HomeMy WebLinkAboutBuilding Permit #290-14 - 623 OSGOOD STREET 9/30/2013 ti r10RTl1
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BUILDING PERMIT
TOWN OF NORTH ANDOVER °
APPLICATION FOR PLAN EXAMINATION *
� -
_
Permit NO: Date ReceivedAre
Date Issued:
�9SSgcHus t�5
4�ItORTANT: A.2plicant must complete all items on this page
ff
LOCATION
Print
i J
.PROPERTY OWNER
Print ;
'MAP NO,: b� PARCEL ZONINO DISTRICT: Historic District a no
— y
Machine Shop-Village ye no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
0 New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
0 Alteration No. of units: 0 Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
0 Demolition ❑ Other
0 Septic 0 Well ❑ Floodplain O Wetlands 0 Watershed District
0 Water/Sewer
I'0
Identification Please Type or Print Clearly)
OWNER: Name:
hcnLkKkt Phone:
Address: 4-577
c-v
CONTRACTOR Name 7Gl�Yi �d q7� Phone: -r'
:Address: Ll
c
IUA
Supervisor's'Construction -License, Ex
p. Date:
-Home-lm
provement
License--Ex
p. Date:. i
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $: _ 5-, 0I1(l FEE: $
j Check No.: !'3 t?:�, Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
-Signature of A Agent/Owner
9 Signature of contractor 1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
i I
Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
,--
- LOCATION' .
Nint
PROPERTY OWNER-
1
_ _
-` r-�rO
- - Y _
Print 100 Year ld`Structure - ye—e s no.r
WPW: ZON1NG'DISTRICT: -.Historic Districf yes, no
°Machine ShopVillageyess ono
TYPE OF IMPROVEMENT. PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
0 Demolition ❑ Other
❑ Septic,. ❑UVellr ❑ Floodplain fl Wetlands Y ❑ 1Natershed District �f<.
_❑',1Nater/Sewer_
DESCRIPTION OF WORK TO BE PERFORMED:
'I
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR'
._Phone:,
Address: `
Supervisor's�G.onstructio,ri'Mense _ _ — _ —Exp Date:,
- -
Home Improvement License
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
� -SI nature'�off°A en O nerd - -' - '' 'Y�:• �`
Si nat cru of°contractor..
.9b
Plans Submitted ❑ Plans Waived 11 Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
-TYPE_OP-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
li
DATE REJECTED DATE.APPROVED S
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
.CONSERVATION Reviewed on Signature
COMMENTS
i
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
I
i Planning Board Decision: Comments
Conservation Decision: Comments
u
Wafer & Sewer Connection/Signature& Date Driveway Permit
DPW Tow;2 Engineer: Signature:
Located 384 Osgood Street
FIRE-DEPAkThI I :N'T -Terip Qum - 'ter on site yes - no
Located at-124,Mair Street
r r
i
COMM.ENTS
i
i
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
r DANGER ZONE LITERATURE: Yes No
MGL-Chapter 166 Section 21A-F and G min.$100-$1000 fine
i
NOTES and DATA — (For department use
El Notifiedfor pickup - Date
E
I [
Doe.Building Permit Revised 2010
Building Department
`rhe foRowing is--alist of the required forms to be filled out for the appropriate.permit to.be obtained.
Roofivg, 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 j
NOTE: All dumpster permits require sign off from Fire-Department prior to issuance of Bldg Permit
Addition Or Decks
Li 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 pp 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Permit Revised 2012
Location 2 3 G �
No.2-9 o Date `�
1
. - TOWN OF NORTH ANDOVER
u
I
Certificate of Occupancy $
Building/Frame Permit Fee $s2TL
R Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
26924 Building Inspector
NORTty
Town of z sAndover
No.
ZD ?.13
C' L^N, h , ver, Mass, 3
coc NIc"awic. �T
�•9 RATED
S V
BOARD OF HEALTH
Food/Kitchen
P.ERMIT T LD Septic System
THIS CERTIFIES THAT ....... ......��.►.�►..1�!O`.........&U-Sleg ..................................................
BUILDING INSPECTOR
Foundation
has permission to erect .......................... buildings on ...� ., I.... .G. , .... Q.A.....
• � ....�............. Rough
tobe occupied as .........��. ......... ....rtfia lf.................................................................. Chimney
provided that the person accepting this permit shall in every respect conform to the terms of 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
J�+ Final
PERMIT EXPIRES IN THS ELECTRICAL INSPECTOR
UNLESS CONSTRUC10 Rough
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.
