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Home My WebLink AboutBuilding Permit #122-14 - 111 WOODCREST DRIVE 8/6/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0117- Date Received Date Issued: _(� IMPORTANT: Applicant must complete all items on this page LOCATION - _ d .. - int PROPERTY-OWNER ...._ _ _ _ -- , - mar 0 .. - Print `100 Ye Id Structure v yes: o MAP NO.: ARCEL':_�n`�` �ONING:DISTRICT .<Historic Dlstriet yes % -no - - R �__y �_. *Shoo - Machine Shop Village _ yes2 o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family clition ElTwo or more family ElIndustrial Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑•Demolition ❑ Other El Septic ❑Well ❑ Floodplain D,V1/etlands ❑ Watershed Distract El Water/Sewer _ E DESCRIPTI N O WORK TO PERFORMED, G O - l Lt d K Sv KSS 6(��ov� kAJv(,& k—, AgA L-kep u�I-t S � Ickm /I CP11'4"to kw_ �t ae Len a Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CON TRACTORName: bone: hwu I Address: � Supervisor s Construction'License �1 _ Exp Date _-- ® _ �.6�0:- Ex _ Date: �Z Z Home Improvement License: O v m p.' _ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT: 12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: a-'�y FEE: $ �S Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acce t eau n and Signature�of Agent/Owner Sig iature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I TYPE-OFSEWERAGE 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 DATE REJECTED DATE APPROVED I PLANNING & DEVELOPMENT" ❑ ❑ COMMENTS I i e .CONSERVATION Reviewed on Signature n i COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer ConnectioniSignature & Date Driveway Permit DPW Tovvo Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Mair, Street Fire Departmerit signatureldate 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 j I ® Notified for pickup - Date r t Doc.Building Permit Revised 2010 Building Department The fol:owing is-a list of the required forms to be filled out for the appropriate permit to be obtained. Roofilg, Siding, Interior Rehabilitation Permits ❑ , Building Permit Application Li Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract Li Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan Li Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract L, Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application o Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 apnaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:¢ted with the building application Doc: Doc.Builjing Permit Revised 2012 . Location ! ►fit>l5 P--�'t No. — Date o - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame PermitFee $ 3 Foundation Permit Fee $ R, Other Permit Fee $ TOTAL $ Check#2�_ - 26703 Building Inspector NORTH own of 2Andover - T No. ;ta 't i b • ver, Mass, �p � T O LAKE COCNIC NE WICK � A044TEO !" S S V BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT .. .! S ....................................................... BUILDING INSPECTOR ..... ... .. Foundation has permission to erect.......................... buildings on ...1.0...... ....... �,, 0.4..'.. Rough f.7%... .. ` to be occupied as ............ ... ...........'. ......... y.N�.......vh............................... 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 S aw UNLESS CONSTRUCTION A S Rough Service ... .... ... . .. ................. BUIL IN. .G.INSPECTOR.. Final 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. SEE REVERSE SIDE � r __ -_.__ - `.fit• I ��e, Tparurltarrtoecc�C�o�V�umamc�au�et�� v _ office,"ME IMPROce of Consumer Affairs&Business Regulation VEMENT i� CONTRACTOR Type: t _registration ;153660 DBA xpiration 12/21/2014 HEAT QUEST INSULATIONQ LLC, t : ! # l ALLAN VEILLEUX JRA 5 SHAWSHEEN RD. a LAWRENCE,MA 01843 Undersecretary Massachusetts.