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HomeMy WebLinkAboutBuilding Permit #242-2017 - 1253 SALEM STREET 9/7/2016 BUILDING PERMIT of No DrH �+ TOWN OF NORTH ANDOVER 02 :wta APPLICATION FOR PLAN EXAMINATION i Permit No#:� �� oR Date Received / ��Ssgc Hus��RS Date Issued: Q k7 IMPORTANT:Applicant must complete all items on this page LOCATION ILS 3 S&Jeri.S� Print PROPERTY OWNER [,% t\ka oti:M6� , • '611za ewe Print 100 Year Structure yes no MAP,I-'� PARCEL:Aia� ZONING DISTRICT: Historic District yes no jyn �3 Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑/ dclition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 7_Sept�ic Well P 0 Floodol'ain ❑Wetlands ❑ Watershed Distr 14 - ---- — ----- Wator/Sewer DESCRIPTION OF WORK TO BE PERFORMED: CA�( Ali rR (,Q-IW t�u i n G, �11R c�n -� 1-�m 0�tyr NAA o- Identification- Please Type or Pri t Clearly OWNER: Name: Phone: Address:ContractorName: Phone: G(It 331D• 3-4 9 3 Email: G,,jY ' Gmo-%k • W� AddressJ Pb( . 3'M 1 x 3� Supervisor's Construction License: � b 2St� Z- Exp. Date: S 1 ZJ,1 7 l IIS Home Improvement License: t �3y �O Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ H ) ' 8k0 FEE: $ Check No.: Receipt No.: NOTE: Persons contrac 'ng with unregistered contractors do not have acce s to the guaranty fund 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENT'S CONSERVATION - Reviewed on ____ Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 7oning 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 ]DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARdTt_MENT T Tem Durn §ter ontsitewk: yes °� no) +-d--._ ^+.c J"t.e .�t.F� `, ^�- Located of 124 MaiStreet +--�. reDepartment�ignafure/date,, s y} i' r i..,,i+... ��V�f.,( '"�' 1-':.jF ,�� i• �••r. r . .art y rr t :i. ;- r a+t;is.ti. C6MMENTS4 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 F Date Time Contact Name Doc.Building Pemit Revised 2014 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 4. Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4. 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 iL 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location No. c �� --d� / Date TOWN OF NORTH ANDOVE9 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ / r Check# `� Building Inspector NORT11 Town of 2 1, sAndover p 0 No. T - �- a i y C, h ver, Mass, 1 MAE 1. COCNICNl WICK �� CRATED r`P��'�y S V BOARD OF HEALTH Food/Kitchen PE . f Ta a T. ' Septic System THIS CERTIFIES THAT ....... . ..6...............................I.... BUILDING INSPECTOR & LD .............................................. ...... has permission to erect buildings on /.. Foundation Rough to be occupied as ..K....�.����.... . ....�s�..� .�. 1.lY... .... ......... ...... .... Chimney provided that the person accepting this pettrllI shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and1.3y-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. ,�/E��r �� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. vim"" Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION Rough Service .. . ...... ....... ...... ' Final BUILDING I ECT 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. CLEAResult CONTRACT FOR PRODUCTS / SERVICE WORK This service is brought to you through rom your local utility This Agreement is made by and among Linda Quimby-Brudette aid CLEAResult 1253 Salem St A'- North 'North Andover,MA 01845-4911 ,y 50 Washington Street,Sui 000 �, Site I&500050226627 O ` x + Westborough,MA 01581 Project ID:P00050259723 Federal ID No.22245 0 Customer ID:C00050229239 (Mail completed con to address above) Contract ID:20160822_WORK 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance with the terns of this Contract,including the attached recontmendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: Description Quantity Location Propavent 2'or 4' 22 Attic-2 $84.26 Damming 88 NIA $192.72 Match:Thermal Barrier Polyiso 2 inch(Attic) 1 Living Space $41.71 Attic Floor Open Blow Cellulose T 683 Living Spaoe 51,044.99 Attic Floor Open Blow Cellulose 7" 678 Living Space 51,037.34 Hatch:Thermal Barrier Polyiso 2 inch(Attic) 1 Living Space S41.71 Install 2"Thermal Barrier Potylso On Kneewall 200 Living Space $880.00 Insulate Rim Joist with 6.25'Fiberglass Batting 10 Living Space $24.00 Sub Total: $3,346.73 Utility Incentive Share 52,000.00 Customer Contribution $1,346.73 For office use only Printed:8/2212016 Page 2 of 2 Il. PAYMENT + Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment Al:S 7 G as a Deposit payable to CLEAResult upon signing the Contract(not to exceed I/3 of thetotal retail costs).Mail check&contract to CLEAResult,Atte EMS,50 Washington St., Ste.3000,Westborough,MA 01581.Final Payment-$ Ng. T 3 as the final payment for the Work shall be payable to the independent Installation Contractor(91V')upon satisfactory completion of the Work.Customer understands that he/she will not be required to pay the Utility Incentive Share or the Contract price in the amount of$ 7060--at, Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION The 0C and Customer hereby mutually,agee in advance that m the event thatthe IIC has a dispute concerning this Contract,the ffC may submit such dispute to a prirate arbitration service which has been EiMraved by the Office of Consurner Affairs and Business Regulation and Customer shall be required to submit to such arbitration as provided in M.G.L c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you otify he seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third busi ess d following the signing of this age a ent. DO NOT SIGN THIS CONTRACT IF THERE A ANY BLANK SPACES. 8 C Date Indicate your selected U her if applicable (OR) Initial here if you want _ irL2 b ZV� � the Program to assign a p Participating Contractor CLE esult Sf a � 4� Date Name of CLEAResult Representative(Printed) TERMS AND CONDITIONS APPEAR ON THE REVERSE. 220¢12-111.16 CLEAResu lte CONTRACT FOR PRODUCTS I SERVICE WORK This service is brought to you through support from your local utility This Agreement is made by and among S� Ca Linda Quimby-Brodette t 1253 Salem St `Fi�1 North Andover,lb1A 01845-491 l �Vton Street,S ' e 3000 Site m:500050226627 IP h,1VIZ01 Project 1D:P00050259723 h, 270 Customer ID:C00050228239d caddress above) Contract 1D:20160822 ASEAL 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the'Work)which are incorporated herein by reference: Description Quantity Location Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 12 Living Space $1,011.84 Whole House Fan Box:Thermal Barrier Po"Is 2'athcL 1 Living Space $168.98 Door Sweep 3 NIA $69.54 Exterior Door Weather Stripping 3 NIA 582.77 Sub Total: $1,333.13 Utlllty Incentive Share $1,333.13 Customer Contribution $0.00 Of'00 For office use only Printed:8/2212016 Page 1 of 2 II. PAYMENT O,Dv Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows Payment NI:$ as a Deposit rt payable to CLEAResult upon signing the Contract(not to exceed 113 of the total retail costs).Mail check&contract to CLEAResult,Attn:NES,50 Washington St., Ste.3000,Westborough,MA 01581.Final Payment-$ 0:QCJ as the final payment for the Work shall be payable to the Independent Installation Contractor("IIC")upon satisfactoy Completion of the Work.Customer understands that ht'Jshe will not be required to pay the Utility Incentive Share of the Contract price in the amount of$ t3 .17 Changes to individual line iterns and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION The 11C and Customer hereby mutually agree in advanee that in the event that the IIC has a dispute concerning this Contract,the QC may submit such dispute to a private ar bilratilon service which has approved by the Office of Consumer Affairs and Business Regulation and Customer shall be required to submit to such arbitration as prmided in M G.L c 14M You m y can 1 this agreement if it has been signed by a party at a place other than an address of the seller, provided you n ify th seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third busine s day f flowing the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. ty 1� Custom r Date Indicate your selected IIC here,it applicable (OR) tiere if you want J ( yaw r the Program to assign a CLEAR t Signature Date Name of CLEAResult Representative(Printed) Participating Contractor TERMS AND CONDITIONS APPEAR ON THE REVERSE. 2200.12-Ri.16 Permit Authorization •' � mast S�V� form C1.01 UMM Site ID: 500050226627 Customer: Linda Quimby-Brodette 1, Linda Quimby-Brodette ,owner of the property located at: (Owner's Name,printed) 1253 Salem St. North Andover IProperty Street Address) (Ory) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: %< < Date: 000000aa000aa>a00000000aoaa000aa000no©00000aoa000aa00000000a0000000000 FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date ps•� CLEAResult • 50 Washington street,suite 3000 • Westborough,MA 01581 • 1800.480-7472 Qj P° Foroffice use.only Rev. 102015 The{:ommonwealth of-lassachusetts ' Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,'11A 02114-2017 wn-w.mass.goi ldia Workers'Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please )Tint Legibly Mone fBusinc�! {Or natation Indi,.idualt: _r 1 wta-1_ yi r�Y,,� Address: ft 130X 314 Citi°;State!Zip: 10Swi O t 3$ Phone L 9 " 3 s`L0- 34% 3 Are you an employer". Check the appropriate box: Ti of project(required): ' 1 am a general contractor and[ 1.9 I am a cmplo�•cr with�i '� emplox-etns(,full and or part-tiine).* ha%c hired the sub-contractors �' ❑leu'cc�n,traction 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employers '1 hc-w sub-contractors hati e S. ®Demolition corking for me in any c2 cin employees and have workers' ' 9. []Building addition [ti'o workers' camp.insurance comp.insurance.' required.] - We arc a corporation and its I0.® Llectrical repairs or additions [] i am ahomeowner doing all work- officers have exercised their 1 I.[]Plumbing repair.or additions myself. [No work-ms comp. right ofcxrinption per �1GL 12.®Roof repairs insurance required.] ' c. 15'_,s 1(-(),and v e ha%e no employees. [\o a"orl:ers' 13.0 Other cornp.insurance required.] '.ins'applicam that chcc+:s hot=1 must also fill out the t ctiarn below slitwutt:hest wotkers m nntana3n Homeowners who submit this atlidactt mdtca:k�they are dotnizVl work ars;:l*cr.hre tx:t:-u1c cm-ractcxs must,uhmit a n-%affida+it ar.dic-31i:s_sec's. tCot:ttacio,s that check ttts box;rust anat;hce an eda tticKul 4irrt shoalt R•i1:c name of tht,ah-cut: wors aN!stare ubcd f tar no,:#mom enwic5 Barr emptoyres. 1 the sub-ihmiitmrwn h3rc-np!in-:s,6n, mw!pmstd:thrix wvr?am camp.pohc�rumba 1 am an empkyer that is providing warkers'�compen3ution im urance for my empkrees. Below is the polict,and job site information. Insurance Company haute: �Ol !hs�(11v nc.Q t � _ Policy=or Self-ins. Lic.-a: 1'"S P�P I P ��ta3�,,� Expiration Date; k 0j 3 O 1114 Job Site Address. I -L S 3 S Ct, {N\ } CitCityState-Zip'tV UfVV11PVr'�`� t,�1 Attach a copy of the workers'compensation polis% declaration page(sho%ing 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 criinittal penalties of a fine up to S1,500.00 andw one-year imprison-wril,as well as civil penalties in the forth of a STOP«`ORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copw of this statement inay be forwarded to the Office of Investigations of the DiA for insurance emcratge verification. t do hereby cerdit,under the paint and penalties of perjury that the information provided above is true and correct. Phone r+: U3c118 Official use only. Det not orrice in this area.to be completed by city or town nfficial. Cit} or Town: Permit/License# Issuing Authority icircle one): 1.Board of Iicalth ?.Building Department 3.City/To"n Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: _ _ - _— Phone#: �4 Massachusetts -Department of Public Safety Board of Suilding Regulations and Standards SUp*i,�.rrr ring c-i.►lh License: CSSL_102562 !CURT R GA t""R °c <` P•0 Box 344 .� uhf W tCtl MA Q t 9A I e Expiration r F LL= Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173410 Type: Individual Expiration: 10/1/2016 Trp 257812 KURT GAUTHIER KURT GAUTHIER P.O. BOX 344 IPSWICH, MA 01938 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA 1 0 2OM-OW11 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: q� +1Jf Registration: 173410 Type: Office of Consumer Affairs and Business Regulation Expiration: 10/1/2016 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER J) 44 ESSEX RD fit/,v. IPSWICH,MA 01938 Undersecretary of valid wi out signature A1'^� DATE(MM/DD/YYYY)� a CERTIFICATE OF LIABILITY INSURANCE 05/13/2016 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 CONTANAME: Kaitlyn Daysh MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE Ext (4 13)536-0804 nic No E-MAIL ADDRESS: kda ySh—(a)m'clayton.com 1649 NORTHAMPTON ST.,RTE 5 INSURERS AFFORDING COVERAGE NAIC# HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325 INSURED INSURERS: GAUTHIER INSULATION INC INSURERC: INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER: 52708 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 U R POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F-1OCCUR AMA ED PREMISES Ea occurrence $ MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per acc dent) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB HCLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE WA E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? WA WA WA MAARP300327 10/30/2015 10/30/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwdtworkers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF GLOUCESTER ACCORDANCE WITH THE POLICY PROVISIONS. 3 POND ROAD AUTHORIZED REPRESENTATIVE GLOUCESTER MA 01930 Daniel M-Crawley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD �E-ow g`o` s O r =Ism h!-90 or g 3sv F—; z° a ACORNCERTIFICATE OF LIABILITY INSURANCE DA'°IM"'DD"""o9/12no1s 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: H the certificate holder Is an ADDITIONAL INSURED,the Policy/1418)must be endorsed. If SUBROGATION 18 WAIVED,sub)ect to the terms and conditions of the policy,certain Policies may require an endorsement, A Statement on this cortlficete does not confer rights to the oerti0cate holder In ltou of such endorseme •. PRODUCER 11- MARTIN J.CLAYTON INSURANCE AGENCY INC PHONE Kali 638-0804 ROME.We h®m)clayton.00m 1049 NORTHAMPTON ST.,RTE 5 t(t4114ERISIAFFORDING COVERAOX _ H IC[ HOLYOKE MA 01041 INaaeRA; ACADIA INS CO 31325 INSURED IpsuRE 41. ^• GAUTHIER INSULATION INC uR CL� ellURIR D PO BOX 344 :uRep • IPSWICH MA 01938 ! COVERAGES CERTIFICATE NUMBER: 78793 URER F. 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. TYraorNtuRANoe Pau LMTe COMM[RCIALO[NEM(�LLIASILIrY EACHOCCURRENCE t CLAIAL4MAD[L.._�OCCUR RER'tE6 MIDIXP(Agonrwnan s NIA PERSONAL[AOV INJURY S OENL AGGREGATE pLpIMpn,APPLIES PER: GENERAL AOOREOATE S POLICY❑JECT LOC PRODUCTS COMPIDF AGO t r __ _�OTHER., i ! AurommiLeLM(UTY sae [ ANY AUTO SOOI.YIN)URY(pr v--)11 M`OWNED SCHEDVLEO AUias AUTOS N(A 900hY INJURY(Prr ecddN,1) 1 HIIaDAUTOa AUTONONS [ I UMMtLLAUAa OCCUR [AGI OCCURItEWS IS SXCISSLME CLAIMS-MADS. WA AGGREGATE Ne WORMNe COMP[N$ATM AND[MPLOYIM'UASa.RY YJN , ANYPROMI[TORMARTNER/EXECUMVE 6.1. E 500 000 A VpFFICERAIIMaEReXCLUDED7 WA NU NM MAARP300327 10/30/2018 10/30r2D18 EACH i IMendOl0 �Y1N EA,OIS[Ae[.EA aMPLOYE S SOD 000 I l DISEASE•POLICY LIMIT 501 000 NIA 09aCR"T10N Of OPORAInIM I LOCATIONS!VENICLIS(ACOR0101,AdROrrM1 PIPrPnr sch.)*m$Y N HtreMd N male•Nee N rrqu(red) Workara'Compenestlon benefits w10 be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 OB S.no authorization Is given to pay claims for benellts to employees In slates other than Massachusetts if the Insured hires,or hes hired those employees outside of MOSSItChUsaRt. This cenill to of Insurance shows the policy in force on the date that INS Certificate was Issued(unless the Expire0on date on the above policy proeedsa Me luue data oT this CamtlCala of Irlsurancel• 'rhe Statue of[hie oove"can be monRomd daily by accessing the Proof of Coverage-Coverage Verification 8081`011 tool at www.mass.govRwtl/workeracompentallonAnvestigationW. 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. 1201 Osgood Street AUTHORITED R[PRi�.'NTATIYe ' North Andover MA 01845 DaanielrilelM M.Cr17v'�sy,CPCU,Vice President-Residual Market-WCRISMA ®1888.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD