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Home My WebLink AboutBuilding Permit #714-2017 - 62 GRANVILLE LANE 1/12/20171 444 -6 Lk BUILDING PERMIT V TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: I it I IMPORTANT: Applicant must complete all items on this page V SS ilV 4a\ �_ \�`.. A 1. LOCATION < Wil!g h ✓ i ll f L✓I - Print PROPERTY OWNER :5 v k h Mf2t-n Print 100 Year Structure yes no MAP PARCEL: o ZONING DISTRICT: Historic District ye no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition El Two or more family [I Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg K Others: ❑ Demolition ❑ Other .�►'►Sv/�tT ✓14 ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFOR ED: P1�5eAI;h� �}niG Snsv/iiia -rp �.-�9 /J"'A Identification - Please Type or Print Clearly OWNER: Name: 2b V\� via /40 Phone: F2E-6D�06- Address: (0,� 6't -g h u ; I/?_ z4✓1 Contractor Namee' Address: 9781-47-7638 Supervisor's Construction License:— ...—Exp. Date: Home Improvement License: ARCHITECT/ENGINEER Address: i0L 6 Exp. Date: Phone: Reg. No. FEE SCHEDULE: BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ V oP0 • o o FEE: $_ _41� Check No.: 1"001 Receipt No.: 30-77 NOTE: Persons contracting with unregistered contractors do not have acces&to the guaranty fund i3 I Location (o'2e- No. Check # ,�` f.35 Date Z TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ �. TOTAL $ j Building Inspector 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 r t .• s, Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: wLocated ss }' on ocated Osgood Street sonoA. �site .IREtOf--TFMENTemp Du psier + Llbcatediat':,124IMa'iN treet �FireDepartmentsi'gnature/date _ - _ i _.r_ _ •+ _ _ = a "."tet .� _ _ «. �.= f a =' --P ef+-.: - •,+-� ».e...e= -..--..uw.-...s z v..--.. ...__. . -a 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 ®ANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine m 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) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products TE: 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 46 2012 I ECC Energy code 4� 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 V-. I !Eft—* � jr \ i 0. _ ? 3• U W Ln Z Z m t O � fu W �= F m LL O W vaf Z m J d J Q 2F U. o OC m v +_U+ .t o LLL N T N u n {n U W Ln Z Z m C — � o LL s : K >.p v c E U m LL O W vaf Z m J d c or: m I1 cic O W d of ? Q v V W W t v > s LL oC O - U nW Z HLLI -C on 0 LL Z W F- F- Q W D LL v m O Z + °1 N N Y 0 {n O M rl M O •Q. L Q cc a +� C O N V EQ• L N d O �0+ N J L W �m a W E O O �•�o-0 W m a -� E o L o Z r m Oa' > 30 c 'CJCC L 0)- m O ca o ti o c S Qvp=a o = a> Q am N O m d to 4).2 t W r- -a O O '' r.. LU Li O N C O E 0-0 r j O W L v O v n co O;cg' n Q 1=— i:Lcc ... Q.ot> > -M7 t cc �CD 0o o CL CL co Q Cc Cc ca J -0 O a) z U) co O co a, W J az LLI Q. Z J m Cl) N 6L z O v v � O � � U to Mui z w v � -M7 t cc �CD 0o o CL CL co Q Cc Cc ca J -0 O a) z U) co co a, W J az -M7 t cc �CD 0o o CL CL co Q Cc Cc ca J -0 O a) z U) area aini*euBIS sdeumo oMeVq uoiaew Aq 03NOIS-3 •peuuoo pouBls a 4pm pllen Aluo sl wjoj siyl -f4iadoid Aw uo )uom wiopad o; pue 11wiad Bulpllnq a ule;go 01 1184e lbw uo joe of `BuuaaulBu3 3SIH jol joloeguoogns pezuoy#ne ue (ssaJppy A:PadoJd) (ss9JPPb APadOJd) azuoyine Agajaq Z�, :1e p81e001 Aliadoid 844 10 Jaunno (aweN s, UMO) f WHOA NOIIVZIIIOHinv H3NMO wo*-s "UI6ua3srd-m w► VNIMNION3 9££9•Z09-6££ 16z0Z0 m `umuso I Z mutt `Plea Mu#x4s 09 3 S 1 8 M A Rya Federal ID # 0"406629 RISE Engineering RI Contractor Registration No 81186 MA Contractor Registration No 120979 CT Contractor Registration No 620120 RISE60 Shawmut Road, Canton,'MA 02021 pp ENGINEERING ACT 339-502-5197 339-502-5197 FAX 339-502-6345 Page 1 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CTA -11.1''..5 ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW �USTOMER John Mako (978)685-0467 12/15/2016 416487 28604 SERVICE STREET 62 Granville Lane 62 Granville Lane SERVICE CITY, STATF, ZIP BILLING C"Y. STATE, ZIP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION AIR SEALING: Provide labor and materials to seal areas of your home against wasteful, excess air leakage. This work will be performed in $1,020:00 concert with the use of special tools and diagnostic tests to assure that your home will be left urith a healthful level of 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.) This will require (12) working hours. A reduction in cubic feet per minute (cfm) of air infiltration will occur, but the actual number of cfm is not guaranteed. At the completion of the weatherization work, and at no additional cost to the homcowmer. a final blower door and/or combustion safety analysis will