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Home My WebLink AboutMiscellaneous - 35 BAY STATE ROAD 4/30/2018 (2)i BUILDING PERMIT o a TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 4 1� Permit NO: Date Received �DAAT[D rpP` cy �SSACHU`�Ft Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION It a u J-� /y, owd ca m Pont PROPERTY OWNER Ls Ls A u4 t Print MAP NO: PARCEL: 23 ZONING DISTRICT: Historic District yes no Machine Shop Village ves no TYPE OF IMPROVEMENT PROPOSED USE C4V -17e•'�350 2, 1 Residential Non- Residential New Building nfamy Addition family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer UhbGK1P1ION OF WORK TO BE PRE t,f ORMED: /` oi, r To Identification Please Type or Print Clearly) OWNER: Name:Rob L d A a c1, n % Phone: G 17 • l o . K7 ? Address: 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: $GJ00, FEE: $ Check No.: � i 70 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the Jivarantr fund C4V -17e•'�350 2, 1 CONTRACTOR 'Name: bor al\ V_ •. (, <�, , l uHl ru wn ePhone: s�� - ct Ott -6 t a a & Address: z o o v i c..Jo cv-o P Supervisor's Construction License: o . `Z2�00 8 Home Improvement License: I y o 9 15- Exp. Date. 12 2 2 0 o 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: $GJ00, FEE: $ Check No.: � i 70 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the Jivarantr fund 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 ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/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 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 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location 34�1s/� No. Date NpRTIy TOWN OF NORTH ANDOVER O�it�ao ,, 1.yp 0 D Certificate of Occupancy $ �ss�cHusE< Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #v 21 i 2 Building Inspector 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature 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 124Main 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 - Date Doc.Building Permit Revised 2008 r d (U O w° h v R V) w A w° a C U x w ac_ cu° w aw. w cn C w" O d � C w w w w " C 0 0. w Y= O W i1. QO `i o. E •� mUS o a COD +- �. m a y C C ca O E m av cm m iy m ' CC ►:Zs o cm Q ® :cc,'Q t m mor ca= 0 0 �o a o c H m y m C C o CL N CL �g l W C O C cr. m LC, mi =. C ►� 13u F— y ar c° c Z � " y o v o o®mac 0 CA CZ m 'O o CA z= ev m`E= CLS Cc 1 N 00 v O O CD 0 CD L C v Z °D 0. O C cm !co 0 _� * p� 0 �� m m 3� CD a� CD i M 0 d C. CMQ c 0 demo c � 0 V —J 'p •C Z di d tS 0 CL C01 v� 0 c _W �. CO) d, O CD C ;;C O 45 C CC3 O ` C H O " C V C.* ;�dfl r C N i m C O � Go :Ea y � y � C 1 N 00 v O O CD 0 CD L C v Z °D 0. O C cm !co 0 _� * p� 0 �� m m 3� CD a� CD i M 0 d C. CMQ c 0 demo c � 0 V —J 'p •C Z di d tS 0 CL C01 v� 0 c _W �. CO) d, � ? � � F � /Of 2- 000 : Gw-c F=LEw zsajs-`i B FAX NO. Anr. 09 2006 111,52W P2/3 Proposal Dornan & Sousa General Contractors 200 A Meadowaott Street I,apweit MA 4tmco Phow 978463-00W /fiA 978 6j;%- ftPwW TU�To: Job Name , am Lenr�tlN Address Jab LOOMbp I� 41 44V40 e/,QL.'tC as Bay StO Rd. N, Ar4mr GLS G�Kp/ YJah� �i% `C��v oate d Pum Phi Pax 017-510-4731 1// 9 heresy Sunni WOWOOM SW e5tirna W fpr; .remove existing slIngles. 8" wMte rn drip edge. water shield on bo tem of roof, and 151b. W paper. vW yest al*1ioBl UW shingly. Appy ridge YeM bn al ridges. not neecMd on unheated garage. Rdkvih chimmey with !sari, and build arIeW behined chimrrtery. Remove an vents am replace missing boards. Replace pipe flange. hmu 8' gutter "r rear door. Clean an0 roMOw all debris involed with job. We c Rte' PoPose any to famish maltertal and !asst' — wmo&e in a%crdar" with ft ebory SpWWCMUOM Mr tern sum of: Wlam Payments to be made as follows; _.c 9mp"M of Job._ aUMUn a #"MGM *M aeew "Aw"www Rey 0=0=30h," wn a..vc�auwe any y on submitted Grog Sousa .a,w.nw� ova► ar�m+x. �n �prwne,do ao,rA�an rM note*. ooama, Of aruyo oayaea npr ix". Note _ iht pry MWbe wbxh m by us ii n A aaoepi w"_M days. Acceptance of opoSa TN atxw PMes, Sp6wk4 its and conditions are signature uftacwv and are MOVby aooeptW. You are - 0d t0 OO"WOf1c res SPediw pavwnoms wN be made as owned