SEE REVERSE SIDE
The Commonwealth ofMassachusetts -
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA.02111
wwH.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumlbers
Applicant Information Please Print Legibly
/ 4
Name(Business/Orgaai'zation/lndividual): �CA 1
Address: x/02 8 C��'2
`p u
City/State/Zip: kag Yt 1 ) �i Phone#:
Are you an employer?Check the appropriate box: Typo of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/orpart-time).* have hired the sub-contractors
2.El am a sole proprietor or partner-
listed on the attached sheet. 7. []Remodeling
ship and'have no employees These sub-contractors have 8. E]Demolition
working for me in any capacity. workers'comp.insurance. 9• []Building addition
[No workers'comp.insurance 5. E We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner,.doing all work right of exemption per MGL 11.El Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12, oofrepairs
insurance a ired.re q ut employees.[No workers'
13.0 other
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 ere doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that checkthis 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 fhe policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: [✓C //i'1C' C. Ekpiratioa Date: _21/C/
6�3 nfx� '_ City/State/Zip:
Job Site Address: ,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 DTA for insurance coverage verification.
I do hereby cert under thepains andpenalties ofperjury that the information provided above is true and correct. -
Simature: 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.Electrical Inspector 5.Plumbing Inspector
6.Other -
Information and Instruction"s
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 ofhire,
express or implied,oral or written.,,
An employes 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 a 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 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required,"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any ofits political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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 notrequired to carry workers'compensation insurance. Han 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 retumed 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 law or if 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 hasace rovided a s at the bo
p p ttom
of the affidavit for you to fill out in the event the Office of Investigations lias 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 permit/license applications", any given ear need onl _su
bmit o
Y � one Y 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 maybe provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or'-ermit not related to any business or commercial venture
(i.e.a dog license orpermit to burn 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 COME onwealth of Q9:ssarhuseffs -
Depaftent offadustrial Accidents
Qf ee of.I1iVestigAtiom
fzQ(}Wasbiogton Street
Boston}MA 02111
Tel,#617-727-4.900 ext 406-or 1-877.;M'ASSAFF,
Revised 5-26-05 Fax#617-727-7749
Building and Remodeling
Construction Company, Inc.
aymeut Schedule
PREPARED SUBMITTED TO DATE
Deanna Ousler 4/18/13
STREET
623 Osgood Street JOB NAME
Roof Renovation
CITYSTATEAND ZIP CODE JOB LOCATION
North Andover,MA. 01845 Same
Designer
DATE OF PLANS ATA&Homeowner
Phone
978-688-4221
Authorized Si nature `�
Acceptance o Payment schedule
Payment Schedule becomes part of proposal at signing.
Date of Acceptance
42 Tower Hill Road Tom Angell, Pres.
North Reading, MA 01864 (978) 664-3364
ATA Building and Remodeling MATE
ESTI
Construction Company ESTIMATE
42 Tower Hill Road DATE ESTIMATE NO.
North Readina_MA 01864
4/18/2013 161
NAME/ADDRESS
Deanna Ousler Ousler
623 Osgood Street
North Andover,MA 01845
PROJECT
DESCRIPTION TOTAL
Strip&re-roof as per specifications provided. 45,000.00
CLEAN-UP&
DEBRIS REMOVAL
All debris related to the scope of work performed by ATA or any of ATA's subcontractors will be removed for proper
disposal
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES 0.00
All work to be completed in a workmanlike manner to standard practices.ATA Building and Remodeling are a MA.
registered building contractor# 107523,Builders lic.#043773.ATA Building and Remodeling are a member of the
National Builders Assoc.Northeast chapter,National Remodeling Assoc.Northeast chapter.Thomas Angeli is Nationally
certified by The National Remodeling Assoc.#2423.
TERMS&CONDITIONS OF CONTRACT
INSTALLED ALLOWACE:The amount of money allocated to cover the cost of both labor and material to the specified
material(s)
MATERIAL ALLOWANCE:The amount of money allocated to cover the cost of material only,excluding the labor to
install the specified material(s).
SUBCONTRACTOR:A sole proprietorship,partnership,or corporation that has been retained by the general contractor to
do a specific amount of work for a pre-determined amount of money.
VARIANCE:The owner shall be responsible for,and pay to obtain any variance or zone changes required,unless otherwise
specified in this agreement.
COVENANTS:This agreement is incumbent upon Owner(s)verification that the proposed construction in no way violates
any restrictive covenants and that any violation shall be the Owners(s)sole responsibility.
Phone#
978-664-3364 TOTAL
Page 1
ATA Building and Remodeling E c T I A�11�AT C
Construction Company �7 G
42 Tower Hill Road DATE ESTIMATE NO.
North Readma. MA 01864
4/18/2013 161
NAME/ADDRESS
Deanna Ousler Ousler
623 Osgood Street
North Andover,MA 01845
PROJECT
DESCRIPTION TOTAL
PROPERTY LINES:The owner shall supply the contractor with a copy of the plot plan with legal description of the
property,and it shall indicate all property comers and property lines,and assume all responsibility for accuracy of same.
PROPERTY OWNER:Owner warrants that he/she owns the real property upon which the work is to be performed.
