HomeMy WebLinkAboutMiscellaneous - 490 DALE STREET 4/30/2018 (3) J/ �,4L,c-- sig �9'�7 \ po No.: w l Date ZZ O�,•o°T a gti0 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT � 09 `�h• �qqO"AT�o�P"( Building/Frame Permit Fee $ SSACNUS� 13y L14�1'.% Permit Fee $ ® Permit Fee $ �D• n� G G �. .1d©ver C011ed0f ,,4 Building Inspector litS' i�L 40l // � PERJIIf NIT APPLICA ION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 { ;IAP K-40. I LOT NO. 2 RECORD OF OWNERSHIP '.DATE BOOK '.PAGE t NE SUB DIV. LOT NO. CATION PURPOSE W U U d S fO (/ e 'V NER'S NAME �Phn S CrUW �"Py NO. OF STORIES SIZE WNER'S ADDRESS C/O Da�e S t. BASEMENT OR SLAB ARCHITECT'S NAME V eI-m U ✓I �- c a S �(rI �' S SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SGP" F SPAN -- DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET " POSTS DISTANCE FROM LOT LINES-SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS -Fe _ v 4 / 3 PROPERTY INFORMATION G 8 3 (� LAND COST SEE BOTH SIDES EST. BLDG. COST / PAGE I FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED 1BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DAT FI �oZ No V Poo BOARD OF HEALTH VVV SIGNATURE OF OWNER OR AUTHORIZE,RIXGENT FEE PLANNING BOARD PERMIT GRANTED BOARD OF SELECTMEN BUILDING INSPECTOR WHITE: Building Dept. CREAM: Assessors CANARY: Treasurer BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY j _ OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL'K. —{ PINE BRICK OR STONE HARDW-D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ 1/1 1/1 '/, FIN. ATTIC AREA _ NO B M'T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I' 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDVV D _ ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER ELK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) — GAMERELMANSARD TOILET RM. )2 FIX.) FLAT 11 SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING WOOD STOVE INSTALLATION CHECKLIST paIMIT NO 4 Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove n/� ,,,t�.a2, A. New Vej1*0nt045 Used t/ B. Type/radiant �. Circulating V0,1-4 iY C. Manufacturer S/+h4 c ab. N Name/Model No. +• i,A `y .�8 47 o size ►tf ,3 ``� Dimensions/Height oZ Length a Width Chimney 4911f A. New ExistingS. Size(flue area) G C. Other appliances attached to flue(Numbe an flue size) e D. Prefab(Manufacturer—name and type) e� W"'r Nc-'a L b e s to-1 e S-2 E. Masonry/Lined Flue liner Unlined (type b manufacturer) F. Height(refer to diagrams) cap .des OVER )c' aER Ip �2h1 f2'� Mlf(. ;2 WN. 2 Mlft. y 12 MIN. X18it MIN. FO 9L/A--,H .QLGESy 4�� HEARTH CHIMNEY HEIGHT Hearth(non-co bust'ble) A. Materials t. j�o"�a r t I' B)1_1 e k �7G ( / / B. Sub-floor construction Wo b •r' Q �1 riC •V., 4d P. HP4 ✓� r� O C. Minimum dimensions(refer to diagram) / Clearances and Wall Protection(s a stove installation clearances chart) A. Type of wall protection provided a ' 7��H ,Q, L41;a) B. Clearances(refer to diagrams) a� u' 0 17 71- FIREPLACE CORNER WALUCENTER 13 i ` L 1 j Tei 5 /4NST �� �onsu � ftnq hubs `- d n f 0 i- vw s To i i i� 1� E� it I) J i I 1 i .,�--. a � r�� - �. � l � 4 ,� � �. � ��,,. t y } 1 � ". y , � r Z � _ � I 1 i CERTIFICATE OF USE & OCCUPANCY uocun oil Geo [ &[Mdow l? Building Permit Number WS-11 Date November 25 , 1988 THIS CERTIFIES THAT THE BUILDING LOCATED ON 490 Dale Street , North Andover, Mass . MAY BE OCCUPIED AS Wood Stove IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. NORTH Q� .a° a 1tiQ CERTIFICATE ISSUED TO Dennis Crowley _ ADDRESS 490 Dale Street vz ,`t3AC14U5� / Building Inspector jPERIfTjT xo. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE l MAP d40. LOT NO. 2 RECORD OF OWNERSHIP JDATE BOOK :PAGE ZONE I SUB DIV. LOT NO. �I } LOCATION y� `� PURPOSE OF BUILDING 1 b T ` OWNER'S NA E t� NO. OF STORIES 1 L_,(3SIZE ✓2hYi�S c rotALY _ OWNER'S ADDRESS L,/� `lql BASEMENT OR SLAB ARCHITECT'S NAME (( a.+ l SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME `� C�ew.g�cc SPAN _--- DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES—SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW T10 SIZE OF FOOTING % IS BUILDING ADDITION MATERIAL OF CHIMNEY Q� IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND�\ WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION . S 11 � LAND COST SEE BOTH 616ES � �2C0 CK�(•K'1�� ifs 1.�x(b a�y �f EST. BLDG. COST 1 a ` SS �� ►�c( —�j _ i1�� x .l. EST. BLDG. COST PER SO. PT. PAGE 1 FILL OUT SECTIONS 1,/---3T- 1701.1 �'�n�` EBT. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 Q t�((Y �G��-H.. Jif —&k5 SEPTIC PERMIT NO. ELECTRIC METEPB MUST BE ON OUTSIDE OF BUILDING w 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS v`1 PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE'-FILED NUILDING INSPECTOR =D SIGNATURE OF OWNER OR AUTHO IR ZED AGENT F E E �J� OWNER TEL.N 506 683 d86ro PERMIT GRANTED CONTR.TELA' / 19 CONTR.LIC.# 0130-9S H.I.C.# ` 2 3 f �S BUILDING RECORD 1 OCCUPANCY 12 1 SINGLE FAMILY I S-ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ 3 1 ? (3 CONCRETE BL'K. PINE BRICK OR STONE HARDW-D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT 11 AREA FULL FIN. B'M'T' AREA _ '/ 1/1 FIN. ATTIC AREA _ NO 8 M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE — �— WOOD SHINGLES EARTH ASPHALT SIDING HARDVJ'D ASBESTOS SIDING COM/+LGN _ VERT. SIDING ASPH. TILE STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 6 FLOOR _ BRICK ON FRAME CONC. OR CINDER SLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR II POOR TE ADEQUANONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) _ GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. 6 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T G UNIT.HEATERS AS 7 NO. OF ROOMS Olt OIL B'M'T 2nd ELECTRIC 1st 13rd NO HEATING DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Number: CS 043095 0410711999 Birthdate: Restricted To: 90 04/01/1960 -w PAUL P CLEMENCE t 135 FENNO DRIVE RON1Ey, NA 01969 qA e eo ; a HOME IMPROVEMENT CONTRACTORS REGISTRATION Board of Building Regulations and Standards One Ashburton Place — Room 1301 Boston , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR — Registration 123458 Expiration 02/20/99e& ,na,,,,M„i�/, ��:lf� ,�., ��� Type — INDIVIDUAL HOME IMPROVEMENT CONTRACTOR Registration 123458 a Type - INDIVIDUAL PAUL P . CLEMENCE -- Expiration 02/20/99 135 FENNO DR ROWLEY MA 01969 PAUL P. CLEMENCE 135 FENNO OR G�c�nco� *iLEY MA 01969 ADMINISTRATOR 1 t �10RT own of : over No. 1 G Z. over, Mass., 19 9TLAN �O7�CO-NICN[MICK 40q4 E 0 S F. BOARD OF HEALTH _. PERMIT TFood/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT N..5........... ... . Foundation l�e W. �. ................................................ has permission to erns#-.......X9-47 pile....... buildings on ......... ..�v....................... .........z...77................. Rough to be occupied as L� -.L^�F..........c.. . ...tib ... ^�� �''��1. ...... .. chimney p a 1/1 ........................ provided that the person accepting this permit shall in every respect conform to the rms of the applicatio on file in Final this office, and to the provisions of the Codes and By-Laws.relating tor_the-tospMiwi,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 INSPE('TOR UNLESS CONSTRUCTION ST Rough Service ... .. ... .............................................. UMDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done IRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Location 4-lo n/d: No. 3 Date / "ORT" TOWN OF NORTH ANDOVER O` �•o ,•'�yO p Certificate of Occupancy $ t},+ I Building/Frame Permit Fee $ Foundation Permit Fee $ a ss^CMUSE Y'+] Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 70606 Building ctor Div. Public Works i PERMIT NO. J 37 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. 11 AGE 1 MA's 4-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE I SUB DIV. LOT NO. �— q I LOCATION T/ QQ �t PURPOSE OF BUILDING OWNER'S NAME DQnn is n rDw /oy NO. OF STORIES / SIZE OWNER'S ADDRESS /.�,(C, c/nl_a,L� /Cy BASEMENT OR SLAB A 1 ARCHITECT'S NAME_I ' c7 SIZE OF FLOOR TIMBERS �1�S/T 2ND 3RD BUILDER'S NAME 4J /J�� / SPAN Pnn!s A()W P�'1 _ DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LI/NES-SIDES REAR "" GIRDERS AREA OF LOT //car. FRONTAGE HEIGHT OF FOUNDATION THICKNESS -< IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION C MATERIAL OF CHIMNEY J IS BUILDING ALTERATION P Dec IS BUILDING ON SOLID OR IrILLED LAND S(J WILL BUILDING CONFORM TO REQUIREMENTS OF CODE vis IS BUILDING CONNECTED TO TOWN WATER ye BOARD OF APPEALS ACTION. IF ANY / IS BUILDING CONNECTED TO TOWN SEWER 81" / IS BUILDING CONNECTED TO NATURAL GAS LINE �jP 3 INSTRUCTIONS 3 PROPERTYINFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE I FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR 1. DATE FILED_ Mn:l 2 (Ij4- BOARD OF HEALTH SIGNATUJtE OF OWNER OR AUTHORIZED AGENT FEE A'�'c3 41"c' lz— OWNER TEL.# ��' 6��f PLANNING BOARD PERMIT GRANTED CONTR.TEL.# CONTR.LIC.# Mr4�1 _ �s SISM I= BOARD OF SELECTMEN —^ �/" BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d 1 2 I3_ CONCRETE BL K. PINE _ BRICK OR STONE HARDW D PIERS PLASTER — DRY VJAII UNFIN, 3 BASEMENT AREA FULL FIN. B M AREA _ '/. 1/1 3/1 FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE ��_ WOOD SHINGLES EARTH _ ASPHALT SIDING NARDN'✓D _ ASBESTOS SIDING COMMCN — VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR POOR ADEQUATE _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH Q FIX. GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET O ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK *� SLATE NO PLUMBING !, TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. - - — - TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B-M'T 1 11 2nd ELECTRIC 1st IV P 13rd NO HEATING Town of oxit , )__ over 0' , No. 139 _,�. , k i_:�?a 7 J_ ? ` Tort dower, Mass., �. 19" o A E CCS(HIC HE W�CH 1!?A r E D BUILD BOARD OF HEALTH Food/Kitchen PERM IT TO Septic System BUILDING INSPECTOR JHIS CERTIFIES THAT....................... .e fJ�t......� ................ .. ............................................................. Foundation has permission to erect........ V.O.�......., buildings on ......dq.4Q....... .�.... . . ... ............ Rough to be occupied as................... Chimney ...... ......... provided that the person accepting this per t 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 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 PERTA T EX-PIR-ES IN 6 MC`N'"FH.S UNLESS C��.��,r,��j .1(�,�i_I(�_1 � k_ _!