HomeMy WebLinkAboutBuilding Permit #142-15 - 960 JOHNSON STREET 8/8/2014 BUILDING PERMIT of"°RT"
T"qti
TOWN OF NORTH ANDOVER o? y y,,.- o
APPLICATION FOR PLAN EXAMINATION
T
��o ey �
Permit No#: Date ReceivedrEV
9q
�gSSACHUs����
Date Issued:
P RTANT: Applicant must complete all items on this page
LOCATION I e 0 'y/-1 17
PROPERTY OWNERS�p ��' �rin
G /fc>/C
Print 100 Year Structure yes no
MAP- PARCEL: 1 _ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition A<ther
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCR PTION OF WORK TO BE PERFORMED:
74 Z
Identification- Please Type or Print Clearly.
OWNER: Name:_ P!/� P ,, �,� G / ✓ Phone:
Address: vl o
Contractor Nam y- W-- `'f"Phone:
Address. -2 y wQ �c�r?V Z
Supervisor's Construction License: Exp. Date: aj Z�
Home Improvement License: A-
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: $ Z FEE: $
Check No.: 11L� �3 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contract ,_-z----
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
e
HEALTH Reviewed on Signature
~C
COMMENTS
" 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 Main Street
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)
❑ 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
o 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
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
❑ Certified Surveyed Plot Plan
Li Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
o Building Permit Application
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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 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
I
Doc:Building Permit Revised 2014
I
Location 1�0 �(/�!'1 LS
Na /V9 Date
. - TOWN OF NORTH ANDOVER
•
Certificate of Occupancy $
Building/Frame Permit Fee 6-0�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
Building Inspector
Massachusetts Home Improvement Sample Contract
This form satisfies all.basic requirements ofthe states Home Improvement Contractor Law(MOL chapter 142AX but does not Include staadard
language to protect homeowner.Seek legal advice Unoceisary.Any person planning home improvtaneats should fast obtain a copy of"A
Massachusetts Consumer Guide to Home hnprovemenr before agreeing to any work on your residence.You may obtain a tee copy by telling the
Office of Consumer Affiirs and Business Regulation's Consumer hrfmmation Hotline at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner Information Contractor Information
Name Cmapany Nam
o
Street Address(do not use a Post Office Bot address) / Cmdractod Saiopersool OwnerName L
C ffovm State Zip Cede Business Address(mtmt inchWe a greet address
I If yi$�L�� -2,9l 0 C'�2,45—' c 4 f <,q i
Daytime Phone BveninBPbote Cityfrown State Zip Cede
Melling Address(ft diffaentfronabove) Business hone erII)orS.S. tan
Is inroremac.W d rRV&M be M*Vl nd•e
ry�ea arrt pato.
h don homaawmbhurl
_ .rasp rea6a.rlo■mneer The Contractor agrees to do the following work for the Homeowner.
(Describe in detail the vlork to completed,specifying the typo brand,sad grade of materials to be used,use additonat Sheets ifnecessarv.)
5 t
Required Permits-The following budding permits arorequired Proposed Start and Completion Schedule-The tbllowing scttdulewill
and will be sashed by the contractor las the bomeownees agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work.
MGL chapter 142A.)
Date when contacted work will be substantially completed.
Total Contract Price and Payment Schedule
The Contractor agrees to peri the work,fiuuish the material and labor specified above for Ne total spm of (�)
Payments will be made according to the following schedule:
S upon sighing contract(not to oxceed 1/3 of the total ooatactpprice X the cr ofspecial order itdw,whichever is greeter)
S�//,(/' by_/ / or upon completion of /�z G
$ by_/ / or upon completion of
$ upon completion of the contract.(Law forbids demanding foil payment until contract is completed to both party's satisfaction)
The following material/equipment must be special S to be paid for
ordered before the contracted work begins in order
to most the eomjdetion schedule(••) S to be paid for
NOTES:(r)mcludiogall finance charges(**)Law requires that any deposit or down-payment required by the contrw1w before work begins may
not exceed the gnaw of(a)one-third ofthe total canoact prion or(b)the neural can of any spechd equipment of custom made material
which rmist be special odered in advance to meet the completion schedule.
