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Home My WebLink AboutBuilding Permit #474-13 - 1 Royal Crest 12/3/2013VA Permit N6.-4* A BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINTI Date Received �yS Are.. Date Issued: I I ORTANT: kpplicant must .................. ... 5Q Royal, Ci Pint RIOT ."RD5 Historic -lMachin( :' Pnr MAP N:O �.5 PARCEL. 35/bb ZONING DIE all items on this I TYPE OF IMPROVEMENT uer Ma k h Non- Residential ❑ New Building ❑ One family t yes no x pV.11la9e.. Yes no . x. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition EXTwo or more family ❑ Industrial ® Alteration No. of units: ❑ Commercial � Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition EKOther o Septic V11ell €n .o FloodplainiVlretlands ❑ V1latersled District: Water/Sewer Provide exterior foundation waterproofing and replace stairs with railings as necessary At building number 1 Identification Please Type or Print Clearly)Dan Millanzzo Cornerstone Land Consultants ,Inc ARCHITECT/ENGINEER John A.Visniewski PE Phone: 978-433-8100 Address: 61 Main St Pepperell, Ma. 01463 Reg. No. PE 20775 FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 12,000.00 FEE: $ 144.00 Check No.: C iifffi Receipt No.: 1,1 ku" NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 19- TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: IMPORTANT: Applicant must( I LO 'ATIO Date Received lete all items on this page m t-, nni:; fPROPERTY OWNER_ .-.� _� _ - : - _ Print 1 OQ Y,ea� Old St[ucture yes, r%o MAP NO.. `�rPARCEL � _ _ ZONING DI.SaTRICT Histone°Distract yes [60 T = �IVlachine�Shop Village1 yeses N d -�.� 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 Bldg ❑ Others: ❑ Demolition fSeptic, ❑IUVeII ' i M _ ❑ Other _ �❑ Floodplain V1/etlands,, - ❑Watershed Distract �. s ❑Water/S,ewer DESCRIPTION Uf VVUMM I U Or- rr-MrUr<mr-u. Identification Please Type or Print Clearly) OWNER: Name: Phone: n _. -1 UUIGJJ. _ _ -- ---- CONTRACTOR'Na►Yie _._Phone Address:. rvisCrueLene_z JatesSupeo ARCHITECT/ENGINEER Phone: 7 Address: Reg. No. FEE SCHEDULE: BOLDING 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.: NOTE; .Persons contracting with unregistered contractors do not have access to the guarantyfund Si aouefA nwenO77, Plans Submitted Ej Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 0 t 4 Plans Submitted ❑ PlansWaived-11 Certified Plot Plan ❑ Stamped Plans ❑ 370E-OF;SEWERAGEDISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑.. Tobacco.Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc..- ❑ Permanent Dumpster on Site ❑ THE. FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM - DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS DATE.APPROVED CONSERVATION Reviewed on i ;� " 3 - / � Sianature V, 1 m 44� COMMENTS /LP- /l) 0 0 I cL - _t Q�k21/V') HEALTH Reviewed on Signature a COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments -Water & Sewer Connection Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street .FIRE DEPARTMENT Temp Dumpste'r on site yes no Lo:ated at :124,Mair, Street: Oil e'Departme►it signature.'ldate COMMENTS Number of Stories: Total square feet of floor area, based on Exterior dimensions._ .Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No ML -Chapter -166 Section 21A -F and G min.$100-$1000.fine NOTES and DATA — (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fol owing ig`a-list of the required.forms to be filled out for the appropriate. permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L.Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cas<s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apo, -al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:?ted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Location No. t ' Da e 4 t Check # �� 27149 { TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL (2 - Building Inspector �! id Q Q Q 0 m N +u_ \ O LL E N U Q Cut zZ Z 0 m 'O 7 tLL t =33 K > O U LL O0 Z m J i OC LL LLA Z V V W W L D d' U > In C LL O a H Q C7 t � d' LL CWC G a W W LL y m ZQj �+ v N + D N Y O N tq—* 3 0 H O Z G Z W w CLx ujF- LU W A O W :a p 0 m H ti •,v �.1 z w a E Z O i t cc CL CA A2 .Q r_ V cc cc CL U) r -M1 no O CL CL � C( Cc Cc J -0 O4'++ Z W AA , Y/ D. Robert Nicetta, Building Commissioner TOWN OF NORTH ANDOVER OFFICE OF Bi[TILDING DEPARTMENT 400 Osgood Street North Andover, :Massachusetts 01845 Telephone (978) 688-95454 Fax (978)688-9542 CONTROL CONSTRUCTION — SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 01845 i, John A. Visniewski HEREBY CERTIFY THAT THE BUILDING CONSTRUCTED AT Bldg. #'s 1 & 2 at 50 Royal Crest Dr. DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: Foundation waterproofing and subsurface drainage piping at the specified buildings. 1� PVjN OF IyAs AUTHORIZED SIGNATURE: t �� aOtiN �yG CIVIL No. 29775 DATE: December 2, 2013 REGISTRATION: Mass. PE # 29775 NOTE: ENGINEER "WET STAINIP" MUST BE AFFIXED TO THIS FORM Control Constr.:ction Form reLiseti I1.14,2004 !;q ri E. -9 f i S 4D iiF i CONSE R'vA:li; ., S; R-23 30 HC;ts CiH6 3S_ 9 510 PL??II.iNC 6S'_-053_ �7 Contract Change Order Contract Number: 15646 - 420571 - CP - 00009 LEGAL OWNER: AIMCO NORTH ANDOVER, L.L.C. COMPANY: Royal Crest Estates (North Andover) Effective Date: November 26, 2013 Contractor: L V M J Co oration Pro e : Royal Crest Estates North Andover Address: 65 Howard Street Location: 50 Royal Crest Drive _, . North Andover. MA 01845 Mawn 3331 Street Road, Su Bensalem, PA 19020 Change urger Sum 135,900-00Number CCO - 00011 DESCRIPTION OF CHANGE ORDER The subject contract is herein modified to incorporate the following: 1.0 WORK SYNOPSIS Bldg_ 1 & 2 Foundation Waterproofing 2.0 SCOPE OF WORK 1. Perform existing contracted scope of work for Foundation Waterproofing (previously referring to Buildings 23, 24, 26, and 49) and apply the same to the additional buildings of Building 1 and Building 2. 2. Refer to the following engineering drawings: a. Document No: 9328 (sheet 1-3) / Foundation Drainage Site Plan BLDG 1 Royal Crest Estates / Rev. No. 10-30-13 b. Document No: 9329 (sheet 1-3) / Foundation Drainage Site Plan BLDG 1 Royal Crest Estates / Rev. No. 10-30-13 • Construction Commencement Date First Building: 1212/13 • Construction Commencement Date Second Building: 12/9/13 • Construction Completion Date: 12/20/13 • All other contract terms and conditions shall apply. • Contractor will carry additional requirements for cold weather waterproofing application. • Contractor will make reasonable effort to maintain steady production in order to complete by the completion date. • Severe weather conditions may impede schedule, but contractor will make every effort to accelerate work where possible to make up lost time, or advance schedule ahead of severe weather. 1 of 2 Contract Change Order Contract Number 15646 - 420571 - CP - 00009 Page 2 of 2 Initial contract value: 253,500.00 Total amount of previously authorized change orders: 36,159.41 The contract value prior to this change was: 289,659.41 Amount of this change: 135,900.00 The new contract value including this Change Order. 425 559.41 The Contract Time will change by: 0 The date of Final Completion as of the date of this Change Order is: 12.20.2013 Please return two original executed copies of this Change Order to: Tracey Warner 3331 Street Road, Suite 450 Bensalem, PA 19020. The price adjustment and time extension (if any) granted under this Change Order constitute payment in full for the Work covered by this Change Order, including without limitation, all direct costs; indirect costs; overhead costs; general and administrative expenses; profit; and all effects (direct, indirect, and consequential, including impacts and "ripple effects°) of the work covered by this Change Order on all contract Work, whether or not changed by this Change Order. The completion date, contract price and all other terms, covenants and conditions of the above -referenced contract, except as duly modified by this and previous Change Orders and Amendments, if any, remain in full force and effect. OWNER: AIMCO NORTH ANDOVER, L.L.C. CONTRACTOR: L V M J Corporation By STEICH MATT as authorized represervIative for OWNER Signature: 1% - -1.141`. L.,'C. .11 a^ ,, Signature: MA -'VL-". Print Name: ` Ma(t Steich J Print Name: Vinnie Mawn Print Title: Regional Director of Construction Print Title: Principal 2of2 LACUS it ly E sr tp10- "Es ILV Site Plan SGtE 1 h=ZOR and — dd3 $RRINR: td3 p¢aplb 9329 F0.1N(J4TIQ1 waTEraaoof vxc ss�Eu tlOaNSPQf, mtu cniv�salrovum �s wuematror+wro aoff sv,.,Eu mrol�rias AT BI1SD@1G Qlf FALL IOGT[1N rauo+Tce,r�Am-rnao�swro,a .a. v��wrtv.�uwi fWtroaTIQ1�Mi-QtPO6 Lff TO1M wp,a„xa,Ta,armuEarc xnan ...e.e..s..d�.� aKrirKlE WOf �qn-QGi1 Ba9'r E Details o-�, F. range -- 8I W reit P c � WzWzG' 3� �'f�i 9 93ffi REFERENCES uc�htwm�..�.em�.wie.�mm aa¢urmawr.. FOUNDATION WATERPROOFING SYSTEM GENERAL NOTES CONSTRUCTION NOTES CONSTRUCTION SEQUENCE i! E¢:o 9328 LOCUS �{ b � 6 / o 42 --� s- c msar P _ m W a� =a• WW o � Nz' u r u. o Site Plan i �,-smrt yew.: mn.m senna:+a3 as�oen e n 9329 OO.Ni90OT CUCi�fI W iB ANp [Raw lFAD7i3 TOUIl04TIOr! aHp rt06 srsEu carlEcnos ai B ViL%`!6 pUIFALy tOGrgN fOk✓d1TgN r+r�aw - ouo¢ w ro u �� fOlQmOgNtiRatR-O AOCa 1A'TO1K ��[� a�e+roiwr�ewron 1 ' y er.rv_ w�rssrtar� SAi� tf 8+4411 _ � STaI®NI1TBatES YATHTfIdT1UmQECU'aEL ON �wer...amabo.r®oa... BY.TOIEBOOT LCNi£CfAN-OW1PlB0.9NE Details s �rumaae 9329 REFERENCES r..mww..r.�+w..wc...a.r a mn...mr...._. GENERAL NOTES CONSTRUCTION NOTES `�A�'•tl'K FOUNDATION WATERPROOFING SYSTEM CONSTRUCTION SEQUENCE M.assachusefts - Department of Public Safety. Board of Building Regulations and Standards Construction Supen-isor License: CS -017809 ]LAWRENCE V MAWN - 65 HOWARD STi9 G '0' BRAINTREE MR 02184 Expiration :'i Commissioner 07/19/2015 To: Page 4 of 4 +� r 2013-09-1 £3 14:40:38 GMT-OS:00 1G17S880432 From: M -d -i- 1 ® CERTIFICATE OF LIABILITY INSURANCE ��- D 9/18/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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 T. Edmund Garrity & Co., Inc. 545 Concord Ave. Cambridge MA 02138 CONTACT Cri Sting NAME: arc No Ext (617) 354-4640 AIC No: (617)354-5828 E-MAIL ADORESs:cristina@garrity-insurance.co>n INSURERS AFFORDING COVERAGE NAIC p INSURERA:Ohio SeCUEitY Insurance Co INSURED L. V.M.J. Corporation 65 Howard Street Braintree MA 02184 INSURER B: INSURERC: INSURER D: INSURER E: INSURER F: ♦rC�llnCr /"GGTICII`ATC \IIIMQGQ M)1 CTFR rnT 'J(11 i KF\/Irl()N NIIIVIKF K' 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 LTR TYPE OF INSURANCE ADDLSUBm POLICYNUMBER POLICY EFF MMIDDIYW POLICY EXP MMIDDIYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 LIA PREMISES Ea occurrence $ 100,000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ 5,000 A CLAIMS -MADE YOCCUR LS1455690302 /13/2013 /13/2014 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,000 $ X POLICYLI PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROP den DAMAGE $ $ UMBRELLALIAB EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAR HOCCUR CLAIMS -MADE DED RETENTION $$ WORKERS COMPENSATION WC STATU LIMIT OTH- AND EMPLOYERS' LIABILITY Y 1 N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEme ER EXCLUDED? ❑ (Mandatoryin NH) NIA E.L. DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Excavation & Hauling. ctK 111-IL;A I t MULUtK .,^I- . " . 1vm46@beld.net Town of North Andover Building Department 120 Main Street North Andover, MA 01845 INS095 oninn5t ni SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Garrity/CRISTI n i auu_,inn Ar(1Rn CORPORATION. All rights reserved. Tha anrip ln name and Innn gra ranictararlmarkc of arnRn From Tonry �f Wed Sep 18 15:38:01 2013 Page 1 of 3 I �►coizD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDO/YYYY) 9/18/2D13 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). PRODUCERL' Albert J. Tonry & Co., Inc. NAME: PHONE (Alc• (617)773-9200 FAx (617)773-4920 L -MAIL ADDRESS: 300 Congress Street INSURERS AFFORDING COVERAGE NAIC # POLICY NUMBER INsuRERA:CoHunerce Insurance 34754 Quincy MA 02169 INSURED INSURER B: INSURER C: L. V. M. T. Corporation INSURER O: FAC7H OCCl1RRFNCF 65 Howard Street INSURER E. INSURER F: Braintree MA 02184 COVERAGES CFRTIFICATF NUMRFReCL139407107 REVISION NUMBER: THI5 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 ACCORDANCE WITH THE POLICY PROVISIONS. ADDLSUBR 120 Main Street POI ICY FFF POI ICY FXP I IMITS LTR TYPFnF IN-aJRANCF INSR WVD POLICY NUMBER M1AIDDIYYYV MMIDDIYYYV GENERAL LIABILITY FAC7H OCCl1RRFNCF :6 I )AMAI' P I U PN 1.1-11 C OMMI=KC:IAL (;tNtKAL LIAL'ILI I Y PREMISES Eok occurrence C:I NMti•MAI )I- n LAAAJR NIH 1 FXP (Any nnn pMrnni :6 F! -K' K ADV INM IMY CENERALACCRECATE 1. Ni -M ACIORF-(iAl I -I IK111 APPI IPC; PF -K' PK(N)ll(:I ti-UDMPIUP A(r(a PUI IC:V PRO AU UMUF31Lt LIA13IL11 Y I OOMBINED SIN+SLE LIMIT Pa accidnnr 1,000,000 DONL'Y INJURY (Per peiwn) I $ ANY nu 1 O _ A 1 I ovvNl n X sc.HP1)uI H) J1808 2/15/2013 2/15/2014 BODILY INJURY (reraccl(lent) 1, nuloS nolo:; XX pIONI CWNCD PROPLERITYtDAMAGG 1, HiRi-n nu 1 os AUTO;; Medical Paymcntn �" b,000 UMBRELLALIAB Orr,UR PAC:HC)C:Cl1kkPN(:P $ EXCESS uAe CLAIMS MADC AGGRCGATC S I)PI) kF-II-N IIONS 5' WORKERS COMPENSATION WC STATU OP I AND EMPLOYERS LIABILITY YIN I OKY I IMI I ti PK ANY PROPRIFTORIPARTNFRIFXFOIITIVF C.L. CACI IACCIDENT OF+r_;LKIM F.Mb6K I-X(;LUDLL)? NIA u (Mandatory in NII) E.L. DI3EASE - EA EmrLQYE 1, E.L. D13EASE-r'OLICY LIMIT I Z. If yyca, dcxribC Undcr DC6CRIPTION Or OPERATIONS beluw DESCRIPTION OF OPERATIONS/ LOCATION51 VEHICLES (Attach ACORD 101. Additional Remarks 5checillle, It more space Is reglllrea) Any and all jobs performed usual to an Lxcavation contractor CERTIFICATEHOLDER CANCELLATION ACORD 25 (2010105) INRI195 rornnnm m (D 1988-2010 ACORD CORPORATION. All rights reserved. Tho Annon „v,,,o -41 1...... -- -k- .,f Annon SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 120 Main Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Jr /CDIGRA L Tonry . ACORD 25 (2010105) INRI195 rornnnm m (D 1988-2010 ACORD CORPORATION. All rights reserved. Tho Annon „v,,,o -41 1...... -- -k- .,f Annon From Tonry Wed Sep 18 15:38:01 2013 Page 2 of 3 4- V MASSACHUSETTS ASSIGNED RISK POOL REQUEST FOR CERTIFICATE OF INSURANCE Use this form to request a Certificate of Insurance fiorn the Assigned Risk Pool Carrier (A.I.M. Mutual Insurance Co,). Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the Certificate of Insurance should be issued. It this Corm is fully and accurately completed, the Certiticate of Insurance will be issued and distributed by facsimile to each fax number provided below, within two (2) business days of the carrier's receipt. This Form may be mailed orfaxed to the Assigned Risk Pool Carrier. To obtain each carrier's contact information referto the Certificates of Insurance section located in the Producer Community section of the Bureau's website (�vwtiy;�rv..c;rl;f3'3,;�3rti.). 1. Name, address, telephone number and facsimile number or email address of the INSURED: Name: L. V. M. J. Corporation dba: Mailing Address: 65 Howard Street Braintree MA 02184-1150 Physical Address: Phone: (781)848-6030 Fax or email: Ivm46 a beld.net 2. Name, address, telephone number and facsimile number or email address of the CERTIFICATE HOLDER: Name; Town of North Andover Mailing Address: 120 Main Street, North Andover, MA 01845 Physical Address: Phone: Fax or email: Fax Number 3. Name, address, contact person, telephone number and facsimile number or email address of the PRODUCER: Name: Albert J. Tonry & Co.. Inc. Mailing Address: 300 Con -gross Street Quincy. MA 02169 Contact Person: Cheryl A. DiGravio Phone: (617)773-9200 Fax or ernail: (617)773-9920 or Certs@tonry.corr► 4. Policy Number, Policy Effective Date and Policy Expiration Date If a Certificate of Insurance is needed for more than one policy term, provide the Policy Number, Effective Date and Expiration Date for each policy term. It the policy has not yet been issued, you must attach a copy of the Notice of Assignment. Policy Number: VWC10060082462013A Effective Date: 4/6/2013 Expiration Date: 4/6/2014 5. List any special requests for optional coverages / endorsements (see Page 2 for listing of coverages available in the pool and the conditions of availability) or additional information (including changes in exposure not yet reported to the carrier) that will assist the carrier in the issuance of the Certificate of Insurance. NOTE: An additional insured(s) shall not be listed on any Certificate of Insurance unless such additional insured(s) is a named insured on the policy. FACSIMILE COVER SHEET PHONE: (617)773-9200 FAX: (617)773-9920 Date:September 18, 2013 From -.Katherine M Pratt Page 3of3 ALDEP-e J. Temp X& Co., Nc. KU Re: L. V. M. J. Corporation Enclosed is the certificate of insurance you requested as well as a copy of our request to A.I.M. Mutual Insurance Co. for a certificate of insurance evidencing workers' compensation coverage. The workers' compensation certificate will follow directly from A.I.M. Mutual Insurance Co.. ea.Yi;ENr,,*Y. iMC:., 72n !:V lW,i1 S4fo.51; Laxii'llzlan, MA U424,71,1 l:l T39Y^� iF l�d�irv:E FE��ti midi' 9:E� t 0 N w.A0EN=1''.. IN=. :: 2.f?'i Milli +1t 3Hi.Wk,sAw, :M Q'I x7i�•? .'1 :3