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HomeMy WebLinkAboutBuilding Permit # 9/7/2016 ... ..... ...... ...... NO R T!-1 BUILDING PERMIT TOWN OF NORTH ANDOVER = APPLICATION FOR PLAN EXAMINATION Permit No Date Received �SSpcc:wUs��4y Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Salem S� Privet PROPERTY OWNER [—; r\&O, Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no J Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑ New Building One family ❑Pkldition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ""`m`.�: r,,: .` '"^B'� ''s`, .ac ✓ ::rre� ."sY xrv., �'�� o ,,� ,u. -�'"-'. "�"�..-a�;,` ` `. '+: .''' ^rr° A'F s.'v e tIlell � ❑ Flood lanWetlands� ,� ��❑ IIID tern.., 'stlictIs.MINEW � - . e..s DESCRIPTION OF WORK TO BE PERFORMED: Gt &I t rR t I i r-. (� %,C(N-4.1 �a&rvx t,r ems►0L_ k � Mentification- Please Type or Pri t Clearly OWNER: Name: -rt�o� �+r►tii-j -- +ro it Phone: Address: Contractor Name: Phone: q -A 33- • 3,A 9 3 Email: r,rovio - '1 .t twrV1) Addres PD R,-Y\ 3y1— WJ ( x 113 Supervisor's Construction License: b Exp. Date: S 115-17 -4" Home Improvement License: �`� �� Exp. Date: ARCH ITECTIENGINEER 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: $ 1 ' FEE: $ Check No.: �' l Receipt No.: NOTE: Persons contrac 'ng with unregistered contractors do not have aece s to the guaranty fund %­____ -- tIQRTk Town o _ O 0 No. a_ a tA�iE h ver, Mass, A91.0C CWICK 4 S U BOARD OF HEALTH Food/Kitchen PE � T � LD Septic System THIS CERTIFIES THAT..................................................... .....&.1044 ..."......................I................. BUILDING INSPECTOR g / ... 3. ��. ... Foundation has permission to erect .......................... buildin son ** .... S ... ........ Rough to be occupied as 4-4r"A- .e /k/a..1 cv.. ,'! fir. .... Chimney provided that the person accepting this pewiliitshall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and y-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. *.tier N! PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ie; PLUMBING Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION Rough Service .. . ...... . . ....... ....ZCT" Final BUILDING1 GAS INSPECTOR Occupancy .Permit.Required to Occupy By 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. CLEAResult r CONTRACT FOR PRODUCTS 1 SERVICE WORK This service is brought to you through rom your focal utility This Agreement is made by and among �A SV l and Linda Quimby-Brodette CLEAResult 1253 Salem St Ate' North Andover,MA 01845-4911 50 Washington Street,Suit 000 Site 10.500050226627 4 �' Westborough, MA 01581 Project ID: P00050259723 ' Federal ID No. 22245 0 Customer ID:C00050228239 1 (Alan completed con to address above) Contract ID:20160822_WORK � 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perrom or cause to be performed the following work on these"Premises"in a professional manner and in accordance with the terms of dils Contract,including the attached recommendationslwork order describing the work in detail(the"Work")which are Incorporated herein by reference Description Quantity Location Pro avent 2'or 4' 22 Attic-2 $64.26 Damming 88 NIA $192.72 Hatch:Thermal Barrier Pol ry issc_2 inch_Atl€c 1 Living Space S4111_ Attic Floor Open Blow Cellulose 7` 683 Llvin Space $1,044.99 Attic Floor Open Blow Cellulose 7" 678 Lwin S ce $1,037.34 Hatch:Thermal Barrier Potylso 2 inch(Attic) 1 LivinU Space 541,71 Install 2^'thermal Barrier Polylso On Kneewall 200 i ving space $880.00 Insulate Rim Joist with 6.25'Fiberglass Batting _10 _ Living S ace $24.00 Sub Total: $3,346.73 Utility Incentive Share $2,000.00 Customer Contribution $1,346.73 Ltff Q For office use only Printed:812V2016 Page 2 of 2 11. PAYMENTmy�.tlG Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payent ill:3 as a Deposit payable to CLEAResult upon signing the Contract(not to exceed U5 of the total retail costs).Mail check&contract to CLEAResult,Atter:HES,50 Washington$t., $te.3000,Westborough,MA 01581.Final Payment:$ as Elie final payment for the Work shall be payable to the Independent Installutton Contractor(91C")upon satisfactory completion of the Work.Customer understands that helshe will not be required to pay the Utility Incentive 9 Share of the Contract priee in Elie amount of$_7110a waL Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Sham- III. DISPUTE RESOLUTION 'lire 0C and Customer hereby mutually agree in advance that in the eventd=1he FIC has a dispute concerting Ills Contract.,the IIC niaysubmitsuch dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regartation and Ctistnmer shall be required to submit to such arbitration as pivvided in tN.G.I«c 142A You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you otify he seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third busi ess d following the signing of this agr a ent. DO NOT SIGN THIS CONTRACT IF THERE A ANY BLANK SPACES. tL f G (oR> Cos r ti eDate Indicate your selected I.I her ,it applivr6le Initial here if you want g �� b the Program to assign a CL>J esult Sf ttL a Date Name of CLEAResult Representative(Printed} Participating Contractor i TERMS AND CONDITIONS AIPPEAR pN THE REVERSE, 2200-12•RLIO CLEAResu It® A, CONTRACT FOR PRODUCTS 1 SERWCE WORK This service is brought to you through support from your local utility This Agreement is made by and among 6Federal Linda Quimby-Brodette t 1253 Salem St Ni nrth Andovcr,MA 01845-4911 ton Street, S ' e 3000 Site[D:SOODS0226627 h,MA 015 Project ID:P00050259723 No. 22 7170 Customer ID:000050228239 d c act to address above) Contract ID:20160$22 ASEAL 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor uqU perform or camse to be performed the roltowing work on these"Premises"in a professional manner and in accordance with the terms of this Contract,including time attached recommendationalwork order describing the work in detail(the"Work")which are incorporated herein by reference: Description Quantity Location f Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 12 Living Space $1,411,84 Whole House Fan Box:Thermal Barrier PoWlso 2'(Attic) 1 Living Space $168.98 Door Swell 3 N1A $68.54 Exterior-Door Weather Sir] fining 3 NIA $82.77 Sub Total. $1,333.13 Utility Incentive Share 51,333.13 Custornor Contribution $0.00 For off]co use only Printed:812,12016 Pago 1 of 2 II. PAYMENT 0,pv Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment H1:5 as a Deposit payable to CLEAliesult upon signing the Contract(not to exceed I/3 or the total retail costs).Mail check&contract to CLEAltestdt,AM,.}IES,50 Washington St., Ste.3000,LVestborough,MA 01581.Final Payment:S d-U C1_ _ as the final payment for the Work shall be payable to the Independent Installation Contractor("I10")upon satisfacto ompletion of the Work.Customer understands that he/she will not be required to pay the Utility incentive Share of the Contract price in tine anmount of Changes to Individual line items and/or previous incentives may increase or decrease the size of the Utility incentive$hare. Ill. DISPUTE RESOLUTION ne 11C and Customer hereby mutually Wee