HomeMy WebLinkAboutBuilding Permit #815-16 - 100 RALEIGH TAVERN LANE 1/20/2016 ��NNN '",' BUILDING PERMIT NO pT b:�tio
TOWN OF NORTH ANDOVER °?
APPLICATION FOR PLAN EXAMINATION
� Z �« fa1
H T
4 4 10
Permit No#: Date Received
gSSACHUS
Date Issued:
IMPORTANT:Applicant must complete all items on this page
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LOCATION �d 0- _-_ G--�./ �i f-l- _ _ ee ✓_ _ _46 -
Print _...
PROPERTY, OWNER- r9✓t p G�� Cr/� _ _ Gc/ 6JAIPQ_
Pri 1 o0 Year structure yes n
MAPPARCE �_ZONING DISTRICT _ Historic District yes n
--
Machine Shop Village yes n _
TYPE OF IMPROVEMENT PROPOSED USE
Resi ential Non- Residential
❑ New Building One family
❑Addition ❑ Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
�d Septic- 'Well ❑ Floodplain p Wetlands ❑ Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
POS 0 e"e- fid" /rU X/ew r,-0-dy't�{�j� Ayrz,;, ' 3z
1- Gye 14-9" JWC " c6o SVr, IA/;i� 1poce�! /�aa" / //Vs/s'/. , -e—
/1/ta/ f!x%v aS y tick/,/y�
Identification- Please Type or Print Clearly
OWNER: Name: /qf v1p Gv 0,y,90Lo 4jS el Phone: P6 6&, �(
Address: 04) /94 014 j J
Contractor Nam- .e:.. ori �� - _ _ - -_ �J7 ��Z '`J 7 4
_ v _
Address:'_ ;?
Su ervisor's Construction License: /a 6 0 0 6 4 `
Up - - - Exp.. Date:
Hortme,lmprovement License: /(y_ �J Exp. Date: -. _-
1„
ARCHITECT/ENGINEER Phone:
L
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: $ OA 3 -
Check No.: c2w Receipt No.: Z
NOTE: Persons contracting with unregistered contractors do not have access to the g aranty fund
- ,Sid gnature of Agent/- nor 4- Signature of contractor
k
Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑
T-'_PE_OF_SE_V&RAGE_DISPO.S.A-L_
PublicSewer ❑ 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
J
`HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
I
Planning Board Decision: Comments
i
L 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
Iooatedl,atI24 Maih Street
Fire'Department.sign.ature/date
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)
❑ 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)
❑ 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 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 �
x
No. Date
• - TOWN OF NORTH ANDOVER
�N Certificate of Occupancy $
._ $
. _ Building/Frame Permit Fee_ !1
- , Foundation Permit Fee $ '
Y t.
o\� Other Permit FeeTM
$
TOTAL $
r
Check#
2993 Building Inspector
NORTH ,
8 r
7Town of nuove
ta- -n
C,, LAKE h , ver, Mass, /-o?O -/4p,
�I- COCNICHIMCN y1.
7,95 RAre9)
V BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ae.V Cti........�0 x.0.41 .4...Lo.�i�4, (.f.'.,l .X.............................. BUILDING INSPECTOR
. .......... .. .... ....
Foundation
has permission to erect .......................... buildings on A.(9..... i.'t... :'............�.........
� *t'ej&11(x4
Rough
to be occupied as .........J.. ......J! .vAM...... ..:�:.....0_/0!^ s.'............. 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 ST TS 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
all To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
214 Sutton Hill Rd
North Andover MA 01845 Contract
978 852-4491 Wondolowski 2015-058
wwwTMKremodeling.com 1[ )1f(Dl✓LIi\'G
CONTRACTOR AGREEMENT
THIS AGREEMENT made this C C
20�by and between T-headers-iE }ra-TMK
Remodeling Construction Supervisor License#105086, 214 Sutton Hill Rd, North Andover MA 01845
hereinafterXIled the Contractor,and Leslie&David Wondolowski hereinafter called the Homeowner.
Z&G
WITNESSETH, that the Contractor and the Homeowner for the consideration named herein agree as follows:
ARTICLE 1. SCOPE OF THE WORK
The Contractor shall perform all of the work described in the specifications entitled Exhibit A—Statement of
Work, as annexed hereto as it pertains to work to be performed on property located at 100 Raleigh Tavern
Lane North Andover MA 01845.
Scope Summary:
Remodel first floor hallway bathroom approx.23 SF in reconfigured footprint. Remove existing fixtures and
finishes. Remove 2 doors and dividing partition between bathroom and adjacent closet. Install new pocket
door. Install 24 SF of oak strip flooring in hallway to match existing. Install new fixtures and finishes. Pantry
Closet: Construct new shelves with vertical dividers. Install new 30x78"6 panel door/frame/casing. W/D
Utility Closet: Install base cabinet with existing countertop. Relocate plumbing vent. Install vertical divider with
hanging rod. Install new GFCI outlet and relocate existing receptacle. Install new strip light. Garage Utility
Cabinet: Construct new 24x30x8O"cabinet in garage at entryway. Construct shelves and vertical dividers with
cabinet doors and install light on motion sensor.
ARTICLE 2.TIME OF COMPLETION
The work to be performed under this Contract shall be commenced on or before January 18, 2016 and shall
be substantially completed on or before February 12, 2016
ARTICLE 3.THE CONTRACT PRICE
The Homeowner shall pay the Contractor for the labor and materials to be performed and supplied under the
Contract the estimated sum of Twenty Thousand Two Hundred Ten Dollars and No Cents ($20,210.00),
subject to additions and deductions pursuant to authorized change orders. The contract price includes two
components;
Fixed cost of Seventeen Thousand Four Hundred Eighty Five Dollars and No Cents($97,485.00)for the
building materials and construction labor as specified in Exhibits A and B.
Variable cost of Two Thousand Seven Hundred Twenty Five Dollars and No Cents($2,725.00)for the. -
allowance items listed in Exhibit B Allowances and-will be-190%.of the actual invoice price paid by the _-
Contractor to his suppliers. Exhibit 8 lists-the allowance items and budget costs the Contractor will purchase
for the Homeowner. Sales tax and freight are not inlcuded in allowance budget.
Contractor will furnish and install all building materials, fixtures and finish items unless noted otherwise. Any
Homeowner supplied materials will be charged a 15% handling and coordination fee based on actual invoice.
ARTICLE 4.PROGRESS PAYMENTS
Payments of the Contract price shall be paid in the following manner from the Homeowner to the Contractor:
Payment 1: 33% upon contract acceptance and signature; $6,736.67
Payment 2: 33% upon rough building inspection;$6,736.67
Payment 3: 33% upon final building inspection and 90% completion of finish;$4,011.67 plus the actual
contract price for allowance items as defined in Article 3; Budget:$2,725.00
Initials " Copyright TMK Remodeling 2014
All Rights Reserved Page 1
214 Sutton Hill Rd
North Andover MA 01845 Contract
978 852-4491 Wondolowski_2015-058
wwwTMKremodeling.com REMO>JELINC
The contract cost for mutually agreed to change orders will be paid 50%at time of change order signature and
50%after completion and Homeowner sign-off.
ARTICLE S.GENERAL PROVISIONS
1.All work shall be completed in a workmanship like manner and in compliance with all building codes and
other applicable laws.
2. To the extent required by law all work shall be performed by individuals duly licensed and authorized by law
to perform said work.
3. Contractor may at its discretion engage subcontractors to perform work hereunder, provided Contractor
shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this
Contract.
4. Contractor shall furnish Homeowner appropriate releases or waivers of lien for all work performed or
materials provided at the time the next periodic payment shall be due.
5.All change orders shall be in writing and signed by both Homeowner and Contractor. The cost for mutually
agreed to additional work, required due to unknown conditions or substantive change orders, will based on the
current bill rates for the actual time used.Additional materials will be billed at contractor cost.All change
orders subject to 15%markup for overhead.
6. Contractor warrants it is adequately insured for injury to its employees and others incurring loss or injury as
a result of the acts of Contractor or its employees and subcontractors.
7. Contractor shall obtain all permits necessary for the work to be performed.
8. Contractor agrees to place all debris in an on-site trash receptacle(dumpster)and leave the premises in
broom clean condition.
9. In the event Homeowner shall fail to pay any periodic or installment payment due hereunder, Contractor
may cease work without breach pending payment or resolution of any dispute.
10. The Contractor and the Homeowner hereby mutually agree in advance that in the event that the Contractor
has a dispute concerning this contract,the Contractor may submit such dispute to a private arbitration service
which has been approved by the Office of Consumer Affairs and Business Regulation and the Homeowner
shall be required to submit to such arbitration as provided in MGL c 142A.
SLI/y//1
Ho owner Date:
Contractor l
Date:
Notice: The signatures of the parties above apply only to the agreement of the parties to alternate dispute
resolution initiated by the Contractor. The Homeowner may initiate alternative dispute resolution even where
this section is not signed by the parties.
11. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes,
casualty or general unavailability of subcontractors or materials, or inclement weather.
12. Contractor warrants all work for a period of 12 months following completion.
4qe___1 Copyright TMK Remodeling 2014
Initials All Rlghts Reserved Page 2
214 Sutton Hill Rd
North Andover MA 01845 '" Contract
978 852-4491 Wondolowski_2015-058
WWWTMKremodeling.comRE
iff3t3 �g; C,
13. Contractor may post small signage(36x36")on property advertising services during the duration of the
project.
14. The Contractor and subcontractors shall be registered and any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business Regulation
Ten Park Plaza, Suite 5170
Boston, MA 02116
Phone: (617)973-8700
15. The Contractor or Homeowner may terminate this contract at any time for any reason by giving 3 days
notice in writing to the other party. If either party terminates the contract as provided herein,then the
contractor will be paid for work(labor and materials)completed as of the date of termination plus any
materials or equipment that are ordered and not delivered. Payment is defined as actual job costs for the
project plus 15%overhead charge. The contractor will provide a written report detailing actual job costs plus
overhead for payment. The Contractor will refund any funds paid by the Homeowner if there is a remaining
balance for the labor and materials used as of the date of termination, plus any materials or equipment that
are ordered and not delivered, plus 15%overhead charge. The Contractor will make arrangements for the
ordered items to,be delivered to the Homeowner.
16. The Homeowner is responsible for maintaining adequate access to the property including snow removal,
personal property storage, and working doorways, stairways and walkways. In the event the contractor is
required to provide access or repair to the doorways, stairways and walkways, then the Contractor will bill the
Homeowner at the hourly bill rate for same.
ARTICLE 6.OTHER TERMS
ARTICLE 7.ACCEPTANCE
Signed this 'day of /0 2C /•
_mss
Homeow r
Contractor
NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute
resolution initiated by the contractor. The Homeowner may initiate alternative dispute resolution even where
this section is not signed separately by the parties.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Initials Copyright TMK,Remodeling 2014
All Rights Reserved Page 3
The commonwealth of Massa0uselts
Department of Ir�dr�stl"rc�l�Accic�erats
M 1 Congress Street,Suite 100
Boston,MA.02114-2017
www.mass.gov/dia
Workers:,Compensation
TOhE�ED'9VXTH�THEPERMI e�'TING.A•UTHORI'1 St.�icians/1'1.umbers.
Information
Please Print Legibly
Alicant
Name(Business/Organization/Individual): ��-
Address:
City/State/Zip: /U. 4vr� 144– Phone#:
Areyou an employer?Checkge appropriate box: Type of project(.Tegnired):
1. T am a employer with___ (full and/or part-time).* 7. Q New construction
2,u I am for in 8. Remodeling
a sole proprietor or partnership and have no employees working
any capacity.[Noworkers'comp.insurance required.] 9, ❑Demolition
3.[J I am a homeowner doing all work myself[No workers'comp.insurance required.]f 10 C1 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
y- prop fetors withno empioyees. -- -—12:E]Plumbing repairs.or additions..,._ ,
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1.3.Q Roof repairs
These sub-contractors bade employees and have workers'comp.insuranc0 14.❑Other
6.FlWe are a corporation and ifs offigers have exercised their right o£exemption per MGL c.
152,§1(4),and we have nq employees.[No workers'comp.insurance required.] -
checks box must also fill out the section below showing their workers'compensation policy information.
`Any applicant that
i Homeowners who checkssubatbhis ailidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
?Contractors that check this box must-attached an additional sheet showing the name of the sub contractors and state whether or not those entities have
employees. if the sub-c6i&acf6rs fiave employees,ley Drust provide their workers'comp.policy number.
lam an employer that is piovidlhg workers'compensation insurance for my employees',below is the policy and joie site
information. ��j�
Insurance Company Name:
—Z 1 T)47 Expiration Date: / Z�
Policy#or S elf ins,Lie.#:
/OD �?-Gf�G �A� City state/Zip: ✓U1.4 �C 7l°i
fob Site Address: �fJ
Attach a copy'of the workers' compensation policy'declaration page(showing the policy number and expiration date).
e u to 1 50
0.0
punishable,b a fin $
� coverage,as re aired under MGL c. 152,§25A is a criminal violation p Y p
Failure to secure 9. e of u to$250.00 a
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fin p
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance
coverage verification.
.rode hereby certify der the pains andpenaIt* ofpe .r��tlaat the information provided above is true and correct.
Date:
Si nature:
Phone If:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one): i
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 a}1 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 6f flire,
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 ofpublic work untilacceptable 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-contractors)name(s),address(es)and-phone numbers)along with their certificates)of
• -- - insurance—Lmuted-Liabihty-Companies-(ELC)-or-Limited Liability Fart ems-In PLP)with no emp ogees 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 maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The'affiidavit*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'entertheir
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. Anew 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.#617.727-4900 ext.7406 or 1-877-MA.SSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
ACOR OP ID: Pr
�.. CERTIFICATE OF LIABILITY INSURANCE01/20/2016
AATE(MM/DDNYYY)
THIS CERTIFICATE IS ISSUED AS q 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 terns and conditions of the policy,Certain policies may raquire an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
Se reve&Hall Insur.Assoc.lnc NAME:
PHONE
3Q North Main St. No FAX Nv.
Andover, MA 01810
1.
Lawrence J.Hall ADDRESS:
PKVc °`�ERID .TMKRE-1
INSURER S AFFORDING COVERAGE NAIC k
INSURED TMK Remodeling INsuRERA:Arbel14 Proteotlon Ins.Co. 41380
214 Sutton Hill Rd INSURER o:AEIC 11104
North Andover,MA 01846
INSURER c:
INSURER 0:
INSURER E:
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. 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.
IN5R
TR TYPE OF INSURANCE Ina VUVDPOLICY NUMBER MMlpMMIDD I IMIT8
GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000
A X COMMERCIAkGENERAL UABIUTY PR 8ES Es ocamenco $ 100,000
CLAIMS-MADE 191 J OCCUR MED EXP(Any one arson) S 55,000
9520037133 0310812015 03/0812016 PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
OENL AGGREGATE.LIMIT APPLIES PER: PRODUCTS-COMPlOP AGO ffi 21000,000
POLICY JECT
PRO LOC $
AUTOMOBILE LIA61LnY COMBINED SINGLE LIMIT
ANY AUTO
(Es accidelro $
ALL OWNED AUTOS '
BODILY INJURY(Per person) $
SCHEbULED AUTO& BODILY INJURY(Per eccideq $
MIRED AUTOS
PROPERTY DAMAGE
(PER ACCIDENT) E
NON.OWNED AUTOS $
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXC2SS LIA6 CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RET NTION
WORK@R8 COMPENSATION WC STATU- I I OTH.
AND EMPLOYERS'LIABILITY TORY MMIT
B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
OFFICER/MEMBER EXCLUDED? LiN/A E.L.EACH ACCIDENT $ 600,00(
(Mandatory in NH) 6006011872 04/01/2015 04/01/2016 E.L.D(SEAgE-EAEMKOYEE S 500,00
Ifyes describe under
DES IPTION OF OPERk
TIONS below E.L.__T DISEASE-POLICY LIMIT 8 500100
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Att2ah ACORD 101,Additional Remarks Schedu)a,If more epaoe Is required)
ref job 100 raliegh tavern road
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
1500 Osgood Street
North Andover,MA 01845 AUTHORIZED REPRESENTATIVE
01988-2009 ACORD CORPORATION. All rights reserved,
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
ems= Massachusetts Department of Public Safety
tfii1 Board of Building Regulations and Standards
License: CS-105086
Construction Supervisor
THEODORE M KELLEY
4 214 SUTTON HILL I Da 11 T
NORTH ANDOVER. -M-- 0,1845
r
.y�
i 5 .)I'li�lA
i
(� l� Expiration:
Commissioner 10/08/2017
/ze�po6nin2ancaea.�o�G���ac/zuaelt"
ffice of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
istration: y a
9 1.65887 Type:
xpiration: "4(5101F DBA
TMK REMODELING r't
THEODORE KELLEY
214 SUTTON HILL RD. 0 =<.x'
r
NORTHANDOVER,MA 01845
Undersecretary
1
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation i
10 Park Plaza-Suite 5170
Boston,MA 02116
i
. I
'; Not valid without signature