HomeMy WebLinkAboutBuilding Permit #184-2017 - 103 FARRWOOD AVENUE 8/22/2016 (/ NORTy
I � ,�j � � BUILDING PERMIT o�,�t,.Eo �bq'�'o
CS
TOWN OF NORTH ANDOVER o� y: '- ...+ a
APPLICATION FOR PLAN EXAMINATION
f• •y
Permit No#: v"1 Date Received TED
9SSAGHUS�IC
Date Issued: U'i
I ORTANT: Applicant must complete all items on this page
LOCATIONcf,&427D A1/L�-
P
PROPERTY OWNER& 1P &TY}rint int Azx 'l AlgoAgcm5ur LLG •
/ -Print 100 Year Structure yes no
MAP PARCEL: l ZONING DISTRICT: Historic District yes no
e o
Machine Shop Village yes
TYPE OF-I'MPROVEMI T PRO .�OSED.yS.E
Residential Non- Residential
❑ New Building ❑ One family +,rNn
'!
El Addition )(Two or more f `mil t dustrial; r
❑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:
op oczsm Li s -7c)
Identification- Please Type or Print Clearly
OWNER: NameAT-FINl iq�6tz-MMLAMLSAI3Phone: 6(7-TZ7-0 13
Address: 63 eV ,,LJ fG
R)10>114� TIMMINJ
Contractor Name: Z Q5ey S Phone:
Emai1:
Address: 37I r
Supervisor's Construction License:L'S—/03045' Exp. Date: 7-X-/7
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER &/y!f Phone:
Address: 48 4910VE 5f. L'i ytReg. 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: $ �� 1 FEE: $ 1 4,5�
Check No.: Receipt No.: c9pr
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
ze
__.: _
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 'iCl.►
Private(septic tank, etc. ❑ Pennanent Dumpster on Site ❑
'x�a ['4"�` �C". .� `�•'� r''t.
`•, ; INTERDEPARTMENTAL SIGN OFF - U F®RM
PLANNING & DEVELOPMENT Reviewed On $�i (Q Signature_
�dj
COMMENTS - NA I •
i.
CONSERVATION Reviewed on Signature
COMMENTS
HEAUT-H �—,- `v',� Revrevt edr% ';. .x�t .�� •�3-Sig tore���•: 7"�
COMMENTS 4}raj 1 �� ,-►- r�{1 ;I.:ie'� i` `
+'ate� ) �(���:�. ��3` �'.. \ A.lt'� \� ..:)!J.•. ►t�t' \ ..�..
,Zoning Board of'A��eals:Variance, Petition No: _�=:-'t*,-Zoning becision/receipt submitted yes
Planning Board Decision: Comments
Con em t'��,"T'. Comments
Wafter & Sewer C®nnecf�on/Signature& Date Driveway Permit
DPW Town Enginecy .qig ature: ._ - `•�
LbCdied;-384 Osgood Street
FIRE DEPARTMENT Temp!Dumpster o_n:site ►yes _ noa
Located;at 1241MainrStr-bet - - - _
Tiee,Departinent signature/date _
VOMMENTSI
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. ❑ Permanent Dmmpster on Site ❑
JF,Pre
INTERDEPARTMENTAL SIGN ®FF - U FORM
PLANNING & DEVELOPMENT Reviewed On $�i l� Signature_
COMMENTS — TVA WARIV4
CONSERVATION Reviewed on Signature
COMMENTS..
,.. ! r S Aattu � a
COMMENTS
•iti...•! "'� y��>:.����t•C' � �/ �i�,''��.f�L��..1.�.>�' �tr't :[ �-� •y r��:.t�S�.`'l��a-1,,.•<.*
;Zoning Board of Appeals:Variance, Petition No: • *.•` `•"_Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
ConsrtiQb��Deeisioif}i�` '!.y;`r, Comments A
WaterSewer C®noircion/Signature& Date 'Driveway Permit
DPW Town Engineerf-SigLvture:
Lo'bdted ;384 Osgood Street
FIREtDEPARTMENT TempQumpster on Ayes
Yi
ated�at�124�MaiiibSt�eet �� � r '- ,. •' . �T'c -' • . �
x ,
e+Department signature/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)
t'+'fir
LI
7 s
t
Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014 T
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
,r< Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
V4� Building PP Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
4r" 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)
NQ Mass check Energy Compliance Report (If Applicable)
�k 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 I ECC Energy code
Engineering Affidavits for Engineered products
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
NORTH
Town of
1, sAndover
I.- !n
No.
�o h ver, Massjj..2blSe
COCI.ICl/NWICK y1.
�,�ADR�tED J.-V
S U
BOARD OF HEALTH
Food/Kitchen
PER LD Septic System
THIS CERTIFIES THAT . ......N........ ..
� � BUILDING INSPECTOR
has permission to erect buildings on .(A....... ...... ... IVt�trCA. Foundation
loia � ,... ... f Rough
to be occupied as���...�... ...... .. .... ......................... Chimney
provided that the person accepting this permit sTlall in eve respect confa�rl► to the terms of theapplication
p p p g p ry pFinal
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 CONST T Rough
Service
..... .......... .. ................ ..... ............... Final
BUI G 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.
Aug 18 2016 03:17PM FP Fax page 2
Aug 02 2016 070PM W Fax page 2
MEMORANDUM OF UNDERSTANDING
N1ernvrandum of undo
up
IPeq ManaprlAge r �g � between VO�negement Company herein defined as
business or Person herein defined managed propany harem defined as •Owner' and the
ed as`Contra,
Date of A9nseanenl: May 24,2016
ROvised,August 2,2016
Owner: Condominium
Property Address:
Meiling Address: Care of Agent at Agent's Address.
Properly Manager/Agent Affinity Realty&Property Management
63 Atlantic Avenue LLC
Boston,Massachusetts 02110
Phone; 61
�227-0893
,X670
Fax.
61
� 7)227-2985
Emarn:glephenealfg 4"alty cam
Contractor•. Building Restoration Services
Contr ctoes
cloy
Contractor Representative:John Childs
Address: 371 Dorchester Awe, Boston, MA
Phone:781492.4355
Fax:617-464.4160 Page:
Tax ID: NA Other:
Email:childbuildingrestorationserv,- m
The Work:DeckI
Replacement 3841 & 103.105 Fare Avenue
SPeCs provided to BRS
Wessling Architects Proied#15075 for Heritage Green Condominiu yReplacement.
Proposal from Binding Redoration Services Corporation(SRS)datedd 01 21-Bolcom 0115
2
herein incorporated into and made a Part of this agreement.
c:tueae�g11°���atBRs co
NiUCTM MEMORANDUM OF UNM"rAN=O.doe A19M 1.2016
y,3
LW
Aug 18 2016 03:17PM HP Fax page 3
Aug 02 2016 0721PM HP Fax page 3
Whwew
A. LICENSES AND PMM M
1 COMUter con6rms that he
has all necessary licenses and
Contt�etor a �+d operagqg p�°ib to perform
standards, etc-- hich a'tl y atsbe q wt he shad be responsible for Abidingb
resptttive ' be required of Aim by all y applicable codes, regulations,
agencies,of5ces,bureaus end other administratiw�h�egul le cry VAtes� federal jurisdictions end their
B. 1211 VWCB
I Contractor shall
6tsttrartx ars provided bepay the Pr ums for and keep in force untincludel the e
this oo urance is to �Qatioa of this contras
owner.
� . All coverage is to be primay of any 1190cable coverage liability��b►the Contractor quant
onhactor under
��Y Manager/Agent or
a Appropriate bodily injury insurartre, with limits of
SUWADO for escb accident, not less than $1,000,000 for each
b• Worktns cmgPansetloa inaurarce as Person and
I prop�y demmge Nabi ' recNired by local and/or stave juriadictians
d. General liability ►ksunowe with a limit Of=less than 81,000,000 for each accident.
e. 1f auto �Y 2M.Mince with a limit of no less than$1,000,000.
motive e9WPMMt is used in the
combined siogie limit of not leas 0 04 'utQmobile bodily i
f. AU policies for inaluaace shall facia�A•000. njury/pr per, dam� with
additioltal nsanad insured es nape- tily m property
Memtgement, LLC and
Owns as
arm.
—underM
Affmrty Really dE property
M
63 Atlarr<ie Avenue �Bereentr LLC
Bion.MA 0211 o
2• Evidence ofcovera
ge via standard Certificate shall be provided to the piny mmgw.
3. Ilbbly'day noise of cancellation,nm-rrrsrewal or
materia a in c
C. �E11'1N11+'ICATION �6 over,ge must be given,
Contractor agrees to indemnify,hold harmless and defend the owner,the agent,the
management&tr4 their officers and
resulting from the Contractor's aegligcato s' subcam4-actors, hefts and assi®ts Eram� Against er�Propmtl'
negligent acts or ootissiona of the p6 OM a of its sl1 claims
him, ConOrsctor's officers,em ��' but onlyto the extent cavBed by the
paoyees,guests,invilees and those doing business with
OTHER CO1VD1Tjo (S
The use of sub•conttaetnrs without the
per written consent ottbe owner!snot allowed114 .
which he�°agrees
he will inform the Properly Mir/Agent of an
with the provisions of this mcnx may affect the work of thin agreeat�, Contractor a all conditions or changes of
emarandum. agrees
to maintain complrance
No work of
anys
ort may be performed in the common
equipment or tools in the common on areas. The storage Of materials,debris,supplies,
areas
is prohibited without advance permission.
The work may not interfere with the comfort and convenience of the
occupant comp(aitt about any activity related to the renovation;the contractor ooccupants rsub-eon
y unit. Should any
tractor will be
C:IUspsWer�Re�elttvplBRS CdB17RACTOR MEMORANDUM OF UNDEA5T.4NDING,dec August Z,2016
Aug 18 2016 03:17PM FP Fax page 4
pug 02 2016 0721PM W Fax Page 4
rupdrcd to imnWi3'cease the activity. This
att udaat to the work of this ageoemCnL pimvision shell not apply 10 M tnmtion Meted noise
Evefy effort tmtat be made to contain
leading to cOMM areas mot aonstrueuot►0e�g+ dust and din to the unit interior. Dpp�
same. The use of the Traria d, ee
lose,
RwMM trust be Placed on all off,as to
pro>v'b71* �dtout pof dmpga f ftumnon. say or m �of am of an � com..and debrk is probibitet
aM
is
All fit►near arterior and
elevator must be deaaeri trt ��'indodma but sat limited m
the stirvve
end of pt.,
m'be required at the sole ''"ait 9ko swices of a p efassional clea 3'S�y
diseaetio�n of the Trust. 6 company
D. PAYLMRM—See atbehed proposal for payout Idwdak
t 11w Comachor
oat'
tht 0 �: m '+ aoee the
Owner sad Comaotor'
roc far Affinity Realty M is . ' nniag rervxxs P .
Pa3znait for auy saviees p�,d or�y ,LLC. The 'n3'and all
AWWty Re31ty&Property eeR LLCmy &b Provided is the sok respo y, �and not cf
L PLACR INTO RFFwT n 0ts,heirs of ass4p,
T�mum and the attacheptqwW d
or m
memofeadum try thea Baty atd o t�0n embody nth,In Witnesses dPatles hes a are no
SISAW this
to weer into this AVICU ent on behalfof��@ WOO who nwesent that they iw...N..
By:Swphen DBdocco
as Agent
Date:
By:
Authori� .
Date: $ 3
I s 7
i .
1
f
G
C-WW3we P%BRS COW7RACTOR bMMORMNDUM OF UNDM-rMMG.doe Argun 2.2016
The Commonwealth of Mass�chusetts
F Department oflndastdaZAceldents
I Congress Street,Suite 100
Boston,MA 02114--2017
www mass.gov/dia
Workexs'Compensation Insurance Affidavit:Builders/Contractors/Electricians/['l=b.ers.
TO BE EZLED WITH THE PERMITTING AUTHORITY'A licant Information • Please Print Le ' l
Name(Business/Organizationlhdividual): !/I �•!1 J l l S
Address: 571
City/State/Zip: 5 'r1 / azfz 7 Phone
Are you an employer?Checktl eappropriate box: 'Type of project(Tequired ):
ldi am a employezwith-4�employees(full and/or part time).* J, [�New cozist[uction
2.1 lam a sole prop fetor or parluership and have no employees working forme in 8. []Remo deag
any capacity.[No workers'comp.insurance required.] 9. ❑Demolition
3,Q I am a homeowner doing all work myself[No workers'comp.-insurance required.]t 10 0 Building addition
4.F1 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.[f Electrical repairs or additions
proprietors withno employees. 12,[f Plumbing repairs or additions
5.r_1 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.FC1 Roof repairs
These sub-contractors have employees and have workers'comp.insurancO 0
14. Other
6.Q we are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we haveno.A dyees.[No workers'comp,insurance required.]
•`Any applicautthat checksbox#1 must also'fill out the section below showingtheirworkers'compensationpolicy information.
Homeowners who stjEif tk w 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•attaghed an additional sheet showing the name of the sub-contractors and state whether ornot those entities have
r. . , -
employees.'if the sub-contractors have employees,they must providetheir workers'comp.policy number.•
X am an employer tli at is providingworkers'compensation insurance for my employees'Below is thepolicy acid jab site
information.
Insurance Company Name: ��S I �/y �_Umawop LLC
�
Policy#or Self-ins. it SCz '+ �IT� -Expiration Date: g•ZZ•l7
Job Site Address: V-41 f Vs Y - � QV& City/State/Zip: AI I'll !►YI 01h�r
Attach a copy of the workers' compepsation policy declaration page(showing the policy number and expiration date).
5A is a criminal violation punishable by a fine up to$1,500.00
' e as required under MGL c. 152,§2
Failure to secure coverag q
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.A.copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification..
Ido herebycertify under the pains and penalties ofperjztry that the information provideed above is r//ue and correct
oo Date:
Signature:
Phone#
Official use only. Do not write in this area,to he 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#:
Commonwea&of///ama4w lb Official lUs,7e�
Permit No. (Z,�
.1Jepart`menl`o� ire�eruice!
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00
(PLEASE PRINT IN INK OR TYPEINTION) Date: I g- ,2 - 1 3
City or Town of: p(` L XM I/e/' To the Inspector of Wires:
By this application the undersigned gives notic of hits or her in 'on to perform the electrica work described below.
Location(Street&Number) ( 0
Owner or Tenant 5 /j S Telephone No.
Owner's Address :!i� r2 s f 0. .
Is this permit in conjunction with a building permit? Yes ❑ No 2—'(Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 0,allboArnalrJ La
Completion o the ollowin table maybe waived by the Ins ector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Total
Transformers KVA
N No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above - ❑ o.o Emergency ig ng
rnd. d. Batteg Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices
No.of Waste Disposers Heat Pum Num er Tons No.of elf-Contained
Total : .... ................. ................ ......._.... Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local Municipal
El Other
Connection
No.of Dryers Heating Appliances KW ecurityystems:
No.of Devices or Equivalent
No.of Water , No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
Tele
No.Hydromassage Bathtubs No.of Motors Total HP communications Wiring:No.of Devices or E uivalent
OTHER:
s
Attach additional detail if desired,or as required by the Inspector of Wires.
stimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. J)
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: LIC.NO.:
Licensee: 0� p-e fx(` i� Signature 1 �Ov�.�.o. LIC.NO.:S a
(Ifapplicabl e�ter"exem 11 in tcense q bA l t)er line.) Bus.Tel.No.• t}0--
Address: R A r -- -17 SJr Pc4 ce 104• D l q Alt.Tel.No.
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owners agent.
Owner/Agent PERMIT FEE. $
Signature Telephone No. ,�--
ACOORVCERTIFICATE OF LIABILITY INSURANCE D /DD/YYYY)
8//22/22/2016
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 NNAAACT
ME: Marjorie Sullivan
Eastern Insurance Group LLC PHONE 505_923-2205 AX N
ok
500 Forest Avenue E-MAIL msullivan@easterninsurance.com
ADDRESS
INSURERS AFFORDING COVERAGE NAIL s
Brockton MA 02301 INSURER A:Em to ers Mutual Casualty
INSURED INSURER B ASSOC Industries Mass Mutual
Building Restoration Services INSURERC:
371 Dorchester Ave, Suite 160 INSURER D:
INSURER E
South Boston MA 02127-2454 INSURER F:
COVERAGES CERTIFICATE NUMBER-CL1682282201 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 ADDLSUSR POLICY EFF POLICY EXP
LTR POLICY NUMBER MMID MID LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea Dnce $ 5O,000
A CLAIMS MADE ®OCCUR D52212 /22/2016 /22/2017 MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICYFX JECTPRO LOC1 1 $
AUTOMOBILE LIABILITYEOMB�INd.%"NGLE LIMIT $ _1,000,000
A X ANY AUTO BODILY INJURY(Per person) $
ALL OWNEDSCHEDULED Z52212 /22/2016 /22/2017 BODILY INJURY(Per accident) $
AUTOS AUTOS
X X NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS Per accident) $
PIP-Basic $
X UMBRELLA UABX OCCUR EACH OCCURRENCE $ 5,000,000
A EXCESS UAB CLAIMS-MADE AGGREGATE $ 5,000,000
DED I X I RETENTION$ 10,000 J52212 /22/2016 /22/2017 $
B WORKERS COMPENSATIONX WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
OFFICERIMEMBER EXCLUDED? ® N/A
(Mandatory in NH) BOO8006422012016A /22/2016 /22/2017 E.L.DISEASE-EA EMPLOYE $ 11000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 1,000,000
A Equipment Police SCS2212 /22/2016 /22/2017 Leased/Rented 300,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more 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
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
Hall
No Andover, MA AUTHORRED REPRESENTATIVE
No A
John Roegel/MSULLI
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved.
INSn95r2ntnnai nt Tha ACnon name anri Inn^aro ra^iafara#4 marka of Armon
17
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