Einess Warr iants be m orm=deo'by the contractor? ❑No❑yd rah tuns of the warrant.must be attached to&acontract)
Subcontractors- contractor agrees to be solely responsible for completion of the work described regardless ofthe actions of arty third
patty/subcomractor utilized by the contractor.The contractor father agrees to be solely responsible for all payments to all subtbnuactozs for
Modgls aadlaboiAder this ame=Mt
Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the
contract shall not imply that any lien or other Security interest has been plated on the residence. Review the following cautions and notices
carefully before sigmlig this contact
• DanR be pressured into sighing the contract Take time to read and Polly understand it Ask questions if something is unclear.
a Mabe sere the chruraactor has x valid Hama improvement Contractor Registration. The law requires most home improvement contactors and
subcontractors to be registered with the Director ofHome Improvement Contractor Reestation. You may inquire about contactor
registration by writing to Ne Director at 10 Perk Plaza,Roost 5170,Boston,MA 02116 or by calling 617-973-8787 or 888.283-3757.
• T)oe.s rho contractor have insurana7 Ask the Contactor for his insurance company information so that you can confirm coverage,or ask to
see a copy of a proof ofinsurance"document
• Know your rights and responsibilities.Read the Important Information on the reverse side ofthis form and get a copy ofthe Consumer
Guide to the Home Improvement Contractor Law.
You may canal this agreement ifit has been signed at a place other Nes the contractor's aortal place ofbusiness,provided you notify the
contractor in writing*his kcr main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight ofthe
third business day foi)owing the Signing ofthis agreement See the attached notice of cancellation form for an explanation ofthis right
DO NOT,SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
TwoidwAdeaphaofOwconum utboeoapktednddRate Oooeop A=Wgotofth mwrc. rhaeftierowd-Mbe kW by the coanarWr.
Ho co er s Si --ceffmows signs—
Date
igns—Date Date
� i
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)if they have a dispute with a contractor. The same right is aZ automatically afforded to a
contractor,howftr. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both parties agreq to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerting this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A.
H wnees Contractor's SiguafiffC
NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not se arately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer
protection laws(to.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners
may be excluded-from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners whd secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvbment Contractor Law. The contractor is responsible for completing the work as described,in a
timely and workd.mlike manner. Homeowners may be entitled to other specific legal rights if the comrattor
guarantees or pr6$ides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts can an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your consunrer/homeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the document until all blank sections have been
filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to
be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing
and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of
the contract,and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deexxia him/herself to be financially insecure. However,in instances where a contractor deems him/herself
to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a j oint escrow
account as a prerequisite to continuing the contracted work Withdrawal of finds from said account would require the
signatures of boils parties.
Additional Infoi*atfon
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights,pr if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
i 10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,889-283-3757 or visit the OCABR website at ht p:#www.mass.trov/ocabr/
If you want to verify the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law,contact
Director ofHome Improvement Contractor Registration
` Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
.617-973-8787,888-283-3757 or visit the HIC website at hip://www.mass,Soy/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
httn://db.state.maus/homeimprovement/licenseelist.asn
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumes Complaint Section
't
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800,508-755-2548 or 413-734-3114
Vesion 2.1-1 r/22/2o10
• F
AL
CHELMSFORD FIREPLACE CENTER, LLG-.,-, �
7 Summer Street !- L ,t (�r
CHELMSFORD, MA 01824
www.cheimsfordfireplace.com �
TEL (978) 256-6328
FAX (978)250-9474 DATE PHONE f
EMAIL cheimfire@aol.com
TO ..m""'-"'�� 00f SHIP TO
V
CUSTOMER EMAIL
s s
on-
/ 1
r r
vj :r
d ,
f
No Refunds on Special Orders. No refunds after 30 days. j
Payment due upon time of order.
All dimensions given by customer are not the responsibility of C.F.C.
All permit fees and additional pipe extra.
Fireplace Width: Height: Depth: Rear Width: Rear Height:
Customer Signature:
JMM
He CommonweaM ofHassa0.asetts , -
))epartmentoflndtfsjWqtAecidiinis
. • Offlee o,f investigations
660 Washington Street
.Boston,MA 02111
-www.mass gov/dra
Worker$,Compensation fusurance MUM:BuRderalContracforsfElec-dolansi�lrrinbeKa
A. Ixcant MorwatiOn Plea;9e,Prxn e bXy
Name(Bnsinessiorgavi'aaaonlln&Idual). e�4 444-2�
Address: IV
City/Slate/gip:_ D 9 Co 7
.Are you an employer?Check the appropriate hox: Type of project(required):
1.❑ I am a employer with_ 4. ❑I am a general contractor and I 6. ❑New construction f
employees(fulland(oxpaxb time)* have loredthe sub-contractors
2.E] I am a sole proprietor or paztn.er
listed on the attached sheet T 7. Remodeling
ship and`haveno.employees These sub-contractors have 8. []Demolition
workers'comp.insurance. 9. Buildin addition
worl�.g for me in any capacity. ❑ g
[NO workers'comp.zo.surance 5. ❑We are a corporation and its 10[]Electrical repairs or additions
rred.� officers have exercised,their
et
3.Ela a a homeowner doing all work right of exemption per MOL 11..❑Plumbing repairs or additions
myself.EEO workers'comp. c.152,§1(4),andwehaveno 11[]Roofrepairs
insuxaucerequixed.]i employees.[No workers' 13.[]Otlier
comp.insurance required.]
