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HomeMy WebLinkAboutBuilding Permit # 11/16/2016 NORTy BUILDING PERMIT ��oy'Y to 6��°` TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATI N - Permit NO: 'r - I Date Received 11 ACMU`����y Date Issued: i lP IM . ORTANT: Applicant must coLn Tete all items on this page LOCATION c . ' l";t(A C'�v�5� Print PROPERTY' QllllNER : X73 . -k' Print M,4P NQ.iPAF2CEL.' ZONING DISTRICT. Historic District yes no Machine Shop:Village yes no! TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne family Addition a Two or more 'family I Industrial Alteration No. of units: C Commercial I::::. Repair, replacement Assessory Bldg Others: Vbemolition Other 7 Septic; f I Well...... FI Floo[Iplain �1Netlaricls Cl Vyatershed District �WaterfSewer. 1�Lov 1 C� W t �.�rC,���a � 1� 1�,1t �l� �A ► C�.it► ' n1�.a,1,+ar1�� Identification Please Type or Print Clearly) OWNER: Name: --� - 4�i� Phone: �"t� -22142 Address: � u A ��®00A CONTRACTOR Name Phone Address: Supervisor`s Construction Licenso. Exp. ©ate: i Home Improvement License Exp. Date. 1:5�Z�l ARCH ITECTIENGINEER Phone: Address: Reg. No. FEF SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ _ 3 b:bo FEE: $ Check No.: zQ �� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty find Signature of Agent/Owner 89 r Signature of contractor ¢ NORTH own of � fAndover 4L io h _ ver, 3 Mass • J� , 24"v � � .EKE COC NSC N�WlCN 41 S U BOARD OF HEALTH Food/Kitchen L D T T Septic System THIS CERTIFIES THAT .... . .............��„�s, +,1'L .,, ...... � "...... ...,. BUILDING INSPECTOR ....... . . ..... . .. . . ...... .. Foundation has permission to erect .......................... buildings on .. �...... . .. .. ................ ..,......>............ �. _ P Rough to be occupied as ...... ., . . .... ........ . .... ..... .. i .. M. ..... . �►. . .............. Chimney provided that the person accepting this permits all 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 CONST 0 S Rough Service .. ..,. .. ... .. .................. ,........ Final BUIL©ING INS TOR GAS INSPECTOR Occu ancPermit Required to Occu Buildin 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. 1 • - Authorization to Perform Services and Direction of Payment Customer Name: Brett Schutzsle Date of Loss: 11/06/2016 Loss Address: 394 Boston Street City: North Andover State: MA Zip: 01845 Insurance Company: Unknown Claim Number(if available): 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 Unknown 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: Brett Schutzsle 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: Customer's Signature: /�� �� Franchise Legal Name: KEJO CORP Printed Name: Brett Schutzsle d/b/a SERVPRO®of: The Andovers Date: 11/06/2016 pate: 11/06/2016 brettschutzsle g Icloud.com E-mail Address: Contractor License#: OSERVPRO®INTELLECTUAL PROPERTY,Inc. ALL RIGHTS RESERVED FE-05`17071,0 28000 05/16 Each SGRYPRO�l,rmrchise is lirdependentty Owned mrd Operated. d I Authorization to Perform Services and Direction of Payment Terms and Conditions of Service READ CAREFULLY Note: This Contract includes a limitation of liability and limitation of remedies. 1. SERVPRO°is one of the largest nationwide Cleaning and Restoration Franchise Systems in the United States.The SERVPRO"Franchise owner identified on the front of this Contract(the"Provider')is an independent contractor who agrees to perform the services identified on the front of this Contract(the"Services").Client agrees to purchase,receive,and pay for the Services pursuant to the terms and conditions of this Contract. Servpro Industries,Inc.,the Franchisor,is not a party to any agreement with Client,is not a guarantor of the Provider's Services,and is not subject to liability arising out of such Services. 