­7�i ELECTRICAL INSPECTOR J Rough �....... .. .... . ..... ............. Service BUILDING INSPECTOR Final OccupCiricy Pcrirlit Reqii1-ed t0 Ocat[)y Buildilig GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Fina► No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT • FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** ZAPPLICANT: DP ,oc u p Phone ZcP3 -V?,1 L. LOCATION: Assessor' s Map Number Parcel Subdivision Lot(s) /Street /f X10 Og/P S�` St. Number ************************Official Use Only************************ RE,COMk4ENDATIONS OF TOWN AGENTS: /-`/�- I)Z�_JQ, 7 . Date Approved Conservation Administrator Date Rejected Comments 9� Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections _ - driveway permit Fire Department Received by Building Inspector Date Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (lease print) DATE oZ �t ?2 JOB LOCATION klg e Dc,lie S 7` Number Street Address Section of town "HOMEOWNER" DPrini �vw�P� L� 3—OCG 4 C4 7P --R3cr-6 Name Home/J Phone Work Phone PRESENT MAILING ADDRESS City/Town State Zip code The current exemption for "homeowners" was extended to include owner -eccuoied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license , provided that the owner acts as supervisor . (State Building Code , Section 109 . 1 . 1 ) DEF_NITION OF HOMEOWNER: Person( s ) who owns a parcel of land on which he/she resides or intends to reside , on which there is , or is intended to be , a one to six family dwell- ing , attached or detached structures accessory to such use acid/or farm structures . A person who constructs more than one home in a two-year period shall not be considered a homeowner . Such "homeowner" shall submit to the Building Official , on a form acceptable to the Bulding Official , that he/she shall be responsible for all such work. performed under the building permit . (Section 109 . 1 . 1 ) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes , by-laws , rules and regulations . The undersigned "homeowner" certifies that he/she understands the "ro,. n. oc North Andover Building Department minimum inspection procedures and rcCLlirements and that he/she will comply with said procedures and recuirements . S 7G"AT7�',RE AP?=,OVAL OF BOILDI:iG OFFICIAL .,o :i= Three famiiV dwellings 35 . 000 cubic feet , Or larger , will be r�d to co� ,pl; with State Building Code Section 127 . 0 , Construe ion MAW WY Wir%Wl Vt`I IiL:.MUiW AWJIAM SAAW'(eiYl«,'.1PXWUii.MW,f+{�•Nk'V'SF/YQ d19 _ - - _ 2p 4 As./ F li X X40. 00 14 NI 4 44 \ \ \ d ,�'�+,� � � �'�'��' ��� ��a ____�.� ,- � '� � � i ��,�,� �� � ��b ,ria �, �,;•`� �' .�. > . -�•W,�'i4 f �,1yj 'jts ••� a. ar t ��, "t �N °'moi i .n"ti. A rq�vywP tap.w!Knrr+o,,.:r..,:s �-••,w .awa +c'cw.�awa•,....•—»° y.,.. ...w.�:wM:„'...:., ,.M•.y„ ... ° - 777 1'1 Y "7. y. . //v ply , ; -I,S °� ✓-� E. 1 i.2 f t�ttSk L �/��f� am-... '�• e i'P nag p..2 8-2.7 a. Y MIN 4 ' � f S t nl ;«y O ° �/ ..� „sru..mr.;y,uurro;>*•..r..;,a,�.:nar.-:v:: aaartr,+ea.. .. - a y tC �etFSac• t �t 1 }A y + A , -za zs /L T.st �/['+7 .s �[���.�,,r�+yJ !�// MINE yq fd ^ °•• J - ... �'At! 1 /N E V.J 4 uJ JV/l✓^,Z, £S - ; ° • y y� s f ti�thy°�I•• x y v' - - �'} ' �p'File W`'E' ' t�#•F �n A NN F 8 ata .S 1 •5t, tt1 7s 11 P i L X °'i^ .r i "E•; e s :: .Iy -f P� 4 °'°,,• .x` �. g„ ;J�'3t r�.r� }±x q n ,{ �, �Yy r �-• certil`y,,/h��1 lhis p'larx ondrsurvey.Awer. 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'+".r'` .� 3F{_ -..•!" �ax4ar i'. ,rx t •�a A -:! � ;�.i 1. �'•_ '�'.. �,4 a�. n .+.�; " 'PA" .' >+''`� ,.nre •• t.t ::a Wa ' :. .two,r. d •a aa%. ''fr c-. k• $'t +., .•�. f anti d hw F±:r.yjM.J.�s 1. i" ''I t�xw i�y''a t ,.• 4am #;;I<. ° + ?��`' `� P e.,•a. "�': G, F :„r.>< •s^'. .. ,�Y.„ ik a •.'.a:: � ?,,f r,,;.�. �• "�t +r°t ° ,t �:'.•t �-�V�! .�. i°� p!' r '... \ ��:r ,{ y �5 S '• 'HT1 ��"' /° Y, t�< { 1M : i .:5 .z,"VE u I :n •c °tir 1 k ,�'..4 .'9+l &? .N, most�� �. 77777 P ;.. ,"r a' }•:;. _ �1 'r y�,; !', fir#e'•�.4� �,, .. .. 1 S. ;b r•"w�;y7:. i.° _• r .