The URL can be used to link to this page

Home My WebLink AboutBuilding Permit # 11/17/2016 �aORTy BUILDING PERMIT OF «fo:6qa TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Z- Permit No#: # f Date Received �S$gC U51-- Date Issued: -!I' LNIPORTAI T:Applicant must complete all items on this page TOLOCATIONI Print PROP€RTY OWNER Print 100 fear Structure yes no MAP 46A PARCEL ,Sr, - ZONING DlSTRIOT: Histartc Distric# yes no Machine Shop Village yes j TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential I K New Building One family Addition ❑Two or more family ❑Industrial E Alteration No.of units: IJ Commercial j ❑Repair:replacement a Assessory Bldg0 Others- 0 Demolition D,Other 0 Septic D Well ❑Floodplain 0Wetlands ❑ Watershed District G Water/Sewer j DESCRIPTION OF WORK TO BE PERFORMED: Identification-PIease Type or Print Clearly OWNER: Name: I _ Phone: ? Address A ' ' , ; Contractor Name: #7 r d6rra,1 _ A' Address:Lly , `f k ; 1 Supervisor's Construction License: — _ Exp Date: ri s I Horne Improvement License: Exp. Date: ARCHITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDINO PERFgIT:.$12.00 PER 51000.00 OF THE TOTAL ESTITUA TED COST BASED ON 5125.0 PER S.F. total Project Cost:$ FEE:$ 4 jam;C{ g Check No.: Z z¢_-Y § Y�, i- a Receipt No.: 31 NOTE: Persons eontp sting with unregistered yWr-actors do not have access to the guar anb,�f d 1 Signature of Agen-VOW her Signature of contractor : Town of OORTH Andover 0 h ver, Mass, �'''0 BOARD OF HEALTH Food/Kitchen PERMIT TO ILD Septic System THIS CERTIFIES THAT .. ,,,.....1.1,!. > ...................... BUILDING INSPECTOR has permission to erect..........................buildings on..�.� � /...has � , Rough to be occupied as.,..... .... K T`....OW ................5 F. ,,,.,,,........ 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 @ q., Final PERMIT EXPIRE IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TINRough Service . ............... ...,, Final BUILDING I CT GAS INSPECTOR Llceu anc Permit,Required to Occu gilding 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. BUILDING PERMIT NORTH o Rro TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION , r Permit No#: l Date Received a,4 >s�5 SSACHUS� Date Issued: 117 l 3 OP116 IMPORTANT:Applicant must complete all items on this page —777 LOCATION 1 O SG GEI�`1 �OGIt3tE ' .' Lr Pant PROPERTY OWNER TZ v z '= =` Print 10036 rStruciure - .yes ono MAPACEL.PARZONING DISTRICT- A-, _Historic D�str�ct yes4 w- Maehine;Shop Village µyes_.=no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential New Building IN One family ❑Addition ❑Two or more family ❑Industrial ❑Alteration No.of units: ❑Commercial ❑Repair,replacement ❑Assessory Bldg ❑ Others: ❑Demolition ❑Other d Septic ❑Well ❑Floodplain ❑Wetlands ❑ Watersh d District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: S - IV lite tification-Please Type or Print Clearly OWNER: Name: TK2 -�-� Phone:CU R141)� Address: �� SUi le ZO r 1��c to Av,k,,f MA 0 IYqS �x Contractar'N rrii6 S I a Phone Email: ' e Address:_ r� P � Exp Dated Su enrlsars Canstructian License Home Imp[overnen#License: ARCHITECTIENGI NEER Phone: Address: Reg.No. FEE SCHEDULE:BULDING PERMIT..$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost:$ L3, C�vvriptTt�a onr(y) FEE:$ 1S0,61) Check No.: 2. Receipt No.: 3103 NOTE: Persons contracting with unregistered co ractors do not have access to the guaranty u d Signature of Agerlybwner Signature of contractor, Plans Submitted Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/BodyArt ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ t i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM PLANNING&DEVELOPMENT Reviewed On b 1 Z6l�— Signature_ COMMENTS% Li CONSERVATION Reviewed on_LD D ,1ta Signature COMMENTS HEALTH Reviewed on Si n COMMENTS p c� 6 Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes- Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer Connection/Signature&Date /DriewaV Permit DPW Town Engineer:Signature; Located 384 Osgood Street FIRE-DEPARTMENT Temp Dumpster on:slte.yes- ,nom Locatedak 124 Main Street r Mlv Flre Departmentslgnature/dajte l r COMMENTS .i Plans SubmittedK Plans Waived D. Certified Plot Plan rQ Stamped Plans ❑ -TypB`bF SEWERAGE DISPO�S}�AL Public Sewer TauninWMassagelBody Art ❑ I Swilumig pools 0 i well ❑ Tobacco Sales ❑ ! Food Packaging/Sales L7 Private(septic tank,etc. ❑ Permanent Dempster on Site 1-1 C THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM PLANNING&DEVELOPMENT Reviewed On�� G� Signature_ COMMENTS CONSERVATION Reviewed on ( Si nature ?/1 COMMENTS �} f HEALTH Reviewed on Si COMMENTS `9 M� n Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer Connection/signature&Date Drivevav Permit DPW Town Engineer:Signature: Located 384 Osgood Street FIRE DEPARTMENT-Temp Dumpster on site yes_m Located at 124 Main Street Fire Department signatureldate � r: COMMENT /�! U ° P( r INFPft dimension Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area,sq.ft.: 2 312- ELECTRICAL:Movement of Meter location,mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$90o-$1000 fine NOTES and DATA—(For department use) i i 2Zv5 X a 3 zS tv 3 0 ego \G X \ ve o_ Ll Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014 � µataTr�Town v1 a No. C, h ver,Mass, A0/ b �qQ°pa TBD $ U BOARD OF HEALTH PERMIT T I LD Food/Kitchen Septic System t THIS CERTIFIES THAT... ...A...Z...R..�'!!..�i..�C�:.l.......................................... BUILDING INSPECTOR D has permission to erect..... .buildings on ,p 7 yr.N 4 .....{' • Foundation y Rough tobe occupied as.........N�! ....... .......�.............................................................................. 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 ELECTRICALINSPEC70R UNLESS CONSTRUCTION ATS Rough Service ............... .. ........... ......................................... Fina BUILDING INSPECTOR GASINSPECTOR Occupancy Permit Required to Occupv 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. 10-3 S T TOM Ii I LL O -D N M U-a= -ios su-r-raw WsLl- Rox-b NOWTtN AMDOVU-,a t t� TSA LLC C-C NX-c.'. fle 1'011 /pi 56-Y#172 CHESTNUT STREET 132 CHESTNUT STREET GREY ROCK CONDOMINIUM" TAX MAP 60 LOT 71 N/F ROBERT&SHERRY MARCONI TAX MAP 60A LOT 22 284.86' N21'46'30"W ~ 37.1' LOT 2 25,312SFt h; C.B.A.-100% Yf q m� O fPm n� niv0. qY WATERSHED BOUNDARY ?g pOHpWFF ?40, LOT 1 UNE TAKEN FROM TOWN p. 0 OF NORTH ANDOVER GIS o GNOR770ry N/F CAH REALTY TR. 370, TAX MAP 60A LOT 17 a IV X40. t�=60.00' �M. 52' ^Z1.3 SHED TO g6:54 BE RAZED PINNACLE WAYyh� V (50 RIGHT OF WAY) ZONING INFORMATION, LOT 3 ZONING OISTRICr, R3 9 I CNRTFY THAT THE FOUNDATION SHOP WAS LOCATED BY AN INSTRUMENT SURVEY �D ON 11/4716 AND THE LOCATION COMPUES FOUNDA77ON AS—BUILT yFo NT THE ZONING SETBACK REQUIREMENTS 103 SUTTON HILL ROAD \ t NORTH ANDOVER, MA y PREPARED BY.