Loading...
HomeMy WebLinkAboutBuilding Permit # 2/23/2017 ------------- BUILDING PERMIT OORTH TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit Nod: Date Received '"Tl,Al Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION I Print PROPERTY OWNER Vit' Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:,,_„ Historic District ye no Machine Shop Village yes no ye Dn s 0 ye no y s 0 Village 7ee n TYPE OF-IMPROVEMENT PROPOSED USE ----R�esicl Non- Residential One fat F1 New Building One family 0 Industrial Li Two ddition lor more family c�A'Iteration No. of units: ❑ 11 Commercial El Repair, replacement E Assessory Bldg 11 Others: [-.1 Demolition 0 Other U 5, RE, [f,, / /i/ / ////iii,����//, 1����1�f��/�/� r DESCRIPTION OF WORK TO BE PERFORMED: A I I o Identification- Please Type or Print Clearly OWNER: Name: Phone:ql1b .31,Q I Icl Address: FL A- W pil-i Contractor Name: VL)V" t C, 0��' Phone: Email: m:f r rM.\,) OJ-�0-\ AddressOt k 3—6 — I Supervisor's Construction License: Exp. Date: �;l L Home Improvement License: Exp. Date:__I Q) ARCHITECT/ENGINEER 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: $ FEE: $ Check No.: Receipt No.: /I t�M NOTE: Persons contracting with unregistered eontractors do not have access to the guaranty fund OORTH own Of $ ndover . 0 ~'` h ver, Mass,, COCNlC K@WKR �� Eff- BOARD OF HEALTH Food/Kitchen E M P FX Septic System THIS CERTIFIES THAT .....M ,. *e� BUILDING INSPECTOR has permission to erect .......................... buildings on Foundation ® fG, ................ ....... ' V � - Rough to be occupied as ............Av4k.S' .,.. V 4- . .. � .1Ae. Vx K.....4N). Chimney provided that the person accepting this perm) hall in every respect conform to the 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 EXPIRESPERMIT IN 6 MONTHSELECTRICAL INSPECTOR CONSTRUCTIONUNLESS T Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR OccupanCE Permit Required to Occupy Ruildiu 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. ro �IUSE ✓righicering Rcotraor Rogl5tration Ivo ttJoB MA Contractor Rg9EDtratlgn No 124879 RISECT ContractorRuillatmoonNo820120 ENGINEgRII�G' 60 8110+vtitet R(ad,Genion,MA 02021 CONTRACT 339,502-6335 FAX 339.500345 Page 1 PROGRAM VA coff"UCT tR rtumm PROIn7i1SMI ln CMA-11CS rrraua etvarvraTiaacuora nranwonrsrsa wacrcuscp n¢iarr cunTarrett 1.", PRONS Wa 6UMP MMORDEn Nestor MatiaS (978)390-5144 01/2012017 444720 23902 aF. Mg J)M.T pa; na zTa[Er 16 Gerry Street 16 Ferry Street 6 AMa CIIY,DTATE.ZaA n}Ll tarp CirY,bTRTE,LP ]North Andover,MA 01845 Nonh Andover,MA 01845 JOB DESCRIPTION BARRIGR:A 0lafs017000r Tcst Will trot be conduetcd at pour hanrc,duc to the presensc ofRsbrstes, SO.UO KNOD L T(11IG 1WRiNG 13ARIULM:The following contract is not valid unless accampanlcd by Ute Prc-'vcathcriz:tion ilurricr lncentivc furor,$igecd by your liecn.-cd dectriclan.Woeg wilt not proceed ivlth this Work until We rcesite a ropy of 1110 Fnrnt, �p�.•,.��,.*�.:,,,....�.,.�.., x`+0.00 AIEt SIiALIl1G;Ph7YldC 1altUf and ntnieriai5 ul seal.tts as of yoar hone nginst wsstuful,excess air Icrsge. 'this work sell Pcrformcd in concerl vdUr file ugc of$pccial 1004 Rad diagnosile 10513 to assure:that your liornu will be Icft with a healdtfut level of air uWlango and indoor air gtlaliEy.0.3atcdRls 10 tm used to seal your Moral'can includ-Cglfll:s,16=3 and other products. Primary areas for scaling include air leal�C to allies,bastnwMs,aitached garages and calor unhealed areas(windowsarc nal generally addressed.) This 3vilf require(8)working hours.A reduction in cubic feet per minute(cam)vrair infiltration will oceur,bat the actual numbcrof cam is not gu=nlctd. At the eorapletion ofthc SvCDlherization%ort:,and at no additional cost to the hamcowner,a Iiaal blal4vr doer andJorL'a lba5lio safit ety frttalyais will be Mducted by the sub-conlmctor to cosurc the sat'etyof rho indoor a1r quality. 8660.OD Alli SRALING;Provide labor raid materials to inslell Q-lon vwrathcmWpping to(2)door($)to restrict air lenkngc. IJ w _ 5l lG.00 I)AA11ttN.-Provide labor and mnt0ritlls to its$tgR n 12"layer of R-3 i unrated ijberglgss hubs to(30)squwc feel for dmumiitn purps :5, t A'rl'lC FIAT;Provide labor and maicrials to instnlf a 9laverof R- 3 Cllikis I Cellulose addcd to(4•I8)square feet ofnpear ullicc space. SG72.00 SLOPES,Provide labor and materials to it,51011 n Sn "Jayer nfR-26 Class i Ceilulosc added to(168)square ftxt ofslapc arca, _ S)M4.Rlt KITIC ACCESS:SS:fT€avide Jaber a0J mu3Lviatc to intiuletc the back af(1}altls hstch with riElif board ar R-30 nr greater tisith lhpA�RT required firic rating.Wcafliowrip the perimelcr, '7— v S60.00 F :Provide labor and muteriuls to inslnil(4)S"diameter railfvenl(s)to increase ventilation[in;[tile urerli. 'E'hr plied in{circle calor)black,ltro%yn,gray or mill tinisb. S343.G0 :d'rovidp latter and rnatcrletsto �atJVCrtEiItlEUrl Ctlati5In75)"Id"ilay,' r flU1V 15 187.50 Peoural ID 006.0405629 RISC Engineering RI Contractornogtotratlon Ho(1186 MA Contractor Etoglatratlan No U0979 RISECT Contractor FtaglatTaiiort Np520i20 ENGINEERING 339-02,633.5 yhntrruot flood,(-`antue,MA i12tl21 CONTRACT 339-5(72-6335 FAX339-402-6395 Page 2 PROGRAM 'ova cbNTnhcM£'rTM0I1rT*trEWMFJ1 ME CMA-l[FS EUDINEERINGA?ZO'DraveTOtMAVOR CranAa c��rsca:aeo aE.MY CUSTOM PANE SATE CUEUTII YiGnn4nat:n Nestor Matlas (973)390.5194 0112OP017 444720 23902 SERNCE STREET a?Li4°..3 DuMET 16 Ferry Street Id Ferry Street 00VY(6 CITY,STA W 0=10 C3Y.4TATe,T.ta North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION BASEMENT SILLS:Provide labor and ma#crials u)install(160)linear feetof R-19 unfacetl fiberglass insulation to 111e perintctcr afthe bltmient ceiling at 111e house Al. $195.00 6 SE%4 rbn f3p01t:Provide labor and mawrials to inmilitc thi ouch of Ilse wawa nt door Icading to the bulkiteatl with rigid baard at ft-10 or Urcincr with Ifie required fire rating; than mcc:is the sections tt-316.5.4 nod 316A requiterucrtts ofbuilding cote. Seal all edges and seams with VSK tape. Sl lt},(ip RISC Engin"ring will apply all applicable,eligible incentivca to this conlraw, You will only he{tilled the Not amount. Curmully, for ciigilile mi=uro,Calumbin Gds offers 73%incentive,not to cxcccd$2,000 per calendar yca,and an incentive of 10011 for the Air Scaling measures up tip the first 5690 and un addilional5340 ifsavings are justified by the auditor. For ilia safety and heallh of your 110flu's indW air quality,%va wit]tic condactioB a blower dour diagnostic of Ilse available air flow in yvur home both before the work is began,and after the%vatherivallon work is complete.We will also conduct a fill assessment of the combustion safety of your heating system and►voter heater.This has a value of 890 and is at no cost to you. Total nllatvnble tvenlbctrrntinrT incentive is S3,1 to, TAic Permit will be scruled by the insulation contractor,at rto sdditionol cost.It is the homeownrr's regPoa MIlly to CIO-30 out this permit by contacting their municipality at the comptetion of this work. u u 9 I] i. 3 9'. Federal ID ft OU405929 RISE 11""gincering RI Contractor R00131rallon Na ijus MA Contractor Raglatraftrt No 120979 CrGontluciarRGgtairatlonPta620'120 RISE tI ' GOShntvmHt Itartd,f:nntorr,A9A 02621 CONTRACT 339-5(17-4335 FAX 339.592.4345 Page 3 PROGRAM CNIA-6IESS E4a UM aANOTNOCaaroSEitFCRSVOZiiAS DESCAMED CELOW CUITCUM Mohr pare eilErrrp ss'aRKaADEIS Nestor Matins (978)390-5194 01/20/2017 444720 23902 armcc aTAEET BRI,I!IO Mau 16 Ferry Street 16 Derry Street DUMCE C{7Y,OTATO,VP 9=.,O crMoYAmm North Andover,,MA 01845 North Andover,10A 01845 JOB DESCRIP'T'ION SKIM Total: $2,841 AS Program Incentive: $2,352.87 Customer 1 oca1: $480.07 M A13REE t{CTiCFiY TO FURNISH SErsv(CS$-COMPLEEra 173:.CCOROIIFiC„Y#1TFI AeOlyd SiPECIR"TIONS.FOIT THE:SUM OF "p"Four Hundred Eighty-Eight&871100 CoBam $4811.317 DPOiTfi!lALIYaPEp71p!1 NFE7AFPAOVAL tlynlpk 8l141t1EE1tI'ip.CSlpTa,VCrt AGt[k'1 C TO NEUT AUGD!rr DDE HIRl!LL.VITEDEaT of{a}'f.Lt.a�CltArIDEo!dl#1111LY DS MAY 1JI[YNa nA1,AI[CE AIZED+ Y'J,aEE aEVZ:SipE TOZ[�JACtiTA!1Tt!:Fat4'AT1O>I Oil flVADA!IIEiBs RI9Nlp tlp tt8C1p16lI,pCHEDVLCIa,.L!1O CO!1TM�TOftlIEOt97)thTIUH. /00 NOT StQN THIS CONTRACT IF THERE ARE ANY El.AWIS SPACES tj AUTirC11'CO4 r�tttl..!F : ti r �J � t tiOTk:Tlllp CC!1TnACT tfhY e_v:llf:i::IhY.�l DYD3 FF!:(yT CXECVR:D Vi1TN:71 DATE OFACMFTNiCE T, ACCET'TNICU OF CONInACT-Tit"ArTWE EDICT-a,CPECiFtCF.Tf4ttL F.•.T1 COMFTMIM ARC VoqAO OAYa. AS pFEC'FiLp AAYFHTVirLl.CE RfA6E nUTI.l,'.'EJAOO`7g8 AOli[aRli1:A TODD 7N@V10,i1i u 9 E 1 RISE80 Shmmut Road Unit 2 I Canton,MA 020291339.M4 35 ENGINEERING wwwAISEengineering,aom OWNER AUTHORIZATION FORM (� O m ctL (Owner's Name) owner of the property located at: � I (Property ) Y p FM C4 01YLIJ (Property Address) hereby authorize G a.,i 16N t rr � rola V`t (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 responsiblllty to dose out this permit by contacting their municipality at the completion of this work. .�j -fl zX- Owner's Sibnatum Date a.�trre The Commonwealth of Massachusetts Department of Industrial Accidents M s Office of Investigations s 1 Congress Street,Suite.100 gy Boston,MA 02114-2017 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AUDDILIAInforampfi—on - - nomExig L ibl Name (Business/organizwonAndividuat): Address: '•0 (30X -34k4 Ci /State/Zi : Au1 q` ^ ri1413 Phone #: • N ° � 10 3 Are Lou an employer Check the appropriate box: Type of project(required.): 1. Are am a employer with_Lk,_y-____. 4. ® 1 am a general contractor and 1 6. ®New construction employees (full and/or part-time).' have hired the sub-contractors 2.U 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. Building addition [No workers' comp.insurance comp.insurance required. 5. We are a corporation and its 10.� Electrical repairs or additions 3.® 1 am a homeowner doing all work officers have exercised their I L[)Plumbing repairs or additions myself, [No workers' comp. right of exemption per MOL 12.[3 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.® Other VM .insurance!fired] *Any apptieantthat checks box#1 must also fill out the section below showing their workers°compensation policy inforimdon, t Homeowners who submit this affidavit indicating they are doing all work andthen 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, lam an employer that is providing workers'compensation insurance for my employees. Bellow is the policy and fob site information. .Insurance Company Name; C-0—kii, Policy#or Self-ins.Lic. #: O 3 Expiration Date: ®V IL Job Site Address,• "[, r6 City/State/Zip: Y�► 'r"]t��W u� `1 �i E 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 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 Hs statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the irforrnation provided above is true and correct. 5' tare Date: l APbQne �- �' � i Official use only. Do not wrlfe to this area,to be conspleted by city or town official. City or Town: Permit/License# Issuing Authority(circle orae): 1..Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#r i CERTIFICATE OF LIABILITY INSURANCE F DATI (MMIDDIYYYY) 46.� 1 10/1812016 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 endoreement(a). PRODUCER CONTACT NA 15: Meg Munroe MARTIN J. CLAYTON INSURANCE AGENCY INC ISHO.No. x (413)536-0804 A o: EMAIL ADDRESS: mmunroe@mjclayton,Com _ 1649 NORTHAMPTON ST.,RTE 5 INSURER 3 AFFORDING COVERAGE NAIC# HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325 INSURED INSURER B. GAUTHIER INSULATION INC INSURER C: INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER: 94521 REVISION NUMBED. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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, IL H TYPE OF€NSUIIANCE ADDL UBR POLICY EFF POLICY EXP 1111350 WVDPOLICYNUMa1 R MNWpIYy MMJ➢ LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F�OCCURDAMAGE TO RENTED PREMISES Me43=rrancs $ _ MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F1&C- ❑LOC PRODUCTS-COMP/OP AGG $ OTHER: _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIM€T $ Ea ac id ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED NIA BODILY INJURY(Per acc dent) $ AUTOS AUTOS PROFERTY1AMAGE HIRED AUTOS AUTOSO NON-OWNED era idem $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LUIB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 A OFMCERIMEMBEREXCLUDED7 WA WA WA MAARP300327 10/30/2016 10/30/2017 -- (Mandatory In NH) E.L.DISEASE-EA FMNLDYEE $ 500,000 If yyes,dasefibe under DESCR€PTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS!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 6,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.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF T14E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WIT14 THE POLICY PROVISIONS. 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel M.Cro4u By,CPCU,Vice President—Residual Market--WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD � �a DATE{MIWDWYYYY) 4.--- CERTIFICATE OF LIABILITY INSURANCE 8/12/2016 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 Ileu of such endorsement(s). PRODUCER CONTACT : Nancy usher Martin i Clayton Insurance Agency, Inc. PHONE xt (413)536-0804 AX Nam-7874 1649 Northampton Street ADDRES P. 0. Sox 989 {NSURER{S)AFFORDING COVERAGE NAIL# Holyoke MA 01041-0989 INSURER A nationwide Mutual-Harleysville Y NATIO INSURED — —� INSURER a Allied world Natl Assurance CO _ Gauthier Insulation INSURER C: P.O. SOX 344 INSURER D. INSURER E IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBERCL1663001850 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ IL7R TYPE OF INSURANCE A L SUER POLICY NUMBS P�CY EFF POLICY E P LIMITS ^ % COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE $ 1,000,000 DAMAGE T-O 9NTE mm 50,fl00 A CLAIMS-MADE X OCCUR PREMISE% Ea=urre $ OL43487P 7/6/2016 7/6/2017 MED_EXP(Any one person) $ 5,000 _ mm PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: W GENERAL AGGREGATE W $ 2,000,000 A POL€CY D PRO- JECT F] LOC -PRODUCTS.COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT � Ea ao'dent ANY AUTO BODILY INJURY(Per person) $ALL -�— AUTOS OWNED SCHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS AO 03�dED PROac icd Y DAMAGE $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1 QOO,000 EXCESS LIAHF! CLAIMS•MADE AGGREGATE $ 11000,000 DED RETENTION$ EBU028251970 10/18/2016 10/18/2017 g WORKERS COMPENSATIONR OT - AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE Yj� NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? �� (Mandatory In NN) E.L.DISEASE-EA EMPLOYE $ €€yea,de&cribs under DES C IPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLER BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1200 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG � Q 1988-2814 ACORD CORPORATION. All rights reserved, ACORD 25(2014M1) The ACORD name and logo are registered marks of ACORD IDPbrdfitbd with pdfFactory trial Version www,_pdffggta_rrV,com u _ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 ]3oston, Massac etas 02116 Home ITnprovement or Registration Registration: 173410 Type: Individual Epiration: 10M2018 'Trd 257320 KURT GAUTHIER KURT GAUTHIER ' I 19 COUNTY ROAD IPSWICH, MA 01939 Update Address sud returu card.Mark reason for cinnge. 1 Address Q Renewal ❑ Employment ] Lost Card scAl 2OM-o it Pbegistration valid for individual 1150 only before the Office of CAwsumw AfWrs&Bassntss pAgw atlon HOME IIAPIiO F.i+IT GOIVTRAl:TOR expiration date. U found return to: i 70 -rypo* deice of Consumer Affairs and Business Regnlation Explrad = 8 Ind'►vldual 10 Farkriaza-Suite 5170 t Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER Board;11 El4shn R4 gzs�u -12 .., KURT RGAtrM*R P.Q EEus 3,47 1psv h WEA 8" nL-��s�YdCi`rv4ft�a�'E�iry 1 RPtbi"fR3Y�::�r:+R�i �NiM+x1f F7