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HomeMy WebLinkAboutBuilding Permit # 3/22/2016 psi TOWN /01D4 N..1��. , he� r � Fm ! �RTANDOVER � e� roup � �'15�,F'�t/ed T � �l e n nn G w a 11.laol�,J rrA�l�� �.��� �x Wq� 74. yrs 1 ,��r %I� S(8a,�.� r q ryrc �. I 1�, n�1� atl Tn '` t ti .,"..., �, �.,�.,�".. �,., .. . .,m. am" e ...."„ w P ? WAI, �� �h ' ���. ..... .. I. "wd". nhM Addlon Two or mom famdy .....m. .. �. �, ... � ; m....,.,,.. ��"'�ti'�'�$� ! � ���������� �iN�" ;'WJ��� �;r��d�� I.IW""at f aewser _ ..... 6s 4 Ma tow ..., .�..�"/'�4�'''f�,�""�,✓" a� �'r ,,,,,,A' Vin° "�`�, �'" �`roA d�'...:� "�� �"w...'„t� ,;,� `” �.�.� ....�.��Aarro .......�"� �m.„�.y.., Ate.�.B,ar�^'.�”" .. � ......... Mh vrMbn Muse'111mi or PrhH (Wily) 0 ISO,rly) " w""k� dr',ad' .i�. . ��,. � A ,,,,.+w w u�✓ 6 ,r" a �" �'""�,.�'d'�"r~w.m �` ..,, ��� ;,F ox'ti'Inmu w;�rn'u v v�wnv�urvavur renmmrnvrnw�w�»wiirr iwrvivrvw vv n',vrn rirarvav nvrva»v v vara wua n ,,,, ,,,,,,,,,,,,,,, ;r SUpervii xll$n Ilr,%r(m 1n r o �� �a �. yjr P ,r x. FEh SCAMDULE BUL LONG �. 8"",� Check � fir— ! � J" �,4;�1�.,,"dit �«"�5.'tl,,,,., r°, WM,,.« G k � crud "�G(<l rd Ft4OR TH Town of Anc'lover "k M ® s - I o L.AKI h ver, SSS' COCA0Tjj 22 A. "IC Na.,.I �• U BOARD OF HEALTH Food/Kitchen P IT L D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ....... ... ................................. ........... ..... .................... ...I........ has permission to erect ............... ..... buildings on .. ... .1.. ... ........ ... . .......... Foundation 0 1, Rough tobe occupied as ........ ..... ....... ... .. . . ........ .........a~ ....................................... chimney provided that the person acceptin 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 EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TARTS Rough Service ..................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Displayin 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. Massachusetts "Oils form satisfics all basic requirements of the state's florne Improvement Contractor Law(MGL chapter 142A),but does;riot Include sta ndard language to protect houncowners. Seek legal advice ifncccssary. Any person planning home improvements should firat obtain a copy of"A Massachusetts Consumer Guide to 1-loinalminowment"before agreeing to any work oil your residence.You may obtain a free copy by calling the Office of Consumer Affairs mid Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-898-283-3757 or on our website. Homeowner Information Contractor Information Nania Corn l'i"Une Din, qt Z�-zl—&1,V .0muse street Address(do not use a Post Office Box ruldrioss) 'onbactor/Salesperson/Owner Name 3 j 5 6y e,4117,�6'11 ; CityTown swe Zip Cix Busurms Addiwa(niust include asIrccl *14/4"Ve,'i 11N Daytime Plione Evening phone Cut/T Stale Zip Codq_, 77y Mailing Address(it different from above) Business Employer ID Or S.S.Number 44. N.W. ExJ* ion e The Contractor agrees to(to the following work for the Homeowner: (Describe in detail the work to completed,specifying tile type,board,and grade of materiat;to ba uscL use additional street;ifirec clarx. as i,A4 4 do,l, it-eZ I Lo!W,� 'r. /I eZ ild, /),z J�;,7j, a'z Required Permits-The following building permits are required Proposed Start and Completion Schedule-life following schedule will and will be secured by the contractor as tire homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own per inits will be excluded from the Guaranty Fund proAsions of when contractor will begin contracted work. MGL chapter 142A.) —1�WDate when contracted work will be substantially completed. Total Contract Price and Payment Schedule 'Ile Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of M Payments,will be made according to the following scluxtric: $ -poll signing contract(not to exceed 1/3(if the total contract price or the cost of special order;terns,whichever is greater) $ by or upon completion of -----------by or upon completion of...... $ upon completion ofthe contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) Ilie following must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.