-Department of.Public Safety i Board of Building Regulations and Standards construction'SupenisorSpecialcc - License: CSSL-099215' . ALLAN M VEILLItUX;JIR 5 SHAW SEN ROA') LAWRENCE MA Jkl R 'I� )I V6 Expiration 08/19/2014 Commissioner Job Number 4361 DATE 20-Jun-13 Client Patricia Franks address 111 Woodcrest Dr city/town North Andover 978-973-0571 contractor Heatquest 1.1NEATIIBRSTRIPPINGJCAULKING QUANTITY TOTAL AUDITOR NOTES Door Kits Q-Lon or Equiv. 4 182.00 may need to get to fit on dbi front door Door Sweeps(Regular) 2 31.50 Door Sweeps(Automatic) 2 46.00 Reglan Windows An.inch 0.00 Window.Weattrstr Schiegal per side 0.00 Terrmat Recessed Can Cover 3 90.00 Attic air sealing per man/hr 1.5 112.50 basement and living space air sealing 3 225.00 SUBTOTALS 687.00 2A-INFILTRATION t INSULATION AUDITOR NOTES Domestic pipe Hot Water Tank 1st 6' 0.00 Sill insulation R-19 CF Q_00 Sill Two Part Foam wt Fiberglass Batt 160 352.00 Drape Perimeter R-5 Anch.Sq.ft. 0.00 Perimeter 2"T-max or equivalent foam board sq.It. 0.00 Drape DOOR R-5 or T-max or equivalent on door. 0.00 Tape Joints(Aluma Grip only)per hr. 0.00 Duct Insulation&Tape sq.ft.R-5 0.00 Rigid Foam Board Anch. 1"per board 0.00 Hydronic pipe insulation to 1"R,5 0.00 Hydronic pipe ins.1.25--1.5"R-5 0.00 Steampipe Ins.to1.25 iron pipe R-5 0.00 Steampipe Ins.1.5"-2"iron pipe R-5 0.00 Steampipe Ins.3"Iron pipe R-5 0.00 Air Conditioner Meeting Rad 0.00 Air Conditioner Cover 0.06 Air Conditioner Cover Special Order 000 SUBTOTALS '=-09 2B.INSLR A710H AUDITOR NOTES Open Unrestricted R 49 0.00 Open Unrestricted R 38 0.00 Open Unrestricted R 30 0.00 Open Unrestricted R 20 1617 2085.93 Open Unrestricted R 10 0.00 Restrict FUSloped R 30 0.00 Restricted FL/Sloped R 20 0.00 Restrict FUSioped R 10 0.00 R-19 FGB open rafterstwalls/kneewalis 0.00 R-11 FGB open rafterslwailstkneewalls 0.00 Attic Stairs(stainnell&common wall) 0.00 Cover Pull Down Stairs Thermadome 0.00 Site built pull down stairs 2"foam box 0.00 AUDITOR NOTES Attic/Kneewal Floor Transition.Dense pack cellulose 0.00 W.S.Hatch Q-Lon or equal 2 63.00 2 hutches are to kwalls, W.S.&bat Hatch R-30/Q-Lon or= 1 33.50 to attic Kneewail R-12 cell behind Per.Memb 0.00 Open Rafter R-20 Cell./w poly 0.00 Open Rafter R-30 Cell./w poly 0.00 Basement Overhead R-19 fiberglass 0.00 Basement Overhead R-30 fiberglass 0.00 Crawipace Overhead<4 high R19 0.00 CrwMpace Overhead<V high R30 0.00 Garage Ceiling cavity filled w/cellulose 0.00 Wood,Shake,Clapboard,Shingles Vicryl 1597 2858.63 Asbestos(single nail)/Asphalt 0.00 Asbestos(doub.Nail}/Aluminum 0.00 Brick/Stucco 0.00 Vinyl over Asbestos 0.00 Multiaayered 3 or more layers 0.00 Drill rough plaster or finish wood plug 110 200.20 garage wall Drill finish plaster 0.00 496 if we do int blow on brick wall Test Drill Walls(all 4) 0.00 SUBTOTALS 5241.26 2.INSULATION TOTAL 2A.+28. 5593.26 3.STORM WINDOWS 1 DEADLITES AUDITOR NOTES Plexiglass up to 88 W. 0.00 _- Additional per UI over 88" 0.00 Other(Negotiated Price) 0.00 SUBTOTALS 0.00 5.OTHER MATERIAL AUDITOR NOTES" Ridge vent In ft. 0.00 Vents Gable rectangular 2 184.00 12x12 for front kwall Varipitch Vent 0.00 Vent Roof 135(1 sq ft NFV)Large 0.00 Vent Roof 865(A sq ft NFV)Small 2 160.00 high side room Vent Soffit Rectangular 12 324.00 4 sWG room 8 main roof rear only Turbine Vents All 0.00 Stade Vent 0.00 Props Vent 12 48.00 Permabte House Wrap 0.00 Vapor barrier 0.00 Energy Star R-4 Rigid Vinyl Repl 94-101 U.I. 0.00 SUBTOTALS 71BAO 6d7.E.C.MATERIAL/LABOR 6986.26 Page 3 Be. HEALTH&SAFETY AUDITOR NOTES. Vent Bath/lgtdten