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HomeMy WebLinkAboutBuilding Permit # 3/28/2016 ............ BUILDING PERMIT 0 TOWN OF NORTH ANDOVER 1� APPLICATION FOR PLAN EXAMINA�. Permit NO: Date Received AT9 0 Date Issued: 41M0_)RTANT:Applicant must complete all items on this page A/4/14 V rr -TYPE OF IMPROVEMENT PROPOSED USE eau Residential , Non- Residential New Building E One family -1 Addition L Two or more family Ll Industrial D Alteration No. of units: ACommercial Repair, replacement E Assessory Bldg 11 Others: �,Demolition Other Identification Please Type or Print 'Y' OWNER: Name: X Clearly) Phone: Address: 7 �a0'n"072S, .............. "'N ..... 10 NIM, 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: $ Jq 500 .OD FEE: $ LA_ Check No.: Receipt No.: NOTE: Persons contracting w7h unpkistered contractors do not have a c to the guaranty fund 4, .9)*o *Ageo t,0RTH own off ndover ® AIL h ver, SSS o I 1 ' 9 COC NIC CRI N@ WICK U BOARD OF HEALTH Food/Kitchen R T Septic System m , THIS CERTIFIES THAT ,......... BUILDING INSPECTOR ......... ... ........ .... ..:...... ....................................... ....... has permission to erect ................ b ildings on . 1 ..,. ,.. Foundation p ... .® ... ............... ........... .. Rough tobe occupied as ....... .. ..... I...... ........... ... . .. .. .................................................................... 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. MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough O o ............ Service .............. .... .��.r�/ . ...................... r BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required t® Occupy Buildinty 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. ENGINEERING&CONSTRUCTION MARCOS A. DEVERS J., P.E. President/Registered Professional Engineer 16 Woodland Street Tel/Fax:978-685-5691 Lawrence,MA 01841 Cell:978-804-7588 mdjincorporated@comcast.net www.rndJincorporated.corn ROOF REPLACEMENT PLAN FOR PATTI MCCRUDDEN 607 TURNPIKE NORTH ANDOVER MA. a. Get roof repair plan all permits for work to be performed. b. Tear off and de-nail existing roof down to sheathing hang heavy duty mesh tarps from eaves of roof to protect house, pard and planting from debris. c. Inspect all wood roof sheathing, re fasten any loose sheathing and replace any damage wood. d. Install GAF stormgard ice and water shield 6' up from eaves of roof and down onto gutter, in all valleys, around all chimneys, skyligths and pipes and against all side and vertical walls. e. Install GAF cleckarmor, premium, breathable underlayment to remainder roof. f. Install 8" aluminum drip edges flashing to perimeter of roof. g. Install GAF prostart starter strip shingles to perimeter of roof. h. Install GAF timberline HD, lifetime shingles to roof using six I Y4" round head, galvanized roofing nails per shingle for 130 MPH wind coverage. L Cover all hips and ridges with matching GAF enhanced hip and ridge cap shingles. j. Replace flashing around all pipes, vents and skylights and at walls of top dormer. k. Replace flashing at all chimneys (aluminum step flashing and lead counter flashing) 1. All workmanship guaranteed 10 years. m. Includes GAF systems plus weather stopper warranty (50 year non prorated coverage on entire roof system). n Clean all debris on a daily basis into onsite dumpster to be re d a completion of project. ..T &/t YW 7T)r-'� I 'A0' Y) TOTAL COST: $14,500.00 S' Contractor: Owner: The Commonwealth of Massachusetts s Department of Industrial Accidents K s I Congress Street, Suite 100 _R.ostHA 0211!_2017 s` www.mass.gov/dia NYorlters'Compensation Insurance Affidavit:Builders/Contractors/Electt•icians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): a CQ Q J Address: 14 DO & City/State/Zip: AU2 Phone#: Are you an employer?Check the appropriate box: Type of project(required): ).if I am a employer with 3_employees(fill and/or part-time).* 7. E]New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. [] Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.O 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 0 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 1 1.E]Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.Q 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. OtheC 152,y 1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box Ill 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 Is providing workers'compensation insurance far my employees. Below is the policy and job site information Insurance Company Name; n �nQl(t�/ Policy#or Self-ins.Lic.