HomeMy WebLinkAboutBuilding Permit #289-12 - 58 MAIN STREET 10/5/2011 TOWN OF NORTH ANDOVER
G APPLICATION FOR PLAN EXAMINATION
Permit NO: �4 l2 Date Received
Date Issued: l ��
IMPORTANT:Applicant must complete all items on this page
LO CATION S (p Y l f a-l/I
/ ,11 f
PROPERTY OWNER �e x � S�e�" Unit#
Print
MAP N06,4e PARCEL:ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
El New Building 11 One family
[I Addition El Two or more family ❑ Industrial
❑Alteration No. of units: `Commercial
;gRepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
MA AM i
I Se F ood-4 1,7� Fplainl � Wetlands� (01 Wat�ershedDistnct;
Water/Sewe a �- a _
DESCRIPTION OF WORK TO BE PERFORMED:
Vtncr� S► AS
i
(Identification Please Type or Print Clearly)
OWNER: Name: , Phone:
Address: J5 8 • (0 MO�n grccl 0 r-ly-, d vei
CONTRACTOR Name: C:A f7�`�U� ���' ��j Phone: 9?1 6632Y2_0
Address: Zoo fi4fi)ki t ec:f- Sv r fe ZZ(. Nva A/tdtvve`
Supervisor's Construction License: Cl qJS Exp. Date: Id-
Home
aHome Improvement License: / 04 -5�( 9 Exp. Date: 7 ^�
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$10p0.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ (Poo. FEE: $ 00
Check No.: 1.2�?,Op- Receipt No.: v2�/ 67-17
NOTE: Persons contracting with unregistered contractors do not have access tot ua n u d
iG�rrn�ti irc rif/�'riant/C�ininPr -
..Siariature
0f-contractor'.:
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS ��-
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
i
Total land area, sq. ft.:
f Meter location, mast or service drop requires approval of
ELECTRICAL: Movement o
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A-1-and G min.$100-$1000 fine
I
NOTES and DATA— For department use
1
CC
f
1 f
I
Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
I
t
-- — r
iana ure d contractor:-.:
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
❑ 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
VOTE: 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
No. /Ze Date
NORTh TOWN OF NORTH ANDOVER
0 .
0
� s
Certificate of Occupancy $
s''^°''ABuildin /Frame Permit Fee $
sncMust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check =ra 7r
/0 SI
24663r
Building Inspector w
NORT�
Towno over
- ,o .
TO
o , '� d.over, Mass.,
O LAKE
COCI-IICHE W ICK �t
�ADRATE D
qS U BOARD OF HEALTH
Food/Kitchen
PF
Septic System= RMIT T D
-
BUILDING INSPECTOR
THISCERTIFIES THAT........ ............ .... ........................................................................................................... Foundation
.... buildings on �..�f.. � r S' .............. Rough
has permission to erect..........:.......................... .................... ...............................................
-
to be occupied as...........................1/. +q.. ./.......��.r/.1.�. .s............................................................................................. Chimn y
e
provided that the person accepting this p6rmit shall in ever respect conform to the terms of the application on file 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
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
0000
. .. .............................................. Service
...................... . ........
BUILDING 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 FIREDEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
- Street No.
SEE REVERSE SIDE smoke Det.
DAVID CASTRICONE,PRES.
CASTRICONE ROOFING& SIDING INC.
ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845
Lt North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhi11978-374-7314
I/we the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary
materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and
conditions,on premises below descri ed: r
...(.. C
Owner's Name... Lj ....../ .l�cS:E. '�....: .. 1..0 1 <....................._.T hone#.../.. .._.. �� ..:r.r ! -��
Job Address. ' .:.-.la CLL. ,�
�• 1 ...t ............City.. �J.n.. i�G.U:�/ j'.................State.....
.. ..........
Specifications:
.................................. . ......�.......................
................ J
��.......i.....,.<'_.,?'... $..i.sa .n.:.....ttr ......../....5':1.x.:( S...C,ria........�'.1J. '....k. le ...
r ! 1I
........: 4tt/.dL4......(:...1,i1.p.!_r,-.f`�..... ...... .••.?......C..:h.d.....s.:d. ,�! f../.i. f
..jj.:...... c_l`.lr,c,ti.yat''� ....e......... G?.A1:.&t. ... 11/./15.,./..4�;1/..1 e��... .........
e ..
A!k' 10......V1.1 ........�::i.�t jry.f; ......�✓1.
f l.zc . .. t:c_ .
...... l 1�. r..r-..... �.. � . :�....... .: _ ..........................
..,f..y.-vt..:tU. ......C� /.¢. r ....... .G:,r1.Y.1�?.....tJ.l. . ',.n......................... ........ ................. ...........................
// !✓
" .....4rlS.t t�.l .atc /..�z��;.tJ.................
