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HomeMy WebLinkAboutBuilding Permit #780-13 - 1018 OSGOOD STREET 5/16/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 3 Date Received ' I Date Issued: I ORTANT:Applicant must complete all items on this page LOCATION{ -Al K`..'1.x. y f N PROPERTY OWNER ✓' Pnn ar Old structure� yes s no fi 3' MAP NO PARCEL ZONING DIST�R.I -T a N,isto c District yes o d . Machine°ShopMillage .;yes' no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units- 0 Repair, replacement ❑Assessory Bldg ❑ Others: Demolition ❑ Other eptic 0 Well loo ' lain,, ❑Wetlands ❑ Watershed District, 0 Water/Sewer DESCRIPTION OF WO Rrc TO BE PERFORMED: C7 1 � 1 h �✓� 9 Identification lease ype or Print C1 1 ) OWNER: Name: �� I I w L Phone: /7 Address: o pec. ,�►� ��C r G Nom``" I �-. CONTRACTOR Name: Phone: - 6� 7. '' 1-2- �, M``w�� �'`S'fGf Address: /�ecc-~4�• � �, v► � . . . "� ` Ex Supervisor's Construction License: ``c� Qui" p.. Home Improvement License: .S q 5 l Exp. Date:. i ARCHITECT/ENGINEER IV Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 1 Cf FEE: $_ 1 o Check No.: 00 3 9� Receipt No.: aha ITdo" NOTE: Persons contracting with u r ist ed contractors do not have access to the r fund :Signature of Agent!Owner Signature of contractor Plans Submitted ❑ Plans Waive ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF-SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ .. .Swimming Pools ❑ Well El Tobacco Sales El Food Packaging/Sales 11Private(septic tank,etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ 171 L, r3 a COMMENTS CONSERVATION Reviewed on 61 1 3 Signature COMMENTS pr, 1, HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ._ ? C.Q. Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit- , �. DPW Town ]Engineer: Signature: R. Located 384 Osgood Street FIRE ®EPARTIt/I i�T - Teinp Dumpster on site yes no Located at,i24 Mair?Street I Fire ®epailmer t-signature/plate COMMENTS �.. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter 16 cation, 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 �1 13 Notified for pickup - Date j i I oc.Building Permit Revised 2010 I I 1 Building Department The foliowing is a list of the required forms to be filled out for the appropriate.permit to be obtained. q Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o- Engineering Affidavits for Engineered products gOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan o Workers Comp.Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application ❑ .Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) e, o Copy of Contract ❑ Mass check Energy Compliance Report Li Engineering Affidavits for Engineered products 90TE: 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 appal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording Ynust be submated with the building application Doc: Doc.Builyding Permit Revised 2012 Location No. Date i esr >r� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee .. Foundation Permit Fee Other Permit Fee 7`" TOTAL $ I Check# - �i 26408 r Building Inspector NORTH own of ndover No. b _ 41 _ ,� hi o ��_ h . ver, Mass, �J- COCHICNIWICK y1. 7,9 AERATED S U BOARD OF HEALTH Food/Kitchen PERMI-T T LD Septic System THIS CERTIFIES THAT .....����...�.�..�..c� .. ..�r:!:�!.SU.............................. ............................ BUILDING INSPECTOR // has permission to.erect buildings on ( D �� Foundation Rough to be occupied as ...................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS- ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service .................. ...... . �..�.................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display i•n 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. SEE REVERSE SIDE The' CO m-o'nwealth of Mas's' achusetts Department of Fire Services . Office- of the State"Fire Marshal. i F:0.Bax.1025 State Road,Stow-MA MA 0I775 . 