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HomeMy WebLinkAboutBuilding Permit #1258-2016 - 10 BEAR HILL ROAD 6/2/2016 00RT a ' BUILDING PERMIT ,x ��°, V. "0 TOWN OF NORTH ANDOVERto APPLICATION FOR PLAN EXAMINATION +� - Permit NO: Cp Date Received / 9q cacaua.ca� Date Issued: �9SSACHUS 1TqPORTANT:Applicant must-complete all items on this page LOCATION BEAR HILL ROAD NORTH ANDOVER,MA 01845 PROPERTY OWNER LISA BERNARD Print Print MAP N0: 064 . 0 PARCEL0062 ZONING DISTRICT: Historic District yesno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE NV Residential Non- Residential ❑ New Building Vbne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic []Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer REPLACE 5 WINDOWS - NO STRUCTURAL CHANGE Identification Please Type or Print Clearly) OWNER: Name: LISA BERNARD Phone: 978-686-6603 Address: 10 BEAR HILL ROAD NORTH ANDOVER, MA 01845 CONTRACTOR Name: Phone: 508-351-2214 RENEWAL BY ANDERSEN Address: 30 FORBES ROAD NORTHBOROUGH, MA 01532 Supervisor's Construction License: Exp. Date: 90125 10-06-16 Home Improvement License: 170810 Exp. Date: 12-23-17 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: $ 7,250. 00 FEE: $ (j I Check No.: wile 2 Receipt No.: 'NUSD NOTE: Persons con cting with unregistered contractors do not have access o the guaranty fund Signature of Agent/OwnerC /r'�'� Signature of contractor �� BUILDING PERMIT OF NORTH qti TOWN OF NORTH ANDOVER h'� `, F APPLICATION FOR PLAN EXAMINATION w M1. Permit No#: Date Received 'Is9 A�w^reo•ea�q`� SSACHus� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP 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 ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well [I'Flo, ❑Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email Address: Supervisor's Construction License: Exp. Dater Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: F 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 contractingv with4unregistered contractors do not have access to the guaranty fund gia nature of,Aqont/Owner __ Sianature of contracfor t Location No. C Date G 1 L 11W • TOWN OF NORTH ANDOVER . � Certificate of Occupancy $ Building/Frame Permit Fee $ ` Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# t) ' tt t'J f Building Inspector i Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments i I Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: ,I o FI PER DE ARTMENT "- p _ g Located384 Osgood Street ' ` °t � .} ;Tem Dunipjster�ontsite, ykes in n bi, , ,FrDepartrnents �7 Dimension 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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1oo-$1000 fine NOTES and DATA— (For department use) ® Notified for pickup Call Email 3 Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4, 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/Cross Section/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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products IS OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 I� 1 f NORTH OTown 2Andover .� . _ Z oh ver, Mass, �nl .Q c)-b coc«�c«ew�cr 1' /tATE0 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System • THIS CERTIFIES THAT L.L�r ......... BUILDING INSPECTOR ............ .. '. . ..... . . has permission to erect ................ ......... buildings on . �1. Foundation .�.... .. .. ...................... .. .:........ Rough to be occupied as ...........�... ..