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HomeMy WebLinkAboutBuilding Permit #711-15 - 1220 SALEM STREET 3/12/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 31415 IMPORTANT: Applicant must complete all items on this page LOCATION ET _ PROPERTY OWNER Print 100 Year Old Structure yesnno MAP NO: _PARCEL: ZONING DISTRICT: - Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT. PROPOSED USE R=ne Non- Residential ❑ New Building ily ❑Addition ❑Two or more family 11 Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please,Type or Print Clearly) OWNER: Name: P�4v- c7t <I Phone: Address: CONTRACTOR Name: Etir to Path, Phone: 7" 3 Hilton Street Address: em 171V Supervisor's Construction License. %7q77 Ex p. Date: q/Z 3 Ile, �i Home Improvement License: L12-0 / Exp. Date: ARCHITECT/ENGINEER Phone: 7 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: $ 12,0 — _FEE: $ � Check No.: Z, Receipt No.: NOTE: Persons contracting with u rggis a contractors do not have access to the guarantyfund _� '_"'""� u—Ce� �y �"`- ^W. _ i nature of coritr-actor :Signature of Agent/Owne w 9 _ _A .___ .� Plans Submitted E Plans Waived ❑ Certified Plot Plan 0 Stamped Plans ❑ �l ! • �_t 1. J1J. 11 n!1 Ir:11 Plans Submitted:❑ Plans Vilaived ❑ .Certified.Plot Plan ❑ Stamped Plans ❑ :TYPE✓_"EWERA:GEDl§PD3AL Public Sewer ❑ Tanning/Massage/BodyArt ❑. . ..Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ - - Food Packaging/Sales ❑ Private:(septic tank,etc:_ - ❑._,= .-PerJnanent Dempster on Site ❑ THE.FOLLOWING SECTIONS FOR-OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM - -DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature 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 Connection/Signature& Date Driveway Permit I PW Tows! Engineer: Signature: Located 384 Osgood Street FARE DEPARTM,.L-NT. Temp Dumpster on site-eyes no Located'at 124 Mair, Street--; Fire De partme► t-siginature/date`~ COMMENTS ` -Dimension- Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total-land area; sq. ft.: Y. 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 EI Notified for pickup - Date E E Doc.Building Permit Revised 2010 Building Department `rhe fol6wing is=a first of the req'uired.forms to be filled out'for the appropriate-permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits a Building Permit Application Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or G.S.L. Licenses u Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire--Department prior to issuance of Bldg Permit Addition Or Decks Li Building Permit Application Li Certified Surveyed Plot Plan u Workers Comp Affidavit a Photo Copy of H.I.C. And C.S.L. Licenses a Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) u Mass check Energy Compliance Report (If Applicable) u 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) u Building Permit Application Li Certified Proposed Plot Plan u Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) u Copy of Contract a Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all case-,if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apu,W 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.Building Permit Revised 2012 . 4 Location No.--) _ Date 3 12 173 . - TOWN OF NORTH ANDOVER • D, Certificate of Occupancy $ Building/Frame Permit Fee $3� Foundation Permit Fee $ Other Permit Fee $ F TOTAL $ Check# 3z� Building Inspector � NORT�y E Town of : . 1} Andover 1 No. �J * h ver, Mass,T COC NIC"am ICK s � BOARD OF HEALTH j Food/Kitchen PERR IT T LD Septic System THIS CERTIFIES THAT ....�... . �.6.1■,!r„ R............................................ BUILDING INSPECTOR .............. ......... .... .... has permission to erect buildings on .....` Q. So Foundation Rough to be occupied as ............ ���L... .�JM1a........ +Or1►. .... ............... 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- MONT S ELECTRICAL INSPECTOR UNLESS CONSTRUCT ST TS Rough Service .............. ....... ...... ................................ Final BUILDING INSPECTOR GASINSPECTOR 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. d2ssachusett§Ff r Meat SRffi Ie ,f^t This fate satisfies t basic r `�-DI frac. —-- Iangua,e w ptntecthomentraers cots of the states Home hn ivtassaehttszns Consumer eek Iegal ndsiceifaen��ent CaotraaorLatr(t41GL chapter 1 OfriccOfCo Guideto$omeInrptOL�ent"b° �p . Imminghome im ).6utdatxnotindndestaDdard Amer:l rrgandBustnMRcEtttatiods eta- 9toa°ynuk Pro�nentsshouldBW btaina llt)rne0fi l°f tiooHottiao YO°rre,idenceYoumayabtainafrceco COPY of"A DEr(nfOTrT)atjOn at61� &787crT.Bg�, pybycalling'he dune 83 3757 or on ournebsite Contractor Information Ci ✓� tx I CDateaot Stry-„t Addrm(do not use a �xa �' r�ce l3mceddrtt()� c i� J / a Cm' o/$alesPetwn Hoer\' e Cirifonn T �j a p / ^ State , _,de -� i�AV ry°I[T�J�Y Byia�rlddtecs(mttstinele Sime PbDn I01-70 Estning Phone CmrTotm Malin"Addrea State zip Cade (It difienntt from^30ce1 BtuintssPhooe r Federal Emaloacrn?ors-S-Number LF-=aeon myae°a b+e �=va�: TheContrtetot 'r� �a°eter IoZO�/ rDacribe in detail then to do the following forthefio j and WE then acdZi ileo / t? /�/ P4 brand,ar d deaF materials ro ba YV/`^-,v _ use4usexddieinnztslue_' `V v�'- c �,�! as-L IT/ c �i s/s 9 Required Permits-The foilotvioe building and nr7t6esecuredbythec l+etmitsaretegtdred Proposed Ommctorasthehomeanne�saetmt StarrandComgleBonSchedtrle- (011'ners oho secure their osrn permits�si[i 6e b`at7tered to and the follouiOg schedule hill excluded from the Guaranty Fundprovisionse eirta rynces bf!Md the can cottnoI arise yIGL chapter I42A.) of : / 3 /� I?ate7ttitenContractorttTlbegin contracted nnt'a, Total Contract Price — —ate when contracted nrorg ltd be rt ,�antialh completed The Conuacror to d PapmentSdnedtde It theHutt;,furnish the material and labor p4ments'ill be made accordingsP heti abate forthe total sum of U Q - to thefolIowingscbtuie (°} S-h!tV_" ipon si_mtittg contract(not S to zcceed IIS of the total contract primo or th by / _ ecwtofspecalordetit m completion of �_ tvhlcl1et' is n"er) or upon completion of4 upon completion of he con �-(Lan forbids deutan _E fait atm The lb"Ot%iegmateialregttipJIIe! P_ ttmtilcontraetiscom t °r'�b•ore the con must be spatia) s F ed to both party's satisfaction) to meet the wapletian ed nab•bins in order to paid f 'dute.t°') _ ` N`0*rES: ('llnctutlin8al(financec+ �� not eceeed the_tsrster hanteOf s(.l ��o'�thin am•drpOsit o dox nitieae mun bespecial ori )one third ofdte tea)contract n FaSro�t rmuired c the contractor befce n eyed in advane a to Puce or(b)theactnat co;t orae• mE buts cone thecomoletionschedule sPwtalequtptaetta mzt E rets 1�arranh_ QPRm�ematerial Trann renrrartan .b Subcontractors-37teeontta rO d Mthernn[rnetOr? Part)'/Subconnacmrt; ized bye ZD besole.] ❑�O Yes It arthewnrrnner mat rials an the conDaetor- The a°nsrble for completion of the icoPn dss�t�d r mtest bearbehrd to the c u, tr abor oder his env COnnaaorfiatbeiaerzestobes rc,*dlessoftheacp Contract Acceptance_U oldyr�sp-indble forall puzmeQu to all ons afan�'third contract shall not impl• pan si ripg this document becomes a bindin subcontractors for carefully }thisanybenorodtersecurit2 interest Inas beengIcantractunder•lan: I3alessothemisenotedWithin before limine this contract paced on the residence•Revien•thefollot.' this docuareo4 the ° Don't be mgcatrlinesandnotices Pressured into signing ° :Mate sure the contr2ctor has v�a�ita H�me ImDro���°�d and full ted subconttaa�ta ae 3 etstaad i[Ask questions ifsomethin eredniththeDirectoro Cmprov meat n o„ 7helaty gisundear Utra rz�snatina by utitint to g1e - at I O p pr a Improvement ie4°�most home improvement�n�aor,and " Does the t antrauorhave' �Room 5170,$ ContractorRe c an 1 ou mayin see a copv rnsttrance• -the Contractor for his instu� L9 03116 or617:973-37 4�e about contractor ofa`7,rooi ofinsttraucC^do �n so- 17-97,3737 or S38-3t 3_375_ ° lnon•)•aurriehtsand re,�onsrbtlt'tie;.nunenL P�yinformationsotbatyouraom�n Gtride;otheHomelm Read die Imponantht rmcotemP.oras4to Prosement Contractor Lan_ formation on the reverse side of this form and get a copy ofthe Consumer You may cancel this Ism ent ifit h�been sierted at a third boor in n:iting at hisArer Main ofnt~ar blanch aScol b tim°therthan e thirdbusines atdinannrat7 contractOPsnattnatIlace ofltusiness, L' daymUoaingthesi_euiogofthis 2ereemenL Seethe Posted 6ytei bydeliv not r�otifvthe DO NOT SIGN 1 P--R�int or THIS attached notice dniehtofthe Ttwidm�eoa orCueoa« NT'RACT j�r M.I;M �aaatiODofthiStigbL t to�,d� d ar mz td;agi:aCr �tY BL��SP�CESM Hameonuer's 5imattue !:••5 F /' 1qt cmtuac[or$ atature 1 I Contractor Arbitration to initiate an arbitration action i as ar. The Home Improvement Contractors acv provides homeowners w 5th the riot alternative to court action)if they have a dispute with a contractor.The same right is not automatically afforded to a contractor,however. The contractorvould have to resolve am,dispute he/she has with a homeowner in court unless both parties agee to the optional clause provided below.This clause would ire the contactor the same ti It to arbitration as is afforded to the homeowner by the Home Improvement Contractor Lav:- The contractor and the homeowner hereby mutually agee in advance that in the event the contractor has a disproved by concerning this contract the contractor pray submitthe dispute to a private arbitration firm Nvhich has been app the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall ba required to submit to such arotuation as protnW7n 1dMwmhusetts General Laws.c ter 142A. s. (/�) �ir,�l � - {-':J BUJ=tt.'•:� L/� • - � � �i1'LLQ ��(�� Homeowner's Signature 1 Contractor's Signature OTICE:The signatures of the patties above apply only to the agreement of the parties to alternative dispute resolution initiated bt the contractor. The homeotwmer may initiate altematuve dispute resolution even where this section is act separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e MGI.chapter 93A)may not be waived in any way,even by agreement. However,homeoww'ners may be excluded from certain rights ifthe contractor they choose is not properh'registered as prescribed bylaw;'. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home lmprovement Contractor Law. The contractor is responsible for completing the work as described lira a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contactor guarantees or provides an express warranty for lvorinnanship or materials. In addition to guarantees or n'arranties provided by the contractor_all goods sold in Massachusetts caro'an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawTully agree maybe added to the terms of the contract as long as they do not restrict a homeowners basic consumer rights. If you have ,ts:contact the Consumer Information Hotline(listed below). questions about your consumer/homeowner rig Execution of Contract The contract must be executed in dunlicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not sign the document until all blank sections have been filled in or marked as void deleted or not applicable. One original signed copy of the contract,,tith attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contact must be in,,writing and agreed In by both parties.Contracted work may not begin until both parties have received a fully executed copy w the contract and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems himtherself to be financially insecure. HOWaVer,in instances-where a contractor deems himthersel f to be finartcially insecure the contractor may require that the balance of funds not yet due be placed in a}oinnt escrow account as a prerequisite to continuing the contracted,,ronin Withdrawal of funds from said account would require the sissnatures of both parties. Additional Information e Improvement ement Contractor Law or other I f you have general questions or need additional information about the Hom fire copy of"A Massachusetts Cam=Guide to Home Improveme consumer rights,or if you wish to obtain a frnt" contact_ Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza:Room 5170:Boston,Mf A 02116 61-7-973-878-7-888-283-3757 or visit the OCABRWebsiteat If you want to verify the registration of a contractor or ifyou have questions or need additional information specifically about the contractor tz-gistration component of the Home Improvement Contractor Law,contact Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation I0 Park Plaza.Room 5170:Boston.MA 02116 617-973-8787,888 283-375 i or Asit the HIC wzbsite at Go online to view the status of a Home Improvement Contractor's Registration: ^i y'^ <t•• l'�tL`l10ii�IF Y ni em-gn Fiis CiL 1i�c.�s4' _ For assistance with informal mediation of disputes or to register formal complaints against a business:call: Consumer Complaint Section Office_bfthe Attorney General 617=127--8400 AMOR Better Business Bureau 508-6524800:508-755-2548 or 413-1r34-:3114 veri;o.?t-I Mr—oto The Commonwealth of Massaclutsetts Department of IndustrialAccidents Office of Investigations ' 1 Congress Street,Suite 100 Boston,MA 02114-2017 sy wwwunass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name{Business/Organization/Individual): Athintic Wr~illheriGi uuii. bi R Jefferson Avenue Address: City/State/7,'p: Phone#: 7 77CY1'/' F/ -5 Are you employer?Check th ppropriate box: Type of project(required): 1. am a employer with 75 4. Q 1 am a general contractor and 1 employees (full and(or part-time).* have hired the sub-contractors 5. 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 8. [] Demolition workingfor me in an•capacity. employees and have workers' �' p ty 4. []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 l l EJ Plumbing pairs or additions myself [No workers' comp. right of exemption per MGL 12.0 R pairs insurance required.]t c. 152,§1(4),and we have no / I employees. [No workers' 13. Others 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. iContractors 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: zu V t cil Policy#or Self-ins. Lic.#: 5 6,2-7 0 /R I Expiration Date: 3/A 0'/S Job Site Address: 19;L0 14-t?!�-t S�- - City/State/Zip: A.I. Aj-tiL�l- fW 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 one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 certif}►u er th% e p an les of perjury that the information provided above is true and correct r.110 Ig S!,nature: Date: c� Phone#: r - 7 4- 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#: page 3 of 4 A00 v® CER DATE(MIN/DDMM CERTIFICATE OF LIABILITY INSURANCE1 3/3/2015 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the teens 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 NAME- Construion Eastern Insurance Group LLC PHONE . (800)%3-7231 FAX 233 West Central St E-MAIL (AIC.Nok D Natick MA 01760 INSURE S AFFORDING COVERAGE NAIC# INSURED INSURER AArbella Protection Ins. Co. 1360 Atlantic Weatherization INSURER B Nautilus Insurance Co 61 Rear Jefferson Avenue INSURER C: INSURER D: SalemNA INSURER E: 01970 INSURER F: COVERAGES CERTIFICATE NUMBERNASTER 2015 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUR DEVISION NAMED ABOVE EOR 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 WAM WN LTR TYPE OF INSURANCE POLICY NUMBERPOLICY EFF POLICY EXP GENERAL LIABILITY MMID IMMID /YYYY LIMITS EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY A CLAIMS MADE a OCCUR 500042816 /20/2015 /20/2016 PREMIS S Ea occurRE rence S 50,000 MED EXP(Any one Pers) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PRO LOC PRODUCTS-COMPIOPAGG $ 2,000,000 AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT A ANY AUTO Eaaodden $ 1 000 000 ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS X AUTOS 020015871 /20/2015 /20/2016 BODILY INJURY(Per accident) $ X HIRED AUTOS X AU0TNO3E0 PROPERTY DAMAGE Per accident $ X UMBRELLA LIAB X OCCUR PIP-Basic $ A EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ 1,000,000 DED RETENTION$ 600058654 /20/2015 /20/2016 AGGREGATE $ 1,000,000 WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY WC STATU- OTH- ANY PROPRIETOR/PARTNER(EXECUTIVE Y I N OFFICERIMEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe Under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below B POLLUTION LIABILITY E.L DISEASE-POLICY LIMIT $ PL200378613 0/1/2014 0/1/2015 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space isrequired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATNE John Xoegel/PMA ACORD 26(si 5) INS025 r7ntnns�n1 ©1988-2010 ACORD CORPORATION. All rights reserved. m Tho Anion nnma and Innn ern rvanie♦prod m2rlte of Ar'nRn AC40REOCERTIFICATE OF DASD° ► LIABILITY INSURANCE 3/10/2014 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 CONTACT NAME: Construction Eastern Insurance Group LLC PHONE (508)651-7700 FAX 233 West Central Street E-MAIL IA C Nal: INSURER(S)AFFORDING COVERAGE NAIC S Natick MA 01750 INSURED INSURER AArbella Protection Ins. CO. 41360 INSURERS Arbella IndemnityIns Co. 0017 Atlantic Weatherization INsuRERcNautilus Insurance Co 61 Rear Jefferson Avenue INSURERD: INSURER E: Salem MAL 01970 INSURERF: COVERAGES CERTIFICATE NUMBER"Aster 2014 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 LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY N D PREMISES Ea occurrence) S 50,000 A CLAIMS-MADE [i]OCCUR 8500042816 /20/2014 /20/2015 MED EXP Any one person) S 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE s 2,000,000 GENLAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG s 2,000,000 POLICY X PRO- LOC S AUTOMOBILE LIABILITYMBINED SINGLE LIMIT B ANY AUTO � Ea accident) S l'000.,000 BODILY INJURY(Per person) s AUTOOWNED SS X AUTOS 020015871 /20/2014 /20/2015 BODILY INJURY(Peraoadw) S X HIRED AUTOSX AUTOS PROPERTY DAMAGE PeraxideM S X UM13REL A UAB XIOCCURS 8,000 OCCUR A EXCESS LU1B CLAIMS-MADE EACH OCCURRENCE $ 1,000,000 DED RETENTIONS AGGREGATE 5 1,000,000 600058654 /20/2014 /20/2015 S WORKERS COMPENSATION AND EMPLOYERS'LIABILITYANY PROPRIETORMTNERWC STATU- OTH Y IN FR OPICERIMEMBER EXCLUDEED?ESE N 1 A E.L EACH ACCIDENT S (Mandatory In NH) If yes,deswbe under E.L.DISEASE-EA EMPLOYEES DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMI S C POLLUTION LIABILITY 00378602^'' 0/1/2013 0/1/2014 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600- OSGOOD STREET NORTH ANDOVER, NA 01845 AUTHORIZED REPRESENTATIVE Ronald Cleaves/SHE - ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. 1NS025 t7nimri m Tho Ar`r1Rr1 nam&anti Innn am r&nicf&r&el rnarke of A('nRn '/:54 :L1 AM PAGE 2/002 Fax Server -- CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDD/YYM T 1714/111/21114 IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 6THCER CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE! T O DANT: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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s. PRODUCER CONTACT NAME; EASTERN INS GROUP LLC PHONE 233 WEST CENTRAL STREET FAX (A1C,No,Ext): (A1C,Noy NATICK,MA 01760 E-MAIL 22MLW ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC rY INSURED INSURER A: AMM17N ZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: 61 REAR JEFFERSON AVE INSURER D: SALEM,MA 01970 )NSURER.E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: T THAT THE POLICES OF INSURANCE LISTECONTRACT B NAVE BEEN ISSUID TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY AFFORDED Y THE TERMOR CONDITION OF ANY CONiRACr OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 6SIlID OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBID NEREIN G SUB ECT TO ALL THE TERMS,IXCUJStONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. INS LTR ADD B POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MWDOiYYYY) (MIADDIYYYY) LIMITS GENERAL LIABILITY rR CURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE �OCCUR. TO RENTED $ S(Ea occurrence) (Anyone person) $ GENL AGGREGATE LIMIT APPLIES PER: L&ADV INJURY $ POLICY �PROJECT❑LOC AGGREGATE $ S-COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE $ ALL OWNED AUTOS LIMIT(Ea accident) BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY(INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIA8 OCCUR EACH OCCURRENCE $ EXCESS LIA8 CLAIMS�AADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-68270121-14 0320)2014 03/20/2015 LIMITS ANY PROPERITORIPARTNERIEXECUTIVE Q N/A OFFICERIMEMBER EXCLUDED? E.L EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 590,000 DESCRIPTION OF OPERAnoNS/LOCATIONS/VEHICLESiRESTRICTIONSJSPECIAL ITEMS THIS REPLACES ANY PRIOR CERT'RCA7S ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORETHE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE W11H THE POLICY PROVISIONS. AUTHORIZED REPR N ANDOVER,MA 01845 :..,. :. ___::; - ;::•:` � s,�yq - - . - -- ACORD 25(2010/05) The ACORD name and logo are g registered marks of ACORD 1988=2010 ACORD CORPORATION. All tights reserved. Massachusetts-Department--.of Public Safety Board of Building Regulations and Standards Construction Supervisor License: 0."87977 ERIC W PALM 3 HILTON ST s Salem MA 01970= Expiration Commissioner O412312016 '7/c OMee of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR istration: 142089 Type: R , piration: 3112!2016 Ltd Liability Corpo: ATLANTIC WEATNERIZATION L.L.C. ERIC PALM 61 R JEFFERSON AVE a SALEM,MA 01970. Undersecretary