'APPLICATION FOR PERMIT Date: N. A n'd o v e r T ermit"1No (City or Town.) ($Applicable) Dig.Safe Numb laaccordanccwith the provisions of MG-L. Chapter 10 as providcdiusectioa 5.27 CMR 34 - applicatiouis'herebymade Start Date l ! jFuil e.ofperson,F' "or•Cnrporadoa) 'State clearly Address d Q� of parposefor �� G Mv. V e-y, " (Street ocP.O.Bax City or?own tr+ N which petniit is requested Forpemussioato locate dumpster for construct _on/rpnnvafii on /rlemnl i tion -of building. Comments: d u m p s t e r mu t be .25 ` ' from structure or 'co ere e at 10 12 G dab c"e N. 2 r 1 (Give loeatio by street and no.,or descn c in suehsnauacr as to pro ed adequate identification of location) Name of competeat'aperator Cert No. (IfAPpliccbk) - Date•Issued-rcieeted By (Signature of•Applicant) =. Date of expiradon Fee S -90 -00 Paid Due ut T Th: C(:)mmon , " O assa sit Departmeh.t of Fere Services ' Office of the State Fire Marshal P. 0.Box 107j State Road,Stow,NU 01775 PERMIT Date: North Andover TermitNo- City of Town) (LFApplicable) Dig Safe Number In accordancd with the provisions of M G-Ll 4 8 Ghap.ter_ ] ( as provided in 34 Start Date This Permit is granted to:. Full name ofpersoo,Firm*or Corporation Permi_ssionto locate dumpster • for construction/renovation/demolition of building. Comments: dumpster must be . 251 from structure if unable to place with required Restrictions:clearance dumps-ter must be covered with plywo-od or tarp end of 'work -da'y at (Give location by street and no.,or describe in such manner a to ovied ode idea tiF on of location) Fee Paid S 50 -00 Fire Chief �c2 This Permit (S ignab-ire of officai granting permit) Offical n gpcmut -mi.1 ) ff II �,- The* Com -n 6nwealth of Massachusetts (� Department of Fire Services Otice' of fhe Stale-Fire Marshal ' =i P:0.Box.1025 StataRoad,Stow-NLA 01775 . 'APPLICATION FOR PERMIT Date: N. A nto v e r Ter-mit-No --Fcity ar Tawn.) (LfApplicable) Dig,Safe Numb in acccrdaaccwith the provisions ofMGl.. Chapter 10 as Provided in Section 527 CUR 34 applicatica is-hereby made Start Date (Full e.of person,Fiffi or corporation) State clearly Address 0 T�l c4 0� ���tl purpose for -Le_G M v im'J (Street or P.O.Eax City or Town �U ri't`e''A wluch•peaait - . t �L/ is requested Forpcanissioato locate dumpster for constructs nn/rennvati nn /riamnl 1 tin, of building. Commcuts: dumpster mucit be .25 ' ' from structure or 'co ere Ts_ .e QS r7 cr I (Give Ioeatio 6y street and no.,or dcsrn a in such tnaaner as.to pro ed adequate identification of location) Name of competentoperator Cert.No. (If Apphc=ble) DateLsmed-rejected ey (Signature of•Applicant) ' Date of cspiration Fee$ 5 0 .0 0 paid Due _ - at Thh-e - �. -n rn IIa th M assach usetts Department of Fire Services ' Office of the State Fire Varshal P. 0.Sox 102 S[itepRona�d,TStavi,NU 01775 ; ... PERMIT Date: North Andover l'ermitNo (-------------- Ctbf of Town) (If Applicable.) °.Dig Safe Number In accordancd with the provisions of iVL G L.l LF 8 Chap.ter. 10 asprovided is sedtion- 5 7 7 f:MR 34 .This Permit is granted to; Start Date I Full name of Person,Firm'or Corporation Pennissionto locate dumpster - for construction/renovation/demolition of building. Comments:' dumpster must be . 25 ' from structure if unable to place with required Restrictions:clearance dumpster must be covered with P17Wood or tarp end of work -da:y- - at (Give location by street and no.,or descn-bc in such manner aceto ovicd adef identiF on of 1'ccatioa) .Fee P aid$ 50".00 � � ( J • l / Fire Chief This Permit will expire. (Sia ature of offi cal granting permit) Ofc"tcal ntrngpctmit (Title) Town'of North Andover o� No DTH qti Building Departmenta o 1600 Osgood Street �' y': 0� North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 �c - �, I my o cocro�ew.c« �1 DEMOLITION OF BUILDING AFFIDAVIT �.9 AERATED SSACHU`-'� DATE L OWNER'S NAME &ADDRESS G-�U 1, CV <,A LLc: LOCATION OF PROPERTY TO DEMOLISH 5 A -- N V4r I"`Ada II DESCRIPTION �eS t G✓� �T Cvl/�' CONTRACTOR'S NAME &ADDRESS 4CLACj DEP!�ATMENT SIGN-OFFS ` DEPT. OF PUBLIC WORKS -WATER: � SEWER: DEPT OF CONSERVATION HEALTH DEP . Septic Well HISTORIC COMMISSION ,Jy GAS ELECTRIC TELEPHONE CABLE -4 TAXES POLICE ' Ndd4J r e FIRE o_ EXTERMINATOR eS DUMPSTER—O OFF TREET W °,S DIG SAFE NUMBER Z,c� . I LI i' a 3-117 DATE REC'D BLDG. INSPECTOR D . oc.form demolition of building affidavit 9 A�® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/29/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,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 CONTACT Elaine Dozois,AAI Fred C.Church,Inc. NAME: 41 Wellman Street PHONE 978 3227243 FAX (978)454-1865 AIC No Lowell,MA 01851 E-MAIL (800)225-1865 ADDRESS: edozois4�fredcchurch.cam INSURERS AFFORDING COVERAGE NAIC# INSURER A: Charter Oak Fire Ins.Co. 25615 INSURED INSURER B: Commerce&Industry Ins.Co. 19410 St.Miguel Construction,LLC INSURER C: 280 Merrimack Street Methuen,MA 01844 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2361s 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. j INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DD/YYYY MPOLICY EFF M UCYEXP LTR DDIIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED 300,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE F_i]OCCUR MED EXP(Any one person) $ Excluded A 680192M8710 10/5/2012 10/5/2013 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- TORY OTH- AND EMPLOYERS'LIABILITY YIN N S ER 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ B OFFICER/MEMBER EXCLUDED? F-1N/A WC3250371 7/21/2012 7/21/2013 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEd$ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) job site-1018 Osgood St.,North Andover,MA CERTIFICATE HOLDER CANCELLATION Town of Andover Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Andoover,ver,MA 01845 36 t THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN M ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ' P Client# 3411 Mst If 23616 Cert Holder# 36181 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/lndividual): i Address: AC'r(-, V,\a 0�< < SU I k, X City/State/Zip: /44?f 41/.v, M O l��qPhone#: 6 / / Are you an employer?Check the appropriate box: Type of project(required): 1NI am a employer with 4. ❑ I am a general contractor and I ❑ �_ 6. New construction employees(full and/or part-time).` have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.# �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees.[No workers' q ] 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below.showing their workers'compensation policy information. Homeowners who submit this affidavit 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert under the a. d pen of erjury that the information provided above is true and correct. Signature: Date: 4-1 .G Z C�l I Phone# 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Inst � •- n�t _ ions . Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees.. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure.to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth ofMassachwetts Department of lndustrial Accidents Office of Investigations 6.00 Washington Street Boston,MA,02111 Tel,#617-72.7-4900 ext 406 or 1-577:Nl'.ASSAFE Revised 5-26-05 Fax#617-727-7749 w .mass,gov/dna • <s Massachusetts- Department of Public Safet% Board of Building; Rel-ulations and Standards Construction Supervisor License License: CS 81897 GREGORY J NOLAN 13.WOODLAND AVE KINGSTON, .MA 02364 Expiration: 10/23/2013 t'oninissiunct Tr##: 7115 i i A� CERTIFICATE OF LIABILITY INSURANCE 042912013MMIDD/YYYY) 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 CONTACT Elaine Dozois,AAI Fred C.Church,Inc. NAME: 41 Wellman Street PHONE 978 3227243 FAX (978)454-1865 (AIC.No.Extid AIC No): Lowell,MA01851 E-MAIL (800)225.1865 ADDRESS: edozois@fredcchurch.com INSURERS AFFORDING COVERAGE NAIC A INSURER A: Charter Oak Fire Ins.Co. 25615 INSUREDINSURER B: Commerce&Industry Ins.Co. 19410 St.Miguel Construction,LLC INSURER C 280 Merrimack Street Methuen,MA 01844 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:23616 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 TYPE OF INSURANCE POLICY NUMBER MMIDD EFF PLIY EXP MMIDD/YYYY LIMBS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 DAMAGE TO T X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 300,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ Excluded A 680192MB710 10/52012 10/52013 PERSONAL&ADV INJURY $ 1.000,000 GENERAL AGGREGATE $ 2.000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 1-1 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA UAB HOCCUR EACH OCCURRENCE $ EXCESS LAS CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION WC TORYSTATLIMU- OTH- AND EMPLOYERS'LIABILITYER YIN B ANY PROPRIETOR/PARTNERIEXECUTIVE Ya WC3250371 7212012 7212013 E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? NIA 1,000,000 (Mandatory In NH) E.L DISEASE-FA EMPLOYE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is rewired) job site-1018 Osgood St.,North Andover,MA CERTIFICATE HOLDER CANCELLATION Town of Andover Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 36 t St Andover,MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Client# Mist# 23616CertHolder# ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD