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HomeMy WebLinkAboutBuilding Permit #145-14 - 86 MARTIN AVENUE 8/15/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: _ \ Date Received Date Issued: s I ORTANT: Applicant must complete all items on this page 4 LOCATION PROPERTY OWNER - n t ( l P(int J 100 Year Old Structure yes MAP NO: PARCEL: ___ ._r_ ZONING DISTRICT: _ _ _r_ _Historic District yes n _ . Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ROfne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well [I Floodplain El Wetlands ❑ Watershed District 0 Water/Sewer n DESCRIPTION q WORK TO BE PERFORMED: ` 1/ l - 1r( Identif at' P ease Type or rin Clearl � Y) OWNER: Name: PhoneJ'� Address: CONTRACTOR Name: Phone: r �. Address Supervisor's Construction License: _ l _ J Exp. Date r . Home Improvement License: ( �� > Exp. Date: 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: $ � � v�-- FEE: $ r Check No.: OA\06 > Receipt NO.: --q2t3� NOTE: .Persons contracting with unregistered contractors do not have access;e guaranty fund Signature of-Agent/Owner Sig ature of contractor Plans Suhmitteci F-1PlansWaived F1 Certified Plot Plan ❑ Stamaed Plans ❑ Building Department artment The foll,o?Wing is'a list 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building pp 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 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 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 apu-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.Bui)ding Permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYP -OF-: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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS v HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Seder Connection/Signature& Date Driveway Permit DPW T ow;� Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMFNt -Temp Dumpster on site yes no Located at 124 Mair,. Street Fire Departffi&A•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 B Notified for pickup - Date i Doc.Building Permit Revised 2010 Location No. J Date • - TOWN OF NORTH ANDOVER V Certificate of Occupancy $ . Building/Frame Permit Fee $�:� �J Foundation Permit Fee $ ,,J Other Permit Fee $ TOTAL $ Check# 10L& 3 26735 Building Inspector r 1 NORTH , E 1, ve . 0 No. ( - RN W.A. h , ver, Mass, S ' 3 COC LAK NICH&WIC. y7. S V BOARD OF HEALTH Food/Kitchen PERMIT T' LD Septic System THIS CERTIFIES THAT ...........10CQ6111111(40 0.10.1. .111111 ... .............................. BUILDING INSPECTOR has permission to erect .. buildings on .:$.&......."NA.IL jux.... .r.NJAW ,... Foundation ........................ .,,.. Rough to be occupied as ............. .. ... ........ .... .� ............... .... ................. Chimney provided that the person accepting this permit shall in every respect form to the term 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 Final PERMIT EXPIRES INSI.MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU STAT 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 r. �ILG�pliryJ7//7Y,M2d!/GCG��iltO�U<�COJOCZG�LLGJe�4 ffice of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Registration: 137193 Type Expiration:. 10/15/2014. Supplement BAY STATE ROOFER-1-NC. I ROBERT O'KEEFE PO BOX 189 4u N.READING,MA 01864 Undersecretary Wissachusetts- Department of Public Safeti Board of�Building , Regulations and Standard Construction Supervisor Specialty License License: CS SL 99895 Restricted to: RF ROBERT OKEEFE 21 FRANCIS STREET NORTH READING, MA 01864 A Expiration: 9/29/2013 Commissioner Tr#: 960 Baystate Roofers, Inc. Proposal P.O. Box 189 North Reading,MA 01864 Date Estimate# Tel. 978-664-0668 Fax 978-664-4333 6/19/2013 15237 Name/Address HIC 4 137193 Wanda Washington CSSL# 99895 88 Martin Ave. N.Andover,Ma.01845 Day Stade Roofers Inc proposes: Remove approximately 1800 square feet of the existing asphalt shingle roof down to the wood decking. Install new ice and water shield along the 6'roof edge, valleys and around all the roof penetrations. Install new 151b felt paper throughout roof area. Install new white aluminum drip edge along the roof perimeter. A new Lifetime GAF Architectural asphalt shingle will be installed over the prepared substrate. A new ridge vent will be installed to ensure the proper roof ventilation. All roof penetrations and flashing will be installed according to manufacturers recommendation, specification and details. Install new pipe flanges. Bay State Roofers will properly dispose of all roof debris in our own waste containers. Any wood decking that needs replacement will be an additional $2.50 per lineal foot. Message New Shingle Roof Authorized Signature: Total $5,790.00 Waste containers supplied by Bay State Roofers, Inc. are for sole purpose of roof debris. Under no circumstance is the homeowner to use these containers for personal use. 10 Year Workmanship Warranty on all roofs. (Except Repair Jobs) CONTRACT ACCEPTANCE The specifications,prices,payment schedule are satisfactory and hereby accepted. Date: — 1 BAY STATE ROOFERS,INC. is authorized to perform work as specified. Payment will be made as previously outlined. Signature ( t �VA'V"- All bills over 30 days are subject to 1 1/2%finance