c a
04 Olds 4z, FimsuiR c:
MCkthborcuun., MA 04532, INSURER O:
COVEPAGEE
THE POLICIES OF IIJ---UPANCF-LISTED BELOW BEEN!SSU=D 70 THE INSLIFED NAMED ABOVE FOR THE POLICY PERIOD INDICA TED-NO-IMTHSTANDING
ANY REQUIREMENT TERM OR CONDrTN OF ANY E`ONTRACT-CR 07Hi=. WITH RESPECT TO WHICH THIS Ct' tFICAT=MAY BE !cSLj--D, OR PER7.AK THE RENT,
AFFORDED By TH=POLICIES nESCMEED HEREIN IS 5U JEOT 70 ALL THE TERIM-1,EXCLUSENS AND 7-OIli:)mi6NS OF iUCF'
REDUCE BY PAID CLAIWZ.
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