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HomeMy WebLinkAboutBuilding Permit # 10/5/2016 p" The Commonwealth of Massachusetts FOR t 1 Board of Building Regulations and Standards MUNICIPALITY ' Massachusetts State Building Code, 780 CMR, Vh edition USE Building Permit Application Revised August, 2012 This Section For Official Use Only Building Permit Number: _ Date Applied: Signature: Building Inspector Date SECTION 1:SITE INFORMATION Residential ❑ Commercial ❑ Other Description: Ll Property Address: 1.2 Assessors Map&Parcel Numbers Lla Is this an accepted street? yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions; Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 one In Flood Zone 1.8 Sewage Disposal System: Public❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Commercial- Scrvice Size Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Reco d: `S $� i X 31` . !) •A �.,A r5l��t� Name(Print) — .._.._ - YAddress for Service: Signature Telephone E-Mail Address SECTION 3.DESCRIPTION OF PROPOSED WORW:(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteratian(s} ❑ Addition ❑ Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work. pA� i dC \p (KDC} LA t�, xs SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) UflPicial Use Only; 1.Building $ I, Building Permit Fee:$ 2.Electrical $ 2 Indicate how fee is determined:. ❑Standard City/Town Application Fee 3.Plumbing $ ❑Total Project Costa(Item 6)x multiplier x 4.Mechanical (HVAC) $ 3 Other Fees: $ 5.Mechanical List: (Fire Suressian) $ Total All Fees:$ 6.Total Project Cost: $ J 05iy_ j Check No.'s 0 Check Amount: _Cash Amount: SECTION S; CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) VJA AC-0 N r e of C -Holder (} License Number Expiration Date Lk u � bbl List CSL Type(see below) Address e Desoii l Signature U Unrestricted u to 35,000 Cu.Ft,) R Restricted U2 FarniI Dwelling "V L92-'ULAI M Mason onl Telephone RC Residential Roonng Coverin kl r( WS Residential Window and Sidin E-mail Address SF Residential Solid Fuel Burnin A Pliance Installation 5.2 Re istered Home Im r©ve�ment Contractor(HIC) D Residential Demolition a IS�21� BIC Co ame or C Registrant Name l Lau Registration Number D t. AKSt�4, 9rlA� It 34/7•e>t1 Expirn�rdt -Dat-_ Telephone}�� E-mail Address SECTION 6: .ORKERS'eOMI�ENSATIt 1N aINSiTIte NCE AEI'IDAVIT:{1Vf Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit, Signed Affidavit Attached? Yes .......... ❑ SECTION 7a:.OWNERA11L1THORIZA TIQN,TO 11 COMPLETED:WREN OWNER'S AGENT°OR:CC?NTRA CTOR APl?LIES FORbtALDING]P!LRIVIIT I, authorize as Owner of the subject property hereby relative to work authorized by this building permit application. to act on my behalf,in all matters Si nature of owner Date SECTION 7b O WNER'QR:AUTHORiZED AGENT D_ECLAItA`1'IOl I, wner or hereby the statements and information on the foregoing application are true ands sao ate,tothe best ofmyuthorizedent andknowled a declare that g and behalf. Signature of Owner or Authorized Agent (Signed under the pains and penalties ofer u Date P ) r5') ,NOTES: I. An Owner who obtains a building permit to do his/licr own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(MC)Program.),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.86 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.)"t.) Grass living area(Sq.Ft,) (including garage,finished basement/attics,decks or porch) Number of fireplaces Habitable room count Number of bathrooms Number of bedrooms Type of heating system Number of half/baths Type of cooling system Number of decks/porches Enclosed Open RT owe. of 2 s �F 6Andover p _ to Ah ver, Mass, / S 0/ 6 cocHu�.ew�cK � •9 ArED 16?�,��(5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .,,.r...... BUILDING INSPECTOR has permission to erect .......................... buildings on .....33..........!„�.��.5.�......... ...... .....�.owr Foundation Rough to be occupied as ............. ;kcW4odl�,...........�.!9?�l .................................. ....,�M w!!!1 aE................................. 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 Fina[ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS COSTRUC CN STAR Rough Service ..... .. . ....�.. .. 1!. .... ....................... BUILDWG INSAECTOR... Final 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 Miall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke pet. Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 'fax ID#02-0353691 Client: Johnson,Ben Home: (978)314-7857 Property: 531 Forest St. Nortth Andover,MA 01845 Operator: STEVEN Estimator: Steven Fumero Business: (978)688-2242 Company: SERVPRO Of Lawrence-SERVPRO Of The E-mail: steven@servprooflawrence. Andovers -SERVPRO Of Salem/Plaistow cam Business: 8 Blakelin St. Lawrence,MA 01840 Type of Estimate: Water Damage Date Entered: 9/27/2016 Date Assigned: Price List: MAEM8X SEP16 Labor Efficiency: Restoration/ServicelRemodel Estimate: 20I6-09-27-1136-1 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 2016-09-27-1136-1 Main Level Kitchen Height: 8' r ^ i ;, wer ca n,cls( I 340.22 SF Walls 137.00 SF Ceiling ii pay Kitchen ; 477.22 SF Walls &Ceiling 137.00 SF Floor N T Ti.�, , n,2 tuz 15.22 SY Flooring 41.67 LF Floor Perimeter `ind ti33 46.83 LF Ceil.Perimeter 'i 7.,1,� Z,,,��, Missing Wall-Goes to floor 2'7"X 6' 8" Opens into Exterior Missing Wall-Goes to Floor 2'7" X 618" Opens into Exterior DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC, ACV 1, Tear out non-salvageable tile floor&bag for disposal 137.00 SF 2,88 2.06 396.62 (0.00) 396.62 2. Tear out non-salt'underlayinent&bag for disposal 137.00 SF 1.24 0.77 170.65 (0.00) 170.65 3. Countertop-flat laid plastic laminate-Detach 12.00 LF 4.89 0.00 58.68 (0.00) 58.68 4. Cabinet-lower(base)unit-Detach 12.00 LF 15.12 0.00 181.44 (0.00) 181.44 5. Sink-single bowl-Detach 1 AO EA 22.56 0.00 22.56 (0.00) 22.56 6. Tear out wet drywall,cleanup,bag for disposal 16.00 SF 0.81 0.19 13.15 (0.00) 13.15 7. Tear out and bag wet insulation M00 SF 0.64 0.07 10.31 (0,00) 10.31 Totals: Kitchen 3.09 853.41 0.00 853.41 Total: Main Level 3.09 853.41 0.00 853.41 Basement Basement Height: 8' 342.67 SF Walls 114.17 SF Ceiling 456.83 SF Walls&Ceiling 114.17 SF Floor 12.69 SY Flooring 42.83 LF Floor Perimeter 1 42.83 LF Ceil. Perimeter DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 8. 'fear out and bag wet insulation 114.17 SF 0.64 0.50 73.57 (0.00) 73.57 9. Clean floor or roof joist system 114.17 SF 0.75 0.14 85.77 (0,00) 85.77 10, remove wet suspended ceiling tile and bag for 114.17 SF 0.36 0.50 41.60 (0.00) 41.60 disposal 2016-09-27-1136-1 9/28/2016 Page: 2 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 CONTINUED-Basement DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV Totals: Basement 1.14 200.94 0.00 200.94 Total: Basement 1.14 200.94 0.00 200.94 Line Item Totals: 2016-09-27-1136-1 4.23 1,054.35 0.00 1,054.35 Grand Total Areas: 682.89 SF Walls 251.17 SF Ceiling 934.06 SF Walls and Ceiling 251.17 SF Floor 27.91 SY Flooring 84.50 LF Floor Perimeter 0.00 SF Long Wall 0.00 SF Short Wall 89.67 LF Ceil.Perimeter 251.17 Floor Area 281.94 Total Area 682.89 Interior Wall Area 820.56 Exterior Wall Area 95.00 Exterior Perimeter of Walls 0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length 0.00 Total Ridge Length 0.00 Total Hip Length 2016-09-27-1136-1 9/28/2016 Page: 3 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5394 978.688.2242 office@ servprooflawrence,com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Summary for Dwelling Line Item Total 1,050.12 Material Sales Tax 4.23 Replacement Cost Value $1,054.35 Net Claim $1,054.35 Steven Fumero 2016-09-27-1136-1 9/28/2016 Page:4 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office @ servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID##02-0353691 Recap of Taxes Material Sales Tax(6.25%) Clothing Sales Tax(6.25%) Storage Tax(6.25%) Line Items 4.23 0.00 0.00 Total 4.23 0.00 0.00 2016-09-27-1136-1 9/28/2016 Page: 5 5ervpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawreiice.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Recap by Room Estimate: 2016-09-27-1136-1 Area: Main Level Kitchen 850.32 80.97% Area Subtotal: Main Level SS0.32 80.97% Area: Basement Basement 199.80 19.03% Area Subtotal: Basement 199.80 19.03% Subtotal of Areas 1,050.12 100.00% Total 1,050.12 100.00% 2016-09-27-1136-1 9/28/2016 Page: 6 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office @ servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Recap by Category Items Total % CLEANING 85.63 8.12% GENERAL DEMOLITION 701.81 66.56% WATER EXTRACTION&REMEDIATION 262.68 24.91% Subtotal 1,050.12 99.60% Material Sales Tax 4.23 0.40% Total 1,054.35 100.00% 2016-09-27-1136-1 9/28/2016 Page: 7 WHITKE1 PAGE 2 NOTEPAD tNSURED'S NAME KeJo Corporation OP Ip: PI Date 091281200 Named insured: Kejo Corporation dba Servpro of Lawrence dba Servpro of Lawrence-Three dba Servpro of Lawrence-Two dba Servpro of Salem/Plaistow dba Servpro of The Andovers .................... Main Level 12' 8" 8' 12' m i Kitchen N _.. _ L)wei Cabinet (B ) 4' 9" Island{133} i•h Main Level 2016-09-27-1136-1 9/28/2016 PaDe: 8 .. . .................................................................... Buset��ent -_101 8rl 10' Basement -� Ll� T, Basement 2016-09-27-1136-1 9/28/2016 Page: 9 t • Authorization to Perform Services and Direction of Payment Customer Name: Ben Johnson Date of Loss: 09/19/2016 Loss Address: 531 Forest St City: NORTH ANDOVER State: MA Zip: 01845 Insurance Company: SAFETY Insurance Claim Number(if available): Bos71783 The undersigned Customer, being the building owner, owner's representative, or resident, authorizes the Provider identified below to perform any and all necessary cleaning and/or restoration services on Customer's property located at the property address above, and with respect to items that need to be cleaned at a remote location to remove and clean such items as necessary. Customer authorizes SAFETY Insurance Insurance Company, herein referred to as "Insurance Company,"to pay Provider solely and directly for that portion of the work covered by Customer's insurance policy. If, for any reason, Customer receives a check from Insurance Company made payable to Customer, Customer agrees to pay Provider immediately upon receipt of the check. In order to expedite payment to Provider, Customer hereby appoints Provider as attorney-in-fact, authorizing Provider to endorse Customer's name on Insurance Company checks or drafts, and to deposit Insurance Company checks or drafts for Provider services. Customer agrees to pay Customer's deductible in the amount of$ $0'00 that applies to this claim. If any amounts owing to Provider for Provider services are not covered by insurance, Customer agrees to pay those amounts to Provider within fifteen (15) days of Customer's receipt of invoice. It is fully understood that Customer and its agents, successors, assigns, and heirs are personally responsible for any and all deductibles and any costs not covered by insurance. Interest and finance charges will be charged at the maximum allowable by law, or at 1.5% per month, whichever is less, on