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HomeMy WebLinkAboutBuilding Permit # 3/29/2016 BUILDING PERMIT TOWN OF NORTH ANDOVER "s APPLICATION FOR PLAN EXAMINATION Permit NO: C.� � > Date Received CHUS Date Issued: IMPORT ITe A licant must cam fete all items cin this a e /i % r , /i /i r/ Di rrr✓/i ///r r/,/ ri//� / / // `' ,,%i. /. / r/✓// / w�. / r�,n� �'/ir�(„/ �r /r /lir r�� �o r ..y r /i�/r. /% /,,. / r/// / ,"„ " ri /i r/ ri�/ / / �✓ �.�- /ir,�,o /i��,,,;r,/;�,/ l/i�/ / i; ri rr ✓i,// r:/r/rrr„ ,;/i/�/,I,/iia r// / ” ,,,wl•••u� Cr",,,;'., u, ,,;,,i, ��" �/ �,�� 1 �$�R���� ,r r � �C,rliNiw��k"� �r r /////i ti�//%/i r� i r r / ";,, % 'r�/ .. ✓ r% �,� r�i '�rr:? �rrrr r/r/ / /r/ ,r"w* ,�r i r/�/#///////i,! // r r /.✓ r ri r/i/ ;,,, / TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 1-1 One family ❑Addition i Two or more family I I Industrial it°,�Alteration No. of units: ❑ Commercial ❑ Repair, replacement n Assessory Bldg I I Others: ❑ Demolition ❑ Other Splr { � 4 (I 11I �; ;,l there t�trlt ""a'aN.'0+ `"' µy-x".;u ,.. � �" � ��N r' /`U"�'� ,a°a_'���� �.�Via,° �""� L✓���`a �� � �°a���rv'�° �e C6 Identification Please Type or Print Clearly) OWNER: fume: Phone: Address: ""4; "`p+w '% C ,,; /./'r //, i;, rrrr /% /-�/%i/ /i/i..,//,i� ;ir, r „i%iq✓1✓, � �i////4r/////f / r/ r/!/ �% J/ �/ r r ,,, / :�jr 'v%7✓ r/r,/,,;. /i�,/��/�// r/�/ r r. r/(r,r ,/�,,,,,, r,/ /,:i r /v/ '. r / r, ;;a,, „/,/�� / �r„ /,�//G/;. ,r,,,✓,J,�r /,. ;i %GO//iii%//,, �r //,l rri/';r%rr �J„ �y;��� / � i/� /, � r ,.. >y //��jf ii// j p r r,�r ,, j� ,rr�r". r /i/lir / / ,,,.•, ";.:. // / ir/rl /i s.. / � %///r(r // / .,, ////j r/ / r/ .�i ,r,r d;1 r�" rr r ✓ /rnr // /.. ,,,, r f ry '((/�,.; rr r//r, i//�/ r� / ,r ✓ /r �,;,,,; �/i�i i/����////orf%; �/i%�r r//�/��/ /a/ r ",r, „/, // r / // i„ r/ /' ✓ �, r r //..// r///' / .../////rJr..r1/r rI/ ..// �/� ...%/l� , ,,, f, r ,/,/i I r ri � ,;,,,/ii - r ' r,` ,,,,,r r i% %ru,,,� �/,, � i � �, e, /,„ ,/ /✓�//fir a,///r r�/,�ilii//. i r, r�,f/,�/„ ,,/,,i r/Ir%J/ii,/r.,,,,%r rr r.i,r„ r ,;4 ARCHITECT/ENGINEER 1 A, Phone: Address: F � Reg, No. FEE SCHEDULE:BULL ING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. ,r) Teal Project Cost: $ "� �� „ �°�� FEE: �' �; Check No.: Receipt No.: �� r NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �l ni are fi gen /Owner , i n r �' r6tr or " � n Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o U FORM PLANNING & DEVELOPMENT Reviewed On �W � Signature_ COMMENTS �iO CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW' 'own Engineer: Signature: Located 384 Osgood Street FyyIRE DEPARTMENT Tem Dum stet onsite n es , ,,, th no � rsycn r• 3 r/^,r 2 .,.zr .N t�ix � r� F � 'fir/,,N 1 "�:. ,�,a'r'e "� j,r fr �r.Y,�',.,.rr' a p,k�",�� f '>.��Td"'�:r?' ,°, ac�� d � ,ri��sl� w�� � ��� l r ✓ r r � t r y r "�s`,r'"�r5 �c�� r !fir:��r It!If"+,`"'?j 12,� �'�y��:r �. & �,>�r, rte�, rf'i! N �."Ise ;f `sf � a''� .�",� sur-✓'' ,�""`rta,'r`��. rare f, fv��� r"r�Fr�i "� COMMENTS r,,: /,, °r � s f ✓ �4 Yfr rka � °����b /E��'j�zk�!r� /� �fJ yr a , s NORTH Town of Alvadover ® aw " ��•' �++ No. AIL T C% h , ver, ass, _3 4,1 2 COC"IC"KWIC" 1' ®AERATED S` U BOARD OF HEALTH ERMImT T Lumml"" Food/Kitchen 17C,- '''� Septic System THIS CERTIFIES THAT ........4�<.'.l..:�.:...:.:�.1......J.,...�����7�.;::� ................................................ BUILDING INSPECTOR / 7 2�4 ( F S1 Foundation has permission to erect .......................... buildings on ........... ............................................................... Rough to be occupied as 7 Co�"!.... �! ��Gic/ ............................................. 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LES CTIO� STARTS Rough Service ......... �./..... .�,/�i�`/ '••�'............................