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HomeMy WebLinkAboutBuilding Permit #459-11 - 851 JOHNSON STREET 12/1/2010TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO. Date Issued: 12-- I '� IMPORTANT: Applicant must 0 Date Received 0J I all items on this MAP NO: Jk?X p.AR.CEL:___(., L ZONING DISTRICT: Historic District yes no Machine Shop Village yes I no TYPE OF IMPROVEMENT ❑ New Building ❑ Addition ❑ Aitdaiion pl�epair, replacement ❑ Demolition Address: PROPOS U5h Res! tial One family ❑ Two or more family No. of units: ❑ Assessory Bldg — ❑ Other DESCRIPTION OF CONTRACTOR' Name: Address: Please Type or Print Clearly) - Supervisor's Construction License: qo�Exp. Date: Home Improvement License: Exp. Date: Non- Residential ❑ Industrial ❑ Commercial ❑ Others: Phone: 46§ i -i 15 Phone: L4 01 3 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: FEE: $ 1 L4n-- Check No.: 3 �3b Receipt No.: �b NOTE: Persons contracting with unregistered contractors do not have access 99"anty fund Ir r 8 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: FEE: $ 1 L4n-- Check No.: 3 �3b Receipt No.: �b NOTE: Persons contracting with unregistered contractors do not have access 99"anty fund Ir Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ r. LSower GE DISPOSAL ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ ❑ Tobacco Sales ❑_ Food Packaging/Sales ❑etc. ❑ Permanent Dumps on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF ' U FORM ,-`z, : \ DATE REJECTED PLANNING & DEVELOPMENT_ _El COMMENTS ` DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS 'HEALTHReviewed on ' _Signature - COMMENTS _ - ��., t { . • v , , ; 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 MainStreet Fire Department signature/date COMMENTS 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 t El Notified for pickup - Date Doc:.Building Permit Revised 2008 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 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 NOW Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o 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 J®TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit x --all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals is t the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording u St be submitted with the building application Doc: Doc -]Building permit Revised 2008mi LocationnS 0 r" �- No. ''- / Date C MO60 RTM TOWN OF NORTH ANDOVER 40 w 9 Certificate of Occupancy $ �ssuMus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ ` TOTAL $ Check # 23756 Building Inspector z s. �¢ w x w o r� w° CO u cn O � z CQ j co -n w° p°G G U cis w 04 a � a a°G w CSG O U w � � u w W v u. QG O v a _ m w z w x w z cn v Q o cn I i� w IM 4..1 co O a) O C3 v O O Z CL y O C I C C cm ca Q y O O �EcoQ C13 m m CL I.-'_ 3� O O CL cmQ C O O CD ca ts C 03 V y O � ca C C d 0 LU LU W LU 19 LUW U) c� o :a+c c U= :•c H O = OLD CLC e® ev O L CD C .r -t CL N .oma c E ..i ® a j vs cn � 3 O y O m W Cc E mCR. vv nv •. 0N m 0 _ 0 cm •O O. = S ma m .mZ `o cc o .a. � H Q y O. C CD C = m COL:s N r H m.2~ D COD Cc 4D •y f... c y.r R .... .m CL= . C m y Z O ci COD ®;C c f— H O' O H �� O _ W` .CLS. I i� w IM 4..1 co O a) O C3 v O O Z CL y O C I C C cm ca Q y O O �EcoQ C13 m m CL I.-'_ 3� O O CL cmQ C O O CD ca ts C 03 V y O � ca C C d 0 LU LU W LU 19 LUW U) Name (Business/Organization/Individual): Address: Cil Phone #: Are y an employer? Check the appropriate box: I. I am a employer with —i r)� 4. E]I am a general contractor and I employees (full and/or part-time).