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HomeMy WebLinkAboutBuilding Permit #16-12 - 54 VEST WAY 7/8/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: � Date Received � i Date Issued: I IMPORTANT: Applicant must complete all items on this page LOCATION 57 l Print PROPERTY OWNER ;c�a� e l S Unit# �l Print MAP NO: �`� PARCEL: ZONING DISTRICT: Historic District yes (no o d Machine Shop Village yes100 year-old structure yeso TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family El Addition El Two or more family El Industrial 11Alte.ation No. of units: El Commercial LkIk"e-pair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �`Sephc . ❑Well []Floodplain> _.❑�We 10( s ❑ Watershed°Distract 4 ClWater/S0wer �DES�CRIPTION OF WORK TO BE PERFO ED: GO� P6110 (Identification Please Type or Print Clearly) OWNER: Name:a 5�� %` Phone: Address: Y l./<ST' In� � ` '' �I � } ` CONTRACTOR NamePAzc(a& C�7�✓wl�v� �✓ Phone: X-C.AR' Vt�3 �- / OJ 9/T Address: 7b 'Ic.-S Supervisor's Construction License: ® co 725 Exp. Date: /0//0 Home Improvement License: /boo? 9J' Exp. Date: G/1s b, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ -71,0 000 FEE: $ �0 Check No.: I� Receipt No.: P- t NOTE: Persons contracting with unregistered contractors do not have access to the guayan fund Signature_of Agent/O.wner.: ;.._ Signatureofcontractor =. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL r 1 t Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ h 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 Siqnature COMMENTS HEALTH , Reviewed on Signature COMMENNTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Siqnature& 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 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 I ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi � I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses o 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: Doc.Building Permit Revised 2008mi Location S � T 1''!J No. Dated 1/ MORTh TOWN OF NORTH ANDOVER jL 3 • i _ Certificate of Occupancy $ �' •'<� Building/Frame Permit Fee $ Foundation Permit Fee $ f Other Permit Fee $ TOTAL $ Check 2451 WB7,Id-,ng!QInspec`t6r j -- PEARSON RENOVATION INC. 76 TRASK STREET BEVERLY MA 01915 978-828-0123 MASS.BUILDERS LICENSE#050929 MASS.HOME IMPROVEMENT#100275 Selbst Residence 54 Vest Way North Andover Ma. Remove existing roof shingles, apply 6ft. of ice and water shield and new 35 year architectural shingles Remove existing masonite siding and replace with Hardi plank cement siding All materials, labor,permit'fee and dump fee's Total $30,000 Payment schedule ; $10,000 at start of work, $10,000 upon completion of roof, $10,000 upon completion of siding Donald A. Pearson Pres. date t Richard Selbst date rdqk r The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Yorkers' Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plumbers _Applicant Information ]Please]Print Legibiy NaMC(Business/Organization/fndividual): ��� r^S� D (rx eve,A-V Addxess: 7/, Li V7 City/State/Zip: r l4 1-1d Phone#: 97e-44 r' 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed m the attached sheet. 7. Remodeling ship and have no employees These sub-camtractors have 8. ❑Demolition working forme in any capacity. wo err insurance. g E]Building addition [No workers' comp.insurance $• e are a corporation and its required.] , officers have exercised their 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs . insurance required.]t employees.[No workers' 13.❑Other 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert fy under the pains an enal s ofperjury that the *formation provided above is true and correct. Simature: S Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: NORTH own of over _ o , dover, Mass., LAKE co HIC HE WICK A \� RATED o''P���S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR T........ ... , �.�.G�,�Ic............. �.. ........................ .......................................... Foundation has permission to erect5.. .................................... buildings on ........�....... .� � Rough to be occupied as . �. Chimney 1.�. .. v...... ..... �. 