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Miscellaneous - 130 LACONIA CIRCLE 4/30/2018
130 LACONIA CIRCLE 210/105.D-0160-0000.0 i L i I. I 1 APO Box 55098 Boston,MA 02205-5098 617-951-0600 Form of Notice of Casualty Loss to Building 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 ,. RE: Insured: GREGORY J SCHMIDT and DEBORAH L SCHMIDT Property Address: 130 LACONIA CIR,NORTH ANDOVER, MA Policy Number: HMA 0003843 Claim Number: BOS00055420 Date of Loss: 3/12/2015 Company: Safety Indemnity Insurance Company 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. Joshua Terenzoni Claim Examiner 3/13/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3287 Fax: (617) 531-6648 :Xmail:-'J6sh.uaTe'renzoni@Safetylnsurance.com I I Date....... t%OR 0 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING U "SACHU This certifies that ..................j....(?..8.4........ .. . has permission to perform ............:5g ...PC �&—!5&....... wiring in the building of...................5-ch.m.l..'07.............................. at.... .......................... .. .orth Andover,Mass. Fee... NoAs..9. 33............. . .... ............. ........ ELECTRICAL INSPECTOR Check # -Z 7988 , Y Commonwealth of Massachusetts Official Use Onl Department of Fire Services Permit No. Occupancy and-Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: ' City or Town of: NORTH ANDOVER To the Inspector of 'res: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 13 D Owner or Tenant I' �t{' S;4t,it Telephone No. 0240 Owner's Address Is this permit in conjunction with buildin ermit? Yes No ❑ (Check Appropriate Box) Purpose of Building 3%fl Utility Authorization No. Existing Service Amps / VoltsV Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: `t '� S �� dam;k +sw ' —Completion o the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators K A No.of Luminaires Swimming Pool Above ❑ In- ❑ o,o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and TotInitiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection El Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of Devices or Equivalent i Heaters KW Ao.of No Signs Ballasts Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent • OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lectrical Work: (When required by municipal policy.) Work to Start: Z/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C 6VERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains a e penalties of per'ury, that the information on this application is true and complet FIRM NAME: 'Ju 6A ,�,) LIC.No. Licensee: Signature LIC.NO.: (If applicable, enter,"exem in th license number li JW Address: a(; �{ �t Bus.Tel.No.. *Per M.G.L c. 147,s. 57-61,security wor requires Department of Public Safety"S"License: Alt.L cl.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ��v Date.9:-.�.,R . TN TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING 41 SS CHUS This certifies that . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . has permission to perfornj,4�-r - . . . . . . . . . . . . . . . . . . plumbing in the buil Ings of . . . . . . . . . . . . . . . at . . . . . . . .. a444-!North Andover, Mass. Fee./.`�/�. . .Lic. -eLUMBINIG'AN PECTOR Check # 5729 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date -2Z-43 Building Permit# (-5-70c? a� Amount Type of Occupancy rEGA bE Ali IAL New Renovation ® Replacement ® Plans Submitted,.Xes ❑ No FIXTURES I z H a � w W p; A W W � E.. En M W aPik (A 0( a d SuMea UNDERGWI MRM 2MRUR 2 31M IrIOQ2 4IH FUM SII3 FIDQ2 61H ROM MRfM r SIH HOQ2 (Print,or type) Check one: Certificate Installing Company Name N U�g P LV M iz 1 h jG t lA e kT I a Corp. Address 2`1 S `)R OW I,d4 0a. El Partner. 4Z1L1_'1?I�jP_i �g ntAi�L Business Telephone� ® Finn/Co. i Name of Licensed Plumber: Insurance Coverage: Indicat the type of insurance coverage byc hecking the appropriate box: t Liability insurance policy Other type of indemnity ❑ Bond 0 Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusettsto Plum 'ng Code and Chapter 142 of the General Laws. By igna icens um e Type Plumbing Lice se Title City/Town 1.1cense Numuer Master ® Journeyman APPROVED(OFFICE USE ONLY Date... � .......J�...... i NORTH °`� °:•'"° TOWN OF NORTH ANDOVER A PERMIT FOR WIRING i r s ° �p•'s ' ,SSACNUSEt This certifies that ........< �... � has permission to perform .. c-... ........................................... wiring in the building of �f IV at../,:,?Q....Zllr( 1'!1......(� C C.�........,North Andover,Mass. -a Fee. 07:)...... Lic.No.L......4'..��Y.............. .:....... - ELE RICALINSPECTOI( Check # 3�— 4795 HE COMMONVW LTH OF MASSACHUSETTS pOffice Use only DEPARTAMW0FPUX1CS4FE7Y Permit No. 7 7 BOARD OFFMPREVEWONREGUMHONSR7 CARI2. Occupancy&Fees Checked APPLICA77ONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ' Ct: Town of North Andover To the Inspector of Wire, The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) `ACQN/l? Owner or Tenant Owner's Address /,3n / AC d/ViA r f/'t'Ito Is this permit in conjunction with a building permit: Yes rn No r7 (Check Appropriate Box) Purpose of Building S,4 th h/R, �,9f fl/'�'FB,��j, �Er jl/OC��/fj,¢J7/' �OUtility Authorization No. Existin Service a o d Amps 4 /o? Volts Overhead a Underground No. of Meters J C /00 Amps 12c/zce- Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work G/I Q lNb f JFLl2° Newl�F9I°I17101h /6o gyy,4, !li6- /fit-�'L No.of Lighting Outlets No.ofki96.T No.of Transformers Total -TACQ 7L S KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground F1 ground No.of Receptacle OutletsO No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch t"4vrts as 3D No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER. Insura=Cowrage RusumittoftleWmriaits ofMas�sGarralLam Dave aomeitLiaaflitylrlsura=PbllcyinchdmgComplee Ckwations CoveWoritsskswtialegtuvalait YES NO Ihav&afti tedvandpoofofsmmtotheOf5ice_YES ' r/ ' If}ouhawdtedcedYES, ofcov>rage�by checking the INK ANCELL] x BOND Q MHR (P1ewespecafy) lWe77t15P-& L�IV S/ ExpirationDate WotktoSart 10170 EMma1edValveofD�calWotk$ h>SpectionDweRapes1Ed Roux Zziitl C46L Final eyi SignedundaTe tiesof FIRM NAAE A014 A A) 7t rl-.tem -QP Q-A' .9 L Iimw lam. 95;?6 U y sofflsee D!4/ GA/ T-S-ri, --fr/9N Signatuue � ` �- LK=wNo 01,P BusitmTelNo. g2 F;7 -Si��' Vldiess. 