•`t.a��: .. .. F,a'�.''yY. � e. a'1'� t em^'xi 1"'{.,i.°R �.* 9'.x r, -�-- , x� PRT eel- -- - v � � X�a v fl 60 w � 1 J. f It �.Q�It wM THE COMMONWEALTH OF MASSACHUSETTS u W SPECIAL COMMISSION ON o VIOLENCE AGAINST CHILDREN 100 CAMBRIDGE STREET • ROOM 2100 BOSTON, MA 02202 Q^M Sven (617) 722-1627 HON. FREDERICK E. BERRY KATHY MITKUS SENATE CHAIRMAN EXECUTIVE DIRECTOR HON. A. JOSEPH DENUCCI MARISSA PIZUTTO HOUSE CHAIRMAN COMMISSION ASSISTANT ft PP. Vv 17H K b 7P YVA L L u t ft-0 AT 5 0 L � a vq 41 fz'-- 4/ 1 CFLOVV 6�- R )9 0 E., lr nl L fV olu of >( Le Cr Cr Go�� 4 V-N CA k THE COMMONWEALTH OF MASSACHUSETTS N W SPECIAL COMMISSION ON VIOLENCE AGAINST CHILDREN 100 CAMBRIDGE STREET • ROOM 2100 BOSTON, MA 02202 (617) 722-1627 HON. FREDERICK E. BERRY KATHY MITKUS SENATE CHAIRMAN EXECUTIVE DIRECTOR HON. A. JOSEPH DENUCCI MARISSA PIZUTTO HOUSE CHAIRMAN COMMISSION ASSISTANT BUILDING PERMIT �� No °TH TOWN OF NORTH ANDOVER 3� y�t. =6 + APPLICATION FOR PLAN EXAMINATION Permit No#: / 4 / Date Received c►+us���5 i Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 4qWl 1 a ' ( ) Pint PROPERTY OWNER L (• Prio 100 Year Structure yes no MAP (10+ PARCEL. ZONING DI TRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial U❑Alt ration No. of units: El Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ Septic Well q Floodplain o'Weflands D Watershed District; D erl WatSew .�er C P ON OF RK TOB ERFOR� tion- P ease Type or Print Clearly Identifi yp Y OWNER. Name: 2. Phone: Address: 49 Contractor Name: Phone: Email: Address: a Supervisor's Construction License:��,/L� ®l_Exp. Date: 2—P /4 Home Improvement License: "/ -3 Exp. Date:::!:6:� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:j$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ' l L FEE: $ - �I Check No.: Ao �/ /&111� Receipt No.: NOTE: Persons contracting with unregistered contractors do ave ac ess,to t' ranty nd r S. v - - - - _.. - A _.. i 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection lsi nature�Date Drivewa Permit y DPW Town Engineer: Signature: Located 384 Osgood Street �FIRE DE_PARJTMENT l�em�p�tDumpster,onisltew j%s,� •` � ,�, no ' a 4Located t 1P24 MainiSfr„eet , , *� Mfr�'� 4 ... r.y `,•�� re DAepa ment4sig tit!-Vd/dates 3 lT w COMMEIVTS�. i _ # €. # 4 i I Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i 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 i 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 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 ISIOTE: 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 4 Workers Comp Affidavit 4� 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 Doe:Building Permit Revised 2014 Location No. / lJ l� Date Cc / /z TOWN OF NORTH ANDOVER • $��T QED jiSg6 Certificate of Occupancy $ Building/Frame Permit Fee y _ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 2r� c) ` r. ilding Inspector OORTH Town of E ,. , ndover No. /® q5op- +� kk -". 9. h , ver, Mass, 'c �r C OC NIC He WICK S U BOARD OF HEALTH Food/Kitchen PERMIT T LD/� Septic System THIS CERTIFIES THAT .......65:Z i�ocJ�� BUILDING INSPECTOR ..................... ................................................................................. C' S J---- Foundation has permission to erect .......................... buildings on ...���..C?..... ..e.f�............................................. Rough to be occupied as ............. ..... .. v `> :...... ��1rr„cr�............................................................. 