• " \ a H r RNomwSULLIVAN ENGINEERING GROUP, LLC a a F1T5 P.O. BOX 2004 m WOBURN, MA 01888 (787) 854-8644 DATE: 11/6/16 SCALE. 1"=20' SuttonHill 11-4-16 103 Sutton Hill ltd.NAndover 10:26am ' y K-012 TN" toff SB 1Lh1 kmBemfw+gu 4.11262 hl fu•- [}mtux 1516 Member Data Description: Member Type:Beam Application:Floor GARAGE HEADER Top Lateral Bracing:Continuous Bottom Lateral Bracing:Continuous Standard Load: Moisture Condition:Dry Building Code:IBCARC Live Load: 40 PLF Deflection Criteria: U360 live,0240 total 1.000"max.LL Dead Load: 10 PLF Deck Connection:Nailed Member Weight: 12.2 PLF Filename:Beam3 Other Loads Type Tdb. Other Dead (Description) Side Begin End Width Start End Start End Category Additional Uniform(PSF) Top 0'0.06' 24'O.W" a&A6' 40 10 Live Additional Tapered(PLF) Top a 0,001, 24'O.W" 0 80 80 0 Live Additional Uniform(PSF) Top 9'0.W, 24 0.09' 1'806' 55 15 Snow Q 12 0 0 12 0 0 2400 Bearings and Reactions Input Min Gravity Gravity Location Type Material Length Required Reaction Uplift 1 a O.OW" Wall SPF Plate(425psi) 18.00U" 1-509" 1101# -- 2 12'OLUT Wall SPF Plate(425psi) 21.006' 1.506' 3206# - 3 24'QOW' Wall SPF Plate(425psi) 184W" 1.500" 1020# -- Maximum Load Case Reactions L.vtl for agFlyin9 fe:nf loatls;crline leeds}Vo cafryNg msmQara Live Snow Dead 1 376# 424# 501# 2 1410# 1211# 1241# 3 611# 424# 244# Design spans 10'6.875' 10 6.875' Product: 2.0 RigidLam LVL 1-314 x 9-1/4 3 ply PASSES DESIGN CHECK Connect members with 2 rows of 16d common nails at 12.0"oc NOTE:Nails must be applied from both sides Design assumes continuous lateral bracing along the top chord. Design assumes continuous lateral bracing along the bottom chord. Allowable Stress Design Actual Allowable Capacity Location Loading Positive Moment 2412.# 23896.# 10% 5.66' Odd Spans D+0.75(L+S) Negative Moment 33904 23896.# 14% 12' Total Load D+0.75(L+S) Shear 14314 107971 13% 11.47 Total Load D+0,75(LS) Max.Reaction 32064 468564 6% 12' Total Load D+0,75(L+S) TL Deflection 0.0613" 0.5286" U999+ 6.18' Odd Spans D+0.75(L+S) Lt-Deflection 00463" 03524" U999+ 1782' Even Spans 0.75(L+S) '.. Cornet: Negative Moanert DOLS: 0-100%Snow=-115%Roof=125%Wind=160% Design assumes a repetitive member use increase in bendirig stress:4% RII poEfet nemeses f®tlameM1so[fpairsxrecllve ownas GopOgM(e)ggf3hy SYmpmn S?mng-ie Canp Inc.ALLRIGuis RESERVED. zsng is de5ned asreeren life member,flomYol9.Qeam or g?Neo�ovm on tNsdrentiig meetzap d?calve tlesgn c!iYede for Loads,loatling�endit?ons antl SpansliSetl an IMSAeet.lY:e dz9en n.fr4 Q..m+finratl Cvaaaallfiad dtsonarorc�sneam(as9nnal as.reamad twaaomval.Ths esen sawmesemduct fnsallaLan ecce rw to lQa manuac umrssacfficalfonz 102 SUTTON HILL 11-7-16 g NAndcver,M.A. 8:48am I Off I neaer 4.11261 Ianr, 11 tx'is nx[al.+x 1516 Member Data Description: Member Type:Beam Application:Floor Top Lateral Bracing:Continuous Bottom Lateral Bracing:Continuous Standard Load: Moisture Condition:Dry Building Code:IBC/IRC Live Load: 40 PLF Deflection Criteria: 0360 live,U240 total 1.000"max.LL Dead Load: 10 PLF Deck Connection:Nailed Member Weight: 14.8 PLF Filename:Beam1 Other Loads Type Ttib. Other Dead (Description) Side Begin End Width Start End Start End Category Additional Uniform(PSF) Top a 0.00" 20'0.00"' 14'0.00" 30 10 Live Additional Uniform(PLF} Top 