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HomeMy WebLinkAboutBuilding Permit # 12/18/2015 XAORT{y UIL.DING PERMIT o��sLao h.... O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION N „qJ me" Permit No#: Date Received 0- �gSS�CNUs���y Date Issued: i I IMPORTANT Applicant must complete all items on this page ,�f"L.,�, ,r,..: L u F..it.�..✓. ..rdrrr .x.,r-. � r r�N ,rr1' :r. .,.r..../,� �.3r,,, ,.,rf a 're rr rE" ld r F .: 1.r''„ ..�. .r� r,r f ,�.'�". 7/ s rr } ..� er r'; :,:r .fir_ � E�, r✓". �.w � .,. c;'f 1. >�, r<.. .-r a,r�rr tr ;;.. t�} .,,.rcr',�. � s.. � fr ::✓ �:-rir. ,+ f.-.=I r h t �.r^ ,rr... ? � r r.f.,i``' .�., _� r�. �..,' xf H ra ,.. ,s f,x;fi / r ,•. .! ,.� ,:,'� . .r?"y 3,. / l:. ,/sem,,, �'�,. ��. ?' �r r=,.`.r J r ,s S r � a-�,x„"'. fii��� '€r- s�:..rrlil J >"rr f �rrui fx t Ir fix ��':rr � ,✓y �,�'� „�:rr ;�ff?�g � try r .trtix r' T4s �f .�> ,�z�`%r. •rr�:x..rr� f'fr,,,..;r � r,=:u ✓ff,.x r�•t�.. � <.r� � ��k�� .."_. ,rr /.�'_��:.�rxr'�''`i�. /✓ c ul,s°xs`,1°f l,r.r3 r- �;r v x; �r7?rk- k � ( x f, ;f� r c-r�rr�r� �:�'� �,:.,r,,r ..,�, �,?, � �r.✓�•r v�trr s%11�,y�`r .a�i,r��k ,,�,�3Y`,,m'' -rx' r,=F� rX ,,�'�y�?a Str�{�rx `' ,?�'w Jtrr r�1� �� s, .�• „�Y,^'"'��"���';� ' ai>t � �� '�"r � �i''^' ^,c,sr; ��'r'' nr�.r'”. „mµ�'�����•�c,✓:x:�tri��.r'r e�r r ;,r k'J'rJ ..,,,.dam ft,�`:u if� .��I,��' `/ ? f�' aP" ,:r f's?'"�` ar y ,r„rr��r r ✓} ��' i•;t fr,,,e rgY`A s �r'r^us' r< _ r�� r � �°�r� � sr".f' r,.1 A „�i .1"✓ter' ,�" ',: +,rr ,:. 6`, f rr .r rL'•`(/rr:T/r"gr'l,_.:, .r„=, 1 _ - p»r��s.�"v%,r7�,�pG`% ,7' "q ?".'v^v.,,"'FF.�"r' '.""a"5>�✓L4'M":."n.` i;':moi -YrF�, �r. 1,r",?,i "bl l;;l ,. / .� �,�� �/�> ✓•r`r.t�r>Y� ,.w,r°.t>' 9 rr _ ;,..,. �,^.A !}rrj ;z'.!:. � ' r'„r�&�`ra:., z,c,,'rr,>u Axa rr''�f x „r..:.0 �,:u�,,,::.,r'„ ,,...n•r_. ,�' '.,�1 ,,.�f �YeS .c .:� 1,.:��., rlr ,�r,. r ,r r".' �� , ri~ :�r r r G: y,� `%''� ' r�t�. .�„a%'tr,�.�'r�:r'".✓',r;� ,^_."r�r . t ; `,-?^f `ryrrr 1t€Ilrli ,r :."fi r,.tt drr.,. r" ,,. r r't ,�'i'�a`.�r:l r``! '✓ .,;!?�..✓ "' :,'”' ,vxY ca rr✓ ,rIr' N�fr�/ZONI G�DISTRICTp�r����r,��HisricfD. t•-: �� �� .� t,�,�,.��.,u strtct�„��r� ,� ; r;fs�rfrrd .� ,�.rar"`.': rr � sr^v- ,,r f s...� r Y :ur•i ' / ..t _>r. .t r.�, esJ"rr~�i`'�'�. Y�r I .s-,�.',�' �"" .m` .s'.d� :; r�::rr b�'. ,-�1 ... r r r:::. rr'r < '.,� t a✓,: ”' .:.f, r,?�. �tt ..:.,,;; i. r''a � � � x r� :z "Y/ r.:r f/ � �r r',u; ✓ r r e� ," r �,rir� �:�"�,� . ,�Xfr� ru .r�, yN� "i=a °3. .�r._� r Yrr•� f,��..r.,+tt.;.,t Jfrfu,.. r�7 r."r� F r;?�,ra � �r�?i'r2 ..r l r.r% r'": +,ti=l � 'Y :''� .-m�x•S„:t,r r .� z•`rt,�� lr rr s, rY,. /rrr„ U ,r / r Machrne Sho Vi Ia e „ ,;.. ,r,k; ,.._ l_,...,,,._,z, ,... ...:.......:. .;..,.,.,:.�f„ ,,,,z...,•, .,.. fr t, � J t t sy��' Xr: r� ��res� n f TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 1� Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other /I t �`� G xF J r°�❑Se tt'��fr�/Q 1/Uell � C(Flood Iain r` y❑rWetla ds ' ` , `�'f f � ` r . �„r r „ p N n �. �, 1.,,r 1❑,,Watershed Qistrict f` >t �..r,`i�✓ .,,.x x,4 rY f'{r•,v= fi«-r' r- r cr, �-r 1 w ,::,r .r .s l r 1, m�1Ju" ,r,,,lf r .f r,� r �` -Y x .i. ✓,;. >:: r X ff-..:1 r t.k1 r-�!` Y ,',.. fr,r" r Mrd .,t �.`.. �` _'rte,` €; ,r%. .�4 ;r„r..;.„.r�r / .d �'. f x�,r 'f r=r rr :.;1�� xr,``r X �- r`rk✓ ,."r`rt&y��^'t�jl'"r��"2l'. Y'�9;�JJ,.=+�s� xd�v�if`r 4 fi.:C r ,,;," ''� t,1/Uater/Sewer-, :.r , {,x'�r, r„r �/ � %'iF rl�:Yrx lir �,r� ;r,' ✓r'r of 4 ::,rr ,af�r•rr?