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HomeMy WebLinkAboutBuilding Permit # 4/25/2016 y%O RTP BUILDING PERMIT °`�,LED 'g� TOWN OF NORTH ANDOVER 0 - APPLICATION FOR PLAN EXAMINATION Date Received ADRATD Permit No#: ��sACEDus�R Date Issued: IT: I �®RT�ANT:Applicant must complete all items on this page LOCATION O-- /VJ d/e S-r--,K S- I Print PROPERTY OWNER b� -e— Print 100 Year Structure yes no q� no MAP PARCEL: U� ZONING DISTRICT:—Historicachine Shop Village y s no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residen ial ❑ New Building ne family ❑Ad ition [I Two or more family [I Industrial Iteration No. of units: [i Commercial El Repair, replacement ElAssessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑<Setic ❑Well ❑ ooain Wetlands P, to n,Fldpl [I a rs a is nc „q Wate[/Sewer;: ' DESCRIPTION OF WORK TO BE PERFORM G ,SIS d Id tification- Please Type or Print Clearly Phone' OWNER: Name: -e ov-a� -� Address: -d [Home actor Name: Eric W.Palm � � Phone: Address: visor's Construction License: ?7 9 -7 Exp. Date: Z3�1 / Improvement License: l�/Z0 � Exp. Date: �3/IZ//� p 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: $_ 02 10V A FEE: $ Check No.: I Receipt No.: X6277 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund --.. -- — 8iqnature of — ---- --- - Agent .,,, t%ORTh Town of Andover i No. 2AI 4 'i -_ , ,'1 ` hVs COC NI1C �i'9 SSS' o � Ami'1. C"1WICK N@ A°RATE o pli? e> S 11 BOARD OF HEALTH TFood/Kitchen PER T Septic System THIS CERTIFIES THAT ......... ... t ...... ... ............................................ ........................ ........... .... BUILDING INSPECTOR has permission to erect buildings on Foundation . % o Rough to be occupied as . ... ... ..... ... ..... .. ... ...,. .. .. ...till!.. ............................................ Chimney provided that the person accepting this permit shall in a ery respect conform 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 PERM-IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS Rough Service ............... ..... .. . . ... . ..... ........................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingr Dry Wall T® Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. This form s tis&ts basic ��� ��� �® lnnguagetoprop ho �+amentsoffltestatdsFlomeim —tract Nalosachusettscoo"ater, Seecle�ad„1 i€n Pro vemenrcontractorymv(t15Q OlSceofCoasumerdE gomeltunrov�� bele AnyP�sonplannutghome cbaFtml42A},6ntdeesaoti�dade S any �v� sbusrstobtaina standard Romeo e °��ssReglrlatforill .in in to an yo�res. LIMYouma a6 COWOf A N 1 eF g"og�a25o °� on%tliacat6l7A73 8787 or I-888y �'n a fife Vpybyci the �ordi� elor I 2833757oronoarwebQte 2 nun etat� StreetAddress C°r01YNama (da not use Post 0 ceEax ad�dressr� �ant� ANatic Cicode ty over -t°S�jC ,oatsalesp�s sate � DaytimePhone - B'��Addtt�s(oa �ytin > '{ � Evenin P j S hone Moiling Add Ciwrawm �s(Itdi&' Q-7 t� �y Stats ZipCodc erenttimn above) RosinsSPhone ' TedernlEmplcterIDorS.SNmnb9 t 4>z5a ,Tvrac•�Cc -Na' "'710 Con(i c?S tb (D cdo tet -cab ibe in detail the Work to eompletF jos sPaiFYinsnteiyp�Im>aomeatyner_ d.and&radeoF!rr�tarra$to ba 2�j 6� 2 /C__ us='d.cs';/additional sh_ eek iFn y.�) acid wiQ as ts-T hefouovrhlg6ntldin /� {Q'as✓Ges"a^t=✓s"Cured by the Orastha �Wrequired I'ragnsed5turr/andC "5e3ttdedfro th � e {�rB rmilswil.$jl��t 6eudherzdlotmlms - stau , edgie-17tefol/nwing�be�o� 1£dC gt1c�€c E ces 6}ond We ?fGLChap'ier142A-) 1,-yRuadpyo�sioa,0. coatimci catihoi,nse �_Datew$en"'Ire torvrt71 b can contracted anrk. TorelContrar::raceandpa - ��13afeiciten ?h0Contraotorngr to Yme4e3chednte cantmctedworkI'll be P�mmthel wad f substantialtyrampleted. t'aS�tentstviilbemeden�rdia 5 umishWe'materialandlabor ec• gtothefa>fov" SF tfiedabovefortheto►alyaroof nn �---_upon signing coatr� g..chedale; S ct•(not to oaceed 113 of _j thetoialcontrotgrice ar tbecostoF Sor upon completion of special orderitems;vow he"j ga') 81",—by -�,oruponcamnletionof l upon impletion oftto caner Thefotter�n �K'Forbidsd "e • ord:rcd before th ���mp`neII 6a. Mandmg_fa11Pa eat unh7 eonttata corft ed tt 'Pacini S rs completed to both mmec t4ecomplctienschedul(*,j order �rto Ga 'd fa FartY'ssaiis6etioa) It105 sss:(>)Including„an finanace! �c d r requires it,= V deposit tffii�must b.'