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HomeMy WebLinkAboutBuilding Permit #630-2017 - 73 HOLLY RIDGE ROAD 12/9/2016LF BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �a` 10l - U16 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial a`;Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition d>2f`L°":'Fgr-1' `�%"h`«"''"t "F"" '.xy` q p X.a �iM >T j-. t c ❑ 1Nelloodplam ❑ Other ., � , p•�„` `- u� '7"' `.�> s ❑ �j #. D Wetlands • .?t"".'4"` "`.' : °�'-_'"..'iS4 tsse.W,ipq Y...V ter$hetl strict - F Ewa, r- 1 c-"� .a+.:q, �'. `� /Sewer w. DESCRIPTION OF WORK i v BE FE FORIVIL-u: Identification - Please Type or Print Clearly OWNER: Name: Mi(Ofl SCh 1-4 Phone:q��i ARCHITECT/ENGINEER Phone: Address: Reg. No, FEE SCHEDULE: BULD/NG PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 301 O lP . I FEE [ O Check No.: � op S. Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to he guaranty fund �inriati irP of Anent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ S immilg 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 COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature Reviewed on Signature Reviewed o Zoning Board of Appeals: Variance, Petition No: nature Zoning Decision/receipt submitted yes Planning Board Decision: Comments a Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locaiea M4 Usgood street aFIREDEPARiTMENT Tem Dum ster�on site \/es�� "o„r I -'t p 7r Loi ated,at 1824 MainStreet ��}art rm nFi_re�Departmentsignatiar�e/date 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine [VOTES and DATA — (For department use) Notified for pickup Call Email f {Date Time Contact Name Doe.Building Permit Revised 2014 No Bui-Iding 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 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location /41-4A, le P No.�36- dot 7 Date 1�0,-) I aol(o TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $ Z4 (.P Foundation Permit Fee Other Permit Fee TOTAL Check# X00 'lid C/ Building Inspector a� 0 a 3 0 H to aus J = LL o Q 0 mN c v Y Y \ o LL E 0 N U Ya (n H Z Z coW O ... ca -O0 � LLL t = d' T a� C E U LL O u HCL Z Z J a L to =3 K io LL 0 u Z V J LUY t to_ m C' u ? S C H 3 1), Federal 1I 05-0405629 RISE Engineering RI Contractor Registration No 8186 MAContractorRegistration No 120979 CT Contractor Registration No620120 RISE 60 Shavi`mutRoad, Canton, NIA 02021 ������ ENGINEERING' 339-502-6335 FAX339-502-6345 Page 1 PROGRAM EcCNMtTGINM�vGu#-lucmtEG CU RmMaa _ OEGCRI9EDBEl:�N CWTSER PHONE DATE aims WORK ORDER Michael Schiff (978)808-3446 11/22/2016 441544 23902°-" ��,...- &ERVICE-WMEET aWNG MET ,,,�,.,••'^"�; (r"^a' ,�^�„ L) 73 Holly Ridge Road 73 Holly Ridge Road ►.�' SERVE CnY.SaA'F ZP MUM tint. S:AE, LP North Andover, MA 01845 North Andover. MA 01845 JOB DESCRU TION U` AIR SEALING: Provide labor and materials to seal areas of your home against Hastcf CcrCass air leakage. This twrk trill performed in concert with the use of special tools and dingnostic tests to assurct hat your home %till be lent with a healthful I eI air exchange and indoor air quality. Materials to be wed to seal your home can include caulks, foams and other products. Primary arras for scaling include air leakage to attics, basements, attached garages and other unheated areas (ivindows are not generally addressed) This will require (12) swrking hours. A reduction in cubic feet per minute (cfm) ofair infiltration will orcin burr the actual nu mbcr of cfrn is not guaranteed At the complet ion of the tteathcrizaton work, and at no additional cost to the homcoarner, a final blotter door anchor combustion safety analysis will be conducted by the subcontractor to ensure the safety ofthe indoor air