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HomeMy WebLinkAboutBuilding Permit #1124-2016 - 88 PEACH TREE LANE 5/1/2018 SaoRT H BUILDING PERMIT of SLED 16gti TOWN OF NORTH ANDOVER �2 y `�'- .6 0 APPLICATION FOR PLAN EXAMINATION ~ '6 Permit No#: _ �� Date Received 4 2,J CHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this Dage LOCATION �e&-k�ly-e4-- Y,e -- P�Jnt PROPERTY OWNER A Q-H rv\-a-r r Print 100 Year Structure yes no MAP _PARCEL: blZ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building CrOne family ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units: 0 Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other U � rl®sc F-f�,-'Seg, lFm W ❑_Napt `N ❑ ltsd awe -- u DESCRIPTION OF WORK TO BE PERFORMED: � Identification- Please Type or Print Clearly OWNER: Name: k ( _�_ Phone: �l�Z • ��`� ' 05'4y �P 6 U Address: ti Pe-0- D-1�""'Cy �-a.YI Contractor Name: V.0 e+ Phone: a,TB 3 S�o • 3`'I 1� 3 Email: r; V on (1,it Address. f D 13oA '144 Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: lv I I \P ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: LA 00-1- -`-I O FEE: 4 ,1- Check No.: Receipt No.: �� `!J'IL/ NOTE: Persons contracting with unregistered contractors do not have access to the gluarantyfund -1 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 4. Building Permit Application 4. Workers Comp Affidavit 4� Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i Addition Or Decks Building Permit Application Certified ;Surveyed Plot Plan Workers 1Comp Affidavit __Rhoto__Cop_y__.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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit f a New Construction (Single and Two Family) Building Application Certified, Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sens of Building Plans (One To Be Returned) to Include Sprinkler Plan And �1 Hydraulic Calculations (If Applicable) Copy of Contract # 2012 IECC Energy code i Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit p p q 9 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 j Doc:Building Permit Rei iced 2014 i 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE 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 ❑ a THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION_ ._ -._Reviewed-on_ ----------____-- -._- Signature-------- COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i Conservation Decision: Comments ,Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: .�. . �. Located 384 Osgood Street F" j 1^ -t�n p f •;fl`• yr+y 4'cr �.'1� „1', ,,t AIREDEPART7 �Temp Dumpster n,, it ,� w t ��...�.�� � r' F�. '� F`C� t�, irocated ata1r24 Mam Street; '`r*r "=Y ur r $'xrtr€ 4 A;.>611 a ire Department signature/date` s.'�r a ^.'�r €r� =J1 Y*!Y: 4' ' r� ,�gP 'ds✓ a{y L� r -' �' CQMMENIT"S r '� e, 3 it t a ec. ar". . - y3 t .fi lk�watP° s? T4Y;U Ada+ 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'approva] of Electrical inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21''IA—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ............ - _ __.. ... ...... ® Notified for pickup Call Email Date Time Contact Name Doc.Bi lding Permit Revised 2014 ��i y a Location (. No. U%4— 7 o. DateIF 4 • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame.Permit Fee $ 'v Foundation Permit Fee $ Other Permit Fee $ i TOTAL Check J2t T Building Inspector NORTH Town of . : ndover No. ®i ' T - h ver, Mass, 12JP. A- coc"Ic M[WKM 7,95 5 R'�TED � �( U BOARD OF HEALTH T TFood/Kitchen PERf Septic System THIS CERTIFIES THAT .................. .. ky••..... BUILDING INSPECTOR has permission to erect ........ buildings o ..... .... �� : �N s Foundation .. ... ` ....... ` Rough to be occupied as . 11..��'.(. �. ... ...�. .. ....�.. ....1.,w.l�h• . .�.�... ..... : Chimney provided that the person accepting this it 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough �� Service ..........................r:.....F......... ..� ( ...................... 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. Federal 10#05-0405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Reglstration No 120979 A division ofThieisch Engineering RISE ENGINEERING 60 Shawmut Unit#2,Canton,MA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 Page 1 PROGRAM TM COnTRACT 19 ENTERED INTO DETWEETJ RISE CMA-PIES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED ammi CUSTOMER PJIONE DATE CUENTa .WORK ORDER Ajaykumar Patel (860219-0546 02/19/2016 429540 00002 SERVICE STREET IULUNO STREET 88 Peachtree Lane 88 Peachtree Lane SERVICE Cn'Y.STATE.ZIP BILUNG CrrY.STATE.ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION HEALTH&SAFETY:Weathcrization work cannot proceed until mechanical ventilation that will provide(1)cfm(cubic feet per minute)of continuous air flow has been installed in your home.ADD A BATH FAN DESIGNED FOR CONTINUOUS OPPI RATION Qu 60 CFM.T141S CAN 3E ON A TIMER TO CYCLE 22 MIN.EVERY HOUR.ONE SUCH FAN IS PANISONIC WHISPER SELECT.CAN FIND AT.EFI.ORG.OR AMIZON.COM. $0:00 HAZARD BARRIER:We have identified that there are recessed lights present in:your home.unless the recessed lights are certified as IC-rated(Insulation Contact Rated)we will create a 3"clearance space around the fixture by using fibergtl-s blanket insulation as a damming material,.no insulation will be installed across the top and closed cavities which contain recessed I 0.06 AIR SEALING:Provide labor and materials to seal areas ofyour home against wasteful,excess air leakage will be performed in concert with the use of spccial tools and diagnostic tests to assure that your home will be tcR av thful.level of air exchange and'indoor air quality.Materials to be used to seal your home can include caulks,foams and o P ns. areas for sealing.include air leakage to attics,basement-,attached garages and other unheated areas(windo e gene 2' addressed.) This will require(12)working hours.A reduction in cubic feet per minute(cfm)of air infiltrati vi ur,but the actual number of cfm is not guaranteed. At the completion ofthe wcatheriration work,and at no additional cost to the homeowner,a final blower d r and/or.combustion safely analysis'will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $1.020.00 ATTIC FLAT:Provide labor and materials to install a 12"layer of R42 Class I Cellulose added to(120)square feet of floored attic space. $236.40 ATTIC FLAT:Provide labor and materials