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HomeMy WebLinkAboutBuilding Permit #575-2017 - 90 LOST POND LANE 11/29/2016 � SyORTy • BUILDING PERMIT o (BLED T TOWN OF NORTH ANDOVER �2 h '`` •"-=6 APPLICATION FOR PLAN EXAMINATION _ 4q 1. Permit No#: 6'7 S - d 017 Date Received II- 'oZq— �0( DAATED RSSgcHUS�� pate Issued: - EVOORTANT:Applicant must complete all items on this page M _ D o ` T iPROPERT�'Y�R1/VNER��L _ Pn f-� �1Yeart�ructure yes. no �" ONINGD1STf21CT' _ 1,11/LAFPARCEL,.. �. Z _�Histonc ®istnct byes ono . � - �i •� ___ ..,�. � � � � '� � ���"" rs�l1/lachine,;,Shop�%illa e'R es s` O. TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑ New Building bdne family ❑Addition ❑Two or more family dustrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Y y -•.. .r+c_ �-�'•<w .. p Septic ❑Well Floodplain _. Wetlaritls Al Watershetl`District t fk OPWater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly' OWNER: Name: 1- c��,wc-, I)AaL e� Phone: Address: Lo 0061 4W- A)o�t' c,�,sw�v, moi - oc k `Contractor Name ��l�fs>�. � _ _ � Phone 1J • ;Address: Loi STs Supervisor'si Const uctiohi L`icense [Datep. - Home Im rove enttLicense ,s__. .. 'Exp 'Date _- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT;$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COSTBAj N$125.00 PER S.F. �- .Total Project Cost: $ 5<S a 0_C50` FEE: $ Check No.: YO Receipt No.: t �S NOTE: Persons contracting with unregistered contractors do not have:access to the guar fu S`ignatiae of_Agent/Owner Signature of contractor 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 ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS a HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes s Y ' ening 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.Main Street Fire Department signature/date COMMENTS t limension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: f ELECTRICAL: Movement of Meter location, mast or service drop.requires approval of Electrical Inspector lies No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— (For department use) i ❑ Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. .-1 r 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 PP uildin Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And G.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 40TE: 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 �U t os / ��.• V L� Location t 1 f No. 75- d 19 17 Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $_ TOTAL $_ Check#7 YO -moi e1L,/building Inspector :. � NORT1� Town of 2Andover No. � Z o h ver, Mass, /its AQ . rt 0I to LAKI COC.IC..WIC. �qS q�rE o h1P����S L) BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System 111�THIS CERTIFIES THAT ..MO.C.A..0 Aw......�.�..�� Ift BUILDING INSPECTOR .......... .......... .. .. .....�. .... �,to;Ot .40F ." .. LNi... Foundation has permission to erect.......................... buildings on ...... �..... ...,. a RRough tobe occupied as ...S. ..!.0 ....... ........ .......................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRAINONTHS ELECTRICAL INSPECTOR UNLESS CONSTS A 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. SKY PHOENIX CONSTRUCTION MANAGEMENT INC. General Contractors & Construction Managers Tel: 617. 596. 1146 101 Holmes St. Alt: 617.818. 7175 Quincy, MA 02171 Email: skyphoenixgroup@yahoo. com NAME/COMPANY: LD e DATE: STREET: o �oS� � �-� PHONE: (33 CITY: STATE: MASS. ZIP CODE: We hereby propose to furnish materials and labor for the completion of- /Strip Str3/4ip Old Rubber,Roof ✓ all "Rubber Roofing Insulation v/LInstall Rubber Roofing ✓Strip Existing Old Roof Shingles Re-nail all loose roof boards. Replace rotted and warped wood at$4.00 per foot or$50.00 per plywood sheet. l Install 3 ft_or 6ft✓ ice&water shield.—Install black Paper 1 nstall Aluminum Drip Edge.v Install Cobra Ridge Vent. vinstall New Chimney Lead(if necessary) _✓ tall New Roof Shingle. Product: Color: Remove and dispose all of the shingles as well as all roofing materials in the dumpster provided. Grand—Total: $$ (�r o--'c>--) [Me propose hereby to furnish material and labor complete` in accordance with above specifications, for the sum of: -ACCEPTANCE OF PROPOSAL- I have read this document and all attached documents and accept the prices,specifications and conditions stated. I understand by signing,this proposal becomes a binding contract You are authorized to do the work as specified. Payment will be made as outlined above. If an attorneys service is utilized in the collection of any amount due,the signer shall be responsible to pay attorney's fee in addition to sum due. You,the Buyer,may cancel this agreement at any time prior to midnight of the third business day after the date of this transaction. Cancellation must be done in writing. Prepared By: Accepted By: Sky Phoe o r ctio nagement e Leu / re - e Owner & Personally and not Individua y (�-- die Commonwealth of Hassachuseffs _ F. Department of IndusWalAcc!dents M "~ 1.0 1 Congress Street,,Suite 100 w' d Soston,MA021142017 www.mass go�v/dza d�A SSV Wa3:kers'Compensation lnsurancedavit:Builders/�G sy 6r�cianslPlum ers. TO BE FILED WU-U TITS TERM I'Il AUTff OBlease Print L I A '•Iicant Information G Name(Business/(jzgavizationadividual): ' Address: ,�) 0Z9 7 Phone City/Statelzip: av k.�,` ex?Checl the approprlatebox: Type O pXOJeCt(regiiixed). - Axepou mplop . —emi ees fuIl and/or part time).' 7. ❑NSW Co bt[on 1. 1 am a employer with_S�-� Y ( 2•❑1 am asole proprietororpartaershrp andhaveno employees Working forme in $. emodelirig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 1 am ahomeowner doing allworkmyself jNoworkers'comp.insmancerequired.I t 10❑Building addition 4.❑1 am ahomeowner and will be hiring contractors to conduct all work on my property. Iwill 11.0 Electrical repairs or additigns ensurethai all co?ftactb=s eitharhave workers'compensation insurance or are sole o eupioyees. L2.j0-Ptunlbitrg repairs or additions proprietors withn 5.❑i am a general contractor and 1 have hiredthe sub-cont-tors listed onthe attached sheet. 13.[]Roof repairs These sub-contractors haus empioyees andhave workers'comp.insurance. 14.n Other 6.Q We are a corporatioli and its,officers have exercised their right of exemption per MGL c. 152.§1(4),-4'we;hive no empldyees.[No workers'comg.insurance required. on *Ane applicant that checks bbk4l mast also fill out the are doingtion below work and then hire oeireutside rs contract contractors Pmustysnbmit a new affidavit indicating suet. T Homeowners-who submit tjj g affidavit indicating they }Contractors that check ihis box must attached additiom shoot showing rhewe nrkers o ome colic number.� and state whether or not fliose entities have employees. Ifthe sub-contractors have employees,they PP Y am an employer that is pxoviding-woxkerrs'compensation ijzsurancefox my employees Belowis thepolicy auzd•job site information. ' Insurance Company Name: S • fir.,,� f ExpvrationDate' Policy#or Self ins.Lac.#: �� _�r ) City/State/Zip: Job Site Address: compensation p obey declaration page(showimg the police number and expiration date). Attach a copy of the workers' to Failure to secure coverage as required under enaltias2mthe form of aaSSTOP WORK OBDERal-violation Iand fine oe by a ffib f up to $250.00a and/or one-year impris onment,as well P ations of the DIA.for insurance Cement may be forwarded to the Office of day against the violator.A copy of g coverage verification. I do liexeby cern d rz perjury fiat tli ormatiorz provided move is txye r?d correct Date: Si ature- Phone#: ' r Official use only. Do r20twrzte in tills area,to he completed by city OF town officiax Permit/License# City or Town- f ssuiTig Authority(circle one): ' 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: i Information and Instrnctions 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 fi 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 trus=tee 6fan 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 tho 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•wlid Ras not produced-acceptable evidence of compliance with the insurance coverage xequited." 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 check-tithe boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),addresses)and phone numbers)along with their certificates)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 in surance 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 peg-uMcene application 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 proof that a valid affidavit is on file for future permits or licenses. A new affidavit must 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 Department's address,telephone and fax number_ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia CERTIFICATE OF LIABILITY INSURANCE 7(MMIDDIYYYY) /28/2016 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 00882-001 NAME, Branch 882-1 WIC Insurance Inc a/CDNNo.Ext: (781)890-0999 A/C.No.: (781)890-7216 230 Second Avenue Suite 105 EMAIL Waltham,MA 02451 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company 33758 INSURED INSURER B: Sky Phoenix Construction Management Inc INSURER C: 101 Holmes Street INSURER Quincy, MA 02171 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE AINSR SWVD POLICY NUMBER MMIDD� MMIDDY� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence CLAIMS-MADE [—I OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE S EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ ---)POLICY ECOT OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ yypRKDEERDg pM RETENTION $ $ AND EMPLOYERS€LIABIIOTY X TORY LIIMITS OER AyFYF P��MTE6%D/�FClI BIWOECUTIVI Y/N E.L.EACH ACCIDENT $ 1,000,000.00 A O IC ME E D'� ] NIA VWC-100-6018994-2016A 7/12/2016 7/12/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1-000,000-00 If yes describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 1,000,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover 120 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD SKYPH-1 OP ID:GP ACORO" DATE(MM/oomYY) CERTIFICATE OF LIABILITY INSURANCE 11/23/2016 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 cAOMNEACT Gail Prescott WIC Insurance Inc. PHONE 781-890-0999 FAX No:?81-890-7216 230 Second Avenue Suite 105 (,VC,No Ext Waltham,MA 02451-1102 E-MAIL Gail Prescott ADDRESS: INSURE S)AFFORDING COVERAGE NAIC# INSURER A:Atain Specialty Insurance Co INSURED Sky Phoenix Construction INSURER B:Massachusetts Workers Comp Management Inc. 101 Holmes Street INSURERC: Quincy,MA 02171 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR IkDDL SUBR TYPE OF INSURANCE POLICY NUMBER MWDDY EFF EXP LTR MWD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CIP209928002 10/01/2016 10/01/2017 PREMISES Ea occurrence $ 100,00 CLAIMS-MADE I—XI OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Excluded 1-1 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS (PER ACCIDENT) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS W►B CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUiiVE YIN CERT TO FOLLOW E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space is required) CERTIFICATE HOLDER CANCELLATION TOWN-67 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of N.Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. N.Andover,Ma 01845 AUTHORIZED REPRESENTA,TIIVVE %w'I;(.e ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-093609 Construction Supervisor, MICHAEL Q LEUNG` 101 HOLMES STREET A QUINCY MA 02171 - d - � n 1a1 �1�./►l"^� vim-- Expiration: Commissioner 10/16/2017 I � C— iA. r-�slC �C097Z77t Ci17CUCCP�l�C�C%!"LCL.1,iQClLLLrCI�.l- i � Office of Consumer Affairs&Business Regulation _ HOME IMPROVEMENT CONTRACTOR