#: 1p5. j A—567 51 —,Q--'1J Expiration Date: PD 116 Job Site Address:_ - _5rni,Ile, L n iidot/e c City/State/Zip:N .444i).e r /iAA, Attach a copy of the workers' compelsation 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. I do hereby certify under the ajh and penalties of perjury that the information provided above is true and correct Si nature: Date: Phone#: Official rise 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 Perron: Phone#: f® From Tonry Mon Mar 28 09:46:16 2016 Page 1 of 2 ® CERTIFICATE OF LIABILITY INSURANCE DATE(MRl10D/YVVY)3/28/2016 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 he 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: Douu..l Hiyyiutu s-Aari Tonry Insurance Group, Inc. HNto,Ext): (617)773-9200 q/c.No): tcr/i/YJ-yv2u 300 Congress Street EMAIL certs@tonry.com Y- com INSURER(S)AFFORDING COVERAGENAIC d .......................... .................................. Quincy MA 02169 INSURERAEndurance American specialty 41718 INSURED INSURERB:L10 •d B Of L011 .O11 :157-9.2............... MDJ, Incorporated INSURER C: .......................................................................................................................................................:.................................. 16 woodland Stroot INSURER D: INSURER E. ......................... ............. ..................................... ............................ ............................... .........:.................................. Lawrence MA 01641 IN3URERF: COVERAGES CERTIFICATE NUMBER:CL1632312820 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 15ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITH6TANDING1 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. ................................................ ..........................................I........... ............................................................................................................ NOV: "•"""•' "•' 11 lCV FFF i Pnl ICY FXP i LTR TYPF OF INSIIRANCF VJVQPOLICY NUI+IBER i IdrA/OD/YYYY MhUDDIVYYY I IMIT9 }{ COMMERCIAL.GENERAL LIABILITY ;........ 000,000 A gLAIM3-MAUI I X;UGCUH .1'100,000 .......... i ...................._.... FACH Oi..... FNCF $ I iAMA(iF 1 U K:f•1 I FU • t,PREA1I5E3{'a occurrcncc), :S CBC10001403603 :12/22/201,91:12/22/20161MFIIFXN(Anynnr.pnrnn) 5,000 ...............................................................................I FNFHhONAI 6 N)V INdUK'f i 1,000,000 rEN'L Ar-OREOATE LIMIT APPLIES PER. OENERALPOOREOATE I5 2,000,000 X r(>I Iov NHa- I nO ,.."....c,......�,...�.^ Q..... C o-al 2,0 0,0 0 i OTHER. AFrLttnnal In:a uwrf HUmtrur S AuloMneatuABlulY CC+Me:NEDSINGLE LIMIT y. arnAcnta...... .. .......................................... I ANv AU H) DUDL•Y INJURY(Per perwn) i All (1W'NFn tiCIHF011l F7) !BODILY INJURY(r6r awlaiA) S i AIII(i5 All I(Xi ',. NON OWNED ........; ;........ PROPERTY T,YnDAMAGE I AUTO: S W UMBRELLA LIAB FAI:H GL:0URHFNCF j$ EXCESS LIAR '• i clalras NIADC':, ............. —.................i_..... ........................ ! ! ................ . FAOVZCGATC Iw I1F11 J i HFIFNllf .................................. ............................................ ',.. WORKERS COMPENSATION ; f ER GTH Y/N; - AND EMPLOYERS-LIABILITY i BTA':IJTC i CR '.. i ;ANY PR6PRIFTOR.'PARTNFR/FXFC;IITIVF ;.E.L.CACI I ACCIDENT u iUhMGhKrMtMHEH eXCLUUEU'i ''.. (Mnndetory in NII) `""""'! '• ! E.L.DI'EASE-EA EME'LO'(EF,S I If ec.dc.crihc undo E , .................................................... ............................................ .... D sCRIPTION Uf OPCRATIONS belaer !E.L.DI6FA9E-POLICY LEMIT!$ '.. B ;DESIGN PROFESSIONAL/ PGIAM0957002 2/16/2016 : 2/16/2017 CAC IICLAIM $1,000,000 I VOLIdI'1'ION I,IAFLI I,I'I'V nRnrrCTTAT.A: $5,000 Af;CIHF(:AIF $'1 ,Clod 000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101.Additlonal Remarks Schedule.may be attacned if more space Is required) Projent: 607 Turnpikn Straet:, Rnvt 114. operations usual to a residential general contractor, when required by written contract executed prior to lows, tho cartificater holder and other parties are includsd as additional insured($) for work performed by the named insured. CERTIFICATE HOLDER CANCELLATION (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town o£ North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Attns Gerald Brown 120 Main Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 L Tonxy -Jr./DONb1AH j fes( - Q 19BB-2014 ACORD CORPORATION- All righty reserved. ACORD 25(2014/01) The ACORD name and logo are roglstered marks of ACORD It1 51175'-xiani5 AC R ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 3/11/2016 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 Donna Higgins—Amari Albert J. Tonry & Co., Inc. PHONE (617)773-9200 AIC N0Y-(617)773-9920 MAIL ---------_._.