HomeMy WebLinkAboutBuilding Permit # 8/5/2016 pORTy
BUILDING PERMIT OF�tL�o .6gtiQ
TOWN OF NORTH ,ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
SSAC14 S
Date lssued: C~'
IMPORTANT: Applicant must complete all items on this page
LOCATION I �
Print
PROPERTY OWNER L k.- rt(-
int 100 Year Structure :yesZno
MAP PARCEL: ZONING DISTRICT: Historic District Machine Shop Village
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
❑Addition ❑ Two or more family ❑ Industrial
Ateration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑Se`�ie ®�1Neil����z��,� �<� del=food !�trt5�° �❑Wetla ds�� �� , � .` ",stnct�� -;- �h
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DESCRIPTION OF WORK TO BE PERFORMED:
- ' ' "` i f> Ca_.
E �
Identification- Please Type or Print Clearly
OWNER: Name: tIC L, r�L� 0 Phone: � S_
Address:
r Phone: 3 S � �-3
Contractor Name: - r,
Email:
Address: N, &x `°[
Supervisor's Construction License: Exp, Date: I Z I
Home improvement License: �` �' Exp. Date: l i
ARCH ITECTIENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDDVG P.ERMJT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ �2 11 , 31FEE: $
Check No.: 1AV Receipt No.: �
0
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
;,
tAORTH '9
own of �� ndover
"t
No. * _
L;K, h ver, Mass,
LOC"Ic"gW K
�7,q ArF o P,I?
S U
BOARD OF HEALTH
Food/Kitchen
PERM LD Septic System
THIS CERTIFIES THAT .................... BUILDING INSPECTOR
has permission to erect .................. buildings on ....X . ... �e.•...............£ Foundation
.. ...+ ..
49
• .� ..�.�.. .. y Rough
to be occupied as . .. .. �� !�.. �!. �, Chimney
provided that the person accepting this pe it 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 theSIC-0t6io
n, Alteration and
Construction of Buildings in the Town of North Andover. q PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
® y ® Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONS TIOM,AJDTC,% Rough
Service
.. ........ Final
BUILDI INSP TOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Ruildin 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 wilding Inspector. Burner
Street No.
Smoke Det.
Federal ID#E 05.0406629
RUSE E,ngiticering R1 ContractorRoglatration No 8168
RISE
MA Contractor Registralfon hto 12097$
A division ofThicisch Engineering
I 60 Slrawmut Unit 82,Canton,NIA 02021 CONTRACT
339.502-6335 1 h\339.502 6345
Pago 1
PROGRAM
rrnscaNtRACTiE ENTERED INTO netwEE>+RISE
C4IA-I"IC',S ENOINnI104OANGTHE CUSTOMER FOR WOW AS
QESCRIaEOULOW
.. ............. --_. ........_.� __... ..
CUSTOlArR PHONE ORT@ CWBirY/ WORK ORO"
Usti Mcconologue (978)655-5583 02/0412016 428343 00002
eERYFCE STREET EILUNO MEAT
15 Ironwood Road 15 Ironwood Road
_..._
aERVFCE cnv,ararE,zr+ nRu.lNc CITY.STATE,zW
Nortli Andover,MA 01845 North Andover,MA 01845
--._ - _.. . . _ 20 ..-.
JOB DESCRIPTION
HAZARD BARRIER:We have identified drat there am recessed lights present in your home.unless lite recessed tights are cert€lied
as IC-rated(Insulation Contact Rated)we will create a 3"clearance spurn around the limure by using fiberglass blanket insulation as u
damming olatetial,no insulation will be installed across the top and closed cavities which contain recessed lights will not be insulated:
50.00
AIR SCALING:i'rrvide labor and materials to seal art;as of your home against wasteful,excess air leakage. This work will be
performed in Concert with the use orspeeial foals and diagnostic tests to assure that your home will he left With it healthful level of
air exchange and indoor air quality.Malarials to be used to seal your home eon include caulks,roams and other products. Primary
areas for scaling inciudc air leakage to attics,basements,attuchcd garages and other unhealed arcus(windows are not generally
addressed.) This will raquir(2)Working hours.A reduction fn cubic feet per minute Witt)ofair inFiiltr tion Will occur,but the actual
number ofcrm is not guaranteed_
At the completion of dK Weatheriration work,and Lit no additional cost to the homeowner,a Gaal blower dour and/or combustion
safety analysis will be conductcd by the sub•conimclor to ensure the safety ofihe indoor air quality.
$170.00
AIR SCALING:Provide labor and materials to seal areas or your home against wasteful,cxoess air teukage. itis work Will be
performed in concert With the use orspecial tools and dlaguostiC tests to assure that your home will tic left with it healthful level of
air exchange and indoor air quality.Matcriols to be used to seal your home can include caulks,foams and other products, Primary
areas for scaling include air leakage to attics,bascmcnts,attached garages and other unheated are4ts(windows are not generally
addressed.) t hl5 will require(8)lvpri ing hours.A redaction in Cubic feei per minute(crm)of air infrltralion wll I occur,but the actual
namber(if cfm is not guaranteed,
At the completion work,and at no adif(ional Cost to the horneouncr,it final hlo+vcr door and/or combustion
safety analysis will be.coaducted by the sub•eoatraclor to ensure the safety of the indoor air quality.
$680.00
Alit SEALING ADDER: (4)working hours,
$340.00
° AUDITOWS NOTES AUDI rOR COULD NOT ACCESS ANY OVERI WAD ATI1C SECTIONS OR 5 KWAIA S 1 NO ACCESS
PANFtS.ASSUMED 64 PGrf.EXIST.
S0.D0
9
DAMMING:Provide labor and materials to install a 12")ayer pi-R-18 uaraccd fiberglass baits to(60)square feet for drunming
purposes.
$I23.00
Xrl'IC FLAT:Provide labor and materials to install an 8"layer or R-28 Class I Cellulose added to(752)square ILTt of upon attic
Space.
$1,030.24
KN1:iMALLS:Provide labor and materials to install 2^ PSK laced semi-rigid fiberglass board insulation In(300)square feel of
knecwall area.
$1,050.00
KNEEWALL FLOOR:Provide labor and matcriols to install an V layer of R•28 Class I Cellulose added to(160)square feet oropcn
kncewdl floor.
$20t.60
e
FodOral Io#os4406629
trsUon No 8106
RISE Engineering MA Contraelorctor�ogtsReglstraton NO 120679
RE A division orrhickeb rnginccring
ENGINEERING' 60 shawmul Unit Q,Conlan,MA 02021 CONTRACT CT
33'1-502 6335 PAX 339-402-6345 1�1'1V
Page 2
PROGRAM
Thhra CONTRACT 1e BHYENEn INTO sErhvEETr aIBB
CNIA-ETES SNOW-f RING AMT11BGUSTONERFOR WORK AS
owaltinPA am.ow
... .... ...... ...... .... .__ ....
CaBTONER PHONE OAi'E CLlFNF Y WPRK 000E31,
Lisa Mcconologue (978)655-5583 02/04/2016 428343 00002
_._ .
SERVICE BTtIEFT SWPI4 STREET
15 ironwood Rend 45 Ironwood Road
BERYICe CnY.STATB.MP BLU140 CirY,STATE.ZIP
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
ATTIC ACCESS:Provide labor and materials to install(2) nese,finished plywood,Willi 2"rigid Therniar board,wcatherstripped
attic space nceess hatch. Prink cant nndlor paint is not included.
$230.00
ATTIC ACCESS:Provide labor and mnicrinis to insulate(1) back of the kocewall halclh with 2"rigid Therntax board,and seal tie
edge orthe batch witlh weuibmaipping.
$60.00
ATTIC ACCESS:Provide labor and materials to make(5) temporary access to an attic ma. The opening will be closed with
materials similar to those existing. Finish sanding and painting is not included.