accounts over thirty(30)days past due. Time is of the essence. Customer agrees that Provider is working for the Customer and not Customer's insurance company or any agent/adjuster. Property Owned By: Ben Johnson Remarks: I HAVE READ THIS AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT, INCLUDING THE TERMS AND CONDITIONS OF SERVICE ON THE NEXT PAGE HEREOF, AND AGREE TO SAME. Customer Reviewed Customer Information Form: O Y ON Provider's Signature: Alc�Customer's Signature: Franchise Legal Name: KEJO CORP Printed Name: Ben Johnson d/b/a SERVPROa of: The Andovers Date: 09/29/2016 Date: 09/29/2016 bjohnson1m31 @yahoo.co E-mail Address: Contractor License#: @SERVPRO"INTELLECTUAL PROPERTY,Inc. ALL RIGHTS RESERVED FE-051707 1.0 28000 05116 Each SERVPRO"Franchise is Independently Owned and Operated. V ' The Commonwealth of Massachusetts w Department of IndustrialAccidents n 1 Congress Street, Suite 100 Boston,MA 02114-2017 a„ www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information QQ Please Print Lep-ibly Name (Business/Organization/Individual): c�e�voRO r Address: y�1AKQ.l.a • City/State/Zip: L.A+u t`DLAE Phone#:(9-.1) Z2 kL Are yo n employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with !(P employees(full and/or part-time).* 7. ���--❑777 New construction 2.[:] 1 am a sola proprietor or partnership and have no employees working for me in $, remolition emodeling any capacity.[Ido workers'comp.insurance required.] 9. D 10 lam a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I Nvill ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.Q 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGI,c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required,] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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 cheek 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 for my employees. Below is the policy and job site information. Insurance Company Name:. 16�d_ �oQ�b�-�Lora Policy#or Self-ins.Lia#: ,,c^^ ^- b�a���C) Expiration Date; Qt�o Job Site Address: 15 l �D �Sk City/State/Zip:l� 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 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 pains and pen ltles ofperjury that the information provided above is true and correct. Si nature; kt Date: Phone#: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATEIMo9/28/Zo1/2016 s 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: _ Dabney Collier PHONE _ FA clo Collier Insurance01 529 2900 Alc No: (901)529-2915 E-MAIL,E MAI 606 S.Mendenhall;Suite 200 ADDRESS: Memphis,TN 38117 INSURER(S)AFFORDING COVERAGE NAIC it INSURERA: American Zurich Insurance Company 40142 INSURED INSURER B: Adams Keegan,Inc. 6750 Poplar Ave Ste 400 INSURER C: Memphis,TN 38138 INSURER D: INSURER E: INSU RER F: COVERAGES CERTIFICATE NUMBER:15TNO09B58085 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. ILTR TYPE OF INSURANCE INSD WVD BR POLICY NUMBER —�� MMIDDIYYYY MMIDDlYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S GE TO REED CLAIMS-MAGE 1-1OCCURPREM SES a oaur encs MI=D EXP(Any one person) S PERSONAL B ADV INJURY S _m GEN'L AGGREGATE LIM€T APPLIES PER: GENERAL AGGREGATE 5 POLICY 0 PRO [:]LOC PRODUCTS PRO- JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIM#T S Ea accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY{Per accident) $ AUTOS AUTOS _ HIRFDAUTOS NON-OWNED PROPERTYDAMAGE-- S AUTOS _Per accident 5 UMBRELLA LIAB' HCLAIMS-MADr= OCCUR EACH OCCURRENCE $ EXCESS LIAB AGGREGATE S DED I I RETENTIONS $ WORKERS COMPENSATIONX PER EORH YIN AND EMPLOYERS`LIABILITY ---- ---- -------_-------- ANY PROPRIETOR/PARTNER/EXECUTIVE E,L.EACH ACCIDENT S 1,()00,000 A OFFICERIMEMBEREXCLUDED? NIA WC 56-11-855-02 12/01/2015 12/41/2018 .— __..,_......__.._-......__.._, (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under ..............., �_.._..._.—.—_ ._. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 1,000,000 Location Coverage Period: 12/01/2015 12/01/2016 Client# 2410-MA DESCRIPTION OF OPERATIONS t LOCATIONS t VEHICLES (ACORD 761,Additional Remarks Schedule,may be attached If more space Is requlred) Coverage is provided for KEJO Corporation dba:SERVPRO of Lawrence 81 only those co-employees Weekly of,but not subconlraclors 8 BLAKELIN ST lo: Lawrence,MA 01842 CERTIFICATE HOLDER CANCELLATION Ben Johnson SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 531 Forest St. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,MA 01845 ACCORDANCE WITH THE:POLICY PROVISIONS. AUTHORIZEDREPRE$ENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved, ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD WHITKE1 OP II3: PI CERTIFICATE OF LIABILITY INSURANCE nATEIMMIDDIYYYY) �—' 09/28/2016 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(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 CONTT CT James R,Me Donald Stanley McDonald Agency PHONE PAX 1101 Main Street (NC.ND,a t•608-788-6160AIc No: 608-788-7012 Onalaska,Wl 54660 DDRESS: James R.Mc Donald INSURER(S)AFFORDING COVERAGE _- NAIL N INSURERA:Rockhill Insurance Company 28053 INSURED K.eJo Corporation INSURER B:The Federal insurance Co. 20281 dba Servpro of Lawrence INSURERC:ACE Property&Casualty 20699 See Note For Named Insured PO Box 328 INSURER D: Lawrence, MA 01842 INSURER E: 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. INSR rypE OF INSURANCE ADDL S B POLICY EFF POLICY EXP LIMITS LTR 3 D POLICY NUMBER MMIDDIYYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ $ 2,000,000 DAMCLAIMS-MADE OCCUR ENVP016006-00 0310112016 03/01/2017 PREMISESGE TO 1K;,:J u encs $ 50,000 MED EXP(Any one person) S 8,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY❑JEC 1:1 LOC PRODUCTS-COMPIOP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea ecolde 1 ANY AUTO BODILY INJURY(per person) $ ALL OWNED SCHEDULED BODILY INJURY{Per accident) $ AUTOS N�OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS Peraccldenl $ UMBRELLA LIAS OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS-MADE M00798617 01/14/2016 01/14/2017 AGGREGATE $ 1,000_,000 DED I X I RETENTION$ 10000 $ WORKERS COMPENSATIONPER TE 0TH- AND EMPLOYERS'LIABILITY Yl N ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-.EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Pollution Liab ENVP016004-00 03101/2016 03/01/2017 Pollution $2miU$3mil B EmployeeDPshonesty 670-66-47 03101/2016 03/01/2017 Crime 26,000 DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLES (ACORD 101,Addltlonal Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION JOHNBEI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ben Johnson ACCORDANCE WITH THE POLICY PROVISIONS. 531 Forest Street North Andovor,MA 01845 AUTHORIZEDREPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORN ' �in7%r i�riNra�NrN�/�r�'•'�lrl.l.l.�r�njr//' registration License or re valid for individul use only �z.i• Office of Consumer Affairs&Business Regulation 6 Y : --THOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to; Office of CAffairs d BiR Consumer ars anusness Regulation Registration: 15827# Type: Of � Expiration: 12/31/2017 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 KEJO CORPORATION SERVPRO OF LAWRENCE, ET ALS. GREGG WHITE 8 BLAKELIN STREET LAWRENCE, MA 01871 Undersecretary thout signature P:4assaC0Use1ts Departoient of Public Safety Board of Buildtnq Reguintions and Standards License CS-067690 GREGG M WHITE 4 CHATBURN RD WINDHAM NH 03087 02/20/2018