* have hircd.thr. :,ilh-contractors 7.. ❑ I am a sole proprietor or partner- listed ori the attached sheet. ship and have no employees These _sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. inr comp. insurance.: surance required.] 5 ❑ 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' ' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. F-1 13. ther VQ 1p.Aaix *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. :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. Insi!rance Company Name: t - Policy # or Self -ins. Lic. #: � 2;352Expiration Date: r Job Site Address: �5 ������_> I City/State/Zip: �/�yf � k, 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 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 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 Contact Person: Phone #: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations " 600 Washington Street Boston, MA 02111 . tly www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: Cil Phone #: Are y an employer? Check the appropriate box: I. I am a employer with —i r)� 4. E]I am a general contractor and I employees (full and/or part-time).* have hircd.thr. :,ilh-contractors 7.. ❑ I am a sole proprietor or partner- listed ori the attached sheet. ship and have no employees These _sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. inr comp. insurance.: surance required.] 5 ❑ 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' ' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. F-1 13. ther VQ 1p.Aaix *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. :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. Insi!rance Company Name: t - Policy # or Self -ins. Lic. #: � 2;352Expiration Date: r Job Site Address: �5 ������_> I City/State/Zip: �/�yf � k, 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 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 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 Contact Person: Phone #: ® DATE (MPAIDOIYYYY) CERTIFICATE OF LIABILITY INSURANCE -02/19/10 PRODUCER 1-404-995-3000 ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY ISSUED OR THIS CERTIFICATE IS ISSUED AS A MATTER OF INI ORMA 1 1U POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRDD'L POLICY EFFECTIVE POLICY EXPIRATION T POLICY NUMBER TMIDOIYYYYI LIMITS'. 1, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 03/01/10 Marsh USA, Inc. EACH OCCURRENCE $ 4,000,000. HOLDER. THIS CERTIFICA-"= DOES NOANIEND, EXTEND OR I j. aomedepot.csrtreq%Lest@marsh.cam ` ALTER THE COVERAGE P,F:=0Rl7EC B`!_Tr4_POLi;_iF Two Allianc= Center, 3550 Lenox Road, Suite 2400 X COMMERCIAL GENERAL LIABILITY Atlanta, GA 30:75 MED EXP (Any one person) 8 EXCLUDED ER AFFORDING PJINGCC,.- S, O C Fax 212) 943-,0912iN5 ---t --- ---- _..--\._:.'._.....__.,...... INSURED j INSUY.GRA: Stara fast Ins. Co 25337 he Home Depot, Inc. — - --- --------_----- i iNSUREP S: Zurich American Ias Co 15535 acme Depot II.S.A. , InJ, 2455 Paces Ferri Road NW e PRODUCTS -COMP/OP AGG S 4,000,000 --_ -- ---.. INSURERC:New Hampshire Ins Cc .----._._.__----- '_23841 Building C-20 _ _ INSURER D: NATIONAL UNION FIRE INS CO OF PITTS 119445 Atlanta, GA 30339 - — ---- -- -- -. _- AUTOMOBILE INSURERE:Illinois Union Ins Cc 127960 03/01/10 C0VFRAr;FS ' COMBINED SINGLE LIMIT $ 1,000,000 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 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. INSRDD'L POLICY EFFECTIVE POLICY EXPIRATION T POLICY NUMBER TMIDOIYYYYI LIMITS'. 