HomeMy WebLinkAboutBuilding Permit #1122-2016 - 91 WEYLAND CIRCLE 5/1/2018 1� �'I✓ BUILDING PERMIT o`t%ORTy ED 'bq+
TOWN OF NORTH ANDOVER 0�2 h ;l' '...+b•'6
APPLICATION FOR PLAN EXAMINATION
T M T
Permit No#: I ''I Date Received 'ZJ4A'Rwreo�4"y4`�
ACHUS
((
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION W e Li <-�- Cl('LLk--
Print
PROPERTY OWNER WA & i
f� Print 100 Year Structure yesrnnMAP W"J PARCEL: b244 ZONING DISTRICT: Historic District yesMachine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
er'Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
! D Septic �`yWell A DE Floodplain ®Wetlantls ❑' Watershed Distnct�
D Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Q�r S-Cr.11 V-e,•, ( -el l J t u�. i t Q. lb L i n kr e-c-w 6 1 S
Identification- Please Type or Print Clearly
OWNER: Name: ' J J w\t ntr Wl& ; Phone: 1 ' (.9 Z0 'I
Address: 01 k W G l ux\a (.x rLu ,
Contractor Name: kcj✓ � O--Jt- %T-,- Phone:
Email: 0\J-tr i v ►�• u•�M
Address. Pp '3`1\-1 , LLk Lk ikp\cii 'SE
Supervisor's Construction License: L S 2- Exp. Date: '5 Z s-
1 }
T
Home Improvement License: V1 1 0 Exp. Date: k b
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: $ Z O Ul . 3 FEE: $
Check No.: Receipt No.: �
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
r
i
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL E
Public Sewer ❑ Tanuing/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑
i
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m 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
4
e
Conservation Decision: Comments
` Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
.F;IRE`DEPlARTMEfVT '�p{`,Tem` Dumpste� onisite : es .� 'y`y' no `s ` " '` t `° �i
x%k- + [�C-' rc 1 e Y D �w.". �yr�s ,5.1i..t IFI�.. .�+ tk'�dlitl.L�`� .... - "4
Lo at 124 Main St ee�t�'- � tu{ ��x' `'
ver ar 1F =AL3 tSw^ # X('D (> •r f #4 14lC �. �,+h. sk:
p r(tment signature/date�� . . �.•. �� ,.,� .:.._ k �..
ari.ti+a7'�1-i
•�27y�;."1'�ss''�M'����r-T�1�'�;�` 'n ":i.S� �..'S.�+tet{"�fF , '.+;'1�V�i's1 3�4..��.�� 1� �l-.Twp s�rai.. � i1�i�'s �t�' ��'4 `�w. '�.,. x �"�j. �;U�a„ Y
COMMENT°S���£ `'���? °��, :i „�r ,°. .•; ,,s -� ., �;1 .� r �l,�; �y��,`� � :,ti
.+. � !"i �tC^R' ,� „'ii•.. �t `.��1t F, r <�b s i�;: '�v x ('(xa °�p' °C f� r �{"moi
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Dimension
l
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location vast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$1o0-$1oo0 fine
NOTES and DATA-- (For department use)
® Notified for pickup Call Email
Date 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.
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
4s Floor Plan Or Proposed Interior Work
a. Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
OTE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2014
Location
! — -�Z 0 ` Date 4{ �
No. 1 I�- [
• • TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�S
Foundation Permit Fee $
Other Permit Fee $ _
TOTAL $
Check#< 1�1
Building Inspector
U
%AO TH
w ndover
o - �►
No.
i� h ver, Mt Z
o� > Mass,
coc«ic"IWIC, IL
1'
7,9 p°RArECD
S tJ
BOARD OF HEALTH
Food/Kitchen
Septic System
•
THIS CERTIFIES THAT
�. le 1��... . BUILDING INSPECTOR
PERM- IT
. ..... ... .... . ... .. .
Foundation
has permission to erect .......................... buildings on .... .,....w. ... ...... :...... .. .. ...... .
