HomeMy WebLinkAboutBuilding Permit #204-2016 - 475 WOOD LANE 5/1/2018 NORTH
t= BUILDING PERMIT LIED
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION `
Permit No#: Date Received 7 '°^�reD
�SV
CHus�t
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 1 ,77 �� ��
Print /
PROPERTY OWNER A /��/' Wood
—� Print 100 Year Structure yes
MAP O� PARCEL 7 ZONING DISTRICT: Historic District yes no`
Machine Shop Village e Y es �
TYPE OF IMPROVEMENT PROPOSED USE
7Re idential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well El Floodplain ❑Wetlands ❑ Watershed District
El Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identificatioy,- Please Type or Print Clearly
OWNER: Name: 0:r-�.y/5Phone:
Address:
Contractor Name: Phone: �
7- 3-5
Email: �-
ted )$AF d jwLfs
Address: 4 ZV /ti L� dpi 7
Supervisor's Construction License: Lt2_1b7&7 Exp. Date: 6�Z,Z�®1
Home Improvement License: /79�c� Exp. Dater
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: $ 6jZX�, ®G FEE: $ �P `
Check No.: eG Receipt No.: l '�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
1—
�I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL,
Public Sewer ❑ Tanning/MassageBody 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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
L=-
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
V
Water& Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 3 St
tate 84 Os
FIRE D MENT� � ""
Osgood Street
v EP°ARdT � 1� rnp p�stern>�s�te� es�,x�.� . no " �:
tLMatedmAt 1.2„4 Maiq Street, ,• # y -x
Fie Departs a tis gna.ure/d to � _ , `; ��'•.� �?
'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)
f
® Notified for pickup Call Email
Date Time Contact Name
F
Doc.Building Permit Revised 2014
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
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
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4, 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)
4 Building Permit Application
4. Certified Proposed Plot Plan
4 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
{
LocationUL� �/.✓�
No. Date
id
1
• TOWN OF NORTH ANDOVER
C"vD
�1 Certificate of Occupancy $t _
Building/Frame Permit Fee $V ,
Foundation Permit Fee $
Other Permit Fee
TOTAL $
Check# �ff
Gam'
t, Building Inspector
2 921 b-
NORTH
Town of . ? E 1. Andover
0 r �
_ ;_' k
t
����No. "q 20
h ver, Mass, (7. 20(5
COC NICNl WICK
A°RATED
s � .
BOARD OF HEALTH
Food/Kitchen
PER 00 1 LD Septic System
THIS CERTIFIES THAT .............. Ir 06% BUILDING INSPECTOR
.. ...... Q .. ..............................
Foundation
Q �.
has permission to erect ................... ...... buildings on ...�.�...... ........ ,.........................
� _f1 � Rough
to be occupied as .....� ..... �A�.�.4......w...�;. �.......................................... chimney
provided that the person accepting his 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 IN 6- MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
Service
................. .lX� '"'1" r:�r�r: ...................................
BUILDING INSPECTOR Final
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.
REMODELING AGREEMENT
Independently Owned and Operated Business:
DPG Home Improvements LLC.
28 W.Wyoming Ave.Melrose,MA 02176 D1d M D
Ph:781-620-2679 Y N 0 EP0T§
THIS CONTRACT is made this _�_�day of !, 20 by and between DPG Home Improvements LLC.,
as AblloWshereinafter referred(hereinafter referred to as"Seller")and the partiesto as"Buyer"):
Customer(Buyer):A Phone 1:
Email: Phone 2:
Install Address: 151,74,__
Bill Address:
Seller agrees to sell,and the buyer agrees to buy,all those materials and labor necessary to install the same as set forth in the following
Specifications and in accordance with the Terms and Conditions below:
SPECIFICATIONS
Color Grid
No. QTY Window TYPE INT EXT Glazing PKG OBS TEMP Pattern Other Instructions:
,
Total Price: J�t � �� Down Payment:$ "V, � Unpaid Balance:$ ,.J, b"7�0
1.This price reflects all trade-ins,specials and discounts.All consumer financing is subject to credit approval and existing interest rates with
approved lending institution.
2.Buyer is responsible to remove and replace any existing window treatments,blinds,alarm systems,as well as the associated hardware
as required for installation unless otherwise noted in this agreement.