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 M NTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI STA TS Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. ' \ The Commonwealth of Massachusetts Department of Industrial Accidents a 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. An licant Information Please Print Legibly Name(Bus inesstOrganization/Individual): Address: D City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): l.n I am a employer with employees(full and/or part-time).' 7. F-1 New construction 2.F-1 I am a sole proprietor or partnership and have no employees working for me in g, ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.F-1[am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions ZI netors with no employees. 5. a general contractor and I have hired the sub-con12.E]Plumbing repairs or additions tractors listed on the attached sheet. 13.❑ Of repairs These sub-coutractors have employees and have workers'comp.insurance.t 6. We are a corporation and its officers have exercised their right of exemption 14. Other ❑ rP g p per MGL c. 152,§1(4),and we have no employees.[No workers'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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: G Policy#or Self-ins.Lic.#: wG 0410125—'1-5-2— Expiration Date:A?,? Job Site Address: �° ! City/State/Zip:, 1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 nad/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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern and naltle erjury that the information provided above is true and correct Signa Date: L Phone#• 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#: .r HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name:Boston Notts At South Date:!�/x� 2011' THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number.31 and 33 908 Boston Turnpike,Unit I.Shrewsbury,MA 01545 Toll Free 877-903.3768 Federal ID#75-2698460;ME tic#C 02439;Irl Cont.Uc#16427 CT Uc#HIG0565522; A Home improvemeat Contractor Reg.8126893 InstalladonAddress: �� K)Awt1% v- City State Zip Purebaser(s)t Work Phone: Herne Phone; Cell Phony. Home Address: (If different from Installer Address) 1 —6City State, Zip E-mail Address(to receive project communications and Home Depot updates): O 1 DO NOT wish to receive any marketing emails from The Home D" Pro ect Infor tion; Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and At-Home Services.Inc.("The Home Depol")agrees to furnish,deliver and arrange for the installation("installation')of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract y Job 8: am—a°''""a) Spec Sheet(s)#: Project Amount Roofing Siding tndUw5 LJ insuhakin ^ OCutlen/Coven []EntryDoors ❑ Ci WL-0S $ P4 Ring USiding LJ Windows insulation $ OGutters/Covers OEntryDoors O Roofing EjSiding LJ Windows EJ Insulation ❑Gotten/Coven ry[]EntDoors© $ Roofing Sirfing 1\mdtnvs LJ Insulation OGutten/Covers OEntryDoorx O $ Minlmum25%DepmitorContract Amount due upon executiuno("contract. Total Contract Amount $ a�s� Mahn Purcha�s may to deposit mo e"t oncVtdrd tithe Contract Amount Cuslonter agrees that,immediately upon completion of the work for each Product.Customer will execute a Completion Certificale (one for each Product as defined by an individual Spec Sheet)and fray any halnnce due. As applicable,each Customer under this Contr.(ct agrees to be jointly and severally obligated and liable hereunder, Tlhe Home Depot reserves the right to issue a Change Order or terminate this Contract err any individual Product(s)included herein,at its discretion,if The Hunte Depot or its authorized service provider dciermine-s that it cannoi perform its obligations due to a structural problem with the home,environmental harurds such"mold,asbestus or lead paint,other safety concerts,pricing errors or because work required to complete the job was net included in the Contract. Payment Summary: The Payment Summary # 104'5—?'