to install a 9"layer of R-30 unlaced fiberglass batt-to(72)square feet of attic space. $120.24 ATTIC FLAT:Provide labor and materials to install a 4"layer of R-14 Class t Cellulose added to(565)square feet of open attic space. $638,45 KNEEWALIS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(210)square feet of knecwull arca. 5735.00 KrTIC ACCESS-Provide labor and materials to insulate(4) back of the knccwall hatch with 2"rigid Thcmlax board:nail seal the edge of the hatch with wcIalmrstripping. $240.00 . A"I`rIC.ACCESS:Provide labor and materials to mike(I) access opening from one attic area to another by cutting a passage through sheathing. 'rhisaccess will be lcfl open as it is between two common unheated non Crewalled attic area,. 531.31 VENTILATION:Provide labor and materials to install ventilation chutes in(28)railer bays to maintain air flow. $56.00 Federal IQ#OS-0405629 RISE Engineering RI ContractorReg!stiaiion No 8186 MA Contractor Registration No 120979 A division nf'fhiclsch Engineering ENGINEERING' 60 Shnwmut Unit!h,Canton,MA 02021 CONTRACT 339-50246335 FAX 339-502-0345 Page 2 PROGRAM CMA-NES EENGINEE,ucu!'INGANDDTTHHECUSTOMEERF 'BAs DESCRIBEDOEtcW -__CU;— _ STOMER PHONE GATE --Mr__CWED WORK ORDER Ajaykurnar Patel (862)219-0546 02(19/2016 429540 00002 SERVICE STREET BILLING STREET 88 Peachtree Lane 88 Peachtree Lane SERVICE CITY.STATE.VP BILLING CITY.STATE.ZIP North Andover,MA 01:845 North Andover,MA 01845 JOB DESCRIPTION COMMON WALLS:Provide labor and'olutcrials to install 2"FSK faced semi-rigid fiberglass board insulation to(240)square'feet of common wall area. $840.00 RISE.rnginecring will applyall applicable,eligible incentives to this contract. You will only be billed the Na amount. Currently, for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2.000 per calendaryear,and in incentive of 1001A for the Air Scaling measures up to the first$680 and an additional$340 ifsavings are justified by the auditor. For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the-wort is begun;and after the Tvcatherimtion work is complete.We will also.conduct a fulfassessment of the combustion safety oryour boiling system and water heater.This has a value of.$90 and is at no cost to you. TotalAkn able went hcriiutiontinecntive is$3.116. 590.00 FEB, 2.. _ LV� Total: $4,007.40 Program Incentive: $3,110.00 Customer Total: $897.40 WE AGREE HEREBY TO FURNISHSERVICES-COMPLETE IN ACCORDANCE WIT►t ABOVE SPECIFICATIONS:FOR THE SUM OF *"Eight Hundred Ninety-Seven&40/100 Dollars $897.40 UPON FINAL INSPECTION AND APPROVAL BY,RISE ENOWEERING.CUSTOMER .O REMIT AMOUNTOUE tN AILL.INTEREST OFT%WILL BE CHARGED MONTHLY OIJ ANY UNPAID BIiIAI 'FTER]D DAYS. -REYERSEfO IMPORTANT INFOR! ON OR.GUARAMTEES,RIGHTS.&RECISION,SCHEDULING;AND CONTRACTOR REGISTRATION. DO IGN THIS CONTRACT IF THERE ARE ANY LANK SPACES A R7tED SIGNAT =RISE .. .-...._ ._.__.__.. ......,-,_... Mng 'rO ACCEPL-0. NOTE:THIS C04MCTMAY DE WNTHDRAWN BY US IF NOT EXECUTED VATNIN DATE OF ACCEPTANCE- .._._.. ..__ _..._.._....____-_,,._,__._._.�........_.___ ACCEPTANCE OF CONTRACT-THE ABOVE PRICES.SPECIFICATIONS AND CONDITIONS ARE 3Q BAYS. SATISFACTORY TO US Ano ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO 00 THE WORK AS SPECiREO.PAVMENrVALLBE MADEAS OUTLINED'ISbVE RISE6 Shawmut Road,unit 2 I Canton,RSA 020211339-5024W5 ENGINEERING www.RISEengineedng.com OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at: �-rr c e G,V (Property Address) l�• ���o Uw'� 1'LLG. l3G�'� (Property Address) hereby authorize Cj a,,J�j L'r I n S V L t0l•d (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on.my properly.This form Is only valid with a signed contract. i OWne Ltd// is Signature Data The Commonwealth of Massachusetts _ Department of Industrial accidents . Office of Investigations u E: 1 Congress Street,Shite 100 Boston,MA 02114-2017 =r" www,rnass govidia % ori ers'Compensation Insurance Affidavit:Builders„'ContractorvllectricianSrPlumbers Applicant information Please Print Legibly Address: 0-d 13 o x 314 Cite,Statr'Zip: l- _w l 3 t Phon # T16 3 r10. 34 S 3 _ Are you an etnpioyer!Check the appropriate box: TV pe ul'project trequired l: 1, 1 am a empioyer Willi 4. ® 1 am a gcncral contractor and i ifs; hired thesub-contractors 6. ®?tete Construction empkivecs i,r ull and"orpart-three1. I am a stele propriclor or pat'tner- listed on the anachod sheet. Rcraxadeltng ship anti have no 4-araployces -1 hese sub-cosra-actors have K ®Demolition working liar me in any rapaciv+- employees slid have Workers' t}. Building addition [\ta wrorkers'stamp.insurance eomp insurance', recluarctl-; etc are a corp©ralicla and its 1011 Electrical repairs or additions tines s hav, cm iss'i#their t l. 1'luftt@ttn rep3i�:!ar addui4?ats C1 I am a htartactass n4 r doing all e���r �] mylldf. tNo-aorl,ers- comp. right o €xernptievi-ser%IGL 12.[)Roof m-pairs insurance required] 152 .�101,olid we have tic, €maplo" es. [!o,,%orkers, l3.®01her comp. insurance required.] "Au, anilicam that cho.: ,%Nt %=t nutq asst,fillout the stv:uuta IVIU.'i�iw%v i g Ethel u't terra'.,t pm. atvkri pc4q u..az¢atAtton i fwftxr nerc wh(%;SUk-wt tris affilda%it.iaadecz an: ;a3&wont v, *.cr.rat..w,%fc cowmc:tuwt mint�tahatat a acro affidavit zsJtc Liu{ vs[h �C:aaratncwn that.owd.;$:5 Geta:must.;a-,.aichs.? .a&'IT- all Alr_r:-jwV%f1-,v tt;e meter(if c,;: asrv:z=.atr t%he,f:er w saw-'hoic cmltn-K ental>1ovllc3. If die hatvc cam,:a ^ret. x4 mmrta,+,rde the cij- p.Fdfi };LU nIN: I um an empkver that is providing workers'rootpensation'insurunce firr my ernrtrryem, Below is the police•and%oh site infornratiot:. Insurance CompanyName: Policy or Self=itts,t_ic, : �”) l �1?.3 9_33 _ _ Expiration Date:_�t;�„� "VCrt'l✓�- a t 4Zu !©b lite:>ddress: Q ,�e� Card Statz'lil;;_ -_ Attach a corp} of the workers'compensation policy declaration psga(showing the policy number and expiration date). Failure',Cx satire coverage as required Lander fiction 25A of r4(;t_c. 152 can lead€ca tits imlwsitiurt of criminal peniltics o a rifle up to Sl,500.00 and or One-wear tnt(arisorarracni.. as well as cf%it penalties in lite foriaa of a S'l OP XN70Rl ORDER and 3 fttae ill'up to S-150,04)a.d,iy against the t iolalm-e Be ada cd that a cope of this statement rma% b�:forwarded to the O lcc o invest-igatiuns ofthe DIA#car insurance cmeratr vvri icatiom I do hereby rertif tinder the pains and penalties of peiYury that the information provided above is tare and correct. Stmatyure: CJu`^-!� �. _ �._ �.._ !)ate. _q L lip Official nese only. Do not orrite in this arca,to he completed by rith or town official. City or Town- � „ Perrttit;License Nsuing Authority(circle ones 1.hoard of health 2.Buiidinp:.Departawnt ;:Cilffl'nwn Clerk 3.Eitctricat Inspector 5.Plumbing Inspector 6.Other CilntAct Pels)n: _. _.,,:._e,, _._. __._ Phone : • ,h r � .. 'r.' � 7z'� f' ,� , II I 1 i I Ij !40 f Y I I ACORU® DATE(MWDD/YYYY) �, CERTIFICATE OF LIABILITY INSURANCE .7/7/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTANAME:CT Nancy Usher Martin J Clayton Insurance Agency, Inc. HCONN E -0804 AX(AIC No:(413)534-7874 1649 Northampton Street ADDRESS: P. O. BOX 989 INSURERS AFFORDING COVERAGE NAIC9 Holyoke MA 01041-0989 INSURERA:Nationmide Mutual-Harleysville NATIO INSURED INSURERB:Allied World Natl Assurance Co Gauthier Insulation INSURER C: 44 ESSEX ROAD INSURERD: INSURER E: IPSWICH MA 01938 INSURERF: COVERAGES CERTIFICATE NUMBER:CL157701379 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMBS LTRuugn X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE FX]OCCUR PREMISES Ea occurrence $ 50 r 000 X GL43487F 7/6/2015 7/6/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 j POLICY�PRO ❑ X $ 2,000,000 JECT LOC PRODUCTS OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION BE020792125-194985 10/18/2014 10/18/2015 $ WORKERS COMPENSATION PEROTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CSG, NSTAR AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MASS SAVE PROGRAM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICES GROUP, INC. ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET WESTBOROUGH, MA 01581 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD MPIMNtbd with pdfFactory trial version www.pdffactory.com CERTIFICATE OF LIABILITY INSURANCE 911W0I5 THIS CERTIFICATE IS ISSUED AS A 44ATTER OF If.FOAMATIOr^t OULY AND IYO RIGWTS U"`�DII The CERTIFICATE H=ER.THIS !!! CERTIFICATE DOES NOT AFFIRMATIVELY OR xMATTVEI.Y AMEND,'7t•T€#D DR ALTER TKE COVERAGE AFMROEV BY THE POLICIES BELOW.THIS CERTIFICATE OF II+SUPLANC DO--S NOT CONSTITUTE A C=ONTRACT SETWES0 T-E ISSUING INSUR R[S),AUTHORIZED REPRESENTATIVE OR PROD-OCEP,AND THE CERTVICATE HOLDER.. IMPORTANT:It the cktiff"te holDCr fS an ADDITIONAL TNSURED,U*pdfry(irs)must he endorse4 ff SUBROGATION IS WAVED.bEItllect to the: Mures and cr'n t ws of the poticrr,c+ertaun paticles may requ"a^c serrent.A staterr,cnt en tlfl5 certtfl,;gte do"na,co-:ffet lights to the CrZAT11Cate h0der In ffeU of SW,J endoesement(5). Clayton Martin J Ins Agency Inc S`fktey Assir40d R'sk Srvtc€ 1669 Northmpton St PO Box 989 �.� fBt�Ii G3c<SSE9 �.Npy 1865 515-8116 Holyoke MA 91444 Zosszs; ''aafcySewl s�i6rxkliys 5 ffiGa _ ,5f1RER w.. A ffia.Irfsta:trc,C iA 31325 Gauittfcf lnsutatlon IncL4E3,R=.iiZ$. PO Bax 344 f iTiET¢ Ipswich,MA 01938 �+ •, COVERAGES CERTIFICATE NUMBER. REVf51DR NIINQBEW THIS IS TO LERT". TKA.T THE POLtCtE'-OF WSURANCE LISTED SEl- VV ,AVE Br V ISSUED 3OT€i NSIITtED tvAItED ASCAIE FCp,'fH=POLICYP.-;iIOD INNCATECe.fttiTVYITfdSTA.OIItt,AhY L*tlinEME4dI,TUWORCOUDffHDNQr lAYY Imo,3 RACT OR OTHER aOCJVFNT WITti RS PELT TO VJMCl4 jMI5 CERTIFICATE mAY!BE ISSUM OR MAY s; AtN Tri£l.'iS€RAMCE A1FORDED BY THE POLIOS OEE'MSED HEREIN 1S.1,UBJEGT TO ALL TRE TERMS., 1=JtCI.,t1,Stf]PF$,W.R?Gw3StOIT F.'S Ctk.SUCH-POL4CIE5 LM4j S$#4i3w LrAY HAVE R,E'DUC£D BY€+Afri Gil f I r rF` TYPE W"'S10j.PuE Y',� It'ig1KY '"+,ti:. -+ - • -_. CLJt 6E'!VE%tAt[ls4'fttF1'. ✓: _ - EACe'ta=AtkE1-Cf f% RCtAi JiEI'vt'*'�UA:lSv— ( CYJ,a.'.e-NADF. IFj"DDC.-IR lay bodqy .. .,EA'C=X,WSAM Leif.'A -r.GDlJ -C{uis 'aQ 5 .;ECT 0'i47C �- AflTtktttF ldABflitY Li{{ y"y ..y -.:.... - '.. Ll Ars Aur y Z06 sc-mssai A T .. Dom,ea iRTM itAa ec3rs-:, crCPl'�'rY sE+�SRif:U lf44 OGC4rR $ - eA,ex�i-;tmaEf;r.:E 5 INDA)MRS C0hW0SATVk `AK -L1�:r'S R _f _ _... AND EMPLAINWRS'UABILM l'.$: I_.;3t)�r E MAQRP.W032? laswois 7Q.+3C 016 eiEAcsr [.z s:: S map >£sc+-m=rx.of osSRAIloNSt,c orfASz-•I'm,crOW 0T7. ui G,- ,.,r 44"lli:A.q., "ftt �aR15ik1+S1E5{Rr'X',G=X,J"r.AtlC/�i=.fi' _,:B•4l ,S iess sroaa3JJ^G1 - �f4�7!4Y:OSC�On' 4WL�K - 4FY 5fb$tilr4�}Y' CERTIFICATE HOLDER CANCELLATION SHOVUi,iVY€7F Tf-F A4FOk'E D,&Mf.BW HO'-iCtE' BE CAWM.LED atPDRRE Clearesult THE E)CPRAT"3 ATE KEREOf.%1M—r-:E VV LL BE 4LfVEI i-D IN Contractor$vcs kCCCMZA-C--WnT-I THE POLCY?RW$J04.9, 50 Washington Street A�. sF an x.E f Westborough,NIA 01581 signature: ACORD 25(2010/OS) SI,AC 3139 Mus�achkas�ttat,p p��artmelt app Public Satoty Scard of Sul ding Regulations and 5tarrdardl Q"ikrsfra;k,k:t�;6$kkYk tkrx,:Nnrrk• �rok*,�Israe,: tc�xaxz CSS.-10562 V P Bou 344 r - { f. yr ` EXpircav C starker 'M512017 r _ �/1?;G' ll%CI��Z�71'l 0??i:!l1�f��l'�j ���..��!CG?;.'1/,lC•CFCa��1GGf1�i�i3• �, Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Y. Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173410 Type: Individual Expiration: 10/1/2016 Tr# 257812 KURT GAUTHIER KURT GAUTHIER P.O. BOX 344 IPSWICH, (VIA 01938 Update Address and return card.Mark reason for change. F" Address F— Renewal �i Employment ��1 Lost Card SCA 1 % 20M-05111 !','.'6 ,( ._ Office of Consumer Affairs,&Business Regulation License or registration valid for individul use only n -- TOME IMPROVEMENT CONTRACTOR before the expiration date If found return to: ^` registration 173410 Type: Office of Consumer Affairs and Business Regulation Expiration:;. 10/1!2016 Individual 10 Park Plaza-Suite 5170 a' Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER 44 ESSEX RD � 4 IPSWICH,MA 01936 — -----_._ Undersecretary of valid wi out signature POBox55098 —t3ostan'ArtA fl3�5=5tJt3-- r Form of Notice of Casualty Loss to Buildin Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 - Imo:- Insured: RUSS-JOYNER and BRENDA JOYNER . Property Address: 88 PEACH TREE LANE,NORTH ANDOVER, MA Policy Number: HMA 0407264 Claim Number: BOS00049655 Date of Loss: 2/13/2015 Company: Safety Indemnity Insurance Company I Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to_the attention of the writer-and include a reference to the captioned insured, location, policy number,`date of loss and claim number. Stephen'Desrosiers Claim Examiner 2/19/2015 Safety Insurance Company 'Homeowners Claims Unit P. 0. Box 55098 Boston,'MA 02205-5098' Phone: (617) 951-0600 EXT 5463 Fax: (617) 531-6658 Email: StephenDesrosiers@Safetylnsurance.com