Rough
to be occupied as . . . .'C* hper
.�. .� �u ..�.!�.7K�.. ...It.. .. . .. ...!.�!..... Chimney
provided that the person acceptin th ;hall in eve res ect conform to the terms of t a licationgevery p pp 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
ti
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION ST TS Rough
G Service
.................... s..... ./...y���...�........................... 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.
i
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RISF 1•.iwiiitecrino Rt Contractor Registration No 8186
RISr MA Contractor Registration No 120978
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(tit Ntssttmut l nit s2,Clinton.\t 1
CONTRACT
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Federal ID M oS-0405629
RISE �, IZ1Sly i'-ngincering RI Contractor Registration No 8106
J MA Contractor Registration No 120979
A di%isinn 4)t'1'11irl ell h:ngincrr(ag CT Contractor Registration No
ENGINEERING' 60 ShnWTnut Vnil IR,canton,N1.%
(4111)784-37011CONTRACT
FAX(JOI)784-37141
Page 2
PROGRAM I"M CONTRACT:SENIEREO WTODETMACN R13f.
(;.iL•l-LIES ENG ft'R O AND THC CUStomEA roR WORK AS
DEacRNEnaCLOW
CUSTOMERDAT CLIENT0 tyWRK OROEn
PIKNIE f.
Nicole Benoldi (617)620-2138 02/'4/-'1116 431134 00002
SERVICE STREET alwoG STRCET
91 Wevland Circle 111 Weclatid Circle-
SERVICE CITY,STATE.ZIP [AII jD CITY.STATE•VP
North Andover.MA 018415 North Andover,MIA 01545
.10I3 DESCRIPTION
ura;henntlilrl uucnuYc is J:.110 C1)o w
1
i Total: $2,604.38
9 Program Incentive: $2,100.78
r Customer Total: $503.60
f
VVE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS..FOR THE SUM OF
"'Five Hundred Three&601100 Dollars $503.60
UPON FINAL INSPECTION ANDAPPROVAL BY RISE EF:GiNEERRIG CUSTOAER AGREES TOREUIT A-ACUNT DUE 114 FULL INTEREST OF 1%VALL OE CHARGf.O UDSIRLY ON A1IY
UNPAID DAL U4CE AFTER So CAYS,SEE REVERSE FOR IV.PORTANT INFORUATIOI ON GUARAtaIEES,RIGNTS OFRECISID.'I,SCHECULiNG.A!iD CONTRACTOR RCGU^TRASION
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Lf-�
AUTHORIZED SIGNATURE-R..d EAIII-MIn9 CUSTOU CCEPTANCE
NOTE.THIS CONTRACT MAYBE VATHORAWIDY tM IF NOT EKfCUTEDYATHUI CATS Or ACCEPTANCE (• ~-���� �F�
11) ACCEPTAUCE OF CONTRACT-711E ADOVE PRICES,SPECIF:CATK)NS AND CONDiT101l;ARE
G� �- SATISFACTORY TO US AND ARE IIEREUY ACCEPTED,YOU ARE AUDIORCCO TO DO:IIE VWRK
DAYS AS SPECIFIED.PAYLIEN'T V.1 t.Or.MADE AS OUTLINED AT1OVf.
RISE 60 Shawmut Road,Unit 2 on MA 02021 1339-502-8335
�Cant ,
ENGINEERING' www.RISEengineering.com _
OWNER AUTHORIZATION FORM
l
(Owners Name)
oxvner of the property located at:
tAv
(Property Address)
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.This form is only valid with a signed contract.
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Owner's Signature
k_ 4A/
r
Date
I
The Commonwealth of 11as-sacluusetts
Department of Industrial Accidents
Oice of Im-estigations
s 1 Congress Street.Suite 100
F' Roston,.11.4 02114-2017
F
w%,w.niasv goi is
Workers*Compensation Insurance Affidavit:$uilders/C'tontractors.jEleetricianstPlumhers
Applicant information Please Print Legible
i�.11t1C dEiu-1 t;�+«rt:rntrlti,n fttJiRu'.ual4: a'14 %-Yf t' �VAN �
� el
--- ---•--1-i—`fie-- ...__... _
Address-, ox
C'irs' Stztte'7i : W t Phone ,:
Are sou an employer:'Check the appropriate box: � '1'r pe oU project lrequired
1. 1:17T7 a�n1p1t71'cr snit#t r��� 4. ® l ain a ueneral contractor and I
4.. tiCRR cclntitraction
cntpins.a.N 3fltl ar7tlR.rr I±:l:rl-tints}' ha-,t:hired itis�idh-it.�ntra:t3,aFs �.
I am a,,olc propnetur or partner- fired on the ai ached,heti. ItcmAldeling
t lieu,uh-c�:t.cract.Rr;haR e
chip and has c no Lrnployek:N x Demolition
working Iitr ntc 3n an% ca acit�. einplo,,cc :ind have ksorkcrs`
p r. Budding additioncoin �•
(\tt RRitrkcr:'comp.trtutr±3tcc r.tn .1ra.tR�." r.
required ' i iiFi a c trt?trrattra:t ttti#iiS [!,
Llectricaal.repairs R1r addition
I ain a hwmiI',l'n.r doing all ttr�r#t t?a'1�i S l::tRc��,rclsed tll�ir #(,®i ltlt3lhln} Fip38r+or�tilR:ittitlt+
mt;zI}. right of ctemt , MCIlion et��,tf RRitf�irS rl;tip. � 11C)lit?tit Fep1tFj
in',Urancc ruquired.] ; c 152 \,10it and Ric 17.34e no i
ctnplu:e:s [No ktorl res- 13.0 t�thLr_
conte.lttaarance require.'..]
_•AnRatt+!r:a�-tbardhc>�SM3�=ITt.�t:t'�v:�tivuttE:cxr.�,attxlu'+ ,t.+<..�;:t;�.:.�c+si,:t ..vr{�w�ird't1.�.: i:.�.-sr,n:�.+n
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fh2 ii incil—,Li.-a\-rircr it,rart w:the trona of t;,.ai oto.X'd',Lt+c a b..3 et ut.t' -t,.s>c't'rtt.4.N%'.
csgttr. _ tt tt'c>ut uectt a.rs 17atic;-r:r't'�Ln.;het mt I:pratir�e cher. s��,�. s.'"eq, pil"
am un et»plot'Fr that 1S,jtr ►tdtn xvrrk�n'crrt►rlrenRr turn irr+rarunce JErr mt'rm�th>v�^er, Below is the policy andjob site
information.
ttt,ttrallcc Company amt:: OL Y-1�o(-Ar,t-k
Psi.P.3Q ?: .� — — C�Etir:itt@ft L,).ite: 4 t � 3 1 —
3�llSitc:addr.ss l(L. C,t Ci*} Stat2fttl !1� �,�Vf!i✓ �� �,�U't�
Attach a copy of the st orkers'compensation polis-* declaration pa-c(shoo int;the policy number and expiration date).
Failure:c1 mccure coverlice as requlrt%i under Scctiort'5�1 R,:`4if;t_c_ t 5_'can Lad to the trttpnttion of crunttKa penalties o;a
litte up to w 1.500.00 and or Qnc-y ear imp;i;omncnt..as RtelI s:ct,;d peri loco tit the '.'treat tof;i Si t i:l#'li`f)RK ORl E R and a tine
of up to S2 50 00 a day°agalns7 the t ittlaur,. Be.Ids I�cd shat a ctrp}R'f 1111S slat nrcut 111aR h;fors%arded IRS the t'ttficc Of
inRcstig.itloms r^+ the DM ttlr MS1!Ta11C,:lrt%XTa11r Rcrtfli;ation.
I du hereby certify under the pains and menet/tics of perjury that tare information provided above is true and correct.
Official use only. Da not write in this area,to be completed by city or town official.
City or Town- � l'erntit:l.icrnsc#
Ksuing Authority 3circle ones:
l.Board of health _'.Building*,Department 3.Cityfl'ow n Clerk 3.Electrical Imspector 5.Mulnhing Inspector
6.Other
Contact Person: .,_ __ __ Phone +: __
AC RD
CERTIFICATE OF LIABILITY INSURANCE
,HIS CERTIFICATE 15 ISSUED AS A HATTER OF)%FOkMATW1ON-ONLY AND CONFERS 40 FUGIMS UnV4:iS CER71FICATE HODER.THIS
CERTIFICATE OOES,.jOT Af,-IAyAT1%,ELY Ck%ErIATwELY ALMt),'4 TEND OR ALTER THE C011ERhGE AFtLRDED eY T:iE POLICIES
BELOW TKISCE;('nFIW-L-0fINSURANCE E>OFS.%OTCO.I.SitTUTEACONTRAC7o'BETV;ES,4'.'!ISSUING INSURER.(S),AUT40RIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIICATE HOLDER
IMPORTANT:If the ceftiG=e Wdv,q an AZOMONA- T%SLIRED,the 001KY(ms)must be endorsed R'SUKOGATION IS WAAfED,subio-d:o tttie
tem-4 and ccqd;uws of ffie palwy,certain polkies m4 Mq-,tre a^er02rsPr-_-nt.A statemeN en this certifk5je OOOS no,confer nghts to the
certificate hofder In Ifni)of s,)ch
1w T
Clayton Martin J ins Agency Inc —5t-4-11.1ey Assigned Risk r,-rVIcc-S
1649 Northampton St PO Box 989 ,. , 1800)634-4585 wal (866)215-13116
Holyoke MA 01041
IS AS 4sF,5 rf6 CCNTR.AA
I
Gauthier Insulation Inc
PO Box 344
10swick MA 01938
COVERAIUS CERTIFICATE/LUMBER: REVISION NUMBER;
THIS IS TO CER T77 T-f-AI THE POLICIES OF T,"�'s-upQZEDSTED beLUIV rtw;:EE04 ISSUED-IG T7E KSUkED%14!ED ABCIVE FOR THE PO:XY PERIOD
NY'ON-k4f_T OR 07-TER DOCjV.ENT%Vnh RESPEI;T TO V"CH T"ZI
t.NOWCATE5 FOOT�%ITHSTANDING ANY R= U;AEMENT TERM OR CO,,44TKis 007 A,
CERTj;:pCATEMA1y BE ISSUED OR MAY TFL 114SURA14CE AFFCRDED BY DESMSED HER&N IS 11J3JEC7 TO AUNt_:TER.MS
EXQLUGK)I�F8 AND CON07IONSO;SUCHfIrmv-7fS.0ATS_1t4_'4VNIVAyHA'61:FIFEW REDUCED EY PAID CLA"S.
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ACORD 25(2010105) BRAC 3139
TE
ACCORV CERTIFICATE OF LIABILITY INSURANCE FDAT/(7/2015Y)
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 CONTACT NNAME: ancy Usher
Martin J Clayton Insurance Agency, Inc. PHONE Ext_ (413)536-0804 ac Nc:(a13)s34-7e74
1649 Northampton Street E-MAIL
ADDRESS,
P. 0. BOX 989 INSURERS AFFORDING COVERAGE NAIC#
Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville NATIO
INSURED INSURERB:Allied World Natl Assurance Co
Gauthier Insulation INSURER C:
44 ESSEX ROAD INSURERD:
INSURER E
IPSWICH MA 01938 INSURER F:
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 ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER M D LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A CLAIMS-MADE z OCCUR DAMAGE TO RENTED 50,000
PREMISES Ea occurrence $
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
X POLICY E PRO-
JECTD LOC PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
NON-OWNED PROPER
eOccidenl AMAGE $
HIRED AUTOS AUTOS
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 COMPENSATIONPER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE I ER
ANY PROPRIETOR/PARTNER/EXECUTIVE 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 1$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
TEI, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSURED(S) ON A PRIMARY AND NON-CONTRIBUTORY BASIS
TO ANY OTHER INSURANCE CARRIED BY TEI, UNDER THE SUBCONTRACTORS GENERAL LIABILITY AND UMBRELLA COVERAGE.
30 DAYS NOTICE OF CANCELLATION
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THIELSCH ENGINEERING, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
195 FRANCIS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS.
CRANSTON, RI 02910
AUTHORIZED REPRESENTATIVE
Daniel Sullivan/MEG `t - ��� -
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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M2ssachusetts-OPartrnant of Public Safety
Board of Building Regulations and Standards
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Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 173410
Type: Individual
Expiration: 10/1/2016 Tr# 257812
KURT GAUTHIER
r KURT GAUTHIER
P.O. BOX 344
IPSWICH, MA 01938 - -
Update Address and return card.Mark reason for change.
Address ; Renewal Employment Lost Card
SGA 1 +0 20M-05111
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
3 " ��IOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
CRegistration: 173410 Type: Office of Consumer Affairs and Business Regulation
It
x6Ex iration: 10/1/2016 Individual 10 Park Plaza-Suite 5170
,a ., p Boston,MA 02116
KURT GAUTHIER
KURT GAUTHIER �l
44 ESSEX RD
IPSWICH,MA 01938 --
Undersccrctary of valid wi out signature