____ 300 Congress Street ADDRESS:certs@tonry.com INSURERS AFFORDING COVERAGE NAIC# Quincy MA 02169 INSURER A Endurance American Specialty 41718 INSURED INSURER B: MDJ, Incorporated INSURER C: 16 Woodland Street INSURER D: INSURER E Lawrence MA 01841 INSURER F COVERAGES CERTIFICATE NUMBER:CL15122812193 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 ADSL SUER POLICY NUMBER POLICY EFF MMIDD� LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ 5 1,000,000 � DAMAGE TO RENTED 100,000 A CLAIMS-MADE 1^)OCCUR PREMISES(Ea occurrence)_._ $,. CBC10001403803 12/22/2015 12/22/2016 MED EXP(Any one person) 5 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 NX POLICY❑JE� [l LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Additional Insured Blanket $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) 8 AUTOS AUTOS ---_ -_- '. NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident __ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONPER AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? NIA (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 I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: 607 Turnpike Street - North Andover, MA. Operations usual to a residential general contractor. When required by written contract executed prior to loss, the certificate holder and other parties are included as additional insured(s) for work performed by the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE L Tonry Jr./DONNAH ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 oninml From Tonry Mon Mar 28 09,46:16 2016 Page 2 of 2 DAYY)CERTIFICATE OF LIABILITY INSURANCE 031 28/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FIGHTS 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 Ilou of such ondorsoment(s), PRODUCER CONTACT NAME; Roni'ca Ganzziias ALBERT J. TONRY& CO,, INC. PHONE 6.17 773-9200 '(A Na: MALL roni(wg(�(onr torn ADblt@SS: Y• 300 CONGRESS ST. INSURER(S)AFFORDING COVERAGE NAIC N QUINCY MA 02169 INSURERA: CONTINENTAL CASUALTY CO 20443 ....................................................................................................................................................................................................................................................................................................................................................................................... INSURED INSURER 0; MDJ INC .......................................................................................................................................................i. ................................. INSURER C: „INSURER D: :` 1E)WQQr)LAND STRPr-T ..INSURER. .r................................................................................................... LAWRENCE.. MA 01ty11 If1sURER F: COVERAGES CERTIFICATE NUMBER: 40069 REVISION NUMBER: 'I'HI$13'1'0 CERTIFY T'HA'I'THF POL.ICIE:y OF IN$URANCF.. I.MI TlI.D BELOW HAVN BEEN I$SUF.'.I)TO THF IN$URFI) 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 ;AODI.:9UBR; i POLICY LFI i POLICY E)[P LTR; 'TYPE,DP INSURANCE. r POLICYNUMBER i MK1vbbIYYYY � MM1Dtl)YYYY i LIMITS '.. COMMCP.CIAL G@11111RAL LIABIL.f9YEACH L....... ....... L.......) i Tl�RftCENCEN D.... .. ............- ................ L....... ......................................... , - P ................................ CLAIPti-MAUL. ()(;(;VHPRCMISFSIra u Cwrremx) MLD_-X ..................................... .. ............................................... N/A PERSONAL R ADV INJURY ........................................ ''. '... 101WI.A(X`iREOATr UMIT APPLIES PER: I OfFNF.RAI.AOQRE4A'1'E. a PRO t I POLICY�........1,If;;(;I (.........L.00 PfdOf)U('IS (:UMFttiF'AGG t 1........ ......................................... 