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Home My WebLink AboutBuilding Permit # 7/6/2015 BUILDING PERMIT �? y` 0� TOWN OF NORTH ANDOVER ° t APPLICATION FOR PLAN EXAMINATION ; 4n '` Permit NO: Date Received °A -< SSACHU`-'�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 'n A s 9' —QN- Pri� C PROPERTY OWNER OS�'^M of Print MAP NO ARCEL: ONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Kone family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg CI Others: ❑ Demolition ❑ Other _:1 Septic r---1 Well 11 Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer F-xis�,^ eGFSAe sSIJ ,,\ %Ce S(\OL1--1) keSe 2 AeCX-S 6 Ctx reo� Ax-MO(1S vJ � Cc6`�� CYv okk(- �,a p acs d h 0(y\ Identification Please ype or Print Clearly) Name: �,. �' Phoneer CONTRACTOR Name: Phone: `�$'� a 2G3 I Address: Soy- 2 23 m Supervisor's Construction License: 7 3991 Exp. Date: *1112-016 Home Improvement License: ' 17 Exp. Date: -7119 1 2c) IS— ARCH I Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PE-$10-00.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ -, �" FEE: $ G l Check No.:/ r Receipt No.: U , NOTE: Persons contracting ith unregistered contractors do not have access to the guaranty fiend , f Of 1 /Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans D TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools U Well ❑ Tobacco Sales ❑ Food Packaging/Sales El 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 F1 ❑ COMENTS —MAI F REJE( I ED UA E A r Pj R CUV F U CONSERVATION F1 COMMENTS E IN2 A')k_c DATE REJECTED DATE APPROVED HEALTH COMMENTS <7 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp, Dumpsteron site yes no Located at 124 Main Street Fire Department signature/date COMMENTS ......:........................... t%O R T'H Andover -Town of - E. ...'.., ® a . n h ver, Mass, O LAKE 1• r COC NIC Hl WICK S ll BOARD OF HEALTH Food/Kitchen PER IT T LU Septic System THIS CERTIFIES THAT ................ S rr'z ul At—, BUILDING INSPECTOR ........ :................................................................... Foundation has permission to erect .......................... buildings on . ....... . .�J........ ................................. Rough to be occupied as ....... ..... .INU.... ........ v�..... � ...1......� 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 E IN 6 MONTHS ELECTRICAL INSPECTOR LESS C T CTI® A Rough Service .................... ........................................................... Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required to Occupy Building Rough Islay in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Page 1 of 7 01 el00 Nexus II Carpentry and Construction Design P.O, Box 2$23 r� Woburn,MA 01888 id 781 760 2031 ' ' Fax 978 975 1263 f a= CS#-073991 RIC#129177 Contract This is a contract between Rosemary Saracusa of 7 Ingalls Street,North Andover MA 01845 (Hereafter referred to as the"owners" or"owner") and Nexus II Services (hereafter referred to as "Nexus") dated June 8111 2015. GENERAL SCOPE OF WORK DESCRIPTION WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: work as stated below for deck replacement and other work required to repair ice/snow damage as noted below Scope of work: General details o Meet with local building official and apply for permits All work will be in accordance with local building code regulations and will be inspected by local officials prior to continuing with the next phase—Nexus will be responsible for arranging and being available for all inspections ® All work will be coordinated directly between "owners", architect if required and Nexus Nexus confirms that it is licensed, insured as required and ensures any sub- contractors utilized on this site will have the appropriate insurance coverage SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 2 of 7 4 Nexus will be responsible for the safe storage of all its property and any materials to be used on the site. Any items left on site will be covered under Nexus insurances * Owner is responsible for removal and return where necessary of all items within the work area and their safe storage prior to our work commencing * Owner will then be responsible for returning all items to the area after completion of the scope of work * Nexus will remove all trash associated with this project into a Nexus supplied dumpster and arrange for safe disposal in to a registered site—if required * Nexus will contact Dig Safe" and confirm all utilities location—if required Scope of work; DECKS; NOTE—all decldng to be secured to the framing using hidden screws with plugs to hide these screws - - no screws or nails to be left exposed on the deck boards NOTE 2 —stainless steel finish nails to be used to secure the trim boards and risers—no plugs required to fill these holes ♦ Provide a dumpster for the collection of all debris associated with this project * Make"safe"the existing collapsed deck and carefully remove the trapped furniture, grill etc. setting to one side for Rosemary ♦ Remove and trash the existing 2 deck structures ♦ Do an