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HomeMy WebLinkAboutBuilding Permit #266-16 - 486 WOOD LANE 9/1/2015 BUILDING PERMIT NORTH Ott LED jb��O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ co y,C Permit No#• _ It/ / Date Received gSSACHUs�,( Date Issued: 0-- 1— IMPORTANT: Applicant must complete all items on this page LOCATION (-A OJ Print PROPERTY OWNER ,n Print 100 Year Structure yes no MAP PARCEL:_ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Res' ential Non- Residential ❑ New Building ebne family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well: ❑ Floodplain 0 Wetlands 0 Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: h Address:4"1�8ONwi Contractor Name: 4 kAM-C.r Phone:-01 Address: Pt 1 fav u-\ MA VCA 3 Supervisor's ConstructionLicense: Z Exp. Date:m �. 13 �aHome Improvement: License: p wL_� _v._-,. ;Exp. Date: n ARCH ITECT/ENGINEER I tine: n Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00'PER S.F. 6 Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons con ratting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 CU:MMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments f Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp fDumpster on site yes_ no Located at 124 Main Street Y - Fire Department signature/date 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) i ❑ Notified for pickup Call Email Date Time Contact Name 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 a 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 a Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract Li Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) L3 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:Building Permit Revised 2014 Location No. Q(d42 Date . - TOWN OF NORTH ANDOVER s • Certificate of Occupancy $ Building/Frame Permit Fee $�_ . Foundation Permit Fee $ Other Permit Fee $ ' rxu� TOTAL $ " Check# Qq �j Building Inspector c'» %246. NORTH Town of EAndov ' o 0 h ver, Mass, d �1 �d t- 04ATED PP�,`'�5 S U BOARD OF HEALTH PERT Food/.Kitchen L D Septic System THIS CERTIFIES THAT ....... .............. .. .��0 ,,,,,,,,, ,,,,,,,,,, BUILDING INSPECTOR ............. ...... ..... .... ............................ . .. .......•....,.... . has permission to erect .......................... buildings on ......... ........ �....... Foundation ..................... Rough to be occupied as .......��, .... �1�1a!1 .. .......�.�.. ftlu....... Chimney provided that the person accepting this permit shall in every respect conform to the term 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 CONSTRUCTIO ARough 00 Service ................. .. ...... ................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. 6-- Federal 10# RISE Engineering RI Contractor Registration No MA Contractor Registration No A division of Thiciseh Engineering CT Contractor Registration No 60Shawmut Unit#2.Cantoo,'NIA 02021 .;,. CONTRACT 339-502dJ35 F'.4.\339-502-6345 Page 1 PROGRAM TM cohImet IS enTem"90 SETWM RISE E1dG1NEEi%IIdG CMA-HES D�ESOCMR0 ER eeuSTOMFOR WORK AS RISEDGELOW ._......._.. � .., ...__.,,_ ..,. ..,..,.. ......... CUSTOMER PHONE. DATE CUENTA WORK ORDER Amanda Rogers (856)5204484 05/28/2015 415429 00002 sEavK E sraEET MUM;STREET 486 Wood Lane 486 Wood Lane21P SR1WO CrMSTATF-ZIPNorth Andover•,MA 01845 North Andover, MA 01845 _.... _.----.._ Jim JOB DESCRIPTION AIR SEALING:Provide labor and materials to scat areas of your home against wasteful,excess air leakage. This w rk will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a h air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) (8)working hours. At the completion of the wentherization work,and at no additional cost to the homeowner,at final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. GIANT CHIMNEY CHASEKITCHEN VAULT KVvALLS.6'FIBERGLASS IS CUT 14.3"WIDE,JOISTS 20'ON CENTER...EFFECTIVE It VALUE. $680.00 AIR SEALING ADDER: (2),vork nghours. $170.00 DAMMING:Provide labor and materials to install a 12'layer ofR-38 anfaccd fiberglass balls to(30)square feet for damming purposes. $61.50 ATTIC FLAT:Provide labor and materials to install a 10"layer of R-35 Class 1 Cellulose added to(644)square feet of open attic space. GIANT CHIMNEY CHASE.KITCHEN VAULT KWALLS.6"FIBERGLASS IS CUT 14.5"WIDE,JOISTS 20"ON CENTER...EFFECTIVE R VALUE. 5946.68 FIX EXISTING INSULATION:Slash the vapor barrier,flip,or re-position(644)square feet of insulation in the attic area. $161.00 KNEEWALLS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(I 18)square feet of kneewall area. $413.00 ATTIC ACCESS:Provide labor and materials to insulate the back of(t)attic hatch with 2"rigid Thermax board.Weatherstrip the perimeter. 560.00 VENTILATION:Provide labor and materials to install ventilation chutes in(30)rafter bays to maintain air flow. $60.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures,Columbia Gas offbis 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Scaling measures up to the first$680 and an additional 5340 if savings are justified by the auditor. For the safety and health ofyour home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the wcatherizatiou work'is complete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has a value ofS90 and is at no cost to yvu. Totat allowable weatheri7.ation incentive is$3,110. $90.00 I i Federal ID# I RISE Engineet ing RI Contractor Registration No E( MA Contractor Registration No A division nrThielsch Engineering CT Contractor Registration No ' 60 Sha>vrout Unit#2,Canton,NIA 02021 339-502-6335 FAX 339-502-6345 CONTRACT SPage 2 PROGRAM TO BETWEEN WE aO-TE O THE CCONTRACT 93 USTOMER FOR A ENGINEERING OESCRISEO BELOW CUSTOMER PHONE DATE CUENta WORK ORDER Amanda Rogers (856)520-41484 0512812015 415429 0000' _..._..._.. . . . ,......... - SERVICE STREET BILLING STREET 486 Woad Lane 486 Wood Lane !1# ___ .. . . ,__.._. ._ .__._ �_ ?..E_.�R .. SERVICE CITY,STATE.LIP SMUNO CITY,STATE,i1P f North Andover,MA 01845 North Andover,MA 0) 45; _.a_-__.__. . _, .NIS— JOB DESCRIPTION Total: $2,42.18 Program Incentive- $2,096.89 Customer Total; $546.29 WE AGREE HERESY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICAnoNS.FOR THE SUM OF `Five Hundred Forty-Six 8L 291100 Dollars $646.29 UPON FD"INS- _N AND PR OV SY E END G.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF i%.WALL Be CHARGED MONTHLY ON ANY UNPAID AFTER i FOR T INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULIN0,AND CONTRACTOR REOISTRATION. DO?/COT SIGH THIS CONTRACT IF THERE ARE ANY BUWIKC SPACES AU aEo IGNATU EnSi UI+S US ER ACCEPTANCE NOTE:THIS CONTRACT MAYBE vATHORAWN BY US IF HOT EXECUTED Wrt}!tN DATE OF ACCEPTANCE _...........,....o... -.-.•....—...—_---. ACCEPTANCE OF CONTRACT-THE ABOVE PRICES.SPECIFICATIONS AND CONDITIONS ARE 30DAYS. SATISFACTORY To US AND ARE HERESY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK. AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE OWNER AUTHORIZATION FORD (Owner's Name) � S rc rn}d 9 owner of the property located at ilinjI _ J1 23115 (Property Address) ver, (Property Address) hereby authorize , (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. 0whees Signature IJI Ile rl- The Commonwealth of Massachuseft Department of 1'ndmtrxal Acc dents t ce o,f lnvestiwions 1 Garrets Street,Srte 100 Boston,MA 02114-2017 www mass gtrold a Workers'Compulsation Insuratrce Affidavit.Bn ers/ 'ant etor E trieia Plumbers Applicant bftmtkn _ Jim ' t LW111 Name(f3ktsinessfCJrgaraiirna,+t ,. tk' 1ttil A : O 01344 Aig Phone SAS le 3 Art you an cn lltayt�Cho*the appropriate box.- am neral contractor and d Type of pproject( ): 1.� l arta�employer Wit ®1 6, �. ��c-� r�tic employees(fralt and/or put-time).*.* have hired the sub-wntwors 2.(3 1 atm a sole proprietor or pattri-T= listed on the attached sheet. 7. 0 Remodeling ship and have:no ernploy s These sub-contractm have: S. 13 Demolition doing for me in any capacity. employces and have Nvor e ' itmr ,$ llttild€rrg addition [tato workers"comp-insurance rem 1'. required.