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HomeMy WebLinkAboutBuilding Permit # 1/30/2017 BUILDING PERMIT TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION Permit NO: l Date Received SSACHUS�t� Date Issued: IMPORTANT: Applicant must complete all items on this page Y" � Il�'I`1�C"1 lrsrt 131trf TYPE OF IMPROVEMENT PROPOSED USE Reside ' l Non- Residential ❑ New Building �ne family ElAddi ' n El Two or more family Li Industrial eration No. of units: ❑ Commercial ❑ Repair, replacement [..;Assessory Bldg ❑ Others- ,11 Demolition ❑ Other �tln�s IWte� Det kczd AOL_ Identification Please Type or Print Clearly) �� L Phone: OWNER: Name: Address: aA F k--) �� 7 l� ....... ........ \ �o,✓/' G „f< ... ...cam . . ARCH ITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: g 7 0d FEE: $ _ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund tgte. � turr ignatire ofi canti�;�ctor ............................................... ..................... ............ ................ .................................. t%ORTH Town of Andover 0 M No. ILII."7611 4 _x h ver, Mas 0 coc"'C"EWICK A're to) U BOARD OF HEALTH Food/Kitchen sk PE IT D Septic System c BUILDING INSPECTOR THIS CERTIFIES THAT ........ .. .............. ....... . ... .. C1. - Foundation has permission to erect .. ............ .......buildings on ......sm ....... 'A Rough tobe occupied as ....... . ........... ­­............................................. ................. ............... Chimney provided that the person accepting his 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 TRC'AWN ST S Rough Service O _E.........................._......... Final BUILDING INSPECTOR 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. Massachusetts ®me IMP,rovement Contract This form satisfies all basic requirements of the state's Hoene improvement Contractor Law(MGL chapter 14211),but does not include standard language to protect homeowners.Seek legal advice if necessary.Any person planning home improvements should first obtain a copy of"a Massachusetts consumer guide to home improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Alfairs and Business Regulations Consumer Inl'ormationHotline at 617-973-8787 or 1-888-283-3757. _ Homeowner Information Contractor Information Name 4- ie& Lisa Ko/.i}I Company Nanre:t'ltCll+'ts: s.t3V;`.1.BU11.,1ti NC ti#;llt'1C 1:S Street:Address(do not use a Post Office Box) Contractor/Salcsperscnl Owner Name,i*LTV,3C CLUkALD1 5 IVadlord sirCut_Nnith Alvdov ter.A1.\tl l Y 1`: Business Address(must include a street address) Daytime Phone Evening Phone >(.I I.1)is 1fi'43<13('till,;A j ',1,N l 03079 liI-7_?5()-7 ,cj;} Mailing Address(it different front above) Business Phone Federal Employer 1D or S.S.Number 603-89$-2477 t5-x o)F 17 . ...w:;1 h01110 .... Ile=lnlproven.Ont Explr LnsNraCxaF .. . .. vlon Pal:...•. .. ..... -..-�.:•,,.•: ...•.. lAA�f'yrlrls that sS ..._ .., lulpruvcttttinl Muttnelms hart a valid reg.nnw6cr /1 ` L lneyd�'ilxff6f3111111111LY li;7(} 1tl�I The Contractor Agrees to do the following work for the Homeowner. {Describe in detail the work to be completed,specifying the type,brand,and grade of materials to be used,use addilinnal sheets if necessalY.) t8r€ereitci PI-ofessionai building.;Scrtilces`admit`3747((1('ltnA ng)atkkched lun-t'tr)ilE t?shi11i1.A Required:Permits-The following building permits are required Proposed Start and Completion Schedule-The following and will be secured by the contractor as the homeowner's agent, schedule will be adhered to unless circumstances beyond Owners who secure their own permits will be the contractors Control arige(pending wealherperiniuing"). excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work(**)l'u`st l�•e6 ul' �r'?li�i-►-:-=tom-'..__—_._......._...�._..–....m, MGL chapter 142A.) 1}ate whet,conlydctett wOtk will he subslanlially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of',' Payments will be made according to the following schedule: upon signing contract(not to exceed 113 of the total contract price or the cost of special order items,whichever is greater) '?,tloo.f o upon substantial completion of materials drop oro or before the work start date 1,.903.3.1 :,; ;;,;r, rl i}3 t lltt (ill xrilkw)upon completion ofthe contract.{Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special$_—N//1 to be paid for N/A _ I Ordered before the contracted work begins iu order SNIA to be paid for NIA _ meet the:completion schedule.(**) NOTES:(*)lncluding all finance cliarges of 1.5%per month from due date until amount is paid in foil plus$50 processing tee (**)Law requires that any deposit or down- ay inert required by the contractor before work begins may not exceed the greater of (a)one-third of the total contract price or(b)the actin tl cost of any spacial equipment or custom made material which trust be special ordered in advance to meet the completion schedule. E x ress Warran r-Is au ex ress warranty behip provided by the contractor? No Yes all tern`s of the warrant ,O be attached to the contract) 5 NT;sr`e'a`r aet4'on Ot fi 1,0111r.Owvm CEnid llti 5inildiard 16"u'lllip.W!$VIN V45xion per i,Aim tale A5 initnChcd iIvVvW h' 1•;altilik};'4$arrwific-,5110.he Owely provRicil Ily t11r('alley Qto3'tei C[w Ilujov,mfwr lsIior lit or€1 inn Ct'impfctitnl i,r illc%S'il'l:,OU W;rrsnty to be r< 'isterarl b (,omrawwr#or Ix'ilentenirttetr ullin3,inb t o-ilt{air,tinrl. Sullcootractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor.The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor udder this agreement. Y Y - _....... ............... __..,.,.. _........ .......-.._- Contract Acceptance-Ulion signing,this document becomes a binding)contract under law.Unless otherwise noted within this document,the contract shall not iDiPlY that any lien or other security interest has been placed oil the residence.ROviOw the following cautions and notices carefully before signing this contract. Don't be pressured into signing the cmitract.Take tune to read and fully understand it,Ask qtmsfions it"something is unclear. Make sure tile-Contractor 1145,kyalid ron-re improvemetit �nLoirThe law reouijcs must 11 contractors and subcontractors to be registered with the Director offlon)c Improvement Contractor Registration.You may inquite about contractor registration by writing to the Director at One Ashburton Place,Room 1301,limton,MA 021 o£i or by calling 017-727-3200 or 1-800-223-0933. Does the contractor have insurance?(,'TlCck to set that Your cOnrl-,ictor is properly insured. form and go,,copy or the consuiner Know your rights and responsibilities.Read die Important Infonnation on the reverse side of this Guide to the lJoine improvement Contractor I.aw. Photography and Teitirrionials All Photoshestn"ollials and rights relating it)thorn,inchldill.('copyright and mviiership rights in the media ru Nvllicb the photos are stored,remain the.sole and e)Lclusive property of the contractor_'rhe Contractor has right to reproduce,publically display,and distribute for promotional turd advertising. You nwy cancel this agreement i,l'it has been signed at a place other than the contractors nortual place ol'business,provided you'i'llify the contractor in writing at hisIbc Main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of ] the third business day following the siguiligon(Willis right. of'this agreement.See the attached notice of'cancellatio"linin tot an explanation DO NOT SIGN THIS CONTRACT IF THE RE ARE, ANY BLANK SPACES!!! , rwo identical coples of the contract crust he completed and sig"CAL 011c COPY sboul(I go to the homeowner.Tire other copy houid be kern by the contractor. '2 roitraolor's Signature Homeowne C Date Date Contractor,Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor.The same right is not automatically afforded to a contractor,however.The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below.This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the I.lome Improvement Contractor Law. The 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 the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. _ )homeowner's Rights A homeowner's rights under the home Improvement Contractor Law(MGI.chapter 142A)and other consumer protection laws(i.e.MGL chapter 93x1)may not be waived in any way,even by agreement.however,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the home Improvetuent Contractor Law.The contractor is responsible:for completing the work as described,in a timely and workmanlike mariner.homeowners may be entitled to other specific legal rights ifthe contractor wan for workmanship or materials,In addition to guarantees or warranties guarantees or provides an express provided by the contractor,all goods sold in Massachusetts tarty an implied warranty of rncrchantabilAy and fitness for a particular.purpose.An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached.Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable.One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor.Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the paymont schedule in cases where the homeowner deems hitn/herself to be financially insecure.however,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of Rinds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of"A Consumer Guide to the Home Improvement Contractor Law,"contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 9 a 9 B ---...._...,.._ - - . _............ __.. - ..._.- --------- _.... ........ ......... _ 10 Park Plaza, Room 5170, Boston,MA 02116 (617)973-8787 or 1-(888)2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Lam,,contact: Director of Hume Improvement Contractor registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 (617)727-3200 or 1-800-223-0933 For assistance:with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755.2548 (413)734-3114 0 B 1. i .._-.______ ....._.. ._......T...��__................. Professional Building Services Estimate ` 9 Olde Woode Rd Salem.NFT Q3079 � rvtr�v.proEessianalbuikdingservic�;s.com p�t� ����a{g�j'- ,. in fo@professionalbuil clin;services.coni 643-898-2977 /781-995-2335 lr2412017` 3747 Exp: Date 1130117 N.arrie I Addres Eric Kozo] 95 S Bradford Street North Andover,MA 01895 IDescrrptrgr► Qty Rat focal OWENS CORNING STANDARD WARRANTY-SILVER PLAN 1 375.00 375,00 Building Permit Administration Fee Rome owner can pull building permit themselves, If customer wishes Professional Building Services to pill]permit, please add 5375. ** Customer to reimburse Professional Building Services cost of permit fee paid to Town/City.** 0.00 0.00 Building;Permit Fee paid to Town/City-TBD This fee to be reimbursed to Professional Building Services or customer call pay directly to municipality Thank You. We look forward to working with you ! Total Page I i i I .... — Professional Building Services Estimate 9 Olde Woode Rd Salem NH 03079 wvvw.professio€€a]bnildingservicesxom Date Stit11 #� in fo@profession alhuiI di€€gservie es.com f" 603-898-2977 !781-995-2335 1/24i'2017 3747 Exp. ]ate 1/30/17 Mama l..Addres Eric Kozol 95 S Bradford Street North Andover,MA 01845 ;.: T3es�ription Qty Rate Total 15 440.00 6,600.00 OWRNS CORNING STANDARD SYSTEM ROOFING WARRANTY Professional Building Scrvices to register warranty with Owe€€s Corning in Homeowner'name. Strip and dispose of 1.layer of existing shingles Cover house with tarps for protection Inspect roof decd. i Install Owens Corning fiberglass reinforced Felt Underlaymerit Install 6'Tri built ice and water shield in all valleys and edges. Inspect all roof flashings and re-ase if possible Install 5"aluminum drip edge and metal flashing Replace all vent pipe boots. Install Owens Corning Starter Shingles Roll on first course Install Owens Coming'frul)ef€nitio€r Duration Designers architectural shingles.Color-TBD Install TriBuilt Roll Ridge vent on ridges Install Omens Corning Hip&Ridge Shingles on hips&Ridges Thank You. We lookforward to working with you t Total Page 2 i ---__--------- ....................... ............ . -- . ....... - Professional Building Services Estimate 9 Olde Woode Rd Salem NH 03079 rvtxnti.profcssionulbuildiatgscrvices.c-0nt lite ESfftClBte# fir, ._ iaafa(c;professioualhuildingservices.com i #V 603-898-29771781-995-2335 3747 Exp. Date 1130117 0101A. s Eric Kowl 95 S Bradford Street North Andover,MA 01845 p�scrtption Qty: Rate:` Total ' . 1 575.00 575.00 Chimney Re-leading/flashing Supply&install new lead flashing on all chimney penetrations 1 275.00 275.00 4''Venture Ridgo vent upgrade f 1 80.00 880.00 2nd layer of rooting,shingles strip and disposal 0 775.00 0.00 OPTION: Supply&.Install Solar powered roof vent "will not need duanpster if there is enough space in existing 0 495.00 0.00 dumpster" 15 yard dumpsterwith 2 tons.If additional dnmpster needed, customer Agrees to pay for additional dumpster or dumping fee of S 125 per ton. 0.00 0.00 R01'RFFAllt-remove,dispose,purchase and install 4x8 plywood -$100/sheet Structureltiame repair rates: $165lhr for Master Carpenter&Carpenter Apprentice Materials receipt to be provided plus 150ro for administration fee Thank You. We loop fonvard to working with you! Total u Page 3 ............................_ -- ....._.. I r Professional Building Services Estimate 9 01de Woode Rd Salem NSI 03079 www.professionalbuildingscrvices.com D£ gtlpi � in I'o@prof essionalbuildi n gservices.conn 603-898-2977 / 781-995-2335 1/24/2017 3747 exp,Date l/30/17 I�atTte I A. .dr .s Eric Kozol 95 S Bradford Street North Andover,MA 01845 ©ascription Qty.. Rate Total 0.00 0.00 CONCLALEIO CONDITIONS:This Agreement is based solely oa the observations Contractor was able to make with thv structuro in its current condition at the time this Agreement vas bid. If additional concealed conditions are discovered once work has commenced which were not visible at the time the proposal was bid, Contractor will stop work and point out these unforescen concoaluf conditions to Owner so that Owner and Contractor can execute a Change Order for any Additional Work. Thunk You. Wer look forward to workilig with you ! Total 98,705.00 Page 4 I, _,.- __........_... _._.�- ........_._. _.._...__.._ ,. _.m. -- t The Commonweatill ()f M0ssac1111Scttv Department of Indtairial Accidents Office of Investigations 600 Washington Street Boston, §14 132111 ;V1V;V,"JaSs.g0V-1(Jia Workers' COMPensation Insurance Affidavit. Builders/Coittractors/Electricians/illumbers APPI cant Inform-ti— Please Print Lcgiblv Name pr <:---- Address: Phone Are you an employer?Check the appropriate box- Type of project{required): 1, 1 am a employer with._ 4. [A lam a general contractor and i e ,* G. Nizw construction 2.0 mplovees(full and/or part-time) have hired tile sub-coniractors Remodeling 1 am a'sole proprietor or partner- listed On the attached sheet. : ship and have no employees These sub-contractors/lave H. Demolition working for me in any capacity, workers' comp. insurance 9� Building addition No workers' comp. insurance 5, We arc a corporation and its required.) 0011cefs have exercised their I O.LJ Electrical repairs or additions I am a homeowner doing all work right 01"exemption[per IM61, i I Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have rio 12 Roof repairs insurance required.]f employees. (No workers' cornp. insurance required] x#1 $11051also fill OL11 the below showiog their workers' pulicy hil'ormaton Any applicant that checks bo I tHomcowners who submit this affidavit indicating[hey are doing all work-and thert,hire outside curltracmfs mus:submit a new affild;sVit flldioatlng such. ,Contractors that check this box must aiiachd an additional sheet stivivilig the name M,the SUb-contractorsand thea wotkcrs'sump.poticy information, r am etn employer That is propiding$workers'compettsutiotr insurance for my enVioyeev. Below is thepolicy ante;'job site Insurance Company Name:, Ar ii--(' Policy d or Self-ins. Lic, Expiration Date.� L q5— 'S &Z ...................- Job Site Address:_ AD 11�:6�-b I�-k-F M cixy/stateizip� 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',MG(,c. 152 can lead to the imposition of criminal penalties ofa fine up to$1,50O.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy Of this Malelnent may be ibrwarded to the Office of Investigations of the DIA for insurance coverage verific-alion, 1'10 h-OrebY cerAf under the pains and penalties oflierjury MW the inforinarion provided above is true and eurrect. SLiLn a t u�re. 7C51 Phone P: Ofjtviftl use only. Do not write in this area,to be completed by vit),or town offleial City or Town- Permit/License Issuing Authority(circle one): 1. Board of Health 2. Building Department .3.Cityrf,o,%yvk Cllerlc 4. F.,1ceti-icat Inspector plunibitig 11j3picctul 6.Other Contact Person: Phone#:__—.__ 1 g DATE(MMfDDNYYY) .d►C<>R o CERTIFICATE OF LIABILITY INSURANCE 1/z7/2o17 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 DOESNOT 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 NAME CT Patricia Blais Financial Insurance Services Inc PHONE (60:3)432-6414 FA N0);(603)432-3852 -- PO Box 950 nD©RRrSS:pblais@fisins.com INSURERS AFFORDING COVERAGE NAIC# Derry NH 03038 INSURERAMain Street: America Assurance 29939 INSURED INSURER B:National Grange Insurance Co 14788 '.. Professional Building Services By PMC LLC INSURERC: 9 Olde Woode Road INSURER D-: INSURER E Salem NH 03079 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1712606662 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 TYPE OF INSURANCE AODL SUER POLICY NUMBER POLICY EFF MMIDD EXP LIMITS LTR $ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGEfO TED A CLAIMS-MADE ❑X OCCUR PREMISES Ea omurrence $ 500,000 MPT1630H .2/5/2017 2/5/2018 MED EXP{Any onepersnn) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X. ❑JECT PRO- ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 % Employment Practices Liab Ins S 100,000 OTHER: AUTOMOBILE LIABILITY Ea BINEDD(SINGLE LIMIT $ 1,000,000 godANY AUTO BODILY INJURY(Per person) $ BALL OWNED SCHEDULED AUTOS X AUTOS H1T1630H 2/5/2017 2/5/2419 BODILY INJURY(Per accident) $ NON OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident I Medical payments 5 5,000 UMBRELLA LIAB Ld OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRiPT€ON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (ACORD Sot,Additional Remarks Schedule,may be attached if more space Is required) u u CERTIFICATE HOLDER CANCELLATION jordan@professionalbuildin SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Eric Kgzgl & Lisa Kozol THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 95 S Bradford Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Sam Fragala/SETH 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r�n�ann AC�� CERTIFICATE OF LIABILITY' INSURANCE �°��-2018 _ _ 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 E AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN 7HE ISSUING INSURER[$),AUTHORIZED REPRESENTATIVE:OR PRODUCER,AND THE CERTIFICATE HOLDER. I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(iesl must ba andoraed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,cerlaln policies may require an endorsement. A statement on this cerliflcato does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ear:TACT HAYS INSURANCE BROKAGE 133 FEDERAL S7 BOSTON,MA 02121 M'il,tf,R(S)AFFORUtMG COVERAGE MAIC i1 IN5UH814 A,THE Y'RAVE.ERS i1.nENNM GUMPANY or AMERI INSURED INAURER Ci ��—��-�� ''. SURGE RESOURCES II INC 920 CANDIA ROAD _..._.._.____,.. .__.......,. _.._..-......-_...-._...._ —_.._____.._ MANCHESTER,NH 03109 INsux�ie o INSLfrelwar: � _ ..�..�....._..— --_ INsuRER F COVERAGES CERTIFICATE NUMBER: .. ..._..RI;VIWO.N NUMBER: THIS IS TO CERTIFY THAT THF 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 CLAWS, WSR AnnL 5UD POLICYerp POLICY EXP LIMITs LTR TYPSOf ENSURANGE INSR WYD POLiCYNUMaER MMA)nlYYYY MMiDOJ'lYYY _ ,..�„_-. _.. OENenALUAPILITY ACI.CGCURRE=tiGfi_._ 5 GOMMEACIAL GENERAL LAABUTY ()A MAL�E-TO RF N1EI y ICLAL4IS•RtAp 1....._f COCCIR P . . nl uttn "EO EXP EXP'€Ar:Y ono porsnn) £ I PI�Rti(lNA[-A NIV INJURY $ C,LN„RAL AGDREaATE S [ifM AGGREOATE LIMIT APPLIES PER: ?ROi7..OTfI -'01 .PW AGG S POLICY JECT I Lcc 9 _ r1MDRIL3 MABFLITY CpM1f.gggc SiNCiLC”Lltitl7 S ANYAU-10 .iC:IiFG{ft Ff7 AUT09 I SMY INJURY?Por P01.11)®ar,) S ALL OWNED Al1T(7S P,OOILIN.I Y URY:Por a<:ra3nml - .. _ ,...�—_.__....._,,..._._._..._ Nr3NOYJNf:O iiQfr,'Ci7Y AMAGi" .�.. IS HIRED AVTQS AU QS UMBRELL.AMA9 OCCUR � EAc;R OCCURRENCE EXCESSLIA$ I CLAIMS-MAOE A= EG lS DEO Rk'TcNTICNS _._ .. &RKERSCPMPFNSATEON._..__.._...--.-.. ---... _.._ _. -... I x wr SIJni OrY ANDEIAPLOYE€iS'LiARILnYfN U2Y1.1 II Era _ ANY PROPMETORfPARTNERfEXECUTM. NIA 3E,L EACHACCIDENT x1,400,000 OTMEt'N�0AMR tXCWDED � BHUB 12-31-2016 12-31-2017 trAmIfitm;n NI11 9F43EId 17 I 111 DrsEaeE-EA EV'PLOYE(_ $1,040,000 11 yna,dasU4KI antler j DESCRIPTION OF OPERATIONS LdOW ._....._�� ,TU8FASE-F �IGY'.IMIi ffi1 b00,000 OESCRIPT1C)N 00 OPERATION$!LOCATIONS f VEHICLES{Aftneh ACORO 1(I1,AddifipnA Remarkt Scheduto,If mann r-pam Is rcqulmd) 'COVERAGE IS RESTRICTED TO THE LEASED EMPLOYESS OF PROFESSIONAL BUILDING SERVICES' CERTIFICATE HOLDER.,..,.. __._______ CANCCLLATION ERIC 140ZOL 8 L15A K070L SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE 95 S BRADFORD S7 CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NORTH ANDOVER,MA 01845 NOTICE WILL, BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORISED REPRESENTATIVE 0)1988-2814 ACORD Ct)Rf't3ftA71Otd.All righis reserved. ACORD 25(2010105) The ACORD name and 1090 are reglslercd marks of ACORD 'u I: XX Mass Z, achusetts Department of Public Safet-V - License or reggistration valid for ir�disitlul case�snl� i & __� � ond Sax before the expiration dateor . I found return to, CS-0976b(I Office of Consumer Affairs and Business Regulation � y � ��� o 10 Park Plaza-Suite 51'() Boston,MA 02116 I PETER M CIARALDI 9 OLDE WOODE RD 4'2�\k-°. SALEM NH 03079 I -cit valid without signature ��'' , a� �t� Fk . .r a--- Commissioner 0718312017 I _ fJffise 0f Consumer affairs&Pusincss Re ar -uln �ME IMPROVEMENT CONTRACTOR gistration: 170870 T ype: -" Expiration: _1110120.18 �Lz PROFESSIONAl-BUILDING SERVICES iNC. PET^EP, CIAR-ALD! 9 CL DE WOCvE RD SALEM, NH 03v79 (;utlCrsecreta;�' i i i i