in advance that in the event that the RC has a dispute concerning dmfs Contract,the 11C may submit such dispute to a private arbitration service which hasLagreement lJlce of Can4wner Allaits and 13mtncss Regulation and Customer sh<�11 he crrtulrued to submit to such ar6imuion as provided in it1.C.L c 142A You m y canent if it has been signed by a party at a dace other than an address of the seller, provided you n if ting by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third busine s daysigning of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE NY 6LANK SPACES. Y applicable (oR) Custom r n Date Indicate your selected IIC here if a licable n U ere if you meant 8 7 l /y, -e' {I4 Y_- time Program to assign a CLE AR tit Signature Date Name of CLEAResult Representative(Printed) Participating Contractor T$RWS A"CONDMON8"FEAR Olt'/HE RUVERSE. 220D 12•l21.1G 1 i Vw urrrr s�,� Permit Authorization , ��!!.. ^ Form�' �� *�.C���' � PARTICIPATING .9a.intrs tnrousih. CONTRACr011 Site ID: 500050226627 Customer: Linda Quimby-Brodette i, Linda Quimby-Brodette ,owner of the property located at: (Owner's Name,printed) 1253 Salem St. - North Andover (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perforin insulation and/or weatherization work on my property. Owner's Signature: k :2�� Date: �aoQoonr�c�ooaooanaonaona�aooaoaaaa�sooa000000aa�ooaor�000aoaaoa00000aq�aca FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor date Clf'Ct CtEAResult 0 50 Washington Street,Suite 3000 0 Westborough,MA 01581 0 1800-460.7472 Qj For Office Use Only Rev. 102015 The C imtmonx'eulth cif llasmchu.seus Uelrartutettr of Ittdrrstrinl ric•cidents Office i,f lnvestigaliotis 1 Congress.Street, Suile 100 Bovon, IIA 02114-2017 •'^^��;-�'' ►t°x�x�.trttt r s.fir,vI cliu W'orkers' Compensation Insurance Affidavit: Btiilders/Contractors;'Elect.r•icianslPluiitlters Applicant information Please Print Legibly Name hI i\iJl1I ,' r Citv'Slale,'Zip: W t 01 pilot�c � 5 Gln 3't Are you an eniph)rer:' Check the appropriate box: I's )e 14'project Ire aired): 1 1 atlt a cn� iil�cr+atilt 1- ® I ain a -cnL'rat Colara tui 'And E P �.. -- 6 �e't�'rtsntirr,u'ti��n CnIpIotccs I -iH and err ptw-tiro }, Ii E Irrrc d tlti Sul ictttr L�tr�rti 2.® I ama �e)Ir��rcaprictor ur par€ricr- ii"ICLi ons th,r trit,'whc�� itcet ?. RGnxtt4clini strip mid havc no cmltits}'ee; I hr���aLallci;t?tEa�ttt5t�)t��� t Clt?�14?`iL'tS 1tF;a haS'C-1k'O!'Iict �c4ti htnt fE)r me ;n a€=� c;r i)t itti cf [ fitlitciln; .1tlLliirin Ct3[T317 ITtilrirtl i. [\ I t�orktr ' cc)tltp. irs,urtlic:e 1 i4}.® i_I�itrt�a? f�Ir�sir>or.tddllliFtl rccluircel.] ® 1;: a k:orpor rtr0rt.Inti its ±. I Stn a IIOtIICIIU'tilr >14Pit1L .9it i5'or1i l)I�'C.I I,;�' kt!'C'[yc'Ll Ifl,ir �.® phin lmo rgairS of scitlttl Ins rich(f)i'rxctnilticr,t terf(.iL t� mvsell. [Nos.�4Frkdrn- ecyntt). _ -r.® t.'ooCrcp;iir 7 i7:�ELri{rlLl rZ i�Uirl U� ti C I�,, �("t).Mid k4� 7 Fl1rk'C ttl) I IML,I)!W,Cew. t",`o.t01kCf'a cosR�. tf)+ifhiL3li'c' F:t]kYirC�.� 'ins �)l� zat Batch .hoc=lmthtal 101 c41lt !or,Aw,,% i- I:i « rntr_ i ". t 3 [ sit i tYVI :7 aen,E.�:c71�.5 .-:¢�Suh_r.n E}•:i�sE.I3•tI t-.J.iu-t-,w I:,.. ,i , :hi, = ra x.,,-.:f.� d:€ f,, ot:.:�,1�t ntra.�.FF,�ra,�t,eth,7. s�i slliil3tia� 'Jicatf';u tiosi�t :r-u_ an it Of ,.eh_'k.r=r r1'?h. Cr,w,:. nru"�Le.�,i;:EIICI t unt an eynplorer(hot is providing ding il'l)rkE'r.5'•{'Flnf(lf.'Jt`;lltllYl7 imurunce fur nr)'emplo,t'ees. Beirm,i.S the polo_{'and job sire information. In"marico: C'oI)I ml. NIRIIC:__. }_CiL6t, A, �nw(oLr\c,k . � Policy n or SCIf- i$, i_IC. � �P.