1 Ch' e provided that the person acce ing this permit shall In eve respect conform to the terms of thea cation on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EMPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC ARTSk, r Rough ................. :?.. ............... .......................... Service BUILDIN INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR gh Display in a Conspicuous Place on the Premises — Do Not Remove F nal No Lathing or Dry Wall To Be Done FIRE.DEPARTMENT Until Inspected and Approved by the Building Inspector. 'Burner Street No. SEE REVERSE SIDE Smoke Det. AORTH To Of 0 ...... .... No. 6 o , dover, Mass., t 'jlA.0 OCMICMEW", RATED U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... ... .t.(�. .............. !�ii.t..bs.. ...................................................................... Foundation has permission to erect.. .....a.............................. buildings on........�....... �jf�. ... . . ...... .........�....... Rough to be occupied as....is.. ....... ........... "..:.. ........... .� . .... .....:.........I.�.... v...... ..ji��S .�. � Chimney was h' provided that the person acce ing this permit shall in eve respect conform to the terms of the on onfile in Final 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 -amu Final Ub PERMIT EXPIRES IN 6 MONTHS HS ELECTRICAL INSPECTOR UNLESS CONSTRUCRTS Rough - ..........T4ivo�BU�ILDIN .......................... Service INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. UN IU:N(9 DATE(MMIDDJYYY1f) CERTIFICATE OF LIABILITY INSURANCE 06/09/11 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 COMNTTACT NA BRIG PH WCC,No Ext): N No): Bernier Insurance Inc. 32 Wakefield Street POB 1268 EMAIL ADDRESS: Rochester,NH 038664268 PRODUCER Nora Goodwin cusroMERro#:DEISX50 INSURER(S) AFFORDING COVERAGE NAIC p INSURED Xavier Deisslee INSURER A:Peerless Insurance 24198 25 Kelly Lane INSURER B:Riverport Insurance Co. Lebanon,ME 04027 INSURERC: INSURER D, INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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. ply - ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMID MID GENERAL LIABILITY. EACH OCCURRENCE $ 1,000,00 NTED A X COMMERCIAL GENERAL LIABILITY CCP9890536 09►28N0 09/28/11 PREMISE& occurrence) $ 50,00 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'LAGGREGATE LIMIT APPLIES PER! PRODUCTS-COMP/OPAGG $ 2,000,E POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ A ANYAUTO BA9895834 09/28110 09/28/11 (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ 600,00 X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Pereccident) $ X NON-OWNEDAUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH AND EMPLOYERS'LIABILITYORY MR ER B ANY PROPRIETOR/PARTNER/EXECUTNE Y/N C288.300318701 04/12/11 04112N2 ELEACHACCIDENT $ 100,00 El OFRCER/MEMBER EXCLUDED? N/A (Mandatory In NH) EL DISEASE-EA EMPLO $ 100,0 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500.00 I i T- i I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remark Schedule,iF more space is required) Carpentry. CERTIFICATE HOLDER CANCELLATION PEARR-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Pearson Renovation Inc ACCORDANCE WITH THE POLICY PROVISIONS. 76 Trask Street Beverly,MA 01915 AUTHORIZED REPRESENTATIVE Nora Goodwin ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD PDF created with pdfFactory trial version www.pdffactory.com A� CERTIFICATE OF LIABILITY INSURANCE °�'�` 9/2011 6/9/2011 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 Phone: (603)225-6677 CONTACT Angela Chicoine Fax: (603)225-4675 Able Insurance Agency,LLC PHO o . {603} FAX No): (603) 130 Broadway Street E-MAIL ang ela , ble2insure.com ADDRESS: Concord,New Hampshire 03301 INSURER(S)AFFORDING COVERAGE NAICLI INSURERA: Merchants Mutual Insurance Company 23329 INSURED INSURER B: New Hampshire Insurance Company 23841 ,Thomas Talbot DBA Talbot Builders INSURER C: „.138 West Parish INSURER D: Concord,NH 03301 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 116 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_ INSRADDL SUBR POLICY EFF POUCY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER D MMID GENERAL LIABILITY BOP1045741 2/3/2011 2/3/2012 EACH OCCURRENCE $ 1.000,000 COMMERCIAL GENERAL LIABILITY DAMAGE T'RENTED A PREMISES jE@ occurrence) $ 500 OOO CLAIMS-MADE F,(I OCCUR MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ Included GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY17]PRO-JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS WNED PROPERTY DAMAGE $ Per accident S UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS4dADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION WC-28-83 003148 00 4/3/2011 4/3/2012 �TATu oTr+ B AND EMPLOYERS'LIABILITY I FR ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N N/A E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? � 500,000 (Mandatory in NH) EL DISEASE-EA EMPLOYE S If yes,describe under 100,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attadr ACORD 101,AddMonal Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Holder's Nature of Interest:Certificate Holder SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Donald Pearson ACCORDANCE WITH THE POLICY PROVISIONS. 76 Trask Street Beverly,MA 01915 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD t FORM 153 The-Commonwealth of Mass2chusetts ;¢ DIAUse Only_ } Department of Industriai Accidents -a Office of Investigations-Dept. 153 �i �• f f� fj 600.Washington Sheet-7th Floor,Roston,iYlass3chuseiis 03111 », x - 1 = httpJ/wwiv.mass_gov/dia IavestJSw IDR AFFIDAVIT OF EYEMPTI— FOR CERTAIN CORPORATE 1 OFFICERS OR DIRECTORS Chapter 169 o•f the Acts of 2002 amended_44.'G.L c. 15?, §1{4) by adding the follo-kving paragraph: "This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation.Notwithstanding section 46,these provisions shall- apply only if the corporate officer provides the commissioner of industi ai accidents v�n_th-a written waiver of his rights undtr this chapter_Said commissioner shall promulgate regulations to carry_out the - _purpose of this D_ _aragrap i Violations of this naragraDh shall subject the corporation.to the-.Denalties set:. forth in section 25C.,, Pursuant to M.G_L_ c_ 152, §1(4)as amended,I[We the undersigned officers of C°a r.Son �n �i71o.v � [,—'lo l�L�t l oll (Name of corporation and Address) each holding at least 25% of the issued and outstanding stock in said corporation,-do hereby invoke the right to be exempt from the provisions of M:G_L_c_ 152, §25A andtherefore_are not required_to ca a workers' compensationpolicy covering the undersigned corporate:officer(s)or director(s)- UWe-the undersigned do also waive any and all fights to--make claims for benefits as defined`iiiM:G L c:15-2.for any injuries that maybe sustained while in the employ of the above-named.coiporati on. • Further,I/we the undersigned do understand that, should the.above-named corporation hire or have in its employ any employees) in addition to the undersigned corporate officers) or director(s),said corporation is required to obtain workers' compensation coverage for the employees)as prescribed ty M.G.L.c_ 152, §25A JJWe the undersigned have read and understand the statements and obligations as delineated above and Uwe have checked the appropriate box below my/our names)indicating iziylour desire to be exempt or not to be exempt from the provisions ot"NLG_Z.c. 152. Siguei d u der e g and-penaltb's o£ pm'Y -aft r_S 0 V?��z-a /_V Signa Print Name&Title Duero(mm/ddlyy ) w h to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Signature Print Name&Title Date,tm:dd,,, ❑ I wish to exercise my right of exemption or, ❑ I wish NOT to exercise my right of exemption E� Signature ..- 1'IstltName&_Fttlt: ❑ 7 wish to exerrisc my right of axcmpoon or C7I wish ,MOT to=crcisc my riosht of exemppoa Signature - M w Print Name&Title Date(mm/dd/yyyy) ❑ I wish to exercise my right of exemption or-❑ I wish NOT to exercise my right of exemption Kote:ALL ELIGIBLE CORPORATE OFFICERS 1YIUST SIGN_ THERE CAN BE(10 MORE THAN 4 SIGNATURES.InS*wc/iOns on back Form 15-3-Revised 10-28-02 Massachusetts- Department of Public Safct) Boat-d of Building Regulations and Standards Construction Supervisor License License: CS 50929 DONALD A PEARSON 87 RIVERVIEW RD GLOUCESTER, MA 01930 Expiration: 1 011 0/201 2 t'unnnisi„nc� Tr#: 3444 Office of Consumer Affairs&B mess Regulation HOME IMPROVEMENT CONTRACTOR Registration: _,:100275 Type: Expiration: 6/1512012 Private Corporatioi PE 'SON RENOVATIONS INC Donald Pearson 87 RIVERVIEW RD:GLOUCESTER,MA MA 01930 Undersecretary