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HomeMy WebLinkAboutBuilding Permit # 12/2/2016 No R T/y BUILDING PERMIT FD.'6a�'o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION " -1Kz ' y Permit No#: ' Date Received 0,.11 �SSAC us�t Date Issued: � � _ � �. '' ` EIZFORTANT: Appiscaat must complete all items on this page OCA,TION .' z - PROPERTY OWNER' PARCEL. ZONING rent 1D�Year Structure yes no MAP OISTR]GT Htstortc District yes no Machtne.Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition aOther ,�� C] Septic ❑.Well Floodplain ❑Wetlands Water, Dtstncfi C]1i11aterlSewe r. . . . .... .... .. . . DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: 'CAQ r a C rCti - R V-0 U Phone: �L Address: -E Cit Y_-� 0 Contractor Name.tAf roc Ph I& 4( Email C Irv.1 VNS4C . C0 Address: .,, Supervisors.,Constrtaction'License: � - Exp:, Date �HbM�el�ARCH ITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F. Total Project Cost: $ z FEE: $ �7_ r � Check No.: "� � ? Receipt No.: i 7 . NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 8igClatuf2 of Agent/Owner Signature„of contractor r � µoR�ry own of 2Andover 0 h ver, Mass, 16% ' z e U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .. .� .M. ..I � .y .st vl . /® BUILDING INSPECTOR has permission to erect .......................... buildings an ..... Foundation p .........C�..�I � .. ..........I.. .,5.4�.® .. �. .................... Rough t0 be occupied a5 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 CONSTRUCTI TARS Rough Service ........ Wr . .... .. ...................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy 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. Federa II D 0 05-0406629 RISE E'nginceiing RI Contractor Registration No 0186 MACantractor Registration No 120979 CT Contractor Registration No020120 RISE60 Shms,mut Road,Cannta,MA 02021 Co ENGINEERING' 339-502-6X335 FA339-502-6345 NTRACT Page I PROGRAM THIS CONMCIIS EUTERSO IMID DEMEEN RISE ENGINEERINOAND'0111 CUSIONER FORWORKAS DESCRIBED BELOW cuslv&ft PHONE ME CILIUM WORKORDER Laura 0-aig-Bray (978)099-2887 11/21/2016 442824 23tX)3 SERVICE SIFIeFT BILLING WMEET 55 Heath Road 55 Heath Read SERVICE CIPt, TE,23P BILLING CITU,SIAIF,ZIP North Andover,NIA 01945 Noilli Andover,MA 0118�15 JOB DESCRIMION PI IAS[:ONE-Proposal for this Calendar year. $(mm HAZARD BARM"It We have identifwd that there arc recesied h6ldspresent in your hank.unless the recessed liglilsore certified its IC,-roted(InsuIntion Contact Rated)we will create a 3" the fixture by using fiberglass blanket insulation its a(Imaraingmaterial,no Insulation will be installed across ilia top and closed cavities which contial,recessed hVins%Ldl Not be 50.00 M R SfA 1.ING:Provide lalmr and materials to sail areas o l'your horns"PlijiMst wasteful,excess air leakage, This v%ork-will lyc performed in concert with the us ofspecial toolsand diagnostic tests to asstue thin your horse%vil]tv left with a healthiltil level of air exchange and indoor air quiday,Materials to Ix used to seat your home can include caulks,foams and other products. primary areas for sealing include air leakage to�'lit ics,1xirn seents,attached garages and other anticated areas(Nvirukms tire Not generally addressed.) This 011 require(10)NwrLing hours.A reduct inn in cubic feet per roinate(01111)of air infiltration w01 occur,but the Bowl nu ober of cfm is not guarainced. At the Completion o1 the wuathcrijalion work,and at no additional cost to the hoincomner,it final dower(k)or anLVor cornhistion safely analysis%Nill be condoeted by the:alb-counraclor to vnsurc the silety of the indoor air quality. $850.00 KNEE"WALLS:Provide labor and materials to install R-13 faced llilx-rglass to(135)sAjwire feet oflneewilL Then install rigid board at R-10 or greater with the required fire nating-.1wal Bit scams with FSK tape, N(yru':CONTRAIZVOR DISCREATIM TKil-IT SPACH, $492,75 KNUTMALI,FLOOR:Provide lidw and materials to install it 6"layer of"R-22 Chmi I Cellulose added III(8(i),,kjoare feet of open knecmall floor.. N('Yl*[::CONTRACTOR DI!X�R)-ATION TIGHT SPACI: S103.20 ATTIC ACCESS-Provide latw and materials to make(3) temporary access to;in attic area. The opening N%ill Iv closed with materials san flar to tiros:existing Finish sanding and pit in t ing,is riot included $255.00 —V,.