investigation dig to establish whether or not the existing"tube" foundations are 4' deep NOTE: if these are not 4' deep then the client must be informed so she can authorize the installation of concrete sona tubes to code NOTE 2: If the existing tubes are 4' to code, it should be noted that Nexus is not responsible for the condition or performance of these existing sona tubes * Furnish and install a new dryer vent cover to replace the one damaged during the storm * Furnish and install pressure treated (PT) frame work to create a new deck to the existing layout 19' 2"x 10' 4"from the kitchen sliding door and to layout drawings * Furnish and install PT framework for steps from this new deck to another deck as shown on the plans and to layout drawings * Furnish and install PT frame work to create a new deck to the existing layout 8' 2"x 18' 3" and to layout drawings NOTE: existing granite step to LH side of existing deck to be utilized as a step to yard ♦ Furnish and install PT framework for steps from this new smaller deck to grade as shown on the plans + Furnish and install aluminum flashing detail to the intersection at the house walls * Furnish and install"Azek Morado"deck boards to both new replacement decks * Furnish and install "Azek Morado" deck boards with"White" composite risers to both new replacement stair systems * Furnish and install "Radiance White" vinyl hand rails with square ballesters and white PVC sleeves over all PT posts NOTE: DO NOT USE"Radiance Rail Express" as this has exposed brackets SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 3 of 7 ® Furnish and install composite trim boards to the skirt boards around the perimeter of the deck and the kick plate going into the house and garage ♦ Furnish and install new cedar shingles around the deck connection area to replace those damaged ♦ Cost for materials and labor is $22, 763.00 Dining room window; ♦ Remove and trash the 3 windows (1 picture window and 2 double hung flankers), in the"bay area" at the rear of the house in the dining room ♦ Furnish and install 1 Andersen picture window—no grills—with a clad exterior finish and a prefinished"white" interior finish—NOTE; existing dimensions to be utilized as closely as possible ♦ Furnish and install 2 Andersen double hung windows—no grills—with a clad exterior finish and a prefinished"white"interior finish—NOTE; existing dimensions to be utilized as closely as possible ♦ Furnish and install insulation to these new window set ups ♦ Furnish and install any interior or exterior trim to these new windows ♦ Furnish and paint the new trim only ♦ Cost for materials and labor is $3, 555.00 Dumpster; ♦ Supply and remove trash - $650.00 Kitchen cabinets; NOTE: wall cabinets x 2 and trim pieces to be SAVED and given to Rosemary to _arrange for collection by the insurance company ♦ Remove and SAVE 3 part trim over the wall cabinets over the sink and to the right of the sink ♦ Remove and SAVE 1 wall cabinet and 1 glass cabinet to the RH side of the sink ♦ Furnish and install 2 new wall cabinets and a run of 3 part trim through Family Kitchens ♦ Cost for materials and labor is $4, 970.00 Sitting area repairs; ♦ Compound the crack in the wall over the top of the existing slider ♦ Sand the compound to blend into the existing plaster ® Furnish a primer coat to prepare for paint ® Furnish and paint with 2 coats the entire wall with the same color as previously used ® Cost for materials and labor is $610.00 General; 0 Leave construction areas in "broomswept" condition SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 4 of 7 The above quotation does not include the cost of any of the following and in some cases where stated allowances have been given to assist you in selection. If requested, we would be happy to provide any costs on items listed below, if not here stated; —Permit costs (plan for$400.00-500.00) or unseen conditions Painting or staining or prep work beyond specifically noted in the scope of work above Upgrades to existing utility conditions or structure Dryer vent pipe work beyond the cover repair noted —Upgrades to mechanicals and any heating changes beyond those required to complete the scope of work —moving of personal property—NOTE: we are happy to help, but would not want to be wholly responsible Asbestos remediation of any kind —Insulation unless specifically noted in scope of work above —Window or door replacement unless noted above — Cabinets or counters supply unless noted above —Appliances, hardware or fixtures Concrete sona tubes or foundation if required - $2, 100.00 quoted All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control owner to carry fire,tornado and other necessary insurance.Our workers are fully covered by Workman's Compensation Insurance. PERMITS "Nexus"has accepted the responsibility to obtain the necessary building permits."Nexus"will act as a GC and work in accordance with fair and reasonable practices,and cooperate fully and under-the guidance of the"Owners"and authorized parties. Standard Exclusions: Unless specifically included in the"General Scope of Work"section above,this agreement does not include labor or materials for the following work(any Exclusions in this paragraph which have been lined out and initialed by the parties do not apply to this Agreement): Removal and disposal of any rnaterials containing asbestos or any other hazardous material as defined by the EPA. Custom milling of any wood for use in project. Moving"Owners"property around the site. Labor or materials required repairing or replacing any"Owners"-supplied materials. Repair of concealed underground utilities not located on prints or physically staked out by"Owners", which are damaged during construction. Surveying that may be required to establish accurate property boundaries for setback purposes(fences and old stakes may not be located on actual property lines). Final construction cleaning("Nexus"will leave site in"broom swept" condition). Landscaping and irrigation work of any kind. Temporary sanitation,power,or fencing. Removal of soils under house in order to obtain 18 inches(or code-required height)of clear space between bottom of joists and soil. Removal of filled ground or rock or any other materials not removable by ordinary hand tools(unless heavy equipment is specified in scope of work section above),correction of existing out-of-plumb or out-of-level conditions in existing structure. Correction of concealed substandard framing. Removal and replacement of existing rot or insect infestation. Construction of a continuously level foundation around structure(if lot is sloped more than 6 inches from front to back or side to side, "Nexus"step the foundation in accordance with the slope of the lot). Exact matching of existing finishes. Repair of damage to roadways,sidewalks,or driveways that could occur when construction equipment and SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 6 of 7 noted. If the"owners"do not spend the frill allowance in an area,this amount will be credited back to the customer and not included in the final contracted amount. If the"owners"spend beyond the allowance noted,then the"owners" shall be responsible for this balance and a payment made to cover this amount either to the vendor,the sub-contractor or to"Nexus" Expiration of this Agreement: This Agreement will expire 30 days after the date at the top of page one of this agreement if not accepted in writing by"Owners"and returned to"Nexus"along with the necessary deposits within that time frame. People Authorized to Sign Change Orders: The following people are authorized to sign Change Orders: "N us": Mark Gotobed or Ged White "Owner/Owne ` Rosemary Saracusa Concealed Conditions: This Agreement is based solely on the observations"Nexus"was able to make with the area in its current condition at the time this Agreement was bid. If additional Concealed Conditions are discovered once work has commenced which were not visible at the time this proposal was bid,"Nexus"will stop work and point out these unforeseen Concealed Conditions to"Owners"so that"Owners"and"Nexus"can execute a Change Order for any Additional Work. Changes in the Work: During the course of the project,"Owners"may order changes in the work(both additions and deletions). "Nexus"will determine the cost of these changes and the cost of this additional work will be added to "Nexus"profit and overhead. Schedule of work It is agreed by both parties that this work will be coordinated with the"Owners"and "Nexus"to be undertaken in various stages to avoid complete disruption of the home environment. "Nexus"will give"Owners"no less than 2 days notice prior to arriving on site for commencement of any of the agreed stages of work to allow"Owners"to prepare."Owners"commits to have sites identified for Page 7 of 7 Contract Cost and Payment Schedule: Total cost of work description and materials included in the proposal (except materials/work stated)- $32, 548.00 (Thirty Two thousand five hundred and forty eight dollars and zero cents) PAYMENT SCHEDULE 1st Payment due upon signing this contract TOT $7, 000.00 2nd Payment due upon receipt of permit TOTAL $6, 000.00 3rd Payment due upon completion of deck framing TOTAL $6, 000.00 _4th Pavment due upon completion of hand rails TOTAL $6, 000.00 5th Payment due upon completion installation of window, and cabinets and trim TOTAL $6, 000.00 Final payment due upon completion of scope of work TOTAL $1, 548.00 J Amount due upon signing this contract i $7 000.00 r� ccc 1132 I have read and understand, and I agree to, all the terms and conditions contained in the proposal above. Date. ." �. ........ "Nexus"Authorization....... Date... ...... "Owner/Owners"AuthorizatiQ ! :�?tc2,� �, ��. AND/OR Date............................... "Owner/Owners"Authorization..................................................... SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT - - 1tit S'S Ole U€ IN i NORTH ANDOVER CONSERVATION COMMISSION a icy. w \,A ` C,6 \ 1 PD ey-Z sof\ (,,4 ck SStAt ?5 ateX+S�� "° t L tt 0-li r,°fie At- 4N fl s Aever- c.es" n :k-�, a' Brox o. The Commonwealth of yavachu etts , - •• ,�e�a�tment of fn��,s�znrAcczc�ents Of lee of fave,stigations 600 Piarshing-tan Street Boston, Nle 02111 www.Tna,ss.govIdIa oxkex ' Com�ensatiox� ante�6.a-dt:Bui dexslCon ca� OxsICX p ase xint��P scant or a fon )e S Seri�C� Nam()(Business/organizaR-0jfidividi l): �J O a� g2 X60 �6� Address' 6W Shona#' C% /state/2jp: �a�tw � we,of Project(xecluixed)• xo .ire yorx as employer?Cheekthe app pxiatebo�:4. 0 Z am a general contractor and Z 6. Q New construction 1.Qam a employer with _--- .. have bixedthe sub-contractors �, n Remodeling employees(full.and/or pmt fie}' listed on the attached sheet. Demolition artner� 8. ❑ -, 2.❑-lam a sole proprietor orp These sub-contractors hav � Building addition ship anShave no employees -workers'comp.insurance (i'� 9. form in any capacitY. oxaRon andi s Elecfxicalrepairs or additions working 5. ❑We are a corp 10.}� ['o workers' comp.jnsurance officers have exexeisedtheir 11.n ,lbg repairs or additions required.]; right of exemption pexMGL Boofxepairs ahomeown-er doing all v+'o c.152,§1(4),andwehave na 72.p \ 2 3. Za s employees. oworkers' 13,�Othex 1� myself.[,No workers' comp. employ G� ed. insurance xeq*ed]? comp.insurance xe uir their workers comp ens ation p c1icY0�a�on. outtho sep'tionbei6vr showing oiio information• x a c t at checks box#I m t �gthey to doing ai]worlcandthenhue oufside eonixacforsm thcirbmit anew a davitindicatmg sue . Y pp davit rn the name of the sub-contractors andtheir workers'comp.P Y T homeowners woo submits afft o �rtg xCoirhacforsthateheckthisboxmintaitachedanadditional shed S ti0�2i12s11�a7leefol,myeTYtpZoyeeS: Berowistheyolieyandj To eN that is pYovidtfig workers'compensation X am an emp Y information. Insurance co xnpanY ams' ExpixationT)ate: PORGY#or S elf ins.Lic.#: City/State/Zip: the olicy numb and expiration date). lob Site Address: oke declaxadon page(sho�'Wg p 1 enalties of a tom ensation� y osition of criminal p A-ttaclx a copy of the workers p ORDER-and.a fine use coverage as requixed under Section.25A of MGL o.ena tiesin the forme f a oxwaxdedo the Offlea of Failure to sec ear p so ant,as wallas civil ft1lb statementmay be f fine up to$x.,500.00 and/or one-y of-UP to$250.00 a day againstthe:yrolator. Be,advisedthat a copy ^ vexrfrcation. Investigations of the DIA for insurance coverage tits irzformcction,pxovided above is trite and cor'r'ect. �tcerttiepains tipena7tiesofpeYjur'yMat Date: `6 t X10]'iere�iy cex'tzfy . Si afore• 60 "2,e3 Phone #- TetetZ�y city or town official vse anry. -VO not write in this area,to be comp - • Bexmit/License# City or Town: C actor 5.plumbing f sp ector Xssuirxg Antlority(eixcXe one): e 1.Board of ) eatth 2.I3uildingDepaAment 3.CitylTowa Jerk .ElectxicalJlnsp 6.Other phone#: CERTIFICATE OF LIABILITY INSURANCEF6/9/2015 DATE(MM/DD/YYYY) 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 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 to 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 CONTACT Lauren Goldman Cross Insurance-Peabody PHONE (978)532-5445 Fax A/C No:(978)532-2217 139 Lynnfield Street E-MAIL 1 oldman@crossa enc com ADDRESS: g g y INSURERS AFFORDING COVERAGE NAIC# Peabody MA 01960 INSURER A:Western World Ins. Co. INSURED INSURERB:Safety Indemnity 33618 Nexus II Services LLC INSURER C P.O. BOX 2 823 INSURER D INSURER E: Woburn MA 01888 INSURER F: COVERAGES CERTIFICATE NUMBER:CL14121825721 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. INSR ADDL SUBR LTR TYPE OF INSURANCE I POLICY NUMBER POLICY POLICY M DDnYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ A CLAIMS-MADE F OCCUR PP8236669 8/12/2014 8/12/2015 MED EXP(Any one person) $ 5,000 PERSONAL RADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PERLOC $ AUTOMOBILE LIABILITY COMBINED SINGLE _.MIT Ea accident B ANY AUTO BODILY INJURY(Per person) $ 500,000 ALL OWNED X SCHEDULED 116632 11/10/201411/10/2015 BODILY INJURY Per accident) $ 500 000 AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ 100,000 Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N E ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Refer to policy for exclusionary endorsements and special provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Rosemary Saracusa ACCORDANCE WITH THE POLICY PROVISIONS. 7 Ingalls Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Timothy Tramonte/NIDI !w Massachusetts -Department of PUbHc Safety BoaM of Building Rer rr9adons and Standards . t;"omtruction .iaup r%ko Uc:ense: CS-073991 GERALD WHITE 23 GLENDALE DR DANVERS MA 01923 Z21 Expiration Commissioner 04/07/2016 - rl it ( i xiirowlic?M111 r 07l79ar//rrr^z. t��c6poilsnjYr#AfaitusinCs�Reila[t►on OME IMNZOVEMENTaCONTt TOR M1 egistration: 129177' "stype: Expiration: 7/19/2015 Individual Gerald White Gerald White 23 Glendale Dr Danvers,MA 01923 Undersecretary I 77, y �r reg # ata �Xtftlf Gtt use oltly, 'o��, �,exgir�gon,dafe„HTf,#'ot#n�c�'r �rn to � fJftice of Consumerairs and$usiness Regalatipn" 10 Pari(Plaza-Suite 5170 Boston,MA 02116 Not valid without signature