HomeMy WebLinkAboutBuilding Permit #768 - 14 WINDKIST FARM ROAD 5/15/2013 TOWN OF NORTH ANDOVER
` APPLICATION FOR PLAN EXAMINATION
Permit N0: / Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION U6�1�i 5 ;IY/'
not yJ
PROPERTY OWNER K ik c. Ce)
Print 100 Year Old Structure yes no
MAP NO: 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
)d Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BEP RFORMED:
fe ekie,e Yric he Cc,61 nef-S _ rO 5-h-cl-�
Identification Please Type or rant Clearly) g
OWNER: Name: Mike- r,a Phone:
Address: y in ki s}
gpT7 Phone:"7i?/
CONTRACTOR Name: Cc �,.
Address: f31 mouti'In"i`If c )t�r�%ve r, li fi Cl R03
Supervisor's Construction License: 0 91 �6o y Exp. Date: . y /
Home Improvement License: a 7<J`�5 Exp. Date: � l
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST,,B/A�SED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: / Receipt No.:
NOTE: Persons contracting w th e tered contractors do not have access to the guaranty fund
u
Signature of Agent/Owner i I ature of contractor` —
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE.DISPOSAL
Public Sewer ❑ Swimming Pools ❑
Tanning/MassageBody Art
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
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
r II
COMMENTS
r
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
9
Plannin Board Decision: Comments
Conservation Decision: Comments
Water & Sewer ConnectioniSignature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes no
Located at'124 Main'Street
Fire Departinert,signature/date
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.$10041000 fine
NOTES and DATA— (For department use
El Notified for pickup - Date
( 4
Doc.Building Permit Revised 2010
Building Department
The fol-paving 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
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
❑ 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/Crossection/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
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
❑ 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
❑ 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 was ors special permit required the Town Clerks office must stamp the decision from the Board of Appeals
p p
that the app.al 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: Doc.Buiffing Permit Revised 2012
Location Y - �- - J-I--,-
No. Date
• - TOWN OF NORTH ANDOVER
• ��xrtt,n,1�4
i, r •
•
a Certificate of Occupancy $
Building/Frame Permit Fee $
e
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
1
Check# q
26398 Building Inspector
NORTH
oven o � ? E :. ., Andover
0
No.
C. h ver, Mass,
COCMIC Nl w.CK �1•
S U
BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT P�`St� BUILDING INSPECTOR
...............Y,�!�;�. -........ .............. ...........................................................
has permission to erect II II'' Foundation
.......................... buildings on ....�.. ........ :lnL[..F-.4J...�:.. t�:n'.`"`
Rough
to be occupied as ......1��. "".......� .....................' ...... ....�.....!'. ..�.14�/.Q .:r....... Chimney
1 �..................
provided that the person accepting this permit shall in every res ct 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
.�--v PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
I UNLESS CONSTRUC TARTS
Rough
Service
........... . .... .......................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancv Permit Required to Occupy Buildin-e 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
Enter construction cost for fee cal - North Andover Fee Cakulat%on
Construction Cost
$ 12,520.00 m
$ - $ 150.24
Plumbing Fee $ 18.78
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 18.78
Total fees collected $ 287.80
14 Windkist Farm Road
768-13 on 5/15/2013
Kitchen Cabinets
NORTH
own of � � E ., Andover
h ver, Mass,
coc«�c«ew�cw �'�•
�d A�R�1TE0 C
s �
BOARD OF HEALTH
PERM *IT T LD Food/Kitchen
Septic System `
THIS CERTIFIES THAT V� ► Pt� BUILDING INSPECTOR
...................`.....�'........ ............ ...........................................................
has permission to erect ..... buildings on ` `I .............. Foundation
Rough
to be occupied as ......1�!. .......�... ....3 .............. ....> ..�.l4 ..Q .. Chimney
provided that the person accepting this permit shall in every res ct 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
.�--U PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
' UNLESS CONSTRUC TARTS
Rough
Service
........... . .... .......................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancv Permit Required to Occupy Buildinjz 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
t
��� 1�:`( �TI CTl('�:•4rw
t' 37 Buckman M.Wobura Me,01801
Page: 1
C.C.R.P.H INC.