�, x: ?'r�rxr*,r�`l�•r r' rx f�mx: f't�`,� :`r,rr €` .r'1.,��r�,_�, ,,.a r,.,,, „�„ ,:,F.„ ,,, b r ,.,.x.,,,, ./, ss.,, ,..,.,,,,, �xu"�,r�,w:u,�lt�re. .ldrF;,f`"�Y�t,`: 5r. �%�srs`,��fi',r,�r.F-,.1rr'!At� .:�.?>:;�„s/✓;✓ a r DEIPTION OF WORK TO BE PERFORMED: A,/-e ^r2-) Identificatign„- Please Type or Print Clearly OWNER: Name: �; res. ('U I',6 A Jct �',� Phone:`)X- 7 7 3 Y2a Address: e►"r i c L /I,, dc \/t(/ R //Ijrr� '-t 1.. r" ✓ ;.r F€, r; F r r.rjxdr:: ..'7t w,'"rr`•rte: rx:J�l f r" r �r .; ¢fir.ur,tF Jr."r,J,r"r `itdr r,r'-� r l,-r�;` r ✓✓ s r"..r y �a �. �X., 5 r rf r- Contrac ¢lr N me r,X y r Phone f :ti rf u rr` ..r C',x .,x .✓N 1 r n �'"-,s�rrrn�; �3` 4�/ h�, f/r"'rr al r r rl l 1 4 rd r ,�k� ',vF',t� r`✓r,rYai t�"c r�"- r r.rb n Ir r,,r... ,z r r"r mail r r? r�r Y �..• �r fx r r�,% a rt,% r r r•"r r rra :a>3ra: ,��✓Er�ly G``rlf�lrrZ ��r�1x r�� i r x j� >� r r rz;,l� �xr �r���,heu' .:e,• .. s r;, r Y ,- ,c r x nr-,r .: r. .t rr. -/ r rt .r m rl I s=: ✓ :..xf,r-, I rP-:x' te.,rr; ;s.' 9 ::xr w'"::: rr� �'..Yr..`r�tYtr�i kr 7' �"as t f,'. l„�+ 7= ��.,.ux >lb n.; ° d ar x,% /d Y ext' 7 ;t: ata �r r�Xd}r �E.�'.�*r,.�r �'-:rr�yr�.r5lr�:� �'"r�r�'`'�'�"": ,1± � ,st"'Y�,.�:nNr err' � r�r.;:• tAd cfeSS °tel � 1 r S r l J>r <� r' �r s� r r�' fY rY'`rr��{ � sr G Y' /r rr �N✓^�r � r .,�" r, 1Gk`�� _„ ✓x X',� : r d. �^ "`er:l.. ,f r rY _ ,d,� nef >z r,r.dt. r:v..✓c` :rF- rs r ::r.:.I .r ,,ro � �d.1� j Ff.:t r �r:,N .r X rr.x ld r`. .r r.d�r rr" �r'"r/ ri,{�. '1 ' yt` ✓,rtr � ".�f >`/'.� ,,, m-.I r-X„�. ;, rr 91•'' r :t U r fi / r I /,.r t rr .✓�..t.;, Frfi', ,.,r f ,�'.r r fz�.;., rrpi r .Y=" .,, s✓ > xr J �� C,la r c .:tn� �r a"_ri xT r .rrt l„ r rr �,, r Fz-,� r r�- .., r'�,�. ,�y,:ry r;Cdr r r.r- a✓,! /f •. '' ,rI'. ?,�,,y-_,; 'x ..r.f,. /x .,p ,y �� .-��' Y r✓F rW -i,.,, ,'"t F,. rr..,r., .� .,- ,.x��;u., ;,. k ,.:,r. {.,yr f,�r :'�i',,rr�•�:-,��1rc'�r Y, ;2�'r/,i',a-;;fia,,.� t ,r ,J,i 6r�;ar,r,,a,"-�,�... � r:r,s %" -,r..Ir.Sr� Ft v „-,.cr .�s4.:,._. r�-z;:.a,,n , r, ., ','."' ,,, ���.. �fjr/,%i,y„i;�r.;,gy',; r �� �h,� r ;,e"�/,r'. ,r'i"r`,>fr� �r="..k” �."'�.z,f���'�.;,°.rl re'r,fx�r s,�" ,r.�z".`�t"� ���,:s"�r„t^� ,° r Y• Xa rr �:. ��,r '.`',- ��"..x I ,u,.,".f�` ��y;� ,`^.� - rr� t/ rrr s.r�.I rf ✓ : ,.�t"'rl f � "uy_,:.1 sr�, �", .✓✓ >i. n �.,�',�,lri.x,•r.. IN:e' .�.,�+`,f�t"1 v���r�°, t� tfY"/ _..r , .'` .,. r��rd",t / ✓,�����% `� rr x;"d,.�. .< `� ,�;µ".,^r'�y,1�,ri,��,,rrt„ a r - s r= ��:; �- :s r� r k m,,Y r E f � •� F .rr� ,�He�I�Proue �enf�r�icer�se�f/��, , ., � ,�• �� .,.��.�,�������� �r��� Ex ,��µµ�,Datem�� ,�,�1�� � �� ,. , � ;�rN�yr t,r,' rrr��P 7 �.��:mm� r '`r�.�r„ .:r',a'.z...m:.r., .von.rsh.<�r�'rrr�,ar.✓sk rr�M=_.._ �, �. �r� uz�iy` 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: $ 6 06 0 t 00 FEE: $ C- (e Check No.: nRt � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the ran fu e Signature:of AgentLOwner: Signature b contractor '' 'Town ofAndover tAORTH f : h' ® �-+ 0% No. 7 C% itK� ver aSS' COCKICK@WICK PP¢,��� U BOARD OF HEALTH PEtxM -IT T LD Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR has permission to erect .......................... buildings on ....(040........ .. ... .. .....lir.. ........... ..