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HomeMy WebLinkAboutBuilding Permit #659 - 43 WOODBRIDGE ROAD 5/7/2008Permit NO: S _ i, Date Issued: 5- a� BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page LOCATION 43 W 001DMO F P, t t" w \j `f S Print PROPERTY OWNER "146 Wk�lltCk 32 46,�� ..a6�6 OCL 0 �Q_ c .uwncw 1. Print MAP NO: PARCEL---a-ZONING DISTRICT: 'Historic District yes no Machine Shop Village ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Two or more family Industrial Alt No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: t"OVC- Sc2VeN5 f -O M 6-y_ (S 0 0 6 013 PwLwe w rN Siy-6 ue ?A W6 f -O Lc I N G cND0as Identification Please Type or Print Clearly) OWNER: Name: 1_'iik(4C W�IWICK Phone: 17f"6 �� $`l to Address: 43 t400T)& .iDGE U, troR�ei Atu�oJ. _MA c)(Tq CONTRACTOR Name: rt a t t,� c� �5raC Phone: a7T• 61fZ-7' 60; Address: l5- I eAN DK uN t f Supervisor's Construction License: tiv2 Exp. Date: s1,016- 2,010 Home Improvement License: 1,11 q� " Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED CO,STT-BASED ON $125.00 PER S.F. Total Project Cost: $ / �5�- FEE: $ Check No.: /a 0ay Receipt No.: - NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund nature of Agent/Owner, Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS 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 signatureldate 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: INSPECTIONAL SERVICES DEPARTMENTMFORM07 Revised 2.2008 Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ ---- pop Building/Frame Permit Fee $ 4r6 --- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #.Id ad 0,�/ 2 1 '142 Building Inspector CA m m m m m mm v H 'O C � � d CO) Cl) CD 'C O C2 Z CA CL =� ? O 0. S. y R 0 v CD CD o CL C7 m d CD CCD O CD C CD y� CL v CO) CCD I � CO! o CD 'D Z lot CD O CD VJ n O Ic Im c?10o =rS o EGG o Q t°ii norm .fl CO) m m Cl) o yc�ao � m Z •- gr -s. h _1 0,: CL m ngO m O �O o o p -•i N o m m 2 > o w m m �pzs Ow O �� O yo C! W S c O a a c � � •y,m CL m o O y CD n= m c amC CD O p� ti CA O.� CS C _ c H CL O X = r CA H So m d H m an �o ®oce� CD m 0 CD % �L 4:;S CL no � o moo: c o moo: o C 0 . z m cn OWNIVir' o -x c o w.GQ : o � n� o m =), 11 •o M ms � •'� i s o cn o -x c o w.GQ : o � n� o •o o °� ar E.zcn Cy a ° 7d G) n r ` < O x x y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone F-1 am a homeowner performing all work myself. F-1 I am a sole proprietor and have no one working in any capacity FV I am an employer providing workers' compensation for my employees working on this job. Company name: NO F+CWSJEC-S, INC.. Address 0Nti 5 City: MEsMyit-0 , ?A k 0544 Phone #: 2- 71400 Insurance Co. 01C RS PRge-9T4 WWWq COMPANY Policv # (AIA -127-561-3-07 Company name: Address City: Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this stater, nt may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herby certify under the Signature_ 0.b Print penalties of perjury that the information provided above is true and correct. Official use only do not write in this area to be completed by city or town official' ❑ Check if immediate response is required Building Dept Contact person: Phone FORM WORKMAN'S COMPENSATION # 978-682- ;;11� ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other ` v The Commonwealth of Massachusetts .. Department of Industrial Accidents Office of Investigations w' 600 Washington Street r Boston, MA 02111 411 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ?a1 IO 0`125 Address: 15 Ig49��` Ci 4L Phone #: ? Are you an employer? Check the appropriate box: I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors '. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance. 5. ❑ 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.] 0- lob Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I ant an employer that is providing workers' compensation insurance for fny employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: c ;2--1LICB R 1;L3B toaolb, Expiration Date: -7 Job Site Address: �3 Gt��.