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HomeMy WebLinkAboutBuilding Permit #319-2016 - 393 JOHNSON STREET 9/14/2015 f�,ow•vED 9/�/r O1 NORTH -1 BUILDING PERMIT tt�FD TOWN OF NORTH ANDOVER 3 APPLICATION FOR PLAN EXAMINATION Permit No#: � Date Received �qs R 7Eo�Q��cS SACHV`' Date Issued: �' IMPORTANT: Applicant mustcompleteall items on this page LOCATION 393 T4 k n S c n Sf, t Print i PROPERTY OWNER Jo n y-\ Fo,r roche\r - Print 100 Year Structure yes no MAP PARCEL: W� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Re si ntial Non- Residential ❑ New Building One family ❑Addition ❑Two or more family [I Industrial ❑ eration No. of units: El Commercial Repair, replacement ❑Assessory Bldg_ ❑ Others: ❑ Demolition ❑ Other Septic 0 Well ❑ Flood plain El Wetlands ❑ Watershed District. O Water/Sewer.. DESCRIPTION OF WORK TO BE PERFORMED: F _roof sZ cA2cL %ro p o i Identification- Please Type or Print Clearly OWNER: Name: 7"0hr\ Fc,.rrW- ar Phone: 97�'-6�6 al6S Address: 393 T o�nson Sf, Contractor Name: �SCoff" Wn O i— Phone Email: Co rn Address: , A"ver- vh o1r8 S Supervisor's Construction License: CS^ i 0SL6C3 Exp. Date: 811.- a0I7 Home Improvement License: 13 8 569 Exp. Date: 1Y/d-017 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: $ 17 a80,00 FEE: $ 2, � 1,� Recei Check No.: t No.:p NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/Massage/Body Art ❑ Swunming Pools ❑ Well ❑ Tobacco Sales 1 ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed 06 Signature_ COMMENTS i CONSERVATION Reviewed on Signature COMMENTS i HEALTH t Reviewed on__ Signature COMMENTS I 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 DEP - nARITMEN;T, TempDumpster ontsite ,yes �. 'anon L=ocated�at"�124iMaintStreet• - - -- - 'FiredDepartmnent signature/date _ .R. a _ 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 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 I sed Work With Sprinkler Plan And Floor/Cross Section/Elevation Plan Of Propo 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 IECC Energy code 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 I No. 6( Date i A • - TOWN OF NORTH ANDOVER • ���LEIx f6ys .. • • Certificate of Occupancy $ vaE Building/Frame Permit Fee �� ., Foundation Permit Fee $ w Other Permit Fee $ TOTAL - $ Check 4t 1 --v + , ; Building Inspector r 1 NORTF{ : c . : ver 0 a36 h ver, Mass,, '� 26145 o COC NICHIWICK IJ BOARD OF HEALTH Food/Kitchen PERMITJ D Septic System THIS CERTIFIES THAT .............. ......................... .......e.................................................... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .... .. ....1 4..No- .............. Rough to be occupied as ........do-p .... ..... ....c .. ....... c.. ... . .. .... ............................................................ Chimney provided that the person accepting 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 6 M THS ELECTRICAL INSPECTOR UNLESS CONSTR C S S Rough - Service ........ .... ................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. 916rHT G UTrERS • Massachusetts Home Improvement Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek Iegal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Arame r Company Name Joh £ Barbara rar�ro, r Street Address do not use a Post Office Box address) Contractor/Sales on/Owner-Name 393 Joknson Sf- sco+ W P,'' ht Cityrrown State Zip Code Business Address(must include a eet address) N, Andovew- mR 018V5 350 guru St, Daytime Phone Evening Phone City/ToAn State Zip Code 9-8- b86--x165 SR M E_ &I, A►dover M A or8v5 Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Homermpiove lCoatradcrft Number Eaphadon date Lon requires that most home avalid rmtsit traattonban 1385-6 The Contractor agrees to do the following work for the Homeowner: r (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) SA np0Qp p kas2 sQR- a;F&c" Required Permits-Thefollowing building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of V-lfhS Date when contractor will begin contracted work MGL chapter 1.42k) u' / Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule '� ,p The Contractor agrees to perform the work,fumish the material and labor specified above for the total sum of !I7 0 t,00 (') Payments will be made according to the following schedule: $ con,tra`ct price op the cost of special order items,whichever is greater) on.00 upon signing contract(not to exceed 1/3 of the total $ 3 8 L(On.00 by ! /_or upon completion of 1V_3 0 f( �O 6 $ 36g000by / ! or up.completiono / f 7'X or I,)6 $ .13 7 Da 00 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special S to or ordered before the contracted work begins in order to meet the completion schedule.(**) S to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Ts an express warranty being provided by the contractor? \o❑Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,tine contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Taw. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESH I Ttvo identical co' the contract must be comp ed and siped.One copy should go to the homeowner.The odier soppy shou ulld be kept by die contractor. Vv Honmeown 's Signature ntractor's Signature 9l/a-1l S Date fDate FREE ESTIMATES PROPOSAL Construction supervisor Lie.# CS102663 FULLY INSURED H.I.C. Reg,# 138569 WWGHT ROOFING-GT,J'I 'ER8 AND HOME IMPROVEMENT All Types of Roofimg& Gutters 350 BERRY STREET e NORTH ANDOVER, MA 01845 TELEPHONE: 978-687-2247 PROPOSAL SUBMITTEDTO PHONE DATE �hn 801r6olra r�G��ac der fi -b - L 9 ra �s- STREET ,toe NAME r LOCATION o n.3o o S, y78 i�-b566 J�-r�► CITY STATE AND ZIP CODE JOB START DATE t Darh � zp r �acevane.vit CLU-t- ` o r c2 F Snc)w. t of (Qaked I`n� C� Aue T e heavy Snow >` ice *At'S fast Wih` k< �'o©F I ranf c 'PA. ZZAack a.v\ ro*4 wood deck Il . SQctof a-.Cn lea 9"e. OfQas ice... � "�s Skilr' �S �2v►e'�r`a'�'o�►J; oval[S ilS� 6 I ©t i CQ E tNC'+tr i.fl�2c� SkJuc2w� V�C �p bocr �S pr w. r. � MVoV-o,O,ryroof � d f ` -f �-Qak ter , n0-o.t r>z (ate i co E t,s G l n , W pQ W ovn cLU ec�.u�S P d-.�.e.s, uSu �Ck�r-�(C)o Vcjo,r (ac-rrt`�r oi� res'�-o� COO oo k1-1 I fa kLSP S . SYS i fA GAS r�rnbar-[�. ��rC�"feC� Sk,1.gAj r-efk tc "-44, �¢ S r�.tt�• CS'J t �new �S1.i� �i �, a 040 d j--b (Qa k; C'�Gcim# i 000,00 (3os�) Sq E -- 0.00 .l , o ) 38 C bU stf .r New. S��[,�-�,;1,t�. �t�s (�)�� ��Y80��Kt�-s F c�s`t�t(��or opt of �►.v��=�c,,�.�-� �� t�. 11 We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:s / / � 80, Q 0 P ent to be made as follows: j "" h ck � �. ��76a � �/�Co v l h otRak iron" 4o -hake CcrjL c exim cost All material is guaranteed to be as specified.All work to be completed in a substantial workmanlike AutfitNlZed manneracconiing to specifications submitted,per standard practices.Any alteration or deviation from above specifications involving wdra costs will be executed only upon written orders,and will become an Signature etre charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control,Owner to carry fire,tomado and other necessary insurance.Our workers are fully NOTE: This proposal may be covered by Workmen's Compensation Insurance.Non payment by agreed party may result in litigation withdrawn by us if not accepted within days. with penalties including court cost and compensation both real and punitive. Acceptance of Proposal - The above prices, specifications and � (4 conditions are satisfactory and are hereby accepted,making this a valid contract. Signature You are authorized to do thew rk as s ecified.Payment will be made as outlined. i Date of Acceptance: Signature The Commonwealth of Massachusetts f Department of IndustrialAecidents r 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass•gov/dia davit:Builders/Contractors/Electricians/Plumbers. Workers'Compensation Insurance Affi TO BE FILED WITH THE PERMITTING AUTHORITY. please Print Le •bl A licant Information Name(Business/Organization/Individual): Address: 35 0 dA e.,�ml� 0i$YS Phone#: 9` 8-68?-AdY7' City/State/Zip: ,.:.: . Are you an employer?Check the appropriate box: Type of project(required); L[9' am a employer with a- employe (full d/or part-time).* 7. ❑New construction 2.F1 I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 3.[] ❑ I will all work on mproperty. er and will be hiring contractors to conduct Y Electrical repairs or additions homeowner 11 p 4.❑I am a hom compensation insurance or are sole ❑ ensure that all contractors either have workers'comp ' plumbing repairs or additions ro rs with no em 12 P loyees. .❑ proprietors contra and I have hired the sub-contractors listed on the attached sheet. 13.[]Rb6f repairs a general co _ 5.❑Iain g _ o0f and have workers'comp.insurance.t ctors have employeesZ f These sub-contra14. Other S 1� f 6.❑We are a corporation and its.officers have exercised their right of'exemption per MGL c. � • 152,§1(4),and we have no employees.