2d Ae tilv A /fie, AIL Tel.No.ThiQ �+; �i ��y )WNER'SINSURANCEWANER Iamawarethatthel.icatsedoesnothavethemstuanmcoverageoritssitLsanWquvakntasiegmedbyMassachusemGaetalLaws nd that my sig name on this penrvt application waives this requirement. Please check one) Owner ® Agent Telephone No. PERMIT FEE$ Signature ot Uwner or Agent W The Commonwealth of Massachusetts d Department of Industrial Accidents FQ Office of investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone# Insurance.Co. Policv#' Company name: Address City: Phone# Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,5oo.00 and/or one years'imprisonment_as_well_as_civil.penattiesinsheform-cfa_STOP WORK ORDER w.d_a fine_of-($1DO-0D)-a-day against-in e. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. !do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name P_hone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check d immediate response is required Ei Licensing Board Ei Selectman's Office Contact person: Phone#: ❑ Health Department Ei Other Location 13 0 1,4CUNi a � ol No. / Date �/c�U0A a MORTq TOWN OF NORTH ANDOVER 0: .ao ,•,bG � a ♦ • • � ; , Certificate of Occupancy $ �, ._�_:.. �• a �'� CM�s t Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /a b d f r Check # c)9 to ` a Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. // n DATE ISSUED: SIGNATURE- Building CommissionEjEtEtor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions:CL \ f �) t , �sf'�nCr ` 3,52°7 Zoning District Proposed Use Lot Ar seaLot sea� Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required I Provided Required Provided .301 jq5, 3o ., 1 :35 30 ` to ' Z 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: T Public .W Private ❑ Zone Outside Flood Zone Municipal ❑ On Site Disposal System SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Cr rc� �i-1���ap��• .j �,wl 1 r,� f � f �,�c��j��J'�, Aa- '4�J, �1 c Name(Print) Address for Service: \(�� Signature Telephone c 2.2 Owner of Record: Name Print Address for Service: tr z M Signature Tele hone go SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ ) Licensed Construction Supervisor: C j 6 p2 17 1901v_�Ie't 018/o License Number Mn Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Cotopany Name ` Registration Number �' /.�atr�/�-f' ST. �/Cly �h�GL�Y ��, � � AdIress rn�s /l 774 00 / Expiration Date /� Signature Telephone Y/ 1 1 J SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes...... No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building Repair(s) -6—P eTations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: et- SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIALXSE-ONLY Completed by pennit applicant - 1. Building $ y (a) Building Permit Fee Multiplier 2 Electrical ��OG (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC / C'R '(0 p 5 Fire Pro tion , ! 6 ;6eta1-. f#N-3*4*'5 ""r' Check Number SECTION 7a TmikizATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �J-r� ,J_�G� iJ as Owner/Authorized Agent of subject property Hereby authorize /M :jam.. �u�yl,��l �j'e5 � i f✓ ' act on My behalf, all matters rela've vyor horized Ky this building permit application. '�5`s/o 3 Signature of Own'eiV Date SECTION 7b OWNER/AUTH/ORIZED AGENT DECLARJATION I, //�G,h•. /ZY/1 � / 1S/ as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/AenntDate u lam, I .._ 7, NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS 1� DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING x MATERIAL OF CHEVMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE y LOT RELEASE FORM INSTRUCTIONS: This for i used to verify that all necessary approvals/permi ts fro Boards and Departments vl jurisdiction have been obtained. This does not relieve the applicant and/or lando from compliance with any applicable or requirements. e ***********APPLICANT FILLS OUT THIS SECTION APPLICANT v PHONE ,/'_ ,7e LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT(S) STREET 2616<21",?. 7 ST. NUMBER / 3� *OFFICIAL USE ONLY REC MENDATION. TOWN AGENTS: CONSERVATION ADMINIS ATOR DATE APPROVED 1 D� DATE REJECTED COMMENTS TOVIfN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD I.NSPE O HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE-11REjECTED- COMMENTS PUBLIC WORKS-SEWER/WATER CONFECTIONS DRIVEWAY PERMIT = FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9W jm FORM U LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary Boards and Departments having jurisdiction have been obtain da Th s does notlrs from Ve the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION APPLICANT G�^PTc�G G y�, PHON -2a5*-6©,�, LOCATION: Assessor's Map Number PARCEL /6 0 SUBDIVISION LOT(S) STREET _ G.®iCO lr^ CI►�G Y, ST.NUMBER / 3® OFFICIAL USE ONLY******"***"--******* �R:EC MENDATIONS, TOWN AGENTS: CONSERVATION ADMINI ATOR DATE APPROVED DATE REJECTED COMMENT S �ro. c� TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPE O HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR—HEALTH _DATE APPROVED ! DATE REJECTED_°?^� Q COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR • DATE----. Revised 9197 jm e l - ,• ��� �, sc+ rT �s 1tloob � t tm t t . 4_�, '�>77' 43 i t iI�IG�le�l�y �011t7171 o� ��co�st7 I.�cdW�n Prudential Home Mortgage AND ITS 1111E INSURERS. MORTGAGE INSPECTION FLAN Lo"Im IN I CERTIFY THAT THE BUILDINGS SHOWN DO ( ) CONFORM TO SETBACK REQUIREMENTS - I.E. (FRONT, SIDE, 4 REAR SETBACK ONLY) OF North Andover N 0 R T H A N D D V E R TTIHEN IREE MI- CHAPTERP40A. SECTION SEo11�TFROM UNLESSS VIOLATION ENFORCEMENT NOTED ENT AcnoN UNDER MASS. c.L MASSACNUSMS I FURTHER CERTIFY THAT THIS PROPERTY IS not LOCATED iN THE ESTABLISHED FLOOD l HAZARD AREA'COMMUNITY PANEL NO.: 250098 009 C DATE: 6/2/93 DEED THIS COMPANY IS NOT RESPONSIBLE FOR ANY INDENTURES MADE SUBSEQUENT TO THE RECORDED BOOK 2376 DATE OF THE LATEST DEED OF RECORD. PAS _ -3-39 WHENEVER BUILDINGS ARE SHOWN LESS THAN ONE FOOT FROM THE PROPERTY UNE IT IS ADVISED THN AT A MORE PRECISE SURVEY BE MADE TO VERIFY THESE MEASUREMENTS. SRT N0. ., THIS CERTIFICATION IS BASED ON THE LOCATION OF SURV41~"a MARKER TNERS, AND DOES NOT PLM! BK. PACE REPPESENT A PROPERTY SURVEY. VERIFICATION OF SURAY M I OFFSETS, AS SHOWN, ((]]p�CC MAY BE ACCOMPUSHED ONLY BY AN ACCURATE, INSTRUMENTt (}( I(y►�S\ PLM! / 985 7 DATED THIS CERTIFICATION TO BE USED FOR OR URPOS ,r Y. At�gt�S _ IoJo�S OFFSETS AS SHOWN ARE � B " ` USED FOR THE ESTABLISHMENT 0 PE E �_� SCALE 1 " 40 ' a°11Ci1a�' ` ' CAT BRADFORD ` ENGINEERING CO. �,•�� �� t�\'�{�y^' ` '•'rte "; i P.O. BOX 1244 JAMES W. BOUGIOUKAS R,L,g' #9529 HAVERHILL MA. 01831 TEL (508) 373-23H I North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit j Number is that.the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A., The debris will be disposed of in: (Locatio of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector I I MAScheck COMPLIANCE REPORT I Massachusetts Energy Code I Permit # I MAScheck Software Version 2.01 Release 3 I I I I I Checked by/Date l i I CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 6-10-2003 DATE OF PLANS: 6/1/03 PROJECT INFORMATION: Schmidt Residence 130 Laconia 'Circle No. Andover, Ma COMPANY INFORMATION: EMH Consruction Corp 9 Bartlet St # 102 Andover, Ma. COMPLIANCE: Passes Maximum UA = 179 Your Home = 178 Area or Cavity Cont. Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 480 30.0 0.0 17 WALLS: Wood Frame, 16" O.C. 1024 13.0 0.0 84 GLAZING: Windows or Doors 132 0.340 45 DOORS 25 0.340 9 FLOORS: Over Unconditioned Space 480 19.0 0.0 23 ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. Builder/Designer � / �h�� ('/"�/ / Y Date S _� i e � Thee Commonwealth of 9b=achusetts Department of IndustridfAccidents 0 f a of Investigations 600 Washgton Street (Boston, WA 02111 Workers'Compensation Insurance Afndavit APPLICANT INFORMATION Please PRINT Legibly Name: Location: City; Telephone#: ❑ I am a homeowner performing all work myself. ❑ I am sole proprietor and have no one working in my capacity I am an employer providing workers' compensation for my employees working on this job K/hy Company Name: 60415 6r4/611L4) Address: "/ /7�Y%lPi� F " _*/0,9L C City: Telephone#: � mss/ 7 l `&9L O_3 Insurance Company: Ll /-L L Policy#: 3Z 7 Y W 507 U 6 ❑ I am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: - Company Name: Address: City: Telephone#: Insurance Company: Policy#: Company Name: Address: City: Telephone#: Insurance Company: Policy#: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains andpenalties OfReerjury that the information above is true and correct. ? Signature: <^-� �V Date: Print Name: Phone# 17 S Z"` 7 81�3 _ Official Use ONLY-Do not write in this area ❑Building Department City or Town: Permit/License#: ❑Licensing Board C)Selectmen's Office o Health Department o Check if Immediate response is required ❑Other l 1 INFORMATION &INSTRUCTIONS . Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, 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 in the workers' compensation affidavit completely, by checking the.box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the . Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' .compensation policy,please call the Department at the number listed below. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Fax# (617) 727-7749 Telephone# (617) 727-4900 ext. 406, 409, or 375 i3 o CAC z BOARD OF BUILDING REGULATIONS est License: CONSTRUCTION SUPERVISOR Number: CS 052262 Birthdate: 05/14/1959 Expires:05/14/2005 Tr.no: 11053 Restricted: 00 WILLIAM A HURLEY- �� 9 BARTLETT ST#102 C4.1-+ ANDOVER, MA 01810 Administrator ✓lie{nom�wm�rea�i a�,./�iaaac/%uae�Ia Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registrittion: 106898 Expiration- 7128/2004 Type: Private Corporation E.M.H.CONSTRUCTION CO. William Hurley 9 Bartlett Street,Suite 102 ,, Andover,MA 01810 Administrator I CERT/F/ED FOUNDA7/ON PLAN LOCATED IN - SCALE.%"= S.L.GILES R.L.S. LAWRENCE a NORTH ANDOVER I' A � , bT b ••"� pp RE C,Ell, BUILMNG !X: i T 1 of � M N m �bQ 1 tf,, Dp R = 6's. / CERT/FY THAT THE OFFSETS SHOWN ARE FOR THE USE OF u ; OFFSETS SHOWN THE BUIL DING INSPECTOR ONL Ya SUCH ' ✓ CONFORM TO THE USE IS FOR DETERMINATION OFZON/NG = 3077 ZONING B Y L A W OF CONFORMITY OR NON CONFORMITY yJor�,—�► �a az WHEN TAKEN. sho wing "As —Built " Site Conditions r LOT# S LACONIA C Prepared For Roberto Goldschneider Scale 1" = 40' Dote: November 11, 1993 Zoning District: R— I Residence 1 Dis tric t (previously Approved Subdivision Under R--2 Zoning May 29, 1985 f Note: This plan has been prepared to occompony o request for a certificate of compliance to the North Andover Conservation Commission under the D.E.P. number 242-257 No te.• Property Line Data Taken From A Plan By Thomas E. Neve Associates, Inc. Doted January 3, 1985 and revised to May 29, 1985 l Hereby Certify That The Dwelling On This Property /s Located As Shown On Plans And Complies With The Zoning Requirements Of The To wn Of North Andover, Mass. `.c Re s ePtd`L Surveyor q In My Opinion, This Dwelling /s No t /n A Flood Hazord Zone As Shown On The U.S.D.H.U.D. Flood Hazard Boundry Maps. Thomas E. Neve Associates, Inc. Enginneers — Surveyors — Land Use Planners 447 Old Boston Road — U.S. Route 1 Topsfield, Massachusetts 01983 887-8586 Job #1250 41.0 St-d 1 t �t'Oj �t'�� L 41"Gt j ' G d Wre6oll-t Gt t3 1 b2C--G4.d-bE13 5c14mI01- mod. lot- 130 LAGalu1A G t AUt Cr t i� No- AIVOOVEK IPA I , .Z ' jcir 61VAPO� H-11 FAIL.-Y.AM stst► A►oMo c 1'� !y,i wJ�J1J•{r• Z Y � Baa •' � 1 _ � . �-- Q5 ' i _ , XAORTFj Tovm Of Andover 0-1-17'1-....... ..... lit No. �/ z 8—/l�—a p03 dover, Mas oc I I A S*p A COCHiCNIC90 ORATED P? BARD OF HEALTH Food/4tchen' PERM IT T D Septic System BUILDING INSPECTOR ... ........... .................. .... THIS CERTIFIES THAT.......(3 .............. ........................................................................... Foundation Rp yo I rjv / & 0, '*C-A..' has permission to erect........ ...................<7(... buildings on ...;.......130 ................... ........................ Rough to be occupied as.... Adel,, Chimney provided that the person accepting is permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relaling 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 PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough Service ....................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. Town of North Andover f NORTH q E� HD I° Office of the Health Department :'° Community Development and Services Division William J.Scott,Division.Director �ro4q<��-�• � 27 Charles Street �9Sq�H„S 4 North Andover,Massachusetts 01845 Sandra Starr Telephone(978)688-9540 Health Director Fax(978)688-9542 Mr. Gregg Schmidt 130 Laconia Circle North Andover,MA 01845 Re: Application for: 2"d Floor Addition Dear Mr. Schmidt: Your application for an addition at 130 Laconia Circle has been reviewed by the Health Department. The application was denied on July 3,2003 for the following reasons: 1. J Missing information 2. J Passing Title 5.inspection of septic system required—chances are that the current system is too small. 