- , included as part of this Cuntract, sets forth the total Contract amount and payments required for the d Tos-its:md final Iraymenis by Product las applicable). NOTICE.TO CUSTOMER You ure entitled to a completely filled-in copy of the Canlrmi at the time you sign, Do riot sign it Completion Certificate(note: there is(me Completion Certificate fur each listed Product as defined by individual Spec Sheets)before work an that Product is complete. In the event of termination of this Contract,Customer agrees to pay The home Depot the costs of materials,labor,expenses and services provided by The Home Depol or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or ufluwed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HO�-fE DEPOT FROM THE DEPOSiT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER RENIEDIES FOR RECOVERY OF SUCH AMOUNTS. Aces lance ad Authorization: Customer agree and understands that this Atrecinent is the entire agreement between Customer and The Honer.Depot with rcgardl to the Products and Installation services and supersedes all fxior discussions and agreements;either (mal or written,relating to said Products and Installation.This Agreement Cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agmcs that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. pted b Sulmuit thy: J x usuomer's Signature 47 Date. Sales Cansuhani s Sig azure e� Date X Telephone No. L 71'-7 Z16,7 3 Customer's Signature Date Sales Consultant License No. CANCELi.ATION: CUSTOMER MAY CANCEL 7711S (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THiRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRiBED BY LAW IN CUSTOMER'S STATE NOTICE:ADDITIONAL.TERMS AND COND11IONS ARE S"TNITO ON THE REVERSE SIDE AND ARE PART OF THIS CONTRAC-T 02.03-15 White—&anchFde Yellow—Customer . , � � z• • �.�' Lne,gYhr:nran—rncan.g . 1 ' Ri :I=..mov: Izbel•a to final ln�e Ilion; SAVE for lulurc relercnc 4'Jezlh:r shield r r� C?D€ CEO-A-57Z -tuns Dp, aline SRC i;oriel 6103 Doubl ' Alin olid the„nzl r�;'e .. � . .. ?J6 Inch ul'c7.ing • Drille in Alt spz:e �o n ?ill _ �1�r�tC.Y 1 � rDR�`1A�lut RY•:� 'vi'nCo:ll';—.n r�st1-Pl I i:�la.rn RAT'Ih1GS . ORMAN 'I ADD L1 ' Ylslbl:lr=nt�lt:_, I O . „ XrB- ����"br b. hll eta LII;L czbrn m Npi.c f t l xFfY lou cnl r.T>^r"c�l L'nvlicvni ri0ul,ct ^c^cR�:�XFFL ntn (,,1 rrf elnq ,1,Jt Pnt,tl n't:1 p ,nl (r cl crrs.� RcdLc ua. nu,W C'slG,c+h ta! .o�N^c11n5or M. L•� cl el ,eArn iud�u la nil,tent hl�u nuc • scull mc,vt,:�ni t tLnun ur 1•J�� „Ir•cn n P•cuter^ UdlH r,t,a 1[otl� Lx2 t'��uy�{v D11:JL L.1-11 1x.1,1, cr t:t,t:r (pp) M pvutt, lmlcu uu, U.1 Y.•11 L•I.n•J r.t•/••... t;1t:n ' RO A`O ® CERTDATE MMIDD fes/ IFICATE OF LIABILITY INSURANCE 02/24(12015 ) THIS CERTIFICATE IS ISSUED AS A MATTER OF IN ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. FPRODUCER ANT: If the certificate holder is an ADDITIONAL INSURED,the poilcy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to s and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the e holder in lieu of such endorsement(s). SH USA,INC. NAME: ALLIANCE CENTER LENOX ROAD,SUITE 2400EMAIL A/C No)* ATLANTA,GA 30326 ADDRESS: 100492-HomeD-GAW-15.16 INSURE S AFFORDING COVERAGE NAIC# wsulu:o INSURER A;Steadfast Insurance Company 26387 THD AT-HOME SERVICES,INC. INSURER B:Zurich American Insurance Co 16535 DBA THE HOME DEPOT AT-HOME SERVICES New Ham 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER C: pshlre Ins Co 23841 ATLANTA,GA 30339 INSURER D:Illinois