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HomeMy WebLinkAboutBuilding Permit #567 - 605 OSGOOD STREET 4/3/2008 OORTy BUILDING PERMIT D�StLMD TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N ` � Date Received -�°f=d`dp" *A° 7 pDR1TED (y* Date Issued: P (�� �SSACHLIS�� IMPORTANT Applicant must complete all items on this page OR - -s:, ,3Z- z.1,, r- ,=s 021 5r ¥ - � ^ eP'�R���yE�����W� _ tiL � � �-•� a� �A� ���i`.L k`� �' "5 � � � t'3 .� s�� Y 3.s��'s,�3� TYPE OF IMPROVEMENT PROPOSED USE Residential Non Residential New Building One family Addition Two or more family Industrial No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Sep#�c WINE WY ooplaela #s � � tersliia �ct DESCRIPTION OF WORK TO BE PREFORMED: w1SmK EX1S�i�L �epw /}►'J0�£ 1��4�2A�� — �O�E 2- �k�lc dc�t5 tZ AA&f- 1w LA to t--w c p"s V w.e N t-S 1W Ys Identification Please Type or Print Clearly) OWNER: Name: D\k6 Kw-�V.� �',�-�, Phone: Address: dos C�s600n s�tZ �'r " "I LPx 4-1 Supras�r �osrafioicensx� a bY � �� #s AR CHITE CT/ENGINE ER 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: $ 2Si y2-8 92 FEE: $ Check No.: �fg Receipt No.: C�) 7 S NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i �I Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools I 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 DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATEAP ROVED ti�v HEALTH COMMENTS th 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 Located at 384 Osgood Street 7fe �'� ;,� -:��` �-`' 3FJRE DEP7�RTNIEN3 Temp Dutps�eronster}es . ur . t+,wv.,, y., ^.,,,. "'' yam. �* �..a F,S x „?r '•-•+ /]AA A E �' `` ',�"��' _" mss- iLocatedoat �3LY tMa1XlStreet d s 2`e b� i PU 3z syr y -`{ �.% a31 - V ire Departfn 'sena u e�r�dmte eek _. ti y�, "4';� t -.,,wyts'9, '„*' � 3:. Viµ"*. sem. �-^f F' .-� v,.a�. <-�"" `} `•,_ .:.5�"'a ` ` 5,.+" `.:i'7 '` 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) ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or'Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i 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 I Doe:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location D D e` No. b Date r NORT1y TOWN OF NORTH ANDOVER .' «1 F Certificate of Occupancy $ �sJ� sEt� Building/Frame Permit Fee $Hwu 3. 1 Foundation Permit 'Fee $ Other Permit Fee $ TOTAL $ r ! Check # g 2 + G45 `` Building Inspector Andover 89 North Main Street ° .� til ® Kenneth M. LaRose Andover, MA 01810 ', + President IM, fi"oi�e As-if at were atw' iaoig, y e'Bs akry Tel: 978-470-4753 Fax: 978-470-0258 www.andoverequitybuilders.com April 2 , 2008 Keith Residence 605 Osgood Street N. Andover, Ma. 01845 Doug's Cell 978-886-4117 Sunnyridge Proposal#8 (Amended) Proposal to Finish the playroom above the Garage Andover Equity Builders Inc. proposes the following cost for finishing the playroom as per the redesigned scope as defined by meeting with Kathy at your house on 2-15-08. Included items in proposal: • Demo the existing stairwell partition wall to allow for the installation of a new open handrail design where the existing plexi glass is. • Supply and install new primed skirt boards with cap from the garage mudroom platform to the top tread below the playroom floor. • Supply and install new oak handrail and a primed baluster system at the top of the opening between the two walls over looking the stairwell. • Remove the set of double doors to the exterior and frame in with four Andersen A-31 or similar operating awning windows at transom height to + allow for the installation of a wall mounted television below. • Completely patch in the exterior trim and siding. • Patch in all interior insulation and sheetrock from the above window installation. • Frame in the four sides of the front dormer walls, insulate, and install drywall. • Frame in the new playroom bath wall as per design by Daher Interior designs. • Supply and Install a new door for the above wall. • Supply and Install all finish baseboard and door/window trim material and labor to complete the above. • Frame the new garage mudroom hallway at the bottom of the playroom stairs. j • Supply and Install the new fire rated entry door from the garage. 1 IAORTH TONM of _ Andover No. 1 . 4 0 13 . 004— Yo yy dover, Mass., - T O LAKE - T COCMICKEWICK 7�ADRATED `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT v 4STJT T a Foundation has permission to erect.............................. buildings on -6-di............ .....Di ...................................... Rough �y 2 QViL� �! Chimney to be occupied as.. J.. .... QN?............... ............... .................... ....GT.7 ..MW............. provided that the person accepting this permit shall in every respec 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. P Rough Final 3,6/ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTS Rough ............ ..................................................-...._.._..................................... Service BUILDIIVG-INSI'-E�TOR Final Occupancy Permit Required to Ocmpy 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. NO R:TH ToWn of yr--• .,,4�. ,�, No. LAK o� dover, Mass.,' ' • 1. COCMICMEWICK ADRATED p'P ` `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING.INSPECTOR THISCERTIFIES THAT........ ....... ............. ................................................................... ..................... Foundation has permission to erect. .... buildings on........6..*. ........4,PWr Rough to be occupied as.... .. .r .. ..I!k.l ............ �..I..� .......40. I......... .. ... ...�n��onWfiilie7in ... Chimney provided that the person accepting this permit shall in every respect conform to the ter of the apFinal 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 PERMrF EXPIRES I 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC I ARTS Rough ............ ...... ..............>......................................................... 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 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. • Electrical: (as per plan by Daher Interior Designs) o Supply and install 9 recessed cans o 1 —floor outlet o Electrical demo of existing lighting and ceiling outlets. o One TV outlet • Patch and plaster any of the remaining openings. • Paint the entire room primer and 2 coats finish. • Removal of all waste materials. Proposed Total: $ 25,732.50 Does not include: ➢ The necessary Building Permit. (Permit is based upon the entire scope and can be determined when options are defined). ➢ Any plumbing to complete the above. ➢ Any baseboard heating removal. ➢ Any finish flooring. ➢ Smoke or carbon monoxide detectors. ➢ Any Alarm wiring. Additional Scope—As required by the North Andover Health Dept. • Open the existing cased opening at the top of the kitchen stairwell wall to the open landing above the kitchen area below. • Reframe the existing opening from 30"to 60"to expand the laundry hallway into the open landing. • Re-case the new opening to match the existing as close as possible. • Install a new door threshold to match the existing flooring and stain as close as possible. • Includes relocating the existing electrical outlet and the wall thermostat. • Prime the new opening and prep for the final painting. Proposed Total: $ 2696.00 2 *This is the total cost of your project as outlined above. Change Orders will be written for all changes in the scope of the work. These change orders are based on the cost of materials and labor plus an 18% management fee. Each change order must be approved by you before the work is done. Payment for all change orders is expected at the time they are signed. Payment Schedule for: Sunnyridge Proposal#8 Upon Amount Due Signing of Contract $10,000.00 After Rough Inspections $8,000.00 Completion of Plaster Work $6,000.00 Completion of scope $4,428.50 $28,428.50 We understand the above Payment Schedule and agree payments are due upon receipt. We will make those payments directly to the Project Manager or by sending them to Andover Equity Builders at the above address. We also understand that Andover Equity Builders reserves the right to delay completion of the work for nonpayment. This proposal expires one month from the date written. If this proposal is accepted please sign one copy and return it to Andover Equity Builders Inc. Signature belo acknowledges re=twos of Rescission forms included below. Signed— Date / 2008 Si 9ned Date / 2008 Andover Equity Builders, Inc. Representative ** Federal Law provides you with the right to cancel this transaction, if you so desire, without.any penalty or obligation, at any time before midnight of the third business day from the date you sign this contract. Any down payment or other consideration you may have tendered on entering this transaction must be refunded to you in the event you cancel. If you desire to cancel this transaction, you may do so by filling out the following form and mailing it to Andover Equity Builders, Inc., 89 North Main Street, Andover, MA 01810 3 r{ �,'W� '�'r'' r�•� � rr "..>i lei - s �`;�''>>�rA�,` ' '. 6',� t r�"'' '�.� J�,'dr Ji. �'e.� ^C!✓,: r�vo'�As'�v i��r.✓,y��� � '` °• r�°>._ "d` .+' " f 1 i V �:. a r� /l> d 7 i�,� . ''; z Fr e.. $^i Fes` ij r ,. i F •✓ 'V j QS 6��� S" t�°�• \`," �� ice•— � o t// e D o O _i9'—D 9 v� �o o�.blu .� 1� I Aow5 ^�. S 54 P��� � DoC21Z 5\rLA(=,s I _ - r Pell i k::;)( lsT/VJGa W ALL J\ f" ti - +f .x-. : ;.r i_. ....:G.-,i >�. ....:..1r ` .. a :�.. < <+n rt 'i .4 a :.Y e 4 -I d .Q, !'r%r.:F x d' r,F L •.r. l'...+;•vy,?•"s. :.,�'F.+4i_ t. ..1� ''r./,. ....... _.I ...-. .z*. ...: __ �,. .., 4 �. � „d'' ,. "E..,r,r✓w„- �y f- �n FP �.. 'w C” t; /x": eK' `/.^,;�,! �. .. ,:. �.y ru"�"r- /,...>G M''�� �'�-�.✓....tF k r-� 6s.. :'r �/ c �'ri'`"a' 4. �{ .,.Y.....'_f' .,�. ... .."�. '.,. „ .. I_,,. .... ...._...._._....,__�..._.._—.—.— _ .l'y, �y r"�,. ."r v 4,.a da`o;� r ,.. �, x( y, qs. �` ! v'"r'�s k -^ ``1F } "(+ :.-Y b'T k '� r r r. + — Y �•WK ":✓3,�7''�� <<`�r^r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ;W Boston, ALA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricans/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Qwb ou L71Q. _W Address: • City/State/Zip: -kwd oy tk+L,kA 01810 Phone.#: J Are you an employer?Check the appropriate box: a am 4. I eneral contractor and I Type of project(required f` 0 1. I am a employer with Q g employees (full and/orpart-time)•* have hired the sub-contractors 6• ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g• F�Demolition working for me in any capacity, employees and have workers' o workers' co co insurance•t 9• ❑Building.addition [N mp.insurance comp. required.] _ 5. We are a corporation and its 10,❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' camp. right of exemption per MGL 12.0 Roof repairs insurance required]t c. 152, §1(4), and we have no 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. t Homeow-ners 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 state whether or not those entities have employees. If the sub-contractorshave employees,they must provide their workers'comp:policy number. I am,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.#i' s O a 3 Ll [ O ZOO Expiration Date: 7- 1-1- 0 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 of this statement may be forwarded to the Office of Investiations of the DIA for insurance coverage verification. I do hereby certifyp under the pains•and penalties of perjury that the information provided above is true and correct Signature• r.V1,�L�� Date--------------- 21 Zq� Og Phone k FOther only. Do not write in this area, tb be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector rson: 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 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 the grounds or building appurtenant thereto'shall not because of such employment be deemed to be an employer." MGL chapter 1:52, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to,operate-2 business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage I 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 comp_ fiance 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-contractor(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 maybe 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 laworif you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured 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 permittlicense 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 bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts De13a1'EZnAccidentsent of Industrial Office of Investigations ons 644 Washington Street: Boston, IIIA 02111 Tel.#617-727-4344 ext 406 or 1-877-MASSAFE ` 2 Fax# 617-727-7749 Revised 11 22-06 www_mass.sov/dia DATE M CERTIFICATE OF LIABILITY INSURANCE 09/14/2006' PRODUCER (603)669-0704 FAX (603)669-6831 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Infantine Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 5125 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ichester, NH 03108 yce Dunlap INSURERS AFFORDING COVERAGE NAIC# INSURED Andover Equity Builders, Inc. INSURERA: Acadia Insurance Co. 31325 53 Porter Road INSURER B: Andover, MA 01810-3703 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH-RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRETYPE OF INSURANCE POLICY NUMBER D E M I I DATE(MMIDDIYYI LIMITS GENERAL LIABILITY CPA013298412 09/01/2006 09/01/2007 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 250,000 CLAIMS MADE M OCCUR MED EXP(Any one person) $ S'000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- JECT El LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR D CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND I TWO STATLI OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Efl— E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? VV VV 1 l� 1(J 0 E.L.DISEASE-EA EMPLOYE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Various Work throughout the policy term. (978)470-0258 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,IT$.AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) FAX: (978)623-8320 1��v` {�-©ACORD CORPORATION 1988 Boar lo w ung* egu a�o s an tan ars I Construction Supervisor License License: CS 75425 Birthdate*,,5/10/1967 Exp%anon /10/2009 Tr# 15439 Restriction 00:T,- I MICHAEL A AMEENt= 1 SORENSON RDS SALEM,NH 03079 ="`"., Commissioner J i I