SEPARATE AGREEMENTS:Owner understands and agrees not to effect any side arrangements or separate contracts with
any of the employees,venders,or subcontractors performing work on this job(project).Any deviation must be approved by
the general contractor(ATA)in writing and the Owner(s)may not hold the contractor(ATA)responsible in any way for
unauthorized work.The Owner(s)will also be responsible for any delay caused by use of outside contractors or unauthorized
persons not hired by the General Contractor(ATA).
DOWN/PROGRESS PAYMENTS:Owner has read,understands,and agrees with the total payment schedule as shown on
this agreement.Owner will pay the contractor the initial investment,progress payments,and the final payment as per
agreement.Final payment is due on the day of completion as set with scope of work completed in proposal.If net amount
due on progress payments is not paid by the Monday of the week following the due date,Contractor reserves the right to stop
work until the progress payment has been made,increased by a reasonable sum for the cost of a shutdown,delay incurred
and startup.The Contractor reserves the right to terminate this agreement altogether if work is stopped for at least ten
calendar days because of failure of the to make prompt payments,together with the right to recover payment for all work
executed and losses from delays or stoppage of the work,including reasonable overhead,profit and damages resulting from
any action of the contractor.In no case will the contractor be entitled to less tan his total expenses plus an additional sum of
33%of total expenses incurred.
ALLOWANCE:When a MATERIAL ALLOWANCE or an INSTALLED ALLOWANCE amount is specified in this
agreement,the following will apply.If the cost of the customer selected materials exceeds the material allowance amount,
then that amount will be added to the next schedule progress payment.If the amount is less than the allowance amount,then
that amount will be subtracted from the final amount due on the contract.If the cost of the installed allowance exceeds the
amount specified,then that amount will be due payable with the next scheduled progress payment.If the amount is less than
the allowance amount,then that amount will be subtracted from the final amount due on the contract.
Phone#
978-664-3364
TOTAL $45,000.00
Page 2
cwtr DATE
' �- CERTIFICATE OF LIABILITY INSURANCE 9/26/2013 26/20 3
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 terns and conditions of the policy, certain policies may require an endorsement. Astatement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
RODUCER GONIACT
NAME
M P ROBERTS INS AGCY INC PHONE
1060 Osgood Street A/C,NoM
,E : (978) 683-8073 C.No):(978)683-3147
North Andover, MA 01845
' ADDRESS:Paula@mprobertsinsurance.com
INSURER(S) AFFORDING COVERAGE NAIC#
INSURER A: AMERICAN EUROPEAN INS CO
1SURED ATA BUILDING & REMODELING, INC. INSURER B: MERCHANTS INSURANCE GROUP
42 TOWER HILL ROAD INSURER C:
NORTH READING, MA 01864 INSURER D:"ASSOCIATED EMPLOYERS INS CO
978-664-3364 INSURER E:
CELL 978-621-1749 INSURER F:
:OVERAGES 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.
rR TYPE OF INSURANCE A L SUBRPOLIGY - -
iNSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,00(
C
I CLAIMS-MADE I OCCUR PREMISES (Ea occurrence) $ 100 00(
MED EXP(Any oneperson) $ 5 ,00(
A SKP200020312 06/10/13 06/10/14 PERSONAL&ADV INJURY $ 1,000,00(
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00(
POLICY [_1JEa CI LOC PRODUCTS -COMP/OPAGG $ 2,000,00(
OTHER: $
AUTOMOBILE LIABILITY WD SINGIE ANYAUTO e
Ea accident $ . 5 0 0,0 0(ALLOWNED SCHEDULED MCA7013039 03/10/13 03/10/14 BODILY INJURY(Per person) $
B AUTOS AUTOS BODILY INJURY (Per accident) $
X HIRED AUTOS X NON-OWNED PROPERLY DAMAGE
AUTOS
(Per acc dent) $
$
UMBRELLA LIAB OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MAGE
AGGREGATE $
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY X STATUTE ER
Y!N
ANY D OFFICEROPRIETR �ER EXCLUDED?EC�� N/A WCC5005009237012013A 05/21/13 05/21/14 E.L EACH ACCIDENT $ 500,00(
(Mandatory inNH)
If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,00(
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500 00(
ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may beattachedif more space is required)
:ERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER
1600 OSGOOD ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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Office of Consumer Affairs&Business Regulation
I ' — OME IMPROVEMENT CONTRACTOR
j - = egistration: ;,173922 Type; E
— . xpiration: 11/26!2014 Corporati6n
ATA BUILDING&REMODELING---
THOMAS
EMODEINGTHOMAS ANGELI g
42 TOWER HILL RD _ 4�. V
r _ NORTH READING,.MA 01864-''" I
Vndersee etary I
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42 Tower Hill Road Tom Angeli, Pres.
North Reading, MA 01864 (978) 664-3364