HomeMy WebLinkAboutBuilding Permit #1050-2016 - 105 MIDDLESEX STREET 4/6/2016 BUILDING PERMIT L NORTF►
O`ttl.ED 6�"IO
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit No#: "— i Date Received
SSACHV`��
Date Issued:
�4 44ORTANT: Applicant must complete all items on this page
LOCATION kC S .MOA1 Q5-� t)+ ' k)-
Print
PROPERTY OWNER AaAL �A n M
Print 100 Year Structure yes no
MAP _PARCEL: (-6'514 ZONING DISTRICT: Historic District yes no p
Machine Shop Village ye no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
El Addition El Two or more family [I Industrial
-sCAlteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain Q Wetlands ❑ Watershed District
I o Water/Sewer
DESCRIPTION OF WORK TO BE PEREORMED:
` Identification- Please Type or Print Clearly
OWNER: Name:G_1 0-�yf-\iZ7 Phone: (09,,?" gCQ i
Address:
Contractor Name: 1C)OCUCd Phone: Q��• �J�� • '1���1
Email: A
Address: Q
Supervisor's Construction License:11J' Exp. Date:
(0' k-0
Home Improvement License: � Qa�� Exp. Date: C D. r�
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: $_�, OCiC-
' FEE: $
Check No.: U b Receipt No.: �
NOTE: Persons contracting with unregistered contractors do not have access to �fjuI
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 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
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
' u Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRED PAl-- - Temp ®ump- ter onasite yes Ino x.
�. ._
� �� �. t1 4iMain�Street `
'Ki Of
f
COMMENTS: ._.
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doe.Building Permit Revised 2014
Building Department
artment
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
a Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
j 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
:rb 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 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
S C
Location �� f
No. , Date ay- Lf
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ �C?�
Foundation Permit Fee $ ,
Other Permit Fee $
TOTAL $
Check# C)�
' t
,� �• Building Inspector
� NORTI�
Town oLAndover
ver, ass �'`
o� > M >
A_ coc"IcHewlcn
7,9s R.ITEO PPa,��(5
U BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THATa <� ` v'�`° BUILDING INSPECTOR
......... ...y.
`� ,So Foundation
has permission to erect buildings on Ib- �`�'
.......................... .............................................................................
Rough
to be occupied as L igC' l;of?.1........................................................................... 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 CONSTRUCTION STARTS J Rough
Service
.................. ..... ...........................................
Final ,
` BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
T.
EIN#51-050-3313 Haverhill MA 978.374.9224
MA Reg.HIC#149221 Amb Lawrence MA 978.687.7339
ppp
MA Lic.UCS#78130 Hampton NH 603.929.9224
BB& Single-Ply License#1711 M�,2ing Hampstead NH 603.329.8200
SCWX4C-e-1932 CO- Toll Free 1.888.SOS.ROOF
265 Winter Street
Haverhill MA 01830
Licensed ,rInsured *Factory Trained Factory Certified 29 /6 Name: Date:
Telephone (0 /�7 �Q Alt.Teelle�ephone: Email:
BillingAddress16 im;Ok" 'Y' City: �.�or� er State: MA
Job Address: City: State:
Scope of Work ,Strip and Re-roof ❑Re-roof Approximate Roof Area:
❑ Prepare for re-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected.
❑ Remove existing layers of shingles down to roof deck and dispose of in a legal fashion fromthejob site.
❑ Inspect wood deck,if we discover any rotted wood,replacement will will performed at*$ per LF for roof deck boards. If
substantial deck rot is discovered,re-sheathing of roof deck can be performed at*$ 2-0 per SR If individual sheets are found to be
rotted/or de-laminated,removal,disposal and replacement will be performed at V per sheet.If any trim boards are rotted,
replacement will be performed at*$ per LF for new pre-primed pine.Inspect siding at roof line and all flashing behind siding,if
we discover any damaged flashing or staling at the roof line,replacement will be performed at*$ �'i If wood deck,siding,and
flashing is sound,we will re-nail any loose wood to rafters, weep deck,and prepare for roofing.
❑ Install 8"drip edge to all rakes and eaves.Color 1.I,1klf .
❑ Apply ice&water shield(UNDERLAYMENT)as—per manufacturers'specifications and/or e 1 ,X
❑ Apply premium(UNDERLAYMENT)to the balance of the exposed wood deck.
❑ Re-flash all plumbing stack pipes,and any roof penetrations as required and dictated by good roof practice to ensure water tightness.
❑ If upon inspection,we discover chimney lead to be wom or deterioratpdrelacement will be performed at*$❑ Install a new: �Year ❑ Traditional hitectural ❑ Designer Color❑ Furnish and Install a new shingle over style ridge vent system ❑Sot system*$
❑ All debris generated by Lambert Roofing Co.,Inc.will be cleaned up and disposed of from the job site in a legal fashion.Under no
circumstances will the waterti ht integrity of the building be compromised.
Special Notesi f
r4 4A iA \
UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OFQ
YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND Llf�YEARS HONORED AND ISSUED BY THE
SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$
*Denotes potential additional costs above the total estimated price.
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work,furnish the materials and labor specified above for the total sum of:$OOff]� (*)
(Dollars)
Payment will be made according to the following work schedule: jf
$ deposit upon signing contract 16
$ by_/_/_or upon completion of
$ upon completion of contract.
(Law forbids demanding full payment until contract is completed to both party's satisfaction)
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram or by delivery,not later than midnight of the
third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES
Acceptance of the Contract Proposal
1 �
Home Owner(s)Signature(s): ) 1 ` Date:
Contractor's Signature: Date: / ! G,
www.lambertroofine.com (Please see reverse side)
i
Company Insurances
TGLRC Inc.DBA Lambert Roofing Company will provide certification of insurances,demonstrating that we are fully insured for worker's compensations,
general liability,automobile liability and an umbrella policy.This documentation will be sent through the US mail to the above named party if not already
provided.
Tri C Inc.dba Lambert Roofing Company agrees to:
• Commence the described work on or about
• Complete the described work in approximately days.
• Not be held liable for delays due to circumstances beyond our control.
• Not be held liable for any damages to landscape and or fixtures due to circumstances beyond our control.
• Not be held liable and not covered under the workmanship warranty,for pre-existing conditions including but not limited to:
• Mold and or wood rot,defective,faulty,rotted or worn building counterparts such as,but no limited to:siding,roofing,masonry,
plumbing and windows,all of which may jeopardize the watertight integrity of the structure.
• Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the
residence.
• This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inc.DBA Lambert Roofing
Company and the Homeowner/Business Owner or Agent.
Permits
A building permit may be required to remove and replace your roof.It is our obligation to secure these permits if required as the home owner's agent.Note:
Homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c.142A.
Accelerated Payment
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be
financially insecure.However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds
not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal of funds from said account would require the
signatures of both parties.
Payment 7krms
A finance charge of 1.5%a month(18%per year)will be added to all invoices on the 31'day.All legal and or collection fees will be paid by the binding holder
of this contract.
• The law requires that any deposit or down payment required by TGLRC Inc.dba Lambert Roofing Company before work begins may not exceed
the greater of-
0 1/3 of the total contract price or:
0 The actual cost of Special or Custom made materials which must be special ordered in advance to meet the completion schedule.
Arbitration
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 Regula on and the consumer shall be required to submit to such arbitration as provided in MGL c 142 .
Owner: � - ' r Date:
Contractor:
Date:
Contractor Registration
All home improvement contractors and subcontractors must be registered,any inquiries about a contractor or subcontractor relating to a registration should
be directed to:
Contractor Registration:
Director of Home Improvement Contractor Registration
Board of Building Regulations and Standards
One Ashburton Place,Rm.1301
Boston,MA 02108
(617)727-3200
Home Improvement Contractor Law:
Consumer Information Hotline
Commonwealth of Massachusetts
Office of Consumer Affairs and Business Regulations
10 Park Plaza,Rm.5170
Boston,MA 02116
(617)973-8787
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumer Complaint Section
Office of the Attorney General
(617)727-8400
AND/OR
Better Business Bureau
(508)652-4800
(508)755-2548
(413)734-3114
Cancellation
You may cancel this agreement if it has been signed by a parry thereto at a place other than an address of the seller,which may be in the main office or branch
thereof,provided you notify the seller in writing at the main office by ordinary mail posted,by telegram sent or by delivery,no later than that midnight of the
third business day following the signing of the agreement
INITIALS
assach usetts
The Commonwealth of M .
F Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dna
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information F= Please Print Le 'bl
Name (Business/Organization/Individual): Prvv' ,
Addres;f_-_ ,�
City/State/Zip_-�,e.4.A t-A Phone
Are you an employer?Check tine appropriate box: Type of project(required):
tam a employer with employees(full and/or part-time).* 7. Q New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 0 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
pro'p'rietors with no employees. 12.[]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 oof repairs
These siib-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
ffi
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 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.
tContractors 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 havo!employ ees,ley must provide their workers'comp.policy number.
fain an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
A
olicy#orSelf-ins.Lie.#: Expiration Date:: t b Site Address: (y 1 �� �5�7 City/State/Zip: 'v
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the forth 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.
X do hereby certify under the pains and penalties ofperjury that the information provided bove is true and correct.
i nature: Date:
hone it
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.EIectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and. Instructions
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 oPliire,
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-contractors)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'
compensatiorii 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(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. 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 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-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CERTIFICATE OF LIABILITY INSURANCE DATE{M:7J0o'YYYYI
,03/28'/
THIS CERTIFICATE E Ia ISSUED AS A NIAT.EEK O. INFORMATION ONLY AND CONFERS NO RIGHTS JPCN THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOIAL THIS CERTIFICATE OF INSURANCE GOES 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 CO TAC=K Jerrold i�arreras
I ALLAN INSURANCE AGENCY INC. NAME, FAX
63 1/2 Jefferson Avenue 2nd Floor
j
BOX
erreid�allaninsurance.cam
P.C. BOX 111
..3<_LL�`'�R +NSUREFr,,Si A fLJ DING COVERAGE i MAIC a
.. FIA 0137fl-fl51�. +
)msuRERA:kssociateri Ind Ins Co.
TGLRC 1�IJ_% RER A-Safety insurance- Co.
+INSURERc:TTatlonal t3nion Fire Ins Co. �
db-A: Lambert Roofing co, r�_� _
ItvSvi4ER D 1-a e .?`i1T er,Can IIl$ilrc`LnCe CO.
265 Winter Street �'-� - _ — j
INSURER E_Ace American Insurance Co. .L
Haverhill MA 01830- wsuRER F _
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
71715 I'S TO CERTIFY THAI THE POLICIES OF INSURANCE LISTED BELO,`i HAVE BEEN 15-q TO ;r) THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
1N;1:CF.7ED NO1T441THS7"HNDING ANY REOUIREMENT Tt_RT.1 -;}R Ct--NDIT: N uF _t RA f,;R OTHER DOCUF.IENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSLrRANCF AFFrTRDFr+ BY IrIF DESCRIBED HFREfN IS SIIBJECfi T4 ALL THE TERMS,EX'--?,t5!nMS AND CONDITIONS OF SUCH PC+LIC?:: '_ih1iT� H+7'::�a r Y lt. F(:f i !iiFL•V i_. 5:•�.C1 n.i;.iS
LTR_
r ._ TYPE OF INSURANCE L.-POLICY EFF - Y EXP POLIC (..—
i
LTR_2 f _ PGLICY NUMBER I.rt_:,ratDO:YYYYt I PNVDr)1YYYYI.i LIMITS
I F GEP.ERAL LIABILITY I r
1[%?"AI _ I E c H,rrIrRRFN r - 11000,000
X 'N 4'.l I I r!•T Y
iitN+f i
-A'. �1c� =r� __-� l, r: ten- `•i x iwL'__�_ SQ,QQO
1,000
X ,per Progect Age National Roofers Assoc. I fE R:r:PJhLBs L,VENtiIr+Y f e 1,000.000
LA .:RE�,giF iIt.IT APPi IE6.'I S? - :--&PA-,AGGRFGArf --`2,000,000
PF -r -cot.,11:OPArc, S 2,000,000
AUTOMOBILE LIABILITY � I - t;UftfilNE li SINGLE LIMIT
L,T_ r`' _, 11000.000
= r -() IL N1�}ft-( `rt:+t:.ra;,^,
If r�r.E.Ii 4' 1
02203819 �1"'15 29 157,/1 E,'-- HOLM'(016+
' $ P'i(IN+Ir2Y.E ::c-r+� ?
t I , E+�•) j—
X ! UMBRELLA LIAB
X
_ ' _
+ •'Ii ,.f=i!ir�'i 5,000,000
-'— EXCESS LIAR �I12
OF—:
E' 1.E IfEr 5,000,000
WORKERS COMPENSATION 3
MNU EMPLOYERS'LIABILITY 1 f + Y `•:.=STAT}i rrTH
r Pi j
r -F,'..,:.a.: i , 'I,c r'52 ti9-:.vv C.:^r --_ vA -E. ;L4,��
lt:eRE .. .." N .N+A. �~� - "�"_ LL EA f,A(,C!'_';_NT 1 000,000
D 'IMndalnryinNH) - �—�` 1 000,000
=s7ir _., ti1OI ASf_-EA EMPLOY;}
r'sEASE-Pr,l if-Y I.Il+iT= 1,000,000
E ;Worker's Compensation
i s,+•,:- rhlsac 1,000,000
6S62UB-6D 5131:-.r-15 r.-u .1Z.'Z2 J5 -2r%11< I6 ar ._ 1,000,000
:)E SCRtIPTIO'u OF OPERATIONS I LOCATIONS:VEHICLES Izach ACOPD 101-Add,P,anaf Remark,Sr-neaw._if n, r shoe isg,„red)
CERTIFICATE HOLDER CANCELLATION
TGLRC dba. Lambert Roofing SHO'iLCANiY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
265 Winter Street ACCORDANCE WITH THE POLICY PROVISIONS.
y;_.
AU1HoFJn DIREPRESENTATiVe f "1•�,p
t ## r t
Haverhill MIs 01630-
ACORD 25(2010105) T 1 'D 1988-2010 ACORD CORPORATION_ All rights reserved.
iNS025 .. The ACORD name and iogo are regisierecl marks of ACs}nTJ
CS-078130 DOW
RICHARD 3 LA1VMT
265 WINTER STREET
Haverhill MA 01830
06102!2016
.,� - �,:�
- by Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 149221
Type: Private Corporation
Expiration: 12/6/2017 Tr# 273093
T.G.L.R.0 dba Lambert Roofing Company
RICHARD LAMBERT —
265 WINTER STREET ----- --- —
HAVERHILL, MA 01830 -
Update Address and return card.Mark reason for change.
SCA 1 e, 20M cnnn 1 L] Address r] Renewal f-I Employment n Lost Card