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HomeMy WebLinkAboutBuilding Permit # 11/9/2016 NO R T!-1 BUILDING PERMIT °� `Y`�� '6�"� TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION * t y * � a 't Date Received t I ` 9__ _4_0 rE ��Ss AP Permit No#: Date issued: 1 r a IMPORTANT: Applicant must complete all items on this page LOCATION print PROPERTY OWNER 1cc Year Structure Yes Print MAP PARCEL. -ZONING DISTRICT: �._._..Historic Disfrict yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Resid tial LJ New Building One family [I Two or more family Ll Industrial ❑Addition ❑ Commercial ❑Alteration No. of units: epair, replacement ❑Assessory Bldg [i Others: G �a... . etc��e�',myu�rxre' ���.£ �r ✓fes �❑%Other Odd Ca j will11 Demolition NEWDESCRIPTION OF WORK TO BE PERFORMED: .� IdentI le tion- Please Type or Print Clearly Phone. OWNER: Name Address: Contractor Name> Phone: Email: Address: S'upervisor'sConstruction Licen Exp. Date._ � Exp. Date: Home.Improvement License: ARCH ITECTIENGINEER Phone. Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12,00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$1S.F. FEE: Total Project Cost: $ $ -. Receipt No.: Check No.: � NOTE: Persons contracting with unregistered contractors do not have access t the guaranty and F fi q0 'T %AORTO own of z F over O - t No. 49b-,-a61_j �� h , ver, Mass, cac.LAKI cK 1 �.QS RArEU U BOARD OF HEALTH Food/Kitchen -PERMIT .T LD Septic System THIS CERTIFIES THAT .�4,. .*VOq.TV.00!. !o.. ,e.... ....3cwov#wj_........ BUILDING INSPECTOR has permission to erect.......................... buildings on .....ls k..&.�,,fts,..,/. o1I,........VJ.4%f... Foundation Rough to be occupied as ............. jj.. .. ..... ..., p' +P� �. ..,. .........Il �go0......................................I............. 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS I Rough ............. ,...�. ...IL ,,................ Service BUILDING INSPECTOR Final 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. Proposal— HIC#174377 Damphousse Roofing LLP 1717T­� A trusted name since 1938 0 Roofing . Siding -Windows 87 Belmont Street - North Andover, MA 01845 P: 978-683 588 F: 978-685-7446 It'd NAMEOFOWNER- <1 /,7 ADRESS OF JOB—, DATE: T E L ------- We will remove all roof shingles off total roof area, layer. Replace any boards or sheathing at additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. Architectural roof shingle installed with a limited lifetime warranty. Install new ventpipe boot flashings. Waterproof existing chimney flashing and remove debris. .00l Shin le Color""" �tPU04' Ridge Vent Upgrade e- Woo heathino Rpnair$3.50 pe ;�4 ZD -r10 U A 0741'a? Prop se herby to furnish material and labor-complete in accordance with above specifications,for the sum of: a5/-J/f s1-anetA-t-4sM' 7 (�A Z�� w v i-ke,1-5 -h> �eo'4�S' a del A Payment t be nade as follo A" 4111 1 A111 Authorize Slgnature�—�����C�-'4�C 00'sd A NOTE:Th s proposal may be w.ZK"n by us if not accUllith in-,e�`days Acceptance of PropoSal - The above prices, specifications and conditions are satisfactory and are herby accepted.You are authorized to do the work as specified.Payment will be made as Outlined above. Signature '-"7 Date of Acceptancl Signature L ptance: HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS M.G.L.142A L WORK:Provided the Homeowner performs under this agreement,the Contractor shall perform the work on the Property as specified Proposal,attached incorporated herein.The work does not include extraordinary conditions of which the Contractor could not reasonably be aware.If such conditions are encountered,this shall be an additional cost to the Homeowner.Materials selected by Homeowner may have to be ordered or custom made,which items are specified in the Proposal.The Contractor is not obligated to agree to any modifications,extras or change orders unless such items are agreed to in writing by the Contractor.All extras and changes shall be at an additional cost to the Homeowner.Contractor shall perform the work in a good and workmanlike manner using materials consistent with this contract.Lawn or Driveway may be damaged by dumpster or equipment. Due to material shortages Contractor may substitute materials of equivalent grade. 