—KH—LATION:11 rovido I'aWr Gad materials to install(I)insulaied cxhaust hose wills roof mounted flapper vent to exhaust exist ing 1xithroom fan(s),kroan model 0 636 or equivalent, $118.75 V1 N"I*11.ATI ON:Provide I it IxI r a I I d materials i o i it st it I I vcntilatfon ul I tit e s i I I(112)railer is,iv s i o maintain i I i r 11 o w. $224.00 Fridoral ID It 06,0405629 RISE, Enginceiing RI Contractor Ragistration No 8106 MAContractor RagIstrallon Na 120979 RISE60 Shalyinut Ilond,Canton,MA 02021 CT Contractor Rogistration no(520120 ENGINEERING' CONTRACT 339-502-6335 VAX339-502-6345 Page 2 PROGRAM IMS CU17RACTIS ENIERED INICEIEWE Ell RISE (:'NIA-Inti Ucualurm rCOWOU AS DESCRIBEDDELOW CUSIDWER PHONE DAIV CUENTO VNCRXCIRDEFI Laura Craig-Bray (978)689-2887 11/21/2016 442924 13903 SERVICE S'MEET 111U.1110 WITUEET 55 Heath Road 55 Heath Road SERVICE CITY,SIAW,23P GIWNG Carl,SIAM,231' North Andover,MA 018415 North Andover,MA 01P5 .JOB DESCRIllyrION COMMON WALLS:Provide labor and materials it)install rigid board at R-10 or greater%with the required fire ruling to(86)stluare feet of,collanion%Vill area. S301.00 COMMON WALL",Providc labor and materials to install rigid tuird at R-10 or greater wtiih the required fire rating to(86)sqmire feet orcorollion wall area. $301.00 BASEMEN'r CIALING:Provide labor and materialsto Install(180)linear feet of R-19 unfaced filwg4m insulation to(lie Perimeter 01*111C Nisel"ent ceilingat the llouw Sill, $315.00 BA,%MENT I)OOR:Provide Inivr and matcriats to insulate the Nick of the basement door leading,to the bulkhead Wth rigid Nnird til It-10 or greater Will the required fire rating that meets the sections R-316.5.4 and 316.6 requirements of building code. Smi all edges and seams Wth FSK tape. 572.22 WINDOWS-OKAY-WINDOWS $0.00 FXIS'l*ING DOOR-DOORS OKAY 50.00 RI'4*Engineering vNill apply all applicable,eligible incentives to this contract. yollwill only iv billed the Net amourn. Currently, I'm eligible measures,Coluillbia Qasofic(s 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Sealing measures tip to the first S680 and all oddil ional$3,10 ifsavings urejnstified try tile audilor. For tilt:'.Ifety and llealill of,your home'%indoor air quality,%%v\01 be conducting to blower door diagnostic of the available air It()%%, in,your home N111 bellore the\\ork is begun,and after the%%vathel-Wition%wrk is complete.We\%ill also conduct;I full assessment orthe Cornbustion s4lilety of your heating system and voter heater.This has a valtic ol'$90 and is tit no cost to vou. Total alk-able%watherizalion incentive is$3.1 liX The Permit W11 tv wcuied by the insulation conlraclor,at no additional cost.It is the horneowier's responsibility to close out this permit by Contacting their municipality tit the completion ofthii\Nork. $90.00 11 2J3 0 \y/ RLFE �q-1 Federal to 9 06-0405629 RISE Engineering RI Contractor Registration No 0100 IAAContractor Registration No 120979 RISE60 Showinut Road,C*an Inn,NIA 11202 1 CT Contractor Registration No620M ENGINEERING* TRACT 339-502-6335 FAX339-502-6345 CON Page 3 PROGRAM '011 CONTRACtIS,ERIE REU IM SETWE E14 RISE CNIA-111,5 En,5*�4EEFUNOANO'OMCUSTCtXRrORViCM(AS DESCRIBEDBELON CUM' 11 PHONE DATE CUENTO VOORKORDEM Utara Craig-Bray (978)()8()-2887 11/21/2016 442824 2.3903 SERVICE STREET UILLING STREET 55 1 leath Road 55 Heath Road SERVICE erly,STATE,Mp BIWNG CITY,STA-15,ZP North Andover,MA 01845 North Andover,NIA 01845 .1013 DESCRIMON Total: $3,122,92 Program Incentive: $2,577.19 Customer Total: $546.73 WEAGFtEEIIE[tEBYTOFUI:tt4l$IISERMCES-C(VAPLETEIN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ""Five Hundred Forty-Five &731100 Dollars $546.73 UPON FlUALUMPECTOR AND APPROVAL BY RISE ENGINEERING.CUSTOM-RAGRCES)DRENITAMNTOVE IRFULL.RHERESTOFM WILLBE CHARGEOMMOLY 01 ANY UNPAID BALANCE AFIER 30 DAYS.SF lit FRSE FaRU1MCR71AN rNPORMATIONONGUARARIEES,RJW"3 OF RECISION,SCMDULING,AND CWI�AUCMR RECAS-RAIC". o T DON?) SIGN nlIS C014TRACT IF EREAREANYBLAN ,SIP ES AMIORIMOSIMIA14RE-RIS E>(m*flrq DU S'M R ACCEP CC GNUS TC�XCCUjC NOIE:THIS C041RACTIMY BE W111 �D WMIn DA'EOFACCEPTANCC ACCEP V%NCE Or CONTRACT-THE ABOVE PRICES.SPECIFICATIONS AND CONDITONS ARE 30 DAYS. SATISFACTORY 10 US AWARE HEREBY ACCEPTED.YOU ARE ALITICIRLZED 10 00 102 WORK AS SPECIFIED,PAYbICNTWILL BE PMOC AS OUIUNED ABOVE � J = RISE60 Shawmut Road, Unit 2 1 Canton, MA 020211339-502-6335 ENGINEERING" www.RISEengineering.com Eiticirnicy£rte•:s;i.c•°" OWNER AUTHORIZATION FORM I, �r� , (owner's Name) owner of the property located at; u g�-5, e q-"ll ACV a , (Property Address) 11.r. 9 d./0 0 tom,^ Yl'z Y Merrimack Valley InsulaIran.�.�M..�°,m�, (Property Address) ..... ....... 23A Sullivan Rd Billerica,MA 01882 hereby authorize , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. wner's ignatur Gate 6.2018 The Commonwealth ofMassachusetts Department of Lrdustrial Accidents Office of Investigutions 600 Washington Street Boston,MA 02111 www.mass.govIdio Workers' Compensation Insuirance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lg ibl PJ Name (Httsiness/Orgenizatioti/lndividtial): � F d U Y�t���. � A i�� �� r Address:—d,5 A City/State/Zip c Ll `C,C),_ JJA ! Phone#: 1- Are ou an employer?Check the appropriate box: Type of project(required): 1.[ I am a employer with _ 4. ❑ 1 am a general contractor and I G. ❑New construction employees(full and/or part-time).* have!tired the sub-contractors 2.❑ lam a sale proprietor or partner- listed on the attached shoet. 7. ❑ Remodeling ship and have no employees These subcontractors have g, ❑Demolition working for me in any capacity, employees and have workers 9. ❑Building addition [No workers' comp,insurance comp.insurance.# required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.[:11 am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions myself.[No workers' comp, right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13 Other, rJC�.�IT/D camp. insurance required.] °Any applicant that checks box Al must also fill out tile section below snowing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then]rice outside contractors must submit a new affidavit indicating such. tcomractors that check 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-coounetars have employees,they must provide their workers'comp.policy number. 1 am an employer drat is providing workers compeasatfon insurance for nty>employees. Below is thepolicy acrd job site irrfarrrraliolt. !E Insurance Company Name: �cc l, J f`r A W 1 111-1 Ca-iv A I ,, wa0-- Policy#or Self-ins.Lie.#: V9 LX q I l q Expiration Date: �,`1,� - I q Job Site Address: City/State/zip: 1/4_4 619 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead 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 fornr of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby cern aide ire p4itis acrd penallles of perfuiy that the ho forination provided above is true and correct: Sietlatttre: ' Date• 3C)� I r Phone#: Official use on1j. 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 Cleric 4,Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: The Connnonwedth qfMissachusetts Ojjice oj'Investigations m 600 Washington Street .Foston,ltd 02111 wwrv.mass,gov/dia Workers' Compensation insurance Affidavit: Builders/C;ontractors/1 le ctricians/Plumbers Aimlicant information Please Print Le ibl arae (E3tisutcss/Orgat7izationJlttdividual):_Merrimact(Valley Insulation Corp Address: 23 A Sullivan Rd. City/S1:ate/:dip:._Billerica,_MA_01862Phone 4: 978-888-3496 Are yon an employer? Check the appropriate box: Type of project(required): 1. X� I am a employer-with 184. [] I am a general contractor and I � have hired the sola-contractor°s b. ❑ New construction employees (full and/or part-tire). 2.❑ I am a sole proprietor or partner.- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees 'these sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ 13uilrling addition [No workers' comp. insurance comp insurance.T required.] corporation We are a S. oration and its 10.❑ Electrical repairs or additions ❑ p 3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MCL 12.❑ Roof repairs insurance required] t' c. 152, §1(4), and we have no employees. [No workers' 13.F1 Other, Insulation comp. insurance required.] "Any applicant that checks box#'fl must also fill out the.section below showing their workers'compensation policy information. I lomcowners who submit this affidavit indicating they arc doing all work and then hire outside,contractors must submit a new affidavit indicating such. ,Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have cluployces. if the sub-contractors have employees,they must provide their workers'comp.policy number. I arrt(ttt employer•tlectt is providing rrior-ker,v'coitiperxsatior7 ittsttrartee for my employ}ees. .Belo)v is the policji ctntl job site informatit)rr. Insurance Company Name: BStar V3 AAIC American Alternative Insurance Policy#or Self-ins. Lic.#: V9WC749118 Expiration bate: 8/18/2017 Job Site Address: 1 __._._ w_ __._...___City/State/'lip:t-�l,i �cl(), r,M .Attach a copy of the workers' compensation policy declaration page(showing the policy nurnber and expiration date). Failure to secure coverage as required under Section 25A.of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$t,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 clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hel-eby cerfify under the pains andpenalties ofperjnry that the iufcrrmatiou provided above is true aur!correct Phone#: 8-888-349 ®'1 cial Ilse only. I)a out write in this area, to be completed Lp city or town offieiat 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 h. tither Contact.Person: Phone#: MERRVAL-03 WEJE CERTI ATE OF LIABILITY` INSUR NCE DATDlYYYYl 61171312312016 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, _ Automatic Data Processing Insurance Agency,Inc PHONE — FAX 1 ACIP Boulevard Arc No.Extt. nFe,No E-AIA1L Roseland,NJ 670613 ADDRESS: INSURE"( I AFFORDING COVERAGE NAIC V INSURER A:5Star V3 AAIC AmeTiCanAlternativeins Llrarr. INSURED Merrirnac1C Valley Insulation Corp INSURERB: _ 23a Sullivan Rd INSURER 0, Borth Billerica,MA 01862 INSURERD: INSURER F' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER_ THIS IS TQ GET MFY 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 VUHICH 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 . I -OJCYF— QICY )PADDL INSISUERI!fLNTSRR_ TYPEOFINSIRANCE POLICYNorABER LIMIDINYYYY h1A11DDIYYYY LINTTS GENERAL LIABILITY I EACH OCCURRENCE j S CO?AI.IERCFALGENERALLIAe1LCTY I PREtd3_SESiEaaccurrenca��s Gi.f+li:§S;AAi7E OCCUP I MED E W(Any ori,pemm) i PERSONAL:ADV INJURY t S t F�ENL GENERALAGGREOATELNITAPPLIESPER: li (PRODUCTS-COIAPiOPAGG S POLICY i l(�'��PRO- ( - f LOC I 5 XAUT 'ABILITY I COMBINED SINGLE LIN11T j , - Eaaccldenl 5 I ANY AUTO i BODILY INJURY(Perpersan) `SED SCriEDUE.EDBODILYINJURY(Peraccident) s AUTOSNON-OWNED f PROPERTYQAtiAGETOS AUTOS SA LFAs OCCUR ' EACH OCCURRENCEUAS CLAIMSWADE DEO RETENTIONS l ---- S WORKeRSCOh1PENSATION STAIIJ OTH- IANDEF.1PLOYCRS'1IA131UTY SIN _1ORYLIA11T5 A tNYPROPRIETORIPARTNEWEXECU3111c ❑ VSWCT49118 611812016 611812017 E.t_EACH ACaDENT — S '1,000,000 C1PFiCERlPl�EFfiBER EXCLUDEDB Y NIA (IAondatory iri NHl E.LDISffASE-EAEUPLOYE S - 1,17170,0170 IFppes,descriUeunder - - OESCRfP GN OFOPERATIONS tm;9N E.L.DISEASE-POLICY UrLIr- S 1,000,©QII i I i i iDESCRIPTIONOrOPERATIONS ILOCATIONS IVEHICLES[AL1achACPRDi01,RddilTonalRemarks5chedule,iPrimorespaccisrequl�nd) i 0 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANGELLED.BEFOORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tgwn of North Andgeer,Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover,MA 01845 THDRIZED REPRESE14TRTIVE I O 1988-2010 ACORD CORPORATION. All rights reserved. ACORL)2S(2010105) The ACORLI name and lo ga are registered.marks of ACORl7 9 I I AC R" CERTIFICATE 4F LIABILITY INSURANCE DA�ii10712016 11..�.. 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 have ADDITIONAL INSURED provisions or be endorsed. if SUBROGATION IS WANED,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 Carolyn A Coughlin Charles J Coughlin Insurance - 14 Dinley Street PHONe (978)957-3588 c Na) P.O.Box 10 E-MAIL carol�@g cou hlinins.com ADDRESS;.... Dracut,MA 01826 INSURER($)AFFORDING COVERAGE NAIL# INSURERA: Northland Insurance Company 24015 INSURED Merrimack Val ley Insulation Corporation Joseph A.Ryan,Jr. INSURERS: Safety Standard 39454 23A Sullivan Road INSURER c: Torus Specialty Insurance Company A0159 N. Billerica,MA 01862 _INSURERD: INSURERE: INSURERF: 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 DFSCRI8ED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE-BFFN RFDUCFD BY PAID CLAIMS. INSR -- - ADDLSUBR — POLICYEFF POLICY EXP —...__..�. LTR TYPEOFINSURANCE p POUCYNUMB£R MM'DO MMIDD LIMITS A COMMERCIALGENERALLIABILnY WS274182 01/21/2016 0112112017 EACH OCCURRENCE $ 1,00{),01)0 �.'" DAMAGE TO RENTED .._...-,.... ..__. CLAIMS-MAOF �/ OCCUR PREMI ES_C�a eccunence $ 100,000 MEO EXP(Any one person) $ 5,000 PERSONAL&AOV INJURY $ 1,000,000 GENLAGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2,000,000 ECT J POLICY LOC PRODUCTS-CONPIOPAGG, $ 2,000,000 EC OTHER mm $ B AUTOMOBILE LIABILITY 6205006 11/25/2015 11/25/2016 COMBINED SINGLE LIMIT $ 1,{)00,000 Ea accident „_ ANY AUTO BODILY INJURY(Per person) $ OWNED / SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY V AMOS ........,....,...-.� / HIRED / NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY __--_ AUTOS ONLY Per accident .$,,,,._�... C UMBRELLALUIB OCCUR 97593LI61ALI 01/21/2016 0112112017 EACH OCCURRENCE $ 1,000,000 EXCESSLIAB CLAMS-MADE AGGREGATE $ 1,000,000 DED RETENTION $0 $ WORKERS COMPENSATION AND EMPLOYERS'LIABIL€TY 87ARTUTE ER ANY PROPRIETORIPARTNER/EXECUTNE YIN E.L.EACH ACCIPFW $ OFFICERIMEMBER EXCLUDED? N 1 A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONSI LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached tf more space Is required) Insulation Installation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE NTH THE POLICY PROVISIONS. Town of North Andover,Massachusetts 120 Main Street AUTHORIZED REPRESENTATIVE North Andover,M A 01845 ..r+r'""'"" ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Corporation Registration: 180506 Merrimack Malley Insulation Corp Expiration: 11/23/2018 23 A Sullivan Rd Billerica, MA 01362 Update Address and return card. Mark reason for change. scn 1 0 20M-05n FJ __ .. _ . n t r'a rrl ; d.dre k. .0.Rennurnl Il ErM'ploti rnent l�I....,q - ,� \ office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only f Type: Corporation before the expiration date. If found return to: ' • Registration fix iration Office of Consumer Affairs and Business Regulation 180506 11/23ation 10 Park Plaza-suite 5170 Boston,MA 02116 Merrimack Valley Insulation Corp Joseph Ryan 23 A Sullivan Rd `Q Billerica,MA 01862 Undersecretary Nota ad �hout signature Board 01 Su"-dinv Rcet:!c.tion's 4--d amu:so: CS-075541 JOSE PH A RYAN�. 200 King I-Zail Thr.:APE 201 LynnfieldM-k 0040 J c - ", 0210A12017