charge per month 08% IJ( i i 1 . PROVISIONS OF THE AGREEMENT L PROJECT PROVISIONS e. Damage to Project: Contractor will not be responsible for any a.Guideline:The Project will be constructed in strict conformance damage caused by the Owner. or other causes beyond the control of to the plans and specifications which have been examined and the Contractor.Owner will pay for any restoration work. approved by the Owner. IV.CONTRACTOR'S RIGHTS AND RESPONSIBILITIES b.Compliance:The Project will be completed in strict compliance with all laws, ordinances, rules and regulations of the applicable a. Delay: Contractor will be excused for any delay beyond his government authorities. reasonable control. These delays may include, but are not limited to c. Control:The Agreement plans and specifications are intended Acts of God, labor disputes, inclement weather,acts of public authority, to supplement each other. In case of conflict,the plans will control the acts of the Owner.or other unforeseen contingencies. specifications and the Agreement provisions will control both. b. Right to Stop Work: If any payment under this Agreement is d.Charge Orders:As directed by the Owner,construction lender, not made when due,the Contractor may suspend work on the job until public body or inspector,any alteration or deviation from the specifications such time as all payments due have been made. Any failure to make that involves extra cost(subcontract, labor, materials)will be executed payment is subject to a claim enforced against the property in only upon the parties entering into a written change order. Expense accordance with the applicable lien laws. incurred because of unusual or unanticipated conditions will be paid for c.Substitution of Materials:Contractor may substitute materials by the Owner. without notice to the Owner in order to allow work to proceed, provided e. Allowances: If the Agreement price includes allowances, and that the substituted materials are of no lesser quality than those listed the cost of performing the work is greater or less than this allowance, in the specifications. then the Agreement price will be adjusted accordingly. d.Salvage:All salvage resulting from work under this Agreement II.FINANCIAL RIGHTS AND RESPONSIBILITIES is to be retained by the Contractor unless other agreements are contained in the written specifications. a. Labor and Material: Contractor will provide and pay for all e. Insurance: Contractor will maintain workers' disability labor and materials necessary to complete the Project. Contractor is compensation insurance for his employees and comprehensive public released from this obligation for expenses incurred when the Owner is liability insurance policies. in arrears in making progress payments. b. Permits:Contractor will obtain and pay for all required building V.COMPLETION OF PROJECT permits and licenses. a. Notice: Owner agrees to sign a Notice of Completion within 5 c.Taxes,Assessments and Charges:Taxes.special assessments days after completion of the project. If project passes final inspection of all descriptions, and charges required by public bodies and utilities and the Owner does not sign the Notice,the Contractor may act as the will be paid for by the Owner. Owner's agent and sign the Notice. d. Deposit of Payments: Contractor is required to deposit all b. Clean-up: Contractor is responsible for removing debris and payments received prior to completion in an escrow account. In lieu of surplus material from the property, and leaving the property in a neat such a deposit,the Contractor may post a bond or contract of indemnity and orderly condition. with the Owner guaranteeing the return or proper application of such VI.CONFLICT PROVISIONS payments to the purposes of the contract. All advanced funds will be a. Arbitration: Any controversy or claim arising out of this deposited as indicated under Special Provisions. Monies used in Agreement that cannot be resolved, is subject to arbitration, with escrow become the property of the Contractor when they are applied an arbitrator of mutual agreement, and all parties (including according to the Agreement payment schedule, when a breach of Owner, Contractor, Architect and Sub-Contractors) are bound to contract by the Owner occurs, or when the Agreement has been this arbitration, If any party does not appear at arbitration substantially performed. proceedings, the arbitrator is empowered to decide the controversy e. Bankruptcy: It either party becomes bankrupt. the other party in accordance with whatever evidence is presented by the has the right to cancel this Agreement. party(ies)that do participate. Ill.OWNER'S RIGHTS AND RESPONSIBILITIES b. Attorney Fees: If either party becomes involved in litigation a. Cancellation: Owner has an unconditional right to cancel the arising out of Agreement, the Court shall award costs/expenses Agreement, without penalty or obligation, until midnight of the third including attorney fees to the party justly entitled to them. business day after the Agreement was signed. Cancellation must be c. Limitations: No action related to this Project may be made done in writing. Upon cancellation, any property traded in, any by either party against the