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HomeMy WebLinkAboutBuilding Permit #1221-2016 - 109 BRENTWOOD CIRCLE 5/25/2016 BUILDING PERMIT of �oT 6 "1 TOWN OF NORTH ANDOVERte.111''' 4; '° o 0 - 7 APPLICATION FOR PLAN EXAMINATION * z Permit No#: L Date Received 512, 7cd °t�T ED r= 1SSACHUS�` Date Issued: J I ORTANT: Applicant must complete all items on this page LOCATION d 1Gt�N� e7O.D P �G I r Print PROPERTY OWNER J/ -NIS Print 100 Year Structure yes no MAP DA PARCEL ZONING DISTRICT: Historic District yes no Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ISep c �❑ells F�IoodplainWaterS'hed ®ist _ z� �. �+t -moi°€�- w DESCRIPTION OF WORK TO BE PERFORMED: o �7 bq� W '� I,)Db bi Identification- Please Type or Print Clearly OWNER: Name:__ F eJ S G�.�C-e Phone: Address: I 0i L-j t ,7 r2 c1R, Contractor Name: U/TL- Phone: Email: SRS ari i.` 0 Address: �`�0 G Supervisor's Construction License: ) Exp. Date: -q Home Improvement License: Exp. Date: "> ARCHITECT/ENGINEER Phone: Address: Reg. 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 Lo , a®�J FEE: $ r O Check No.: '2— Receipt No.: �`�� NOTE: Persons contracting with un egistered co tractors do not have access to e my d --.� Sa-,kts. � r n�—'�v , , - F 771 Location � � 'A AAAA i 42 — L c) _Date' 1,74 -) i No. t 1 1 • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $t� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ j I Check !� i } i Building Inspector j 30406 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ElTanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ To Sales El Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent 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 ori Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 0 -Conservation Decision: Comments Water& Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: N Located 384 Osgood Street nFIRE DEPARTMENT'S " ;rte � " . j g ,. t.� a N71�. Temp Dumpsfer�onisite,�yes+ 3 `" $Located at 124 MainStreet � *��"^ t - fig X`,• - Fire Deprtrnent signature/dat� �� ��� � ,COMMENTS �, r aIe F Y a " rNmension 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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10o-$1000 fine NOTES and DATA— (For department ease) i r i ® Notified for pickup Call Email a IDate I — Time Contact Name Doc-Building Permit Revised 2014 f E i 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 IN 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 1 Workers Comp Affidavit i Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And i Hydraulic Calculations (If Applicable) ' Copy of Contract i � 2012 IECC Energy code Engineering Affidavits for Engineered products IN 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 t%ORTH Town of ,, Andover : : - s to h ver, Mass at, coc»ic»ewic« V BOARD OF HEALTH PER IT Food/Kitchen LD Septic System ` THIS CERTIFIES THAT ....... ...le.41 .�i.. ..... �.N ....... ,,,, BUILDING INSPECTOR has permission to erect ....... ................. buildings on ... �..... , d. Foundation . ...... ...... Rough to be occupied as ... ..7M!l�."�. �f......1�.....w. ���b............................. 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 CONSTRUCT10 S ARTS 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. Proposal for Services (PFS)- Project: 109 Brentwood Circle 109 Brentwood Circle North Andover, MA 01845 Prepared For: Denis Dragonas 109 Brentwood Circle North Andover, MA 01845 Prepared By: Chuck Huntley r Schernecker Property Services, Inc. a 283 Second Ave, Waltham, MA 02451 (781) 487-2516 chuck.huntley@spsincorAine.com www.spsinconline.com SPS HIC #: 123615 Expiration Date: November 5, 2015 Date Submitted: August 27, 2015 Proposal #: 5440987 - s I 109 Brentwood Circle 109 Brentwood Circle I Proposal#:5440987 Scope of Work General Description: SPS,Inc. will provide the necessary supervision,labor,and materials to perform the work specified in this PFS in a good and workmanlike manner and in compliance with applicable laws and codes. The pricing provided in this PFS encompasses, in general,the following: Misc. Repairs at 109 Brentwood Circle in North Andover,MA. Included Areas: ' • Pressure wash with bleach/water to remove mildew,surface dirt,and dust to provide a clean surface for paint adhesion. • Furnish and Install(19)Harvey Building Products"Majesty" Double Hung Vinyl Replacement windows with Clear Pine Wood Interior/White Clad Exterior,LowE/Argon, Simulated Divided a, Lites and Half Screens. a• Exterior Staining-Power wash to remove dirt,debris and mildew. Scrape to remove loose and peeling stain and spot prime bare wood with an alkyd Stain. Apply(2)Full finish coats of 100% Semi Transparent Alkyd Stain by Cabot to the exterior of the Home. Prep and Paint all Exterior Doors with 100%Acrylic Latex Paint by Cabot. This includes staining mailboxStand. a ,• Spot Carpentry Replacement-Replace rotted Clapboards, Corner Boards, Storm Door Gasket at Breezeway,Front Door Trim Moldings,Lattice Repairs,Broken Deck Boards,Rear Garage Door . Gasket,Any Gutter Damage,Replacement of Woodpecker damaged T&G Siding and necessary repairs to Cupola. • Re-Flash Rear Study at 2nd floor to Main House. • Clean all Roof Shingles \ • Clean All Gutters and Downspouts,Replace cracked and broken downspouts,Tar inside Gutters and fix gutter supports where necessary. • Seal Chimney and Fix Rot at House Transition • Install Gutter screens on all gutters. • Furnish and Install new Shutters on(4)Front windows of main house only. • Strip Breezeway roof,Install full Ice and Water coverage and flash roof to house transition • properly and install new roof shingles. (6 feet up and 20 feet long-Total area= 1.2 squares) Repair Rear Spigot Leak �;• Remove and Replace(2)Garage Doors with"Thermacore" Sectional Doors as manufactured by the Overhead Door Corporation(Doors only,existing motors will stay). Remove Weathervane from Garage Cupola,Transport to Don's Brass and Copper Polishing,Have it re-finished,Transport back to 109 Brentwood Circle and Re-Install(Allownace only until Don ,INcan see the weathervane). v• Stain(19)Interior Windows to match existing Interior Decor. Excluded Areas: • All other requests T otal Price for work as f specified in the Scope p p o Work. $33,000.00 Additional Items, Alternate Items and Unit Prices Schemecker Property Services 1 283 Second Avenue,Waltham MA 024511800.424.24681 spsinconline.com Page 2 of 8 109 Brentwood Circle 109 Brentwood Circle I Proposal#:5440987 Pricing provided on Page 5 is for specific items not included in the contracted Scope of Work.Please note that these items are additional to the"Total Price". Schedule of Work (determined at proposal signing)The work heretofore described is scheduled to commence on with an expected duration of approximately days. Substantial completion is expected by Acceptance of Proposal The undersigned,as authorized representative(s)of the property listed,have read the terms stated herein and accept the terms as written. 08/27/15 /` SIGNATURE DATE SIG DATE Chuck Huntl Vice President Denis Dragonas NAME TITLE NAME TTTT_,E I I I Schemecker Property Services 283 Second Avenue,Waltham MA 02451 800.424.2468 1 spsinconline.com Page 3 of 8 L 109 Brentwood Circle 109 Brentwood Circle I Proposal#:5440987 Total Price for work as specified in the Scope of Work Type of Price/Type Item Description Quantity Quantity of Quantity Extended Price 1. Furnish and Install(19)Harvey Building Products 1.00 Entire House $16,205.00 $16,205.00 "Majesty" Double Hung Vinyl Replacement windows with Clear Pine Wood Interior/White Clad Exterior, LowE/Argon, Simulated Divided Lites and Half Screens. 2. Exterior Staining-Power wash to remove dirt,debris 1.00 Entire House $5,900.00 $5,900.00 and mildew. Scrape to remove loose and peeling stain and spot prime bare wood with an alkyd Stain. Apply (2)Full finish coats of 100%Semi Transparent Alkyd Stain by Cabot to the exterior of the Home. Prep and Paint all Exterior Doors with 100%Acrylic Latex Paint by Cabot. This includes staining mailbox and Stand. 3. Spot Carpentry Replacement-Replace rotted 1.00 Entire House $3,500.00 $3,500.00 Clapboards,Corner Boards, Storm Door Gasket at Breezeway,Front Door Trim Moldings,Lattice Repairs,Broken Deck Boards,Rear Garage Door Gasket,Any Gutter Damage,Replacement of Woodpecker damaged T&G Siding and necessary repairs to Cupola. 4. Re-Flash Rear Study at 2nd floor to Main House. 1.000ne Location $750.00 $750.00 5. Clean all Roof Shingles 1.00 Entire House $300.00 $300.00 6. Clean All Gutters and Downspouts,Replace cracked 1.00 Entire House $500.00 $500.00 and broken downspouts,Tar inside Gutters and fix gutter supports where necessary. 7. Seal Chimney and Fix Rot at House Transition 1.00 Chimney $425.00 $425.00 8. Install Gutter screens on all gutters. 1.00 Gutters $375.00 $375.00 9. Furnish and Install new Shutters on(4)Front 1.00 Shutters $600.00 $600.00 windows of main house only. 10. Strip Breezeway roof,Install full Ice and Water 1.00 Breezeway $1,325.00 $1,325.00 coverage and flash roof to house transition properly Roof Schernecker Property Services 1 283 Second Avenue,Waltham MA 02451 1 800.424.2468 1 spsinconline.com Page 4 of 8 109 Brentwood Circle 109 Brentwood Circle I Proposalk 5440987 and install new roof shingles. (6 feet up and 20 feet long-Total area= 1.2 squares) 11. Repair Rear Spigot Leak 1.00 Spigot Leak $50.00 $50.00 12. Remove and Replace(2)Garage Doors with 1.00 Garage $2,385.00 $2,385.00 "Thermacore" Sectional Doors as manufactured by Doors the Overhead Door Corporation(Doors only,existing motors will stay). 13. Remove Weathervane from Garage Cupola,Transport 1.00 Refinish $250.00 $250.00 to Don's Brass and Copper Polishing,Have it re- finished,Transport back to 109 Brentwood Circle and Re-Install(Allownace only until Don can see the weathervane). 14. Stain(19)Interior Windows to match existing Interior 1.00 Stain $1,045.00 $1,045.00 Decor. 15. REPEAT/LOYAL CUSTOMER DISCOUNT 1.00 DISCOUNT ($610.00) ($610.00) Total: $335000.00 Additional Items, Alternate Items and Unit Prices Type of Price/Type Item Description Quantity Quantity of Quantity Extended Price There are no additional or alternate items to note. Schernecker Property Services 283 Second Avenue,waltham MA 024511800.424.2468 1 spsinconline.com Page 5 of 8 The Commonwealth of Mlassgehusetis z F Department of Industrial.Accidents = 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia ,�. Workers'Compensation Insurance Affidavit:Builders/Contractors/Elee.tricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legitbly Name (Business/Organization/Individual): P .Address: C­�P 1017 yr City/State/Zip: (7r Phone#: Are yon an employer?Check tfi a appropriate box: Type of project(xequired): 1. 1 am a employer with__LD! employees(full and/or part-time).* 7• New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8• Remodeling any capacity.[No workers'comp.insurance required.] 3..❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition []4.F1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. ' 12..❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.[� oof repairs These sub-contractors have employees and have workers'comp.insurance.$ ) 6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.. Other �� W 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] r: Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information Homeowners who submit#his 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 a employees. Lathe sub-contractors have employees,ley must provide their workers'camp.policy number. Iain an employer that is providing workers'compensation insurance for my mployees.'Below is the policy and job site information. r Insurance Company Name: J Policy#or Self-ins.Lic. 6 WL2 / Expiration Date: oa > �c1t-� Job Site Address:—/0 >5� � Czty/State/Zip: Attach a copy of the wor ers'compensation policy declaration page(showing the policy number and expiration daee). 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 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. I do hereby cer 'y and the pains nd tiles ofpeijury that the information provided a ove is trife and correct. Si nature: Date: Phone#• �Z 2 ✓ 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#: Informati®n and Instructi®ns 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 '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=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 foi•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(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 I Client#: 1025557 SCHERPRO ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/19/2016 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(les)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 NAME:CT Kathy Wagner USI insurance Solutions, LLC PHONE 413 750 4222 6 123 Interstate Drive E-MAIL Est: ac,No: 10 537 9481 West Springfield,MA 01089.3600 ADDRESS: Kathy.Wagner@usi.biz 855 8740123 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:ABC Mass Workers Comp Self-Insu 99999 .INSURED Schernecker Property Services, INSURER 8: 283 Second Avenue INSURER C: Waltham,MA 02451 INSURER D: 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 CONTRACTOR 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 ADDL SUBR POLICPOLICY EXP LTR INSR WVD POLICY NUMBER MWDDY EFF MM/DD LIMITS COMMERCIAL GENERAL LIABILITY -EACH OCCURENTED RENCE $ CLAIMS MADE OCCUR PREMISES Ea o ence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: / $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS AUTOSNON-OWNED PROPERTY DAMAGE' $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION ABCMA12000116 01/01/2016 01/0112017 X I R&TE OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1 OOO 000 OFFICER/MEMBER EXCLUDED? a N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1000,000 Ifes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Proof of Massachusetts Workers Compensation Coverage CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S17877327/M17054616 PZTZP ,eco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �•� 5/18/2016 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 CONTACT Claire Boutilier NAME: Cleary Insurance IncPHONE (617)723-0700 AX No:(617)723-7275 226 Causeway Street ADORES:cboutilier@clearyinsurance.com INSURERS AFFORDING COVERAGE NAIC# Boston MA 02114-2155 INSURERA:Continental Western Insurance 10804 INSURED INSURER B Acadia Insurance Company 31325 Schernecker Property Services, Inc. INSURER C: 283 Second Avenue INSURER D: INSURER E: Waltham MA 02451 INSURER F: COVERAGES CERTIFICATE NUMBER:2015-16 Liability 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 ADDL SUB POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE FX OCCUR DAMAGE To RENTED 300,000 PREMISES Ea occurrence) $ CPA 0183614-19 12/31/2015 12/31/2016 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,O G,000 POLICY ECT F—] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED MAA 0183615-19 12/31/2015 12/31/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION$ CUA 0183616-19 12/31/2015 12/31/2016 $ WORKERS AND EMPLOY RS'LIAABIILIITY Y/N X STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? NI N I A B (Mandatory-in NH) WCA 5074780-13 12/31/2015 12/31/2016 E.L.DISEASE-EA EMPLOYE $ 1'000'_000 If yes,describe under Excludes MA DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) The Town of North Andover is included as an additional insured for general liability per insurance coverage form CLCG0492 (02/12) when required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE John Bernardin/CTB -©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 OnlAnal ��e�Jrr�n�nrztoe�c�/�-c��C�iflriaaac�ttsc/13 f ►;e of Consumer Affairs&Business Regulation E IMPROVEMENT CONTRACTOR I ,f2-gistration 123615 Type: Expiration 3/1412017:. : Supplement CE�ej k Schernecker Property;Services�'Inch CHUCK HUNTLEY 283 Second Avenue Waltham,MA 02451 Undersecretary U Massachusetts Department of Public Safety �V Board of Building Regulations and Standards License: CS-081428 ;M �• Construction Supervisor r CHARLES E HUNTLEY Jla.`: ' 25 HEARD DRIVE r ` IPSWICH MA 0938ti � 3 r-'jZCK n Expiration: Commissioner 07/28/2017 6 I