2. PERMITS:If a building permit is required for the work,the Contractor shall obtain same as Homeowner's agent.Contractor is not responsible for any other permits that may be required for the Work,and homeowner is responsible to determine whether any zoning,planning or wetland related permits or approvals are necessary.Homeowners who secure their own permits or deal with unregistered contractors will not have access to the Guaranty Fund. 3. COMMENCEMENT AND COMPLETION; Homeowner acknowledges the commencement date of the work is fluid,and is subject to numerous factors such as scheduling other contractors,delivery of materials and weather,Contractor and Homeowner shall deternzine the commencement date of the Work when a more definite determination can be made and shall execute a written acknowledgment of same.The Work shall be substantially completed within 7 days of commencement,except for longer periods as may apply to particular projects as Contractor shall notify Homeowner in the Proposal,and subject to delays for circumstances beyond Contractor's control.Notwithstanding,the commencement date and substantial completion date quay be extended,and file Contractor will not be liable for delays caused by,labor or material shortages,delays in delivery of items selected by the Homeowner,governmental action, and unforeseen events beyond the Contractor's control,including but not limited to weather,strikes,war,the acts of third persons or the acts of the Homeowner.The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractor's other jobs. 4. PAYMENTS:Contractor agrees to perform the Work and to furnish the materials and labor specified in the Proposal for the amount as stated in the Proposal.Thirty percent(30%)of the total is to be paid as a deposit with the signing of this contract.Upon cancellation prior to commencement of the Work,any remaining deposit will be returned less the costs for materials ordered for which Contractor was unable to cancel.Final payment shall be due upon completion of the Work and Homeowner agrees it may not hold any retainage.Late fees may be applied for late payments. Homeowner shall pay Contractor's reasonable costs of collection,including attorney's fees and costs.Time is of the essence hereof. 5. WARRANTY:For a period of 2 years after substantial completion of the Work the roof will be free of leaks caused by defects in workmanship, but not those caused by ice backing-up or extraordinary weather events, including blizzards,tornadoes,hurricanes or storms of greater than a twenty-five year duration or intensity.Contractor gives no warranties with reference to any materials or equipment installed in the Premises,passes any such warranties directly to Homeowner,and Homeowner agrees to look only to the manufacturer with reference thereto.This limited warranty extends to the 1-lomeowner only and is not transferable to succeeding Homeowners.This Limited Warranty specifically excludes(i)all consequential and 'incidental damages;(ii) damage due to ordinary wear and tear,abusive use,misuse,or lack of proper maintenance;(iii)defects which are the result of characteristics common to materials used;(iv)defects in items installed or supplied by anyone other than Contractor;(v)work done by anyone other than by Contractor,and(vi)loss or injury due to the elements.There are no other expressed or implied warranties or representations inade or given. 6. ENTIRE AGREEMENT:This contract and all documents referenced herein constitute the complete and final agreement between the parties. In the event that any of the provisions of this contract shall be held to be invalid,the remainder of the provisions of this contract shall remain in fall force and effect.Two identical copies of this contract have been completed and signed.Homeowner acknowledges receipt of a completed contract signed by the Contractor. 