National Insurance Company 23817 INSURER E: COVERAGESINSURER F CERTIFICATE NUMBER: ATL•003242685-09 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED MIMEONAMED NUMBBOVE OR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR LTR TYPE OF INSURANCE POLICY EFFPOLICY EXP A GENERAL LIABILITY POLICY NUMBER MM/DD/YYYY MM/DD LIMITS GLO 887714 OS 03/01/2015 03/01/2016 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 91000,000 CLAIMS-MADE [__�]OCCUR LIMITS OF POLICY XS PREMISES(Ea occurrence $ 1,000,000 Or SIR:$1M PER OCC MED EXP(Any one person) s EXCLUDED PERSONAL&ADV INJURY S 9.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 9,000,000 X POLICY DMT 171 LOC PRODUCTS-COMP/OPAGG S 9,000,000 B AUTOMOBILE LIABILITY BAP 2938863-12 s X 03/01!2015 03/01/2016 COMBINED SINGLE LIMIT ANY AUTO Ea accitlent S 1,000,000 ALL OWNED SCHEDULED BODILY INJURY(Per person) s AUTOS AUTOS SELF INSURED AUTO PHY DMG HIRED AUTOS NON-OWNED BODILY INJURY(Per accident) S AUTOS _ PROPERTY DAMAGE S Peracc nt UMBRELLA LIAB $ OCCUR EXCESS LIAB EACH OCCURRENCE s CLAIMS-MADE DED RETENTIONS AGGREGATE S C woRKERs COMPENSATION ;WC.173 AOS AND EMPLOYERS'LIABILITY ( ) 03/01/2015 03/01/2016 X WC STATU- OTH- C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N (AK,KY,NH,NJ,VT) 03/01/2015 03101/2016 D (Mandatory MBERIn NH)EXCLUDED? NN NIA E.L EACH ACCIDENT S 1,000,000 (Mandatory In NH) WC017731494(FL) 03/01/2015 03/01/2016 It yes,describe under E.L DISEASE-EA EMPLOYE S 1,000.000 DESCRIPTION OF OPERATIONS below Conitnued on Additional Page E.L.DISEASE-POLICY LIMIT S 1,060,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks ScheduM,K more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. DBA THE HOME DEPOT AT-HOME SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEO REPRESENTATIVE of Marsh USA Inc. I Manashi Mukherjee _Mauvot ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I Y 7 �• ti t � ,�, KP It. - r t p :4•; Y � � yy'' � �' � ; r H 'A. ». '°Its �,wT M } '�s ° �.�~ yr. r 5 at.. 'W L tt ����� �,� '• � � f '.'nK � �"��. 7 � fFg ��?��"�''TD+�.7 � . Y h :. � �'�b�.. � �:.. �:... ��'♦� � �`4r"i r�� ���S7 ���`� ' .t � � _�� r �� � i"r����. ",w h r,£,. .a �- �£ 'Le... � r'>�*Yr� � rGa �` 4 +, fr'� �y•"'t f� ' - rt �. r..+. - a•:.a tµ is a. .`>'� r ,+ v f w K. S �huse'�� "aDgpart i en �f � ` Board of �3.t�r)daa��[ ��.cal��t �a�� end ���� �� �r�`�fr� � �� � t �� " ews �w L� CSSL-10fi006 cense'. t�'yt�r7 v, BENJAMIN y�x + ° BENJAMIN PARKER .I<P. � . . T,1.�;+ e r .s.•� 7 v� � � at "'�. 1z+{�: ,14 fi R�ENOU�ak�-R®A3 C. 43 € Rr k Plaistow NH 03865 M ¢� ' �.irY�►� ss.:.rt,ts>yr 0211112018 ; ��+ " ti `a VAu-it 1 ° # � �¢T t:_ ;�b = iuf` �,.•-,�.� ^b:T��Y�.�� N'�,v; �;.0 ''� Y7�✓��,it �'.u+,��,� t 'z "�"�� r ' � � sj�ak �,"� >5'7-dT�D �"'.• � xF� � 3' �4,r vij'1,;int 5� r<�s,r�'tY„ ? "p�• sit f yot �a ���`i nrR4a ', ll�y;'c., i 4v1'G4b'Gaoa • rermrt�ervfcas � . ��,- sus'~ • , . wr �-. �- ^�/ ��/;r✓.r,�2�lam.` o e ul 2t1 oa ssR g 011lce o% Cons=, Altai , and Busin� 10 Pa-yk?laza - Suite X170 may' Boston, ?vlassachusetts 0211-6 �� station Y, L-nprovement*Contracto. ozne ?moi:'o*j�n: 125893 SOP?Iemenl Cara 8f3r201_175 li lt�h' S�I���� , NIC. _-- GAiJJ� d rrn card. a:k r .scc_f:7 Ups^tt =xr u ��;. '•`r„y,.,n.,rrrn/r/, ,,' /,,::r• .,,,. .'• ,2[id LicccSc CrCor indtridul sc°il•`' ip z�on ' Could rcturn O.u:c cf Cc:s•.racr._r.JirS bcfc;c the csplrslic❑da:. [( Bt--inL's Hc„ -„cn '-pC airs znd —G--:...•.� a?OV=S:� T i r 0— O1Ti=o{Consucr.c. � .. ii0}1°U/ 7y?c: 10?irk P1:n•Sui;L51 r S.0 enenl and BeS cn,M.k0211.6 S_R✓`.. .. ��✓ Y.J�r.c Cc?07 At. wGheL. 26� ✓ }iplvilid _ .. _._ L:dcrs:crc::n. . r, J ' I t