���i�,�� City/State/Zip: /�• 9n�o✓l s, W4 e18'4S' 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 certify under, fits and penalties of perjury that the information provided above is Vue and correct: 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 #: METHUEN (978) 682-7400 �tE�INC. TAUNTON (508) 822-1966 WORCESTER (508) 756-2141 E!�OSUFAX (508) 821-9339 FAX (978) 682-0061 TOLL FREE (888)333-1966 "An Employee Owned Company" 15 AEGEAN DRIVE UNIT 5 500 MYLES STANDISH BLVD. METHUEN, MASSACHUSETTS 01844 TAUNTON, MASSACHUSETTS 02780 HOME IMPROVEMENT CONTRACT MASSACHUSETTS REGISTRATION #117565 DATE:JI-11,194 /200Z' Page 1: I, we hereby accept your proposal to furnish all ab r and materi�l necessary to perform the following work on the premises of the Owner " r•; located at� ) in the City ofAf Ph - State of Zip / Tele: u Customer E-mail address: This contract shall be considered non -cancelable after legal cancellation period has expired. THE WORK TO CONSIST OF: Single Glazed AIIView„adld All non -thermally brgken sunrooms with insulated glass ARE NOT designed to be heated or air,.conditioned. (Initials) h Any inquiries about a contractor or subcontractor relating to a registration should be directed: Director • Home Improvement Contractor Registration • One Ashburton Place, Room 1301 • Boston, MA 02108 or call (617) 727-8598. --go to page 2-- ■ METHUEN (978) 682-7400` ' "- TAUNTON (508) 822-1966 WORCESTER (508) 756-2141 ,ENCLOSURES, INC. FAX (508) 82179339 FAX : (978) 682-006.1 'An Employee Owned Company®` ' TOLL FREE (888) 333-1966 15 AEGEAN DRIVE - UNIT 5 500 MYLES STANDISH BLVD. METHUEN, MASSACHUSETTS 01844 TAUNTON, MASSACHUSETTS 02780 HOMEL IMPROVEMENT CONTRACT MASSACHUSETTS REGISTRATION #117565 Date: r;. 20 ' Page, #2: Seller, agrees to furnish labor and materials at Buyer's: request, and for the contract amount, to complete the work described above, subject to the terms and conditions which appear.on both Page I &Page 2 and on the REVERSE sides of this contract. Work to start approximately;/ weeks from the date -of this. contract and to be completed approximately weeks after commencement if not delayed by building, permit; delivery of, materials, weather, strikes, fires, or other conditions beyond Seller's control. The completion date is not.of the essence. . Buyer represents and warrants that legal title to the property, which is to.be improved, is in the following owner(s): Tt NOTICES 1. Seller and/or all subcontractors, if any, who perform on this, contract, and who are not paid, may have a claim against you which may be enforced against the property being improved; in accordance with the applicable lien laws. 2." YOU, THE BUYER, MAY CANCEL THIS TRANSACTION" AT ANY TIME. PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER ,THE. TRANSACTION, DATE (THE DATE ON WHICH YOU SIGN THIS CONTRACT). SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. THIS RIGHT IS IN ADDITION TO ANY RIGHT YOU OTHERWISE MAY HAVE TO"REVOKE YOUR OFFER. The contractor and the homeowner hereby mutually agree, in advance, that'"in the event the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in MGLC. 142A. Contractor Owner NOTICE: The signatures of the parties above apply ONLY to the agreement of the parties to alternative dispute settlement initiated by the contractor. The owner may initiate alternative dispute resolution even where this section'is not separately signed by the parties. ,, ,- WHERE REQUIRED HOMEOWNER TO GET PERMIT. Source of Sale: 7 Contract Price $ THE DOWN PAYMENT SHALL BE A Down Payment $. -7Ut`)�"J r"tii !r 130 Pq y f..; -L NONREFUNDABLE DEPOSIT ONCE THE THREE DAY CANCELLATION PERIOD HAS EXPIRED. $ THIS CONTRACT CONSTITUTES THE ENTIRE Balance Due UNDERSTANDING OF THE PARTIES. Upon Installation $ Customer acknowledges receipt of a copy of this contract, product warranty and duplicate notices of cancellation. DO NOT SIGN THIS C NTRACT IF THERE -AR > ANY BLANK SPACES Date Down Payment Received:�� (Customer Signature) (uf By (Signature of P0 Representative) (Customer Signature) Subject to the terms and conditions which appear on both Page 1 & Page 2 and REVERSE sides of this contract. ADDITIONAL WORK AUTHORIZATION PATIO ENCLOSURES, INC. 15 Aegean Drive - UNIT 5 METHUEN, MASSACHUSETTS 01844 (978) 682-7400 Manchester (603) 645-8538 Toll Free 888-333-1966 OWNER'S PHONF M U 3q/ DATE0q/A/ 0 NAME ---. STREET JOB NAME JOB q9MBER CITYSTATE Iq ` STREET A.'