S425.00
VENTILATION:provide labor and materials to install(2)insulated exhaust hose with roafnlOunted hopper vent to exhaust
existing bathroom runts).
sza7.�a
VENTILATION;Provide labor and motcrials 10 install ventilation clinics in(70)raRer bays to maintain air flow.
$140.00
i
COMMON WALLS:provide labor and materials to install 2"FSK raced semi-rigid fiberglass board insulation to(124)square reet of
common wall arca.
5434.00
RISE E igincering will apply all applicnblc,eligible incentives to this contract. You will only be billed the Net amount. Currently,
u far cligibiu mensures,Columbia Crus oilers 75%incentive,1101 to exceed$2,000 per calendar year,and an incentive or 100%for the
Air Scaling;measures up to the first 5580 and an additional$340 ffsavings air:justified by the auditor,
For the safety and ltcallb of your bomc:v indoor air quality,we will be conducting a blower door diagnostic or the available air flow in
your home both before Ute wort:Is begun,and after tic Wcatherization work is complete.We Will also conduct a full assessment of
the combustion safely oryoun ccating system and water heater.1119 has n value of 390 and is at no cast to yon. TOW nitoWable
wcatherization Incentive is$3,110.
590.(!0
Federal 10 N 9541406629
. RISE Engineering IT1euRlTeetnTRagFwtraUottNo6498
INA Contractor Rogtstratlon No 120970
RISEA division nffhielseh Engineering
ENGINEERING 60 Shosvmut Unit HZ,Canton,MA 02071 CON A-iV CT
339-502-6335 FAX339-502-6343
Pape 3
PROGRAM
TIUS CONTRACT IS ENTGREO INTO BETWEW RIB4
CMA-HES ENOINEERnNTAW TTIECUEYOMER foa YtOR(AS
DeSCRIDWSILOW
CUSTOMER PHONE. DATE CUENTN WOAK nRD#R
Lisa Mcconologue (978)655-5583 02/04/2016 428343 00002
SERVICE STREET aftim STREET
15 Ironwood Road 15 Ironwood Read
%M$0E CITY,STATE,ZIP ......PILLWO CITY,STATE,1'1P
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
Total: $5,291.34
Program Incentive: $3,019.99
Customer Total: $2,191.34
WE AGREE HEREBY YO FURNISH SERVICES.COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM AF
"`Two Thousand One Hundred Ninety-One&341100 Dollars $2,191.34
UFONTitML MISPEC Am KOVAL BYROM EERNKI.CUDTOBER AUR#TIi YORSMITAMOUNTOUEINFUU_e MIATOP i%ws LBE CHARGED MONTHLY ON ANT
UNpAKf BALANCE R71 TS.AER ROMEi WORTAW IW TION ON al"WrEEs 01GY AOF RECISION,SCNEWLLMO,ANOCCNTRACFOR REOISTRASFON.
ON THIS CONTRACT IF THERE ARE ANY$ ANK SPACES
AUTTiOR a NATUR4- " estm.e,w ""^�� -
NOT#I TH13 CONTRACT MAY BE VATNORAWN MY US IF NOT ERECUTEO WITNW SATE OP ACCEPTANCE .... ........... - - .-___. .-._--•-_— -
ACCEPTANCE OF CONTRACT-TN#ABOVE PAICUE SPLCINCAYIONS AND CCNRITIONS ARE
�l3
SAtISPACTORY TO US AND ARE HEREBY A=911110VOU ARE
AUTNOREfEO TO DO 7H#WORKGAYS. AS SMA
FEC06D.PAYM9M WILL Be D AS ODU"90 ASW#
F[_a 21,016
Y
RISE60 Shawrnut Road, unit 21 Canton, MA 020211330-502-6336
ENGINEERING www.RISEengineering.com
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the properly located at:
(Property Address)
(Property Address)
hereby authorize o
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property.This form Is only valid with a signed contract.
0
Ow is rgnature
0
Date
Olt)
0
The Comfit onicealilt of.l1assaclruxetts
' Department of 1,idustrial Accidents
Office !J� Int>EStt�+dttte3nS
i _: 1 s I Cctngres•s,Street,Suite 100
�r Bosfon,NI 02114-2017
'Norkers' Cornpensadon Insurance INdavH: Buildu&Comr:actors/Electi-icians/Plttttihirs
Applicant Information Please Print Legibly
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Addressi
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.are you,?:n ernployer'' C'heCk the aplrropriate boo: � 1 pe of project lrequirvdr
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I ane an emphger that is pre)vidin.q;corkers'compensation insttrunc•e dor na.tenmplovee.s. Beton-is the policy and job.sire
inforneation.
IoIicy '=or SOAK. I_.i.. r: iJQ_� �r-_ _... . .-- -------- ---_-" _.
loll itcAdttr ss 1 l 1r_l7.'�1U�cu-.- Citti Slate Zip '..
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4ttach a copy of the workers' compensation pestle► cieelae'afelin l)a;,e[sh(ming the It,:ihcy reuelebcr and expiration date).
j I'aikae io re.ctire co empe as rvqt red t tiler Seth m 25A of MO.c. 152 Wn Wad to the ii irvs!lioll.of Clinlileal pcnalhes o-'3
liiic Icp to SI,;00-00 i3n ,'or otic `oar a4 ls'cli is tie ii l,en iic in the Val of a S1 OP t'l ORK 13RDER and a He
4( -.ap to` 25(i O a day agab st The vied al" He [¢l11'jwj iltmi a Ty t flits matr:tonn ! my he fa"arded WOR 00e o
1€vestig;l6uns of 1he FHA Or in);t_rmce c ciage veri'icAhmi.
I do her ki,MY)under the pain;and pe naltit`s of perjury drat flit,information provided above is true and correct.
Dmy
—_
(lffecial cele onl1'. Do no!;+'rite in this area,to be completed ht•city or town oJlicial.
Cit) or Town: Permit/License
1sNuing Authority icircle one):
1.Board of lleahh 2.Building O pallme.nt i,('it}'Fnwn(.Awk 4. Electrical Inspector 5.Numbing insprct0
6,Other
('mitact 1'ersou: t'hune#:
GATE(MWDD/YYYY)
ACoRV CERTIFICATE OF LIABILITY INSURANCE
6/3o/zo16
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 pollcles 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
OONTCT Nancy Usher
PHONE 413 536-0804 FAX (413)534-7874
Martin J Clayton insurance Agency, Inc. A/C.No.Exty_..�.__ )
1649 Northampton Street E-MAIL
P ADDRESS: ..........
P. O. BOX 989 AFFORDING COVERAGE I- NAIL#
Holyoke MA- 01.041--0989 INSURERA:Nationwide Mutual-Harleysville NATIO„ _
INSURED INSURERB:Allied World Natl_Assurance Co,_
Gauthier Insulation INSURER C_: _....,
P.O. BOX 344 INSURER D; --
INSURER E
IPSWICH MA 01938 INSURER F;
COVERAGES CERTIFICATE NUMBER:CL1663001850 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.
LTR - TYPE OF INSURANCE A66L SUBR - � �POLICY£FF POLICY EXP LIMITS
POLICYINAn NUMBER D/YYV MM/DD/Y Y
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0001:DAMAGE TO RENTED...... 50,000
A CLAIMS-MADE l n S OCCUR PREMISES(Ea occurrence $
�..
X GL43487F 7/6/2016 7/6/2017 MED EXP(Any one parson) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY F PRO LOC 'PRODUCTS-COMPIOP AGG $ 2,040,000
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LI IT $
_(Ea accident) -
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
_r AUTOS AUTOS
HIRED AUTOS NON-WNED ROPERTY DAMAGE $
Per accident] �,,_,_
$
UMBRELLA LIABOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
B _.,,.,.m.. _., --M �......._ _._..,.._,� --
DED I I RETENTION$ RE020792125-194985 7.0/18/2015€10/18/2016 $
WORKERS COMPENSATION ! PER OTH
! STATUTE_ FR
AND EMPLOYERS`LIABILITY YIN -,— _
ANY PROPRIETORIPARTNER/EXECUTIVE L
� N/A E. .EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? f -..--. __......,.-
(Mandatory In NH) E.L.DISEASE•FA EMPLOYE $
l yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space la required)
a TET, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSURED($) ON A PRIMARY AND NON-CONTRIBUTORY BASIS
p
TO ANY OTHER INSURANCE CARRIED BY TEI, UNDER THE SUBCONTRACTORS GENERAL LIABILITY AND UMBRELLA COVERAGE,.
30 DAYS NOTICE OF CANCELLATION
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THIELSCH ENGINEERING, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
195 FRANCIS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS,
CRANSTON, RI 02910
AUTHORIZED REPRESENTATIVE
Daniel Sullivan/MEG
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
11MP914F4N+1nrl %with nr1fFartnry trial in-rginn to/rnrs.n/ ndffAr;tnry rnm
x
AiC-"R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM!€]DIYYYY)
��. 0511312016
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 CONTACTNAME; Kaitlyn Daysh
MARTIN J. CLAYTON INSURANCE AGENCY INC PAID sa Ex1; (413)536-0804 FArc Na;
ADDRESS: kdaysh _miclayton.Gom
1649 NORTHAMPTON ST.,RTE 5 INSURERS AFFORDING COVERAGE _ NAICB
HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325
INSURED INSURER B: .._,...
GAUTHIER INSULATION INC INSURERC:
INSURER D
PO BOX 344 INSURER E:
IPSWICH MA 01938 INSURER F:
COVERAGES CERTIFICATE NUMBER: 52708 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 13Y 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 SUER POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDDIYYYY
COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $
GE TO R T D
CLAIMS-MADE LIOCCUR PREMISES Ea occurrence $ ._
MED EXP(Any one person) $
mm N(A PERSONAL&AOV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY[JECT PRO LOC PRODUCTS-COMPIOP AGO $
OTHER:
ACOMDPNED SINGLE LIMIT
AUTOMOBILE LIABILITY
Ea accldenl
ANY AUTO BODILYINJURY(Per person) $
ALL OWNED SCHEDULEDNIA BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HiREDAUTOS AUTOS Per accident! -
$
UMBRELLA LIAB __JAOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE NIA AGGREGE
AT $
TIED RETENTION$ $
WORKERS COMPENSATION X STATUTE ORH
AND EMPLOYERS'LIABILITY
ANYPROPRIETORIPARTNERiFXECUTIVf YIN £.L.EACH ACCIDENT $ 500,000
A OFNCERIMEMBEREXCLUDED? WA NIA NIA MAARP300327 10/30/2015 10/30/2016
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
NIA
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It 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. a 1Iwd1workers-com pensationfinvestigationst.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF GLOUCESTER ACCORDANCE WITH THE POLICY PROVISIONS.
3 POND ROAD
AUTHORIZED REPRESENTATIVE
GLOUCESTER MA 01930 Daniel M.Crowfey,CPCU,Vice President--Residual Market—WCRIBMA
O 1968-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 173410
Type: Individual
Expiration: 101112016 Tr# 257812
KURT GAUTHIER
KURT GAUTHIER
P.O. BOX 344
IPSWICH, MA 01938
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
Office of Consumer:lffairs&Rusiness Re-_ulatioa License or registration valid for individul use only
j the expiration date. 1f found return to:
HOME IMPROVEMENT CONTRACTOR before
1?e s'�stration: 173414 Type: office of Consumer Affairs and Business Regulation
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Expiration: 14/1/2016 Individual 10 Park Plaza-Suite 5170
Boston,Mia 02116
KURT GAUTHIER
KURT GAUTHIER jJ
44 ESSEX Ria
IPSWICH,MA 01938
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License: CSSL-102562
KURT IR',GAtJTI.J"
P.0.&x 344 2 41"0
1p-swich IWA 0193N 4
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