� �> �`c a t�aaticarr and its t{f-��dcctriCal airs tar€alcdititarr 3.13 l am a homeowner doing all work officers have exercised their 11.®Pdtaartlaing repairs or additions, myself:flab worlters'Cotrap. right of exemption per M61.: 1113 Roof repairs insurance mquinul. # c. 152,§1(4),and we have to employees. workers' 13.[30thcr 00111 .instrraaxace required "Airy l cM ttat a box#I ttttr9l aua Ct11 out ern k�luv �rrrr�tI r womk "t�amptrt�srsour icy iaaftMaa26Jtr.. TIMMWACM Atto aatrert t this affiII&Vit meta ns they=doingill%ak wW thm hire orttude c&ntraatja omwA submit rz r ew sffi&s°it indjcatrng SUCI tC mmam dw Cas e this bux rmw hed sn ealtmegth&i sbrrtu %the testae of iheskab omtramr m mA*tat4t to t&—to cam*how aWtift byem If tt}t a**-ontWm have mot ,they nw prmi&tbear umttt 'gaga,pojwy ndmtw ldmanemplojwtkwisprovhfi*gworkers'compemWioninswwweforayemplojves. 8dow is the prly and,(ob site utfar�>z. Insumcc Company Nanic:—ftcoLo Policy d car Self-ins.Lic.4: i tea 1 q „ ..� xpirnaon Late. Joh tt ity/Statel fA 4 Attach O COPY of the stiorktrs'compensation policy declaration page(showing the policy number and expiration date). Failure to secure ooverage as required under motion 25A of MCL c. 152 can lead to the imposition of criminal penalties(if to fine up to$1,500.00 and/or Me-.year ImPrIs011iftwnt,as v 11 las.Civil penalties in the form of a STOP WORK ORDER and a fine of up to S250M a dale againg the violator. Be advised that a copy of dais staietnx rt may be forwarded to site Office of Investigations of the DIA far insurance coverage verification, I don he by en fy ander at pms and penabes of jvgwy that the infotmahon Mvt&d err rs hwe amt correct. "t S tart �, -' `"` -.. lfalc: 3 'S3 tJ, idid ase MO. Do coed wMe in this ars,to he ea t1rtt d`by dlp or tow rof 1. City or Torn. r it#Lieen�p 1s ting Authority(dia cine) I.&nerd of health I.Building Department 3.City 'o 4.Electrical Inspector Plumbing mor fa.Ott" Conte Fe snt Thione#. TE A 0RO CERTIFICATE OF LIABILITY INSURANCE DAT/(7/2015Y) 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 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 CONTANAME:CT Nancy Usher Martin J Clayton Insurance Agency, Inc. PHONE (413)536-0804 FAX (413)534-7874 _C No Ext_1: tAIC.Nok 1649 Northampton Street ADDRESS: P. 0. BOX 989 INSURERS AFFORDING COVERAGE NAIC#_ Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville NATIO INSURED INSURERBAllied World Natl Assurance Co Gauthier Insulation INSURER C: 44 ESSEX ROAD INSURER D: INSURER E., _ IPSWICH MA 01938 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL157701379 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 ADDL SUBR LTR TYPE OF INSURANCE POLICY NUMBER POLIDY EFF POLICY EXP LIMBS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE F_x1 OCCUR DAMAGE TO RENTED _PREMISES(Ea occurrence $ 50,000 X GL43487F 7/6/2015 7/6/2016 MED EXP(Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT 0 LOC PRODUCTS-COMP/OP AGG $ - 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED id P BODILY INJURY(Per accent AUTOS AUTOS ( ) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident) X UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ __'1_t_0091090_ B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 BE020792125-194985 10/18/2014 10/18/2015DED RETENTION $ WORKERS COMPENSATION PEROTH- AND EMPLOYERS'LIABILITY YIN N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A -- -- — (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CSG, NSTAR AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MASS SAVE PROGRAM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICES GROUP, INC. ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET WESTBOROUGH, MA 01581 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG _— ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD MPrdrd2tbd with pdfFactory trial version www.pdffactory.com ( IJ 10 l'P%A 1'2/10/2014 1 :21 :37 PM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE �� Jn:'ii fR1LVC+C:vFwy ' j >., ...