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HomeMy WebLinkAboutBuilding Permit #816-2016 - 1401 GREAT POND ROAD 1/20/2016 1 ao ,tulo -14,, BUILDING PERMIT 3? $ TOWN OF NORTH ANDOVER p P6 �, APPLICATION FOR PLAN EXAMINATION Permit NO: r �� Date Received '�4 �4SSACHUS���� Date Issued: Q d 'IMPORTANT:A licant must complete all items on this page LOCATION l `l0 I �r t � [No( Print PROPERTY OWNER Print MAP NO: 90 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition 9-m or more family El Industrial ,p. leration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: �0 ,4 SC� A- Phone: ���•3��" 32�� Address: CONTRACTOR Name: Eric W.Palm Phone: q1f" 70 Address: Salmi I1fiA 01970 Supervisor's Construction License: g 7g-7 -7 Exp. Date: y /2 3 Home Improvement License: Exp. Date: 3112, 14 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ '©d S Check No.: 1 I SR Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne -gnature of contractor 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 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses .6 Copy of Contract 4. Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (if Applicable) Engineering Affidavits for Engineered products . OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan .. Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 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 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 Date Time Contact Name 2 Doc.Building Permit Revised 2014 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_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes f Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit PPW Town Engineer: Signature: Located 384 Osgood Street IREDEPAR+TMENT`}}rTlemp Dumpster onsite.;yes -4,;' nom? �.�°` �".� (1}a} A it ri' S ' 1 11af T ♦\-.i' \ ra.,ta.. "1 ♦ X11+ . �n .... ;�y.,a+ +�� i l +L•ocated of 12,4, iStreet 1 w FireDepartnient�ignature/dae: a i.*.a t � r-{ � 1 r rti. F~ . _ . ,• .. � l r i t ,lr..,, Location / %y i ��` 7 ✓✓a No. /f t Date /-�✓�jd . - TOWN OF NORTH ANDOVER EB • . . . -- Certificate of Occupancy $ Building/Frame Permit Fee $-6/- Foundation L/Foundation Permit Fee $ t Other Permit Fee $ TOTAL $ Check# j Building Inspector � �1pRTF/ own of ndover / hMass, f � o K ver, COCHICNlw#CK �'►• �9S R�TEO I�Pa�,(5 U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System ° © a.JS.C_1, BUILDING INSPECTOR THIS CERTIFIES THAT ........... ... ....°Y........... ........................... .i....................... .................................... yC% CJ l�t t�'p�� �G� Foundation has permission to erect .......................�....... buildings on ............................................................................... l.�ll ..�?.�.Gvl�. r✓ c� Rough to be occupied as ........... .........� � �G a...�....`.'..�7.............................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT O�N STARTS Rough Service ....... ..... `................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No.Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Thisfo:- x'1'1'J�FL�rF c rs " `sa 2ii trs;c 1e4u m � aft e , f"t officte=a Frac barr ;veT Ofthes*�-te's13oaID - eof GuidetpHomelmaotraeg Y Anyp ttptpt£ cy Q 7A},bn�da aa;= officeof , - tzr 14 x�, F Bain p 2 e e.ote� in amyyt��n�oe�m"M�shouldfustabL�in2ca stand,r? a.zE;meryv'.:, 7R. nsina Info. Mune-3 idsnc '� yobtaipaLrze pJ' nT - fPi-23�r_5vi x617-973-$7-7oe'1'S8. "J -vcaRkCthe .nE 2533757 or anatn•t3• t 2ee4D?L't7t ; ec St CG:Redness rdDV v`ry� C�l�fiY177i. nat[1522?DSt Q $t Cit}itau- 1"L't:L Canto,-taatS,J }=`��«t��g`=.f 3L-LCLEUjl,ul�,; fIN t`s's. a :T'^`yce SLtZD code ta _j� 'r" t.. A. 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"e RCvtea•t}etodet::agstadons�d ibe 2cccytr2"icr�io' wavaiidif or dander 1t sb- b azz scraft.i�iha�i �atCanGzcior_n, diL`'c7=Q-=�pnsifsame aOn n s unclear. =a�,c�L<< erss�asua 4? Ask a1 ,Zca7t�$ct.e nL c' rt°a oum qm-smastbom 't � aa�c?az and k� , oa.cf;ayr,� eC���a.".tnrfor6• "•!V=`tGLcIGOr -alin�ititeabout:.a o'`- urr•' �:dec teal -� 3 v uJ'�ng Si7-973 '�C!ot ;fir d,�}aastaUid-- Cana ryittfo,•9 ✓;787 or 268-3 Guide tc t:e_; �-R�r, nf0�,r _e thzt;nu 83 3757. oaC i>L� menti Cc �- rott"t r Ott confirm cavi. n actor i -am on me ze or=i:to au zn-.. D ode of lois iorII an' ztacoPYofQtcCon con ar n .: '.�, � ticirh_b srmer illirC n tib�?!d:%7!?ra. '^``'I9tedita77- busi_ s d ' eUac' '-'m-1, oSCc ,cmc o- c'oUt Lha teaCoa r �-S'ti esi ir'"'Min-.1, orsIIo ra t-, r 1"r__.'I 1_[ii •^; ��or IMS a� -mall p—I, BY tele�"-aII�`.�,,o:.�� C3nOtiCzofcaicellaionav nt t3"delttr�y nOtla*Mtbrui� ytlte r :cam E_• a _ s=-_v;�:r t ttr a e�Lntati �gSt o,the � _�t1rgZ 1•t-�:�:E3_Lk l lfj,-ii .�t� ,II OE thiS;i<nt aL`=L;.^_'-I•..__s �:14.ttu rJ �:, up49 Liemxit:ae: "! © ct ?�r'dSsL-t3t•t`_-cam.» V,r +' P et ContrC[or's Sim�t t e v Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same richt is not automatically afforded to a contractor_hovrever. Tile contractor would have to resolve any dispute he/she has with as homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the borcowner by the Home Improvement Contractor Laty. The contractor and the homeowner hereby,mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may,.s tb--m the dispute to a private arbitration firm which has been approved by the Secretary of the ExecuAve Oi&c'U Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitmatipn a§;6AHddr n4Massachuset`s General Laws,ebaer 142A. Homeowner's Sigm—wre Contractor's Si�iature NOTICE:The signatures of die parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not 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.