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Home My WebLink AboutBuilding Permit #109-15 - 10 WALKER ROAD 7/30/2014 5 w �yt CF NO RT a qN BUILDING PERMIT °L M TOWN OF NORTH ANDOVER ° p APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Arap Date Issued: 1 �9SSAC I P/ORTANT: Applicant must complete all items on this nage LOCATION V (Ov' J17- t.l � / f PROPERTY OWNER SCG I" L.1 Q,vyt Print MAP NO: ID'600 PARCELZI O ZONING DISTRICT: Historic District yesno 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 ~kkCrGV- ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer U/l�T- ^JJ ,a4 dentificcatiion Please Typk eor Print Clearly)OWNER: Name: ��1 Rt2 (— Phone: �kl" 3 q7 G�d�2n'1 Address: Un 17- CONTRACTOR Name: Phone: V I Q Address:-9il adwo^'/ 4id MA- &1M,31 - Supervisor's A' GIM,31Supervisor's Construction License: Exp.. Dater 7- g a3h 6 Home Improvement License: /`f 3"7 u Exp Date: wa III� ARCHITECT/ENGINEER Phone: ^ Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ L3 CA 10, FEE: $ !411— Check No.: Receipt No.: 2-1 i' 2 NOTE: Persons contracting with nregister c ntractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor W s e t%0RTfh1 BUILDING PERMIT O�tt\ED ,bggo TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIONto Permit No#: Date Received �4�Dg17ED " �y �SSACHUSS� 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 ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: _ - 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: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r` Sgnature of Agent/Owner Signature of contractor ; i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAI, 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS + Zuning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) i ❑ Notified for pickup Call Email 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 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/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 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) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: 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 Location No. I 09 t "15 Date 7 1-3d . - TOWN OF NORTH ANDOVER ED Certificate of Occupancy $ Building/Frame Permit Fee $ _ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#0 / `� ! Building Inspector i i I 9 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-067602 DAVID R HART PO BOX 1723 `�t'a 211 BROADWAY r* Haverhill MA 01831 ,,,,•. o--Z� , +'`' Expiration Commissioner 05/23/2016 (ply'//'r.'/rale'/rruC.'cal/�O�C-.?�Gt�Cal;;c6c�cr.;C-�fi Office of Consumer Affairs&Business Regulation _,(MOME IMPROVEMENT CONTRACTOR #2egistration x.143708 Type: Expiration y6.-kk16 DBA SERVPRO OF HAVffk. L DAVID HART 230 ESSEX STREET HAVERHILL,MA 01830 - Undersecretary i i Page 1 of 2 '"�I • ° Authorization to Perform Services and Direction of Payment Customer Name: Kendall and Adam Ellard Date of Loss: 07/23/14 Loss Address: 10 Walker Road#2 City: North Andover State: MA Zi 01.845 Insurance/Customer: SAFETY Insurance Claim Number(if available): BOS00044383 The undersigned Customer, being the building owner, owner's representative, or resident, authorizes the Provider indentified below to perform any and all necessary cleaning and/or restoration services on Customer's property located at the property address above, and with respect to items that need to be cleaned at a remote location to remove and clean such items as necessary. Customer authorizes SAFETY Insurance Insurance Company herein referred to as "Insurance Company," to pay Provider solely and directly for that portion of the work covered by Customer's insurance policy. If, for any reason, Customer receives a check from Insurance Company made payable to Customer, Customer agrees to pay Provider immediately upon receipt of the check. In order to expedite payment to Provider, Customer hereby appoints Provider as attorney-in-fact, authorizing Provider to endorse Customer's name on Insurance Company checks or drafts, and to deposit Insurance Company checks or drafts for Provider services. Customer agrees to pay Customer's deductible in the amount of$ _ that applies to this claim. If any amounts owing to Provider for Provider services are not covered by insurance, Customer agrees to pay those amounts to Provider within fifteen (15) days of Customer's receipt of invoice. It is fully understood that Customer and its agents, successors, assigns and heirs are personally responsible for any and all deductibles and any costs not covered by insurance. Interest and finance charges will be charged at the maximum allowable by law, or at 1.5% per month, whichever is less, on accounts over thirty(30) days past due.Time is of the essence. Customer agrees that Provider is working for the Customer and not Customer's Insurance Company or any agent/adjuster. Property Owned By: Remarks: I HAVE READ THIS AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT, INCLUDING THE TERMS AND CONDITIONS OF SERVICE ON THE REVERSE SIDE HEREOF,AND AGREE O SAME. iV Customer Reviewed Customer ormation Fo Y O N Provider's Signature: Customer's Signature: Franchise Legal Name: Printed Name: Kendall and Adam Ellard d/b/a SERVPRO° of: Danvers/Ipswich Date: Date: Customer's Email: ©SERVPRO®INTELLECTUAL PROPERTY,Inc. ALL RIGHTS RESERVED FE-051707 1.0 28000 08/12 Each SERVPRO®Franchise is Independently Owned and Operated. r1 NORT1i _ . WL . _ _ 2 s ic ve, C y. No. soh ver, Mass, k J!j LAKG coc"IcHtWKK 7,95 Rwreo �`4a,��(5 U BOARD OF HEALTH Food/Kitchen PER TT LD Septic System THIS CERTIFIES THAT �:14I. .�I,r.)�.....'. 151.1. , , BUILDING INSPECTOR ....... . . .... ..... .. ..... ...... .. ... . .. .... .. ..... has permission to erect ................. buildings on 1�L...��w... � � Foundation . . .. Rough to be occupied as ......ref► ..W..&4 .................................................... 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 CONSTRUCTIO S 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. Page 2 of 2 AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT Terms and Conditions of Service READ CAREFULLY Note: This Contract includes a limitation of liability and limitation of remedies. 1. SERVPRO@ is one of the largest nationwide Cleaning and Restoration franchise systems in the United States. The SERVPRO®Franchise owner identified on the front of this Contract(the"Provider")is an independent contractor who agrees to perform the services identified on the front of this Contract(the"Services"). Client agrees to purchase,receive,and pay for the Services pursuant to the terms and conditions of this Contract.Servpro Industries, Inc.,the Franchisor, is not a party to any agreement with Client,is not a guarantor of the Provider's Services, and is not subject to liability arising out of such Services. 2. Provider's performance of the Services is limited by,among other things,the pre-existing conditions and characteristics of the premises,material, fabrics,furniture,and/or other items. PROVIDER EXPRESSLY DISCLAIMS ANY RESPONSIBILITY OR LIABILITY FOR ANY PRE-EXISTING CONDITIONS. Client shall retain responsibility and shall be liable for all effects of and costs necessary to correct such conditions, including,by way of example and not limitation,the conditions identified below: (a) Provider may, in its sole discretion,pretest materials for removability of spots or stains;dye or color fastness;shrinkage; fading; adhesive breakdown; or other problems. It is not always possible to determine these conditions in advance. PROVIDER DOES NOT GUARANTEE SPOT OR STAIN REMOVAL AND COLOR FASTNESS OR PREVENTION OF SHRINKAGE, FADING,OR ADHESIVE BREAKDOWN. (b) Provider DOES NOT GUARANTEE that wall and ceiling cleaning will restore the original color to painted surfaces. (c) Not all fabrics are conducive to cleaning. Provider shall use reasonable efforts to advise Client of any adverse effects which may be reasonably foreseen due to the nature of the fabric or material involved. PROVIDER DOES NOT GUARANTEE THAT SUCH MATERIALS CAN BE CLEANED OR THAT THERE WILL BE NO ADVERSE EFFECTS TO ANY ATTEMPT TO CLEAN SUCH FABRICS. (d) A variety of materials are used in the manufacturing,upholstery and/or installation process. These materials include backing,lining,tacks,or other unknown substances that may cause discoloration or other adverse effects to the face material. Client acknowledges that it is impossible to determine when such adverse effects may occur and PROVIDER DOES NOT GUARANTEE AGAINST SUCH ADVERSE EFFECTS. (e) Client acknowledges and agrees that mold is commonly found throughout the environment and that it is impossible to eradicate mold. PROVIDER DOES NOT GUARANTEE THE REMOVAL OR ERADICATION OF MOLD. 3. PROVIDER SPECIFICALLY DISCLAIMS ANY AND ALL OTHER WARRANTIES AND ALL IMPLIED WARRANTIES(EITHER IN FACT OR BY OPERATION OF LAW)INCLUDING,BUT NOT LIMITED TO,ANY IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE OR ANY IMPLIED WARRANTY ARISING OUT OF A COURSE OF DEALING,CUSTOM OR USAGE OF TRADE. THIS CONTRACT PROVIDES FOR THE PROVISION OF SERVICES AND DOES NOT PROVIDE FOR A SALE OF GOODS. 4 Limitation of Liability: IN NO EVENT SHALL PROVIDER, ITS OWNERS AND OFFICERS,DIRECTORS,EMPLOYEES OR AGENTS, FRANCHISOR OR AFFILIATES BE RESPONSIBLE FOR INDIRECT,SPECIAL, NOMINAL,INCIDENTAL,PUNITIVE OR CONSEQUENTIAL LOSSES OR DAMAGES,OR FOR ANY PENALTIES,REGARDLESS OF THE LEGAL OR EQUITABLE THEORY ASSERTED,INCLUDING CONTRACT,NEGLIGENCE,WARRANTY,STRICT LIABILITY,STATUTE OR OTHERWISE, EVEN IF IT HAD BEEN AWARE OF THE POSSIBILITY OF SUCH DAMAGES OR THEY ARE FORESEEABLE;OR FOR CLAIMS BY A THIRD PARTY. THE MAXIMUM AGGREGATE LIABILITY SHALL NOT EXCEED THREE TIMES THE AMOUNT PAID BY CUSTOMER FOR THE SERVICES OR ACTUAL PROVEN DAMAGES, WHICHEVER IS LESS.IT IS EXPRESSLY AGREED THAT CUSTOMER'S REMEDY EXPRESSED HEREIN IS CUSTOMER'S EXCLUSIVE REMEDY.THE LIMITATIONS SET FORTH HEREIN SHALL APPLY EVEN IF ANY OTHER REMEDIES FAIL OF THEIR ESSENTIAL PURPOSE. Some states/countries do not allow the exclusion or limitation of incidental or consequential damages,so the above may not apply to you. 5. Should Provider bring legal action to collect monies due under the Contract or should the matter be turned over for collection, Provider shall be entitled,to the fullest extent permitted under the law,to reasonable legal fees and costs of any such collection attempt,in addition to any other amounts owed by Client.This attorney fee provision shall not be effective or enforceable in jurisdictions where attorney fee provisions are made reciprocal or invalid by operation of law.Consent is hereby given for filing of mechanic's liens by Provider for the work described in this contract on the property on which the work is performed if Provider is not paid. -. 6. Any labor, materials or other work beyond that identified in this Contract shall require a written amendment to this Contract and will result in additional charges 7. Any claim by Client for faulty performance,for nonperformance or breach under this Contract for damages shall be made in writing to Provider within sixty(60)days after completion of services. Failure to make such a written claim for any matter which could have been corrected by Provider shall be deemed a waiver by Client. NO ACTION,REGARDLESS OF FORM,RELATING TO THE SUBJECT MATTER OF THIS CONTRACT MAY BE BROUGHT MORE THAN ONE(1)YEAR AFTER THE CLAIMING PARTY KNEW OR SHOULD HAVE KNOWN OF THE CAUSE OF ACTION. B. A failure of either party to exercise any right provided for herein shall not be deemed to be a waiver of any right hereunder. 9. CLIENT AND PROVIDER EACH WAIVE THEIR RESPECTIVE RIGHTS TO A TRIAL BY JURY WITH RESPECT TO ANY AND ALL CLAIMS OR CAUSES OF ACTION (INCLUDING COUNTERCLAIMS)RELATED TO OR ARISING OUT OF OR IN ANY WAY CONNECTED TO THIS CONTRACT AND AGREE THAT ANY CLAIM OR CAUSE OF ACTION WILL BE TRIED BY A COURT TRIAL WITHOUT A JURY. 10. If any provision of this Contract is found to be ineffective,unenforceable or illegal for any under present or future laws,such provisions shall be fully severable,and this Contract shall be construed and enforced as if such provision never comprised a part of this Contract.The remaining provisions of this Contract shall remain in full force and effect and shall not be affected by the ineffective, unenforceable or illegal provision or by its severance from this Contract. 11. No modification,termination,or attempted waiver of this Contract shall be valid unless in writing and signed by the party against whom the same is sought to be enforced. SERVPRO®Franchisees are always looking for motivated employees. SERVPRO's individually owned and operated franchises offer a variety of positions including crew chief, production techician,marketing representative,administrative assistant and many more. ©SERVPRO®INTELLECTUAL PROPERTY,Inc. ALL RIGHTS RESERVED FE-051707 1.0 28000 08/12 Each SERVPRO®Franchise is Independently Owned and Operated. Main Level 26' 10" 10' 4" 15' 6" Pink Bedroom cn Kitchen o p 2' 8"-� 2'4' °O 12' 10" 0„ 1' 2" 3' 9' 6" Hallway Bathroom �' b� 8' 111 N M 11' 6' 10" 1 �5' 7„ N Livingroom i` Fn kn Blue bedroom LRJ 13' Main Level SHAWMUTPROB10U2 �,,,r 7/29/2014 Page: 6 p The Commonwealth of Massaeh.useft . De,�azrtmento,�'.�nc�'�c�hzccZ.Accic�en�� • . Office oflnvestigations 6114 Washington.Street .Boston,MA 42111 ww1-s.mass.govIdia wor exs'Cow emationY surance.Af'idavit:BaderesIContractors)FIectricianstTT*Z erp A- na. neantMoration Please,PrimLe 'bZ f I" 'Name(Rusin.essl0rganizationlfndz`viduat): Address: c� - Cz y/5ta�el�ip: hone : -7 .Are you an employer?Check the appropriate box: Type of project Crecluired): I.K I am a employer withC-�_ `l'. [1 Z am a general contractor and I 6. El Now contraction F employseshave Wredthe sab-contractors 2.El am.a sole proprietor or p ar[n.ez listed on the attached sheet. 7. El E emodeling ship and`havena.employees The.-aob-contractoxshave, 8. WDemolition�-- e working forme in.any capacity. workers'comp.insurance. 9. []Building addition [N'o workers'comp.insurance 5. [I We are a corporation and its 10.0 Electrical repairs or additions re claired.] officers have exercised.their 3.0 X am a homeowner doing all work right of exemption per MGL 11._[j 1?lumbing repairs or additions myself PTO workers'comp. c.1.52,§1(4),a-adwehave no 12.PRoofxepairs insuranceregated.]i employees..[No workers' aEl Other comp.insurance required.] Any applicautthat checks box#I must also fill outthe section bel6w showingtheir workers'eompensationpolicy information. ?Homeowners who submitibis affidavit indloatingthey ae doing allworlc and tfien hire outside contractors must submit anew affidavit indicating such. TContractors that checktbis box must attached an additional sheet showingthe name of the sub-contractors and their workers'comp.policy information. .i'arnanempl'oyeNiiiaiisp�ovirlingworl�e��s'compevsafloniasuranceformyemployees Berowisgepolicyczr2cijo�s�e Mformation. Insurance Company NaM0,:Ajt4-L—�- j Policy#ox Selz ins.LIG.#: Ii�' Expiration Date: ' lob Site Address,— I O i �- City/State/Zip: f r .Affach a copy ofthe workers'compensationTollcydeclaration page(showing-the policy mmber and M' iration cl-ate). Failure to secure coverage as xequixedunder Section 25.A.ofMGL e.152 can.lead to the imposition,of crha alpenalties of a eine up to$1,50 0.00and/or one�y'ear impriso�xtent,as well.as Devil penalties in the form of a STOP WORD ORDER.and a Arte of-up to$250.00 a day against the violator. Be advised that a copy ofthis statementmay be forwarded to the Office 0. investigations of the DIA for insurance coverage verifleation. do liereby cert under tree pains andpena ties of eYpTy treat tree information provided'above is true and correct. - Si ature: Data. Phone# ofcial use o tly. .Do not write in this area,to be coxazpleted ry city or town ofcia7. City or Town: PermifflIcense 9 Issuing Authority(circle 6ne): x.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other 11 Information a� . d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute e� CC an n To eeis defined s P y a ..,every person ru the service of another under any contract o�bire,- express orimplied,oral oxwxitten.." . .An.enTloyWisdefined as"an.individual,partnership,association,corporation other . a. � x gal entity,ax an two oxanore of the foregoing engaged in a joint enterprise,and includingthe,legal representatives ofwdeceased employer,,or the receiver or trustee Qi~an individual partnership,association ox other legal entity,employing employees. T�owevex the owner•of a dwelling house havingnotmorethmthreeapartments andvvhoresidesthereinoxtheocoas. wove dwelling house of another who employs persons to do maintenance,construction or•repair work on such.dwelling house ox onthe grounds oxbuR&g appuAenamttherefo shallnot because ofsuch employmentbe deemedto be as employes." MGL chapter 152,§25C(6)also states that"every state or local Zic-ensiag 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 r•egquked." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nox any of its political,subdivisions shall enter into any contract for the performance ofpublze work until acceptable evidence of compliance with the insurance requirements of Us chapter have,b con presented ta the cgnfxacting authority," Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation an d i£ iiecedsary,supply sub-conixactor(s)name(s),addresses)audphonenumber(s)along with their cexti£"zcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orPF[uers,arenotrequiredto carry workers'compensation iasurance. If an LLC orLLP does have employees,a policy is required. De advised thatthis affidavit maybe submitted to the Department of Thdastrial, Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit: the affidavit should be retumedto the city or town thatthe application for theperunit or license is being requested,not the Department of Industrial Accidenfs. Should you have any questions regarding the law ox if you are xequired to attain,a*orkers' comp ensationpolicy,please call the Department at the number listed below: Self insured compa�ries should enter their self-insurance Incense number on the appxopxiate line. City or Town Officials Pleasebe sure thatthe affidavit is complete andprinted legibly: The Department has provided a space atthe bottom o£the affidavit£oxyou to fill out in the event the Office ofTnvestigatiOnshas to contactyouregardingthe applicant. Please be-sure to:M inthe pema t/license number which-will be used as a reference number, Tn.addition,an applicant thatmust submitmultiple penmif/license applications in any given year,need only submit one affidavit indicating current palicy information(i£necessmy)and under"Yob Site Address"the applicant shouldwrite"all locations in (city or town).". copy co affidavit that has been Officially stainp ed or marked by the city ox town may be prov_fd�d to the applicant as proofthat a valid affidavit is on Mei for future p ermits or licenses, .A new affidavit must be filed out each year.Where ahome owner orcitizenis obtaining a license ox�enrnitnot related to anybusiness or commercial venture (i.e.a dog license orpermitto burn leaves eta,)saidperson is NOTrequiredto 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 aiud fax number; Ua CQ ouman ofM-0auO wattq Dopaxtmont dkduatdal AcC.l 044 d0 wuwngtm Boston,MA021x1 Mum 49 Revised 5-26-05 FOX#61MU 7749 WWW- aa5,,%gQ-V1ChN ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)08/04/2014 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). PRODUCER WNIALA NAME; Emily Costello COSTELLO INSURANCE AGENCY PHONEA/c No E,): 978.374.6352 (A/C,No:978.521.5127 2 South Kimball St. ADDRESS: ecostello@costellonh.com PO Box 5248 INSURERS►AFFORDING COVERAGE NAIC# Bradford, MA 01835 INSURERA: Liberty Mutual Fire Ins. -ARWC 16586 INSURED Servpro of Haverhill INSURERB: DBA: 211 Broadway Realty Trust INSURER C: 211 Broadway INSURER D: Haverhill, MA 01832 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 2013-2014 WC 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. INSR AUUL POLICY EFF POLICY Ext, LTR TYPE OF INSURANCE INSR VWD POLICY NUMBER MWDD MWDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE F—]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PROECT LOC $ J AUTOMOBILE LIABILITYEa acLUMtSc dent $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED P BODILY INJURY(Per accident)AUTOS AUTOS ( ) $ HIRED AUTOS NON-OWNED $ AUTOS Per accident UMBRELLA UAB HOCCUR a EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC531S368163013 08/19/2013 08/19/2014 X TORY AND EMPLOYERS'LIABILITY Y/N LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIV� E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? I • i N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if nv"space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Kendall & Adam El 1 and AUTHORIZED REPRESENTATIVE 10 Walker Road, Unit 2 North Andover, MA 01845 Emily Costello ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I