� 7-w/ oo �� EXIST1IqG CONTRACT NUMBER DATE OF EXISTING CONTRACT CITYIV- Ebt65 STATE mvi You are authorized to perform the following specifically described additional work: 7 ..... .. ..... ......... . Z A- 7 V r�r- ................... ... . .. ... ........ ............ ... .. ... .. ........ 1,79 a 7 .......................................... .. .................................................................. . &-L «r DF-R�, ADDITIONAL CHARGE FOR ABOVE WORK IS: $ A Payment will be made as follows: C—#,L ci� 17*-- C;to Above additional work to be performed under same conditi =ntractpecifiedotherwise stipulated. p Date Y" O Authorizing Signat e WNER SIGNS HERE) We hereby agree to furnish labor and materials - complete in accordance with the above specifications, at above stated price. Authorized Signature Date (CONTRACTOR SIGNS HERE) THIS IS CHANGE ORDER NO. NOTE: This Revision becomes part of, and in conformance with, the existing contract. / CONSUMER INFORMATION FORM — "SUNROOMS" W " Massachusetts State Building Code (780 CMR, Appendix J, SectionJ1.1.23.1) The Massachusetts State Building Code (780 CMR) includes provisions to ensure that houses and house additions meet energy efficiency standards. This supplemental CONSUMER INFORMATION FORM is to be filed as part of the building permit application when a builder/contractor or homeowner, special energy conservation exemption option for "sunroom" additions to an existing house (780 CMR, Appendix J, Section JI. 1.2.3.1). This FORM is not intended to prevent a homeowner from selecting a "sunroom" of any size, configuration, orientation, form of construction or percent glazing, but rather is only intended to assist homeowners in becoming aware of some of the important energy conservation and year- round comfort considerations involved in selecting and utilizing a "sunroom" addition. The connection of "sunroom" structures to residential buildings My create comfort and energy consumption issues due to uncontrolled solar gain or uncontrolled radiation cooling of the main house. In the selection and construction/installation of "sunrooms", included below is a non -required, open-ended list of product and design considerations that a homeowner may wish to consider before actually their designer, builder or contractor, in order to minimize potential energy consumption and/or house discomfort issues. In addition, the qualifications and reputation of the company or individuals to be hired are important considerations. PRODUCT AND DESIGN CONSIDERATIONS RELATED TO "SUNROOMS" • Solar Orientation and Natural Shading • Type of Glazing o Insulating value o Solar heat gain o Frame materials o Glazing to frames sealing and gasketing materials/seal durability and/or weather tightness of the sunroom • Adequate ventilation — Operable windows and fans • Applied Shading Systems • Insulation level in floors, walls and ceilings • Possible Sunroom isolation from the main house via a wall and/or Moor slider • Heating and Cooling Methods: Efficiency, Zoning and Controls Homeowner Acknowledgment The Massachusetts State Building Code, Section11.1.2.3. I, requires that the actual property owner (not the owner's agent or representative) acknowledge receipt of this CONSUMER INFORMATION FORM prior to issuance of a Building Permit for a project that includes "sunroom" additions to an existing residential building. In accordance with this requirement, the undersigned hereby acknowledges that she/he has read the information in this document concerning sunroom comfort and energy conservation. 