7. HOME IMPROVEMENT REGISTRATION: In accordance with M.G.L.c. 142 A, §9,Contractor is registered with the Bureau of Building Regulations and Standards Registration No: 174377.Homeowner may verify by contacting the Director at(617)727-3200,ext.25205.A Homeowner's rights under the Home Improvement Law(M.G.L.c. 142A)and other consumer protection laws may not be waived in any way.Homeowner acknowledges receipt of a copy of 780 CMR R6 and Massachusetts General Laws chapter 142A,and which are available online at www.mass.gov.Questions may be directed to the Consumer Information Hotline,(617)727-7780. 8. ARBITRATION:Contractor and the Homeowner hereby mutually agree in advance that in the event the Contractor has a dispute concerning this contract, the Contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c. 142A.No lien or security interest is imposed on the Property as a consequence of this contract,but Contractor has the right to record this contract or a notice of this contract,or seek a lien if the Homeowner breaches this Contract. s 9. HOMEOWNER COVENANTS:The Homeowner agrees,represents and warrants that(a)the Homeowner grants pet-mission to the Contractor to enter the Property to perform the work as covered by this contract;(b)the Homeowner has funds available to make fiill payment under this contract to the Contractor 3 upon completion;(c)the Homeowner understands that construction as contemplated by this agreement creates a dangerous condition,and agrees not to enter portions of the Property under construction until the Contractor advises the Homeowner that the construction is completed;(d)Contractor may need use landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and(e)that code requirements may result in roofing nails penetrating through roof decking and will be visible on the underside of some surfaces.The Homeowner indemnifies,exonerates and holds harmless the Contractor from any loss,damage,claim,liability or expense(including reasonable attorney's fees,deposition costs and court costs)resulting from a breach of this provision.Contractor is not responsible for damage to landscaping that will grow back during the next growing season. 10.CANCELLATION: Ilosneowner may cancel this agreement provided Homeowner notifies the Contractor in writing at the address listed in the Proposal riot later than midnight of the third business day following the signing of this agreement. pHOMEOWNER/jJ/J� 1� DATE: Shingle: � �� �. DEPOSIT: _ t 'r � The Crtzrutton3vealth ofMassachusetts gip\ Departinent of Industrial Accidents go t � Of Tee of 1"tz>>estigations { 600 Washington Street ,rte {� Boston, MA 02111 lvliiltt.]ttass.gll vIditi Workers' Compensation insurance Amada-vit: Builder s/Contractorsll;lectricianslPlu tubers Applicant InformationPlease Print Legibly / t NaMe (Btasine .5/Oreanizationflndividual); 1�CttIe55: 7 a 0 ��. , 4, City/State/Zip- Phone�; Are y lr an employer? Check the appropriate box: Type of project(required): 1_ I am a employer with `i'. ❑ f am a general contractor and 1 have lured the sub-contractorsG. E]New construction employees(full and/or part-time).* Remodeling ?-E] I atxt a sole proprietor or partner- listed on the attached sheet, �• ❑ ship and have no employees These sub-contractors have S. EJ Demolition employees and have workers' working for me in any capacity. 7 9. 0 Building addition n workers' eom insurance corp.insurance.= p 5. ❑ We are a corporation and its 10,[]Electrical repairs or additions required.] officers have exercised their l 1.❑ Plumbing repairs or additions 3.