............... .5... .eC:...[.t..d.. .......�,e�„11,:4. 2-1.1
.Ll:.� � .....
� II
r• 'r -
Two Year Workmansht Warranty(Not Tgnsfehable) Manufacturers Warranty as specified by r aFufacturer 1
The cot actor agrees to erform the work and fu�rnis he materials specified above for the SUM of S......�..i..�..(.�. 1..........
peyable � -c,on.....t.� r� Sfl S L"
Payable.z` % 1.......... „�...�r ...O- payable JQL
on......... ? glance ayable on uanpletion of
Owner or Owners are not responsible for Property Damage or Lia ity while 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,exposed nails)or
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,theirioint 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.Property may be subject to mechanic's lien if unpaid.It
is further agreed that this contract may be 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 arc)the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their)
names(s).There arc 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 the Office of Consumer Affairs and Business Regulations,Tel.(617)973-8700.
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 CON'T'RACT IF THERE ARE ANY BLANK SPACES
This contract may be cancelled,without penalty or obligation,within three business days of the below-referenced date.Mail or deliver
a signed and dated notice or send a telegram to Castricone Roofing&.Siding Inc,200button St.,No.Ando er,MA 01845.
IN WITNESS WHEREOF,the parties have hereunto signed their names th' .. 4 day of...,_�:cy' .,
?�- ...
Accepted: F/ to, `(7�- ) 'ej'l Si e � -rt :. ,. f .... .:... Owner
.. .. ...... .
\ Li
i
.... � � --'- Signed.............................:............................................... Owner i
Ft:'.��{:...j(.Jw'K.,�;�r:.�r!•L-G/ ��11
David Castricone,President /� elk c,K"_fes. c, �`41 el
r�i�
The Commonwealth of Massachusetts
c I Department of Industrial Accidents
r, Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): .UAV I I CNyicl(oNt Poo F i IvN ' Si p/,*, INC.
Address: 10 (j Su T To&3 STrZ t.4�_r SU ;T& 2 L�
City/State/Zip: N o. AN bo ie oc. N/A 6 11 4S Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with t 4. E] I am a general contractor and I
6. New construction
employees(full and/or part-time).* have hired the sub-contractors ❑
2.❑ I atm a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ 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.❑ Roof repairs
insurance required.]t employees. [No workers' 13�. Other lb 110'_
comp. insurance required.] /
*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. n
Insurance Company Name: C A 2TA S
p Y
Policy#or Self-ins. Lic. q#: ljf� C[� 897a-; Expiration Date: a _
Job Site Address: 5�1 Co q Im 6L;f\ S- - City/State/Zip: N • A-rJ \f, PA 6 fi-YJ
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the ains a—n�d}ppenalties of perjury that the information provided above is true and correct.
Si nature:
e Date:
Phone#: q 7 3 J 4 a0
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):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
ACORD� DATE(M1DDIYYYY)
�. CERTIFICATE OF LIABILITY INSURANCE '9/9/2011
THIS CERTIFICATE 18 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: It tM certlticate holder la an ADDITIONAL INSURED, the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the pollcy,certain Policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsemen a.
PRODUCER NTACT
NAME:
Willows Insurance Agcya. , 978 4T5 3414 FAz _-
51 Cochichewik Dr
ADDRE7j6:._—.. --
PRODUCEJ --•••••-
CUIPMFA In I.
North Andover MA 01845
INUMM(S)AFFORDING COVERAGE _ NAIL y
INSURED INSURERAMaiden SPecialty Ins Co
DAVID CABTRICONE ROOFING & BIDING INC IN6URERa�•.
INSURER C:
200 Sutton St Suite 226 INSIJRsaD: —
NORTH ANDOVER MA 01845 INSURER E.
INSURER F:
COVERAGES CERTIFICATE NUMBER CL119906255 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.
I
ITRA' -TYPE OF INSURANCEAnza POLICY NUMBER PLICI EiF Mwop Y1POLICY LIMR9
GENERAL LIABILITY
EACH OCCURRENCE _ S _ 100_0_000
X COMMERCIAL GENER(A�L LIABILITY POWGE TO RENTED
REM _ I _50000
A _ CLAY434AADE I x l OCCUR 00031600 9/06/2011 /6/2012 �P(1���m) S
MED EXP An one en S 1000
" ' _PER.40NAL&AOV INJURY S 1000000
GENERAL AGGREGATE S 200000_0
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY PRD PRODUCTS-COMPIOP AGG S 1000000
LOC .. . ._.S ..
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT S
ANY AUTO (Ea ocaidenl)
ALL OWNED AUTOS BODILY INJURY(Per Demon) S
SCHEDULED AUTOS BODILY)INJURY(Per ac6dant) S
HIRED AUTOS PROPERTY DAMAGE f
(Per a dclard)
I_ NON-OWNED AUTOS
S
UMBRELLA uAs $
=0C _
"Cass Lim EACH OCCURRENCE AGGREGATE
DEDUCTIBLE A— .