� .. .... .!~[,R� �. !! ................................ Chimney provided that the person accepting &s pe mit 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 CONSTRUCTION ST RTS Rough Service �� ............... . ... .. ...... .... ..........................:......... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. n Agreement Document and Payment erre lir 'L 4bci nrwrtl 6 ALndmoft,or Ro"m tjrm lurmrd toxo 14 aia rl 'W'11 WAr4mv tCc. No Hill Hd 1:70910 r`X"i Andover,MA U I Wt, -2a FlAis Foiwdl Wdibuough,W{s'IV52 (970566-51593 R-cew 5B-351-2200!F—:u:IW- t I ('M11,14mm Naorwn L1511 Win,Ird 05119116 Pear H1111 Rd, on,h.kin Si i vei ALlcll^*- 1-0 :M k Oil$45 1%13111j-F'lEJLr'1-1(AjW MR156-bl:('97-8JI6864603 lAv-plikiate mumixt:(50,8023-6300 m2mr,Fmaj: lisa-bernardftomicag,net Puy-M-4)herkb),pial litlyoInd werallyagrms ic-purcluir diCIVIAC106, by Anderwo 1110O[VaHmmul by AvArvACH 44`14911ii ilk Acq ol, in acamlinow yvid-1 the'Itralh MIA W101C19111(9&M-flb0d 111 thh,Apeo5vattNfc4liviclit whil VAY'lilgoN Nmh-p Ordrt-keerpo'WAu molly,81111vq r o'-qt"Ahillp.Torm od Cookild-mm OrSiilr, i1irni. W-0m.Owiwr or Builkler,Rclo'j'c Alf ��ocjncju'and jr-ij,'d0cc docimbionr ArraAA q-)qW,Aluccomic Dvicummi,ibc winisAllf.which,air all agrmd m by dirpa"loi lural incoilmulvd. Immill by rdetorrsix(m.11 wi%*'thkq'Arpelm-ul").Buyuriq)herAvaprm tv m1p a L'runyleiian ceffILGE31c;rte7 crinlraccur his Complatud-1111 wurlx tsod'cr ihis Arjownwill- Tt jobhouituat: WA 57,230 FAY';"Ping'thir agrolmiunt,po;4m.44gc diLm Av RiUA�m Pur and 4be.Am gum - - -4 * cr o tkp.&il 1114"AW9s $2,4116 54,83411�i:inucal Cumpki 101k! so 6-8 weeks 1.2 dAys' Paymcm: Credit Card, sc.Wdle inmdlarlorvs bemed ort dw date Gf the Am cd conuam and sk-c-ondardly Q-ft the dare 6 which-,,%v comt�lem 16 oerhnicalman-mm-mmm-71w inwrAbdum-,Ltc thir U 2 ES: 113 dowo'$2416, 113 at %wam.pmvW[rjg at this time is onbi-.artmimaic.WcAiff 1ximmunficatcan o.fficiaj Luc start 52417. 1/3 at and cimt at a hLer date, Rain amd jutct ot Wc.nhey ate dt,--moa c-orlumbil ouitl rur sobstontial completion May- $2417 Crodit Card.Ai em 0.5120 Pu yet('Q-A 9 14.'V;,t I-id I I n d'e F lun ds I I I at this Alm i m c n 0 W fit i i I Li t em the v u r I m,u jul c isund I JILP Mir l;(rtl,, - kjL'jij LIt man ibis Agfumeric miU -rald ,jot no ktilu-Of this., No Aximioi dedid-utts.f bL t7 514 the.simmet,wrrr- o(kinse T ofth Thcu�cdr)xnd, on trao Q r, Bvwtx)h * iw +dW.. i Rmyrr(S) W,;4 vq J rhis Agmmtnt,u;4crsrands,dx-ttnmr•of llis A mtm,, and,bas Fcce-iwd a comptewd,skpod,and da a ccIP111 of t'-6,5 Agm-mcnc,incUlffllf the mm ztmchoct N'vticmoFC-'=cr11ztion,ma the ditz first written alxvv.t!aril.2361 waF orally hiforimed of Bu-.vF!r ffi&In C.2ncd this Apmmcl3t. OWN1,-Xil 11b mot illol Ellh-comllmtcc if 6614.VIA!AW 0161,6d 90 JrL-61K,-jf 11AV COLIC OIC 0111W.lit-no You kilf1m YOU,THT,I&OW"'Ro;KAY CAN CELO-110 TRANSAC,17110N ATAN "11M, C' N(Yr[JUKA THAN M[I)NIC11 IT OF 05124/2016 ORTHEE THIRD BUSS NESSDAY AFFER TMDATE OFT.HIS TRMSACTION, .&D. M "TE-SW ER.SMMn11 ACHED NOTICE OF CANCELLATION FR&f OFOR A HIS N JiJS I HIS RIGHT. S Richard Diorlo Lisa, Bernard IN-im Njinvo(Sido P-mun W1,11[dime 111im Nome Mal Itemized Ord-or Racellpt 01 4WLI likimmall liv U&C114ittir B41110 Vu Unrwril 4 W gtmP Cirrwm*vill bv'4n*r%1 LL( 1.13 Upf Hill Hil 11708 10 lhMh Aridowr.MA A U 1.3 41-, 33-Fvws R*A 1 wilftefough.uK1,115v K i'vM66.56133 Ronviri held Mlvc: wAtirl NrLw, (fedol adjusligiefit. Friculd from Noy.'Gl 5 Adl uArnen t Proms 20 16 increase. 1 201 Bedl Window;�Double-Hurig,Equal, Slope Sill ln:-Er�Contemporary Checkrall. UXTERIOR White, INTET.11JR White, 151,45v Silk All: Hig,l)Pr0cirrivince SmailiSen Glass, No Patton, Fardwava; VArijtt' $Lcroanl rIb0eqIas$,rull S(ircpjk, (.flll# Style:Inj WaDd Only(114M), Grille,Pattern,: Sash All: Caamal 4:m x 3h. MAISC! Non .2,02 Bedl Wi ndow, Doub le-Hurig. Equal, Slope Sill Insert"Contemporary Che(khill, f,,;(TERIQR W'hitc% IVTf,R1QI1i Wh�ltp,,Qlast: All; Digit Pfidurin4iricv 5rnate5un Glatv, Nrj P,iittani, HAr-dWnfaq vim i1o,$croo 11: ribelglais'I ul I Scirip'-o' Old 116 $tylo:Ini 1'rlo Wmd Only(I NFAI), Grille Patterni,.Sash All-- Colla nial 4v.i x 3h, Misc Non 201 Offire Window; Double-Flung, Equal, Slope Sill Insert,Contemporary C ho(h I All, VIER ION Whttc!,1N11;14101;Whi fe, Gjasj�: Seth AlI1 lliqli Poilortrimca Smaidirn 61o&, Na Paucin, 14,aidwhira; Who% $7cracn: Fibriglass, gull ktqmn, gills=� - -St y1c., 'Arwd Only(I NTW), Grille Pattern,Sash All. C&anial 41P.,x 3h, Msz. Nor, 204 Office Win4,ow,- Double-Hurig.equal, 51tipp Sill iniad,Conte iin pom ry Cherklall, 0191110K M.Utc-,4014101t White,61,Rs : All: High Pinfortrionce SmailSun Qav�,No flxtern,Hardword, Vhrnlie,Scram: Flbeoqlass,gull Scirijeo, Gip]I le Style! Ih1wI01 Mod Only(Ir FAI),Grille Pattern: Sash All.-Calcmial 4vf x 3h, Mist: Non Faqe 4 1 1 N.- 1A-611 l Item, llzed; O II��e r ■ ecei pit � f � d6ii Rcoma11ty 4mJawa6E� tin u t r trl tebsler,ern}, Pvtm l hW Arr NSM ltC Mtararlifil oil 170�1iA Q ARdover,NO 01041 MmErCFe �eei�wefm�wr MFuttis!4 �1}i ,fterough..r,�A4,1 :?.2 E'S�7 a6Iii5503 Ft?e+: -"53-3,25•1-220)IFf'a:l P5.' 4M1 ��14n E� h.�it .. �nr.�;��r� C-L5Qv.6Z3Av308 ti t s IMM . 205 11mil12mr_.m Wlnd0Vj, l)aubIro-Hing,(quaNt, a"It>pf?Sill Insurl, Con1vmpuur Chef,kiall, C;(TER 1QR Mite,IkTr RILlI;whtteM GJ.A !�.501h all; igh Perfivrmsnce Smar,,Sun Glass,No Pattern, Temp,_-red Gtass, fiard%vafe.' Mae_ Screem: FibtLagIaEs,Full Screen, Grille Stl lm,. Interiar Ylooad Only SINTVVJ, i3rdle I abler : talh Alk Colmilal 4%v x 2h. Mist- Nrin L)Pf)ATCI) 05119t1f; rampvirg'whh d)w r m1rl r�r�'1r raf..� �War*Pr.v.rrC rj jpc!•,NJ AY 11W r1j' ., SISli�P9tP��'E'�r.� a7 1'hi3 Amcsrdmcnt C`Atncrult oul)is to file cuss-ro1+11AstlGl7 1V-�1(�Cs Ilt?Qk i FMfiG7t i tNc•Ai.l:k i MOrf.t„tS rccnauit')�w+;tncl 6ctwecla hcticwtd by ,1'srcJrrscn nl"CrtrilcrMusitschttseitsanti N(cW Ifamushirr and Viigc-s'("bttyge)listcttsine..ConIracl and buyer's hereb_va taernscaittand modify Clic. c�gANCrtrr nt rts•indirnted holow,ether then:is SpoCificdlly nrdiculai W.Ow,all Qtc Jcrills rstrd cQndiliolrs of Ilrc atgrectnettl wilf'rcinrtin in fall 1161-c:and&WI. 1111i.+urten;Jtuetst is sntijcx•t to the toms and corlaillons.of the r;,vccmc tu,Tile following.addilions.n(tcrmions,or,d cleticros.to the prW ucrls and wrvi:cs. boyci'ls)ordureci are l>Gittg made, RIF Ii • lu a rCsult of these ctiati`ts,the follotcrit)g terns&of the atgrennrent ut3c also cls;urging=:Gf-them is,rro ch:m$e:-,tn item will-beta blank-or marked•*s"N/A". indicstia .tirut nochangr:tpplicrs: New total job aunount, A.11 NO tolaf'hence amotmt: agew cs(imatcd;sturt.date: Nc%v deposit mccived: deposit: f ft{w eslimtited citar>Eileiit n'ttttte; t _ P New baliit _— Icc at start of job; ,illtiltit'+ci`.z7t liaY out: Clieckktoh i ! - i tYCv bstltnac at suiutanlial tv'ewfitutnce lxrlance,ut cryclihcrd: Complotion of job. , / 5bbsi:tntial completion �! of job: Imo' I it is:cgrew and understiaW by anti betwccir thevudr 111111 this r%mctrdment.along witirthe orig inn t reemerit constitute the entire understanding 1>istwectt,ilte p:tetics,and there are no vetbal mtderstastdittgs=changiits.ar motOying any,of the terms.ituvc^(s)hercby-�ucknwvledgi thtd llzty,.r(s)has rid this Amcndmrni and tw.r'r=ivcd;t CcOlAetul,signed mid tutted xpy of this rmzq.xd.m;nl�ou telt utelistpd ubovw licttcwaJ bWjrpc"3' guycrfsl Suy (s} 1 y r,1V i Sigcr S' nature S(�,ttttturc- Renewal byAndersena WINDOW REPLACEMENT anAndev;cxCntrjRgy Wood/Vinyl Composite IF Dual Argon Low E4 SmartSun j .Y:Cd a Double Hung 100-00473618-010 ENERGY PERFORMANCE RATINGS U-Factor(U.S)A-P Solar Heat Gain Coefficient 0.® 211 9 0019 - ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0 ® Manuheturar stlputatesihat there Wrings conform toappfcah%NFRC procedures for determinieg who%product perrormanae.NFRa.11,ware datenninedfor a feed eat of environmental condalene and a apaoft product sae. NFRC does nm recommend any product and does not warrant the suhaohdyel any product torany specirio U. census monulaeturef%literature for other product pedo maraca Informatba. www.ntlo otg This product meow Oman -.: a" .� ' '�.r,•ry' Seal's eave nmeetel eemes 3 standards governingenergy !,+,gg;. r %*• heavy mefaG int;;•` r, E.<•.•n ''a the home and cash P 't'N� rytgY f -tarot paclost"and ,`}'3 bM hF.•x 'fit �• X eooeumer ad.catimrel n vtY YC Ct•. materals .r.ien�'�v •.5..__� ^a.F�..if� Q DESIGN PRESSURE(PSF). PATA SUM M-- No- p r r,'� m9leW!7L H-�• �z5 www.�[p'�IL,hRbA DB Slopl DH IN halo%ateadarae• dears of exceeds M.E.C.,C.E.C,a I.E.C•C.Alf Infiltration requirements WOMA habork cenifical'nn fkogram. • .... ......... ....._...._.. I I r a The ComwxPftwA of Mmae#rnv* Office-a f f testteatdoilw rlioa'ton,A"®.Ire Workers' Comi-ensrfslrn latymcce Aliffidavic r;ti�lAijlcktn' ?at7tn eta p:119a 26ft �'.$It1C tlwsfress�ih a�wrstittnMcii�tstita:' RENEWAL BYANDERSEN__.___,,_.___,._____, Addre g; 30 FORBES ROAD Cit /St '71 NORTHBORO MA 01532 pyotle??• 508-351-2200 ArVou an empleyer4 Cheek!bc appropriate box: Y 'lope of Rr'u ert t.regniredy. 1'.t__I 1 am a atnployer with _30 1. Q 1 am a Scoeml ixmvactor and I ©New ew omftvfim employees(tau an&or pa:t-tfrnu).'' nave hired the-ittb-voMra ors I " Remodeling 2.C] I ani a sole proprietor or pmuw- hsfsd ren the attached After • 3 g ship and have ne,s mployeus 1h"sub-:eritrsi.-tcxs have S. o!)anolititm workingfor me in am Licit}. workers'comp-insivanc^e. o, (�But"Iclittg addition [IVa workers'comp.intura.!tee 5• ❑ We are a empi ration.andl:l�trleai required-I afficev;have raerciK-d their l rq*rs or Aditiuns 1.am a homeauner doing all work right per Mot. "1 Plumbins repairs or additions m}�lf:jNo work'comp+ c.152,411(4,aW we have mi 1Z.,:,]Roofrqtaira insurance raqsual.j I etrrphrvm[bio works' i "p.insinancejequtred.j --- ------ �+16}appz:caat that i :i k,%44,must Xu:fill,%the vvhcm Genoa s m%n ilmir wvu"G :�rw;rs u m panic;tna;mraw i iomwwrm wh t wAmon thi,affi"vit iadkWm&9m a,domg M%oh tuw d=tit Mei&iuwaUan must wbmu a aft-awj&vi rndi,4*a,•wh k'mU 4,Wrs mi mck th"tsr,mat viWwa at adou-mll A90 AkA fw"W"WE of trk turd thea'%or 'aura)t pNtcy tmoctr�twn J am icer enrptovtr the.is proelrtir�worl4ers'ro»iyit�arrstioa insrtrvnreJpr aiq'emp/o3'eres. 1'ielot:� Ire prrlicy axd,jab she �ornrrltiem InMrWW QxrDat'v ivatpe: OLD REPUBLIC INS. CO. nialicw'#:.or Sel%itis Lk. _._ I?xpirdion!late._10-0116 Job Site Address: 10 BEAR HILL ROAD NORTH_ANDOVER,MA0164 5 -- C'i SSta`Lip _ Attach a cap. of the worl+eW compensedon pilfer tfec tfon;nV(rhWing the poLtty aumbe.and expiration dew). Failure to Wure coveiage as requiwd un& Section,25A tX11,10,c. 151;.earl kad to the ijApnsition of criminai pvvabki of a fine.up to$1,50.00 andior dna-year.iniprisunt '04 as well as Civil penuttie'S in dv fu-.-m of a S:r()P WORK(AMER wW a fine of up to S0.00 a day agate the violator. Be advised that a copy of this statementstun-bye fm wardad tic the Office of lrveftattotr,of the INA for insurance co-*ane vt'rification. I do h ender ire p& is ondpena*%of pedWY th&Ae f#jw-ft Pwr pmrkkd vb0-e is ern€ward cMat. Phone.:., 08-351-2200 QWid rete aj*. fro not write ig this wMa�to be conipkUd by rip or town v,okkt C Ky or Town: PerrnifP..icease# Issuing Aattt i-ih^(dfCf c oar): 1.Board of Health 2.Buiding]epartrxent 3.Cit)!Town, !erk 4.Electrical Inspector.S.Fim id"Umpector 6.Other intact Person; Nbase#: ANDECOR-01 YADAVYO CERTIFICATE OF LIABILITY INSURANCE F°"�'"'�'°°'YYYY' 10/1/2015 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: R the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,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 Willis Cerdflcate Center Willis of Minnesota,Inc. PHONE c/o 26 Century Blvd FAnc No): 888 487-2378 P.O.Box 306877 945-7578 91 11 ;Cerdficahm@willis.com Nashville,TN 37230-6191 INSURE AFFORDING COVERAGE NAIC 0 RISURER A:OId R ublic Insurance Company24147 INSUREDINSURER B. Renewal by Andersen LLC INSURER C: 30 Forties Road INSURER D; Northborough,MA 01532 INSURER E. INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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, Ink AUDI.51JISH POLICY Kw- TYPE OF INSURANCE LTR WVp POLICY NUMBER MfD LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 0. cLaMs AOE 0 occuR MWVZY 305440 10101/2016 10/01/2016 PRELUSEs Me omuffence $ 500,0 MED EXP one person) $ 10,000 PERSONAL&ADV INJURY S 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,OM X POLICY 0 JE-CCTT EILOC PRODUCTS-COWIOP AGG S 4,000, OTHER: S AUTOMOBILE LIABILITY OB D SIG Luf— 5,000,0 01 A X ANY AUTO MWTB 305M 10101/2015 10MI2016 BODILY INJURY(Per person) 1 $ ALLOWNED 8CHEDULED AUTOS AUTOS BODILY INJURY(Per eocidard) ; HIRED AUTOS P A O D eE S Pr eoddent $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LAS HCLAIJ4S-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X PEATUTET ER AND EMPLOYERS LABIUM A ANY PROPRIETOWARTNERfEXECUTIVE YIN MW 030643700 10!01!1015 10/01/2016 OFFICERIMEMBER EXCLUDED? ® NIA EL EACH ACCIDENT $ 1,000, under(Mandd dealxibesc In uandE L DISEASE.EA EMPLOYEE $ 1,0wow If yyeess,, OESCRWTIONOFOPERATIONS below E.L.DiBEASE-PoucYumIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may De aRached N mon space Is regahtld) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE YYILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Evidence of Insurance ©19B8-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD MaSnachusette-Department of Public Sallky Board of Building Regulations and Standards Comtrutllon Saperrisor Yt .�... .d: . 119" � Expiration ta,r�tliirlon� 7W08f2S9�; 4_ cTls�rwmvmmancUea./,b'i a�r'�aaaa�uaella I ice of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Registration_: ,1?to#0 Type: Expiratim,}��T Supplement Card RENEWAL BY AND •LkC JAIME MORIN 30 FORBES RDy:--- NORTHBOROUGH,MA 01532 Undersecretary