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Home My WebLink AboutBuilding Permit #443 - 339 WAVERLY ROAD 12/1/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIONoNa DTH q4. o Permit NY Date Received Date Issued: —,N CHU`5+ IMPORTANT: Applicant must complete all items on this page LOCATION 33q U),4 1/15,8.it/ Rty- Print, PROPERTY OWNER ,C� 416'e5 Print MAP NO.: // PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building <One family ❑ Addition 0 Two or more family ❑ Industrial ❑ Alteration No. of units: Repair, replacement 0 Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving(relocation) 0 Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: 3�F- J Phone: Address: �'j"3 ) U f5-k 1v i CONTRACTOR Name: V (' � 2 j, Phone �S'� Address: 17 /"I 1 Lax( 977 yv'aT M-A- 0 ) g z/ Supervisor's Construction License: G e)l 36 Exp. Date: O Home Improvement License: p , Exp. Date: ARCHITECT/ENGINEER ,/�/ - Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$__9,793z&1 FEE:$ q� Check No.: 70 `�� Receipt No.: Page I of 4 I TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ F1 Tobacco Art ❑ Public Sewer Tobacco Sales ❑ Food Packaging/Sales ❑ Well ❑ ❑ Permanent Dumpster on Site Private(septic tank,etc. ❑ Electric Meter location to proj ect NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ i COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS ' I DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS f f FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date 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 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA—(For department use) 00 Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Jan.2006 J �I 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 5a/Building Permit Application ir/workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ 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) 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 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:BPFORM05 Page 4 of 4 Location ✓�� '"'"'�"i ��"' No. Date MO�Th TOWN OF NORTH ANDOVER Certificate of Occupancy $ s'•.•Eta' Building/Frame Permit Fee $ S�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 70 19850 Building Inspector F NpRT1y Town of over No. 144( 3 ~ _ LA E dover, Mass., _ ' O G COCMICMEWICK AERATED Ok `S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ ........... .. .... ..........Mrc-1......................:.................................... .............. Foundation has permission to erect..................................6-4.6.0 buildings on 401....... ..... .�.......... Rough to be occupied as......S. .l. ............................... .. ............1.4.... Chimney ................................................... .. provided that the person accepting this permit shall in eve spect conform t he 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 %P aw PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU TS Rough .... .... ........ ... .......... .. ................. ..................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Ocmpy 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. ��tP, i�ani�rt4�tu�ealC� a�✓`Zaaoac�u�.ft4 ` Board of Building Regulations and Standards -- HOME IMPROVEMENT CONTRACTOR, Registrattori101841 i*or ltiorw g/29/200t3 Type: PdV'ate Corporation �{�h ,22'FTE-GONs-rRUCTION-CO. INC:__ _ - --- 17 MILTON'. Dracut;MA 01826 Deputy Administrator i BOARD OF BUILDING REGULATIONS License: CONSTRUCTION;SUPERVISOR' 1 Numbers:CS 021304 Birthdate 01/20/1.948 f' Expires 0i/20/20.08 Tr.no: 14604 Restricted M-1- ROGER 0 ROGER G PAYE?TE' i 17 MILTON ST G— j DRACUT, MA 01826' } �� ..�...-__..._... Commissioner � Y The Commonwealth of Massachusetts t Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): VAul��'� Address: /�f j L?2 V City/State/Zip:` Phone#: �Sy L50?o Are you an employer?Check the appropriate box: Type of project(required): 1.ted,I am a employer with 1 4. ❑ I am a general contractor and 1 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. T 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.❑ 1 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.tg�Roof repairs insurance required.] t employees. [No workers' 13.0 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 are 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:k3oe-%�L��1j /1if�l/1 L//,o Policy#or Self-ins.Lic.#: Weel._)Csc_)—IOP� Expiration Date: Job Site Address: _;59 2 VI �y City/State/Zip:,V®,4/,d0 M,4 6)� 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. I do hereby cer ' er the p penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: S Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i i 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 be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 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 burn 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia PAYETTE CONSTRUCTION CO. AGREEMENT Homes&Additions of Distinction 17 Milton Street Dracut,Massachusetts 01826 OFFICE(978)454-5223 License No.021304 FAX(978)453-0829 paycons(&-comcast.net Reg.No.101841 TO: Daniel Mees DATE: October 27,2006 339 Waverly Rd JOB NAME: Re-roof No.Andover,MA 01845 TELEPHONE:617 2019131 FILE NAME: 06meesl EMAIL ADDRESS: danm@text100.com DESCRIPTION: Strip and re-roof house as described below PRICE: $8,783.00 JOB TO INCLUDE PLANS:All plans,if any,necessary to obtain a building permit. PERMIT: Builder to obtain building permit. Owner to pay permit fee. DEMOLITION: Price includes removal of up to two layers of old roof shingles. Any additional layers will be removed at extra cost of$1.00 per square foot for removal and disposal costs FRAME:All framing,if any,to meet or exceed state and local.building codes. No framing labor is included or anticipated. If,however,any structural deficiencies are encountered they will be repaired for time and materials. ROOF: New roof to be Owens-Corning 30-year architectural series,owner's choice from builder's selection. Ice and water shield is to be installed on al roof edges and in all valleys. Any areas with a pitch shallower than 4/12 will be fully covered with ice and water shield. PLUMBING:New roof collars will be installed on any penetrations. RUBBISH REMOVAL:Builder to remove all debris generated during construction only. Rubbish containers are not for homeowner use unless otherwise agreed upon by both parties. PAYMENT SCHEDULE : ,,pp PERCENT PMT.: UPON COMPLETION OF: AMO "` f hRpa) ° S 10/ UNTO B ° SIGNING OF THIS AGREEMENT 900.00 W N 10% OBTAINING BUILDING PERMIT 900.00 30% START OF WORK 2,600.00 30% FRONT OF HOUSE COMPLETE 2,600.00 20% SATISFACTORY COMPLETION 1.783.00 100% 8,783.00 AMENDMENTS:This section to be used to list any changes to this agreement. I PAYETTE C T. C B NAME: MEES SUBMITTED BY: ACCEPTED BY: RODE A TTE DATE:October 17.2006 DATE: PAGE: 1 OF:2 r i TERMS OF AGREEMENT (Not all will apply to all projects) 1. Both parties must agree to any changes. Initialing said changes shall indicate such agreement. 2. Payment for each phase of construction must be made before the start of the next phase. Such payment indicates owner's satisfaction with that phase. 3. Owner agrees to immediately notify builder of any situation that might cause a work delay or stoppage so as to minimize losses to the builder. 4. Satisfactory completion:If dispute arises over satisfactory completion,work will be determined to be satisfactory or unsatisfactory by an impartial third party in the building trades. Such third party is to be mutually acceptable by both parties. 5. When a second floor is to be added to an existing home,the builder will take all reasonable precautions to prevent water damage due to rain. NO GUARANTEE,however is either expressed or implied that,if such damage occurs,repair is the responsibility of the builder. 6. The builder assumes no responsibility for any thing encountered during excavation that is beyond the builder's control,such as, BUT NOT LIMITED TO,ledge,excess concrete from other building projects,high water table or any other obstacles which would cause a work delay. 7. Unless otherwise previously stated in the specification sheet(s)the following items are NOT INCLUDED:Finished landscaping (shrubs,raking,seeding,mulch,etc.),gutters and downspouts,storm windows and doors,floor.coverings(rugs,inlaid,tile etc.), dryer vents,microwave oven vents to outside,towel racks,toilet tissue holders,door stops. S. Builder to provide proof of contractor liability and worker's compensation insurance before start of work,however,owner is responsible for providing hazard insurance for the structure as it is completed. This may be obtained as a rider to the existing homeowner's policy. 9. When remodelingor adding to an existing house owner is to provide builder with access to the house for the purpose of resetting g g � P P �'P g circuit breakers and for bathroom use. If owner wishes,arrangements could be made for electrical generators and chemical toilets to be used at the owner's expense. 10. It is understood that heavy equipment will be needed to perform different functions during construction. All reasonable precautions will be taken to prevent driveway or lawn damage,however,repair of such damage,if it occurs,is not the responsibility of the builder unless otherwise described in the specifications of this agreement. 