other more than 2 years after the payments made under this Agreement, and any negotiated instrument completion of work. executed will be returned within 10 business days following receipt by VII.GENERAL PROVISIONS the Contractor of cancellation notice. b. Property Lines: Owner shall locate and point out property a. Notice:Any notice required or permitted under this Agreement lines to the Contractor.Contractor may,at his option,require the Owner may be given by certified or registered mail at the addresses contained to provide a licensed land surveyor's map of the property. in the Agreement. c. Liens: Failure to pay persons supplying materials or services b. Prohibition of Assignment: Neither party may assign this according to the terms of this Agreement may result in the filing of Agreement or payment due under this Agreement without the written consent of the other party. mechanic's liens on the affected property. Owner has the right to ask the Contractor for lien waivers from all persons supplying these c. Qualification:This document constitutes the entire agreement materials or services. In the event any mechanic's lien is filed through of the parties. No other agreements exist. This Agreement can be no fault of the Owner, then the Contractor agrees to take all steps modified only by written agreement signed by both parties. necessary for the release and discharge of such lien. d.Insurance:Owner will maintain property damage insurance at d.Governance:This Agreement shall be construed in accordance least equal to the Agreement price. with and governed by, the laws of the state in which the Project is located. The Commonwealth of Massachusetts Department ofIndustrial Accidents tip 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 LeLyibly Name(Business/Organization/Individual): Address: City/State/Zip: ` Phone#: Are you p employer?Check 11W appropriate box: Type of project(required): 1.Rfam a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL l l.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t 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. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this 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 the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: 4—(1— /14, —(1^ R <na Job Site Address: City/State/Zip: 4 W\.A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dame). 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 maybe forwarded to the Office of Investigations of the D or insurance coverage verification. I do hereby c rti nder hep ns n ' s perj that the information provided above is true and correct. Signature: Date: ► 'l ~/ Phone#. —04 6 P 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#: 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 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 of its 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 not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be 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 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 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 permit/license 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 roof that a pp p valid affidavit is on file for futureermits or licenses. Anew affidavit must t 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 604 Washington Street Boston,MA,42111 Tel # � . 617-7 7- .404 est 446 or 1-877,7MASSAF& - Revised 5-26-05 Fax#617-727-7749 wwwanass.govldia �Za A� CERTIFICATE OF LIABILITY INSURANCEF6DATE/19/2013YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOE NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER S 0 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 endorsement(s). PRODUCER CONTACT NAME: Commercial Lines A & K Fowler Insurance PHONE (978)664-0366 FAX IAIC . (978)664-2209 200 Park St. EMAIL A DRESS, INSURERS AFFORDING COVERAGE NAIC# North Reading MA 01864 INSURER A:Western World Insurance INSURED INSURER B Merchants Mutual 23329 Baystate Roofers Inc. INSURERCACE American Insurance Com an P.O. BOX 189 INSURER D: INSURER E: North ReadingMA 01864 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1361902260 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER M LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence TO RENTED $ 5O,000 A CLAIMS-MADE 1XI OCCUR TBD /15/2013 6/15/2014 MED EXP(Any one person $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 1,000,000 ' X POLICY RO- PLOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ 20,000 B ALL OWNEDSCHEDULED qCA7015534 /15/2013 6/15/2014 AUTOS X AUTOS BODILY INJURY(Per accident) $ 40,000 X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ C WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N CRYLIM TI ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICEWMEMBER EXCLUDED? N I A (Mandatory in NH) 6S62UB4509Po6213 /12/2013 /12/2014 E.L.DISEASE-EA EMPLOYE9$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance Verification CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Baystate Roofers Inc. P.O. Box 189 North Reading, MA 01864 AUTHORIZED REPRESENTATIVE K Boutin, CIC CRM CIS ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).ot The ACORD name and logo are registered marks of ACORD