3. ❑ Location of structure not acceptable To address the problem(s): 9#1 is checked,please supply: a. Floor plan of existing and proposed addition—all rooms b. Certified plot plan showing house,septic system and proposed project in scale N#2 is checked: a. d Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If#3 is checked: a. Relocate the project Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Reviewer Cc: Building Department File BOARD OF APPEALS 688-954.1 BUILDTNG 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PL.ANTNING 688-9535 Date. /. �.G. .?. . .. .. TH Of NOR11' o� 6TOWN OF NORTH ANDOVER P ~ p ' PERMIT FOR GAS INSTALLATION 9 t. �9SSACMUSESS This certifies that . . L . . ..`.. .. ... t. . . .. . . . . . . . . . . . . . . . has permission for gas installation / . . . :':' `.` . . . . . . . . . . in the buildings of . . Sc. �.�? : r(... . . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. Fee. .�?-. :. . . Lic. No.?./2. '. . . . . . .� �:° t�Y?. . . . . . . . GAS INSPECTOR Check# VVV 4180 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date �GP-4�. 'ermit # Y(}PU Building LocationISOAde,01V14 �f6' Owner's N ma e !KL �C:`� "� t Type /Occu pan cy 4�a/WeAl:)1/,�/ LNew ElRenovation ❑ Replacement C;1� Plans Submitted: Yes ❑ No [:1 FIXTURES to NW U. � ]4Z tY to n U of LW Uj VW H W O V fb Z z O OC Q z 2 0 W W z F- z J n ¢ U U W 2 Z OF O oe > W W W N Z Q = N W W OC ~ Y U ~ ~ Z r FW` W 0 z Q W WU J Vf W Q LU . oe W 2 Z Q iY Q 0° O O W 0 s^ F z S O U = W 0 U U ce > O a 1W O ' I SUB-BSMT. BASEMENT 1st FLOOR 2nd FLOOR 3rd FLOOR 4th FLOOR 5th FLOOR 6th FLOOR 7th FLOOR 8th FLOOR Installing Company NameGLIMATE DESIGN' Check one: Certificate Address 7 '_' Corporation y 1/.3 Cy Haverhill, MA 01830(978) 372-9999 Partnership Business Telephone Lic. Plumber: Michael H House Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of,11GL Ch. 142. Yes 7�e- No C If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity G Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hereby certify that all of the details and information I have submitted for entered)in the above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 14 of the General-Laws. type of License: 8Y , _Plumber =Gasfiner Tule SAaster Signature o licensed Plumber or Gas fine Journeyman / City/Town License Nu ber / APPROVED(OFFICE USE ONLY) t FINAL INSPECTIONS SKETCHES BELOW FOR OFFICE USE ONLY PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME & TYPE Of BUILDING LOCATION OF BUILDING ati PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED Date 19 Gas Merc. final Insp. Gas Inspector do io Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form Z — Determination of Applicability 1 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 i A. General Information Important: When filling out From: forms on the North Andover computer, use . Conservation Commission only the tab key to move To: Applicant Property Owner your cursor- p y (if different from applicant): do not use the Deborah Schmidt SAME return key. Name Name 60 130 Laconia Circle Mairmg Address Mailing Address North Andover MA 01845 Crtyffmn state Zip Code citylrmn State Zip Code 1. Title and Date (or Revised Date if applicable) of Final Plans and Other Documents: RDA application 6/26/03 Title Date Site Plan 6/26/03 Title Date Title Date 2. Date Request Filed: 6/27/03 B. Determination Pursuant to the authority of M.G.L. c. 131, §40, the Conservation Commission considered your Request for Determination of Applicability, with its supporting documentation, and made the following Determination. Project Description (if applicable): Construction of an addition to an existing single family home located in the buffer zone to bordering vegetated wetland. Project Location: 130 Laconia Circle North Andover Street Address cityrrown 105D 160 Assessors Map/Plat Number Parcel/Lot Number wpaform2.doc•rev.12/15/00 Page 1 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection _Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) The following Determination(s) is/are applicable to the proposed site and/or project relative to the Wetlands Protection Act and regulations: Positive Determination Note: No work within the jurisdiction of the Wetlands Protection Act may proceed until a final Order of Conditions (issued following submittal of a Notice of Intent or Abbreviated Notice of Intent) has been received from the issuing authority(i.e.,'Conservation Commission or the Department of Environmental Protection). ❑ 1. The area described on the referenced plan(s) is an area subject to protection under the Act. Removing, filling, dredging, or altering of the area requires the filing of a Notice of Intent. ❑ 2a. The boundary delineations of the following resource areas described on the referenced plan(s) are confirmed as accurate. Therefore,the resource area boundaries confirmed in this Determination are binding as to all decisions rendered pursuant to the Wetlands Protection Act and its regulations regarding such boundaries for as long as this Determination is valid. ❑ 2b. The boundaries of resource areas listed below are not confirmed by this Determination, regardless of whether such boundaries are contained on the plans attached to this Determination or to the Request for Determination. ❑ 3. The worts described on referenced plan(s) and document(s) is within an area subject to protection under the Act and will remove, fill, dredge, or alter that area. Therefore, said work requires the filing of a Notice of Intent. ❑ 4. The work described on referenced plan(s) and document(s) is within the Buffer Zone and will alter an Area subject to protection under the Act. Therefore, said worts requires the filing of a Notice of Intent. ❑ 5. The area and/or work described on referenced plan(s) and document(s)is subject to review and approval by: Name of Municipality Pursuant to the following municipal wetland ordinance or bylaw: Name Ordinance or Bylaw Citation wpaform2.doc•rev.12/15/00 Page 2 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) ❑ 6. The following area and/or work, if any, is subject to a municipal ordinance or bylaw but not subject to the