quality. GIANT OPEN CHASE WHERE CURVED STAIRWAY AND ATTIC i 00R'MEET. $1,020.00 -- DAMMING: Provide labor and materials to install a 12" layer of R-38 unfaced fiberglass baits to (88) square feet for damming purposes. $150.40 ATTIC FLAT: Provide labor and materials to install a 6" layer of R-22 Class I Cellulose added to (1291) square feet of open attic space. $1,626.66 ATTIC ACCESS. Provide labor and materials to install (I) easily moved, insulating cover for the attic access folding stair. A small flat surface of plvtuood %till be created around the opening within the attic. Thisttill allow the cover's integral vgathcr- stripping to restrict air leakage: $237.65 VENTILATION: Provide labor and materials to install (3) insulated exhaust hose to existing buthroom fan(s). $150.00 VENTILATION: Provide labor and materials to install ventilation chutes in (63) rafter bays to maintain air flow. 5126.00 COMMON WALL& Provide labor and materials to install rigid board at R-10 or greater with the required fire rating to (136) square feet of common Mall area. ALSOINCLUEDS 2 SKY LIGHT S IAFTS. $476.00 RISE Engineering still apply all applicable, eligible incentives to this contract. You will only be billed the Net amount. Currently. for eligible measures, Columbia Gas offers 75% incentive. not. to exceed $2,000 per calendar year, and an incentive of 100%for the Air Sealing measures tap to the first $680 and an additional $340 if savings are justified by the auditor. For the safety and health of your home's indoor air quality, tic will be conducting a Mortar door diagnostic of the available air dour• Go Fedora! ID 005-0405628 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120879 RISE 69 ShawCT Contractor Registration No620120 ►Tnut Road, Caston, NUN ���A �� ENGINEERING 339-592-6335 FA\339-592-6345 R i Page 2 PROGRAM DCIS CONTRACTIS ENMRED INIOBETNEENRISE CMA-HF5 ENGINEERING AND DIE CUS=ER FORINORK AS DEOCRIBEDnEtAw CUSWBER PHONE DAM CUENTO WORK ORDER Michael Schiff' (978)808-3446 11/2212016 441594 239(2 SERVICE STREET- BUM SWET 73 Holly Ridge Road 73 Holly Ridge Road SEMACE CnY,6A1E.ZP OWNS CITY,SAM. EP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION in your home both l -fore the %,.urk is begin, and ality the %umtherization mork is complete. We %till also conduct a full assessment of the combustion safety of your heating system and eater heater. This has a value of S90 and is at no cost to you Total ailonabie %watherization incentive is$3:1 10. The Permit %Q] be secured by the insulation contractor. at no additional cost. it is the homeowic s responsibility to close out this permit by contacting their municipality at the completion of this wa& �,. $90.00 Total: $3,906.71 Program Incentive: $3,110.00 Customer Total: $796.71 WE AOREENEREBY TO FURNISH SERVICES- COMPLETE IN ACCORDANCEWITH ABOVE SPECIFICATIONS. FOR SHE SUM OF ' Seven Hundred Ninety -Six & 711100 Dollars $796.71 UPON RNAL DISPECTON AND APF RMQ'CU IMrtRAGRFES'WRENTAMMMMMINFUU-L4ERESTCFI% WILL GE CHARGED A%W'HLY CN ANY UNPAID BALANCE AFM = SE FOR WORWrl'INFORNAMOt CN GUARANEEG, RIGHU OF RECISION.SCREDUUNCL AND CCWMC70R REGISIRAVON. or DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AUIH S RISE Fn0wertV CusxiviR ACCEPDLNCE NCE: LTL" CONRACTIMY" WnMMWN BY US IF NOTEXECUED WMN DAM OF ACCEPANCE ACCEMUCE OF CONFRACr-DIE ABOVE PRIC£S, SPECIFICAltOtS AHD COMMONS ARE 30 SASISFACIDRY TO US AND ARE REREBY ACCEPMMaYOU ARE AUIMORUED R700IME WORK DAYS. AS SPECIFIED. PAYNENTVII LBE rtADE AS OUAINED ABOVE "'ISE -502-6335 � 60 Shawmut Road, Unit 2 Canton, MA 02021 1339 ENGINEERING www.RISEengineering.com OWNER AUTHORIZATION FORM 1, /•l1CYl�t� / �C'yfi�� , (Owner's Name) owner of the property located at: 73 Hollv 9-, (Property Address) Merrimack Valley Insulation 23A Sullivan Rd hereby authorize Billerica. MA 01862 , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. 