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Massae"SettS Rome M antract ii Thisfamesat rote thomoroquireinetUtsofthestate'sHome7mprovementContractorLaw(M(3L,chapter142A),butdoesnotincludestandard language to protect ItamCU59trc'118celt legal advice if necessary.Any permplanning home improvements should fast obtain a cagy of"A Massachusetts Consurnar tauide Hamc Improvement"beforo agreeing to any work on your residence.You m3 obtain a flea txr Office ofConsumerAbairsand y ourwchsite. the Begulatioa's Cansanter BtformelianHatline at 617-9,73-8797 or 1-888-283-3757 or on our website.. Homeowner Contractor Info ��" t �4 "� rmalapn •, Information t arae I " Cam ?i arae trodAdduss(donotuseaPostofT address Dox ) r/ S � � art SelespersallovmerNeme t� 4 ,u t' ' W 6 gra G1tylrownState Zip Code L 73usmess Address(roost include a street address) 4 t °, ( tt, AaytimmePhone Ev nmgPhone uny/rown Stale Zip Code t lvlailing dmss(ttdiffamntfrom owe) Business T'hpne FedamlEmployer n7orS.S,Number Ian regni,rq Wnt mcatbmnp Ilmaaimp,ati'atcaaan«rnnta.xaaaer a=m,trl��tc �,. irapr*rcetcat ccntrnsPunbnrc � � � � The Contractor agrees to do the i0owing workfor the Homeowner: (Describe in detnH the wodcto completed•,spcGWAng the type,brand,and gmda of materials to be used,use additional sheets WrIgmsary) law 3c,V,( Ir Required Permits-The folluddingpemtits areowin N r required Proposed Start and Completion Schedule-The following schedule will andwill be secured by the contrac*as the homeowner's agent: be adhered to unless circumstances beyond the contractors control arise (Owners who secure their oven permits will be excluded from the Guaranty Fazed provisions of MGL chapter 142A.) 2'114_.!LDat-when contractor wall begin contradedvrark V t ) Date when contracted work will be substantially completed, ;i Total Contract Price and Pa specified The Contractora ymeSchedule rit grecs irr parfarmtho wa famish the material and labor above forihe total sum 011 a ri i, Payments will be made according to�he following sabedodez $ 7 ) upon signing cant' at(not to exceed 1/3 of the total contract price or the cost of special ander items whichever is greater) $ „ by or upon completion of $ by // or upon completion of upon completion Dfthe contract• (Law forbids demanding fill payment Until contract is completed to both party's satisfaction) The folowingmateriallequipmAnoustbespecial SL_to be paidfor ordered bef rc the contracted v 4 begins in order to meet the completionschedula,(**) $ to be paid for NOTES:(4)Including all Saame charges(**)law requires that any deposit or down-payment not exceed the one-thirderequiredbytheconnectorntorrcworkbegins at which must be I�al ori&-rd in advance to meet the completion schedule,ct price or(b) a ctUal�of any special equipment or custom made material Subcontractors h contractor arrTntvbeina mvidedbvttteconiracter? ❑No les(atltermsofthe w"rrnntvmust bgattached tothe conhmct) Subcanhuctors The contractor agrees to be solely responsible for completion ofthe work descubed re party/subeanimetor utilized by the crdntmatm•.The contractor fnrtber agrecy to be solol ?mess ofthe actions of airy third t 'a and]almond this a t yresponsible for all payments to all subcontractors for Contract Acceptance-Upon signing,USdocument becomes abinding contract under law.Unless otherwise noted within this documcnythe contract shall not imply that any lieularathersecm*interesthas been placed onthe residence.Review the following cautions andnotiew carefully before signing this contract! f� Don't-bapressured into signing the contract Take time to read and Rakesum the contractor has alvalidgn,„ r y Understand it Ask questions ifsomrthing is unclear, eat CrntraplQrRogistration.The law requires mosthome' subcontractors to be registerediwrth the Drrectcr of Home lmprovenmat Contractor Re • improvement contractors and registration by writing to the a! eclar at 10 ParkPIaze,Ream 5170,Boston,i4IA 02116 p lay�aa>ling617-973-8787nquinquire 888-283-3757. actor o Does the contractor havenrsuraAce?Askthe Contractor for his insurance company information so that you tern confirm cc erage