� Foundation Rough tobe occupied as ......... .... ................................... ................................................................... Chimney provided that the person accepting this permit shall in every pect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS S Rough Service .......... ............................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy BuRough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. s y 'l KEEN CONSTRUCTION CO. A ° 1175 TURNPIKE STREET NORTH ANDOVER, MA 01845 All home improvement contractors and subcontractors Tel: (978)691-5201 engaged in home improvement contracting, unless Fax:(978)682-3231 specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered Submitted ,\ c-, 1V\ccGCli r with the Commonwealth of Massachusetts. Inquiries To, \ about registration and status should be made to the Director,Home Improvement Contract Registration,10 G� `� Park Plaza, Room 5170, Boston, MA 02116 617.973- 1 {1 t 8787 Owners who secure their own construction related permits or deal with unregistered contractors will be..excluded from the Guaranty Fund Provision Of MGL c.142A. PHONE DATE % REGISTRATION NO. EIN NO. /f tf AAA. H.I.C. 108383 46—3783401 > C/S=Customer Supplied S+I=Supply+Install ❑ See Attached Appendix A We hereby submit specifications and estimates for work to be performed and materials to be used: t io -Ve CA V � 1 > Construction related permits: WORK SCHEDULE Contra for wil not b gi he work or order the materials before the third day following the signing of this Agreement,unless specified hw in..writi g� 0 1,GrAor will begin the work on or about (date). Barring delay caused by circumstances beyond Contractors control,the work will be completed by ` date).The Owner hereby acknoMadge and grees that the scheduling dales are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY `. P (— The Contractor warrants That the work furnished hereunder shall be free from defects in materials and workmanship for a period of I following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Contractor,his employees or agents,is discovered within one year after completion of any job,including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied, repaired,or replaced,such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: dollars($ 0 0 Payment to be made as follows: )" /o ($ ) upon signing Contract; ROBERT A. KEEN Name of Contractor/Designated Registrant /o ($ ) upon completion of 1175 TURNPIKE ST. Street Address ($ ) upon completion of N. ANDOVER, MA 01845 City/State shall be made forthwith upon (978)691-5201 (978)682-3231 completion of work under this contract. Phone. Fax Notice: No agreement for home improvement contracting work shall require a >down payment(advance deposit)of more than one-third of the total contract price Name n1 Setesman- or the total amount of all deposits or payments which the contractor must make,in i� .-- / advance,to order and/or otherwise obtain delivery of special order materials and Authodze&Signature equipment,whichever amount is greater. Note:This Proposal may be Withdrawn by as if not accepted whin days. Acceptance of Proposal-I have read both sides of this document and all attached documents and accept the prices,specifications and conditions stated. I understand that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You,the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Cancellation must be done in writing. �+ D?,NOT SIGN THIS CONTRAST IF THERE ARE ANY BLANK SPACES. Sig�ature Dale I I j _ Signature Date IMPORTANT INFORMATION ON BACK I► The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 .