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HomeMy WebLinkAboutBuilding Permit # 2/1/2017 NORTH ..•• 00 "ev BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received z' �sSACFiiSSF'tI( Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATI�I� 411 I RP� OEI P�Crtf MAS ILIO I��O� �OC�iI�DKIT�CT �IltorYc�tr�t �� rte ht & 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 BldgOthers: Demolition Other epYc �C4�ell €I`loclplaYetat� Wsr ltrict Identification Please Type or Print Clearly) L' a Phone: ' OWNER: Name: ,c- r i Address: {yy per dress l i Sr per or 5 Q)XISO., Ht� e It �rert�e �ce��e p Wit+" ARCHITECT/ENGINEER Phone: Address: Reg. No. PEE SCHEDULE:SULDING PERMIT:$72.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F. �L V — Total Project Cost: $ '` FEE: $ Check No.: i I 1 Receipt No.: int g unregistered contractors do not have access to th nd NOTE Persons cantractin with unre ?a � s ( a Si at O N enV.Wi er'� � j� S� natt re cif�c�rYtra g star - >t TA®RT� �4 Town of s bAndover ANK, No. ORT , C%� p h ver, Mass, 2..A17 �y cacwic�rw�c� v1' A°.9.4rED S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .......... Q�i. ,,, C BUILDING INSPECTOR ............ ........... ........ .......... has permission to erect .......................... buildings on ..��.�... ........ ..... ..... , ..... .......... ............. Foundation .�.... .I Rough t0 be occupied as ........ ...... .... ..... ..+.�4e ............_.........................,...... Chimney provided that the person accepting this permit shall in eve re' 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 I E IN T ELECTRICAL INSPECTOR LES � T ST T Rough . Service ... ... ... ... ........................................... ••••• Final BUILDING INSPECTOR GAS INSPECTOR ccuMncy_Permit Required to Occupy BuildiuRough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Miall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Sweepnman, Inc. Proposal 108 Main. Street Bldg H North Reading, MA 0 18 64 Rate Proposal# Phone# 978-664-6642 12/9/2016 1868 Fax# 978-664-1298 Project Address ' Name 1 Address Richard Gacioch Richard Gacioch 58 Russell St 58 Russell St North Andover,MA 01845-2716 North Andover,MA 01845-2716 E-mail Web Site Customer Phone# dee.kelly@sweepnman.com %vww.sweepnman.com 978-265-4899 Description Qty Rate Total Removal&Disposal of the pipe in the chimney on the first floor 1 300.00 300.00 and bricking up the hole. Installation of Oil Flue Liner including all components necessary at 1 4,490.00 4,490.00 termination and breaching to connect 4 existing vent connectors. Thermal wall barrier: Installation of a thermal wall barrier between 1 600.00 600.00 the combustible floor joists and the vent connector. DISCOUNT TO BE APPLIED 1 -200.00 -200.00 i pMu 'J Total $5,190.00 Acceptance Signature J This Proposal is Valid for 45 Days u The Commonwealth of Massachusetts Department of Industrial Accidents 1' V Office of Investigations i1 ' 500 Washington Street t f; Boston, MA02111 11� ' www mass.gov/dia Workers' compensation Insurance Affidavit: Builders/Contractors/El Pease Print Le bl tricia Applicant Information Nalne (Business/organization/Individual): Address: 7/ City/State/Zip: '/511 Phone #: Are you an employer? check the appro late box: Type of project(required): 1.[9 1 am a employer with 4• ❑ 1 am a general contractor and I 6 ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. F1 Remodeling 2,❑ I am a sole proprietor or partner- These sub-contractors have g. E] Demolition ship and have no employees employees and have workers' 9 Bding addition working for me in any capacity. ❑ uil irisurance. [No workers' comp.insurance comp. l 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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 13.M Other �I employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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-contractors have employees,they must provide their workers'comp.policy number. Iain an employer that is providing workers'compensation insurance for any employees. Below&the policy and,job site information. Insurance Company Name: co Policy#or Self-ins. Lic. Expiration Date: / - a __City/State/Zip: (1 Job Site Address: /Zi �� f� �. ���.� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). r•I 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$1,500-00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern rder the gains andpenalties ofper jury that the information provided above is true and correct5� . Signature: r�S_ Date: Phone#: V Offteial use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk g.Electrical Inspector 5.Plumbing Inspector b.Other 1 Contact Person: Phone#: rtD DATE(MMIDDIYYYY) ACC)RV CERTIFICATE OF LIABILITY INSURANCE 3./31/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT Scott Leavitt, CIC, LIA PRODUCER NAME; _ PHONE (978)667-9031 FAX (976)667-1018 MTMBrainerd Inc A1C - Alc No;..._ _ EMAIL scottl@brainerdinsure.com lA Andover Road ADDRESS: INSURER($)AFFORDING COVERAGE NAIL# Billerica MA. 01821 INSUReRA:James,River Insurance Company INSURED INSURERB:Safety Indemnity Ins Company_,_, Sweepnman Inc. INSURER C: 108 Main Street Bldg H INSURER D: _.. INSURER E North Reading MA 01864 INSURER F: COVERAGES CERTIFICATE NUMBER"aster Cert 2015 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. €NSR '_ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE p POLICY NUMBER MMJDDIYYYY MMlDD1YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 A CLAIMS-MADE n�OCCUR PREMISES(Ea occurrence)_., $ X Blanket Additional 000691691 11/18/2016 11/18/2017 MED EXP(Any one person) $ 1,000 Insured 13y Contract PERSONAL&ADV INJURY $ I,000,000 GEN'L AGGREGATE LIM€T APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ' X POLICY L] PRO- LOC 2,000,oao JECT PRODUCTS-COMPlOP AGG $ OTHER: Employee Benefits J $ COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILE:LIABILITY E_a accident) _ .... ' ANY ROTO BODILY INJURY(Per person) $ B ALL OWNED �. SCHEDULED __ ..W -..... 6236353 11/18/2016 11/18/2017 BODILY INJURY(Per accident) AUTOS X AUTOS X HIRED AUTOS X NON-OWNED (peragidcnt�PROPERTY DAI+AAGE . AUTOS $ UMBRELLA LIAR OCCUR EACH OGGURRENCE $ EXCESS LEAS CLAIMS-MAGE AGGREGATE _ $ l IEDRETENTION S S WORKERS COMPENSATIONSTATUTE L OTRH- ';r. AND EMPLOYERS'LIABILITY YIN i, ANY PROPRIETORIPARTNERIEXECUTIVE "' E.L.EACH ACCIDENT $ _ OFFICERIMEMBER EXCLUDED? NIA ""� "" (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ _ If yyes,describe under i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 901,Additional Remarks Schedule,may be attached If more space Is required) This Certificate of Insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Richard Gacioah THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 5$ Russell Street ACCORDANCE WITH THE POLICY PROVISIONS, North Andover, NIA 01845 AUTHORIZED REPRESENTATIVE S Leavitt, CIC, LIA/S ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 11/15025 t�m4mi DATE(MMIOD/YYYY) AC40R o CERTIFICATE OF LIABILITY INSURANCE 01/31/2017 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT -NAME; Scott Leavitt MTM INSURANCE ASSOCIATES LLC iucNE .r:,t): (978)667-9031 C,No): ADDRADDR ottl scbrainerdinsure.com ESS: .._,_@ ._,_,_ _ 1 A AN DOVER RD. INSURERIS)AFFORDING COVERAGE NAIC# BILLERICA MA 01821 INSURERA,I, LM INS CORP 33600 INSURED INSURER B: SWEEPNMAN INC INSURER C, INSURER D: 108 MAIN STREET BLDG H INSURER E: NORTH READING MA 01864 iNSURERF: COVERAGES CERTIFICATE NUMBER: 923319 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDL SUBR -� POLICY EFF POLICY EXP !NSR TYPE OF INSURANCE LTR D WVD POLICY NUMBER MMfDOfYYY MMfDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _$ E _15ATO RENTED CLAIMS-MADE L_._.J OCCUR _PREMISES(Ea occurrence $ MED EXP(Any one person) $ ._ NIA PERSONAL&ADV INJURY $ ............ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY D PRO 1-1 LOG PRODUCTS-CAMPlOPAGG $ OTHER: $ AUTOMOBILE LIABILITY BINED SINGLE LIMIT Ea accident) $ Ea acci ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED NIA BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS AUOTOSWNED (Pe�ac iCden�AluIAGE $ ._...._.._. _........_._ $ UMBRELLALIABOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE NIA AGGREGATE $ RED RETENTION $ i PER OTH. WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN— E.L.EACH ACCIDENT $ 100,000 I A OFFICERIMEMBEREXCLUDED7 NIA NIA NIA WC531S388139016 12/18/2016 12/18/2017 V (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 I NIA 0 DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES(ACORD 109,Additional Remarks Schedut%may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govilwd/workers-compLnsation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Richard Gacioch ACCORDANCE WITH THE POLICY PROVISIONS. 58 RUSSBII Street AUTHORIZED REPRESENTATIVE �L S North Andover MA 01845 3: Daniel M.Crq ey,CPCU,Vice President---Residual Market—WCRiBMA PI ©1988-2014 ACORD CORPORATION. All rights reserved. it ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Ac R" CERTIFICATE OF LIABILITY INSURANCE DATE[MMIDDNYYY) 1/31/2017 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 Scott Leavitt CIC LIA NAME: r MTMBrainerd IncCNEx (978)667-9031 arc NPI {97a)667-lois lA Andover Road E-MAIL scottl@brainerdinsure.com _ ADDRESS: INSURERS AFFORDING COVERAGE MAIC If Billerica MA 01821 INSURERA:James River Insurance Com an INSURED INSURER B:Safet_y, Indemnity, Ins_CompApy Sweepnman Inc. INSURER C: 108 Main Street Bldg H INSURER D: INSURER E: North Reading MA 01864 INSURER F: COVERAGES CERTIFICATE NUMBER:Master cert 2015 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. ILTR TYPE OF INSURANCE IN$P SUBDR POLICY NUMBER POLICY Err MMI[30NYYY LIMITS X COMMERCIAL GENERAL.LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 A _ CLAIMS-MADE �OCCUR PREMISES Ea occurrence)_.__. ._....._._.�__..__..—...__..__..... X Blanket Additional 000691691 11/18/2016 11/18/2017 MED EXP(Any one person) $ 1,000 Insured By Contract PERSONAL&ADV iNJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JECT PRO LOC PRODUCTS-COMPIOP AGG S 2,000,000 PRO- OTHER: Employee Senefrls $ AUTOMOBILE LIABILITY COBI EaMacciNED SINGLE LIMITdent $ 1, �000 000 ANY AUTO BODILY INJURY(Per person) $ BALL OVYNER FX_ SCHEDULED AUTOS AUTOS 6236353 11/18/2016 11/18/2017 BODILY INJURY(Peraccden{) $ NON-OWNED PROPERTY DAMAGE $ li HIRED AUTOS X AUTOS Peraccidant $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEO I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ERANY PROPRIETOR/PARTNER1FXECUTIVF E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ It yes,descd6a under —.. ., ._. ........_...W....._..__.,.. ....�._--- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES (ACORD 105,Additional Remarks Schedule,may 6e attached If more space Is required) This Certificate of Insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street Ste 2035 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE S Leavitt, CSC, SETA/S x01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 rPn1 ansa AC`RU® CERTIFICATE OF LIABILITY INSURANCE °ATE(MMI°°""'"' 01/31/2017 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 15 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: Scott Leavitt MTM INSURANCE ASSOCIATES LLC PHONE _ (978)667-9031 FAX Ne: E-MAIL scottl brainerdinsure.com ADDRESS: Gay 1A ANDOVER RD. INSURERS AFFORDING COVERAGE NAIC# BILLERICA MA 01821 INSURER A: LM INS CORP 33600 INSURED INSURER B SWEEPNMAN INC INSURERC: INSURER D: 108 MAIN STREET BLDG H INSURER E: NORTH READING MA 01864 INSURERF: COVERAGES CERTIFICATE NUMBER: 123321 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 ADDL SUER POLICY EFF' POLICY I XP LIMITS LTR D D POLICYNUMBER MMIDOrM MMIDD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 1-1OCCURPREMISES Eaoccurence $ MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 11JECT PRO- [A LOG PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED AUTOS AUTOS NIA BpDILY INJURY(Per accident) $ NON-OWNED PROPERTYDAhAAGE $ HIRED AUTOS AUTOS Per accident W UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE NIA AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X PER _ ER Y r N ANYPROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100,{)00 A OFFICERIMEMBEREXCLUDED? NrA NIA NIA WC531S388139016 12/18/2016 12/18/2017 - (Mandatary in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 500,000 NIA DESCRIPTION OF OPERATIONS I LOCATIONS 7 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govllwd/workers-componsation/investigations/. CERTIFICATE HOLDER CANCELLATION 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. 1600 Osgood Street Ste 2035 AUTHORIZED /REPRESENTATIVE North Andover MA 01845 Daniel M.Crory ,ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Massachusetts Department of Public Safety = ©apartment of Public Safety jf` Board of Building Regulations and Standards License: BU-026558 License: CSSL-100886 t. DAVID A BANCROFT l DAVID A BANCROFT SWEEPMAN INC SWEEPMAN INC ' 108 MAIN ST BUILDING H —A 108 MAIN ST BUILDING H NORTH READING MA 01864 NORTH READING MA 01864 Expiration: pirat iori: Commissioner 03109/2018 -ornmissioner 03/0912018 Ernptoyer:Sweepnrnan Inc. Construction Supervisor Specialty Restricted to_ �`� CSSL-sF-solid Fuel Burning Device Oil.Burner Technician Certificate Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: yW.1yIASS.GOVIDPS DPS Licensing information visit:UWVW.MASS.GOVIDPS ---- _ 4 {,, r��r•�nttrtnr»rrtrcn�/�r��',�lrr.;;rlc�tr.;e/(� - �� � _. 1. Office of Consumer Affairs&Business Regulation License or registration valid for individual use only 1`1 --'— THOME.IMPROVEMENT CONTRACTOR" before the expiration date. If found return to: � 1 Registration: 160389 Type: Office of Consumer Affairs and Business Regulation Expiration: 7/16/2018Private Corporation 10 Park Plaza-Suite 5170 =' Boston,141A 02116 SWEEPNMAN, INC. DAVID BANCROFT 108 MAIN STREET BUILDING H NO.READING,MA 01864 Undersecretary Not valid without signature i I Office of Consumer Affairs&Business Regulation License or registration valid for individual use only i� �l`NOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 160389 Type: Office of Consumer Affairs and Business Regulation 0 f Expiration. 7/16/2018 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 SWEEPNMAN, INC. DAVID BANCROPT 108 MAIN STREET BUILDING HAlilP NO.READING,MA 01864 Undersecretary Not valid without signature e