11. When a flat or nearly fiat rubber roof is installed,it is common for rain or melting snow to puddle in low spots. This is common and has no adverse effect on the roofing material and is not indicative of poor workmanship or structural flaw. 12. It is common for concrete to crack,pit or flake. This is not an indication of defective material or workmanship. Cracks will be filled if they occur within the one-year warranty period. No other consideration will be given. 13. All work is guaranteed for one year from the date of completion. Completion is defined as the date that the occupancy permit is secured,or when all final inspections are signed off. Any"punch list"items will be dealt with separately from guarantee items. PAYETTE CONST. CO. JOB NAME: MEES SUBMITTED BY: ACCEPTED BY: ®r ID ER PAYETTE {�-JV DATE:October 27,2006 DATE: I'L lot PAGE:2 OF:2 WORKERS COMPENSATION AND EMPL&Efts-dABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company Burlington, Massachusetts (800)876-2765 NCCI NO 40959 POLICY NO. I WCC 5004956012006 ITEM PRIOR NO. WCC 5004956012005 1. The Insured Roger Payette dba Payette Construction Co Mailing Address: 17 Milton Street Dracut MA 01826 (No. street Town or City County State Zip Code ® Individual ❑ Partnership ❑ Corporation ❑ Other FEIN 04-2796792 Other workplaces not shown above: 2. The policy period is fron,03/15/2006 t,03/15/2007 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 500,000 eachaccident ' Bodily Injury byDisease $ 500,000 policylimit Bodily Injury byDisease $ 500,000 each employee C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual of Annual Remuneration Remuneration Premium INTRA 001111 SEE EXTI-NSION OF INFORI 4ATION PAGE Minimum premium$ 500.00 Total Estimated Annual Premium $ 2,146.00 As indicated,interim adjustments of premium shall be made: Deposit Premium $ 2,228.00 ® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg. $1,856.00 x 4.4000% $82.00 This policy,including all endorsements,is hereby countersigned by 01/12/2006 Authorized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Boston Insurance Brokerage Inc MA 5645 7 505 24 Federal Street 4th Floor WC 00 00 01 A(11-88) Boston,MA 02110 Includes copyrighted material of the National Council on Compensation Insurance. used with its permission. From:<Apleb &Wyman> To: 19784530829 PaC: e: 112 Date: 11/14/200611:12:04 AM V- W. /4L' (;tKfItIYA I t Ut' LIAMLI I Y I1VSUKAW; h 1 11/14/2006 PRODUCER (978)692-3330 FAX (978)692-0728 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Appleby & Wyman Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 301 Littleton Road HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 330 Westford, MA 01886 INSURERS AFFORDING COVERAGE NAIC# INSURED Roger Payette INSURER A- National Grange Insurance Co. 14788 DBA: Payette Construction Co INSURERB: Associated Employers Ins. Co. 17 Milton St INSURER C: Dracut, MA 01826 INSURER D: INSURER E: OVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADO'L TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION LIMITS YY) DATE IMMODNY) GENERAL LIABILITY MSB95067 03/16/2006 03/16/2007 EACH OCCURRENCE $ 1 000 X COMMERCIAL GENERAL UABIUTY DAMAGE TO RENTED SPREMISES(Fa ocamanca) 50 ,0001 CLAIMS MADE rR]OCCUR MED EXP(Any one person) $ S, AlfPERSONAL&ADV INJURY $ 1 000 DO GENERAL AGGREGATE $ 2,000, GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPiOP AGG $ 2,000, POLICY JECTPRO- LOC AUTOMOBILE LIABILITY COMBKED SINGLE LIMB ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODLYINJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTYDAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. AGG $ EXCESSIIMIBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION AND WCC5004956012006 03/15/2006 03/15/2007 1 TORYSLAwirfrS I X I ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT S 500 0 00 B ANY PROPRIETORlPARTNERIEXECLnWE OFFICERIMEMBER EXCLUDED?WE.L.DISEASE-EA EMPLOYEE S 500,000 dcribeunder PROVISIONSbelow E.L.DISEASE-POLICY LIMrT Is 500 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS Re! 339 Waverly Road. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, No. Andover Building Department BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 400 Osgood Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. N. Andover, MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25(2001108) FAX: (978)688-9542 ®ACORD CORPORATION 1888 This fax was sent with GFI FAXmaker fax server. For more information,visit:hftp://www.gfi.com