1 ql� Signa a of Actual Buil mg Owner Date Print Name Address of ermitted Project Owner Address (if different than project location) Owners telephone number Board of Building Regulations and Standards Construction Supervisor License License: CS 96425 Birthdate: 7/8/1969 Expiration: 7/8/2010 Tr# 96425 Restriction: 00 WILLIAM MEREDITH... 34 ROSS DRIVE LONDONDERRY, NH 03053 Commissioner ✓1ze �omvrnaiuvea� o���aclucaeba Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR l:egstration: 117565 Expiration: 10/19/2008 Type: Supplement Card PATIO ENCLOSURES.INC WOODY MEREDITH. 500 MYLES STANDISH BLVD.�r TAUNTON, MA 02780 Administrator C- License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 ba. Not vlid without signature I PATIENC-09 BUKR -7YYYY) ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE 7//3/200312007 PRODUCER (216) 622-7400 The James B. Oswald Company 1360 East 9th Street, #600 Cleveland, OH 44114-1730 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Patio Enclosures, Inc. ALL LOCATIONS 700 East Highland Road Macedonia, OH 44056 INSURER A: Travelers Prop Cas Co of America 25674 INSURER B: Charter Oak Fire Ins Co 25615 INSURER c: Nat'l Union Fire Ins Co of Pittsburgh PA INSURER D: INSURER E: COVERAGES 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 TR DD'L N D TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMID POLICY EXPIRATION DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR G660291 DO360 7/5/2007 7/5/2008 LU PREMISES Ea occurence $ 500,00 MED EXP (Any one person) $ 10,00 PERSONAL& ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 POLICY X PEO- LOC CT B AUTOMOBILE X LIABILITY ANY AUTO GJCAP291DO359 7/5/2007 7/512008 COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per accident) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 5,000,00 C X OCCUR CLAIMS MADE BE2963369 7/5/2007 7/5/2008 AGGREGATE $ 5,000,00 $ DEDUCTIBLE X RETENTION $ 10,000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? GC2JUB9123B60907 7/5/2007 7/5/2008 XWC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 It es, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,00 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ACORD 25 (2001/08) © ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) © ACORD CORPORATION 1988 Pat� ENCLOSURES, INC. Owner Authorization for Permit Application as owner of the A subject property located at �3 ; ZLL-12 hereby authorize Patio Enclosures Inc. Methuen, MA to act on my behalf in all matters relative to work authorized by this building permit application. L Signature of owner Date rrom: "ts[en gums ^t: uswaio uomparnes raxlu: zw-fizz-t4uu I o: "sten wamwngnt Y � 010514 TRAVELERS J� NJ TAX IDENTIFICATION NO.: $41007831000 TYPE V Date: 8/142007 10:37 AM Page: 2 of 4 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GRJUE�-9220657-3-07 ) RENEWAL OF (GRJUB-922J657-3-06) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA y NCCI CO CODE: 13579 INSURED: PRODUCER: PATIO ENCLOSURES. INC. JAMES B OSWALD CO 700-720 EAST HIGHLAND RD 1360 EAST STH ST #600 MACEDONIA OH 44056 CLEVELAND OH 44114-1715 Insured Is A CORPORATION Other work places and Identtfloation numbers are shown In the schedules) attached. 2. The policy period Is from 07-05-07 to Q7 -p5 -Oa 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here; MA NJ WI rt 13. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed In Item $.A. The limits of our liability Under Part Two are: Bodily Injury by Accident; $ 1000000 Each Accident Bodily Injury by Disease: $ 1000000 Policy Limit Bodily Injury by Disease: $ 1000000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, Ilsted here: A2 OR D. This policy Includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required informatlon is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 07-27-07 FG OFFICE: CLEVELAND 042 PRODUCER: JAMES B OSWALD CO HF637