above. Data or AcMtan=^� Signatures T'd EET6-Z6E-BL6 tuzpegel qQ8 e6Tr60 80 ST .odd m:Chrls Andlno, Hub International NeTo:Certlficate of Insurance for Dornan & Sousa GenIS; 22 C4118108GMT-D4 Pg 02-03 Client#: 26904 11DORNANSOUS ACORD- CERTIFICATE OF LIABILITY INSURANCE )D1YYYY1 MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXC^L'JSIONS AND CONDITIONS OF SUCH 04118f0 PRODUCER THIS CERTIFICATE 13133UED AS A MATTER OF INFORMATION HUB International NE (LCL) 40 Church Street Suite 102 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lowell, MA 01852 POLICY EXPIRATION AT IYY 978 657-5100 INSURERS AFFORDING COVERAGE NAIC # INSURED Dornan & Sousa Construction INSURER A' National Grange Mutual Ins CO INSURER 6: Safe Insurance Co Paul Dornan &Greg $OUSa 3 Gatecliff Street INSURER C. INSURER 0 Billerica, MA 01821-0853 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERICD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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, EXC^L'JSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN `AkY HAVE BEEN REDUCED BY PAID CLAIMS, LTR N8R TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE !1'Y POLICY EXPIRATION AT IYY LIMITS A GENERAL LIABILITY MPS31157 08119107 08119108 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ® OCCUR DAMAGE TO RENTED $500 000 PREMb 5 Ea occurre re MED EXP (Any one persue) S10,000 PERSONAL S .ADV INJURY $1,000,000 -GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: =RODUC75-COMPIOPAGG $2,000,000 POLICY PRO LOC B AUTOMOBILE LIABILITY ANY AUTO 2400751 11127!07 11/27/08 I-OME"NED SINGLE LIMIT iEaaccideni $ BODILY IN,i$100 000 ;Fe, persanl ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY $$00,000 iper accidant' HIRED AUTOS NON-OPJNED AUTOS PROPERTY DAMAGE �Fer accident' $100 +000 GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S OTHER THAN Eh ACC S ANY AUl D AUTO ONLY: AcG S EXCE981UMBRELLA LIAStUTY EACH OCCURRENCE $ AG6REGA`,E $ OCCUR ❑ CLAIMS MADE S S DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU. OTH- lr 1 EMPLOYERS' LIABILITY ANY HHUPkIt I UKiPAK 1 NtkIEXEUV I NE F I FACH ACCIDFNT $ L D64 --ASE - EA EMPLOYEE $ OFFICERMIEMBER EXCLUDED? N Jes. dascrthe under SPECIAL PROVISIONS belm E . DISEASE POLICY LINT' $ OTHER DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS Workers Compensation certificate to be issued direct by carrier as the Agency is not authorized to issue same. Town of North Andover 120 Main Street North Andover, MA LO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL . n DAYS WRITTEN E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IE NC OBLIGATION OR LLABIL17Y OF ANY HIND J 10 THE INSURER, ITS AGENTS OR AUTHOR REPRESENTATIVE 191 .9V _. TATIEVMV. 006- ACORD 25(2001108) 1 Of 2 #9364341M14211 CA001 L ACORD CORPORATION 1988 4/29/2008 2:17:49 PM 8740 2 04104 i{n59 vi 'tN "i U"i 7 11-0'1 W 1 Y 7 CG -Mk» �3y i"•:t✓a M'S:1. ISSUE. DATE 0412912008 1k1 ��+ie. rr�»S ✓ILfI �f.a�i,",`..;w.T .•, ,,- b`��+j .. T. ,. L"SS i{�C3'4. Y.ue ,�,a�,e.t��,h,1 :4 ��i""?r PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOPMATiON ONLY AND HUB International New England CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE LLC DUES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 40 Church Street Suite 102 COMPANIES AFFORDrNTG COVERAGE Lowell, MA 01852 INSURED Paul Doman & Greg Sousa dba Dornan & Sousa COM'ANY A A.I.M. Mutual Insurance Co LETTER 3 Gatecliff Street Billerica, MA 01862 Y r 'fl.'f u. s Pa'fS.f.gk' dr3b't4S..yim i+iz Yii'1b '�""Y`.'d, 1., Stl.s.+f l } t v� ?! 7iikt fSDHtrbt'i H' 3Nrc.1r w -id 31Yi ^T'S3.:it _f6'%'KS `K5`_s THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TC THE NSURED 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 ORMAY PERTAIN, THE INSURANCE AFFORDED BY TBE- POLICIES DESCRIBED -HEREIN IS SUBJECT TO ALL TIM TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHCII N MAY HAVE BEEN REDUCED BY PAID CLAIMS. C" LTR IYPE 13FI11SURANCE POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION DnTE(MMIDWYY) DA7E(&IMIDD,`-1) LIMITS GENERAL LIABILITY 3EHERALAGGiEGATE t PRODtiCTS--OMP1J?t00_ 6 COMMERCIAL GENERAL LIABILITY PER5JNA;, Lk.ADV. INJURY 6 = CLAIMS MADE C OCCUR EACH OCCURRENCE 6 OWNER'S & CONTRACTOR'S PROT, FIRE DA:NA3E iAn1— tiro) 6 MED. DaIENSE(Ary—P!