Massachusetts Wetlands Protection Act: ❑ 7.if a Notice of Intent is filed for the work in the Riverfront Area described on referenced plan(s) and document(s), which includes all or part of the work described in the Request, the applicant must consider the following alternatives. (Refer to the wetland regulations at 10.58(4)c. for more information about the scope of a#ematives requirements): ❑ Alternatives limited to the lot on which the project is located. ❑ Alternatives limited to the lot on which the project is located, the subdivided lots, and any adjacent lots formerly or presently owned by the same owner. ❑ Alternatives limited to the original parcel on which the project is located,the subdivided parcels, any adjacent parcels, and any other land which can reasonably be obtained within the municipality. El Alternatives extend to any sites which can reasonably be obtained within the appropriate region of the state. Negative Determination Note: No further action under the Wetlands Protection Act is required by the applicant. However, if the Department is requested to issue a Superseding Determination of Applicability,work may not proceed on this project unless the Department fails to act on such request within 35 days of the date the request is post-marked for certified mail or hand delivered to the Department. Work may then proceed at the owner's risk only upon notice to the Department and to the Conservation Commission. Requirements for requests for Superseding Determinations are listed at the end of this document. ❑ 1. The area described in the Request is not an area subject to protection under the Act or the Buffer Zone. ❑ 2. The work described in the Request is within an area subject to protection under the Act, but will not remove, fill, dredge, or alter that area. Therefore, said work does not require the filing of a Notice of Intent. ® 3. The work described in the Request is within the Buffer Zone, as defined in the regulations, but will not after an Area subject to protection under the Act. Therefore,said work does not require the filing of a Notice of Intent, subject to the following conditions(if any). See attached ❑ 4. The work described in the Request is not within an Area subject to protection under the Act (including the Buffer Zone). Therefore, said work does not require the filing of a Notice of Intent, unless and until said work alters an Area subject to protection under the Act. wpaform2.doc•rev.12/15/00 Page 3 of 5 Massachusetts Department of Environmental Protection L7� Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) ❑ 5. The area described in the Request is subject to protection under the Act. Since the work described therein meets the requirements for the following exemption, as specified in the Act and the regulations, no Notice of intent is required: Exempt Activity(site applicaNe statuatory/regulatory provisions) ❑ 6. The area and/or work described in the Request is not subject to review and approval by: Name of Municipality Pursuant to a municipal wetlands ordinance or bylaw. Name Ordinance or Bylaw Citation C. Authorization This Determination is issued to the applicant and delivered as follows: ❑ by hand delivery on ® by certified mail, return receipt requested on Date Date This Determination is valid for three years from the date of issuance (except Determinations for Vegetation Management Plans which are valid for the duration of the Pian). This Determination does not relieve the applicant from complying with all other applicable federal, state, or local statutes, ordinances, bylaws, or regulations. This Determination must be signed by a , ajority of the Conservation Cammissi . copy must be sent to the appropriate DEP Regional Office( Appendix A) and the property o er(if different from the applicant). ❑OSi9 natures: 1. J Date wpaform2.doc•rev.12/15/00 Page 4 of 5 Negative Determination of Applicability Conditions Issued 7/10/03 130 Laconia Circle 1. Prior to construction, erosion controls must be installed in the locations displayed on the Site Plan dated 6/26/03. 2. Prior to construction, all leaf and grass clippings in the vicinity of wetland flag A-10 must be removed outside the 25' No-Disturbance Zone. 3. Wetland markers must be placed every 25' along the 25 foot No- Disturbance Zone. Markers are available for sale at the Conservation Department. 4. Prior to construction, the Conservation Department must be notified to schedule a pre-construction inspection of the conditions outlined above. 5. Upon completion of the addition, an As-Built plan must be submitted to the Conservation Department for review and approval. Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. G. 131, §40 D. Appeals The applicant, owner, any person aggrieved by this Determination, any owner of land abutting the land upon which the proposed work is to be done, or any ten residents of the city or town in which such land is located, are hereby notified of their right to request the appropriate Department of Environmental Protection Regional Office (see Appendix A)to issue a Superseding Determination of Applicability. The request must be made by certified mail or hand delivery to the Department, with the appropriate filing fee and Fee Transmittal Form (see Appendix E: Request for Departmental Action Fee Transmittal Form) as provided in 310 CMR 10.03(7)within ten business days from the date of issuance of this Determination.A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant if he/she is not the appellant. The request shall state clearly and concisely the objections to the Determination which is being appealed. To the extent that the Determination is based on a municipal ordinance or bylaw and not on the Massachusetts Wetlands Protection Act or regulations, the Department of Environmental Protection has no appellate jurisdiction. wpaform2.doc-rev.12115(00 Page 5 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Appendix A - DEP Regional Addresses Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Mail transmittal forms and DEP payments,payable to: Commonwealth of Massachusetts Department of Environmental Protection Box 4062 Boston, MA 02211 DEP Western Region Adams Colrain Hampden Monroe Pittsfield Tyringham 436 Dwight Street Agawam Conway Hancock Montague Plainfield Wales Alford Cummingbon Hatfield Monterey Richmond Ware Suite 402 Amherst Dalton Hawley Montgomery Rowe