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Home My WebLink AboutBuilding Permit #479-13 - 46 MAGNOLIA DRIVE 12/20/2012Permit NO: 1/7 �—/3 Date Issued: %?A BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received .t-!e_;r �.f4;t�1-- TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial replacement ❑ Assessory Bldg ❑ Others: ,XRepair, ❑ Demolition ❑ Other b.Septic O Well 0 Floodplain ` Wetlands El Watershed District. Water%Sewer. DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: n&J- i() A fo Phone: 978 3 003 Address: y(o fflaQnQ1Ia Nva. I1 12o��n . q CONTRACTOR Name: Caj.*n�otz .. - I � � W 3 Address: :� v� .S �tJt �J':A W .<1;1I V��... 1�► ©� i )�. . ..� .g•t•. •; : „= +:..: - .. � c ' - Supervisor's. Construction License: Exp. Dater 001 3 5 ( a2 -01 I. .� ?7 iHomImprovement License: Exp. Date:'. •U ARCHITECT/ENGINEER Ph Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ '13 sou o FEE: $ Check No.: 16V3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to theuara it fund Signature of Agent/Owner Signature of contractor J 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 ®TF: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Yn 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 2008 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Tobacco Sales ❑ Permanent Dumpster on Site ❑ Swimming Pools 1❑ Food Packaging/Sales ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments t Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPART I ENT - Temp Dumpster on site yes. Located at 124 Main Street Fire Department signature/date COMMEN Located 384 Osgood Street - no 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 Dor—Building Permit Revised 2010/October Eq ui 2 LL < m C Nm u Y O LL E 41 TO Ln u O. (n U Z Z G J_ C + v c 7 LL r to_ 7 W T v c U LL 0 �" Z Z m J Qr s 7 d' _ LL 0 Z Ucc F W J W t to 7 d' �_ Z r to _ LL oc 0 Z Q s 7 OC _ LL z W Q W W 25 LL a`i m O Z +� N VI N v Y O M O N � 0 •� L � C �� •�O—, CUD, V `'�► CL L N am c 3 N � N N o-oa > •00 Q N rn o O v,O3 = E Q CL ':3 a) t m 0 m 0 N ED _ o r c Q L L •a •O ujBW = 'a +r O O Li •� � � N � O .2 Z 'E v •a r v O W L v a) ._ O H C3 C d O •a yL, co m '� C J UM) s o O F=— Q -0U > 0 i E d C Z O N W Q .E CD m m >1 O CD v in O O Q � Q O M ca r Z d 0 CL V N c CLU B LLI vI LU I'M) 19W W 19 W U) O a coZ . CD Z m Cl) 2 Z k O 1 W tin Z \a/ /\ O UJ Cl) a Z 0 i E d C Z O N W Q .E CD m m >1 O CD v in O O Q � Q O M ca r Z d 0 CL V N c CLU B LLI vI LU I'M) 19W W 19 W U) DAVID CASTRICONE CASTRICONE ROOFING & SIDING INC. ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 a3 I R e10*2UTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 In North Andover 978-683-3410 In Boxford 978-887-6147 In Haverhill 978-374-7314 Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to famish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and conditions, on premises bel described: ..1.2 y Owner's Name......�.:1'k.............. ..l.o d.. 13................................X�*,-*-'-'-*Aj.,1 ..Tele ne#......��,.J.......�..�..1..3 Job Address .... �.(s.......... ... ..Y..L. ..1..1.f !.: ........... city .... z ,Ill ......... State......1. . Specifications: ........................................................................r..............7.).......... ✓Strip existing shingles �� ply new drip edge to all edges. rile Q > 8 ...................................................................................................................................................................................................................... v4Cpply _feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane in valleys and bottom edges of any unheated areas of house. ....................................................................................................... r pply felt paper underlayment. Ia$tall rid event to r� O/� ....................................................................:......................................................... / /�....................... roof using k�B 1p1 !d= f. shingles with ayear warranty. r e ...................................... .. ............. ................................................. ..... �nterflash chimney. ew vent;pipe/flashing. mal disposal of all debris. ...................... ..... rj.......... Area(s) to be worked on: .� .// ......................................................................... ..........................................t�' ..........t" fr^ ......... b....tz•D.le!r✓` U.. �4a�?yt,t....:........%.dt.1�( ....................................................................................................................... ............................................................................�. `� .I ,>`,.................................................. I......................... ........ ........... ....... ........... ...................................................`....�o... ........................................................................................................... Roof board replacement if necessary@� D/sheet qF _ Lfoot. .................................................................................................... .................................................................-....... ................. Two Year Workmanship Warranty (Not Transferable) Manufacturer's Warranty as sp ' ted by manufacturer The c fora esvt� a bran the work and ish the materials specified above for the S of S...,/:�.$ �1,�..--.00 @ . O O I ayabh�(,Q......... on ..,5 �'Gu.......... Payable ........ .'--:............... on ......... .`'�.................... �alance payable on completion of job. _ /� J? j�� Owner or Owners are not responsible for Property Damage or Liability whi fob is in operation. Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, ex conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living spaces). Items in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract maybe assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they aro) the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s). There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108 Tel: 617-727-8598 Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction - related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A. Approximate starting date of work ................................................ Completion date ......................................................... Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation). un ) IN WITNESS WHEREOF, the parties have hereto signed their names this ... 1 day of Accepted: Signed 1 [ w [.AjI..la/t7 k1:,2.r.. ?�,./..a....7_114�.. Owner �...........' ...... .... Signed ....................................................................... Owner David Castricone, President The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information cPlease Print Legibly Name (Business/Organization/Individual): CA S-ffi j CONE o 0 F/ N& Address: T tb S-M&F T" JA City/State/Zip: D A'nboV x HA ONS Phone #: 918 - 6 j3 -3ga o Are you an employer? Check the appropriate box: 1. I am a employer with 7 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 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 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.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F-1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. N Roof repairs 13.❑ Other *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 tContractors 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: 1k A (Zrl d WPolicy # or Self -ins. Lic. #: C D ® 3 o. [ $ 9 71.3 Expiration Date: -` Q - 0 3_P2 Job Site Address: 14 in M r0(_.la. 16ye. City/State/Zip: No, An&)yejt NA 0 W 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 SWOP WORK ORDER and a fine of up to $250.00 a day againsf the violator:- Be advised that a copy of this statement may be forwarded to the Office of Investigations *of the DIA for insurance cover�Lg� verification. I do hereby certify under the pains and penalties of perjury that the information provided above, is true and correct C ,- Date: [a) 19 112 - Phone #• 9 7 E � 1 3. 3 y d o. 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 #: Town of North Andover Nnk7N U Building Department 27 Charles Street '' A North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 -PA OR1TlD � cs,4 CW U DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c.l 1, s150a.. The debris will be disposed of in /at: kZ--�- S, SNC Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. i 4' I(assachusetts - Department of Puhlic Sufeh Board of Building Regulations and Stan(I,u-d Construction Supervisor Specialty License' License: CS SL 99358 Restricted to: RF,WS DAVID CASTRICONE 31 COURT STREET NORTH ANDOVER, MA 01845 Expiration: 12/16/2013 ( „uunissiu°rr Tr#: 7924 SCA 1 0 20M-05/11 �� ,� � ,`a\ re oiu. ff2irtuCrc�Cl7 re�n Y'�Ci.;Ju(Ye rrae( Office of Consumer Affairs & Busi6ess Regulation yAOME IMPROVEMENT CONTRACTOR ��_ , _ � egistration: 104569 Type: �'- ,expiration: 7/14/2014 Private Cor s poratic i1 DAV CASTRICONE ROOFING, SIDING & David Castricone 231 R SUTTON ST SUITE 3A NORTH ANDOVER, MA 01845 Undersecretary F91'2 ATE (MM DD/YYYY) ,�C"R CERTIFICATE OF LIABILITY INSURANCE 4/2012 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: M the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Select Dept exI 66807 Eastern Insurance Group LLC - Main PHONE -7 00 ac No :50 -653 89 233 West Central Street E-MAIL Natick MA 01760 ADD REss: e ctworke easte' ns u ranceom INSUREMSI AFFORDING COVERAGE NAIC s INSURER A: INSURED 31969 INSURER B: David Castricone Roofing & Siding Inc INSURER C: 231 Rear Sutton Street, Unit 3A INSURER D: North Andover MA 01845 rnV9PAnFs CFRTIFICATF NUMRFRR 1rQRF010d7 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 REOUIREMENT, 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 LTR' TYPE OF INSURANCE D IN S W POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DDiYYYY LIMITS AUTHORIZED REPRESENTATIVE GENERAL LIABILITY CONVAERCIAL GENERAL LIABILITY CLAIMS -MADE 7 OCCUR •..tStS1 ` y� I EACH OCCURRENCE $ AM -- PREMISES Ea occunence $ MED EXP (Any one person) $ PERSONAL R ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO POLICY JEC I LOC PRODUCTS - COMP,'OP AGG $ $ AUTOMOBILE L LIABILITY ANY :UTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED I HIRED AUTOS _ AUTOS Ea a.idertt BODILY INJURY (Per person) $ BODILY INJURY (Per acr.ident) $ PROPERTY DAMAGE $ Per accdent $ UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONS $ A WORKERSCOMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERRv1ENIGER EXCLUDED? (Mandatory In NH) 11 ves, describe urdei DESCRIPTION OF OPERATIONS below NIA WC003989723 /23!2012 /23/2013 X I T�`STATIU I OTH- ER E.L EACH ACCIDENT $100,000 E.L. DISEASE - EA EMPLOYEE $100,000 E.L DISEASE - POLICY L11A'T $500,000 I I DESCRIPTION OF OPERATIONS; LOCATIONS i VEHICLES (Attach ACORD 101, Additional Remarks Schedule, i1 more space is required) CERTIFICATE HOLDER CANCELLATION 0 1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SHOULDANY OF TME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Castricone Roofing & Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. 231 Rear Sutton Street, Unit 3A North Andover MA 01845 AUTHORIZED REPRESENTATIVE •..tStS1 ` y� 0 1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD A CERTIFICATE OF LIABILITY INSURANCE DA9/11//11/DDIYY2012 2 PRODUCER 978 273 6368 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Willows Insurance Agcy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 51 Cochichewick Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover MA 01845 'INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:WESTERN WORLD INSURANCE CO DAVID CASTRICONE ROOFING & SIDING INC & INSURER 8: CASTRICONE ROOFING & SIDING INC INSURER C: 231 Sutton St #3A _..- .... _INSURER D: NORTH ANDOVER MA 01845 INSURER E: I COVFRAGFS 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 ADD'L POLICY EFFEC'n E LTR N RD P F IN RAN POLICY NUMBER DATE MMI POLICY EXPIRATION —'-------" DATE MMI D LIMITS GENERAL LIABILITY ----i EACH OCCURRENCE $_ 1000_000 COMMERCIAL GENERAL LIABILITY - —, _ _ LIAMAGE TO RENTED PREMISES_(Ea occurrence $ 50000 A CLAIMS MADE I X OCCUR IPP1332888 19/6/2012 _. MEDEXP (Any one person) $ 1000 19/6/2013 1 - _ ...