0'000" 20'000• 0 65 Live 8 0 0 Q 8 0 0 Q 4 0 0 2000 Bearings and Reactions Input Min Gravity Gravity Location Type Material Length Required Reaction Uplift 1 a 0.000" Wall SPF Plate(425psi) 3.500" 1.5W" 2249# -- 2 9 0.000" Wall SPF Plate(425psi) 3.50(7' 2.859" 6379# -- 3 16'0.00.7" Wall SPF Plate(425pst) 3.500' 2.216" 4944# -- 4 20'0000" Wail SPF Piate(425psi) 3.500" 1500" 1173# -328# Maximum Load Case Reactions �setlW p�ting point loxdsfvrine lead;I.csryln4 mem0ers Live Dead 1 1556# 692# 4272# 2107# 3 3456# 1485# 4 962# 211# Design spans T 9,375^ 8'Row, Product: 2.0 RigidLam LVL 1-314 x 11-1t4 3 ply PASSES DESIGN CHECKS Connect members with 2 rows of 16d common nails at 12.4"oc NOTE:Nails must be applied from both sides Design assumes continuous lateral bracing along the top chord. Design assumes continuous lateral bracing along the bottom chord. Review gravity uplift reaction force of 328lbs at bearing 4 and ensure that the structure can resist appropriately. Allowable Stress Design Actual Allowable Capacity Location Loading Positive Moment 36604 299941 121A 3.33' Odd Spans D+L Negative Moment 4802.# 299944 16% 8' Adjacent D+L Shear 26544 11419# 23% 7.22' Adjacent 1 D+L Max.Reaction 6379.# 8646.# 73% 8' Adjacent 1 D+L TL Deflection 0.0281" 0.3891" 0999+ 3.72' Odd Spans D+L LL Deflection 00210" 02594" 0999+ 3.72' Odd Spans j Cont.t Max.Reaction DOLS: Uve=10076 Sn(=115%Roof=125%Wind=160;`. Design assumes a repetitive member use increase in bmdirg stress:4 Pop j.ct aamesare twdamaMs.nlrsn repxcliae opaars fi tl L be p.119.1!_ Y 5 'tl+ary.3 FW'aJle ass4nc lE'f l oad�ng�Conj:ronsand5 :his9r_el.The deg n9mu9Wn: va.ua.tPeddes desvn omtevaon re....red to n9, a. seaon ammaxvicd ion sect nvfolhe manofa .calept Sutton Hilt 11-4-16 103 Sutton Hilt Rd.NAndover 14:1ale looff I CSB 11126t 0 6¢t3cam 7'fgve4 t126_I 43 ter Lc pamLe�IS16 Member Data Description: Member Type:Beam Application:Floor '.. Top Lateral Bracing:Continuous Bottom Lateral Bracing:Continuous Standard Load: Moisture Condition:Dry Building Code:IBC/IRC Live Load: 40 PLF Deflection Criteria: U360 live,U240 total 1.000"max.LL Dead Load: 10 PLF Deck Connection:Nailed Member Weight: 12.2 PLF Filename:Beam1 Other Loads Type Trib. Other Dead (Description) Side Begin End Width Start End Start End Category Additional Uniform(PSF) Top 0'900" 19 0A0" 6 8.00" 30 10 Live Additional Uniform(PLF) TOP 6'0.00" 16 O.W, 0 80 Live Additional Uniform(PSF) TOP 0'0.00" 16 0.00" 0'8.06' 20 10 Live Additional Tapered(PLF) TOP a 0.00" 16 0.00" 0 80 80 0 Live Additional Uniform(PSF) TOP a OW, 16 006" 1'806' 55 15 Snow 1000 Q 0 10 0 0 Bearings and Reactions Input On Gravity Gravity Location Type Material Length Required Reaction Uplift 1 6 Q.QW1 Wall SPF Plate(425psi) N/A 1.506" 1714# -- 2 10'0006' Wall SPF Plate(425psi) N/A 1.500" 1678# -- Maximum Load Case Reactions U.i MraPPtYing poral leads S=rune toaEst to cam{ieg maabess Live Snow Dead t 503# 465# 987# 2 646# 465# 844# Design spans 10'1.759' Product: 2.0 RigidLam LVL 1-314 x 9-1(4 3 ply PASSES DESIGN CHECKS Connect members with 2 rows of 16d common nails at 12.0"or; NOTE:Nails must be applied from both sides Minimum 1.60"bearing required at bearing#1 Minimum 1.60"bearing required at bearing#2 Design assumes continuous lateral bracing along the top chord. Design assumes continuous lateral bracing along the bottom chord. Allowable Stress Design Actual Allowable Capacity Location Loading Positive Moment 3781.