3. For owners with homes built before 1978,customer acknowledges receipt of EPA"Renovate Right"booklet. INITIAL:
4.Final Payment(any unpaid balance)MUST BE MADE UPON INSTALLATION. If additional work is required as part of the installation,
a change order with associated costs Will be presented by your installer. 7
5.Buyer may cancel this transaction at any time prior to midnight of the 3rd business day from the date of this transaction.
Notice of cancellation must be received in writing within 24hrs,following the 3rd business day. INITIAL:
6.Buyer acknowledges that all warranties and representations contained herein are between Buyer and Seller.Further,buyer acknowledges
that Seller alone is responsible for the installation,craftsmanship and any field service warranties presented with this agreement.
I(WE)HEREBY AGREE TO THE TERMS AND CONDITIONS OF THIS REMODELING CONTRACT.
Customer / Customer j
Signature: ` ^ 4rll i' �r� PRINT NAME: �� "
TERMS&CONDITIONS
1.By execution of this agreement,the buyer(Buyer)is subject to these terms and conditions as set forth by the independently owned and operated business
(the Seller)identified on the front(reverse)side of this agreement.
2.Damages for Cancellation.You have a limited right to cancel this contract.You may do so only in the time stated in the contract or allowed by law.Cancellation
by the buyer of this agreement,after the cancellation period entitles the seller to damages equal to 33.3%of the agreed contract amount,or any deposit paid,
whichever is less.
3. Reasonable Access.You will permit us to install this project within 72 hours of notification. Any delays must be approved by the seller in writing.You will permit
us to go onto the premises.The premises include the land and the building.You will get any consent needed for us to go onto other premises to complete work. If
we are prevented from completing the work,because of denial.of access,then we have no further duty to perform the contract.You will then immediately pay us
agreed damages.
4. Insurance.We have Public Liability Insurance,Property Damage Insurance,and Installer/Applicators have Workers'Compensation Insurance.
5. Interference with Performance.We are not responsible for any interference with performance for reason beyond our reasonable control.This includes strikes,
fires,weather,inability to obtain.materials,etc.
6.Consumer Credit Contract Notice.If this document applies to a consumer credit contract,this notice applies:Notice:Any holder of this consumer credit contract
is subject to all claims and defenses,which the debtor could assert against the seller of goods or services,obtained pursuant hereto or with the proceeds hereof.
Recovery hereunder by the debtor shall not exceed amounts paid by the debtor hereunder.
7. Entire Agreement.This contract sets forth the entire agreement between the parties and supersedes all representations made by Seller, its agents or
representative.This contract can only be changed in writing by an amendment signed by both the Seller and you.Anything not specifically stated or agreed to by
the Seller is waived to the extent permitted by law.
8. Local Laws.Some parts of this contract may not apply to you in whole or part because of local laws.Here are some examples:a.Some states have rules or
limits as to attorney's fees.b.Some states do not allow the exclusion or limitation of incidental or consequential damages.c.Pennsylvania has a 10%limit on
agreed damages if an installment contract is involved.
9.Transfer.You may not transfer your duties under this contract to any person without written consent by us.
10.Successors.This contract binds your heirs,executors and administrators.
11. Installation of Replacement Windows.During some installations,interior trim stops(moldings)will be removed and then reinstalled.This can result in some
chipped paint.Should a piece of molding break,the broken piece will be reinstalled. If reinstallation is not possible,the Seller will replace the broken piece only,
using best effort to match existing molding.Seller will not sand,seal,paint or otherwise finish existing or new molding in any manner.Should some exterior
damage occur such as cracked or broken shingles,Seller will refasten the broken shingles where possible,Seller will not replace,sand,seal,paint or otherwise
finish the shingles in any other manner.
WARRANTY COVERAGE
Products Warranty—licensed Window Depot USA partners provide products manufactured by the finest window&door companies in America. These
companies supply the product warranty that is the foundation of our Product Warranties.
Under this protection,the vinyl components of the window will not blister,peel,rot,or corrode.Additionally,mechanical/working parts are warranted to be free from
manufactured defects in material and workmanship.Replacement parts will be supplied at no charge. Length of warranty coverage,along with other terms&
conditions are defined by the original manufacturer warranty document;
WINDOW DEPOT USA IS NOT A MANUFACTURER OF HOME IMPROVEMENT PRODUCTS.ALL WINDOW DEPOT USA PRODUCTS CARRY THEIR OWN
PRODUCT WARRANTIES,SUPPORTED SOLEY BY THE MANUFACTURER. A COPY OF THAT MANUFACTURERS WARRANTY SHALL BE SUPPLIED TO
YOU BY YOUR LOCAL WINDOW DEPOT USA LICENSEE.