- I! 12%10!2014 THIS CERTIFICATE IS ISSIJEO AS A MATTER OF INFORMATION 01•ILY AND CONFERS 110 RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY Olt IIEGATIVELY AMEND, EXTEND Oil ALTER THE COVERAGE AFFORUE1.) BY THE POLICIES BELOW. THIS CERWICATE OF 114SURA14CE DOES HOT COIIST1TUTE A C011TRAC( BETWEEN THE ISSI.111IG INSUREII(S), AUTHORIZED E IIEPRESEIITATIVE OR PRODUCER,AND THE CEItT1FICATE HOU)ER. 11111ORTAHT: If the certificate holder if,an AWATIOIIAL INSURED,the polleytles)must;be endorsed. If SIJBItOGATION IS WAIVED,suhjecl,to the terms and condifions of the policy, certain policies may require an endomernenl. A AalrineL on this certificate does not confer rlghlc to the cert:iflcaLti holderin lieu orsuch endomerrent(S), ---- - T--- _....------------- - ...._._ Clayton Martin J!ns Agency Inc av Berkle Assigned Risk Services ( 1649 Northampton St %`A~*�E+ 600634.4589 ;n Nn; %6 215-8118 PO Box 989 nwRFss. PolicyServicesCherkfeyrisk.wni Hol oke MA 01041 h3 N1ER S n;'rUNUIroG I.cv 6I7 nGC• kN+;A �kSUREG N„ 3112.5 Gauthier Insulation Inc NSLr:�RR. PO BOX 344 Ipswich, MA 01938 Ns xER° INSLNERE NS V1 ER F' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 71115 IS TO CERTIFY TI1AT THE POLICIES OF ItJtiURANOE LISTED BELOW HAVE BEEN 1551 ED TO THE NSU1<LV MNILD ABOVE FOR THE POLICY PERIOD PJDIC.:ATED. h107WITHSTNJDING ANY REcJUIREMENT,TERM Oil CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO lk-HICH'THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE NSURANCE AFFORDED BY THE POLICIES DESCRIBED HEFEN IS SUBJECT TO ALL THE TERMS. EXCLI.T,IONS AND(C)NDII'IONS OF SUCHPOLIGfES.LIfAITS SHOWN MAY HAVE BEEN REDUCED BY PAR)CLAIMS. l'Yt+t IkSIIRAk;:F ` ' nr.Ilr,Y'NUMRF r. ++- r' I+.r GENERAL LIABILITY IN$R YtVU b1 MlDD%Y"Y Yl h1A5,T)nlYYYY', i AUTOMOBILE LIABILITY WORKERS COWEWATION I 1: AND EMPLOYERS`LIAOILITYY,N C, ( Wf`°TAI(iC7N AkYPRPR+F.?(?Ri,�hR1NCR:. iORY CItAI'r.<, F.R .FKE CUllVr A nrruli'141;:MUUZ M LULTO © NLA WC-20-20.001661.00 10!3012014 10130201.5 e t FACII ro7Cmf5Nt 8 500.000 f WriA wlnry Si,NRy 1!y«z.Cvscl:ln v,:de fir-SVPW1Y-IN GF""'PER.t'IIQNSb.>Iu..t :Ie..ASr'. `MPI , � 'SoO,(xIo .11FScrlr 4N'C4 OPG A?ION51?OcnnONSri. = cA ^L{+Yf_4711 500,000 I.1lI('.C.,,(Atf�rl:ACbR(?!D+ n.d d:t�En I It!::5 rh;Srind.k,d .o.e xu i,:e err«�„r9d1 Election Coverage Catryory Effect.Status Name States) All EntitieS/Locations Officer Exclude Kurt Gauthier MA OfFrcer include Brittnie Aiello Gauthier Insulation Inc 44 Essex Road Ipswich, MA 01938 C L ELI l0 31K)ULDANYOFTHE ABOVE DESCRIBED POLICIES BE C:AWELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Mass Save Program/Conservation Services Group,Inc A(X:ORDAl`K:E WITH THE POLICY PRt)VIsION5. 50 Washington Street L West Borough,MA 01581 ACORD 25(2010t0,) BRAC 3139 u, 4. a.;�L+' j° , Office of Consumer Affairs and Business Regulation" 10 Park Plaza-.Suite S 170 :Boston, Massachusetts 02115 Home ImprovementC trasem.ctor Registration Registration: 173410 E Type: Individual x s g Expiration: 1011/2016 Tr# 257812 KURT GAUTHIER � .... .. KURT GAUTHIER _.w P.O. BflX 344 _ _..,__ _,w____._ �u a IPSWICH, MA 01938 � � � ._� . -------_.. .. _.. ._ ._,... 2 � 4 :°;i Update Address and return card.Mark reason for change. f Address I Renewal Employment Lost Gard SCA 1 G 2�WR O&ii _ C_�_ 3 Office of Consumer Affairs*Business Regulation License or registration valid for individul use only t3fNE tltIPROVENlENT CONTRACTOR before the expiration date. If found return to: �egistration 473410 Type: Office of Consumer Affairs and Business Regulation xptration 1WI 016individual t0 Park Piaui-Suite 5170 Boston,MA 02116 KURT GAUTHIER j KURT GAUTHIER f 44 ESSEX ROsha— IPSWICH,MA 01938 __ Undersecretary 'ot valid wi out signature a, mpatrie"t of Board of Bujidjog R004A Public safety �Fcertae:+ �� IXCIMMr Jftt+GA Do 3" fur top AM Expiration Cam,Ostwft, 16