or ask to see a copy cf a proof of insur�ce"document, Know your rights and tesponAilities.Read the Important Information on the reverse side aftbis form and get a copy ofthe Consumer GW&to the Home LmpraN; rt Contractor Law. :i You may cancel this agreement ifit Pas been signed at aplace other than the contractor s normal place of brdelivery, ,provided you notify the contractorinvnitiugatbis/hatmaimr�officeorbranchofficebyordinary raatlpasted,b tele b7third business day following the signmg ofthis agreement. Seethe attached notice ofealowllah'on form fuoat Inter than midnight ofthe DO NOT STG THLS CONTRACT 1I { t lanation ofthis right TYvatdantiont ,;raafde mantueeampl adna� 'Pial":RT,AREAMBLANKSPACESM o signrb nae cowshoald as to ttm}mmemvner.The nuuz<47 chmad bo bVtby We oaaactor. a Si I 1W C auunus Signature I lZ..' ' Date Date I GMdCIiMx'Hx Adam Brien CSL 104428 417 Waverly Fid. HIC 168512 North Andover, MA 01845 LLC 978-479-1526 3/7/16 adambrico@gmail l ill' J Il ttfll ilU tt Illlll/ffU IIII I!IIIAOIlf!11111 IIIIIIIQMdff11kdANI1VkI1M0//l/;YiINN'ttiWiPINNi,N'MIINiI1CIV/MINIAttfttil/UWY%nII11N;lMOIIk IPA' ORMOMwN'!llNrN1161411f111YalIINIfAUPIININ%MNII!NI61011idAflll911AWCdlllRffflAfflVdNIIl11NllINIIIttN!kN/MdlfHdll!U'J/dId11114'XONAIIIHODIIIIlm1IlNM0iYM/�NnIIWIkANAII'/NdM11A14/AIIIIAIWIflIH 97;lflIfINIWXRIRM17NIUIIIIdHIfVAIfIIS4'C(RIIINNPX'NN!NIIIIl17fN7A+.11U"14MNdN IYI1WYf N I fAll AI 1pN I!11I Iif Ahren Lippman 275 Dale St North Andover MA 01845 JobDescription: Construction of front entrance "Portico" design to mimic picture sent. New Front entry Door. • Supply and install materials to construct "portico" roof. Posts to be 4"x4" Fur lagged to granite landing. All work performed to MA building code. • Posts to be wrapped with "Versetek" PVC material • All trim to be PVC, "Versetek" • Roofing and siding to match ® Underside of roof to be PVC, wainscot style ® Installation of light from center of ceiling and removal of side sconce utilizing existing switch location. Light to be supplied by owner. • Installation of front entrance door. Door selected and ordered previously. Door surround insulated. Interior trim installed to match. Exterior trim to be incorporated into portico details. All exterior trim to be `Versetek". Door handle to be removed and re- installed. All debris disposed off site Permit Fees included ® Paint not included Total contracted cost$8,900.00 First payment of$4000.00 is due at the beginning of construction. Balance is due at completion Any extra work resulting from unforeseen problems will be priced accordingly on site and be done with written approval. BriCo is not responsible for anything that occurs on site that is not directly involved with the construction of this project. BriCo Building and Remodeling is a fully licensed and insured LLC company. License numbers are provided in the header above and current insurance documentation upon request. All subcontractors must carry the appropriate license and insurance to perform work in the state of Massachusetts. The contractor agrees to perform this work in a competent and skillful manner according to standard industry practices, and all work performed shall be subject to final approval by Owner. All work to be done incompliance with Massachusetts building code. BriCo takes on full responsibility of all necessary inspections. . BriCo warranties all construction related to this project for two years after completion. Dated:. -A It — Signature of Owner: 1-4 Signature of Contractor- ............ Any unforeseen work or necessary repairs found during this project to be brought to the owners attention as soon as possible. Any extra work resulting from unforeseen problems will be priced accordingly on site and be done with written approval. BriCo is not responsible for anything that occurs on site that is not directly involved with the construction of this project. BriCo Building and Remodeling is a fully licensed and insured LLC company. License numbers are provided in the header above and current insurance documentation upon request. Dagle Electrical Construction Corp. JOB P.O. Box 760982, Melrose, MA 02176 SHEET NO. CF AIM Oak Tel: 800-379-1459 / Fax: 781-937-7678 CALCULATED BY DATE ® ® ® E-mail: dec@deccorp.com CHECKED BY DATE www.deccorp.com SCALE Local 103 IBEW KI I f g 1 I AI ` x . t r { � 6N North Andover MIMAP March 29, 2016 rrm, Yti'd 064.0-06��7 � / 064.0-0030 2:44 eft I 1 ^ X40 t1i4LE��T(i r / v r � i MVPC Bo Inlerstales Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, _...I Meters Data Sources:The data for this map was produced by Merrimack SR tAORT11 Valley Planning Commission(MVPC)using data provided by the Town of Roads ��tr�,an 'qrV North Andover.Additional data provided by the Executive Office of 4 u Easements } �b orb O� Environmental Affairs/MassGIS.The information depicted on this map is Parcels G for planning purposes only.It may not be adequate for legal boundary 0 ,-` " definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 13 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING it y, THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY aF i ^ .Y OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT MG o q ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF pp�rcoW^°°�+ THIS INFORMATION C18U5�S 1"=52ft � }� The Commonwealth ofHassachusetts Department ojlndustrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 wwwinass.gov1dia Workers'Compensation Insurance Affidavit:Builders/Contractors/F lectricians/Plumbers. TO BE FILL D WITH THE PERMITTING AUTHORITY. Annlicant Information Please Whit Legibly Name (Busitiess/Organization/Iiidivi(lual) i!,i: address:_LWI city/state/zip:J,, ,,-q,q1A-1"I L�, �,% �Phone# L Are you an employer?Check the appropriate box: Type of project(required): I.E]Iamaemployer with E]New construction ---,,'-employees(full and/or part-time).* 7. 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity,[No workers'comp.insurance required.] 9, El Demolition 3.n I am a homeowner doing all work myself.[No workers'camp.insurance required.]t 10 0 Building addition 4,[:]1 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 ILF1 Electrical repairs or additions proprietors with no employees. 12.n Plumbing repairs or additions S.F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. l3.FJ Roof repairs Those sub-contractors have employees and have workers'comp.insurance) 6.n We area corporation and its officers have exercised their right of'exemption per MGL c. 14,E]Other VOX V t 152,§1(4),and we have no employees.[No workers'comp,insurance required.] I *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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, Ialit aiteiitploye)'tliatispi,ovitlitigipoi-Ifei-s'compensation litsui-aticefor myei?iployees. Below is the policy and Job site information. Insurance Company Name: "WL L,r; K Policy#or Self-ins.Lie,It: n,_`0 i�,,.-l 6 t2 i"''4, Q Expiration Date- !L `tel Job Site Address: City/State/Zip: iw,�i>o iz Nrk 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. I(Io hereby certify miler the pains and penalties ofpeijwy that the inforinationprovitted above Is true and correct, Signature: Dat Phone#: c. . ...... 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): i 1.Board of Health 2.Building Department 3,Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Ate'®R®® °TI I I ILIT I DATE(I�/DaYY�Y) 3/8/16 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 ofthe 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 Konnie Phifer Michaud Insurance PHONE (978 683-7676 FAX Al.N (978) 794-5409 105 Haverhill St ADDRESS: Konniephifer@michaudinsurance.com Methuen, MA 01844 INSURE S AFFORDING COVERAGE NAIC# INSURERA:Northland Insurance INSURED INSURER B: '.. BRICO Building & Remodeling LL INSURER C: Adam J Brien INSURER D: 417 Waverley Rd INSURER E: N Andover, MA 01845 