Insulated Glass Warranty—the sealed insulated glass unit is warranted against defects resulting in material obstruction of vision from film formation caused by
dust or moisture in the dead air space of the sealed unit(Seal Failure). If the glass unit fails,the Manufacturer will provide the Owner with a replacement insulated
glass unit at no extra charge.
Optional Glass Breakage Warranty-For the term of the warranty,the Manufacturer will provide the Owner with a replacement insulated glass unit in the event of
accidental glass breakage.Lifetime Glass Breakage option must be selected on the original purchase contract. Please see manufacturer's warranty for additional
details.
Labor Warranty-all labor necessary to correct any item covered by this warranty will be provided at no extra charge by the Seller for a period of 36 months from
the original date of installation.There-is a nominal trip charge after three years for all service calls.Labor Warranty is the responsibility of the locally owned and
operated business identified on your Window Depot sales agreement.
Transferable Warranty-This warranty may be transferred to a subsequent owner of the sameresidence.Please see original manufacturer warranty for additional
details and transfer instructions. Your local Window Depot USA partner will gladly assist you with this transfer.
General Limitations and Exclusions
1.Acts of God(hurricanes,tornadoes,flood,etc...)acts of war,riots,fire,stress resulting from localized heat,modification,acts of war,terrorism and vandalism
are not covered by this warranty.
2.Color variance may occur between replacement parts and weathered original material.
3.Labor warranty does not transfer to Owner's immediate transferee.
4.Any replacement warranty parts may incur a shipping/freight charge.
5.This warranty is exclusively for windows installed by the Seller.Any additional products,such as doors,installed by the Seller,in conjunction with the window
contract/installation will carry the warranty provided by the appropriate manufacturer.
it
I
: The Commonwealth of Massa chusetts
z . Department oflndustrialAccidents
1 Congress Street,Suite 100
`= Boston,MA.02114-2017
www mass gov1dna
Sy Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Anjilicant Information Please Print Le0b
Name(Business/Organization/Individual)' PX ,01ye- ,tJ/v✓��fe� �`�
Address: /2% --
City/State/Zip: e�r'G�S 14 f /7,(, Phone#:
Are you an employer?Check the appropriate box: Type of project(re uire�'
LE]Yam.a.employer with : employees(full and/or part-time).* 7, ElNew construction
2. am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodelilig
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition .
3.FJ I am a homeowner doingall work myself o workers'cam .insurance required.]t
y Cl`T P q
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.[❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ $ 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.❑We are a corporation and its off cers have exercised their right of exemption per MGL C. 14. Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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 state whether or not those entities have
employees. If the sub-contractors fiave employees,they must provide their workers'comp.policy number.
dam an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information. Q
Insurance Company Name: /��� ,✓f ��`5����G� /�+
Policy#or Self
ins,Lie.#: �/'/ LQD�j/* Expiration Date:
Job Site Address: '/'5 "cc/ I-vNe City/State/Zip: WAZo m', A/ l Y
Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cer fy under du epaiW and penalties of perjury that the information provided arbo a is true and correct
Signafore: �� Date: D �7/1���
Phone#: &
Official use only. Do not write in this area,to be completed by city or town official..