�A www.mass.gov/dia bV�V Workers' Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: -p 5 City/State/Zip: k) Iqv-) "��'py�gP one Are you an employer?Check the appropriate box: Type of project(required): 1.[Z I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12,0 Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14.Q Other 6.FJ 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'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing worlcers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: f�� lo-5 l Policy#or Self-ins.Lie.#:6 j4 U 3 9,9 r_I� I 5S Z — Y�� Expiration Date: <�-(/ City/Sate/Zip 6/ Job Job Site Address: OCCEIJI�,' L r 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$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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify and r th pai. .,andpenalties ofpeijuly that the information provided above is true and correct. Date: 12-- Sip-nature: 922- }} Phone#: l 7 2 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#: AC® CERTIFICATE CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `� 1 10/23/2015 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(ies)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 Barbara McDonough Gilbert Insurance Agency, Inc. aHcoNtu Ell: (781)942-2225 PAC No;(781)942-2226 137 Main Street E-MAIL ADDRESS: g g bmcdonou h@ ilbertinsurance.com INSURERS AFFORDING COVERAGE NAIC# Reading MA 01867-3922 INSURERA Norfolk & Dedham Insurance 23965 INSURED INSURERB:Safety Insurance Company 39454 Keen Construction Company INSURERC:Travelers Ins. Co. 0031 483 Chickering Road INSURER D: INSURER E: North Andover MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER-CL1552101779 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 TYPE OF INSURANCE ADDL S BR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DDMYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X❑OCCUR AMAGE TO RENTED 100 000 PREMISES Ea occurrence $ , ND-P-010078/000 3/13/2015 3/13/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY El PET LOC PRODUCTS-COMPlOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ '.. ALL OWNEDIx SCHEDULED 6228807 COM 01 5/23/2015 5/23/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Underinsured motorist $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OT - AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA A E.L.EACH ACCIDENT $ 100,000 C OFFICER/MEMBER EXCLUDED. F (Mandatory in NH) 6HUB-9991M58-2-15 10/8/2015 10/8/2016 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below I I I I E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) '.. CERTIFICATE HOLDER CANCELLATION (978)623-8320 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. AUTHORIZED REPRESENTATIVE M Gilbert, CIC/BARBAR ©1988-2014ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) Massachusetts -Department of Public Safety Board of Building Regulations and Standards l,tllllll 11 LLll/il JVIICI VIS1'/l License: CS-076691 ROBERT A KEEN-` 12 E WATER STlow ME North Andover AR 0 !. a Expiration Commissioner 06/16/2017 ,p�, �ie�poo�t��zoruuea�Gf a�C��ca:tacicoleCtr Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Vx�epglstration: , 68183 Type: Iration: . 8L18%2Q.16 DBA KEEN CONSTRUCTION C4 ;s Kenneth Keen 1175 TURNPIKE,ST g r NO.ANDOVER,MA 01845`"{ '" Undersecretary