2. Provider's performance of the Services is limited by,among other things,the pre-existing conditions and characteristics of the premises,material, fabrics,furniture,and/or other items.PROVIDER EXPRESSLY DISCLAIMS ANY RESPONSIBILITY OR LIABILITY FOR ANY PRE-EXISTING CONDITIONS.Client shall retain responsibility and shall be liable for all effects of and costs necessary to correct such conditions,including,by way of example and not limitation,the conditions identified below: (a) Provider may,in its sole discretion,pre-test materials for removability of spots or stains;dye or color fastness;shrinkage;fading;adhesive breakdown;or other problems.It is not always possible to determine these conditions in advance.PROVIDER DOES NOT GUARANTEE SPOT OR STAIN REMOVAL AND COLOR FASTNESS OR PREVENTION OF SHRINKAGE, FADING,OR ADHESIVE BREAKDOWN. (b) Provider DOES NOT GUARANTEE that wall and ceiling cleaning will restore the original color to painted surfaces. (c) Not all fabrics are conducive to cleaning.Provider shall use reasonable efforts to advise Client of any adverse effects which may be reasonably foreseen due to the nature of the fabric or material involved. PROVIDER DOES NOT GUARANTEE THAT SUCH MATERIALS CAN BE CLEANED OR THAT THERE WILL.BE NO ADVERSE EFFECTS FROM ANY ATTEMPT TO CLEAN SUCH FABRICS. (d) A variety of materials are used in the manufacturing,upholstery and/or installation process.These materials include backing,lining,tacks,or other unknown substances that may cause discoloration or other adverse effects to the face material.Client acknowledges that it is impossible to determine when such adverse effects may occur and PROVIDER DOES NOT GUARANTEE AGAINST SUCH ADVERSE EFFECTS. (e) Client acknowledges and agrees that mold is commonly found throughout the environment and that it is impossible to eradicate mold. PROVIDER DOES NOT GUARANTEE THE REMOVAL OR ERADICATION OF MOLD. (f) Client acknowledges and agrees that limited photographs or video of the damage and cause may be made solely for work process and insurance claims purposes. 3. PROVIDER SPECIFICALLY DISCLAIMS ANY AND ALL OTHER WARRANTIES AND ALL IMPLIED WARRANTIES(EITHER IN FACT OR BY OPERATION OF LAW)INCLUDING,BUT NOT LIMITED TO,ANY IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE OR ANY IMPLIED WARRANTY ARISING OUT OF A COURSE OF DEALING,CUSTOM OR USAGE OF TRADE. THIS CONTRACT PROVIDES FOR THE PROVISION OF SERVICES AND DOES NOT PROVIDE FOR A SALE OF GOODS. 4. Limitation of Liability: IN NO EVENT SHALL PROVIDER,ITS OWNERS,ANY OFFICERS,DIRECTORS,EMPLOYEES,OR AGENTS, FRANCHISOR,OR AFFILIATES BE RESPONSIBLE FOR INDIRECT,SPECIAL,NOMINAL,INCIDENTAL,PUNITIVE OR CONSEQUENTIAL LOSSES OR DAMAGES,OR FOR ANY PENALTIES,REGARDLESS OF THE LEGAL OR EQUITABLE THEORY ASSERTED,INCLUDING CONTRACT,NEGLIGENCE,WARRANTY,STRICT LIABILITY,STATUTE OR OTHERWISE,EVEN IF IT HAD BEEN AWARE OF THE POSSIBILITY OF SUCH DAMAGES OR THEY ARE FORESEEABLE;OR FOR CLAIMS BY A THIRD PARTY.THE MAXIMUM AGGREGATE LIABILITY SHALL NOT EXCEED THREE TIMES THE AMOUNT PAID BY CUSTOMER FOR THE SERVICES OR ACTUAL PROVEN DAMAGES,WHICHEVER IS LESS.IT IS EXPRESSLY AGREED THAT CUSTOMER'S REMEDY EXPRESSED HEREIN IS CUSTOMER'S EXCLUSIVE REMEDY.THE LIMITATIONS SET FORTH HEREIN SHALL APPLY EVEN IF ANY OTHER REMEDIES FAIL OF THEIR ESSENTIAL PURPOSE.Some states/countries do not allow the exclusion or limitation of incidental or consequential damages,so the above may not apply to you. 5. Should Provider bring legal action to collect monies due under the Contract or should the matter be turned over for collection,Provider shall be entitled,to the fullest extent permitted under law,to reasonable legal fees and costs of any such collection attempt,in addition to any other amounts owed by Client.This attorney fee provision shall not be effective or enforceable in jurisdictions where attorney fee provisions are made reciprocal or invalid by operation of law.Consent is hereby given for filing of mechanic's liens by Provider for the work described in this contract on the property on which the work is performed if Provider is not paid. 6. Any labor,materials or other work beyond that identified in this Contract shall require a written amendment to this Contract and will result in additional charges. 