07HE.'fi: R AU'IOMOMI- LIABILITY COMBINED SINGLE LIMIT ICU auuidenl) 3 ANY nU'I'0 BODILY INJURY(Per person) S ALL OWNED SCHEDULED ...... AUTOS AUTOS i N/A BOI')tl Y INJURY(flor orodpm) !......... i i erG ...............T.............................................NON-()WNFn HIRFDnLI08 hDcdenLAu\C-E............................................................... ... L....... UMBRELLA UAB QUCUR [Act I OCCURRENCE............. $............................................ EXCGSSLIAti CLAIMS PdADtI N/A .............�— 1 t AO... GIiEGATt DrD 'RETENTION, 1 i !WORKERS COMPENSATION 1 ! v F•• IAND EMPLOYERS'LIABILITY VJNt p ........................ ANI'PHOPRE:I OH/PAK INI:R/1::KIcaU I IVI:: `• ' EACH 5U0,OQp A iOrFICEPIMEMDEREXCLUDED? N/A:NIA NIA 6S5JUBBB75�367015 1'1/20/2015: 11/20/2016> ''............•ACCIDENT (Mandatory in NTA) E I?.l..DI8FA3E-EA E1dPL0Yf'F'. ti 600,000 'If you,deeurba under ❑ESCRIPTION OF OPERATIONS Lwlury F..L.DI;EASE•F'OLICV LIMIT $ 500,000 •: N/A .........................................................................................._.............................................................._......_......:......_......_......_....._......_......_......_....:........................ ...._......_...................... ............ _..................... ... DESGRIPTION OF OPERATIONS I LOCATIONS I VEHICLE$(AGORD 101,AdtllNanil Remarks SchedUle,m,ily i 0 OtteChgd trmoro space is rgqulrod) Workers'Compensation benelils will bo paid to Massachusetle employaes only.Pursuant to Endorsement WC 20 03 0613,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance:shows the policy in force on the date that this certificate was Issued(unless the expiration date On the above policy precedes the issue d ale of 4tti;r,Brtirirwle of in;uranrf). Ttle slHlij;of Ihiq cnvera9e(:an he rnnnitored dHily by facrf?ssinrl the.Pronf nt Coverage-(-.nvfaragfa Verification Soarch tool at WWW.mass.gov/lwd/workers-compoi)satlonfit)vostig@tions/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover Building Department ACCORDANCE WITI•ITHE POLICY PROVISIONS, 120 Main Street AUTHORIZED REPRESENTATIVE North Andover MA 01845 I ytt6gl fA,t;tf,y ;r,CPCU,Vice President Residual Market WCRIBMA (d 1988.2011 ACORD CORPORATION. All rights reserved, ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 0 IY DATE(MM/DDYYY) AC"R CERTIFICATE OF LIABILITY INSURANCE 03/11/2016 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(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 NAME: Roni'ca Ganzzllas ALBERT J. TONRY&CO., INC. PA1CHONE Ext); (617)773-9200 aC No: E-MAIL ronica ton com ADDDREDRE SS: g@ ry• 300 CONGRESS ST. _ INSURER(S)AFFORDING COVERAGE _ NAIC# _ QUINCY MA 02169 INSURERA: CONTINENTAL CASUALTY CO 20443 INSURED INSURERS. MDJ INC INSURERC: _ INSURER D: 16 WOODLAND STREET INSURERE: LAWRENCE MA 01841 INSURER F: COVERAGES CERTIFICATE NUMBER: 36544 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. INSRADDLTYPE OF INSURANCE IVSD SUER POLICYNUMBER MMI DYEFF MMI DYEXP LIMITS LTR wVD COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE 1-1 OCCUR PREMISES(Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY F]JECT L__]LOC PRODUCTS-COMP/OP AGG $_ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea agciden�_ _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ ---- NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS _(Per_accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB_ CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X I STATPERUTE EORH AND EMPLOYERS'LIABILITY A OF CERIMEM OEREXCLU ED?ECUTIVE WA NIA NIA 6S59UB5B75967015 11/20/2015 11/20/2016 E.LEACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 U yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD IOf,Additional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS, 1600 Oscgood Street STE 2035 AUTHORIZED REPRESENTATIVE Cr North Andover MA 01845 Daniel M.Cro,4vPI CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD `,�"Yfd r'dAa iRrr AOp/V'irdJf'r t• �,4'z oxnrrywn'xr� to of oM r/\ff�iYO station 4 q, IMMVEMENT OR r7 1 S6 Ty 40EMRir r+: 71242010 PdVate 001 MDJ INC. Mar= Dwers 61 WOOD LAND STREET 3 LAWRENCE,MA 01841Ua dt retary Massachusetts Department of Pub0c Safety Board of Building Regulations and Standards License: C$ WQ56 b s i MARCOS A DE'VER-S 16 WOODLAND ST LAWRENCE MA 01841 r-1. C, xpairato-cwn: Com' missioner 10/2512017 Project Address: The above licenses oriz r the project a $s stated above only. DO NOT REPLICATE. Air_....oft—In _1 nntu . or Initials MDJ Engineering&construction Marcos A. Devers J., P.E. 16 Woodland Street Lawrence,MA 01841 (978)804-7588