—) 6 AUTOMOBILE LIABILITY COMNINED SINGLi t LIIbI' ANY AU aLLOWNEDAUT05 \ BOP"I INILS'J 7R9 KI FLY t SCHEDULED AM S HIRED AUTOS' NON -OWNED AUTOS ) BODIL't iNJJRY t GARAGE L:ABL LI'Y I (ier ardent) PP.OFERTV DAMAGE t "'LIABILITY EACH OCCURRENCE6 ADGRKATE t UMBR'sLLA lro. F 0T.'gER-HAN UNIBRELLA FORM 4�'� - .:4�4 �� L pgw d�Y �' �t'•�• 3..,;`� WORKERS COMPENSATION AND STATUTOKYLI-MrrS OTHER EMPLOYERS LIABILITY X EL EACH ACCIDEA'T SlO0,000 HE PROPRIETOR' A FARNZILnXE_U'iJi FmcIERSARs: INCL ®EXCL 6008288012008 04/13/2008 04/13/2009 ELDISEASE•-POLICYLIMrr S 5oo,wo ELDI5EASE.-EACH 100,000 EAffLOYEE COMMENTS DESCRIPTION OF OPERATIONS OR LOCATIONS: IN 0 PARTNERS ARE COVERED BY THE WORKERSICOMPENSATION POLICY. k`wj• u, Va ri�aris''s+ , x '.'` ✓ wna' „� .,P"„ x 3a�k ° ""M ,• ;' ,...lkl b PONT HOULD ANY OF THE ABOVE DESCRIBED PCLICIES EE CANCELLED BEFORE THE ENTIRATION DATE TOWN OF NORTH ANDOVER HEREOF,THEISSLTNGCOMPANYVULENDEAVORTOPLklL'f WMITTEN NOTICE TO THE CERTIFICATE OLDER N-kMED TO THE LEFT, BLT FAI URE TO NUIL SI.iCH NDI'LCE SHALL IMPOSE NO OBLIGATION PLIABILITY OF ANY FIEND LPON THE COIeANi'. TIS AGENTS OR REPRESE.NTATAT:'S. 1120 MAIN STREET (NORTH ANDOVER, MA 01843 w7rHORIZEDREPRESENTATIVE 6796 Information and Instructions Massachusetts General Laws chapter 152 requires all employdrs 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 be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to,operate-a business or to construct buildings in the commonwealth for any applicant 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may 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 permitilicense 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. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. 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 0.2111 Tel. # 617-727-4900 ext.406 or 1-$77-MASSAFE Fax # 617-727-7749 Revised 11.22-06 www.mass.gov/dia F� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 SY �` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print i_,eeibly Name (Business/Organization/Individual): Pa -se- .6—, l v n F `L c f u✓ s Address: z u City/State/Zip: (, Old S2 Phone 9: 17g• �35'57oZl 75- - 66 b$C� AEe;p an employer? Check the appropriate box: 1. I am a employer with 4. EJI am a general contractor and I * have hired the sub -contractors employees (full and/or part-time). 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# S. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' insurance Type if project (required) , 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Pl repairs or additions 12. oof repairs 13. ❑ Other *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, tContractors 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 isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:' 6 0 D$ 2 $ U 2 O O S' Expiration Date: O C) Job Site Address: 3 5- /3 �� 1-e_. PJ, City/State/Zip: 11/: 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 Investieations of the DIA for insurance coverase verification. I do hereby certify under the pains pIdpenalties ofperjuty that the information provided above is true and correct. 2 8/266 Phone #: . f 7 S'? 3 S- Sy 2- ) I 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 S. Plumbing Inspector 61. Other Contact -Person: Phone #: IL Board of Building Regulations and Standards HOME IMPEgOVEMENT CONTRACTOR ' Registra�b\ 140915 E.0M .52-2009 Tr# 26457 � t P 9 t 9 p I% 1° DORNAN & SOUSr; ! F TORS GREG SOUSA 3 GATECLIFF ST `> > �� ✓.;aJ BILLERICA, MA 01821 Administrator -�-� 00 �5 000 cf enclosed space License or registr before the expiratation valid for individul use only MGLC 112 $ 6oL) ion date. If found return to: 1A Masonryonly Board of Building g 1 G i 2 Family Hames g Re ulations and Standards R Fa1lur@`io'�pos8e9s apurrentedit�on of tfie One Ashburton place Rm 1301 Massachusetts Sti;t9 �w111,;, Code Boston, Ma. 02]08 , is cs le for revocation of-tlais'IicerSse. No alid without signature `^��tjlG"'SAFF� CALtLCENTERi (888=344-7233