�odared,-oo,von! Wwntra^tryicaor@)`WePa hialuCost edby*�eMot, SPaCle ctor before narti epns G„-army fmm� -Ps nn ' �tWacomptelionsc(,dule cgtupmeotorcuslommademaleria[ Suhcant �rsq rrnntv�etng avid �-oni-r Part0seccinhactorntill��cior88'rlIdbssolel `��rrhanntr ata s QP:,}�I materials and labarr byWecontractor, Y"e"Potudb forcompletionof a1lhm;nFtfiann Con. mder this aereernent The conftE!torftrri►rera tbeRarkdesggb� ° "' treattncrrrxl to tZtcC dcceptnnp-Uponsi ��tbbcsoleIy re�•diesso£theactlonsofrmy a4nrtl contractsballnotimPlYthat its this!docrrmentbe ' 'nr'srble;orallpaymcntsta carefitllybeForesi anylieaoroibfrs comesat 111 aUsubcoatmytorsfor gWtscontracE. t3rmteesthasi � etIlaw.UnlessoffierwiyenatetiivithintLlsdo Don'theprai dinrosi 12eviEvrihefallotylo ° nFakesurethe gamgthcl gcautiousandmno�h'� e ubcontractors to be�tor has a vaiidjjl ---`Le lime to read and felly and reasttation 'a9stet�tyiththe� _ YneatCon tractorp edit As1:qu ionsifs D�o3lbeconhn b havcrnscwante7r flFarcFl Onto seaeea trrQTnelavirgplr mnstIrom gisundear. copy ofa`Proafo€' do the Contra1ot r or��'Eogon,iblA 02I l� o y You�3 inquir about ctorsand �'-nowyotrrights�d nr��u�" ttmeat mttn 1 mf 9'17473-8787or888- Guidoto the$oae' dead tTta aunpale r Z 3757• ponstbIIiti- anna6on so �FrovemcntCon nactor bnPotiarttrnfotma>ion tbatyant rrcon>imrcoverage.oraskto YOuMa c, I tr an Me reverse sideofthisfomtaadgetaca Y �ncclihisementifitlrrrsb pyofthcConsomer contrzcs- essvritingatI1iFJh-- - r�ulata thirdbusinesdai,follottinstlrw� Georbiata?ta$Te b}Q�erWanthetwntr^�tot'saomral _ gofihisagrzernent See�EW�pal bytele P-- banaess,Provided ✓t� (�j ,ria 1 ^, Weattachednoticeof Seatorbpdelly younclarythe rnota�n ,max h Py cancellation, ew,noflaserthnnm?dy�tofthe `"0°o mn t fie >ritC'ii 7r =� arm thran m-PLmadon nfilrisri capyrytsa��^AREalt' SPA��get �entJv^rCa Roli;meYsSignafure Dare 2- cmtraetnr's Signature: Date y7- i Contractor Arbitration The Home Improvement Contractor Lav provides homeowners with the right to initiate an arbi ration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not antou atically afforded to a contractor,however. The 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 Nome 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 rliaytsub 6Ahe dispute to a private arbitration firm which has been approved by the Secretary of the Executive bfce of o ger Affairs and Business Regulation and the consumer shall be required to submit to such ar)li{tratipli:ap�-6ei� achusetts General Laws,cha er 142A. ® i Homeowner'`s Signature I Contractor's Signature i NOTICE:The signatures of the parties above apply only to the agreement of the parties to alt ative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties_ II homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement Iioweve,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowner who secure their own building permits are automatically excluded from all Guaroty 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 maybe entitled to other specific legal rights-i the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees 0r'W provided by the contractor,all goods sold in Massachusetts carry an implied warranty of mer6lantability and fitness for a particular purpose. An enumeration of other matter on which the homeowner and contractor lawfully agree may be . added to the terms of the contract as long as they do not restrict a homeowner's basic consum�r rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed beloi v). Execution of Contract The contract must be executed in dunlicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties aro also advised not to sign the document until all blas ksections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contrat with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original c6ntract must be in writing