# 207804 18% 6 Total Load D+L Shear 12644 93894 13% 9.57' Total Load D+L TL Deflection 0.1151" 0.5073" U999+ 4.99 Total Load D+0.75(L+S) LL Deflection 00529" 0338T' L1999+ 501' Total Load075(L+S) Cartrol: TL Deflection DOLS: U-100%Sna—115"-,5 Roo1=1255 Wind=160% Design 355tlltIPS 2 re(K#rtN2 nlen152r USe I(1Gtea5e In bN!dirlg SIfPSS:4% All p;oawN nates ae Iredemaks of Uerrc�edive owners CopytlghttC)20134y Simpxn Slrcn9-ia Cwsgan't rnc.AtU fitGFffS RESERVE6. Ccntlitians anO Spanslf4ea on tMS Teet.iT.e defnea siwban tFa member,gowjoi9.Seam argiNeS Town on ItAsdrnvin4 meetsep aStaaMe desgn c=lana br Load;LazaFng vea�.mns ba 2vie„aa b.aacapaad aasenEor aa9aa amra�nnar aareaa,raa ra.aooavar.mea ennn as9,maap.aaaer�nsanarana�aomo-.-,wma man"raerpmr:meabea..ons Home Energy Rating Certificate Property HERS CL-EAResuW Rating Type: Projected Rating Certified Energy Rater: Peter Virchick 10 Great Lake Lane Rating Date: 7/25/16 Rating Number: North Andover,MA 01845 Registry ID: 11 .............. Pd ojectcu.J Rating: Based on Pla-qs - Field Confirmation Required. Estimated Annual Energy Cost Use MMBtU Cost Percent HERS Index: 53 Heating 38.5 $1753 45% i Cooling 1111 $180 5%General Information Hot Water 5.3 $426 11% Conditioned Area 3291 sq.ft. House Type Single-family detached Lights/Appliances28.7 $1383 36% Conditioned Volume 28046 cubic ft. Foundation Stab Photovoltaics -0.0 $_0 _0% Bedrooms 4 Service Charges $137 4% Features Total 83.7 $3880 100% [A�e�_can�ial-S--y-stems' Heating: Fuel-fired air distribution,Propane,96.1 AFUE. Heating: Fuel-fired air distribution,Propane,96.1 AFUE. Criteria Cooling: Air conditioner,Electric,13.0 SEER. This home meets or exceeds the minimum criteria for the following: Duct Leakage to Outside 9833 CFM25. Massachusetts Stretch Energy Code' Ventilation System Exhaust Only:56 cfm,11.0 watts. Compliance is determined by the rater. Programmable Thermostat Heat-Yes;Coot-Yes Shell Features —_ Ceiling eaturesCeiling Flat R-44.4 Stab R-9.0 Edge,R-18.0 Under Seated Attic NA Exposed Floor NA Vaulted Ceiling R-39,5 Window Type U-Value:0.290,SHGC:0.300 Above Grade Watts R-21.0 Infiltration Rate Htg:3.00 CIg:3.00 ACH50 --------------- —----- Foundation Walls NA Method Blower door test Conservation Services Group 50 Washington 5t [Lights and Appliance Features Suite 3000 Percent Interior Lighting BO 00 Range/Oven Fuel Electric Westborough,MA 01581 Percent Garage Lighting 0.00 Clothes Dryer Fuel Electric 508-836-9500 Refrigerator(kWh/yr) 691 Clothes Dryer EF 3.01 www.csgrp.com Dishwasher Energy Factor 0.46 Ceiling Fan(cfm/Watt) 0.00 Certified Energy Rater: RE WRate-ResWenflal Energv Ana9ysin ancl Rat ng Software v1 4.(x.3 This information does not constitute any warranty of energy cost or savings.Q 1985.2016 Noresco,Boulder,Colorado. The Home Energy Rating Standard Disclosure for this home is available from the rating provider. ®®®®O Verizon LTE TV:UU AIVi ...,.., Soni from my Pad ACCIRDP CERTIFic.4-rE OF LIABILITY INSURANCE I .