City or Town: PermitUcense#
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#:
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 thegrounds 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-contractoi(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-insure_d 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-AIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
(MMID xYYM
aC<>Roa CERTIFICATE- OF LIABILITY INSURANCE
DATE6/8/15
THIS CERTIFICATE 1S 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: Nthe certificate holder is an ADDITIONAL INSURED,the policyCiies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions ofthe policy,certain policies may require an endorsement. Altatement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRoaICER NAw Names G. Beaulieu
Paul T Murphy Insurance Agency PINE (781) 321-9700 �x No): (7gi) 324-4253
628 Broadway Rt 99 An%
Malden, MA 02148 AoaREss: imm @ tminsurance.com
INSURER S AFFORDING COVERAGE NA1C B
INSURERA:Arch
INSURED INSURERS:
DPG Home Improvement LLC INSURERC:
28 W. Wyoming Ave INSURERD:
Melrose, MA 02176 INSURERE:
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER;
THIS IS TO CERTIFY THAT THE POLICES 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.INS —
LTR TYPE OF INSURANCE AE7DL SIIBR POLICY NUMBER PM Y�EPF WNIDO�Y D� LIMITS
A GENERAL LIABILITY Y AGLOO13747-01 5/28/15 5/28/16 EACH OCCURRENCE $ 11000.1000
X COMM ERGALGENERALLLABIUTY PREMISES MAGETO��ED $ 100,000
CLAIMS-MADE OCCUR MED EXP(Anyone person) $ 10,000
PERSONAL&ADVINJURY $ 11000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMITAPPLIESPER PRODUCTS-COWIOPAGG S 2,000,000
POLICY PROT LOC $
AUTOMOBILELIABIU7Y COMBINED IdeNSINGLE LIMIT $
ANYAUTO BODILY INJURY(Pei pamon) $
AUTOS
ALLOWNED SCHEDULED BODILY INJURY(Per accident) $
OS
NON-OWNED PROPERTY DAMAGE $
HIREDAUTOS _AUTOS eraeddeM
$
UNBREU.ALIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS•MADE AGGREGATE $
DED RETENTIONS $
VYORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y t N !11641
ANY PROPRIETORIPARTNERIEXECUTNE NTA EL.EACH ACCIDENT
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) EL.DISME-EAEUPLOYEE S
ITyes,describe under
OESCRIPTIONOFOPERATIONS below E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEJACLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required)
Window and Siding Contractor. Policy terms,conditions and exclusions apply
Decroteau Brothers Realty, Inc is scheduled as Additional Insured per forts CG 2011 Oi 96.
Form Attached.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE L BE DELIVERED IN
Decroteau Brothers Realty Inc ACCORDANCE WITH THE POLIO O s
28 West Wyoming Ave
Melrose, MA 02176 A1THORIZED
1988.201 D 5111 `tltsere .
ACORD 25(2010105) The ACORD name an ret marks- _ � �
Phone: Fax: E-Mail: dennll@yahoo.com
U21e tpomznza�zureal! a�UlOdrecfZUJe
Office of Consumer Affairs&Business Regulation
rME IMPROVEMENT CONTRACTOR
jistration: x.79900 Type:
piration::_:9_/2212016, LLC
DPG HOME IMPROVEIVfENTLLC?:.: =
DENNIS GRYNKIEWICZ _.: .,..:.
28 W WYOMING AVE..; ( —
MELROSE,MA 02176
Undersecretary
r
rnen�jpub�lic
tyetts DePa Stanads
Massachus Regulations and
Board of guitding icor
Slip
corlstructi��CS_10766T �
license• ''/,.
NICZ
DENN�S GRY
13 OR
Cambridge �.
'41 0611112017
UlvllvLvlY Yri tpl l vt aruavvr.a� v.,+-.
EXECUME OI'I'ICL-'OF LABOR AND WORKFORCE-DEVELOPMENT
-- = DEPARTMENT OF LABOR STANDARDS
19 STA\IFORD STREFT,BOSTON,MASSACHUSLn:s 02114
LEAD-SAFE RENOVATION CONTRACTOR LICENSE
DPG HOME IMPROVEMENT LLC
28 W.WYOMING AVE
MELROSE MA 02176
LICENSE: LROO1825 EXPIRES: Monday,May 20,2019
IN ACCORDANCE'WITH M.G.L.C. 111; 5 197B(b)AND 454 CMR 22.04;THIS LICENSE-'IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF
ENGAGING IN LEAD-SAFE RENOVATION AND/OR MODERATE-RISK DELEADING WORK.
1
L
1
THIS LICENSE IS VALID FOR A PERIOD OF FIVE(5)YEARS.
i
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR IN ACCORDANCE WITH M.G.L_C. 111;
j j 197B(b)(2)AND 454 CMR 22.04 WHEN ENGAGED IN LEAD-SAFE RENOVATION AND/OR
MODERATE-RISK DELEADING WORK.LEAD SAFE RENOVATION CONTRACTORS MAY NOT
PERFORM MODERATE RISK DELEADING WORK UNLESS THEY EMPLOY A SUPERVISOR,WHO HAS
TAKEN T14E REQUISITE TRAINING AS REQUIRED BY 454 CMR 22.00;TO OVERSEE THE WORK.
UEATHER E.ROR'P.;DIRECTOR
Please detach this mailing tab and keep your license certificate in an accessible location.A copy
of this license must be maintained at each worksite.
'DPG HOME IMPROVEMENT LLC
28 W.WYOMING AVE
MELROSE,MA 02176