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. rLTRINSR ADDLSUBR POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER MIDDY MMIDDIYYYY LIMITS GENERAL LIABILITY WS201172 4/13/15 4/13/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMASEJMoccENTurrence) $ 100,000 CLAIMS-MADE [il OOCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADV.INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-OOMP/OPAGG $ 2,000,000 POLICY JEp LOC $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT '....... a accident $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ '.. AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS _AUTOS eraccident $ UNIBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION '...... WORKERS COMPENSATIONWC STATU- I OTH- AND EMPLOYERS'LIABILITY Y/N — '.. ANY PROPRIETOR/PARTNER(EXECUTNE E.L.EACH ACCIDENT $ '.. OFFICE RIMEMBER EXCLUDED) N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE '... Ifrys,describe under DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ahren Lippman ACCORDANCE WITH THE POLICY PROVISIONS. 275 Dale St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Konnie Phifer ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACORD Phone: (978) 685-2549 Fax: (978) 258-6953 E-Mail: konniephifer@michaudinsurance.com ��, 0 DATE(MM/DD/YYY`) CERTIFICATE LIABILITY INSURANCE 03/08/2016 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: Trudy Lawler MICHAUD INSURANCE AGENCY PHON o Ext): (978)685-2549 FAX AIL No: EMAIL ADDRESS: trudY lawler@michaudinsurance.com 105 HAVERHILL ST. INSURERS AFFORDING COVERAGE NAIC# METHUEN MA 01844 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: BRICO BUILDING&REMODELING LLC INSURERC: INSURER D: 417 WAVERLEY RD INSURER E: N ANDOVER MA 01845 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 35808 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 LIMITS LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER MMIDD MM1DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DA AGE TO RENED CLAIMS-MADE FIOCCUR PREM SES(Ea occu ence) $ ',... MED EXP(Any one person) $ '.. N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO ❑LOC PRODUCTS-COMPIOP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPER ..Z 11 r cc $ HIRED AUTOS AUTOS '.... $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE EOR" AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? NIA N/A NIA 7PJUB4618P50715 04/19/2015 04/19/2016 (Mandatory in NH) E.L.DISEASE-Flt EMPLOYEE $ 100,000 If yes,describe under '.. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe 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 Ahren Lippman ACCORDANCE WITH THE POLICY PROVISIONS. 275 Dale St AUTH)`ORIZED REPRESENTATIVE Andover MA 01845 C� Daniel M.Cr , y,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 w' Yle Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02116 Horne Improvement Contractor Registration Registration: 168512 Type: LLC Expiration: 3/1/2017 Trl# 262883 BRICO BUILDING AND REMODELING LLC ADAM BRIEN — - - - - -- 417 WAVERLY RD ---- -- - -- NORTN ANDOVER, MA 01845 -- -- Update Address and return card.Mark reason for change. sCA: Co 20M«usr: [j Address n Renewal Employment Lost Card �,�.," �=��MAf,^���'G JSP AIPvn rlPl/P4✓/A�Jp.�,'s�'�C'�/��7:dle'YC'W/a'l.affzt'f�b Office of Consumer Affairs&Business Regulation License or registration valid for individul use only before the expiration date. If found return to: OME IMPROVEMENT CONTRACTOR p s registration: 16812 Type: Office of Consumer Affairs and Business Regulation Expiration: 3/1/2017 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 BRICO BUILDING AND REMODELING LLC ADAM BRIEN 417 WAVERLY RD NORTH ANDOVER, MA 01845 Undersecretary Not valid without signature M vssaci:ptsetts .1 Dei trlineni of Flub' ic Safety Board of tts:oialoi�ag I'7ere u.alatu4�>ns and Standards t uar n+s , CB-104428 ADAM J BRIEN � 9 417 WAVMRLY RbAI99U�1 iI North Andover MA 0� (�,J j'A t.az p i o.,t C'1�,)a"a 05/12/2010