[] 1 am a homemvuer doing all work right of exemption per MGL tztyself. [oto workers' comp. 1..v _ 1 oof repairs aired. insurance re c. 152, §1{�),and we have no required.] employees. [No workers- 13•❑Other comp. insurance required.] t.Ajiy applicant that cheeks box,'fl must also 17,11 Out the section below showing their workers'compensation policy information. t submit this affidavit indicating they are doing all work and then hire outside cOOtmctors must submit a new aE'Ttdavit indicatine such. lemntmeters that check this bas must attached an additional sheet showing the nume of tltc sub-contractors and state whether Or not those entities line employees. Ir tine sub-coatmctnm have employees,they must provide their workers'camp.policy number. all,all elliplo}ler that is providing rvorkers'cottipensation insurance for my employees, Beloty is the palu3}artd job sitr' infaruratiarl. lusuratice Cotrtpany Name: J , 1 �'l �' Expiration Date: Policy 7=tar Sel. itrs.Lic.r: �' Job Site Address: 1 City/State/Zip' Attach a coley of the workers' eampertsation policy de oration page(showing the policy nrxEnher and expiration date). Failure to secure coverage as required under Section 25A of MOL 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 a STOP WORK ORDER and a fife of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded ro the Office of investigations of the DIA for insurance coverage verification. I do hereby cerl;4 Hid Ir el nits acrd prutalties of pea jury that the iu formation protlitIL'tIl a/bole is tare and correct. Stott a€ure: lh'�`t� Date: Phone : Official use onljt Do not write ill rhes area,to be completed by city or town official City or Town: Permit/License Issuing Authority(circle floe): 1.Board of Heald► 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector [.Otber• Contact Person• Phone T: ® CERTIFICATE OF LIABILITY INSURANCE OATE(MEAfDprYYYY) AC(3RL] 10113/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES HOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an andoreemont. A statement on this cartlffcate does not confer rights to the certificate holder In fieu of such endoneement s. PROOUCeR Diane LeBlanc _ DOHERTY INSURANCE AGENCY INC PNaN 978)4750250 o rg .dlablan dohertyinsurarso9.00m _ _ T P.0 BOX 1985 -___-- IH$UAER(8}AffORbIH6C05tEAgee NAICo W ANDOVER MA 01810 MURER A t TRAVELERS INDEMNITY CO OF AMERICA 25666 MURSO MURER 0: TWOMEY&LEGARE CONTRACTING INC w9URERC: � IN9URER0• . ` � . .- — 87 BELMONT STREET VISURER s 1 NORTH ANDOVER MA 01845 UmuRB T_� COVERAGES CERTIFICATE NUMBER: 93248 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.TERAS 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 iYPSOPWOURANCE vimYNUMeHR POU BLIP COMMURCLALGIMeRALLrAeILITY ACHOCCUARENCR f _ CLAlAtS•ATADE GGCURPlI urs S rarwa S MED EXP l om nan 3 E SONAL f 3 ADV INJURY _ — wa P A GENE AGCRtECATE LIAOT APPLIES PEW GENERAL AGGREGATE S POLICY JECT LOC PRODUCTS-COAIPIOPAGO f AUTOr11oweL1A91LRY $0148a !N DISIN13LE LI IT T ANY AUTOALL O"ED aGD1LY ENJVAY(PCI parwnt T AUTOS AUTOS NIA BODILY INRMV{Par atwwij I HIREDAVTOS AUTOSWNfD PPDPERTY T UAIDRELLALLAO OCCUR EACHOCCURRFHCE T @ACES$LIAR I CL US•AMWE NIA AGGREGATE _ D 1 1 RETENTIONS ^- WORKERSCOMPENSATIONX AT E 101R , _ ANDEMPLeYEWLIABILnY YIN A OFOICERIMEMMIIEREXCLUDEED C wE wA NIA MA 6HU1302SOM99416 09118=16 09/188017 E-L.EAc"ACCIDENT T Y 500,00p IUyes�yes. � E L DISEASE•EAEUPLOYE T- 5_00.01 0 DSSCAPTION O�OP E RA T 1.0 N 9 b a 4 a w E L.DISEASE•POLICY LUwT t500.000 NIA eE$CWPTIONOfOPERATIONSILOCATIONSJVENICLES fACORD10I.AddlWr ft=rM04*6 ara.MybooMuthadItmsmspasahrqqW96 Workers'Compensation benefits wilt be paid to Massachusetts employees only,Pursuant to Endorsement WC 20 03 05 B.no authorization Is given to pay claims for benefits to employees In stales other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurarxe shows the policy in forte on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue data of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Vedfication Search loot at www.mass.govtiwdANorkem-compensatioMnveatigaUonsl. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELv4RE0 #1 Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street AUTHOR11110REPRESENTATIVE North Andover MA 01845 ''-'{ %• `' Daniel M.Cra Iv sy.CPCU,Vice President—Residual Market—WCRISMA 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are regietered marks of ACORD Client#. 