-6121;16: THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO.RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMIATIVELY 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 IN5URERIS),AUYHOR)ZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. Ift§FORTANi: IF the certificate holder is aR A➢DtTONAL INSURED,m Po)icy(ias)must Vo endoneJ.!f SUBROGA710N IS WAIVED,suU}ect to the terms and conditions ofthe policy,certain policies may requere an endorsement.A statement onthis ceniH.w,does not confir rights to CNe certiftcate holder in liars of such eedarsementis). osar,a� M;anrPe —_ rM P rLnsuranc Robe_ l ie Agency r�a n: (478) 683-80 _I I,__+s} • 1060 Osgood Street nJ sand 0 p bort - _ .nee com _.. NoTti, Andover, 1•lA 01845 it SUiE`5)nFFORD Ya GOlePM10E tnle� uuUREan:'ssex SnS—ce CG C5eRE0 Iv .A:rociated Employers in..urarec 'LKZ, LLC CJO TOM ZAHORUSAO - 78 GREAT POND ROAD It. _ _ ... NORTH ANDOVER, I'M 018,`5 COVERAGES CERTtFICATEN U@i➢E R' '+ REVISIONEMPABER- IS 7S Q CERTIFY FJ{T Tllf PQ IC--SOL INSU`LV I ItSTED DEL(- I I1VE CCC!I SUED TO TI FE INSURED NAtStO 6D�E fOR TkIC i'Clt 1 E¢ :: role.TAT.NOTMTFt ISSUED OR MAI PERTAIF HE ERMOmC.E ffOl)ED N 111,1T-0,,OR OTHERDOlUfLEN 17RFIIESPCT ITIll IL IS C RTIE'IG{TE MAY 9E ISSUED OR I.fAt PERTAIN.TtIE VSURA.LE Af:O1ir.EU ttY(tE F Ye;ILS G�`;CYt,OCD,iz C v IJ SUvJF..T T+J nLL TIll iLhtu. FhY LU OIS ANOGO Fi IOVSC S R POLIGYFS.I1T5 cyp{r t A NAVE 6FE IRFDt,CFC£Et PAIt,cA IF oU t - A s -3➢x4436 7t 1.fI15 t13J16:E t 1,L)QO 000 6 .t INSG OvIt It v-u. 4000 t, a - .,• .. 5,,000 [ ctr:nu _.r.,X,.luoccuR I -. r'. 1,000,000 11-. ;I"'1 2,000,000 lui- w O!QPILE UnaWtt i_t...,Igt I r - �', I faNEu -,e 1 i e, ! - -- NCC5005006517-2019:._ 18!3115 30/1/36_,{ + 13 t5'i SCO`r SIVO! nomPlo ERS me 'x r r _ i 1 000,000 Y �'Tr A: 1,Dao Doa + i.000 coo ' ul i I TnrOFnrLRATlerisiL�rs„a,srvE, re Ivry e , ��o,niR��..�,sr - I,,..i, — _ I i CERTIFICATE HOLDER CANCELLATION SHOn LD ANY OE THE AEOVE OESERISED AOL{CIES[SE LANEELI11 H FORE THE ORoancEEXPIRATON BAAIE THEREOF,N NDTOE Y L BE DEUVEREO N i MVIN OF NORTH ANDO'dDR cCVnM In nLrc inns HUSLDZNG DEPTAnti4CdiZEO FN,FSIrtAR”) 1600 OSGOOO NORTH AN➢017CR, NA 0180 -— 1996.2910 ACORD CORPORATION.Att right*reserved. ACORD 25(2010;05) The ACORDnarneandloeo a reregistoredmarRsot ACORO phn)P.: Fax: e-nhtl: TICE NOTICE T -1 �l `'` ,'` T EMPLOYEES ; ��' �� EMPLOYEES ,rtf The Commonwealth of Massachusetts DEPART'MEN'T OF INDUSTRIAL ACCIDENTS 1 Congress Street,Suite 100,Boston,Massachusetts 02114-2017 617-727-4900 As required by Massachusetts General Law,Chapter 152,Sections 21,22,&30,this will give you notice that T(we)have provided payment to our injured employees under the above mentioned chapter by insuring with: Associated Employers Insurance Company NAME OF INSURANCE COMPANY P.O.Box 1070 Burlington,MA 01803-0970 ADDRESS OF INSURANCE COMPANY WCC-500-5006517-2016A 10/01120-16-10/01/2017 POLICY NUMBER EFFECTIVE DATES 1060 Osgood Street M P Roberts Insurance Agency North Andover,MA 01845 (978)683-8073 NAME OF INSURANCE AGENT ADDRESS PHONE TKZ LLC 4 High Street 1201 North Andover,MA 01845 EMPLOYER ADDRESS 0810412016 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act.A copy of the First Report of Injury must be given to the injured employee.The employee may select his or her own physician.The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are herebv notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO RE POS'T'ED BV EMPLOYER Massachusetts Department of Public Safety Board of Building Regulations and Standards License:GS-055417 % THOMAS 0 ZAHORUIKO 4 HIGH STREET SWE 201 " •�"" NORTH ANDOVER MA 01845 r-j""x Vim..- Expiration: Commissioner 04/05/2018