Fan 0.00 11 Dryer vent w/exhaust dud Heartland 0.00 Dryer Transition Dud only 1 40.00 Blower Door Test Pre Post 1 45.00 `;:;_ 11:1NAS';tNCLIt)E Prti4NQ P ::; ;' Att(11141f :1A1( PtG3O SUBTOTALS 85.00 _ 8b.REPAIR MATERIAL/LABOR AUDITOR:NOTES Basement outside door only 0.00 Basement outside door w/iambs 0.00 Door Repl pre hung 32-36"Steel"w I Lite 0.00 Door Repl interior solid core 2832" 0.00 Door Repl pre hung 3236"wood-w/Lite 0.00 Window Replacement w/SIR less than 1 0.00 Basement Window Repl.Awning/Hopper 0.00 Basement Window Reps.With a frame 0.00 Lockset(door)Schlage or equal 0.00 Repair/Refit Door 0.00 Replace Side Stop 0.00 Replace Casing 0.00 Glass Replacement to 64 u.i. 0.00 Glass Replacement per u.l.over 64 0.00 looking to replace rotted bow window Sash Sidelock/Top Replacement 0.00 will discuss when contractor on site Threshold(Wood) 0.00 owner will need to contribute Threshold(Aluminum) 0.00 Slide Bolls 0.00 Plug Plate Cover 0.00 Cut/finish atticacneewali access 0.00 Cut/dose attic-kneewall access 0.00 ' close off fascia rear of the house 0.00 Labor Rate Hours 0.00 als time Inc moving f/g to airseal Labor Rate Hours 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Permits/Fees(wap bF on 0.00 SUBTOTALS 0.00 TOTAL REPAIR+HEALTH&SAFETY 85.00 GRAND TOTAL WORK ORDER S (A) 4387 7081.2 Any alterations or deviations from the above specifications involving extra costs must be cleared in writing before installation_ The Work Order must be complete within 15 working days from acceptance date below: CONTRACTORICOMPANY: Heatq uest ACCEPTANCE:CompanylContrador AUTHORIZED SIGNATURE: Date AGENCY APPROVALS: CTI Authorized Signature: Date GLCAC Authorized Signature: Date Greater Lawrence Community Action Auditor:John Guay Phone : 976-590-6504 Job# 4631 Date: 6/20/93 Client First: Patricia Last: Franks Address: 191 Woodcrest Drive City: North Andover Zip Code 01845 Phone 978-973-0571 Phone 2 House Type: Cape Ranch Split 6;m) 2 lam 3 fam duplex 4 family VIZ Colonial Tenement Siding Type: ood Vinyl Alumn Asb Sin le Asb Dble Condition Go Fair Poor Vinyl overAsb T11 Brick Stucco Asphalt Comments: a&04- Roof Type Roof Material abl Hip Flat Gambrel ate Rubber Tar&Gravel Condition Fair Poor Age of House Heating System Prat out Manufacturer: Efficiency Excess Air CAZ Base Reading :Pre Post: Stack Temp CAZ Worst Reading : Pre Post: Primary Temp Oxygen FHW Steam FHA Space Heater CO. 2 Oil as Electric CO Wood Pellet Coal CO Air Free Flame Color Treated Ducts : Yes No Age 7 yrs Pipes Yes 0 tjo� ba�-' s Ambient CO 0 Domestic Hot Water Tank Smoke Reading Gas Oil lean Tank less -"va-c Referred to HWAP Yes No Gallons Temp Setting Date referred Draft Spillage Yes ! No Spillage Amb CO: Stack CO: Draft direct vent Add 6 Feet of pipe wrap YES I Comments: Number of occupants Number of smokers b Number of pets 2 Ambient CO Readings : Stove 0 Oven s Broilers Dryer The Commonwealth oflMlassachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0b � I Name(Business/Organizationflndividual): ( k Address: k / City/State/Zip: � ,?� Phone#: Are o n employer?Check a appropriate box: Type of project(required): 1. am a em ith 4. ❑ I am a general contractor and I ' P 6. El New construction employee d/or part-time)." have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. nco 1�tSC'i'L�C r #or Self Lic.#: ll/✓[O O�'J�CN dl�- --Expiration Date:-_-.`l /3- Policy -- - -- ._- ._---.-. Job Site Address:_1/(� ��ZJ �e�f � City/State/Zip: /"d 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 fine up to$1,500.00 and/or on r nment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a a to . Be advised that a copy of this statement may be forwarded to the Office of Investigations th r' s c overage verification. Ido here77 by c r i i andpenalties ofperjury that the information provided ab ve is rue and correct. Si atur : Date: � 7 Phone#: A Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and 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 of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity;employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed,to:be an employer." MGL chapter 152,§25C(6)also states that"every state or local li.c'ensing 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is-being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials -Please be sure-that-the affidavit-is-complete and printed legibly- The Departmerifhas 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 numbef.Jn addition,an applicant that must submit multiple permit/loense 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Commonwealth of 1\iassachtzsPtts Dopartment oflndustrial Accidents Office of Investigatitons 6.00 Wasbington Stteot Boston,MA,02111 Tel,#617-727-4900 ext.406 or 1.-8777 ASSAF`B Revised 5-26-05 Fax#617-727-7749 www-mass.gov/dia 08/06/2013 13:29 19785212751 ANTHONY&MALCOLM INS PAGE 01/02 RD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) 08/06/2013 DucER (978)373-S623 FAX (978)521-2751 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION rTHONY & MALCOLM INSURANCE AGCY. , INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3 50. CENTRAL ST. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR BRADFORD, MA 01835 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED ATIan Veilleux, Jr. d/b/a INSURERA; Phenix Insurance Co. Heat Quest Insulation Company LLC INSURER B; Safety Insurance 5 ShawSheen Rd. INSURER c: The Hartford Lawrence, MA 01843 INSURER D: INSURER E: -COVERAGES 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 CERTIFICAPE 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRLTR_INSDD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EKPIRATION LIMITS GENERAL LIABILITY CPP0713253 12/27/2012 12/27/2013EACH OCCURRENCE 8 1 1000,0001 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEll $ 50,OOO CLAIMS MADE D OCCUR MED EXP(Any ona pnrnon) $ 51000 A PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE.LIMIT APPLIES PER: PRODUCTS-CDMP(nP AGO $ Z OOO OO POLICY F7 j%ef JECT LOC AUTOMOBILE LIABILITY $021421COM07 12/26/2012 12/26/2013 COMBINED SINGLE LIMIT ANY AUTO (Es accldenl) $ 1 000,000 ALL OWNED AUTOS BODILY INJURY S B X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Por accldont) PROPERTY DAMAGE $ (Per Bccidenl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO EA ACC S HOTHER THAN AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 6S60UB9609L39012 11/08/2012 11/08/2013 WCSTATU- I JOTH_ HMPLOYERS'LIABILITY — TORY LIMITS PR C ANY PROPRIETORIPARTNF.R/EXECUTIVE E.L.EAC14 ACCIDENT $ 1,000,000 OFFICER/MEMFER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000,00 I(yes,deseribe under SPECIAL PROVISIONS b?Iow E.L.DISEASE-POLICY LIMIT I$ 1,000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS insulation -CERTIFICAIg HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL Town of North Andover Inspectional Services 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 1600 Osgood St. Bldg. 20 BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY Suite 2/36 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Q L North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Frederick Malcolm ]r. JA ACORD 25(2001/08) FAX: (978)6$$-9542 OACORD CORPORATION 1468 08/06/2013 13:29 19785212751 ANTHONY&MALCOLM INS PAGE 02/02 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108)