and agreed to by both parties_Contracted work may not begin until both parties have receivedi 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 of the dates specified on the payment sch�jd�le in cases where the homeowner deems him/herself to be financially insecure. Howeve,in instances where a contractor deems him/herself to be financially insecure,the contractormay require That the balance of funds not yet due be laced in a joint escrow account as a prerequisite to continuing the contracted work- AVithdrawal of funds from said accountvaould require the signatures of both parties. Additional information 11 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 t)Home Improvement' contact: Consumer Information Hot]'me a Office of Consumer Affair and Business Regulation 10 Parklilam,Room 5170,Boston,NLA 02116 617-973-8197;8188283-3757 orvisit the OCABR website at htt-1/ii—Tiv.nlassf.Qov/ocabr/ If you want to verity the registration of a contractor or if you have questions orneed additional information specifically about the contractorregistration component of the Home Improvement Contractor Lav,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 ParkPlaza,Room 5170,Boston,MA 02116 617973-8781,0088-293-3757 or visit the ITIC-website athtto:/hN,v%v.niass Dov/ocabr/ Go online to view the status of a Home Improvement Contractors Registration: httl):/Idb.state.ma.us/homeiMDro-%,ement/licenseelisLas For assistance with informal mediation of disputes orto register formal complaints against a business,call: z_ onsumer C plaint Section oney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or413-73-1-3114 Version 21-11/2'2010 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ivwt%v.mass.gov/dia Workers' Compensation Insurance affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print I.,egibly Name (Business/Organization/IndividuaI): Admi'p!btnx, y��L}}��tl��i [statppt���ppldpi�{,LLC, Address: S,,Ijer l4 A 1111170 City/State/Zip: Phone#: j Are yo n employer? Check the appropriate box: Type of project(required): 1.EY1 am a employer with 4• ❑ I am a general contractor and I employees(full and/or part-time).` have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have 9. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp, insurance.t 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no 12.❑ Roofr pairs employees. [No workers' comp. insurance required.] "Any applicant that checks boa 91 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. tContractors that check this boa 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 and an employer that is providing fvorkers'compensation insurance for lny employees. Below is the policy and job site information. Insurance Company Name: Lj ,C_ Policy#or Self-ins. Lic.#:tea 7 Q J Z 0 Expiration Date_JIZ-01/ -7 Job Site Address:_ fin J City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifv under the pains andpenalties of perjrtly that the information provided above is true and correct. Sianature; ? , �' E�;1` (�1 Date: ly ZU Phone F fici'al use only. Do not write in this area, to be completed by city or town official t�r 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#: i ACCORE0 ® CERTIFICATE LIABILITY I DATE(MWDDlYYYY) 3/9/2016 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 isian 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 endorse�ment(s). PRODUCERCONTACT NAME: Construction Eastern Insurance Group LLCI PHONE (800)333-7234 ac No 233 West Central St E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Natick MA 01760 1 SURERA:Arbella Protection Ins. Co. 41360 INSURED INSURER 8-Nautilus Insurance CO Atlantic Weatherization INSURERC: 61 Rear Jefferson Avenue INSURER D i INSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER aster 2016 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 LTR TYPE OF INSURANCE INSR BWVD POLICY NUMBERPML CY EFF DrCfM POLICY NU D LIMITS GENERAL LIABILITY EACH OCCURRENCE $ I'000'000 ,OOO,O00 X COMMERCIAL GENERAL LIABILITY PREMISES Ea oocu ence $ 50,000 A CLAIMS-MADE a OCCUR 