14415 DA PHOUSSE ACORDTM CERTIFICATE CIF LIABILITY INSURANCE DATEIMMIDOfYYYY1 1110912(}16 PRODUCER THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O.Box 1985 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 21 Elm Street Andover,MA 01810 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A Western World Damphousse Roofing LLP INSURER B: 87 Belmont St INSURER C' North Andover,MA 01945 INSURER D: INSURER E; COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTq TYPE OF INSURANCE POLICY NUMBER CY EFFECTIVE POLICY EXPIRATION LIMITS A GENERAL LIABILITY NPP8296488 04112/16 04112!17 EACH OCCURRENCE S1,000,000 �( COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED rice S100,000 CL OJMS MADE a OCCUR MED EXP(Anyone person) S5 DDD PERSONAL&ADV INJURY S1.000.000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIAUT APPLIES PER: PRODUCTS•COMPlOP ADG s2,000,000 :X1 POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO (Ea aaadont) ALL OWNED AUTOS BODILY INJURY SCHEOULEDAUTOS (porpersanl $ HIREOAUTOS BODILY INJURY $ NON•OWNEO AUTOS (Por aocidoni) PROPERTY DAMAGE S (Por acddont) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY EACHOCCURRENCE S OCCUR D CLAIMS MADE AGGREGATE S DEDUCTIBLE S RETENTION S S WORKERS COMPENSATION AND WC STATU• DTH- EMPLOYERS'LIASILITY ANY PROPRIETORIPAATNEIVEXECUTIVE E.L.EACH ACCIDENT S OFFICERrtAEMOEp EXCLUDED? E.L.DISEASE•EA EMPLOYEE S 11 yyas.Aesui7a undor SPECLAL PROM I TIS holow E.L.DISEASE•POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EKCLUSIONS ADDED BY ENDORSEMENT J SPECIAL PROVISIONS Covering operations usual to Damphousse Roofing LLP... CERTIFICATE HOLDER CANC>ELI_AMON 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DE84RIBFD POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL I_ DAYS WRITTEN 1600 Osgood Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 80 SHALL North Andover,MA 01845 IMPOSE NO OBLIGATION OR LIABILITY OP ND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REP ESENTAn E ACORD 25(2001/08)1 of 2 #S34292IM34249 DML o D CORPORATION 1988 I DATE(f NVDDIYYYYI CERTIFICATE OF LIABILITY 8 SURANC E 6411612016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIG14TS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NO� AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TH15 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRboUCER,AND THE CERTIFICATE HOLDER,. IMPORTANT: If the certificate holder-Is an ADDITIONAL INSURED,the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions Q'I f the policy,certain policies may require an endorsement_ A statement on this certificate does not confer rights to the _certlllcate holder In lieu oflsuch endorsement(s), PRODUCER DONEf�TY INSURANCE ADEN'._ C NT CT Diane LeBlanc �I NAASE: _ AGENCY INC PHONE , (978)475-0260 FAX yalc,tool: i E-MAIL SS: dleblanc@doher( insurance.com _ P•fl BOX 1986 INSURERtS)AFFORDING COVERAGE I NAIL d ANDOVER NIA 01814 INSURER A. AIM MUTUAL INS CO s 33758 INSURED INSURER 8: DAMPHOUSSE ROOFING LLP INSURER C; INSURER D; I 87 BELMONT STREET INSURER E: --- NORTH ANDOVER MA 01845 INSURERF: COVERAGES CERTIFICATE NUMBER: 45456 REVISION NUMBED?: 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 RESPcCT TO WHICH THIS CERTIFICATE MAY BE ISSUE() OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITI&S OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lHS.RR TYPEOFINSURAN�E 1145D UBR POLICYNUMIBER MIO,€lMOMYYY MAIIloorri nr LIMITS COMMERCML GENERA�BMTY U—( EACH OGCURRENCE 5 CEAIA15dtADE OGCUR i {{ PREMISES Ea at;cursonca 5 J MEO EXP(Any are person) S it l NIA PERSONALE AOV INJURY 5 GEMLAGGREGATE LIMIrAPPI)ES PER; 1 GENERAL AGGREGATE I S POLICYED ECT ''E LOG PRODUCTS•COMPIOP AGG 5 OTHER-. -. AUTOMOBtLEL[ABlL[TY COMOME0 SINGLE LIMIT IS lea aecicenn `ANY AUTO j BODILY INJURY(Per parson) i S ALL OWNEDSCAUTHEDULED NIA BOBILY INJURY(Per accigenty 5 W OS AUTOS NON-AWNED PROPERTYDAMAGE - HIRED AUTOS ALTOS Per accidonl) NS �S LIMSRELLALtAEI ;OCCUR EACH OCCURRENCE �S EXCESS LIAO C A[MS-MAOE NIA AGGREGATE DEC} I I RETENTIONS WI5 WORKERSCOMP✓:NSATIONt AcR DTH- I AND EMPLOYERSLIABILITY I STATUTE ER j ANYPROPRIETORIPARTNERIEXECLI'TIVE! YIN I E.L.EACH ACCIDENT I .5{30,006 A OFFICERWEMBEREXCLUDED?it NrA NIA NIA AWC40070287742016A 0411712016 04/17/2017 (hFandalory In HH) I E.L.DISEASE.EA EMPLOYEE S 506,60() If yes,dosoribo under DESCRIPTION OF OPERATIONS balow E.L.DISEASE.POLICY LIMIT 5 566,666 NIA ! i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additiono!Ramarka SChodulo,may be altachad If mars space Is raquirad) r Wormers'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 employes in slates other than Massachusetts if the insured Hires,or has hired those employees outside of Massachusr~tls. This certificate of insurances,ows the policy in force on the dale 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 wwm mass.gov wdlworkers-eompensationlinvestigationsf. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE T14E EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERSO IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Andover i MA 01 B10 { ` 1 Daniel M.Cr y,CPCU,Vice President--Residual Market—WCRIBIYIA ©9988-2014 ACORD CORPORATION. All rights reserved, ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i Client#- 14415 DAMPHOUSSE ACORD,u U TIFIC TE OF LIABILITY INSURANCE 04118i2o1�YYY, PRODUCES THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agen� y,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.D.Box 1985 ; HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND Ott ALTER'f HE COV€RA09 AFFORDED BY THE POLICIES BELOW. 21 Elm Street Andover,MA 01810 INSURERS AFFORDING COVERAGE NAIC 9 INSURED INSURER A Western World Damphousso Roofing LLP 87 Belmont St INSURER B'. !� INSURER C- north Andouer, MA 01845 INSURER D. INSURER E-. COVERAGES II 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY HE ISSUED OR MAY PERTAkN,THE INSURARp AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TQ ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIAI(. SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. FOLSCY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF MSUR NCE POLICY NUMIMA D AT 0 Y D @ M!, D Y LIMITS A GENERAL LIABILITV I NPP8202847 0411206 04112/17 EACH OCCURRENCE i 7X COMMERCIAL GEN-RAL LIABILITY DAMAGE RENTED-PREMISslfl€I()DD � CLAIMS MAO tI ®OCCUR MED EXP IA iy ana ae(son) S5()p(I PERSONAL d ADV INJURY Sj G0()000 II GENERAL AGGREGATE -52000000 GENL AGGREGATE LIMN APPLIES PER: PRODUCTS-CONINOP AGG $2000.000 I }( POLICY ,JECTT LOC AUTOMOBILE LIABII-17I COMBINED SINGLE LIMIT ANY AUTO (Ea ameenu S ALL OWNED RUTO j BOpILY INJURY � SCHEDULED AUTO (Per mescn) HIRED AUTOS BODILY 114JURY S NON•OY/NED AUTOS {Pal acaaerq PROPEiRTY DAA1AGE S ,,� {Peracciaer.I) GARAGE LIABILITY E AUTO ONLY•EA ACCIDENT S ANY AUTO ', I OTHER THAN EA ACC S AUTO ONLY: A S EXCESS UMBRELLA LIABU TY EACH OCCURRENCE 5 OCCUR CLAIMS MADE AGGREGATE _ S 5 I DEDUCTIBLE RETENTION WORKERS COAIPENSAMON At D WC STATLI• acom• i EMPLOYERS'LIABILITY ANY PROPRIETORPARTN£R:E ECUTIVE E.L.EACH ACCIDENT S OFFICER,MEMBER EXCLUDED, E.L DISEASE•EA EkPLOYEE S If yes.dounbo unler SPECIAL PROVISIONS W—, E.L.DISEASE=-POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS/LOEIATIONS/VEHICLES f EXCLUSIONS ADDED OY ENDORSEMENT/SPECIAL PROVIS(ONS Covering operallons usual 910 Damphousse Roofing LLP... i CERTIFICATE HOLDER ? CANCELLATION 1G pa S for ikon-Pa menZ SHOULD ANY OF THE ABOVE DESCRIBED POLICIE5 BE CANCELLED BEFORE THE EXPIRATION -- i DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR To AML 41 DAYS WRI'!T'EN NOTICE TO THE CERTIFICATE HOLDER NABBED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UA131LTTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR '.. REPRESENTATIVES. ' AUTHORIZED REPRE NTAT ACORD 26(2001108)1 of 2 1 #S33484/M33480 ML 0 ORD CORPORATION 1988 Massachusetts Department of Public Safety Board of Building Regulations and Standards License: C"67560 C01IstrscU011 SUpaerVisor SHAUN M TWOMEY fit PATROIT ST NORTH ANDOVER MA 01845 ^^^ - Expiration: Commissioner 10/2612017 f✓r�, {rrcU�ar�saarreue o�✓Gacrc�iu�tt ; Offiec of ''onsunicr Affairs BSc Thi siness Rc8nlatiori HOME IMPROVEMENT CONTRACTOR Registration: 174977 Type: .# Expiration: 2/4/2017 LLP DAN1PhI0USSE ROOFING LLP SHAUN TWOMEY 87 BELMONT ST N.ANDOVER,MA 01845 Undersecretary