7. Any claim by Client for faulty performance,for nonperformance or breach under this Contract for damages shall be made in writing to Provider within sixty(60)days after completion of services. Failure to make such a written claim for any matter which could have been corrected by Provider shall be deemed a waiver by Client. NO ACTION,REGARDLESS OF FORM,RELATING TO THE SUBJECT MATTER OF THIS CONTRACT MAY BE BROUGHT MORE THAN ONE(1)YEAR AFTER THE CLAIMING PARTY KNEW OR SHOULD HAVE KNOWN OF THE CAUSE OF ACTION, 8. A failure of either party to exercise any right provided for herein shall not be deemed to be a waiver of any right hereunder. 9. CLIENT AND PROVIDER EACH WAIVE THEIR RESPECTIVE RIGHTS TO A TRIAL BY JURY WITH RESPECT TO ANY AND ALL CLAIMS OR CAUSES OF ACTION(INCLUDING COUNTERCLAIMS)RELATED TO OR ARISING OUT OF OR IN ANY WAY CONNECTED TO THIS CONTRACT AND AGREE THAT ANY CLAIM OR CAUSE OF ACTION WILL BE TRIED BY A COURT TRIAL_WITHOUT A JURY. 10. If any provision of this Contract is found to be ineffective,unenforceable or illegal for any reason under present or future laws,such provision shall be fully severable,and this Contract shall be construed and enforced as if such provision never comprised a part of this Contract.The remaining provisions of this Contract shall remain in full force and effect and shall not be affected by the ineffective,unenforceable or illegal provision or by its severance from this Contract. 14. No modification,termination,or attempted waiver of this Contract shall be valid unless In writing and signed by the party against whom the same is sought to be enforced. SERVPRO®Franchisees are always looking for motivated employees. SERVPRO's individually owned and operated franchises offer a variety of positions including crew chief, production technician, marketing representative,administrative assistant,and many more. 28000 05/16 L'ach SEKYPRW Fremehise is Independently Owned and Operwed. ii Servpro 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 1D#02-0353691 Client: Schetzsle,Brett(Permit) Home: (978) 810-0976 Property: 394 Boston St. North Andover,MA 01845 Operator: STEVEN Estimator: Steven FuYnero Business: (978)688-2242 Company: SERVPRO Of Lawrence-SERVPRO Of The E-mail: steven@servprooflawrence. Andovers-SERVPRO Of Salem/Plaistow coin Business: 8 Blakelin St. Lawrence,MA 01840 Type of Estimate: Water Damage Date Entered: 11/8/2016 Date Assigned: Price List: MAEM8X SEP16 Labor Efficiency: Restoration/Service/Remodel Estimate: 2016-11-08-1513-1 u. Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688,2242 office@set•vprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 2016-11-08-1513-1 Main Level Kitchen Height: 8' 7 �31'7';T-'1 749.78 SF Walls 355.55 SF Ceiling k-7" 1105.33 SF Walls &Ceiling 277.61 SF Floor i 7-'2 2" 14'---' 30,85 SY Flooring 93.00 LF Floor Perimeter X4' MM-^^- ^^'� 27'3"--' 97.33 LF Ceil, Perimeter Missing Wall-Goes to Floor 2'2" X 618" Opens into Exterior Missing Wall-Goes to Floor 2' 2" X 6' 8" Opens into Exterior DESCRIP'T'ION QUANTITY UNIT PRICE TAX RCV DEPREC, ACV 1. Tear out wet drywall,cleanup,bag for disposal 120.00 SF 0.8E 1.43 98.63 (0.00) 98.63 Totals: Ii;itchen 1,43 98,63 0.00 98.63 Total: Main bevel 1.43 98.63 0.00 98.63 Level 2 Bathroom Height: 8' i all 200.00 SF Walls 34,81 SF Ceiling F- 'B,,n, u,j 234.81 SF Walls&Ceiling 34.81 SF Floor a°. 3.87 SY Flooring 25,00 LF Floor Perimeter a rMni .z z 25.00 LF Ceil. Perimeter DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 2. Cabinet-vanity unit-Detach 3.50 LF 12,94 0,00 45,29 (0.00) 45.29 3. Sink-single bowl-Detach 1.00 EA 22.56 0.00 22.56 (0.00) 22.56 4. Countertop-solid surface/granite-Detach 3.50 SF 6.51 0.00 22.79 (0.00) 22.79 5. Tear out non-salvageable tile floor&bag for disposal 34.81 SF 2.88 0.52 100.77 (uo) I00.77 6, Tear out non-saly underlaytnent&bag for disposal 34.81 SF 1.24 0.20 43.36 (0.00) 43.36 Totals: Bathroom. 