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 thisy&r . A ---c &"� Owner's Sig6hture 111,2-60 Date IORI 6.2016 MERRVAL-03 oRsWE JE DATDDYYYY,CERT.RRUATE OF LOABILOY INSURANCE 6 11a12 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 bolder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 1S 11lrAIVED, subject to the terms,aild 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 ofsuch endorsement(s). PRODUCER- CONTACT . NAME: Automatic Data Processing Insurance Agency, Inc PHONE — — i FAX 1 ADP Boulevard AIC. No Ext): I Arc. No). EASAIL .. Roseland, NJ 07066 ADDRESS: INSURED Merrimack Valley insulation Corp 23a Sullivan Rd North Billerica, MA 01862 INsuRERA:5Star V3 AAIG American Alterriaiive E: COVERAGES CERTIFICATE NUMBER_ RFVI.StnN Ml IM RFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE- LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIGY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR.CONDrrION 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_ —.__-...-. _.. ..._-. _. .. ._.. . !INL TRSR I TYPE OF INSURANCE INS! R 1 W VD l POLICY NIUPABER I h7PNDDIYYYY 16R71DOlYYYY 1 UatITS I GENERAL LIABILITY EACH OCCURRENCE j S AMA' t 1 PREidISES a accurlence 15 _— I COINAERCIAL GENERAL _ CLAIt•.1S44ADE OCCUP, tEDEXP(Atryanzperson) i 5 �� __ ; PERSONALu ADV IN.IURY S— IS GENERAL AGGREGATE _ _ —" GEtJ'L AGGREGATE UMITAPPLIES PER: i j PRODUCTS-COi71P/OP AGG ! 5 I (! PRO- n l ----- S POUCY , ..,ECT LOC l ( i AUTOP.SOBILE LIABILITY i j I COMBINED SINGLE UPdR ( Ea accident S BODILY INJURY (Per person) IS i ANY AUTO i ALL OWNED SCHEDULED I BODILY INJURY ! 5 AUTOS AUTOS I {Per accident) i NON -OWNED vi RED AUTOS AUTOS 1 I i I % I _ i PROPERTY DAMAGE 3(Per accident) S . —.V UPABRELLA LIABOCC HCLAIUIRS-FOADE1 I EACH OCCURRENCE 5 `EXCESS UAB AGGREGATE_ S DED RETENTION S _ — S I tI { WORKERS COhIPENSAT10NWCSTATU- OTH- ANDEF.7PLOYERS`LIABILITY YrN TORYLih1ITS EP. EL. EACH ACCIDENT 'S ' - 1,000,000 A 1 AVYPROPP.IETOR/PARTNERIEXECUTNEV9WC749118 OFFICEREXCLUDED? Y NIA 6118/2016 6118/2017 — _ EL DISEASE -EA EMPLOYE S -1,000,00 (Mandatary I (Mandatary iA NH) If Lres, describe_under E.LDISEASE -POLICY UrLrr' 5 . 1,000,00 DtSCRIPTIONOFOPERATIONS.beAv i f� f i f F DESCRIPTION OF OPERATIONS P LOCATIONS! VEHICLES (Atfach"ACORD 707, Additional Remarks Schedule, ifmore space is mquired) I j 'SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEMBEFORE THE EXPIRATION DATETHEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover, Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street THORIZED REPRESENTA-TIVE North Andover, MA 01845 1 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered: marks of ACORD AC<:>RQ® CERTIFICATE OF LIABILITY INSURANCE DATE / 11/07/2/07)2 01616 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), AUTHORED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or 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 Charles J Coughlin Insurance 14 Dinley Street P. O. Box 10 Dracut, MA 01826 CONTACT CarolynACoughlin P" o (978) 957-3588 ac No: CESS: carolyn@coughlinins.com INSURERS AFFORDING COVERAGE MAIC # INSURER A: Northland Insurance Company 24015 INSURED Merrimack Valley Insulation Corporation Joseph A. Ryan, Jr. 23A Sullivan Road N. Billerica, MA 01862 INSURER B: Safety Standard 39454 INSURER C: Torus Specialty Insurance Company A0159 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: RFVMInN Nt7MRFR- 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 I LTR TYPEOFINSURANCE ADDt SUER POLICY NUMBER POIJCYEFF MIDDM-Al POLICYEXP (MMIDDlYYYYl LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FOOCCUR WS274182 01/21/2016 01/21/2017 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED 100,000 PREMISES Ea occurrence S MED EXP (Any one person) S 5.000 PERSONAL & ADV INJURY S 1,000,000 GENL AGGREGATE UNTAPPUES PER �JPOLICY F1PEd F-1 LOC OTHER GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 S B AUTOMOBILE -0AUTOS LIABILITY ANY AUTO 4 OWNEDSCHEDULED 1 AUTOS ONLY AUrOS 11 NREO NON -OWNED ONLY V AUTOS ONLY 6205006 11/25/2015 11/25/2016 COMBINEDSINGLEUNT S 1,000,000 Ea accident) _ BODILY INJURY (Per person) $ BODILY IMURY (Per accident) S PcciderrtDAMAGE S 5 C J UMBRELLAUAB EXCESS UAB OCCUR CLAIMS -MADE 87593LI61AU 01/21/2016 .01/21/2017 EACH OCCURRENCE S 1,000,000 AGGREGATE S 1,000,000 DED I RETENTION S 0 S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRETORIPARTNERIEXECUTME ❑ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA I PER OTT+ STATUTE ER _ E.L. EACHACCIDENT S E.L. DISEASE -EA EMPLOYEE S �F-L DISEASE -POLICY LIMIT I S DESCRIPTION OF OPERATIONS ILOCATIONS IVEHICLES (ACORD 101, Additional Remarks ScheduK rnay be attached ff more space is required) Insulation Installation CFRTIFICATF Hn1 nFR I -AMI Mt r ATle%kt @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Ando%er, Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 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 Please Print Legiblg Name (Business/Organization/Individual)t Merrimack Valley Insulation Corp.. .Address: 23 A Sullivan Rd. City/State/Zip: Billerica MA 01862 Phone # 978-888-3495 Are you an employer? Check the appropriate box: Type of project (required): 1. 71 1 am a employer with 18 4. F1 I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 6. New construction. tu 2. ❑ I an a sole proprietor or partner- listed on the attached sheet. 7. ❑ .Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. [] Building addition [No workers' comp. insurance comp. insurance.* required.] 5. C] We are a corporation and its 10.0 .Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself ' right of exemption per MGL y �o workerscomp. 12. ❑ ;Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. X� Other Insulation comp. insurance required.] * Anv 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. 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: 5Star V3 AAIC American Alternative Insurance Policv # or Self -ins. Lic. #: V9WC749118 Expiration Date: 6/18/2017 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA'for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town ofjlcial City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: (Q, Office of Consumer Affairs and Business' Regulation 10 Park Plaza - Suite 5170 Boston, Mashusetts 02116 Home improvemen ,;,Contractor Registration r Type: Corporation. ` Registration: 180506 Merrimack Valley Insulation Corp$!, i¢ r Expiration: 11/23/2018: t 23 A Sullivan Rd ' �y Billerica, MA 01862 � � SCA 1 is 20M-05/11 �+a, :''`'�/rC �OJ)IT)T4?[CIJC!!f[!t (�)��(•11TwiCICJLlC3C�c+ ' Office of Consumer Affairs & Business Regulation �j HOME IMPROVEMENT CONTRACTOR y Type Corporation `Registration Expiration 78A5Q6 11/23/2018 MerrimackValleyliasula. Corp Joseph Ryan 23 A Sullivan Rd- Billerica, d Billerica, MA 01862- Undersecretary Update Address and return card. Mark reason for change. D--Add-re--J • Ran --in f_.n Fmplr —ept r1 1 —st rard _ Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business. Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not V id ithout signature 1 ei�sSscv i?11SE`'S Le 3 ..a�'t C��...._g. and.. ican se: CS -07564_1 JOSEPH A RYAN;-" ' .• �� 200 ;dun„ Rail Dr A- 101 — 13rnaficl(I 1A. 017940 r- 4- ..i 92— 0210412017