("'Po) $ — to be paid far NOTES:(*)Including all finance charges(I-)Law requires that any deposit or down-payment required by the coutinctor before work tuogins may not exceed die greater of(a)one-third of the total contract price or(b)the actual cost orally special equipment or custoni made material which must be special ordered in advance to meet the ExuressNVarraiitv-lsariexnr�swiri"antvbeta tearo odh I centracatia-1 W.f-1—1— Subcontractors-The contractor,agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payrneins to all subcontractors for materials and labor tinder this agrectLient Contract Acceptance-Upon signing,this document becomes a binding contract under Jaw. Unless otherwise noted within this document,the contract shall riot imply that any lien of other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract-'rake time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor his a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information oil the reverse side of this form mad get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing ofthis agreement. Seethe attached notice ofeancellation form for an explanation of this right. DO NOT SIGN IT-US CONTRACT IF THE RE ARE ANY BLANK SPACESM Mml-� identical copies oflif�oattriffithu qxbgi!cd and signal-One copy should go to th.hurry ,nar.The other copy st...Id be kept by the contractor. ............ Homcr witer a Signature 1��Zlhl �00 Contractor's Signature ---—-- Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the tight to initiate an arbitration action(as an alternative to court aa.-tion)if they have a dispute with a contractor. The sante right is not automatically afforded to a contractor,however. 'fire contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Horne Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office 9LACO sumer Affairs and Business Regulation and the consumer shall be required to submit ich arbitration as ided lil aSsachUsett,General Laws,chapter 142A. t t �'C`arbi,-- HWA.owner's Signature Contractor's Signature NOTICE:The signatures of the Parties ab apply only to the agreement of the parties to alternative dispute 1, resolution initiated by the contractor. T e I tincowner may initiate alternative dispute resolution even where this section is not separately signed by the M Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGI,chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded front certain tights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warrant),for worlarranship or materials.Is. Iiiaddition toguarantees orwarranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which tire bomcowncr and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consurner/horneowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract intist be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have beery attached. Parties are also advised not too sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance ofthe dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-293-3757 or visit the OCABR website at If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,889-283-3757 or visit the HIC website at Go online to view the status of a Home Improvement Contractor's Registration: For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-6524800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 Hie Commonwealth ofWassitchusefts Dcparanent of'IndustrialAcrielents I Congress Street,Suite 100 Boston,MA 021142017 wwwanass.govIdia Worlters'Compensation Insurance Affidavit;Builders/Contractors/Electricians/Pharrmbers. TO BE FILED WITHT11E, PEE TING AUTHORITY. Applicant Information Naine(J3usiness/Orgaiiizationffndividtial): Dest,k,,*id e 6',re g,,,e— Address: 0 1J fid city/state/zip:A el I'A7 AIR Phone#: 9 7:;- Z/-,f 6 '50 Are yo7, /,in employer?Check the appropriate box: Type of project(required): 1 lQ'I am a employer with—/—employees(full and/or part-time).* 7. 0 New construction 2.®I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.[J 1 am a homeowner doing all work myself.[No workers'romp,insurance required]t 10 Building addition 4fl 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 I I.E]Electrical repairs or additions proprietors with no employees, 12,E]Plumbing repairs or additions S.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 13.EJ Roof repairs These sub-contractors have employees and have workers'comp.iDSUrmlCeJ 0 W,',1 dow 4ep. If 6,®We are a corporation and its officers have exercised their right of'exemption per MGG,0. 14, Other 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, f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. fContractors that check this box must attached an additiorial 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. lattiair einployei'iliatisprovidiiigiporl(eis'conipetisalloislitsuraiieefor itiyenil)loyee.y. below lsthe Polley andJo bsite infortnation. M q Insurance Company Name: ("11,4 C/ C„,1°e"r r I C C", Policy#or Self-ins.Lic.ff: 7 Expiration Date: City/State/Zip:IV X-11 ell"I Job Site Address:- J ?d5;e,1 5t­ 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 tip 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. Idohei-ebycei�t;(,Otitideribepaitison(,I enalfres ofpeijury that the information pro vNed above is true and correct. Si nature: Date: Phone 4 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): i 1.Board of Health 2,Building Department 3,City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector, 6.Other Contact Person: Phone 0: %N insurance Solutions Corporation - Page 1 of 2 DATG(MM/DD/YYYY) ® � CERTIFICATE OF LIABILITY INSURANCE 3/18/2016 !THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THHUTORZIESELOW_ THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the oertlfloate holder Is an ADDITIONAL INSURED, the polloy(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 oertlfloate holder In Ileu of such endorsement(s). PRODUCER Kathleen Miller, CISR, CP IW Insurance Solutions Corporation (A/C, (603)382-4600 All No ; A1609>9e2-2094 A/C No Ext E MAIL 60 Westville Rd ADDRE69:km111er@iso—insurance.com INSURERS AFFORDING COVERAGE NAIC Plaistow NH 03865 INSURER Merchants 23329 INSURED INSURER B! David M Degagne INSURER C: 1049b Mammoth Road IN6URGR D: INSURER E: Pelham NH 03076-2193 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1631826091 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 ECERTIFICATE XCLUSIONS ANDYCBE ISSUED OR MAY PERTAIN,ONDITIONS OF SUCH POLICIES.LFE INSURANCE AFFORDED BY THE IMITS SHOWN MAY AVE BEEN REDUCED BIES Y PAID CLAIBED MS. HEREIN IS SUBJECT TO ALL THE TERMS, IMS INSR NoTYPE OF INSURANCE POLICY NUMBER MM/OD/YYYY MMIOOIYYYY LIMITS LTR 1 000 000 X COMMERCIAL GBNBRAL LIABILITY OCCURRENCE EACH $ A tu CLAIMSMADE ❑X OCCUR PREM18E3 Ea occurrence S 500,000 ROPIO87053 11/4/2016 11/4/2016 MEDEXP(Anyoneperzon) $ 15,000 PERSONAL a ADV INJURY $ Included GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ X POLICY PRO-CT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 Property darnage-sholelimlt $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY r BODILY INJURY(Per person) $ ANY AUTO ALL OVvNEDSCHEDULED BODILY INJURY(Per ecddent) $ AUTOS AUTOS PROPERTY DAMAGE g NOWOMED Peraoddent HIRED AUTOS H AUTOS $ UMBRELLALIAB occuR EACH OCCURRENCE $ EXCE08 LIAR CLAIMS MADE AGGREGATE $ $ DED RETENTION WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y I N ANY PRO PR IETORIPARTNERIEXECUTIVE *s�E e�Low E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? F7 N/A (Mentletory In NH) E.L.DISEASE-EA EMPLOYE $ If as,dexri6e under E.L.DISEASE-POLICY LIMIT $ DrSCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarlle Schedule,may be attached it more apace le required) *The insured has purchased Workers' Compensation coverage through the MA Worker's Compensation Assigned Risk Pool. We have requested the servicing carrier issue a Certificate of Insurance on your behalf. Agents are not permitted to issue Certificates of Insurance for Workers' Compensation coverage on policies issued through the MA Worker's compensation Assigned Risk Pool. CERTIFICATE HOLDER CANCELLATION (978)688-9542 t3MOULD ANY OF THE ABOVE D98CRIDED POLICIES DC CANCELLED DEt'ORL' Town of North Andover TNG EXPIRATION DATE THEREOF, NOTICE WILL CE DELIVEIIED IN Attn: Building Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Keith Maglia/KRM <_ ®1888-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) ,ac R CERTIFICATE O LIABILITY INSURANCE DATE(MMIDD/YYYY) 03 18 2016 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 NAME: INSURANCE SOLUTIONS CORP. PHONE FAX AIC No Ext): AIC, IC No): 60 Westville Road E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# _ Plaistow NH 03865 INSURER A: AmGUARD Insurance Com an —+2390 INSURED -INSURERB: DAVID M DEGAGNE INSURERC: 10498 MAMMOTH ROAD INSURER D: INSURER E: PELHAM NH 03076 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE E OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ '.. GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS F NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE 1$ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N R2WC658267 11/4/2015 11/4/2016 TORY LIMITS _ ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT Is 100,000 OFFICER/MEMBER EXCLUDED? Y❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE$ 100,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) The workers compensation policy does not provide coverage for David M Degagne CERTIFICATE HOLDER CANCELLATION Town Of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 Osgood St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover, MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Insurance Solutions Corporation - Page 2 of 2 1,18,2016 17141:43 BH Insurance OMC ID 16037416 1/1 ' ' � ��I INSURANCE ■ DATE(MMIDDIWYY) AC ORO TVI 03 18 2016 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. It 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 oertlfloate holder In Ileu of suoh endorsement(s). PRODUCER NAMIB: CT INSURANCE SOLUTIONS CORP. �P,gHOONE A1C No E�£dA� Ext..........................................._................................................(.......,.._..1:...................................................... . 60 Westville Road ADDR1169: INSURER(S)AFFORDING COV5RAGS NAICO Plaistow NH 031365 INBURERA: P RP-,LO. #flQ".gym I� 2390 INSUR@D,,v��,,�„ ,.��� ..,,�.��.. INSURERB: DAVID M DECAGNE x N ,w:.:w 10498 MAMMOTH ROAD ,INauasR .:............................................................................_..................................,................... ................................... INSURERE,' w..M.. .,....,.w PELHAM NH 03076 INSURERF: COVERAGES CERTIFICATE NUMBER: 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 R DU�,CyyEDPBY P PIIDCLAIMS...........................................................................................I.......... ........... iLTR TYPE OF INSURANCE ADpTINSR9UtTR POLICY NUMBER M1AT'YY MMII] W%y LIMITS GENERAL LIABILITY EACH DAMAGE TO R N I ED 6 OOMMCRc1k OL;NER _3_ AL LIABILITY PEtFMI FF"1Eta n cx renrel...... . ..............................._ D ........_.. CLAIMS-MADE OCCUR MED EXP(Any one oersonl S PERSONAL&ADV NJUR".... ................................................... ...................._..............--.......................................... ...........................-............. GENERALAGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER: ;BODILY CTS-COMPJOPAGG $ 8 POLICY PRo• LOG AUTOMOIBIL19 LIABILITY IdaraS ANY AU 0 INJURY(Per person) E ALL ovAwc) 9CFIP:DULEL7 BODILY IN.oJRY(Per acrlrenry 3 AUTOS AU105P PER] o n 4 NON-OMED {er acrid?n J HIRF-D AITOS AUTO'S S UM13RELLA LIAR UCCUk EACH OCCURRENCE 8 µ fi10ESO LIAB CLAIMS-MADE AGGR OAmmrF.,. M N: S ~ DED RETENTION STAT1.1- 1­11 WOitt(ERSCOMPENSATION R2WC659267 11/4/2015 1/4/2016 Il�fiY1,IMfCS. . ,.,ORM.,,,,_ ,,,, ..,.,,,n ....... JITH- A AND EMPLOYERe'LIABILITY Y/ry 100 000 ANY PROM- IETORIPARTNERrEXECUTIVE NIAtm.L.lACf1ACGIDE„NT .� ..........f.................................. OFFICERIMEMBEREXCLUDED4 � E.L............................................ (Mandatory In NH) E.L.DI6EA.3...... 113LCYE" $a00E000 If yes,describe under E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OFOPERATIONSbelow DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remake Schedule,If more apace Is required) The workers compensation policy does not provide coverage for Davld M Degagne CERTIFICATE HOLDER CANCELLATION Town Of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood 5t ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED ` [x 7 R 1 rt _. AUTHOhIZED [2 41888-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010106) The ACORD name and logo are registered marks of ACORD �/�2 CPO�)Jl/))LO�LCC{BfC�IL O- °� � aye of Cons�drae5 Affi s&Business Regulation 1flE iPJi RG-VEMEi If coViTRACTOR TYPg: ,gistra$i��a: ":,;7566 w-piration:.;5/2S/?b16: Individual DA�IID DEhAGNE DAVID DtOAGNS. "049 MAMMOTH RD U�IiT B pELHAM,NH 0376 Ondersel rAt' y License or regisi'r0lt ' valyd fo:.tAvidul use only before the expiration date. Iffound rp.urn to: -®ff'icq.of 1Conse mer A_ff#j sand Business Regulation X10 Park Plaza-Suite 5170„'{,. Boston, `•c.”'y,-�' i.g en' d_.?'A..0 .a6' M ,s. r���5 `�,f vaii �vithout siga' e IMassachusetts Department of Public Safety Board of Building Regulations and Standards V License: CS-075353 j Construction Supervisor �4 DAVID M DEGAGNE ' 1049B MAMMOTH RD PELHAM NH 03076 q Expiration: Commissioner 08/23/2017,