__._ _.._. ........___.__._ PERSONAL 8 ADV INJURY $ 1000000 ! GENERALAGGR_EGATE $ 2000000 GEN'LAGGREGATE LIMIT APPLIES PER:; - j i PRODUCTS - COMP/OP AGG $ 2000000 PRO POLICY : T I LOC ' ---- .------ -- --- -- --- AUTOMOBILE LIABILITY j-� ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS j j SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS ------ — -- --- — -- _. _.- BODILY INJURY I NON -OWNED AUTOS $ i (Per accident) PROPERTY DAMAGE j I I (Per accident) $ I GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ :ANY AUTO ! � - _ _ I OTHER THAN EA ACC $ I AUTO ONLY: AGG j $ EXCESS / UMBRELLA LIABILITY I I EACH OCCURRENCE $ OCCUR- j CLAIMS MADE -- � I !AGGREGATE 1$ ---- ------ — DEDUCTIBLE i 'RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE I $ WCSTATU- OTH- T Y 1 T - --"'---'--- OFFICER/MEMBER EXCLUDED? ❑ i j (Mandatory in NH) E.L. EACH ACCIDENT 1$ -- - If yes, describe under E.L. DISEASE__- FA EMPLOYE $ SPECIAL PROVISIONS below .OTHER ; I I i j E.L. DISEASE - POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CPRTIPIrATP unl ncD _ Castricone Roofing & Siding Unit 3A 231 R Sutton Street North Andover, MA 01845 IiMIV IiCLL1i I ILIN SHOULD ANY OFTHE 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, BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRES ATI ACORD 25 (2009101) © 1988-2009 ACORD CORPORATION. All rights reserved. INS025 (zooeo,).ol The ACORD name and logo are registered marks of ACORD 5 3 6;1^ !1 FOR PERMIT TO DO GASFITTING Date �7 Permit # o Owners Name �( Plans Submitted p�S (Print br Type) Check one: Certificate �R Installing Company Name .,� Q Corp. X Address CS artner. 'F5 Firm/Co. Business, Telephone: 14";Name o:Licensed Plumber or Gas Fitter ,� r a Insu0ah6a..Coverage: Indicate the type of insurance coverage by chegking the appropriate box: T Liability, insurance policy Other type of indemnity Q Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of t��rx this application does not have any one of the above three insurance coverages. qt AmSignature of owner aplent of property Owner Agent Q Vy{ ! We* oerti k that ad of the detuits and Information 1 hare submitted (or entered) in above applicati hdie and atxaratk to the best of my ; j, kittiivledge and di tt ill pluhtbint work and Installations performed under' Permit imed for this sppUcL o wW 6e compllanoe with n (kovWaas of the Wita&usetts'Slait Cas Code and Chapter 142 of the General Laws. i'FAPPROVEID, TYPE LICENS :le Gasfitter Signal •of Licensed MasterPlumb or Gasfitter y/Towt1:Journeyman (OFFICE use ONLY) —License tJtllnber • V • IWAC (Print br Type) Check one: Certificate �R Installing Company Name .,� Q Corp. X Address CS artner. 'F5 Firm/Co. Business, Telephone: 14";Name o:Licensed Plumber or Gas Fitter ,� r a Insu0ah6a..Coverage: Indicate the type of insurance coverage by chegking the appropriate box: T Liability, insurance policy Other type of indemnity Q Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of t��rx this application does not have any one of the above three insurance coverages. qt AmSignature of owner aplent of property Owner Agent Q Vy{ ! We* oerti k that ad of the detuits and Information 1 hare submitted (or entered) in above applicati hdie and atxaratk to the best of my ; j, kittiivledge and di tt ill pluhtbint work and Installations performed under' Permit imed for this sppUcL o wW 6e compllanoe with n (kovWaas of the Wita&usetts'Slait Cas Code and Chapter 142 of the General Laws. i'FAPPROVEID, TYPE LICENS :le Gasfitter Signal •of Licensed MasterPlumb or Gasfitter y/Towt1:Journeyman (OFFICE use ONLY) —License tJtllnber t 5 U 0 Date 4 TOWN OF NORTH ANDOVER a rr '� PERMIT FOR GAS INSTALLATIONS 5r This certifies that . ................... has permission for gas installation .. . �3...... L...... ...... �G in the buildings of .%�` T.�: �� ... ��! U .�.�.4 .............. . at..y. ' %`! �f �: !" • • .�� !? • • • • , North Andover, Mass. Fee. _..... Lic. No./. C 3 v /... .. ��j/t....... . GAS INSPECT WHITE: Applicant CANARY: Building Dept. PINK: Treasurer