be conducted by the sub -contractor to ensure the safety of the indoor air quality. DAMMING: Provide labor and materials to install a 12" layer of R-38 unfaced fiberglass baits to (74) square feet for damming purposes. $151.70 ATTIC FLAT: Provide labor and materials to install an 8" layer of R-30 Class i Cellulose added to (1324) square feet of open attic space. $1.906.56 %1iOLE HOUSE FAN: Provide labor and materials to fabricate and install a rigid foam insulating cover for the whole house fan. $209.21 ATTIC ACCESS: Provide .labor and materials to install (1) easily moved, insulating cover for the aitic access folding stair. A small flat surface $237,65 of ply%%vW will be created around the opening within the attic. This will allowthe cover's integral weather-stripping to restrict air leakage. VENTILATION: Provide labor and materials to install (2) insulated exhaust hose with roof mounted flapper vent to exhaust existing bathroom $237.50 fan(s). Broan model 4 636 or equivalent, VENTILATION: Provide labor and materials to install ventilation chutes in (8 1) rafter bays to maintain air flow. $202,50 i - V _ . _ ��1� t DEC C- Federal ID A 064405629 RISE Engineering RI contractor Registration No $186 MA Contractor Regletratlon No 120978 C7 contractor Registration No 620120 RISE60 Shawmnt Road, Canton, MA 02021 ENGINEERING CONTRACT 339-502-5197 FAX 339-%2-045 Page 2 PROGRAM TrRaYrRAcrratNronrETYr�aaraE CMA-HES TI�CVaTOaERFORMAnaAS CUSTOMER PHONE DATE CUENT# VOORKORDER John Mako (978)685-0467 12/15/2016 416487 28604 UWMCE STREET WPW 62 Granville Lane 62 Granville Lane North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION RISE Engineering will apply all applicable. eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible $90.00 measures, Columbia Gas offers 75% incentive, not to exceed $2,000 per calendar year, and an incentive of 100% for the Air Sealing measures up to the first SW and an additional $340 if savings are justified by the auditor. For the safety and health of your 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 weatherization 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 of $90 and is at no cast to you. Total allowable weatherization incentive is $3,110. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. Total: $4,055.12 Program Incentive: $3,110.00 Customer Total: $845.12 WE AGREE HEREBY TO FURNM SERVECES-CONOU"M of ACCORDANCE VOM ABOVE SPEC IMATM& FN THE SUM OF A�� "'Nine Hundred Forty-Five 812/100 Dollars �E ap►�rN�� $945.12 Y�NDa11FMAUNCEAFiBlON i0 DAY8.ON �RlNIRBEF AaNr OGORaA WA8W6MT8OFCUSTOMER AGREES TO WO AMOUNT WFULL INTEREST OF 1% WILL REQ�ON. CbN1RACrRgE618TRAT�ION. E-SIGNED by Michael Trudeau E-SIGNED by Marion a o N.• TINS CONTRACT MAY SE VNIMMMM BY OS W NOr EIIECUTEDUM DATEOFACCEPTANCE ACCEPTANCEWCOUMCT-THEA8Afl6FACTORY 1b yg AKD ARE NLN�BYACCBFrEDUAM VOU ARE AUrIORQfD MASK 30 DAYS, A88FO4nED.FAY�7iTWI I MADEA80URaODABOVE AC40REP CERTIFICATE OF LIABILITY INSURANCE o Bio"" azo 6» 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(ies) 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 andorsemen s . PRODUCER -NAME.CONTLinda Bogdanowicz Insurance Solutions Corporation PHONE (603)382-4600 FAX No(603)362-2034 E-0AAIL lindab@isc-insurance.com ADDRESS: 60 Westville Rd INSURER AFFORDING COVERAGE NAIC 9 EACH OCCURRENCE $ 1,000,000 INSURER A 3fe8tern World Plaistow NB 03865 INSURED INSURERB:Hautilus Insurance Group INSURER C: Polar Bear Insulation Company Inc INSURER D: PO Box 958 INSURER E: AUTOMOBILE INSURER F : Andover MA 01810 GUVEHAUES CERTIFICATE NUMRFRCL1632326134 RFVISI[ mNIDIRER- 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 WTH 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. ILTR NSRTYPE OF INSURANCE B POLICY NUMBER M UCY EFF POLICY EYXYP LIMITS A R COMMERCIAL GENERAL LIABILITY CLAIMS -MADE $ OCCUR UPP9274967 3/24/2016 3/24/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISESEaoccurrence $ 100,000 MED EXP (Any oneperson) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: S POLICY � ECT F] LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Fa accident BODILY INJURY (Per person) $ BODILY INJURYPeraccide $ ( n� PROPERTY DAMAGE Peraccide $ $ BEXCESS R RDED UMBRELLA LIAR UAB OCCUR CLAIMS -MADE AN026107 3/24/2016 3/24/2017 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABIUTY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? r_1N/A (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below PER OTH- STATUTE ER EL. EACH ACCIDENT $ E.L. DISEASE- EA EMPLOY $ EL. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space to required) Town of North Andover 1600 Osgood St, Ste 2032 North Andover, IKA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE th Maglia/SJA 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 rgnunn 1/3/2017 Insurance Services ACC)RD CERTIFICATE OF LIABILITY INSURANCE FGATE(MMlDD/YYYY) 0110311017 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 CONTACT NAME: Automatic Data Processing Insurance Agency, Inc. FAX PH Ext): NC, No ADDRESS: 1 Adp Boulevard Roseland, NJ 07068 INSURERS) AFFORDING COVERAGE NAIL s INSURER A: NorGUARD Insurance Company 31470 MED EXP (Any one person) $ INSURED INSURER B: POLAR BEAR INSULATION CO INC PO BOX 958 INSURER C: INSURER D: Andover, MA 01810 INSURER E LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOSNON-OWNED AUTOS INSURER F: COVERAGES CERTIFICATE NUMBER- 593370 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 LTR TYPE OF INSURANCE INSD U WgI POLICY NUMBER MM1DD POLICY EW MIDDIYYYY LIMITS North Andover, MA 01845 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F—I OCCUR EACH OCCURRENCE $MMUETO MU PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ L AGGREGATE LIMIT APPLIES PER: POLICYJET LOC POTHER: GENERAL AGGREGATE $ PRODUCTS- COMPiOP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOSNON-OWNED AUTOS Ea aoodent) $ _ BODILY INJURY (Per person) $ BODILY INJURY (Per acdderd) $ Per acadent $ UMBRELLALIAB EXCESSLJAB HOCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE $ DED I I RETENTION$ S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVE YIN OFFICERAEMBEREXCLUDED? QNIA (Mandatory in NH) ky� desenbewula DESCRIPTION OFOPERATIONS t�ow N POWC840361 01101/2017 0110112018 X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYE $ 11000,000 E.L. DISEASE - POLICY UMIr S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached Hmorespaoe is required) Contractor License: CSL 106017 HIC 102726 CERTIFICATE HOLDER CANCELLATION AW 1955-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD https://adpia.adp.com/ISExtemal/app/index.html?clientid=2037315&requestFrom=tan#/home 111 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main st AUTHORIZED REPRESENTATIVE North Andover, MA 01845 AW 1955-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD https://adpia.adp.com/ISExtemal/app/index.html?clientid=2037315&requestFrom=tan#/home 111 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information POLAR INSUV710N Please Print Legibly Name (Business/Organization/Individual): PO BOX 958 ANDOVER, MA 01810 Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. IP I am a with employer ( 4. ❑ I am a general contractor and I 6. F-1 New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance required.] 5. E] We are a corporation and its 10.❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.Q Other employees. [No workers' coma. insurance reauired.l *Any applicant that checks box #I 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. :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 -contractors have 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: !q) (� V A k'6 :3� S v t' R W to 6-0 )ih Q4 to Policy # or Self -ins. Lic. #: ? p t./ C Y-1 D 16 / Expiration Date: at /01 1.9 Job Site Address: (o 4— toy, I (C Lrl City/State/Zip: %�. ii A�CJd��' PV1 /4 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 th_,_pains andpenalties ofperjury that the information provided above is true and correct. :. WMA AZA Phone #: q%s--- 1/0;>- ;) 03 A Official use only. Do not write in this area, to be completed by city or town ofciaL City or Town: Permit/License # 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 #: CJ sWcvnwwnweaN, 0�,`i� Office of Consumer Affairs and Business RegWation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home improvement CRegistration - _ Regisbation 102726 Type: DBA Expiration: 7/2!20'18 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOX 988 - ANDOVER, LUTA 01890 - SCA 1 €5 2oht4a911 ��e �nnev�a»meu�lf af'C%�jfiSi(ICIJt�SCtl1 Orilee orConsumerALMai s &Busmessilegalation HOME IMPROVEMENTCONTRACTOR Registration: 1o= Type: Expiration: 7/21.2018 DBA POLAR BEAR INSULATION Vincent LeBlanc 51 SO. CANAL ST. 45A LAWRENCE, MA 018.1 lTudersecrelarp Trd 419291 Update Address and resin card. Mark reason for chansQe Address C]Renewal D Employment Q Lost Card License or registration valid for individual use only before the expiration date If found return to: Office of Consumer ASairs and Bnsmess Re_oubftn 10 Park Plaza -Suite 5170 Boston, MA 02116 %IV riot valid without siguatnre I Massachusetts - Oeparlment of Public Safety Board o: Building Regulations and Standards Cs1n+tracticm Surcniin r Specialty � _ cense: CSSL406017 I PETER A LESLANC 2 EAST PINE STREET o Plaistow NH 038155 P - Expiration Commissioner 04/2812018