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BUILDING PERMIT ✓ oF,�L�o ,6�.
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TOWN OF NORTH ANDOVER o y -
_ APPLICATION FOR.PLAN EXAMINATION '' _
Permit No#: /7 Date Received P'/6 V-0/(o
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Ac"►1
Date Issued: r_ _ 2-916
LVRORTA,NT:Applicant must complete all items on this page
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i P4ROPER4TYiOWNER _C . c� _ (� -��IT>- u .�.
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DD Year S�[e=- � yes.
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EMAP . � ; PARCEL , ZONIfVG�D1STRICT.� HistoncDistnct ,n � yes� ,ne
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,,� Machine Shop Village__yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ Qne family
❑Addition KTwo or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic 0 Well ❑ Floodplain oWetlands D.Watershed District
rti
0 Water/Sewer,.
DESCRIPTION OF WORK TO DE PERFORMED:
r ✓aid
2W%Qa� 94r24 (2-A% F-444Z)
Ide tification- Please Type or Print Clearly
OWNER: Name: j U DnD ,( Phone: l7-gam-
Address: 1
Contractor Name _ Phone::
-Address ./�1r�lz� = � � � 2;
Supervisors Construction°LicenseDate
Home Improvement License:. __. _. _ Exp
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.
_ .dotal Project Cost: $ C7,&-1,ao FEE: $ [ ��
Check No.: � ceipt No.: 1 7`0
NOT Person tracting witli unregist red contractor o of ve:access to the guarantyfund
---- -- - — - — ----- - ------
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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
uildin Permit Application
10 4 g pP
orkers Comp Affidavit
oto Co Of H.I.C.
. Copy And/Or C.S.L. Licenses
Copy of Contract
door Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2014
Plans Sub.i-flitted Plans Waived Certified Plot Plan ❑ Stamped Plans ❑
•TYPSbF 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 o U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
4'CaOMMENTS
HEALTH Reviewed on Signature
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
COMMENT S
-imension
a
Number of Stores. 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
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
ate Time Contact Name
Doc.Building Permit Revised 2014 _-
Location
No. � 7 ' �6J"7 Date
• • TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ �
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# -5
d
J
31206 Building Inspector
Enter construction cost for fee cal - North Andover Fee Cakulatlon
Construction Cost
26 000.00 m
$ - $ 312.00
Plumbing Fee $ 39.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 39.00
Total fees collected $ 490.00
31 Mill Pond
532-2017 on 11/17/2016
kitchen remodel
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U BOARD OF HEALTH
Food/Kitchen
PERMIT D Septic System
ONN *3..k 0" � IV M L�
THIS CERTIFIES THAT ........ .......................... ..................................................................................... BUILDING INSPECTOR
has permission to erect .......................... buildings on .......... .� I� ;� ��. J'1/� Foundation
............... ...... ........... .......................
e /t ® � Ir Rough
to be occupied as ...........�:��.......,. Y�/Ir� IV �.�
.... .............. ................ ............................................... Chimney
3rovided that the person accepting this permit shall in every respect conform to the terms of the application
in file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final
Oonstruction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
/IOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION „ TS Rough
Service
................. .... ... ......... ..ING.. .
Final
BUILDINSPECTOR
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.
J.J. MCNALL CONSTRUCTION ANDREW D.CRAIG/ PATRICIA A. DONNELLY
JOHN J. MCNALL 31 MILL POND
84 MARBLEHEAD STREET NORTH ANDOVER,MASS. 01845
NORTH READING ,MASS.
01864
PROPOSAL
SCOPE OF WORK:
* REMOVE EXISTING CABINETS AND COUNTER TOPS .
* REMOVE EXISTING FLOORING IN KITCHEN.
* REMOVE A SMALL PORTION OF HALLWAY WALL BETWEEN EXISTING KITCHEN DOOR WAY
AND OPENING TO DINING AREA. ( NON BEARING WALL,SEE PLAN PROVIDED)
* REPAIR ANY WALL BOARD AND PATCHING PRIOR TO HANGING OF NEW CABINETS.
* INSTALL NEW CABINETS PROVIDED BY OWNERS.
* NEW STONE COUNTER TOPS TO BE SUPPLIED AND INSTALLED BY OTHERS.
* INSTALLATION OF NEW STONE FLOORING TO BE INSTALLED BY US.
* ANY PLUMBING OR ELECTRICAL WORK NEEDED WILL BE PERFORMED BY LICENCED
PROFFESIONALS.
*THIS DOES NOT INCLUDE PAINTING.
* ALL DEBRIS SHALL BE REMOVED BY US.
WE HERE BY PROPOSE TO FURNISH THE LABOR AND ANY MATERIALS,OTHER THAN PRODUCTS
SUPPLIED BY OTHERS,TO COMPLETE THIS KITCHEN REMODEL.ALL WORK IS TO BE DONE AS
1
04
MENTIONED ABOVE WITH ACCORDANCE WITH ANY SPECIFICATION OR DRAWINGS SUPPLIED.
ALL WORK TO BE COMPLETED IN A WORKMANLIKE MANNER FOR THE SUM OF :$6800.00
SIX THOUSAND EIGHT HUNDRED AND ZERO CENTS.WITH PAYMENTS AS FOLLOWS: FIRST
PAYMENT 40%,SECOND PAYMENT AFTER CABINETS ARE HUNG IS 30%AND THE REMAINDER
APON COMPLETION. (2720.00, 2040.00,2040.00)
NOTE :ANY ALTERATIONS OR DEVEATION FROM THE WORK EXPLAINED ABOVE WILL COST
ADDITIONAL MONEY.THIS WORK WILL BE APPROVED BY OWNERS AND PUT FORTH IN THE
FORM OF CHANGE ORDER PRIOR TO WORK BEING PERFORMED.
RESPECTFULLY SUBMITTED:
ACCEPTANCE OF THE PROPOSAL:
DATE:
NOTE:THIS PROPOSAL MAY BE WITH DRAWN IN 30 DAYS IF NOT ACCEPTED.
SIGNATURE OF PROPOSAL IS AUTHORIZING US TO PERFORM THE WORK AS MENTIONED ABOVE
VIA DRAWINGS AND SPECIFICATIONS PROVIDED.
THANKYOU FOR THIS OPPERTUNITY
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All dimensions .size designations This is an original design and must Designed: 10/2/2016
given are subject to verification on not be released or copied unless Printed: 10/212016
i job site and adjustment to fit job ` applicable fee has been paid or job - -
conditions. order placed.
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All dimensions _size designations This is an original design and must Designed: 10/2/2016'
given are subject to verification on not be released or copied unless Printed: 10/2/2016
job site and adjustment to fit job applicable fee has been paid or job
conditions. order placed.
a0202664.kit - -_- �— -- �— -- I Notes TDrawing #: 1 No Scale.
The Commonwealth ofMassachusettS
Department of IndustrialAccidents
I Congress Street,Shite 100
.Boston,MA o2114_2017
X.. www mass.gov/dia
7ld�Al 5
yPalkexs'Compensation Insurance Affidavits Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE RERAffrmG AuTHORTz . Please Print Le 'bl
A '•licant bnfoxmation �J/J G�� �
Name(Business/organization/Individual): `�068�
Address: 5 �
one#. 9�
City/State/Zip:
Type of projeet Oreclui�ed);
Are you an employer?Check theaPP roP nate box:
em to ees full and/or parttime).* 7. ElNe�i'c6nstraction
1.F]1 am a employer with P y
2.N 1 am a sole proprietor or partnership and have no employees working forme in 8. &"Omo delbi g
any capacity.LNoworkers'comp.insurance required.] 9. ❑Demolition
3❑1"homeowner doing all workmyseli;.[No workers'comp.insurance required.]T
10❑Building addition
¢,❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 L[]Electrical rep;
airs Or additions
airs or additions
ensure that all contractors either have workers'compensation insurance or are sole
proprietors withno entployees. 12,[]�Plumbing rep
s.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 110 Roof repairs
These sub-contractors save employees and have workers'comp.insurance# 14. Other
6.❑We are a corporation and its,offices have exercised their right of exemption per MGL c.
152,§1(4),and we have no e_mpldyees.[No workers'comp.insurance required.]
Any applicant that checks box-51 must also fill out the section below showing their workers'compensation policy information
Homeowners who subDlc§bis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
Contractors that check fihrs box must attached an additional sheet showing the name of the sub contractors and state whether or not(hose entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
X am an employer that is providing worke?s'compensation insurance for my empMoyees. Below is the policy ajzdjob site
information.
Insurance Company Name-
• ExpixationDate. •
Policy#or Self-ins.Lic.#:.1 ` C)Iel;l
j / �Vy 2 City/State/Zip �/�1/✓. �'Y�///gip 7
fob Site Address: a policy number and expiration date).
7 e(show-in
th y
eclaration a g p
Attach a copy of the workers' corapensatron p�oJlcy d P g (
Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a full up to$1,500.00
and/or one-year imprisonment,as well as civil penalties inthe form of a STOP WORK orwarded to the Office of Inveessttigations of the DTA for insuran ER and a fine of up to Q a
day against the violator.A copy of this statement may b f
coverage verificationn
X do Iiere/iy cern un er tliep "ns andpenaldes ofperjury that the information provided above is true and correct
Date: / J
Si afore:
Phone
Official use only. Do not write in this area,to he completed by city or town official.
Perndt/License#
City or Town-
issuing Authority(circle one): i
1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other
Phone#-
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer 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 b6 deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe 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. Self-insured companies should enter their
self insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write•"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Depar4nent of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
o: r-HULr1UI rage2of2 2016-11-1615:25:37(GMT) 17817230355 From: J.J, Ruddy
Ace a CERTIFICATE OF LIABILITY INSURANCE °ATE`-KVDNY"Y)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY DR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject lo'
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACTGale Fanciullo
HAVE:
J.J. Ruddy Insurance Agency Inc. PRONE (781)396-4900 (761)791-7597
.A_.'CyNo,EM§-
153 Main St. MAIL fanciullo@ jrudd insurance.com
a-MAIL ;9 77 Y _ _
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INSURERM AFFORDING COVERAGE - NAICI
Medford MA 02155 INSURERA:Vermont Mutual Insurance Co. 26018
INSURED {{{'''ItRumne:Liberty Mutual Insuranca 16586
JOHN MCNALL `INSURER C:
84 MARBLEHEAD ST INSURER D: --
INSURER E:
NORTH READING MdA 01864-1527 IINSURER W'- -^--F
COVERAGES CERTIFICATE NUMBER-.CL16111601242 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 CONOiT;ON 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.
W q TYPE OF INSURANCE I POLICY EFF POLICY EXP r �-
POLX:YNUMBERI 1 LIMBS
X COMMERCIAL GENERAL LIABILITY I
EA04.OCCURRENCE S 1,000,000
A (AAIMS-MADEOCCUR [0� e W50,000
1 tPFEM,ISESewtrenc21 _--,_____
6P1.101249i 15/9/2D3G S 5/9/2017 1MED EXP'Any one son) S 5,000
IPL-RSONAL ADVINJURY 5 1,000,000
OEMLAGGP.EGgTE UdIT AP?UES PER: NERAL AGGREGAi'E E 2,000,000
X POLICY 0 j T I`I LOC ( i PRO:NJC"S-COMMOP AGG E 2,000,000
OTHER: j I '?rdpany dama6e•amgle enit S 250
AUTOMOBILE UAMLITYCOMBINED SIN
ISGLE LIMB $
Acc:dcnl
ANY AUTO BODILY INJURY(Ver personi E
ALL OWNED SCHEDULED t
I AUTOS AUTOS ( :BODILY INJURY(Pe eccidemj S
ON-OVIREO AUfUS
AUTOS
!Z Eec�rZDM!PGE $
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i UfeaRELLA LIAR j OCCUR i i EACH OCCURRENCE E
-- j
EXCESS L_ j CIARF.S•MADE ' AGGREGATE
i
DEC ? RE1FN1ION E _ g
I WORKERS COMPENSATION O H-
iAND EMPLOYERS'LIABILITY YIN STAME ER
!ANY P1;0PA4TO!LPARrNMFXE CUTIVE El.EACH ACCIDENT S 100 000
B
10FRE EMaER EXCLUDE N;A , --.-'
(tAaneetory In NR) WC531538798605 12/9/2015 12/9/201.6 E.L.DISEASE-EA EMPLOYEE$ 100,000
U if yy�eC,d-UlIe tinder ^^-
DESCRPTtON OF OPEFiAT;ONS betce j El,DISEASE POLICY LIMIT E 500,000
John MCNall is excluded
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DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks SchadWe,maybe artached a more spaee IS required)
Project : 31 Mill Pond, North Andover, MA 01845
CERTIFICATE HOLDER CANCELLATION
(978)688-9542
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
31 Mill Pond
North Andover, MA 01845 AUTHORIZED REPRESENTATIVE
J Hackett, Jr.., CTC/3
0 1988.2014 ACORD CORPORATION. A11 rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
(NS1012S IZDlan11
Massachusetts Department of Public Safety
LJ�C,<�p77h%/ICl II/I/G'GZII�[ (1iI�/fJL6C'�[CiC, '
Board of Building Regulations and Standards
ftiee of Consumer Affairs&Business Regulations
ME IMPROVEMENT CONTRACTOR cense: CS-057560
Construction Su ervisorx
registration 113241 ^,� Type: p
Expiration: --5/27/2017-1 Individyal
JOHN J MCNALL {
JOHN J. MCNALL 84 MARBLEHEAD STREET : '
l NORTH READING MA 01864 ;
JOHN MCNALL ;
84 MARBLEHEAD ST
r N.READING, MA 01864
iJridersCcrtary Expiration:
Commissioner 10/17/2017