1, CENERALLIABILITYGL04887714-00' 03/01/10 03/07/11. EACH OCCURRENCE $ 4,000,000. RENTur uAMAGE TO ` X COMMERCIAL GENERAL LIABILITY PREMISES Ea o enc $ 11000,000 MED EXP (Any one person) 8 EXCLUDED CLAIMS MADE M OCCUR PERSONAL &ADV INJURY $ 4,000,000 . _ GENERAL AGGREGATE $ 4,000,000_ GENT AGGREGATE LIMIT APPLIES PER: e PRODUCTS -COMP/OP AGG S 4,000,000 _ POLICY PRO- POLICYF] IFQT LOC H AUTOMOBILE LIABILITY BAP 2938863-07 03/01/10 03/01/11 COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO 1 (Ea accident) - BODILY INJURY $ ALL OWNED AUTOS r i SCHEDULED AUTOS, - (Per person) _ HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ X SELF INSURED AUTO PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ —_ ANY AUTO AUTO ONLY: AGG $ A EXCESS I UMBRELLA LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE S 5,000,000 — X OCCUR a CLAIMMADE AGGREGATE 4 :10001000 _ $ DEDUCTIBLE $ RETENTION $ C WORKERS COMPENSATION WCO20342355 (AOS) 03/01/10 03/01/11 WCSTATUIMj OR X 'TORY L D AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCO20342356 (CA) 03/01/10 03/01/11 _ E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E OFFICER/MEMBER EXCLUDED? (Mandatory in NH) WCO20342357 (FL) 03/01/10 03/01/11 _ E.L. DISEASE -POLICY LIMIT S 1,000,000 Ilyes,desulbe under SPEC IAL PROVISIONS below E OTHER TX Employers Excess TNSC46242373 (TX) 03/01/10 03/01/11 Occurrence/SIR 30M/2M D Workers Compensation WC0910566 WSI) 03/01/10 03/01/11 C Workers Compensation WCO20342358(KY,MO,NY,WI, ). 03/01/10 03/01/11 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE LI\11 VV.v V,♦ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN HOME DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 2455 PACES FERRY ROAL NW' BUILDING C-20 FSENTATIVES. ATLANTA, GA 30339 - [�� ZEDREPRESENTATIVE USA ACORD 25 (2009/01) Jthornton-hd © 1988-2009 ACORD CORPORATION. All rights reserved. 14481889 The ACORD name and logo are registered marks of ACORD "OMF- IMPROVIJ1 MNT CONTRACT PLI.ASE READ 117111S Branch Name; Boston Date: ±I—Lu / 10 Sold. FamishW and htstalled b); TND At -Hunte Servin c in• dWa The Yonas: Dt:put At -Home Service's B=Flth Number. 345A Greenwood Sooner. Unit 2- Worromicr, IMA nl6()7 'roll Free Mn) 657-5182-- Fou (508) 756.88'''; I mlenil ID 4 75-36731(10: ME lic #C (L)439- RI Cont-1.icJa 16427 Cr lLic # 565522: MA limes lmgnv v ; cot ConnanttLx Reg. #126S93 hsstauttGtttt Aadtrss S j �b� 1�5r : n .'— �--`-N Ph (c1 i� d .f 14 C� GLY S1atcp rumrauer6sJ: ' Work Pboer_ Rteaee Phone,-_ _ CcJF !'leen¢ Q�t1iQ C1`r`fTo pl.er { } _ {�l� ] d��-Y3tS c I;WICSI: ilf dill'erent from Insudlatioo Addrea's) City Seate Zip — R -mal Address (to native pmject comalunicanions and Home Depot opdmtz). ❑ 1 DO NOT wish to receivc>tnY Irlarlaeting email frolnThc Home Depot—_----- Proietl [nfarngiiun: UndttsiK»cd ('Gam^) etre Ow[tps of the prope(ty Ior-;kd at I11C aiar+e Instalhai:m address dds ss, astr(a W buy, and TH1) At -Nome Scnicn;, Inc. (` The Home Dcpof') a� to furwxh. deriver and arrange for the inanllatien J' Installation-) of all materials dcecribed on the below and on the telaelrcxd Spec Shwt(s), aQ of which are incorpuntted into this Contract by this rcf"Ence, along with any applicable Stale Supplement attd Payment Sulamay at�hcd hereto and any Change s (eolMcti•rely_ "Con hxeP): ` ,lob". ( ltd - nofe»g S9e1Fr� Windoars- tns7ilatiaa 5Leet(s) I) Pm'era Alan -S3�i5�o3 Qc�tter.,ica.� pentr.w� p _ � rad, �3 � Rw�irrg �Isdiog ntlow: Jnsulaltos - -- — p(;trttlsslC;anas ©sear tAtrus D . � Rooliag Sdiag Windows Insslatitlo r-- �"-"_-- _ �1Guin:tslbovbs �Fatry�loor�I�i _ ��oRnrlt-m—�sidfiag �Windaaa Jnwtatian ".