Any applicantthat checks box#I mustalso X11 outthe section beiowshowingtheir workers'compensationpolicy information.
t Homeowners who submitthis af'f'idavit indicatingihey go doing all.work and then hire outside contractors must submit anew affidavit indicating such.
Tcontraetors that chackthis box must attached as additional sheet showkgthe name ofthe sub-coutractors andtheir workers'comp.policy information.
larnanemvloyeNtfiaiispYoviclingwoslkers'eornpexasatianinsumeef0frIlyernp10yees Bat 0wastliep0zieyan�jDi`xsite
infn:�mation. .
Insurance CompanyName; C�/�
Policy 0 or Selz"-ins.f dc. Expiration.Date:
lob Site Address: CitylState/Zip:
Attach a copy of tf.e workers'comp ensation-polxcy declaration page(showing•the 1rolicy number and expiration date).
I`ailure to secure coverage as requiredunder Section 25A.of MOL o.152 can lead to the imposition of eriminalpenalties ofa.
flue up to$1,500.00 and/or one=year imprisonment,as well as c101penalties in the form.of a STOP WORTS ORDER.and a fine
of-up to$250.0 0 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office flf:
Investigations of the DIA.for insurance,coverage verification.
do lZeieby CBPflfy undergeyairn andpenart`ies of pert ury Mat Me informailo7Zprovidedabove is ftue and correct. -
Sxnature T�
Data. L �(
—7C/�r
O�eial use axtly. Do not 1prite in ifils area,to be convIefed ry city o�totvr2 0 Mal
City or Town: I'ermitl>!Jicense#
Issuing Authority(circle One):
1.Board of Health 2.BuildingDepartmend 3.CityHown Clerk 4.Electrical.Inspector 5.Numbing Lspector
f.Other
Information and Instructions _
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuaait to this statute,an era is defured es"...evezp person:E th e service of another underany coriixact of hire;
express orhaplzed,oral Orwritten!,
Aa erfaployeu=is defned as"an individual,partnership,association,coxpoxation or otherlegal entity,or anyiwo oxmoxe•
'Of tbeoxegoingengage dinajointenterprise,
and includingtlie,legalxepxesentativesofwdeceasedem To ex,ortbe
receiver ou trustee of an individual,partnership,association or other legal entity,employing employeeg. Sowevex the
owner of a dwelling house having not Moro than three apartments encs and who resides therein,or the o ccupant wavy
dwelliaug 7iouse of another who employs persons to do ofthe
maintenance,construction or repair work on suds dwelling house
or au the grounds or building appurtenant thereto SM not because of such employ nentbe doomed to be an employer:"
MGL chapter 152,§25C(6)als o slates that"every state or Weal Incensing 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 hasnot produced-acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states `Neitherthe eommonwealthnox any ofits political subdivisions shall
enter into any contract for the performance ofpublic workuntil acceptable evidence of compliance with the insurance
requirements Of Us chapter have b can presented to the contracting authority."
Applicants
Please fill out the workers'compensalzon affidavit completely,by checking the boxes that apply to your situation and,ii
necessary,supply sub-conixactor(s)name(s),addresses)and phonenumber(s)along-with their certiixcafe(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other thata,the
members orpartners,are notrequired to carry workers'compensation insurance. IfanLL C orLLP does have
employees,apolicyisxequired. Be advisedthatthis afddavitmaybe submittedto the Department of TndustM
Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. ilia affidavit should
ba retumed to the city or town that the application for the peumit or license is being requested,pot the Devaartment of
Industrial Accidenfs. Should you have any questions regarding the law or if you are xegaired to obtain,a*arkers'
comp ensation policy,please call the Department at the number listed below. Self insured companies should enter their
self iusurance license number on the appropriate line.
City or Town Officials
Pleasebe suxe thatthe af,".zdavit is complete audpxinted legibly. The,Department has provided a space at the bottom
of the aflzdavit foxyou to fill out in the event the Office of Investigatioaus has to contact you regarding the applicant.