RETENTION a
WORKERBCOMPENSATION S
AND EMPLOYERS'LIABILITY WC S_TATU-Y!N TRYLIMITSANY PROPRIETORMARTNER/EXECUTIVE D •
OFFrCERAIEMBER EXCLUDED? NIA E.L.EACH ACCIDENT f
(Mends"In NH)
Y yes.describe undo E.L DISEASE•EA EMPLOYE S
DESCRIPTION OF OPERAT10N5 bob« — _..—--•
E.L.OI$EA$$•POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Attach ACORD 707,AddalonalROMWXa SCMdUnl,N mere apace le Nqulrad)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE 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.
! Castrioone Roofing
200 Sutton Street Suite 226 AU 0ORiMWMAENTAWA
N Andover, HA 01845 4a I
�7
ACORD 26(2009109)
IN5023(zo0eoa) The ACORD name and logo are registered marks of' ORDORD CORPORATION. Ati'rights reserved.
aco CERTIFICATE OF LIABILITY INSURANCEF912011
DATE(MM+DDIYYYY)
23
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(Sy, AUTHORIZED
nw�n�►ITA Trrrr nn wwnwirn�w •►rw T�r�I+�wTIr-In 11Tr�rnr www
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. It 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:
Eastern Insurance Group LLC — Main PHONE :AX
No:
233 west Central Street fA/C.N
508-653-8089
Natick MA 01760 ADDRESS:
INSURERS AFFORDING COVERAGE NAIC B
b'
INSURERA:Comnerce insurance Company 34754
INSURED 31 969 INSURER B:
David Castricone Roofing & Siding Inc INSURER C:
200 Sutton Street #226 INSURER D:
North Andover MA 01845
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2141633907 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 An
MWI MU
rvua.r i.umocn 9r�r��iYeEFF miTiuttiLvrlxP
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
PREMISS aocc rrenos $_
CLAIMS-MADE FIOCCUR MED EXP(Any ore person) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $
POLICY PRP LOC $
A AUTOMOBILE LIABILITYBCNGCV /1/2011 /1/2012 F�aoc1mt. 1000000
ANY AUTO BODILY INJURY(Per person) $20000
ALLOWNED SCHEDULED
AUTOS X AUTOS BODILY INJURY(Per accident) $40000
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS Per accident $
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS LIAB HCLAIMS.MADE AGGREGATE $
DED Ll RETENTION $
g
WORKE RS COMP ENSAT10N C003989723 9/23/2011 9/23/2012 X WCSTATU• O -
ANDEMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER+EXECUTIVE E.L.EACH ACCIDENT $100000
OFFICER/MEMBER EXCLUDED? N f A
(Mandatory in
h)res,describe under E.L.DISEASE-EA EMPLOYE $100000
DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $.500000
—TI
DESCRIPTION OF OPE RATIONS/LOCATIONS r VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more space Is required)
CERTIFICATE HOLDER CANCELLATION
Castricone Roofing 8a Siding SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
9 9 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Suite 226 ACCORDANCE WITH THE POLICY PROVISIONS.
200 Sutton Street AUTHORIZED REPRESENTATIVE
North Andover, MA 01845 �_�
®1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
�1;t.�,ailui,cfl, ll�'Itarlrnrltl ul' Puhlic Nafm
+ �/�t V,CI/l7IL{/'/IUY:(L/L17P''•.•L f.IIJJLtC/tN�J
1l of liuilllitt� 12r ula[iult, mit! \I;u111:11'II, r' office of Cuum
suer Al'f'uirs&1i,1siucss Iteguintion
Construction Supervisor Specialty License
HOME IMPROVEMENT CONTRACTOR
License: LS SL 99358 Registration: 104569 Type:
Restricted lu: RF,WS y► „'4 r Expiration: 7/14/2012 Privale Corporatio
DAVID CASTRICONEt. `.
,:�,..;,.:n,,., , DD CASTRICONE ROOFING,.SIDING 8
31 COURT STREET }
NORTH ANDOVER, MA 01845 : ` l David Castricone
200 SUTTON ST SUITE 226
NORTH ANDOVER, MA 01845 llu�crsccrcturY
Exptralion: 12!16/20
11
l nuwi�ci ui'r 1"ra: 99358
.4
Town of North Andover Nnkr�
o {taco
C
Building Department o -
27 Charles Street '' A
North Andover, Massachusetts 01845 aV.
(978) 688-9545 Fax (978) 688-9542 O<1LA I
<IKWKAye D4
SSACNUst
ry
I
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:
Facility location
L2f
Signature of Applicant
Date
NOTE: A demolition permit from the Town of
project tluough the Office of the Building Inspector, Andover must be obtained for this