�.��.3 �fiLl itttiotDol _. 0_ 3 0{ 1(.� _ Jot)Site_lddre s:: 1 t S 3 Sal-te`'��� e , v Stale Zip, '`lov '/fl Attach a rope of the workers' compensation polis► declaration pale isllo%'iglu the polis% number and expiration slate). I MILLrc iia se(-,are-i-overa,-, ,Is roquircd finder S,:tilion_5A t,I Mtit. C. 152 o:j:i {Cad toy th% inipw i ion of etE[11l.ml peE]id6c, u i Ii3IC ifO til SI,%i)00 aji&�or otc-y,ir tt'lpritiL)n371i11t, as NVCII Iii iiWI1 pk:nn fes Irl the iom,ora S'IOf'WORK ORDER and a fille ofllP to$250.00 it day Ai'ilmst the %iolmor_ X L4 ach'iscd thaf a cop Of{Inti�t:11.'[Iti'rY[tII<L� Iu fol 41 fO 111C(_>'ztt4"L of Ir�srstig;7tion>of the DIA ti,r inil:rastcc CMCFagc ,4cwic uwl. I do hereb),gcert(fv under tire pains and penalties of perjury that the informatioer prftvide(l above i,c true and correct. ()ffrcial use opil-v. Do not w'rife i)t Ihis area,to be completed 1)',•city or town rojfcirtl_ City or Town: _-.__-- Permit/License 1"uing Authority`icircle one): I.Board of Ilealth 3.Building Department 3.t'ily"I'emn Clerk 4.Electrical Inspcetor s".PlimiNtim Inspector Pi.Other t'enttad Person: Depaftrn�t ot PLibhC Safet Board of B»id.nq F<c9lilations C -102562 SSL KURT R(;AEITBWR P-0,Box 344 IP-swich MA 019,* 11 OS75t2017 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02115 Home Improvement Contractor Registration Registration: 173410 Type: Individual Expiration: 1011!2016 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 Affairs&13usincss Regulation License or registration valid for individut use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to. <- ., `Registration: 173410 Type. Office of Consumer Affairs and Business Regulation tL, Expiration: 10/1/2016 Individual tU Park Plaza-Suite 517(1 Boston,,NIA 42116 KURT GAUTHIER KURT GAUTHIER 44 ESSEX Rt] - _-- IPSWICH,MA 01938 E'nderscrretary :`ot valid wi out signature DATE(MMIpp1YYYY) CERTIFICATE OF LIABILITY INSURANCE ,01 05/13/2016 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 NAOMEACT Kaitlyn Daysh W MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE ) (413)536-0804 Marc Noz E-MAIL kda sh micla ton.com ADDRESS: Y � Y 1649 NORTHAMPTON ST.,RTE 5 INSURER(S)AFFORDING COVERAGE NAIC# HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325 INSURED - — INSURER 8: GAUTHIER INSULATION INC -INSURER-C: _. INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 1 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 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. IEXP LTR TYPE OF INSURANCE ADD R POLICY NUMBER MMID YYY MMID©NYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ CLAIMS-MAGE FIOCCUR PREMISES Ea occur encs $ MED EXP(Any one person) $ _ NIA PERSONAL&ADV iNSURY $ GEN'L AGGREGATE LIMIT APPLIES PER: G_E_NERAL AGGREGATE $ JECT POLICY E PRO- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODII.YINJURY(Per person) $ ALL OWNED SCHEDULEDNIA BODILY INJURY(Per accident) $ AUTOS AUTOS -- NON-OWNED PROPERTY ROEd YDAMAGE � $ HIREDAUTOS AUTOS fP.c ----- $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB _ CLAIMS-MADE NIA AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X 011,1- AND EMPLOYERS'LIABILITY X YSTATUTE _ ER ANYPROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER McMBERExCLUDEoz NIA NIA NIA MAARP300327 10/30/2015 10/30/2016 (Mandatory In NH) E.L.OISEASE_EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMBT $ 500,000 NIA DESCRIPTION OF OPERAT€ONS 1 LOCATIONS/VEHICLES(ACORD 10f,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.govllwd/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 CITY OF GLOUCESTER ACCORDANCE WITH THE POLICY PROVISIONS. 