31 Mountain Rd Estimate
Burlington Ma, 01803 Number: E347
781-844-0083
Date: March 26,2013
Bill To: Ship To:
Mike &Sandy Pasco
14 Windkist Rd
Andover, Ma 01845 978-621-8386
Project
KITCHEN
Description Amount
OBTAIN ALL NECESSARY PERMITS& INSPECTIONS 500.00
DISPOSE ALL DEBRIS ASSOCIATED WITH THIS PROJECT 300.00
RE-WORK SKIM & PATCH WALLS 400.00
INSTALL CUSTOMER SUPPLIED CABINETS TRIM &MOLDINGS PER DESIGN 3,600.00
INSTALL CUSTOMER SUPPLIED INSTANT HOT WATER DISPENSER
INSTALL CUSTOMER SUPPLIED COOK TOP, DISHWASHER, FAUCET
INSTALL ICE MAKER TO FRIDGE
INSTALL NEW PLUMBING DRAIN &CLEANOUT TO SINK
total plumbing 2,800.00
INSTALL CUSTOMER SUPPLIED VENT HOOD VENTED TO EXTERIOR 685.00
INSTALL CUSTOMER SUPPLIED BACK SPLASH TILE 1,500.00
MODIFY& INSTALL BOOZE BLOCK 350.00
FRAME BENCH AREA 300.00
Contractor cost profit&overhead 2,085.00
C.C.R.P.H INC. Estimate
Al Mountain Rd
Burlington Ma, 01803 Number: E347
781-844-0083
Date: March 26,2013
Bill To: Ship To:
Mike &Sandy Pasco
14 Windkist Rd
Andover, Ma 01845 978-621-8386
Project
KITCHEN
Description Amount
Total $12,620.00
MASSACHUSETTS HOME IMPROVEMENT CONTRACT
Customer Information Contractor Information
Name Company Name
Mike& Sandy Pasco Classic Construction&Remodeling inc.
Street Address Contractor/Owner Name
14 Windkist Rd Anthony Rosenstine
City/Town State Zip Code Business Street Address
Andover Ma, 01845 31 Mountain Rd .
Daytime Phone Evening Phone City/Town State Zip Code
978-621-8386 Burlington Ma. 01803
Mailing Address(If Different From Above) Business Phone Federal Employer ID
781-844-0083 20-1407122
WORT{TO BE PERFORMED AND MATERIALS TO BE USED
Contractor Agrees To Do The Following Work For Customer:
Perform work specified in Estimate E347
All work will meet or exceed current building and energy codes All trade individuals
shall be licensed and/or H.I.C. Registered with current Workman's Comp and liability
insurance.
The following schedule will adhered to unless circumstances beyond the contractor's control arise:
Work Schedule To Begin 5/6/13 Expected Date Of Completion 5/20/13.
(Date Contractor will begin contracted work) (Date when contracted work will be substantially completed)
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The contractor agrees to perform the work, furnish the labor specified above for the
SUM of $12,250.00
Payments will be made according to the following SCHEDULE:
$ 2,812.00 Upon signing contract.
$ 2,81 3.00 Upon Start ,{�AA
$4,000.00 Upon Completion of Cabinet Install
$ 2,625.00 Upon Completion of Contract(sink/faucet/ice maker hookup &backsplash)
(*Law forbids demanding full payment until contract is completed to both parties'satisfaction.*)
In order to meet the completion schedule, the following material/equipment must be
special ordered before the contracted work begins.
L
DP NO I S CONTRACT IF THERE ARE ANY BLANK SPACES
Ho eo er's Sbdtur6 ntractor's Signature
Date Date
You may cancel this agreement if provided you notify the seller in writing at his main
branch by ordinary mail posted, by telegram sent or by delivery, no later that midnight of
the third business day following the signing of the agreement.
See attached notice of cancellation for an explanation of this right.
REQUIRED PERMITS
The following building permits are required. It is the obligation of the contractor to
secure such permit as the homeowners agent:
Building permit, Electrical permit, Plumbing permit
NOTE: Owners who secure their own permits or deal with unregistered contractors are
EXCLUDED from the Guaranty Fund Provisions of MGL a 142A.
Is an EXPRESS WARRANTY being provided by the contractor? NO YES
Warranty Length from date of completion: (l) One Year
"All terms of the warranq must be attached to the contract"
NOTE: All home improvement contractors and subcontractors shall be registered and any
inquiries about a contractor or subcontractor relating to a registration should be directed
to:
Director,Home Improvement Contractor Registration
One Ashburton Place,Room 1301
Boston,MA 02108
617-727-8598
Unless otherwise noted within this document, the contract shall not imply
That a lien or other security interest has been placed on the residence.
ARBITRATION
The contractor and the homeowner hereby mutually agree in advance that in the
event the contractor has a dispute concerning the contract, the contractor may
submit such dispute to a private arbitration service which has been approved by the
Secretary of the Executive Office of Consumer Affairs and B, iness Regulations
and the consumer shall be required to submit to such it i n as r�ded in
M.G.L. c. 142A
Contractor. Homeo
Date: 1Z.A Date: i
NOTICE:THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE
AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT
INITIATED BY THE CONTRACTOR THE OWNER MAY INITIATE ALTERNATIVE
DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPERATELY SIGNED
BY THE PARTIES.
ACCELERATION OF PAYMENT
Homeowner's Financial Insecurity—A contractor may not demand payments in
advance of the dates specified on the payment schedule in cases where the homeowner
deems him/herself to be financially insecure.
Contractor's Financial Insecurity—In instances where a contractor deems him/herself
to be financially insecure, the contractor may require that the balance of funds not yet due
be place in a joint escrow account as a prerequisite to continuing the contracted work.
Withdrawal from said account would require signatures from both parties.
THIS CONTRACT ALSO CONTAINS:
Other documents that are part of this agreeme t.
Contractor: Homeowner:
Date: Date:
If you have general questions or need additional information about
The Home Improvement Contractor Law, contact:
Consumer Information Hotline
Commonwealth of Massachusetts
Office of Consumer Affairs and Business Regulations
10 Park Plaza,Room 5170
Boston,MA 02116
617-973-8787
If you have a question about Contractor Registration, contact
Director of Home Improvement Contractor Registration
Board of Building Regulations and Standards
One Ashburton Place,Room 1301
Boston,MA 02108
671-727-3200,x25205
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR
OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE.
IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENT MADE BY
YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE
INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN
BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR
CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF
THE TRANSACTION WILL BE CANCELED.
IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR
RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN
RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR
SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF
THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE
SELLERS EXPENSE AND RISK.
IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE
SELLER DOES NOT PICK THEM UP WITHIN 20 DAYS OF THE DATE OF
CANCELLATION, YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT
ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS
AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO
THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR
PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION,MAIL OR DELIVER AS SIGNED AND
DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN_
NOTICE, OR SEND A TELEGRAM TO CLASSIC CONSTRUCTION&
REMODELING INC. 32 BUCKMAN ST. WOBURN MA 01801
NO LATER THAN MIDNIGHT OF / I
I HEREBY CANCEL THIS TRANSACTION
Date Buyers Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information' Please Print Leeibly
Name(Business/Organizationfindividual): C C-/ /
Address: 3 O oUA-6;v� /2,f
City/State/Zip: i6u rl;r< n�k— Phone#: k�" ��/�/'�2�
Are you an employer?Check the appropriate box: Type of project(required):
1.al am a employer with - 1 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet. �• Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. g 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 I LM 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'
q ] 13J]
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 ire 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 their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. r f
Insurance Company Name:. SR 7e 1'y —Tn- 5yra n -P— (0
Policy#or Self-ins.Lic.#: (v Z Z V 6 Y6, a MS e a- Expiration Date:
Job Site Address: / ( w',�idkf-5 i /tel /y,"&/ City/State/Zip: 0 cf _
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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$250.00 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.
X do hereby certify der the pains andpenalties ofperjury that the information provided above is true and correct.
Sip-nature Date Y/1�—Jl
Phone# 7 6 0
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 Instrnetions
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 5Person 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 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained 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(ifnecessary)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 maybe 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 burn leaves etc.)said person is NOTrequired 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:
The ComTonwealth of Massachl)sPtts
Department of Industrial Accidents
Office ofInvestigat ions
600 Washington Street
Boston,MA.02111
Tel,#617-727-4900 ext 406 or 1-877:MASSAk'B
Revised 5-26-05 Fax#617-727-7749
\RfSMU M1300 rrnYsm,.�
,,�" �v� i,.v. v,�vvl , u/� ,vlvv./vlvv I II-'1 LV LV1V 1V•1"•1 1 .VV
CCRPB,-1 . OP ID.ST
A�oiro� CERTIFICATE OF LIABILITY INSURANCE 704/23/13
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 Phone:78.1-665-2990 CONTACT
T F Ward Insurance Agency,Inc aNONE
403 Franklin Street Fax:781-665-8703 Ala Na E FAX No:
Melrose,-MA 02176 e{,tAIL
Dottie Campbell DaRE66:
INSURER IIAFFORDING COVERAGE NAM S
INSURERA:Safsiy Insurance Company 39454
INSURED CCRP&H INC INSURER 8:
Anthony Rosenstine INSURER C:
31 Mountain Road
Burlington,MA 01803 - INSURER 0,
INSURER E:
bNouRr;R
-
LN6uRER 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 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.
ILTICS TYPE OF INSURANCE AUDL SUBS
POLICYNUM8F,R MOOD M/DD P UMIT8
GENERAL LUU31l mY EACH OCCURRENCE S 1,000,00
A COMMERCIAL GENERAL LIABILITY ISMA0016513 11/16/12 11/16/13 p EMI rrenoe $ 100,00
CLAIMS-MADE F1 OCCUR MED EXP(Any one person) S 10,00
X Business Owners
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $ 2,000,00
OEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS,COMP/OP AGG $
POIJCY 171 PRa Lac $
AUTOMOBILE LIABILITY CO BINED INGLE LIMIT
Fn aceider t
ANYAUTO BODILY INJURY(Par pereon) S
ALL OS SCHEDULED BODILY INJURY Par accident $
AUTOS AUTOS ( 1
HIRED AUTOS NON-OWNEDERTYOAMAGE
AUTOS ,r=6&2ritj $
$
UMBRELLA UAu OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
D RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYID2w LIABILITY WC LIMIT ER
ANY PROPRI670R/PARTNERIEXECUTIVE YIN
OFFICERIMEMBER EXCLUDED? r-1 NIA EL EACH ACCIDENT $
(Mandatory In NH) E,L.DISEASE-EA EMPLOYE S
if=describe u dar -
DES� PTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S
PROPERTY 3,12
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Adcouonal Remarks BePeduls,If more apace le mQuired)
CERTIFICATE HOLDER CANCELLATION
TOWNN01
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover THE EXPIkATION DATE TMEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
120 Main Street
North Andover,MA 01845 AUTHORIZED REPRESE,,NppTA��TIVE
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
- MELROSE INS. GROUP Fax:7816658703
Transmit Con•F _ Report
P. 1 Apr 23 2013 1005
Fax/Phone Number Mode Start Time age Result Note
18776343710 NORMAL 23,10:05 /33" 1 * 0 K
MASSACHUSETTS ASSIGNED RISK POOR
REQUEST FOR CERTIFICATE OF INSURANCE
Use this form to request a Certificate of InsyrancC from an Aaslgned Rlsk Pool Carrier.
Please provide ell of the requested information:Including the facsimile number(s)cf the person or persens to wryom
the aen)<Cete of tneuranae should be issued. If this form is fully and akccurately completed,the CerttlIcMe of Ins,wall
be issued and diatnbuted by fam3nule to each fax number provided below,withlrt two(2)business days of the
carrier's receipt.
This Form may be mauled or faxed to the Assigned Risk Pool Carver, To obtain each canice-v contact information
refer to the CeAificet s of M�• amec 9,edion located In the PmducerCammwu/yse0on of the Bureau's website.
f. Name,address,telephone number and facsimile number of the INSURED:
Name: CCRP&H INC Arltho Rosen58ne
Meiling Addreu; 31 Ma, twin Road Burlinannn.MA 01805
Physical Address: SAME
Phone: Fax!
2. Name,add,ess,telephone number and hcsimpa number of the CtERTIFICATE HOLDER:
Name; Town of North Andover
Mailing Addrew ,120 Main SL N Andover,Maes 01846
Physleal Address:
Phone: Fax:
3. Name,address,cdnlect Person,telephonenumber and tecalmilenumber of(he PRODUCER:
Name: T F Ward Insuranee enc x,Inc
Mailing Address: 44Franklin Street,Melrove INA 02176
Contact Person: Susan Tura
Phone: 9p 1M%?9 Q, Fax: (181)665.8703
A Policy Numeer Percy Ellecbve Date and Policy Eviralion Date
If a Cer6ficate of Insurance is needed for more than one policy term,provide the Policy Number,
Effective Date and Expiration Date for each policy term.
!Ft a DOIITi ey�has not•ye Di 2P�it59ued,you mug attach a ropy of the Notice of Assignment.
Itey Number. �gZZUB4mPs6_a-12\
LL EflaWve Oale' / ration Oate: o4 ism
x Iist any'We-W requests tempt. weragWa4domoments(see Page 2 t f rrsting of coveivges
�aYpliable In ilia Fc,OI and ra pions of avai►abbdiy)or addi'Mwal Information(inctudfng changes in
exposm�i ha ref ieported to me censer)that w711 assist the carder in the issuanov ofthe Cer0cate of
Insurance.
NOTE:An addr7ional insured(s)shall not be listed on any CeRMcete of Insurance unless suen additional
Insured(s)is m named insured on tMa policy,
PLEASE FAX DIRECTLY TO PRODUCER. DO NOT MAIL,
Ta: zrrricn Arrteriean
FAX; 877-634-3710