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HomeMy WebLinkAboutBuilding Permit #050-2017 - 103 FULLER ROAD 7/18/2016 V1 0'119'11 (� , NORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 7D � Z _ b Permit No#: Q 2,e 11 Date Received �.9'ORArEO SSACHUSE Date Issued: ks. IMP TANT: Applicant must complete all items on this page LOCATION 10 3 ?.opal Print PROPERTY OWNER GU0 I Print 100 Year Structure yes MAP Co� PARCEL: _ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial f<Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain El Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: &Q&W kZo,-�oyn: akr SUAl^a darnrwin Qk'!A.Swl� Vtk k ache. Identification- Please Type or Print Clearly OWNER: Name: Phone(61-1) 201- Zoos Address: o3, Fug.\ a K, o t-1A 0 Contractor Name: PVc lno-tA Jb, l Phone: (SN) M-2077 Email: tn�a �J_tw:\t cA w�exav.c,sw. Address: %0(,, s3. 1Ao.r.r.lnz�r,r, W" 0%ko2 Supervisor's Construction License: CSSI.- to(ao35Exp. Date: 81'112,01? I Home Improvement License: =1412 Exp. Date: -7 /27 Z-011 I_ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F. Total Project Cost: $ Z,458. yo FEE: $ /SEb Check No.: I ) 1� Receipt No.: 2%cQ 2_3 NOTE: Persons contracting with unregistered contractors do not have access to the 7ntyfund NORTld BUILDING PERMIT 0����ED ,6 91� TOWN OF NORTH ANDOVER 32 5t 4` APPLICATION FOR PLAN EXAMINATION Permit No#: - 2,,e Date Received �y Q�qA7eo V SSACHUS� Date Issued: ` IMP TANT: Applicant must complete all items on this page LOCATION 102, Print PROPERTY OWNER MAP 6//_ Print 100 Year Structure yes PARCEL:_ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other aNQ :eI F - Mai. g eta d reR n , R DESCRIPTION OF WORK TO BE PERFORMED: A&WX kz-0-h +\: air & aJ,kpa dannmin a ; !A.1Watc. yw &*ic- W Identification- Please Type or Print Clearly OWNER: Name:_ Phone(G11) 2oi- 2ooa Address: o N-u.\ m o t-1A 0 Contractor Name: laic hac l y Phone: ^•'� ° (Sb�) 382-2on Email: % Address: to Supervisor's Construction License: 0551-- locao3S Exp. Date: 81'7/2,018 Home Improvement License: 182"11)2 Exp. Date: '7 Z eon ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 2,LI58. 4o FEE: $ Check No.: I "� Receipt No... � LY Z3 NOTE: Persons contracting with unregistered contractors do not have access to the gua anty fund Location No. (_.J �� Date ---7 k k0 • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $30 ^- Foundation Permit Fee $ Other Permit Fee $_ ` TOTAL $ Check Building Inspector I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ FWei PE OF SEWERAC'TE DISPOSAL lic Sewer ❑ Swumnin PoolsTanning/Massage/Body Art Elgl ❑ 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 s'oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes a Pianning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/signature MJate Driveway Permit DPW Town Engineer: Signature: - - Located 384 Osgood Street FIRE DEPAR=T,MEN�T - Te mp�Dumpster,onss fe, ,yes r o3 - Lodatedjat 124iMain:St�eet m-_ Fire-Department.sig nature/date COMMENTS t 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 I Doc.Building Pennit Revised 2014 r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work �. Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products 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 own of ndover No. — 2,b 1j _T ;N*00h ver, Mass, 2,bi 4 coc"Ic"awicw 1' R^rE V V BOARD OF HEALTH Food/Kitchen T LD Septic System THIS CERTIFIES THAT PERML r�®4................... ..................... BUILDING INSPECTOR " W .7 Foundation has permission to er ct .......................... buildings on ....wt).tp...... !T ............:"...."��!! .................... Rough to be occupied as .. .. 1.. .. ��....r..( 1► �. . t......!!� ... ... ....... t�. .... Chimney provided that the person accepting this pe�mii'shall in every respeononform 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 Ins ction,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 ION Rough Service . ....... . ....... ...... .... ......... ...... ....... Final BUILDING SPE OR 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. a Federal ID if85-0406629 RISE Eo4 neerinD RI Contractor Registration No 8186 RISE __ MA CantractorRegtstratton No 120979 "` A division orThielseh Engineering ENGINEERING- 60 Showutut Unit#2,Cunton,,MA 02021 CONTRACT 339-502-6335 FAX 339-5024345 Page 7 PROGRAM CMA-HES V e�roamS�TOMElt:onrMWOWcr�i s DEacRt=eo eEsotrr CUSTMeFt PHONE --DATE ICUFUTE VKMK DISDtaT Andrea Keyo (617)201-2009 02/092016 429050 00002 SEinfaT M ——— — BUMG STREET 103 Fuller Road 103 Fuller Road C SERVICE CTJV,STATE,MP_ _ DnlrkrG QT/.;rTRTF 2tP Notch Andover,MA 01845 North Andover,MA 01845 JOB AESCTION HAZARD BARRIER:We have identified that there arc recessed lights present in your home.unless the recessed lights are eertifod as IC-ratcd(Insulation Contact Rated)we will create a 3"clearance space around the fixture by using fiberglass blanket insulation as a damming material,no insulation will be installed across the top and closed cavities which contain recessed lights will not be insulated. $0.00 AIR SEALING:Provide labor and materials to seal areas of)our home against wrastcf il,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air oxhange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sting include air Ic6mgc to attics,basements,attached garages and other unhealed areas(windoits are not generally addressed.)This will require(8)working hours.A reduction in cubic fact per minute(crm)of air infihration will occur,but the actual number of elm is not auarantecd. Al the completion of the wcathervization work,and at no additional cost to the homeowner,a final blower door andlor combustion safety analysis will be conducted by the sub-contractor to cnswc the safety of the indoor air quality. 5680.00 AIR SEALING ADDER: (2)working hours. 5170.01) DAMMING:Provide labor and materials to install a 12"layer of R-38 unlaced fiberglass baits to(88)square rcet for damming purposes. 5180.40 ATTIC FLAP.Provide labor and materials to install a 6°layer orR-2I Class I Cellulose added to(900)square feet of open attic Spam $1,134.00 VENTILATION:Provide labor and materials to install ventilation chutes in(102)roller bays to maintain air flow. 5204.00 RISE Engineering will apply 211 applicable,eligible incentives to this contract. You will only be billed the Net amount. Ctmently for eligi4le measures.Columbia Gas offers 75%incentive,not to exceed 52,000 per calendar year,and an incentive of 100%for the Air Sealing measures up to the first 5680 and an additional 5340 irsavincs arc justified by the auditor. For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in )our home both before the work is begun,and 28cr the v%mtthheriration work is complete.We will also conduct a full assessment of the combustion safety ofyour heating sysicm and wags hater.This has a value of$90 and is at no cost to you.Total allowable wcathemation incentive is$3,110. 590.00 i Federal 10 9 050405629 Tl!�f IUSE Engineering RlConfractorRegistration No8186 RISEtr MA Contractor Registration No 120979 A division or9'hie1sch Engineering pp//�� ENGINEERING' 60 Slwwmu(Unit N2,Canton,AIA 02021 CONTRACT 339-502-633:1 FAX 339-50216395 Page 2 PROGRAM CMA-HES EEmN MD CONTRA=M mmtFORWORKAADENAMN S DESCR®ED BEUM CUSTOUER PHDRE - DATE CLE IF WORK ORDER Andrea Keyo (617)201-2009 02/09/2016 429050 00002 SERVICE STREET -- DLIIHG STRIA" 103 Fuller Road 103 Fuller Road SERNCE CnY.STATE,IIP _ _ —._w BILLING CnY.STATE,ZIP __ _ _. _ Norah Andover,MA 01845 North Andover,MA 01845 .IOD DESCRIPTION Total: $2,458.40 Program Incentive: $2,078.80 Customer Total: $379.60 WE AGREE HEREBY TO FURMSR SOMCES,COMPLETE 4N ACCOFWkffCE VM ABS SPMMCATIONS.FOR THE SUM OF "`Three Hundred Seventy-Aline 8L 601100 Dollars $379.60 UPONMALSLS MTMANDAPPROVALBYF=ENGINEEMM.CUSTOMERACFIFESTo MWAIWMTDLEnFILL.UFnMMOFS%MLDECNARGMLM=MYONANY WZIJUD BALANCE AFTEN W DAM SEE RydERSE FOR IWWRTAVT W%ORAT=On GUAR1I WEES.PCWMOFRECMW).sC*WMRMC AWCDUr"CMRO;MWATIDN. 0o NOT SIGN THOS CONTRACT IF THERE ARE ANY BLANK SPACES AM 810!111 nO'M TIPS CONTRACT MAY BE W"PRAYIN BY LIS IF NOTEJRWTED WFM DAIS OF ACCEPTAME —- - ACCEPrARCE OF CONTRACT.THE ABOVE Pax:MsPEctneAnons AND COtmrWIMARE 30 DAY$. SATISFACTORY 70US AW ARENERSDY ACCFnUX YOU Ann AUTHORED To 00 THE WORK AS SPECIFIED.PAYMErnTYRLLBE MADE AS OUTUNED ABOVE C x r RISE ~ 60 Shawmut Road,Unit 21 Canton,MA 020211339-502-6335 rENOINEERING www.RISEengineering.com OWNER AUTHORIZATION FORM (Owner's Name owner of the property located at: u �Jic L., I 16 lf (Property Address) • �!���!'C'.�'"', 1'���'' GFS�'' ° (Property Address) hereby authorize I A& Lim Wx!aU (Subcon or) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This foram is o valid with a signed contract. Owner's 15ri Date I The Commonwealth of Massachusetts 7 Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation insurance Affidavit:General Businesses. TO BE FILED WITII TILL PERMITTi1�'G AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:Mill City Energy Address:PO Box 6411 City/State/Zip:Manchester, NH 03108 Phone#:603-391-7923 Are you an employer?Check the appropriate box: Business Type(required): 1.Q I am a employer with 12 employees(full and/ 5. [l Retail or part-time).' 6. F]Restaurant/Bar/Eating Establishment 2.El I am a sole proprietor or partnership and have no 7. EJ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8• F1 Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4);and we have IO.❑Manufacturing no employees.[No workers'comp.insurance required]* 11.0 Health Care 4.0 We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.0E Other V AU41do *Any applicant that checks box#t must also fill out the section below showing their workers'compensation policy information. s;lf the corporate officers have exempted themselves,but the corporation has other employees.a workers'compensation policy is required and such an organization should check box 41 lam an employer that is providing workers'compensation insurance for my emplgyees. Below is the policy information. Insurance Company Name:Clark Insurance Insurer's Address:One Sundial Avenue Suite 302N City/State/Zip: Manchester, NH 03102 Policy#or Self-ins.Lie.#MIWC791896 Expiration Date:4/29/2017 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,ur . ins and pe+ralties of perjury that the ir+formation provide4 above is true and correct SiLrnature7 Date: -7 Phone#:603-396-7520 Official use only. Do not write in this area,to be completed by city or tmvn official, City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other _ Contact Person: Phone#: wzvw.mass.govfdia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizationAndividual): Mill City Energy,LLC Address: P.O.Box 6411 City/State/Zip: Manchester NH 03108 Phone#: 603-391-7923 Are ou an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 6 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors b. E]New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' y p �• 9. ❑.Building addition [No workers'comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1.am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]f c. 152,§1(4),and we have no employees.[No workers' 11KA Other WeamuAd-ch comp.insurance required.] 'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site information. Insurance Company Name: Liberty Mutual insurance Policy If or Self-ins.Lic.#: WC5-31S-391202-025 Expiration Date: 7/25/2016 Job Site Address: 100 FAff ?l City/State/Zip: NQdli GkoYW.MA Ok%45- Attach a copy of the workers'compensation policy declaration page(showing the policy number anti expiration date). Failure to secure coverage as required under 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 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. I do hereby certify un a ns and penalties of perjury that the information provided above is true and correct sign Date: Phone#: 603-391-7923 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.Cityfrown Clerk 4.Electrical inspector 5.Plumbing inspector 6.Other Contact Person: Phone#: MILLCITY-1 AGOULD A�c,a,Ran CERTIFICATE OF LIABILITY INSURANCE DATDIYYYY) 7//19/219/2016 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 License#AGR8150 CONTACT NAME: Clark Insurance PHONE FAX One Sundial Ave Suite 302N (AIC'No Ext):(603)622-2855 ac,No:(603)622-2854 Manchester,NH 03102 AD E-MAIL agould@clarkinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Mutual Insurance Co 17000 INSURED INSURER B:AmGuard Ins CO 43290 Mill City Energy INSURER C: 106 Joseph St PO BOX 6411 INSURER D: Manchester,NH 03102 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. INSR POLICY EXP — LTR TYPE OF INSURANCE IANSD SWVD POLICY NUMBER mmUBRI f&EFF MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR 8500065735 04/29/2016 04/29/2017 A 300 000 PREMISES Ea occurrence , $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICYF ]PET El LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (COMBINEDSINGLELIMIT $ 1,000,000 A X ANY AUTO 1020050919 04/29/2016 04/29/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED R BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LI AB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE 4600065736 04/29/2016 04/29/2017 AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVEN/A MIWC791896 04/29/2016 04/29/2017 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ® DATE(MWDWYYYY) AC O CERTIFICATE OF LIABILITY INSURANCE8/6/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(fes)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 JE4MIL E: Sarah Lauersen Slawsby Insurance Agency NE , (800)258-1776 FAX 3 Mound Ct, Suite B SSslauersen@minutetnangroup.com PO BOX 1501 INSURE AFFORDING COVERAGE NAILK Merrimack NH 03054-1807RERA:Liber Mutual INSURED INSURER 8: Mill City Energy LLC INSURERC: PO Box 6411 1NSURERD: INSURER E: Manchester NH 03108-6411 INSURER F: COVERAGES CERTIFICATE NUMBER:2015-2016 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. )NSR POLICY EFF POLICY EXP LIMITS LTR. TYPE OF INSURANCE POLI:/NUMBER MW MMI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DA N Ems— $ CLAIMS-MADE n OCCUR P EMISE Ea mcurr _ MED EXP Any one person) $ PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY a j�7 LOC PRODUCTS-COMPIOP A�'$ OTHER: COMBINEDLIMIT AUTOMOBILE LIABILITY Ea accident — $ BODILY INJURY(Per person) S ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED Per DAMAGE $ Peraccident HIRED AUTOS AUTOS S UMBRELLA UAB OCCUR EACH OCCURRENCE $__ EXCESS LIAB CLAIMS•MADE AGGREGATE $ _ $ DED RETENTION S WORKERS COMPENSATION STATUTE ER _ AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 500 000 NIA OFFICERIMEMBEREXCLUDED? A (Mandatory in NH) wC531S391202-025 1/25/2015 7/25/2016 E.LDISEASE-EAEMPLOYE $ 500 000 If Yes,RIPTION OF OPERATIONS babes describe under DESCE. DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS I LOCATIONS t VENICLES(ACORD 101,AdOlonal Remarks Schedule,may be attached R 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ;—�, !�, David Herod/SARAHr L� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD INS025(2ouoi) Massachusetts Department of Public Safety 119,, Board of Building Regulations and Standards License: CSSL-106035 Construction Supervisor Specialty { MICHAEL JOY 106 JOSEPH STREET - MANCHESTER NH 03102., � 4 51 `7- 1 Expiration: Commissioner 08107/2018 4.. J/� TF r,tt,upJxtM,�/J/,o 'c ,u<�r/rtreJl only d License or registration valid for indiviuuse on Office of Consumer Affairs&Busifess Regulation g Y --� OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: A " egistration: 182792 Type: Office of Consumer Affairs and Business Regulation xpiration:- :7/27/2017, LLC 10 Park Plaza-Suite 5170 Boston,MA 021.16 MILL CITY ENERGY,LLC: MICHAEL JOY 106 JOSEPH STREET MANCHESTER,NH 03102 Undersecretary �� N vat ithout si ture