8500042816 /20/2016 /20/2017 MED EXP(Any one person) $ 5,000 X CONTRACTUAL LIABILITY PERSONAL&ADVINJURY S 1,000,000 X CG0001 10/01 FORM GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS PRO $ 2,000,000 X POLICY PRO LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 5 2 001,000 AANY AUTO BODILY INJURY(Per person) S ALL OWNED X SCHEDULED 1 1020015871 /20/2016 /20/2017 AUTOS AUTOS BODILY INJURY(Per accident) $ X NON-OWNEDHIRED AUTOS X PROPERTY DAMAGE AUTOS Peraccident $ PIP-Basic $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS 10,00C 4600058654 /20/2016 /20/2017 S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERlEXECUTVE YIN ,i OFFICERIMEMBER EXCLUDED? El NIA E.L.EACH ACCIDENT $ (Mandatary in E.L.DISEASE-EA EMPLOYE $ If yes,describe under nd DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ B POLLUTION PL200378614 0/1/2015 0/1/2016 EA POLLUTION CONDITION $1,000,000 GENERAL AGGREGATE $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) i 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 OSGOOD STREET NORTH ANDOVER, MA 0184 AUTHORIZED REPRESENTATIVE John Koegel/SME — ,Y� -- ACORD 25(2010/05) ! ©1988-2010 ACORD CORPORATION. All rights reserved. INS(125 mmnnst m l ha ArnPn names and Innn ara raniafnrarl marlrc of A`f)Pn ••�_ <- c.. �.�. c.v-Lv o....�z c.s r�r1 r['1l,IL 6/VV6 rctA 0t;x_VC1- C ERTIFICATE OF LIABILITY INSl1RANCEDATEU21 3/2018 tMM/DD/YYYY► rTHISCERTIFICATE FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS E DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.. OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE ER 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such end 6rsement s . PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 W CENTRAL STREET (A/C,No,Ext): (AIC,No): NATICK,MA 01760 ADDRIEss: 22MLW INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: AM&RICANZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LL INSURER B: INSURER C: i INSURER 0: 61 REAR JEFFERSON AVE INSURER E: SALEM,MA 01970 j 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 OFANYIICONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 PAK)CLAIMS. NSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE j L R POLICY NUMBER IR4M1DD1YYYY) (MMtDD\YYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE ®OCCUR. AMAGE TO RENTED $ REMISES(Ea occurrence) MED EXP(Any one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERALAGGREGATE S POLICY ®PROJECT®LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) A HUMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE DEDUCTIBLE $ RETENTION $ $ KER'S COMPENSATION AND WC STATUTORY OTHER EMPLOYER'S LIABILITY Y%N UB5B270121-16 0320/2016 03/20/2017 x LIMITS ANY PROPERITOR/PARTNERIEXECUTIVE OFFICERRAEMBER EXCLUDED? NIA E.L EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 Ir yes,describe under DESCRIFMON OF OPERATIONS below EL DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. i I i CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRVE N.ANDOVER,MA 01845 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 19138-2010 TA ACORD CORPORATION. All rights reserved. Massachusetts Liepar`trrtent of Pubiic Safety Btaard of Building Recttiatir�s anti Bta:tcierds Construction Supervisor Restricted to: License C"117077 Unrestricted-Buildings of any use group which contain •� a.� i,u �- less than 35,000 cubic feet(991 cubic meters)of a nt enclosed space. ERIC W PALM 3 HILTON ST A SALEM MA 019,70 CA-, Failure to possess a current edition otthe Massachusetts Ce¢arnissior�er 0412312018 State Building Code is cause for revocation ofthis license. DPS Licensing information visit:WWUW.MAISS.GO'V/DP5 e _.. _ %,rr.i%rSrr:„r�>ar�r rrrl�,/rel x^f rfrsrrr/r,rac?�: License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation ,,• ME IMPROVEMENT CONTRACTORg egistration: 14208g Type. 10 parlt plaza-Suite 5170 �. xplratlon: 3//212018 Ltd Liability Corpor Boston,MA 02116 ATLANTIC WEATMERIZATION L.L.C. ERIC PALM ,.' 61 R JEFFERSON AVE :>,. ,_y- �, �-� — SALEM,MA 01970 Not valid without signature Undersecretary