-"- 00uttas I Coves ❑EM, Doors Aladnem 2556171rpaeitdConfray ArnoeM doeupat e%ecu6wl of iOlsaelrind btalne[Lnelglstsrsrtkanet*3cp�anleleel�+rmr•thitaoftBet:orurnrinroeuat. TOW CenirattAmount $ ill 63 7 Cttsm;ncr agrvcs tlwL irmncdialohy upotl completion of tJu: wart for each Priduct. Customer will execute a Cjmtpletion Cerlitie,-atu fait ten' each Pttduct ars (4dined Ivy an in(rvkltral Spec Shed) altd pay any tru)ancc due. As applicable, each Customer under this C7t121Utecl amens to he jointap and sorerally abligand and halals hamindct. t'te N.ntte DCfxtt ruserycs the right to issue a Chaapt Order or iemtioate tiiis Contract Orally individual Producils) included hastel at its disuruticon. if Tl)c Homs Dt7tat or it anlelt"'d se ice prnrider detemincs that it a anom pedorm its obligaliam due to a mructwal pro114e.3 with the home. enviroamental hazards such as mold. asbestos or lead paint. other safety concern., pricing cmws or because .vmk required to tmtnplcie the job was not included in the Contract_ t'avment Sunemarv- The Payritent Summary # 3 11 indudLd as pari n( thiN Conit.wl, sets 170rtb the total C:orcntct alnoum and pa)mtcuts restated For the de:pmits and final payments by Pndul.t ;;as applicabk). NOTIC1i TO Ci1S7 <)? IM You are enticed to a eninpletely fNed-in copy ortbc Contract at the time von sigh. I),, not sign a Complettinm C'ertiricate I trate there Cs one C omplelkm Certirmalc for each lister Product Product as delb" by iodiviiitm; Sues Sbeetst Itrforc yet k on Ir T�'t+wote: is complete 1n the event of tenuivatiin or this Conlrml. Castomcr a=%bes to pay The ¢tome Depot tele costs of watn iala, lahor, expenses unk services provided by Tire [glome Depot o; Authorized Service IRovider Utrough tee dale of Je miamion, plus any other 21tMnrnts set forth in this Agro emeat or aLeowed under zpprembie Ian. TFCp Hk), Y tLE!*4)'G :r1,3T' WTTr-S4iOl.1) AMQtlNTS OWE)) TO THE HOME DFA'OT FROMTHE DEPDSIT PAL'ME'NT OR oy-tj,S4 PtY114FN• ,% YfA1)1 VP[1'lEQ)il£ LMTTINGTHE H0NTEDVAI(Yr"St)T€I.ERR1r EDIE,RF0121tBCOVF.it: OF SL)CliA'NLIE)U?aTS lcpclltalaae seal lotbor"va[iun: Costarlxv shoe and underarand;c that d)i= Al reaarcm is ri�xitxt;t bctwz:cu Custottkr and 77tc Hns orDgxrt with rr� to the Products artel installation szrvi es a»d .,gess cox of I le cutin: aprior disco stem and acrt-m nts, eidtrr Mal or written- miating to said Ptt)ducts and htslalfatinn. This ALrecment caaaot be assigned ac amented exe'pl by a writing sicaicd by Cwttuterand The Home: Depot. Castatty z acknowledges and agrees that Customer has mad, undersctnds. voluntarily accepts the tenth of aced has received a eopv of this A=eemcnt- Accepted bv, , Customer - Siombtta Die X Ctestomer's Signature testi -- 4'ANty`EI I r>1TI0�1: CYIISTOMER MAY CANCEL THIS AG}Ch'EJ1'ENT WP) ROUT PENAL'T'Y OR OBLIGATION BY DFf,r4iiRtNG WRIWL%4 1WJt'tCB To TOE HOME. DEPOT BY MIDIVIlGHT ON TIM TWRD BtMNESS DAY" AFTER SIGNM(; TtM AGRE'NIEN[ THE STATE SUPPLEMENT ATTACHED HERWTO / th r a roc ♦ rnrrH -r" 6 wrr rr Al 1.^ SPECIFICALLY PRESCRIBED BY LAW IN � CUSTOMER'S SPATE. XMMC& ABUS 7 14AL TF:1th1S A1k'D CYN ILPMONS ARL•' STAT 11-30-09 C -SC VOW-Brarch Ede Ydbw-C submitted bv: i1 -Il -to Sties Crmsultan('s Siprlalt; Telephone No. —6O Sales Consattant License No. �'-- _ !rn "ppFicabkl EI/ (HV'CNE JrEVElLS1? Skt►F AIV!} iliF: P:+,tt7' (>F Tlllti ('()NI'RA(:'I' US14(ner Pink.-Actk..R r.nnudr"ro L'd 6669-C9L-009 BLC:90 OL Z L AON FRQ�-,Pn. AT HOZ SEW)) Zs Pr Le i I)c1lanmem tirpumic Onarif or Boil Kt �ulafintl> ("n' "1111ol Construction S, Pervisor ILIceft" Uctftse-' CS 101433 . . ..... Restrictedto: 00 SMG10 SANTOS UAWyjfqS STREET NO I SOMERVILLE. MA 02143 Expiralton: 8/JaW2 Te--: 101433 r 3 ,p� ✓IZC.�0971�YGO9ZGI�Q�GiL O�✓I�GClO6Q.C✓�LCLdeGG6 � �\ Office of Consumer Affairs & Business Regulation OME IMPROVEMENT CONTRACTOR j Registration 126893 TYPE Expiration 813127012; Supplement, They Home Depot alt Hajne Senr�ces .. r RICHARD FALL& -� 2690 CUMBERLAND RAE�KWQY S AfLJAM, GA 30339'`' Undersecretary