3 POND ROAD AUTHORIZED REPRESENTATIVE GLOUCESTER MA 01930 Daniel M.Crowley,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 i' 6___ CERTIFICATE 4F LIABILITY INSURANCE °"08`12 D15 Bazlanosa THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMAT'NELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT C09STITUTE A CONTRACT$ETWEEN THE ISSUING INSURERIS),AUTHORIZED j REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT! M the cordflcaW holder Is an ADOffIONAL INSURED,the potieypos}mus;be andorsod, U SUBROGATION IS WA VED,Sub)eet to the terms and condlduna of the policy,certain policies may r"uhe an endarsament,A atatsmont on this oertlflcata done not Canter rights to the E ceNtlicate hotder in lieu of such 17ndoreome s, PRODvcan X MARTIN J_CLAYTON INSURANCE AGENCY iNC P cNe 413[AD536-0804AhInEK ,H` L We h mldeyton.cdm 1949 NDFRTHAMPTCN ST.,RTE 3 nuvRra s AFPoaClNd cavtRaoe NAite HOLYOKE MA 41041 I ReRA: ACAOIAINSCO 31325 w4ufto WBURE e: _ GAUTKER INSULATEON INC arsweaRe; j wauRaRo: __ PO BOX 344 uhNme I=sWicH MA 4193a awaeRx: COVERAGES CERTIFICATE NUMBER:76793 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUtREM&Mr.TERM OR CONDITION OF ANY COWtAACT OR OTHER DCCUMENT MTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRSED HEREIN IS SUSJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LfM#TS SHOWN MAY HAVEBEEN REDUCED BY PAID CLAIMS, LVI Tr"OPINRURAII" POGeYNUMSER PO t PO11CY P LNnfa I COMMaRCIALOQ]F.RAL LNBILnY 1f I IIACHOCCURRENCE t CLAIMSMADC❑OCCUR I I fiTO REo .msl 7 • II NIA MED Exp env 7 PERe0IvALaADVhJURY 7 { OMAOCREDATE LIMRARAASPER� I Ct11CRAL AOOReeAYE S ... i PR POLICY LOC I .IEC PROCc1CTs•CAMP/DP AOG 7 OTHER q AVTOMeeILRLJRAaf1Y I q {ANY AUTO I agCS.Y W7uRY(fmr yerrei} 9 i ACy1F:0D eCHECVLE6 E 'AV10SAUTO$ E N(A � n0MLV IlUURY(Px kq'IJpMj S HrRE0AUT06 ALTOS V t I Iow"POLLAL7l9 i OCC IR GaDH xDURRExcE oxCaee LL&O t CWMa•MACE ! N!R AOOntC<ArE S D nION7 s WORN"OOMPeN7AMN X i� A10EYPLOVLRa'LIAaRrfY Y!R AN19RCMEIOM+ARTNEFf]IF�UTIVE EL EACH ACCIDfM s ,D00 A tM_,., 8WEREXLUCE07 WA NU N!A MAARP300327 10136201610=12016, 3 Lrrn,,w'rif Nraunoa. :E.L,CISEASE,EA EMFLOYO S 500,040 xyyNvr e.r.4s OE3CEy ON PERAnoNe balan I-1111EA51,•POLICY LIMIT S 344,004 t NIA E ceaChTe'T16N or oPP.RATroHslLocATloRsIVENICLea ULCCRO To7,Arelua,mwa,Nw.xn.e,A,,mI>/m atuenea x„ern�*.>,nWinNi Workars'Compensation beneftts will be paid to Massachusetts employees only.Pursuant to ErlddrSe[ITent WC 24 03 OB S.no audiorizelien Is given to pay Claims for benefits to employees In states other than Massachusetts itthe Insured hires,or has hired those arnWoyoos outside o;Massachusetts, This cerd4osla Of insurance shows the Polley In force on the date Thal this caMcate was issued(unless the axpiratlon 4 to on the above pe11 precedes the Issue date of this cardlicale of Inauranre} The status lit this covom4a Can ho monilored deity by accessing the Proof a;Coverage•CoveraBa Vad4ceiion Search loot atwww.mass.gavhwd/wontera-campanaellonlinvesligatlonel. CERTIFICATE HOLDER CANCELLATION 9HOULDANY tlF 7HE ABOVE OE5CitIaED POUCHES BE CANCELLED BEFORE THE EXPIRATION t1ATE THMOF, NOTICE WILL SE DELIVERED IN Town of North Andover ACCORDANCEWRH THE POUCY PROVISIONS. 1200 Osgood Street AurxaRttEoxersaseNTwnrE North Andover MA DIS45r Cr Daniel M. y,CPCU,V'wa PresEdent—Residual Market—WCRIBMA O 1588-2014 ACORD CORPORATION,All rights reserved. ACORD 25{2414101] The ACORD name and logo are registered marks W ACORD Y f