HomeMy WebLinkAboutBuilding Permit # 2/23/2017 BUILDING PERMIT t%ORTN
TOWN OF NORTH ANDOVER
10
APPLICATION FOR PLAN EXAMINATION
Permit Date Received
Date Issued: c U
iiORTANT: Applicant must complete all items on this pagc;
LOCATION La. (NA,k
Print
PROPERTY OWNERh.--
- I.
Print 100 Year Structure yes no
MAP Z6(,� PARCEL: ZONING DISTRICT: Historic District yes
f s no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building [---r'one family
'Ation 0 Two or more family 11
Industrial
Alteration No. of units: F1 Commercial
I.] Repair, replacement I.']Assessory Bldg Others.,
Ll Demolition F-1 Other
lggr
mra ir
1111rrcia0
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly— --
OWNER: Name: S K<-r-� jr e,,L2� Phone: M 34 3
Address:
Contractor Name: Phone: ?J--Co -POY3
Email: ti r U �-nv-L- —
Addres
Supervisor's Construction License: Exp. Date:....
H � -k 34 IQ
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: $ LFEE: $
U-C 6 --
Check No.:
Receipt No
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
.......... .............. .............
tIORTH
It
Town of Andover .
®.
� � � �
1VL
Ver, Mass,
4'rIE f:
BOARD OF HEALTH
IT T ENO
Food/Kitchen
Septic System
THIS CERTIFIES THAT ....... khftlfow k . ....
kAA ,*ee BUILDING INSPECTOR
.1 Foundation
iw..
has permission to erect .......................... buildings on...
n
Rough
to be occupied as .......
Chimney a
provided that the person accepting this per 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 Tbwn 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 START Rough
Service
BUILDING INSPECTOR..
Final GASINSPECTOR
Occupancy Permit Rguired t® 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.
Federal ID 005.0405629
RISE Enriineel'iilly RI Contractor Registration No 0155
MA Contractor Registration No 120979
CT Contractor Registration NoE20120
fit)Sh:llculnt Hn:ut,Cnlftlln,IJA 112021 �n
ENG 1 if CONTRACT
TRA T
339,502433.5 1-':1\33`),:+02-6343
Pape 7
i'iZQt iKYI�i
TnI�ca:TRhcT Is Cr[tEIiED a:To ucn�.xrt:RISD
CN1A-I1rS 11KOINIIERhSGAW'"Il3CUMVEITMRwaRYAO
MCRIE[EDNOW
CUMMER PIIDnR DATE CLIE'iT.1 VIORHORIIER
Stephen Karma (978)314-7376 0 111 6i2017 4445695 23904
(IMICE:iTRFET 0141.110 STREET
292 Candlestick koad 11)2 Candlestick Koac1 ;
5ER410E CITY.3mm,ZIP DILL140 CITY,5TATfl,ZIP
North Andover, MA 0 18 45 North Andover-MA 01845: i
JOB DESCRIPTION
I'[1ASF()t~ft?-k'oopos;d flir[ilia Calendar 1 Cur.
I f AL.AM)HARRIER:We have i;Ieati€ied that(beet etre fcc'--s ail li_111"prevent ill ghat home"unless lite recc-sed li_Ihlr.are t:cflifled
as 1C idled llnsll than f:c rtlat l t?:tiL'dt c&e%till crtr.Ie;s; Jearulme iptic,-arntlnd lit L'lltitlife 11,fI;:ITEl'.11110cl h i W211"M Intin121€nti A:!
a d;ninmim maicrial,i)o iii nlalnUt;4111 be itI'1Al';d lit:;til",>III,to ,'13111 Catitse;ullich li!Ahl::clli t;nl :
insnhucd
�tJ.CIQ
Alit NFrNHNfj:Provide Iahor;uld miticriak Eu sell)arras nt'}our lutfna s aiutil t.:lelclill.Excess.lir lca).lw� 'illi,sstlr€;will lac
Imlimilcil ill concert willi the llse of special Moats and dill'"ostic Icstti to a$511i1'Hili)your home will Ile 1e11 tslh a 11011l1kill IC1101 Ell'
air cwhanp and indoor air quality.Nialef ak-to tic used it)seal your braille Cali hiclude calOhm roallis and IRlrer productti. I'nmary
;reeds I'm scltling include air Ica)a c In ntsics.irtsemenis,attached garag,;5 and littler unheated arcus(ttindows arc not 9clivrall�,
ttddrtiseil,) '111is LOU tequirc t Ill Klirkili hutlr&.A Ndactioll ill cllllic tact per ll iallic(efnt)of uir ifildlfallem will oeClr,hill Clic
actual litaillier of elan is not guaranteed.
At lite comptclion of the neatkierir:ttiun Icor;;,and at no allthtiraal co:E to Cite blintentsnai,a final blotter door mWor combustion
y:di E}nllal}Sas crit!ile Conducted bq the sol;-4anlrnctur til ensure tbe.safelE Mile indopr air qualify
$l,tl?O.OtI
t,\i fil\'At,4.5'I'rov'idc labor amu nl,iterinl"to itl%t',dl dg.id Minn)at R-II or�gw ler ttith the required lire rdiug W l 1 I;,i Square l';-M
oi'k nvi:,t;elf area
5454.30
2; II?ii41':11.1.1:1.000 Provide hrhnr and RlaNrials 1+i imi;di a T'1s}er Itf IZ-14 Chtsa I Cclfu€nse addci€to 1!12)square fact ul'o11en
Rncctttdl€loot.
S 134,411
A'l'fIC ACCT SS:I'tiovi+lc labs=T;tnd nl:uclials to install i I I easik}n1mcd,im;vIali[lg cover ton tate:rluk:;tee:+�folduig�Aaif. A
simill flat stlrlilct of plyx000"ill be crealt:d around Ow opelling,x0thin the attic. This will;thou the eoscr s isne�ral+vcatht r-
stripping to restrict uif leakage.
>237.0
\'l"l'IC"At'l'li5ti:k'luvide labor slut nl:Itetials Ili msnlult tits b;tel:ur the attic di+in tcith rigid lum(d at R-10 or grcatef will,lite
required lire rasiEl/. :Inti o al tb d:'+•T':Cil ec 1%itlt;w;altc["rippit?w Sul ,t;iel air teal:age.
S110.00
A'I"t'IC AC'CIiSti:Iirttvidc labor altd ntetcri;lls to Rlakc(2) lcmporaT}access lu lila attic arca. 'k'Itc urcninla evil)he Closed+cilli
malcriaEs sinitial at lianas existing f=inish ccunlitlg aml Ilainling is our inclfldcd.
$170,00
\'F.N'PLA'l'ION*,Pwvidt:labor mid malcrials to isisGdl 111 insltl:ttel€ecll3ast 1%11.;e whit rink nine tied 1larilm%con to v. last
txislill,IlathTl om I,^.tti�),l;roali model 1;1,3C.of stliliv,:lcnl.
po -
B
0
i
Federal Id ri 05-0405629
RISE E)tgitnerittg RI Contractor Rogistration No 81 BG
PAA Contractor Registration No 120979
CF Contractor Registration tto620i20
GI)tib;lumut ltuod,C_',rutan,.11;\1121021 �� � �
RISE
1 �t '
3301)-51)2-(133i FAN 339-5E)2-1134:`+
Page 2
PROGRAM
T013,MITRACT 17 EIITEAEO VjT0 UBtwilEfr R:S$
CiNIA-11ILS EN"UIEER1ft0 AND 701E CUSTOMER r0RMAK A5
RESCRIREDUPLOW
CUSTOMER FIOMC OATS CLIENTf+ ;1011H ORACR
Stepliell Kareta (1)78)314-7376 01/W2017 445695 23904
SERVICE STOW att,M STREET
292 Caudlestidc Road 292 Cmidlestid R ad
SERVICC CIT1 ATATE,BP VILLI M,CM.STATr:,i1P
North rltiduver, MA 01345 North.Andover, tMA 01,145
,JOB DESCRIPTION
VENTILATION:Prnsidr labor and 11t0lcriiil5 tea install fit iusuERlcd ext€.Inst lens% with run!'mjilultecl llapper tient io"Imust future
b:€tttrannt flog,!
_ S!I;I,7j
C[7 151(fti;1S';iL.1.5:1'nlsidc labor zinc{imiteri£tl,In i€r'tt£II rigid fmal(l£It It-!9„r LiC:itcr sell!€t)Iti recltriJt d lira f.flfn';1=�f I_' i
squa€re feet 1'rCUMIMIll s£€II arca
1.7+T3,itft
It[SI;linwinecrirtg willapply all applies€b1c,cliriblc itimitives to this eonlraCl. You%sill 41111y Ile billed 11ju Nd antrum, Currertlly,
for efioibls ntetLsrlres,Culnmhia Oas offers 73%incl olive.not 1tf exceed$2,0110 per calendar yum,and tan incenliw of 1401";for
the Alt Swim,-n€camilcs tttl to tin first fi6titl anti an til)ifril€tool 534iS if 4ir5.3lip lire jImiSICti 0,Ibc tandilor.
For the snl'cty and licaith uryuur llunte's induor air qualily,we%sill be conducting a blamer dour diaicun+tie of the avoi1£tblc air Iltns
in yollr home bull)bctbrc the work,is begun.and after the nathertzation wolk is collip1C1e.WC will also cotlduet a!lull assessmem
of the cului%ustiun safely ul'tour I;calini:system told%s£€ter hcatcl.'!alis has a%:-tic of SIM and is at mf ctfit to you. Total
allow•aWc%sealherizaiion utcenttee ir'S3.I W.
'lila Permit%sill lie metiml by the inmulatinn writrackir,at no additional clot.It is t4c homeowwr's mspkmsibihty tar clnsr nut{itis
pennit by cumaclin-,their rnuilieipUlity;u the cumpletiuil ui Ihis lwrh.
. t
i'
i9
i
Federal M V06-0405629
RISE Enghlem.ing R1 COMMCI If ROIJIS1100011 NO 8186
IIIA Contractor Ro4lstratlon No 120979
CT Contractor ReOlstratlon N0620120
R[SE
60 ShIllast ItnR+I, iI11h1I1.M. )2II2I
ENGINEERING' F1\,39.513-63.15 CONTRACT
Page 3
PR[)C;Et,1M
TH13 Call pAc r IG fillTEREO illlU fiG T'a rEEli RI.E
C7'lA-111;8 ENGIUEERIN5 Alio VE CUSTOV111 FOAWOU AS
nE$CR;BE. USM111
CUGTOA1Eq PHONE GATE CUEIFTo V1OFRt ORDER
Stephen Karelia (978)314-7376 01l16i2017 44_5695 33904
SERVICE 57REET OILY*STREET
292 Candlestick tkaad 292 Cit4idiestick lkwid
5EHVICE CITY,STATE,LP D WNG CITY,STAYS,ZIP
North Andover.MA 0 1845 North Andover,NIA 01845
JOB DESCRIPTION
S9f.1.[tIl
Total- $2,946.66
Program incentive: $2,487.49
Customer Total: $459.16
WE AGREE 11CREBY TO FUFtH3&H SERVICES,COl,4YLETE III ACCOROAIICE'I'MH AY€CIVE SPECIFI,^.AT10f1S.FOR THE SUM,OF
'"Four Hundred Fifty-Bine 161100 Dollars $459.16
UPQ71FINAL4f43PECTIO�1 A!;6,:PPIIGVAL UYRI7EZ%rC;EEFIIIlG.CUST3ME11 AMU'!;I0IIS=!I1A!.!tlR::TDUEI:1FULL.ItITfiFtE^u7 Of V,,vALt.8E VOR011 10!111ILVO:1AI:Y
Impt.11)DALAnce AFTEa 1•.1 DAYS.Jfit HEMOL FOR 11,:POft WO 710WItlAV000r;GUANAMTEES,RIGHTY OF REMICIl,'3CIIERUU40,AVD COUTRACTOR REO13THAIMN,
DO NOT SIGtI THIS COMRACT IF THERE ARE ANY 13LANK SP�CES._.:
Rof
.1UTiSDR1.I:R GIGf1ATUpE•{tIC..Cn}.n?Cl:n'J� ,; CU5 'lER r,
YOIL:TIi:I COHYRACTI.IAY UEVNTIHIRAYfll AYU31F:;DT ERECU7ED 4Yi7iIL'1 RATE OF ACCEPTNICE }
.1CCEPUNCE OF COIITRACT.THE ABOVE PRICES,SPECIFICATION Atte COMITI6t15 ARE
3Q DAYs SAILSPACIDIIVTOU3AnDARE HnREDYACCE7TED.YOU ANEAUTIMP1260TODO7nEWORK
A:SPECIFIED.PAYhSEHT MILL 8E M..RE AS DUTI.tli£U AUtlVE
The Commonwealth of Massachusetts
Department of,Industrial Accidents
w Oce of Investigations
I Congress Street,Suite 100
Boston,MA 021.1412017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/El Flews P niuL b er 1
a t I b tion
Name (BusinesslOrganizadorvIndividual): ••-
Address: f- 4 GUX '3'4 1
City/StatelZi :-.1- Sq; (.1r �''i JA 3 Phone #. l� t� '
Are You as employer Check the appropriate box: Type of project(required):
4. �] I am a general contractor and I
1. I am a employer with�_ fi. New construction
employees (full and/or part-time).* have hired the suis-contractors
listed on the attached sheet.
7. Remodeling
2.® I am a sole proprietor or partner- These sub-contractors have 8. ®Demolition
ship and have no employees employees and have workers'
working for me in any capacity. 9. [ Building addition
[No workers' comp.insurance camp.insurance t
S. � We are a corporation and its l0.[�Electrical repairs or additions
required.] officers have exercised their 11.®Plumbing repairs or additions
3.® I am a homeowner doing all work per of right exemption MGL
myself. [No workers' comp. g p p 12,[]Roof repairs
insurance required.] t c. ployee(4),and or have no
i
employees. [No workers' 13' other
camp,imurance required.]
*Any applicant that checks box#t must also J17H out the section below showing their workers'compensation policy fnformatfon.
doing all work and then hire outside contractors must submit anew affidavit Indicating such.
t Homeowners who submit this affidavit Indicating they are
g the name of the sub•eontractarsnnd state whether or not those entities have
$Contractors#hat cheek this box must attached an additional sheet showh►
employees, If the sub-contractors have employees,they must provide their workers'comp.policy number.
I arra an employer that is providing workers'conWensadon Insurance for my employees Below is tits policy and tab site
informadon.
Insurance Company Name: 1 V
Policy#or Self-ins.Lia. #:_U±LA12Oo Expiration Dater�0
rflla site Address:
2^ C a !! C S11 C L� —City/StateI�
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/ay one year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine
of tap 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.
X do hereby cen fy under the pains and penalties of perjury that the iq formation provided above is true and correct.
Dal
Si t re'
e:
Phor
Official use only. Do not write In this area,to be completed by city or town official.
City or mown: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
b.Other
Contact Person:
Phone#:
DATE(MWDD)YM)
AC"REP CERTIFICATE OF LIABILITY INSURANCE
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
REPRE=SENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. It 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 Meg Munroe
ll
MARTIN J. CLAYTON INSURANCE AGENCY INC tAIC.No PHONE : (413)536-0804 tACC,No):
E-MAIL
mmunroe mjclayton,com
1649 NORTHAMPTON ST.,RTE 5 INsuRER s At FaRDiNG covERAGE NAIC 0
HOLYOKE MA 01041 INSURER A: ACADIA iNS CO 31325
INSURED INSURER B:
GAUTHIER INSULATION INC INSURER 0:
INSURER D:
PO BOX 344 INSURER I-:
IPSWICH
:IPSWICH MA 01838 INSURER F;
COVERAGES CERTIFICATE NUMBER: 94521 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 ADDL9UBR POLICYNUMBER MWDMCY FF POLICY EXP LIMITS
LTR
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE ❑OCCUR P&AMES Eaoccurenca $
MED EXP(Any one rson $
NIA PERSONAL&ADV INJURY $
M'OTHER:
L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
PQLICY[7]PRO• M LOC PRODUCTS-COMPlOP AGG $
JECT $
AUTOMOBILE LIABILITY OMBiNED SINGLE LIMIT $
Ea acddent _
ANY AUTO BODILY INJURY(Per person) $
ALL OWNEpSCHEDULED NIA BODILY INJURY(Per accident) $
H RT D OS AUTOS
AUTOS NON OWNED PROPERTY DAMAGE $
AUTOS Per accident
UMBRELLALIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS•MADE NIA AGGREGATE $
DEC) RETENTION $
WORKERS COMPENSATIONQTH-
AND EMPLOYERS'LIABILITY Y/N /� STATUTE ER _
ANYPROPRIETOR/PARTNERIEXECUTIVE I E.L.EACH ACCIDENT $ 500,000
A OFFICER/MEMB£REXCLUDED4 I NIA WA NIA MAARP300327 10/30/2016 10/30/2017
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,doscdbe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
NIA
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached It more space Is required)
Workers'Compensation benefits wdi be paid to Massachusetts employees o€►ty.Pursuant to Endorsement WC 20 03 06 t3,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 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,
1200 OSGOOD STREET
AUTHORIZED REPRESENTATIVE
NORTH ANDOVER MA 01845 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD
ETE lEI
(MMDA'YYY)
AC RVQ CERTIFICATE OF LIABILITY INSURANCE
1a/xal6
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: It the certificate holster Is an ADDITIONAL INSURED, the policy(les) must he endorsed, If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement an this certificate does not confer rights to the
certificate holster In ffeu of such endorsement(s).
PRODUCER co"E;OT Nancy usher
NAM
Martin J Clayton insurance Agency, Inc. PRONE xt (413)536-0604 _ _ f .No):Ea13)534-7874
1649 Northampton Street
E-MAIL
P. O. Box 989 INSURER S AFFORDING COVERAGE NAIC#
Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville � NATIO
INSURED _ INSURERB Allied World Natl Assurance Co
Gauthier Insulation INSURER C
P.O. BOX 344 INSURER O
INSURER E: _m
IPSWICH MA 01938 INSURER F;
COVERAGES CERTIFICATE NUMBER:CL1663001850 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 SHOWNMAY HAVE BEEN REDUCED BY PAID CLAIMS. _
INSR TYPE OF INSURANCE DL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
_71DT RENTED 50 000
A CLAIMS-MADE OCCUR PAMAGE REMISES(Eeoc�usrertu�_ $ r
OL43487F 7/6/2016 7/6/20.17 MED EXP(Any ane person) $ 5,000
-� PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY 1 j JECT El LOC PRODUCTS-COMP/OP AGG $ 2 r 000,000
OTHER: $
AUMMOBILE LIABILITY Ea acs dent I LE T $
ANY AUTO BODILY INJURY(Per person) $_W
ALL OWNED SCHEDULED BODILY INJURY{Per accident) $
AUTOS NQS Q ED PROPERTY
PERT DAMAGE $
HIRED AUTOS AUTOS — —
X UMBRELLA LIAB OCCUR EACH OCCURRENCE
3
I B EXCESS LIAR CS-MADE AGGREGATE
LA#M $ 1,000,000
DER RETENTIga.1 EBU028251970 10/18/2016 10/18/2017 $
WORKERS COMPENSATION STAT TE ER
AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y� NIA F.L.EACH ACCIDENT $
OFFICERIMEM BER EXCLUDED?
(Mandatory In NH) E,L.DISEASE-EA EMPLOYE $ _
it Il' es,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Addltlanal Remarks schedule,may be attached If more space Is required)
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
1200 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS.
North Andover, MA 01845
AUTHORIZED REPRESENTATIVE
Daniel Sullivan/MEG
0198&2814 ACORID CORPORA710N. All rights reserved.
ACORD 25(2014f01} The ACORD name and logo are registered marks of ACORD
LL
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Sure 5170
Boston, Massac 02116
Home Ifir provement or Registration
Registrm#ion: 173410
Type: IndWidual
ExomUon: 10111201$ Trp 2.9132o
KURT GAUTHIER
KURT GAUTHIER A a
I 19 COUNTY ROAD
IPSWICH, MA 01938 ,
Update Address and return card.Mat reason for ctange.
gCQ 1 i5 20Ma?6I11 ❑ Addre.s Rewwal C] Fanployment LoM Cwd
Mm of Cawamer Affairs&Business R%gda ion Registration valid for individual use only before the
HOME MDexpiratin data if found return to-.
18 Type- Office of Consumer Affairs and Business Regulation
Exp1raU `- 8 1nd'wMua1 10 Fant Plaza»sante 5170
A (: Boston,MA 02116
lC;JRT GJ�UTFIfER 41 =1 -- .
{NFiT GAtlTHIER
F
P.a an 344101.1
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RISE
60 Shawmut Road, unit 21 Canton, MA 020211339-502-6335
ENGINEERING" www.RISEengineering.com
OWNER AUTHORIZATION
I, Gip h e "
(Owners Name)
owner of the property located at:
(Property Address)
Property Address
( )
6 __ . _. .._ .
hereby authorize K SUL I V�'L-
(Subcontractor)
an authorized subcontractor for ELISE 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.
Owners ignature
w' q
Date
6.2016