0.72 234.77 0.00 234.77 2016-11-08-1513-1 11111/20I6 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 Total: Level 0.72 234.77 0.00 234.77 Basement Basement Height: 8' 3!t' T 1092.00 SF Walls 981.17 SF Ceiling �� m 2073.17 SF Walls&Ceiling 981.17 SF Floor B wni- g .N ' 109.02 SY Flooring 136.50 LF Floor Perimeter ' I 136.50 LF Ceil. Perimeter DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 7. Tear out wet drywall,cleanup,bag for disposal 24.00 SF 0.81 0.29 19.73 (0.00) 19.73 8, Tear out and bag wet insulation 24.00 Sl~ 0.64 0,11 15.47 (0.00) 15.47 Totals: Basement 0.40 35.20 0.00 35.20 Total: Basement 0.40 35,20 0.00 35.20 Job DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 9. Equip.setup,take down&monitoring-after hrs 1.00 HR 69.28 0.00 69.28 (0.00) 69.28 10. Emergency service call-after business hours 1.00 EA 192.80 0.00 192.80 (0.00) 192.80 11. Equipment setup,take down,and monitoring(hourly 4.00 HR 46.14 0.00 184.56 (0.00) 184.56 charge) 12. Asbestos test fee-full service survey-base fee 1.00 EA 380.00 0.00 380.00 (0.00) 380.00 13, Asbestos test fee-full service survey-per sample 5.00 EA 50.00 0,00 250.00 (0.00) 250.00 14. Add for NEPA filter(for negative air exhaust fan) 0.20 EA 184.46 2.19 39.08 (0.00) 39.08 15. Negative air fan/Air scrubber(24 hr period)-No 2.00 DA 72.99 0.00 145.98 (0.00) 145.98 monit. Used during demo to minimize dust particles in the home. Totals: Job 2.19 1,261.70 0.00 1,261.70 Line Item Totals: 2016-11-08-1513-1 4.74 1,630.30 0.00 1,630,30 2016-11-08-1513-1 1I/11/2016 Page: 3 is 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 Grand Total Areas: 2,108.89 SF Walls 1,375.92 SF Ceiling 3,484.81 SF Walls and Ceiling 1,297.97 SF Floor 144.22 SY Flooring 262.89 LF Floor Perimeter 0.00 SF Long Wall 0.00 SF Short Wall 267.22 LF Ceil. Perimeter 1,297.97 Floor Area 1,465.90 Total Area 2,108.89 Interior Wall Area 2,418.83 Exterior Wall Area 271.97 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 u 2016-11-08-1513-1 11/11/2016 Page: 4 i 1 33 3 i Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawi-ence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Summary for Dwelling Line Item Total 1,625.56 Material Sales Tax 4.74 Replacement Cost Value $1,630.30 Net Claim $1,630.30 Steven Furnero 2016-11-08-1513-1 11/11/2016 Page: 5 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 4.74 0.00 0.00 Total 4.74 0.00 0.00 u 2016-11-08-1513-I 11/11/2016 Page: 6 I 1 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 97 8.688.2242 office @ servp roof]awrence.corn PO Box 328 Lawrence,MA 01842 Tax 1D#02-0353691 Recap by Room Estimate: 2016-11-08-1513-1 Area:Main Level Kitchen 97.20 5.98% Area Subtotal: Main Level 97.20 5.98% Area: Level 2 Bathroom 234.05 14.40% Area Subtotal: Level 2 234.05 14.40% Area: Basement Basement 34.80 2.14% Area Subtotal: Basement 34.80 2.14% ,fob 1,259.51 77.48% Subtotal of Areas 1,625.56 100.00% Total 1,625.56 100.00% 2016-11-08-1513-1 I1/11/2016 Page: 7 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawi-ence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Recap by Category Items Total % GENERAL DEMOLITION 275,41 16.89% PERMITS AND FEES 630.10 38.64% WATER EXTRACTION &REMEDIATION 720.15 44.17% Subtotal 1,625.56 99.71% Material Sales Tax 4.74 0.29% Total 1,630.31) 100.00% 2016-11-08-1513-1 11/11/2016 Page: 8 NOTEPAD WHITKE1 PAGE 2 kNSURE]'S NAME KeJo Corporation OP ID: PI pat© 11111/2016 Named Snsured; 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 A,ndovers i 3 Main Level 31t Tt BloA(B1) g' Kitchen "' o "_' I BIock2(B2) l I -Z- 71 M 37' 11" F 38' 7" MaIn Level 2016-11-08-1513-1 11/11/2016 Page:9 Level 2 ^ 5' T t, 411111— Bathroom ' 11ttBathroom i— 2' 7" 2' 2"- 1 X21 2,1 TBathroom Clogel °O Ott I— T 2" =ei 1 51 1 t, Level 2 2016-11-08-1513-1 11/11/2016 Page: 10 Basement 38' 8'• 38' r, b 3' 11"--+ i 31 11 - ;n -• Basement N �t vz N o Basement 2016-11-08-1513-1 11/11/2016 Page: 11 SN- the Commonwealth of Massachusetts Department of IndustrialAccidefits _ Y I Cong-ress Sheet, ,. l4 to 100 Boston,MA 02114-20I7 -wwwmass.go-w/dia erasationxnsuxance Affidavit:Bu d.exs/Cont�•actoxslEXect7riciax�sl inmbexs. Wovkexs' Comp G c�U O1ZIZ . TO BE FILED'P�ffElTHE:'FRMMM 1' ease Print Le 'bl A litcantb1foxnaation Name(Business/bigahizaiion[ndividual): A.�.dx�ss; � � L�k�tt• �� Z2-u 2 Citylstato/zip: ( �-I i Phone#: Type of p o-t(,Tegi&cd Are you an empXoyer?G`hecicthe appropriate box: aemployer with I employees(iuil audlor part tizne).k 7. [1 Ne 1,p Tam vJ'doxtriiclon S. [�Ramodeli`rig 2.[]1 am a sole proprietor or partnership andhave no employees working forme in Demolitlon any capacity.[No workers'comp.insurance zequired.j 9. � D 3.E]x am a homeowmr doing all workmyse3f.INo workers'comp.insurancerequired,]t 1 d E])3uil.ding addition g,❑1 am ahomeowner andwili be hiring contractors to conduct all work onmy property. 1 will l l..❑Electrical 3 epaixs or additions ensure that all contractors either have workers'compensation insurance or are sole 1.2�+` uo7bg repairs or:additions proprietors with no b`r pbyees. • 13.[�Raof xe�a�rs $E]i am a general contractor and have]w edthe sub-canrractors listed oil attached sheet. These sub-contractors have employees and have workers'comp.inswance t 14. other (,❑We are a cnrporatiori and its ofT7cers have exercisedtheir right af'exeuiption per IVIG c. 152,§1(4),and}ve have no emplciyees.iN,workers'camp.insivaxtce required] * a ltcantthatchecksb.j)k61 iustalso llourtthosectionbelowshowingth irworkers'compensatiunpolicyinfoxruation:' AuY pp they aro iHomeownerswhosua now bmzt•this,af�damtindid���nalsheegshowiirgthen�ameofthesub-contractorsandstatew.the o�notfhoseeniti b ve tConizactars that cheokthis bo, •••.•. employees. iftho sub-contractoxs have employees,they mustprovido their workers'comp_policy number xa rn an ern layer Mat is pNoviding voxlcers'compensation insur�ancefor°racy erMployaes .8eloty is tliepolicy orad j o�site information. Insurance Company Name: �i - [,r. -{' 1�, —02 ExpirationDate: Policy#.or Sel:-fi s.liC.6 . " {} CitylStatelzip: {�.� M t CtilLon �1��� job Site Address: `� a copy of theworl�exs' coxnpensRt1orzpoli�cy declaration (showing tTtepo cynum�be�an piya toq,500.00 ,. AttachpY §25A is a criminal-violation punishable y l? pailuxato seccxre coverage asrequixedunderMGL c.X52, and/or one, ear impxisomnent,as well as civil penalties in tlxa fox3n to th Offix a o£f InvOgations of the DIA for insuxanc�a y day against the violator.A copy of this statement may be forwarded cnvexage verjftoation. X clo liereliy cerci under tliepains and penalties ofper jury Haat tIze information pr ovided move is true an correct Si ature: Phone#: Official use only. .Do rzot-Wr•ite 1n triis area,to be completed by city or town affxciar PermRiLicense# , City or Town= i o Issuing A.utthoxity(circle one): ' 1.Board of llealti, 2.wilding Department 3.City/Town n Clerk 4.Bleetxxcal Iuyspectox 5.plumbing xxrspector 6.Other phone#: Coxatact Persorx: DATE(MMIDDIYYYY) AC4c R" CERTIFICATE OF LIABILITY INSURANCE 11/11/2016 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 CONTACT NAME: Dabney Collier PHONE FAX c/o Collier Insurance (A.1Q__0 Ext: (901)529 2900 arc No): (901)529-2916 E-MAIL 606 S.Mendenhall;Suite 200 ADDRESS: ------ Memphis,TN 38117 INSURERS AFFORDING COVERAGE NAICN INSURER A: American Zurich Insurance Company 40142 INSURED INSURER B: Adams Keegan,Inc. �.�_..__.._.. 6750 Poplar Ave Ste 400 INSURER C: Memphis,TN 38138 INSURER 0: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:15TNO09858085 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MMIODIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _. CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea accurrence $m,-.,,_ MED EXP(Any one person} $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ElJECT EJ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ mm ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONX STA UTE ORTH AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? NIA WC 56-11-865-02 12/01/2015 1210112016 - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEd$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 Location Coverage Period: 12/01/2015 12/01/2016 Client# 2410-MA DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101,Additional Remarks Schedule,maybe attached If more space Is required) Coverage is provided for KEJO Corporation dba:SERVPRO of Lawrence Bi only those co-employees Weekly of,but not subcontractors 8 BLAKELIN ST to: Lawrence,MA 01842 CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main St. ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD WHITKEI . OP ID. PI .4C'CJRL�° CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11/1112016 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)i 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 NAP" James R. Mc Donald 110,StanMcDonald Agency PHONE NO; 6_08-788-7012 1409 Main Street Ar a x(•608-788-6160 Onalaska,WI 54650 UnoRILSs: _ James R.Me Donald — INSURER(S)AFFORDING COVERAGE NAIC# INSVRERA:Rockhlll Insurance Com an 28053__ INSURED KeJo Corporation INSURER BI The Federal Insurance Co. 20281 dba Servpro of Lawrence INsuRERc:ACE Property&Casualty 20685 See Note For Named Insured -- PO Box 328 INSURER D: Lawrence,MA 01842 INSURER E: [INSURERF., COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS 1.0 CERTIFY THAT THE POLICIES OF INSURANCE: LISPED 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE DDS D POLICY NUMBER MMIO�NYYY MMIDOfYY 1 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR ENVP016006-00 0310112016 03101/2047 PAEMISES Eaoccurrenre $ 60,000 MED EXP.(Any onaperson) $ 6,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ 3,000,00_0 POLICY p.jEt° F] LOC PRODUCTS-CUMPIOP AGG $ 3,000,000 OTHER: Is AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTOALL BODILY INJURY(Per person} $ AUTOS OWNED AUTOSSCHEDBODILY BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS' a ccida t $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS-MADE M00798617 01/14/2016 01/14/2017 AGGREGATE $ 1,000,000 —TOED I X RETENTION$ 10000 $ WORKERS.COMPENSATIONPER DTH•- YIN AND EMPLOYERS'LIABILITY ST TE PR ANY PROPRIETORIPARTNERIEXECUTIVE NIA E.L,EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? — (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yos describe under DESL(RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S B Property Section 670-66-47 03/0112016 03/0112017 B Crime 670-66.47 0310112016 03/04/2017 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be a(tached If more space is requiredi Certificate Holder Is Additional Insured Per Attached CG 2037(07/04)And CG2010(07104)A.T.I.M.A.Policy#ENVP016006-00 CERTIFICATE HOLDER CANCELLATION TOWNNO3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. BUlldfng Department AUTHORIZED REPRESENTATIVE 120 Main Street I North Andover,MA 01845 OO 1988-2014 ACORD CORPORATION, All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD i -1 k, 7-, ruin /'W'lea r �Ir:.;,�,ir'I 1i, /i�. Office of Consumer Affairs&Rusin ess Regulation License or registration valid for individul use only s '1:HOME IMPROVEMENT CONTRACTOR before the expiration da(c. If found rel urn to, Registration: 158271 Type: Office of Consumer Affairs and Business Regulation Expiration; 12131/2017 Private Cofporation 10 Park Plaza-Suite 5170 Boston,MA 62116 KFJO CORPORATION SERVPRO OF LAWRENCE, ET ALS. GREGG WHITE 8 BLAKELIN STREET LAWRENCE,MA 01841 Undersecretary k6-valid without stgrta'fure J NlassW;husetts Department of PUblic Sri€ery Board of Building Regulations and Standards License: CS-067690 d3 �. GREGG M WHITE ? 4 CHATBURN RD WINDHAM NH 03087 02/20/2018 9