Please be-sure to fill iuthe permit/license number whichwill be used as a reference number. In addition,an applicant
thatmust submitmultiple permit/license applications:h any given year,need only submit one affidavit indicating current
policy iuformation(ifuccessary)and under"Job Site Address"the applicant shouldwrite"all locations in (city ox
towtl)."A copy of flie affidavit that has been officially stamped or marked by:the city or town,may be provided to the
applicant asproof that a valid affxdavit•is on fie�'ox future p emsits or licenses. Anew affidavit must be filed out each
year.-Where a 7rome owner or citizen is obtaining a license ox permit not related to any business or commercial venture
Q.e.a dog license orpermit to burn leaves eta.)said person is NOT required to complete fhis affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and shQuld you have any questions,
Please do not:hesitate to give us a,all.
The Department's address,telephone and fax numb er:
Tho CQ Oz-W0am ofS�0agarhwetts -
Depa e t Q S du tx aY cc cle4--t
• t�£l�c�o�'I'uv��tx�a�un.�
• �Q(��as�a�ng�atZ��re�t
T01 617H7-2`L-4900 W406 Q-r 1-877-9 _
P.evised 5 26-054
«4010 Jotul C 550 CB Clearance
J�TUL
Revision
July 24,2014
As a result of Jotul product modifications and certified Clearance Reduction Kit 157705
testing by Intertek Testing Services,Inc.,the following This kit is available at no charge to field-update
clearance specifications supercede those previously C 550 inserts having serial numbers prior to 11903.
published.Stoves having serial numbers beginning The kit includes a shroud extension,fasteners,a new
with 11903 may be installed to these new clearance Owner's Manual,Approval Label,and kit installation
specifications without further modification.These instructions.Contact your Account Manager to order.
units will be clearly identified on the shipping crate.
Minimum Clearances Mantel Clearances
All clearance specifications are approved for both The installation must conform to the minimum mantel
the U.S.and Canada,except as noted.Clearances clearances specified in the chart below.These clearances
are measured from the hearth surface,door open- may be reduced with installation of Jotul Mantel Heat
ing,or centerline as noted below. Shield 156448 as specified in the chart.Clearance
reduction to mantel construction may also be made in
conformance to NFPA 211 or CAN/CSA B365.
A: Hearth Protection,width from centerline:..........
.........................................................181/2"(470 mm) i
B: Hearth Protection,forward from door opening:
...................................US:16"/ CAN:20"(5o8 mm)
C:To Side Trim, from centerline 3.5`
<1"thick................................................ 213/4„(552 mm) 5.5^
>or=to 1"to 6"max.thickness.....23"(584mm) A 95
D:To Side Room Wall,from centerline.....28"(711 mm) B 115
E:To Top Trim,1"max.thickness,from hearth:
... ..1
...............................................................39" 991 mm
F:To Mantel,31/2"max.depth,from hearth: D
........40"(1o6o mm)
To Mantel,111/2"max.depth,from hearth
... 46"(1168 mm)
See fig.2 for clearances with Mantel Heat Shield. a
e •i
_ Figure 2.Mantel Clearance Detail-measured
from
the hearth surface to the lowest mantel surface.
i F A B C D E
I e E
46" 441/2" 43" 411/2" 40"
i , 116.8 cm 113 cm 109.2 cm 105.4 cm 1o1.6 cm
c With Mantel Heat Shield 156448
43 411/2" 40" 381/2" 37•'
�4. \ 109.2 cm 105.4 cm 1o1.6 cm 97.8 cm 94 cm
Figure 1. Minimum clearance to combustible materials. NOTE.Installation of the Mantel Heat Shield oes not
permit clearance reduction to Top Trim as designated
in Figure 1.
7
1 Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialty
License: CSSL-100468 £.-
Stephen A Brissette-`
291 W.Erie Street
Manchester NH 63102.
Expiration
Commissioner 04/23/2016
Office of Consumer Affairs and usiness Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement-Contractor Registration
Registration: 152802
Type: Individual
Expiration: 10/212014 Tr# 231608
STEPHEN BRISSETTE
STEPHEN BRISSETTE -
291 WEST ERIE ST.
MANCHESTER, NH 03102
Update Address and return card.Mark reason for change.