[No workers'comp.insurance required.] gsu *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 ang ditio nal doing showing the all work andname of the sub-contractorsen hire outside and state wrs must hether or not thoseentities,have h at check this box must attached $Contractors that policy number. employees. If the sub-contractors have employees,they must provide their workers'comp p y I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. jj .. l A Insurance Company Name: U �� u I I�AX� � • Policy#or Self-ins.Lie.#: �. lnr_?�5-387187-oly Expiration Date: / �S �- 11l Andaver rf'►A ol�ys lob Site Address: 9 3 J 0 11 S°n St ��` n t�0 tJ�� n1A City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a foie up to$1,500.00 Failure ER and a fine of up to $250.00 a ent as well as civil penalties in the form of a STOP WORK ORD e- ear imprisonment, e DIA.for insurance and/or i y p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of coverage verification. I do hereby certify nder �,epalns�an nal ' perjury that the information provided above�t and.correct. Date: Si ature: Phone#: 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 Phone#• Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An 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-contractors)name(s),address(es)and phone number(s)along with their certificates)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 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#617-727-7749 Revised 02-23-15 wwwmass.gov/dia 77W 1YYYY)A�VCERTIFICATE OF LIABILITY INSURANCE �- 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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 endomement(s). PRODUCER T A SULLIVAN INSURANCE AGENCY INC NCAO MV c 135 MERRIMACK ST PHONE FAX METHUEN,MA 01M-1414 M4 I Atc No 844 E-MAIL ADDRESS; INSURERS AFFORDING COVERAGE NAIL 0 INSURER A: LM Insurance Corporation 33600 INSURED INSURER 0: SCOTT WRIGHT DBA WRIGHT GUTTERS INSURERC: 350 BERRY STREET INSURER D: NORTH ANDOVER MA 01845 INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: 25682752 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 EXP .TRR TYPE OF INSURANCE L POLICY NUMBER MWDD SUOR EFF MMIODY ILIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE D OCCUR PREMISES a oewrrence $ MED EXP(Any arm person) S PERSONAL&ADV INJURY $ GENrL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑jE O- 0 LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITYEeMUaI LIMIT— $ ANY AUTO BODILY INJURY(Per pmn) S AALL UTOS OwNED AUTOS SCHEZJULED BODILY INJURY(Per accident) S NON-OWNED PROPERTY DAMAGE9 HIREDAUTOS AUTOS S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DEO RETENTIONS S A WORKERsCOMPENSATION WC5-31S-387187-014 9/30/2014 9/30/2015 STA urE DR AND EMPLOYERS'LIABILITY ANY PROPRIffOR/PARTNER/EXECU'TiVE YIN NIA E.L.EACH ACCIDENT S 1 OOOOO OFFICER/MEMBER EXCLUDED? Y (Mandatory in NMI E.L DISEASE-EA EMPLOYE $ 100000 If gee,doseribe under DESCRI N OF OPERATIONS below E.L DISEASE-POLICY LIMIT 1$ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddMMI Rernsrks Schedule,may be attached H more apace is r"ukad) t- , THE VfORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SCOTT WRIGHT. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers'compensation coverage. WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. CERTIFICATE HOLDER CANCELLATION Al �Q � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ,AJn Of /`a1 jkd VP-I- THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN t t -1ASpLcf-0�r ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 25682752 1 1-387187 114-15 We I shankar.gadaleelibertymutual.com 17/22/2015 11:28:27 AM (PDT) I Page 1 of 1 t, ��fr Int fit r.l/ll'Plr��f Office of Consumer Affairs&Business Regulation - a`AOME IMPROVEMENT CONTRACTOR I� tegistration: •138569 Type: "Expiration: 4/14/2017 DBA WRIGHT GUTTERS SCOTT WRIGHT 350 BERRY ST. NO.ANDOVER, MA 01845 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without stgnature Massachusetts De a rtment of Public Safety Board of Building Regulations and Standards p License: CS-102663 Construction Supervisor r NN SCOTT W WRIGHT-I 350 BERRY ST NORTH ANDOVER MA 01P-J849 Com"'z'z `-A-- Expiration: missioner 08/12/2017 Unrestricted-Buildingsa of any useg Prou which Contain less than 35,000 cubic feet(991m)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS