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HomeMy WebLinkAboutBuilding Permit #503-14 - 1 FERNVIEW AVENUE 12/16/2013 (3) TOWN OF NORTH ANDOVER 4APPLICATION FOR PLAN EXAMINATION Permit NO: �b 7 �� Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION' .c- _,hr.Ci � Print,- _ PROPERTY OWNERo _ C �✓ivg - Print 100+Year _1d Structure yes no M MAP NO ----.--- ,,PARCEL: _ ZONING DISTRICT Historic District yes no Machine,Shop Village yes no TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial 0 Alteration No. of units: Commercial ❑ Repair, replacement Assessory Bldg Others: ` ❑ Demolition t0ther //< - 0 Septic ❑Well D Floodplain fl Wetlands: ❑ Watershed District Water/Sewer .. z - DESCRIPTION OF WORK TO BEP RFORMED: -r-':g- Identification 'Identifikation Please T pe or Print Clearly) OWNER: Name: �' Phone: Address: �o CONTRACTOR Name:. � Phone:,__ �- =T . Address: Supervisor s�Construction License: C''-r` ..�__. ` z j Exp. Date Home Improvement Licenseq _a -___ Exp Date: 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: $ b Check No.: � � Receipt No.: fir NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r SignatureofSAgent/Qvvner3 g-1ature,of contracto Plans Submitted EJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location I -bP4l-�y i e" t/N T r No. i505 Date It t� L ILZ • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee �— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# " �•' Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 81950.00 m $ - $ 107.40 Plumbing Fee $ 13.43 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 13.43 Total fees collected $ 234.25 1 Fernview Apt. 1 503-14 on 12/16/13 Kitchen Remodel ,}� ��e �paJ�vr�io�JzureczCt�:b�C�/�zaeaclivaeCtiJ. �\ Office of Consumer Affairs'&.Business Regulation OME IMPROVEMENT CONTRACTOR egistration: !,i88.93,, Type: xpiration: = 5/3/20_15 DBA C.S.P.CONTRACTING_..: _Y DANIEL WIRTH 11 WAGON TRAIL RD,' CHELMSFORD, MA 01824 r g �` — Undersecretary JIM Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS-004021 DANIEL R W IRTT� 11 WAGONTRAILRD' Chelmsford MA 01824 ' 92, )1,11A IN Expiration Commissioner 06/10/2014 The Commonwealth of Massachusetts - Department of IndustrialAccid&ts Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print LeLyibV Name(Business/Organization/Individua Address: City/State/Zip: Zae IVIZ Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. Q New construction employees(full and/or part-time).* have hired the sub-contractors 2.L I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. workers'comp.insurance. 9. Q Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.E]Roof repairs insurance �ired.re q ui employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i'Homeowners who submit this affidavit indicating they lire 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self ins.Lie.#: Expiration Date: Job Site Address: Zf41-f City/State/Zip:4�-�,��/, Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of 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. X do hereby certrider file sins and penalties of perjury that the information provided ahove is true anti correct. Si are: Date:Phone#: Official use only. Do not write in this area,to he 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 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required:' Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of M-assachusetts Department o ladustdal Accidents pff`ice dIavestigatioas 6.00 Washington.Street Boston}MA.02111 Teel,#617-727-4900 at 406 ox 1-877-MASSAFE Revised 5-26-05 Fay#617-727-7749 www.ntass,gov/d%a r- 1 NORTH w: �. . i. .c . : ve: . 0 In No. 60s— * t - h , ver, Mass, coC"IC"IW#cK �'► S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System f� THIS CERTIFIES THAT .��.I. ......... BUILDING INSPECTOR .. V��foa �� I. Foundation has permission to erect .......................... buildings on .`.... .. .... . ........ .......... t Rough tobe occupied as .......... .. .♦.. ... ..... :... .. ................................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this.office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU N T S Rough Service ......... ..................................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Buildinz 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. SEE REVERSE SIDE Smoke Det. Home 1m This age satisfies all basomen etluirements of the slate's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek Iegal advice if necessary. Any person planning home improvements should first obtain a copy of 11A Massachusetts Consumer Guide to Home Improvement"b efore agreeing to any work on y Office of ConsumexAffairs and Business$egulation's Consumer Infolour residence.You may obtain a free copy by calling the Homoowal.elt'�on�.�.�.® znationHotline at 6.7 7-973-877 or 1-888-283-3757 or on our website. >n. - 'Contractor JCnifDrmatxon Name U LAR VJ , 10��j Company Name f StreetAddress(do notuse aPost Ofmce Box address) �`� `�+ "' -``''�� Contractor/Salesperso OwnerName A ✓ A0 - 1 City/Town State Zip Code � . Business Address(mustincludedress) .astree NdkT 1-1- k0 d V c P A- © 12 Lj r Daytime Phone Bvemng Phone ��S C� Ir/� GI-T-$ (_4 9- _4'31 r � ' State Zip Code v Mailing Address(It different from above) , Business Phone Federal I;r>iployer ID or S.S.Number HomeampmvementcontmutorReg:Number Expiration date • xawregniras tbatmostiiofie improvement contractors Itave n valid reglsfnition ntinver The Contractor agrees to do the following worm for the Homeowner: (Describe in detailthe workto completed,speci:Vngthe type,brand,and grade of materials to be used,use additional sheets ifnecessa Required Permits-the following building permi=ts are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as•the homeowner'S agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permirts:WM be excluded from the Guaranty Fund,provisions of Date when contractor will begin contracted wont. MGL chapter 142A.) Date when contracted work will be substantially completed. Total ContractP-ice and Payment Schedule The Contractor agrees to perform•the work,furnish the material and labor spco fed above for the total suns.of: Payments will be made according to the following schedule: upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) by / / or upon completion of $ by — / / or upon completion of upon completion of the contract, (Law forbids demanding full payment until contract is completed to both patty's satisfaction) . The following material/equipment must bespecial $ ordered before the contracted work begins in order to be paid for to meetthe completion schedule,('N) $ to be paid for NOTES:(1)Including all finance charges Law requires that any deposit or down payment required by the contractor before workbegins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost ofany special equipment or custom made materi which must be special orderedin advance to meet the completion schedule. al x ress Warrant -Xs an et r ess warrant bein rovicted b the contractor? ❑No Subcontractors-The contractor agrees to bs solelyxesponsiblefor completion of•work descri6edregardless ofthe actions ofytaontraet party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all a materials and labor under this a Bement p yments to all subcontractors for Contract Acceptance-Upon signin this document , & beco conteactmes abindin contract un sg der hall not im law. UxI].e plythat w.y lien or other security tote ss otherwise noted within this docume carefull before signing t3' rest has been placed on the residence, Review the folio 'the y going this contract• wi=ng cautions and notices ° Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear., ° sub ce sure the contractor has a valid PTome In rovement Contractor Re 'stration. The law requires most home improvement contractors and subcontractors to ti registered with the Director oL-aa, Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Par1cl'laza,Room 5170,)�oston,MA-0217.6 or by calling.617-973-8787 or 888 283-3757. ° Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can eonf m coverage,or aslc to see a copy of a"proof of insurance"documentKnow . ° Guide Yto the Home Iinprovemenl Controur ,rights and responsibilities. Read the Important Inform=ation o actor Law; n the reverse side of this foam and get a copy of the Consumer Guide You may cancel this agreement if it has been signed at a place other than,the contractor's normal place of business,provided you no' contractor in writing at his/her main,office or branch Office by ordinary mail.posted,bytelegram sent or by delivery,notlate thanmifTthet of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for el explanation er this right, D®S+OT'SZGN TMS CONTRACT IF TBERE Two identical copies oftlte contractmust be completed and signed. One copy should go to the homeoj me��ciber SPACEcontractor, •� u � Iomeowner's Signature ontr,ctor's Signature /2_ 13 t3 aOt� 'Date Date Condracior Arb:itritiosu The Home Impiovement Contractor Law provides homeowners WI&the right to initiate an.arbitration action(as an 'alternative to court action)if they have a dispute with a cont.Tactor. The same right-is mot••automatically af-oxdedto a contractor,however. The contractor would have to resolve any dispute he has a ome howner-in court unless both parties agree to the optionafl clause provided below. This clause would give the contractor the same xi arbitration as is afforded to the homeowner by the Hht to Home improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute eoneeMi g this contract;the contractor may subunit the dispute to a private arbitration, tan which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be xequimed to submit to •such arbitration as.provided In Massachusetts General Laws, chapter 142A.. Homeowner`s Signattixre • Contractor's Signat=a NOTICE:The signatures ofthe parties above apply only-to the agreement of the pau-ties to alternative dispute resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even section is not separately signed by the parties. where this Elomeowner's Rights . A homeowner's rights under the Home Improvement Contractor L4.w(MGL chapter 142A)and other consumer Protection laws (i.e.MGL chapter 93A)may not be waived in any way, even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is n.ot properly registered as prescribed by law. Homeowners who secure their own buildi7ag permits are automatically excluded'f:om an Guaranty Fund provisions of the Home Improvement Contractor-Law. The contractor isf responsible for completing the work as described,in a timely and worlmanlike manner. Homemmers may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for woxknanship or materials. In,addition to provided by the contractor,all goods sold-in Massachusetts carry an implied warranty of merchantabiiluxty andfitness for a palticular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree maybe 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/homeow er rights, contact the Consumer Iufoxmation Ilotliue(listed below). Execution of Contract- The ontractThe contract must be executed in du licate and should not be signed until a copy of all exhibits and referenced docruments lave been attached. Parties are,also advised not to sign the document until all blank sections have been ract with attachments is to filled in or marked as void,deleted, or not applicable. One original signed copy of the cont 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 be gin turtil both parties have received a fully executed copy of -the contract,and the three day rescission,period has expixed. Accelerated[payments A contractor may not demand payments in advance of the dates specified on the•payment schedule in cases wher/hee the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems himrself to be financially insectiue,the contractor may require that the balance of funds not yet due be placed in,a j oint escrow account as a prerequisite to continuing the contracted work. Withdrawal of fLmds From said aecouunt would require the signatures of both parties. :Additional bdo:rxm.ation xf you have general questions or need additional in Corniation about the Home Improvement Contractox Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Grade to Home improvement" contact: Consumer luf-brmationHotline Office of Consumer Affairs and Business Regulation 10 Park Plaza',ROOM 116 61.7-973-8787; 888-283-3757 or'visittthe 0CA33Rwebste at1 1a2/ .mas aboutthe conwant to contractor registration verify the registration of about a contractor or if You have questions or need additional information specifically t component of the Hone Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration, O:C-Eice of Consumer Affairs an,d•Business Regulation lb a 617-973-8787, 888-283-3757 o vi,sitthe HCC website,�02116 at b.IlwwwTl'1�SS Go online to view the status of a I-Iome llmprovemelt Contractor's Regisiration: htt7r//db.state ma uG111omeirnt�oveir�ent/lYcenseelist.as For assistance with,informal mediation of disputes or to register formal complaints against a business,saness, calx: Consumer Complaint Section Office of the Attorney General. 617-727-8400 AND/OR Better Business Bureau S08-652-4800,508-:755-2548 or 413-734-3114 RWL' PROPOSAL ND. SHEET NO. DAMPROPOSAL SUBM17TED TO: WORK TO BE.PERFORMED AT I /O�✓ NAME ,. � { ADDRESS _ ADDRESS DATE OF PLANS fw PHON N0. CH 6P'2 We hereby pr e.to fu ish LtheqZmateis and perfo the labor necessary for the completion of IX s Cir : .tet ♦ '��♦ ��~ '� .tel.. 'L ' qf/-go/- All y All material is guaranteed to be as specified,and th above work to be performed in accordance with the drawl sand specifications submitted for above work completed in a substantial workmanlike manner for the sum of Dollars ($ )with payments to be made as follows. G IK-e�-. Any alteration or deviation from above s ec'rtications involving g extra costs erill be executed only upon written order,and vAl become an extra charge Respectfully over and above the estimate. All agreements contingent upon strikes, submitted accidents,or delays beyond our control. P Nate sal may wiL'tdravr,t tis if not accepted v�' days: ACCEPTANCE OF PROPOSAL The above prices,specifications,and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payments-will be made as outlined above. Signature Date PIC, O �•6 l3 Signature 1 aadaur D8118 3-12 ' =SHEErNO. ' DATE PROPOSAL SUBMITTED TO--,-" WORK TO BE PERFORMED AT- NAME ADDRESS lft� /4el ADDRESS 41 Z.DATE OF PLANS PHONE NO: ARCHIT&E We hereby pr o furnish the materials and perform th bar n essary for the co pletion of 9 ♦ L � � a G•`. Gam♦ 'r' _ / 7 i v ♦ � 4ZZ�2fL All material is guaranteed to be as specified,and the above work to be performed in accordance with the drawings and specfications submitted for.above work and completed in a substantial workmanlike manner, e�sum f Dollars ($ r /. )with payments to be made as follows. d4d Any alteration or deviation from a ve specifications involving extra costs vrill be executed only upon vrritten order,and will become an extra charge Respectfully over and above the estimate. All agreements contingent upon strikes, submitted- accidents, ubmitted accidents,or delays beyond our control. Nate aposal may be withdrawn by us if not accepted wi to days. ACCEPTANCE DE PROPOSAL The above prices,specifications,and conditions are satisfactory and are hereby accepted. You are auftrized to do the work as speeifted. Payments will be made as outlined above. Signature Date �-< t �-� ( 3 Signature >admiw D8118 312 L�12/13/20133/ 17:41 16038826137 FRENCH INSURANCE PAGE 01/01 DATE(MMIDDIwYY) IwIV CERTIFICATE OF LIABILITY INSURANCE 12/13/2013 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,th6 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 endorsemen s . CONTPRODUCER NAME:CT RHONDA PHELPS French Insurance Agency, Inc. PHON_fA1C NoE. , (603) 682-9532 FAC (603) 992-6137 12 Derry Street e•MAIL RE01MAPHELPS@COMCA,ST.NET INSURER 3 AFFORDING COVERAGE NAIC# Hudson NH 03051 INSUR12R A.UNITED STATr4S LIABILITY INSURED INSURER B: COOLIDGE BUILDERS INSURER C 102 SOUTH SHORE RD INSURER D: INSURER E; SALEM NH 03079— INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE_FOR THE POLICY PERIOD INDICATED, NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MICH 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 OP SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INS POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBLR DON MM A GENBRALLIABILITY Ct1171650E 08/10/201308/10/2014 EACH OCCURRENCE $ 1000000 COMMERCIAL GENCRA4 LfABILITY / / / / PREMISES Ea o e $ 7.00000 CLAIMS-MADE a OCCUR / / / / MED EXP(Any one arson) $ 5000 PERSONAL&ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GENI AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS,COMPIOPAGG S 2000000 JECT X POLICY 0 PRO_ LOC / / / / $F-1 AUTOMOBILE LIABILITY OCM61eNI:17l0ent SINti.� Eecc LIMYI ANY AUTO / / / / BODILY INJURY(Per person)^ S ALL OWNED SCHEDULED / / / / BODILY INJURY(Pnr nooidont) s AUTOS AUTOS TY DAMAGE_ $ NON•OWNED HIRED AUTOS AUTOS (Poraccident) UMRRFLLA UAB OCCUR / / / / EACH OCCURRENCE S EXCESS LIAR CLANS-MADE / / / / AGGREGATE S DEC) I I RETENTION$ WORKERS COMPENSATION I WC STATU• I OTH- AND EMPLOYERS'LIABILITY YIN TDRY LIMITS UL ANY PROPRIETORIPARTNERIEXEOUTIVE N/A / / / / G.L.P-ACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) / / / / E.L.DISFASF•FA FMPLOYE• $ If ryes,describe under DESCRIPTION OF OPERATIONS Delow / / / / DISEASE•POLICY LIMIT 9 If If DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedulo,If morn apaca IA mgvlmd) CARPF4NTRY-DOOR AND WINDOW INSTALLATION CERTIFICATE HOLDER CANCELLATION ATT: BRIAN LEATHE INSPECTOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL DE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISION$. BUILDING DEPARTMENT TOWN OF NORTH ANDOVER MA AUTHORIZED REPRESENTATIVE FAX 1-978--688--9542 'PH.%FR C`j INSU me. r. {c;. ACORD 26(2010105) C)1988-2010 ACORD CORPORATION, All rights reserved. INS025(201006).01 The ACORD name and logo are registered marks of ACORD