Address rJ Renewal ❑ Employment ❑ Lost Card
)PS-CAI is 5oM-04104-6101216
✓Z. _ License or registration valid for individul use only
n.'.� Office of Consumer Affairs&Bdsiness Regulation
before the expiration date. If found return to:
49 HOME IMPROVEMENT CONTRACTOR
=_ Office of Consumer Affairs and Business Regulation
Registration: 152802 _ Type:
�., 10 Park Plaza-Suite 5170
Expiration: 90/2/2014 Individual Boston,MA 02116
STEPHEN BRISSETTE
STEPHEN BRISSETTE /
291 WEST ERIE ST.
MANCHESTER,NH 03102 Undersecretary Not valid without signature
08/07/2014 16:09 FAX 6036410222 FOY INS MANCHESTER 10001
;1"7/2014
QE(MMIDOMM)
A� CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE iOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY fHE 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(IGS)must be endon;ed. If SUBROGATION IS WAITED,subject to
the terms and conditions of the policy,Certain policies may require an endorsement. A statement on this Certificate does not Con4er rights to the
certificate holder in lieu of Such endorsement's). CONTA Jeeso Gas'main
PRODUCER Me' AX
PHONE (509)641-8111 .161 31 641-980 9
Foy Insurance Group - Manchester E-MAIL
1899 Elm St NAIC0
INSURE S AFFORDING COVERAGE
Manchester NH 03104 INSURER A Oerchants M1ltual Insurance 23329
INSURER B
INSURED
STEPHEN BRISSETTE INSURERC:
291 WSST £RIE STREET INSURER D:
INSURER E:
MANCHESTER NH 0JI02-5058 INSURER REVISION NUMBER:
COVERAGES CERTIFICATE NUMBER:CLi47233581
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 OLL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED OU CY Epp Y PPO ICYY AID II PS LIMITSIl SR A POLICY NUM a
TYPE Of INSURANCE RRENCE 1,000,0001
EACH OCCU9
GENERAL LIABILITY 500,000
PR ■0 co
X COMMERCIAL GENERAL LIABILITY /11/2014 /11/2015 MEO FXp One orsan I 15,000
JAML IX
CLAIMS-MADE J OCCUR OP9097148
PERSONAL 6 ADV INJURY 1,OOO,OOO
X 3/U 82 77 11 11
GENERAL AGGREGATE 2,000,000
PRODUCTS-COMPIOP AGG ;< 21000,000
GENL AGGREGATE LIMIT APPLIES PER
X POLICY PRO [71 LOC COMBI, SINGLE L IT
AU70MOBILELIAMUTY cAa ' 1.0110.000
BODILY INJURY(Per Person) I
A ANY AUTOINJ
ALLOW OWNED X SCHEDULED IOd0224 30/21/2013 0/21/2014 BODILYURY(Per ecOWen!) I
UTOSNON-OWNED -PROPERTY
AMAGE I
X accidal
MIRED AUTOS X AUTOS 1
X Comb$250 X Coll$500 Medicala morns 5000
UMBRELLA UABOCCUR EACH OCCURRENCE $
EXCESS IJAa HCLAIMS-MADE AOGREGATE f
s
DEC) I I RETENTIONSX VJC STATU- OTH-
A WORKERS COMPENSATION
AND eMPLOYERS'LIABILITY A State NN E.L.EACH ACCIDENT 8 500.000
ANY PROPRIETOMPARTNERIEXECUTIVE NN N I A
OFFICERIMEMBER EXCI.UDED7 ❑ !033879 0/4/2013 0/4/2014 E L DISEASE-EA EMPLOYE - 500,000
(Mandatory In NH)
,,go,dacglpe under E.L.DISEASE-POLICY LIMIT S 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IAImoh ACORD 101,Addalonal Romana Selledula•N Tore apeaa Is esquirod)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Jeremy Rochoford
960 Johnson Street AUTHORIZED REPRESENTATIVE
N. Andover, Mik
Lisa BiSSOn/MMACY
ACORD 25(2010106) Q1988-2010 ACORD CORPORATION. All tights reserved.
INS025(2010os1•o1 The ACORD name and logo are registered marks of ACORD
RTH
Town of s ndover
O ;' to
No.
2 Ih ver, Mass
o .
coc Nlc KtwlcK y1•
�.9 A,0RArEc rPP��S
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT D Septic System
THIS CERTIFIES THAT ....... ,.,,,��,.... BUILDING INSPECTOR
...... .. . .. ... ............ .... ..... . .
has permission to erect .. .... buildings on ..... . Foundation
11110 Rough
ie w; 1111
to be occupied as .......kW.�.Q... . .. ............ ........... .. .. .. . .... .....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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
V • UNLESS CONSTRUCTION T 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.