Warwick Springfield,MA 01103 Ashfield Deerfield Heath Monson Russell Washington Phone:413 784-1100 Becket Easthampton Hinsdale Mount Washington Sandisfield Wendell Belchertown East Longmeadow Holland New Ashford Savoy Westfield Fax:413-784-1149 Bemardston Egremont Holyoke New Marlborough Sheffield Westhampton Blandford Erving Huntington New Salem Shelburne West Springfield Brimfield Florida Lanesborough North Adams Shutesbury West Stockbridge Bucktand Gill Lee Northampton Southampton Whately Charlemont Goshen Lenox Northfield South Hadley Wilbraham Cheshire Granby Leverett Orange Southwick Williamsburg Chester Granville Leyden Otis Springfield Williamstown Chesterfield. Great Barrington Longmeadow Palmer Stockbridge Windsor Chicopee Greenfield Ludlow Pelham Sunderland Worthington Clarksburg Hadley Middlefield Peru Tolland DEP Central Region Acton Charlton Hopkinton Millbury Rutland Uxbridge 627 Main Street Ashbumham Clinton Hubbardston MilNille Shirley Warren Ashby Douglas Hudson New Braintree Shrewsbury Webster Worcester,MA 01605 Athol Dudley Holliston Northborough Southborough Westborough Phone:508-792-7650 Auburn Dunstable Lancater Northbridge SouthbridgeWest Boylston Fax:5M792-7621 Ayer East Brookfield Leicester North Brookfield Spencer West Brookfield Barre Fitchburg Leominster Oakham Sterling Westford TDD:508-767-2788 Bellingham Gardner Littleton Oxford Stow Westminster Berlin Grafton Lunenburg Paxton Sturbridge endon Blackstone Groton Marlborough Pepperell Sutton nchester Bolton Harvard Maynard Petersham Templeton Boxborough Hardwick Medway Phillipston Townsend Boylston Holden Mendon Princeton Tyngsborough Brookfield Hopedale Milford Royalston Upton DEP Southeast Region Abington Dartmouth Freetown Mattapoisett Provincetown Tisbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Attleboro Dighton Gosnold Nantucket Rehoboth Wareham Lakeville,MA 02347 Avon Duxbury Halifax NewBedford Rochester Wellfleet Phone:508-946-2700 Barnstable Eastham Hanover North Attleborough Rockland West Bridgewater Fax:508-947-6557 Berkley East Bridgewater Hanson Norton Sandwich Westport Bourne Easton Harwich Norwell Scituate West Tisbury TDD:508-946-2795 Brewster Edgartown Kingston Oak Bluffs Seekonk Whitman Bridgewater Fairhaven Lakeville Orleans Sharon Wrentham Brockton Fall River Mansfield Pembroke Somerset Yarmouth Carver Falmouth Marion Plainville Stoughton Chatham Foxborough Marshfield Plymouth Swansea Chilmark Franklin Mashpee Plympton Taunton DEP Northeast Region Amesbury Chelmsford Hingham Merrimac Quincy Wakefield 205 Lowell Street Andover Chelsea Holbrook Methuen Randolph Walpole Arlington Cohasset Hull Middleton Reading Waltham Wilmington,MA 01887 Ashland Concord Ipswich Millis Revere Watertown Phone:978-661-76W foto Danvers Lawrence Milton Rockport Wayland l Bemont Dedham Lexington Fax: 97861-7615 Nanant Bowler Wellesley Beverly Dover Lincoln Natick Salem Wenham TDD:978-661-7679 Billerica Dracut Lowell Needham Salisbury West Newbury Boston Essex Lynn Newbury Saugus Weston Boxford Everett Lynnfield Newburyport Sherbom Westwood Braintree Framingham Malden Newton Somerville Weymouth Brookline Georgetown Manchester-By-The-Sea Norfolk Stoneham Wilmington Burlington Gloucester Marblehead North Andover Sudbury Winchester Cambridge Groveland Medfield North Reading Swampscott Winthrop Canton Hamilton Medford Norwood Tewksbury Wobum Carlisle Haverhill Melrose Peabody Topsfield i Wpaform2.doc•Appendix A•rev.11/22/00 Page 1 o 1 I LlMassachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands WPA Appendix E- Request for Departmental Action Fee Transmittal Form Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. Request Information Important: When filling out 1. Person or party making request (if appropriate, name the citizen group's representative): forms on the computer, use Name only the tab key to move your cursor- Mailing Address do not use the return key. CitytTown State Zip Code Phone Number Fax Number(if applicable) Project Location ,ease Mailing Address City/Town State Zip Code 2. Applicant (as shown on Notice of Intent (Form 3),Abbreviated Notice of Resource Area Delineation (Form 4A); or Request for Determination of Applicability(Form 1)): Name Mailing Address City/Town State Zip Code Phone Number Fax Number(if applicable) 3. DEP File Number: B. Instructions 1: . When the Departmental action request is for(check one): ❑ Superseding Order of Conditions ❑ Superseding Determination of Applicability ❑ Superseding Order of Resource Area Delineation I Send this form and check or money order for$50.00, payable to the Commonwealth of Massachusetts to: Department of Environmental Protection Box 4062 Boston, MA 02211 wpaform2.doc•Appendix E•rev.2/00 Page 1 of 2 Massachusetts Department of Environmental Protection IL7/1 Bureau of Resource Protection - Wetlands WPA Appendix E — Request for Departmental Action Fee Transmittal Form Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Instructions (cont.) 2. On a separate sheet attached to this form, state clearly and concisely the objections to the Determination or Order which is being appealed. To the extent that the Determination or Omer is based on a municipal bylaw, and not on the Massachusetts Wetlands Protection Act or regulations, the Department has no appellate jurisdiction. 3. Send a copy of this form and a copy of the check or money order with the Request for a Superseding Determination or Order by certified mail or hand delivery to the appropriate DEP Regional Office (see Appendix A). 4. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant; if he/she is not the appellant. wpaform2.doc•Appendix E•rev.2(00 Page 2 of 2 f NORTsj TOWN OF NORTH ANDOVER PUBLIC HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER,MASSACHUSETTS 01845 sACHUs Sandra Starr Telephone(978)688-9540 Public Health Director FAX(978)688-9542 July 30, 2003 Gregg Schmidt 130 Laconia Circle ti North Andover, MA 01845 Re: Application for 2nd floor addition Dear Mr. Schmidt: Your additional information for the application for an addition at 130 Laconia Circle has been reviewed by the Health Department. Although originally designed to serve a four-bedroom dwelling without a garbage grinder, under current Title 5 regulations the septic system has been found to be undersized,both for the existing home and for any addition. Furthermore, since the original septic design was not sized for a garbage grinder, the existing grinder must be removed immediately. The removal must be inspected by Board of Health staff. In order for the Health Department to approve your application for an addition, the septic system will have to be upgraded to comply with current Title 5 regulations. If you wish to proceed with your plans for an addition, I suggest that you hire a civil engineer and/or a Massachusetts DEP certified site evaluator to apply to the Health Department for soil tests. Hopefully the enclosed documents will be of help to you if you choose to proceed with this upgrade. Please call the office at 978-688-9540 to set up an inspection date. Sincerely, Sandra Starr, R.S., C.H.O. ' Public Health Director W/enc. Cc: Building File NORTH BUILDING PERMIT o� �yeD '6,�'�'o TOWN OF NORTH ANDOVER 32h — APPLICATION FOR PLAN EXAMINATION �c �` 7• y T Permit No#: qb�-k�l Date Received / �gssgcHus���y Date Issued: v � IMPORTANT:Applicant must complete all items on this page LOCATION �� ? j�(V-c I -e Print PROPERTY OWNERD,eL -OZ t j Print 100 Year Structure yes no MAP PARCEL: I�� ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial 2T-Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑':Septic: ❑1N'elll DFlood'pla�n 'Wetlantls ❑ MN '46 i O UUater/.=S"ewer 4 . rIFSCRIPTIONOFWOIRK TOB ,PERFORM��� Id ntification- Pl ase Type or Print Clearly OWNER: Name: 5L t` Phone: GIM–502–g5. Address: C Contractor Name: Phone: 7 '-4 Email: < < C� Address: ' Supervisor's Construction License: Exp. Date: Z ,a Home Improvement License: Exp. Date: G ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDI PERMIT.•$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: j - FEE: $ — Check No.: 1 Receipt No.: 7?UA 6 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund e- :wcs' . .eE fi.,.Y _ i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i i TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ i Private(septic tank,etc. ❑ Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM I PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS WEALTH Reviewed on Siqnature COMMENTS i Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes I Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& ®ate Driveway Permifi DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT ' 4 , Temp Dum ser on si e, yes ,a „ ,� �n"`o Loca14d at 124 Main Street *,rtC 40 � pt` t � �' sr . RlN•re , ./'�._.;..+E;u^ .:4-, i7t,>,'• ir�} y ;-r� ,�w ,X x. ; Fireepartrnen�t sigriature/date s �,;; �` 1,,}ix�•.,�'�+y.{�'�. : '* 1'�i �A t! 7►I�„ ;t� t . ,}( . ) �>' . { N.l' jt'�d14 ,'t �.A'#"T Je'. 1 a � t! 3VT fie+ �' 'i' f- COMMEI *' t ^fir Mst^'a.`=. �) yr !ti +r 7#tte'i w•5 t fit `�.x { �� NTS, , ► ,,,, �,,� .. � +. , t , h, ►°' k a....r, '' 4 1 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 apse) i 1 I ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 it 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 4. 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 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 i Location Ctl lk No. 9W" Zok , Date ZZ i • • TOWN OF NORTH ANDOVER " n Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ ' TOTAL $ i Check# i 1 �1 t: •. r 9. 30035 Building Inspector k 1. _ � f,10RTly own of 2 n over No. 4-,h . ver, Mass , 2226 [OC NIC Nl WKK y1` - �.qs Rwreo �Pa��S U BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT ............... ......... . ,�. , ....�................... ....... .............. BUILDING INSPECTOR ..... ...... ..... has permission to erect .......................... building on ..� Q....� 1[�1 ..C.WAW%.r........... Foundation Rough • t0 be OCCUpled as ........... .............. ... f.... ........................................... 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 UNLESS CONSTRUCT TTARTS Rough Service ......... ....... -- Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin 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 M 0 RISE Engineering RI Contractor Registration No MA Contractor Registration No -ria A division ofThielsch Engineering CT contractor Registration No 4 ,t 60 Shawinut Unit#Z,Canton,MA 01021 +w N 339.502.6335CONTRACT FAX 339-502-6345 1 PROGRAM Page THIS CONTRAer is OnVIED taro SEh5Q M ME ENGINEERING CNA-HES &NOMMMAND THE=TOM FOR WORK AS OEaetu6®9EUWJ cusTOMFR _ --- ,_ -.�. PHONE •--_._..—_ DATE etJQritt W6RKONDFR Debbie Schmidt (978)502-8311 05/1 414583 00002 SElRner svREEr — —. MUAO ontm, 130 Laconia Circle130 Laconia Circle L!r! (L4 SSE9,ArX CITY.aTATE,IIP ry 811=0 COY.STAM IIP - North Andover,MA 01845 Notch Andover,MA 01845 MAY 1 a 2095 JOB DESCRIPTION ".. AIR SEALING:Provide labor and materials to seal areas of your home against wastefut,excess air leakage. This work will be performed in concert with the use of ficial tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include cauda,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garagcs and other unheated areas(windows are not generally addressed.) (8)working hours. At the completion of the weathcrization work,and at no additional cost to the homeowner,a Final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $680.00 AIR SEALING ADDER:(4)working hours. 5340.00 AUDITOR`S NOTES DRYER VF,NTS TO ATTIC.-,DRYER MUST BE VENTED OUTII! $0.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fibaglass halts to(40)square feet for damming purposes. $82.00 ATTIC FLAT:Provide labor and materials to install a 4"layer of R-14 Class I Cellulose added to(1080)square feet otopen attic space. $1,220.40 ATTIC ACCESS:Provide labor and materials to install(1) easily moved,insulating cover for the attic access folding stair. A small Pat surface cf plywood will be orated around the opening within the attic. This will allow the cover's integral weather-stripping to restrict air leakage. 5237.65 VENTILATION:Provide!oboe arrd materials to install(3)8"diameter roof v4,n4s)to inerease v Ttiiation in attic areas. The vent can be supplied in(circle color)black,brown,gray or mill finish. S25650 VENTILATION:Provide labor and materials to install(1)insulated exhaust hose with roofmounted flapper vent to exhaust existing bathroom fan(s).AUDITOR'S NOTES DRYER VENTS TO ATTIC DRYER MUST BE VENTED OUTII! $118.75 VENTILATION:Provide labor and materials to install(t)exhaust hose with wall mounted flapper vent to exhaust existing clothes drycr(s). $147.00 [USE Engineering will apply all applicable,eligible incentives to this contract.You will only be'billed the Net amount. Currently, fnr eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Seating measures up to the first$680 and an additional$340 if savings 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 work is begun,and atter the weatherizalion work is complete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you, Total allowable wcathcriraGon incentive is S3,1 10. L $90.00 S RISE Engineering Ri co alar Reegisvanon No 4 A division aCThielsch Engineering MA Contractor ReglsftUon NoCT Contractor Registration No " 60 ShawMRt Unit 1412,Canton,MA 02021 339-502-035Fnx339-5026348 CONTRACT R S E PROGRAM Page 2 EhIGtldEE13lNG CMA-RES THOS CONTRACT IS ENTERED DRO BETWM RISE - eX"EMMANDTHECUST=MFORWaMAS BORROW . ctmm m¢ . PHONE — 467E euFsrta WORItoR»>ze Debbie Scbmidt (978)502-8311 05/14/2015 414583 00002 SERVICE STREET .......V....._.�—. mum 130 Laconia Circle 130 Laconia Circle U M7- SERVICE CITY,STATE,AP _..._.-. BILLDIO CITY,STATE,21P L- North Andover,MA 01845 North Andover,MA 01845 MAY 1 9 2015 JOB DESCRIPTION - LO Total: $3,172.30 Program incentive: $2,656.72 Customer Total: $516.58 WE AGREE HEREBY TO FUMISN SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUN OF ***Five Hundred Fifteen&581100 Dollars $596.68 UPON FINAL R9WODN ANO APPROVAL BY ING.CUSTOMER AGREES TO REIOTANOUHT DUE IN FULL INTEREST OF 1%WILL 8E CHARGED IµONTNLY ON ANY UNPAID 300AYS,SEE VAPORTANr INFORMATION ON GUARANTEES.RIGIM OF RECISIOk SCHEDWNO,AND CONTRACTOR REGZTRAT= 00 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AVM SIGMA DAB ..._. _�.(J �-•v V ACCEPTANCE NOTE THM Co Y BE WRHORAWN BY US W NOT E)MCUTED WITIIIH DATE OF ACCEPTANCE —. _ 30 ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATION,AND CONDITIONS ARE DAYS AS OPECIFl®,PA�YNENT�ML9,BE REBYAOCPDTED.YOU A MRitORM TO DO THE WORK I i - k The Commonwealth of Massachusetts Print dorm Department of Industrial Accidents Office of Investigations s I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/individual): Builders Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03063 Phone #:603-324-1974 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 100 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other Weatherization comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ACE American Insurance Company Policy#or Self-ins. Lic. #:WLRC 48151553 Expiration Date:6/30/2016 Job Site Address: 130_1_OlC0111 ri e`er 1 -e— City/State/Zip: (JA4o Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certi under the pains a d pengftigs ofperiury that the information provided above is true and correct. Si nature: _.. _ __._ . .......... Date: _ Phone#: 603-324-1974 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Vb? DATEOW412(MMOW016YYY) ' CERTIFICATE OF LIABILITY INSURANCE F THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING MURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. i IMPORTANT;If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endomem6nt A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT 13 NAME: Aon Risk ServicesINC.No,Ext; (866) 283-7122 Central, inc, PHONEFAx Southfield mi office ) 363-0105 z 3000 Town center E4/AIL suite 3000 ADDRESS: Southfield mi 4807S USA INSURER($)AFFORDING COVERAGE NAIL# INSURED INSURERA6 old Republic insurance Company 24147 Topsuild Corp. INSURER B; ACE American insurance Company 22667 260 )iMMy Ann Drive Daytona Beach FL 32114 USA INSURER C: ACE Fire underwriters insurance Co. 20702 INSURER D., INSURER F: • FINSURER F; COVERAGES CERTIFICATE NUMBER,570058348882 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. Unift shown are as requested INSR A SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WDS%Wvo POLICY NUMBER (NAQ= ImuloolyYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY mwzY304bS4 EACH OCCURRENCE $2,000,000 -1 OCCUR U otcurranraCLAIMS-MADE S2,00bl000 MED EXP(Any one persm) $25,000 PERSONAL&AOV INJURY $2,1300,000 GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE S4,000,000 FD F� CT LOC JE CT JR PO- r PRODUCTS-COMPIOP AGG S4,000,000 co OTHER: AUTOMOBILE LIABILITY mwre 304835 06/30/2015 06/30/2016 COMBINEDl)SINGLE LIMIT $5,000,0210 Me pc'Amn X ANY AUTO BODILY INIURY Per person) C) ALL OWNED 60HEOULED BODILY INJURY(Per acddtAb AUTOS AUTOS PROPERTY DAMAGE HIRED AUTOS NON-OWNED AUTOS (Pei ar.6donf) 1E Ix I 1 0 4 UMBRELLA LIAE OCCUR I EACH OCCURRENCE EXCESS LOS H CLAIMS-MAD AGGREGATE DED77REEETENTIC 8 WORKERS COMPENbA I IUN AW WLRC481SI553 06/907201S 06/30/2016 X PTARTITI TH- E EMPLOYERS'UABIUTY YIN All other states II 10E ANY PROPRIETOR I PARTNER'EXECU'T E,L,EACH ACCIDENT S1,000,000 C OFFICERIMFMBER EXCLUDEDI F;�NIA SCFC4915190 06/30/2015 06J30/2016 (Mandatory in NH) L__J wi only E'Ll DISEASE EA EMPLOYEE sl,000'000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S1,000,000 If DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addffi*rW Remarks Schedule,may be 4nuched if more spa"is required) Evidence of coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Builder services Group, Inc. AUTHORIZED REPRESENTATIVE A TopBUild Company 260 liMMY Ann Drive Daytona Beach FL 32114 USA e� @1988-2014 ACORD CORPORATION.All rights reserved. ACORD 26(2014104) The ACORD name and logo are registered marks of ACORD A Cuff Ce 0onsur�erf airsn slnesS ReuatOn ICI Park 'laza Suite 5170 :. Boston, Massachusetts 02116 Dome Improvement Contractor Registration Registration; 17914 Tym Supplement Card BUILDER SERVICES GROUP, INCExpiration: 0125�0t. � RICHARD SCHWARTZ 110 PERIMETER RD NASHUA, NH 03063 Update Address and return card.;Mark reason for change. Address Renewal Employment Lost Card i7f rtti nr "'nnsumer Affasrs S Business Rcgulacir,rt License or registration valid for individul use orth 3tdi'W 1MPRt�VE�+ENT CONTRACTOR before the expiration date. If found return to; r Office of Consumer nsumer Affairs and Business Rvoulation "Registration: 117914; Type; 10 dark f'laa Suits 51,70 Expiration. X512016 St;ppiesnen€-a rd Boston.MA 0 116 BUILDER SERVICE'S GROUP,INC, 260 JIrJIfJiY ANN UP1VS jAYTONA BEACH,.L 321;4 ~ t`rdrr erreter} tits valicl-Vithout Signature I y` CSSL-105992 19-i HUNTRESS STREET NmIjocholerNI'l (0102 ogt2612016 Restr€rted To" C SSL,IC-,[ttsttf 1tiOtl{Cart€8ctar { Failure ta Posses! 1'1�rent edition of theMa-,owichus',(Ifts stzat>6vogirlcot iacg�e for€aVoration of this license. ��