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowner may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by taw. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Lay. The contractor is responsible for completing the work as described,in timely and workmanlike manner. Homeowners may be entitled to other specific Iegal rights if the contractor guarantees or provides an express warranty for worlonanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lav dully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer ruts. If you have questions about your consiuner/homeowner rights,contact the Consumer information Hotline(listed helov). Lsecztion of Contract The contract must be executed in duolieate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to 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 with attachments is to be given to the ovmer and the otherkept by the contractor. Any modification to the original contract must be in«•citing and agreed to by both parties_Contracted work may not begin until bath parties have received a fully executed copy of the contract;and the three day rescission period has expired.? Accelerated Waynmeats _contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems bim/herself to be financially insecure. However,in instances tonere a contractor deems him/herself to be financially insecure,the contractormay require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contacted wra work. Withdwal of-ands Ro said account would require the signatures of both parties. Additional 111Ormation if you have general questions or need additional information about the Home Improvement Contractor Laworother consumer n-Jits,or if you wish to obtain a five copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston_%Ck 02116 617-973-087837.30.8.283-3757 or visit the OC.-kBR iyebsite at hrm:l!;i%Vw-Mass=ov/ocabr/ if you want to verify the registration of a contractor or if you have questions or need additional information specificaLy about the contractor registration component ofthe Home Improvement Contactor Lav,contact Director of fIome Improvement Contractor Registration Offrca of Consumer Affairs and Business Regulation 10 Pari:Plaza,Room 5170,Boston,l%,Lk 02116 617-973-3737,308-283-3757 or visit the HIC website at itt :(h;;;w.nmass_ov/ocabri Go online to view the status of a Home Improvement Contmetoes Registration: hrtn-//db.state-nia.us/homeimi)rovementAicenseelisLasE) ror assistance with informal mediation of disputes or to resister formal compiainr;agaiust a business,ca11: --Consumer� plazut Section :Ofimcvfi "A orney General 617-127-3400 ASID/OR Better Business Bureau. ;OS-652-4,00.503-7:55-21548 or 413=731-3114 Version a_t-ttn?l3Dro Elie Commoanveapa On, zasec�s rn p� _ y A R DepaiLre2-ont df-�6�t7Gms ri ll ccidee�is -7 Congress st eet,s�V e-too BOStoF2,fI4 02-114-:20.17 ivilri5lr g ovIdlar 11'oricers'Co"pens2'r70H i=nsurance Arldavit:Builders/Cog,tracto;rs/E Ieetr eians/Plumbers TO BE FILED rsi'I T-U THE FEi�X T hqG AUTHORITY. Aa licant Information Name a Tease I'ritat �,eaibly B ( usinesJO ganizationdndividual)' 0fi i't. htpt'v�E:tia. ✓( nddress: R kfa sn City/State/Zip: Phone#: q 7 8 .� e� t�� Arc�1�m employer?Check the ` r t gpropriate box: I.� employer u�ih employees(foil and/or part-time).* Type of proijPaidd1t,1(.2n uired): 3.Q I a sole proprietor or partnership and have no employees working forme in o' \yew Con any capacity.[No-,vorkers'comp.insurance required.] o- F1 Remod 1CJ 1 am a homeowner doing all work myself[NO workers`comp_insurance required)t 9. ❑Demoli ?_�iam a homeowner and will be hiring contractors to conduct all work on my property. I uill 10[]Buildingn ensure that all contractors either have workers'compettsadon insurance or are sole proprietors with no employees_ 11.0 Electricals or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12-Q plumbins or additionsThese sub-contractors ha:•e employees and have workers'compinson the1.3-QRoa-red•0 t.'e are a corporation and its officers have exercised their right ofexemption per MGL c. 14I5? §l(—'),and we haveno employees. Other � ft [1Vo workers`comp,insurance required] Ary applicant that checks box rl must also fill out the section below shoning their workers'compensation policy information. r Homeoumcrs who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheetshowing the name of the sub-co ether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp_policy ntractors and state whnumbet am arz efnplolPer tlratis providirrgzvorkers'corrrperrsation insr_._rice or:r ert2plottees Beloit,is tyre olic r ,;_ f n, inforrrtatiorr. A y acid job site Insurance Company Name: ,z,Utr,'r—k Policy-or Self-ins.Lic.T: � 1 Expiration Date: ,:J7,/0-6 4' Job Site Address: GNs� A ttaelt a copy of,, •vary ep ' 'z^ City/State/Zip: •/'7N Ol�Pil i"t'7 s ear tpensat,or Policy declaration page(shOlving the policy nju mbea and of;Pir e). Failure to secure coverage as required under 1IGL c. 152,s25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$350.00 a day against the violator.A copy ofthis statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. Mu=qder elaepets orad per:allies o� ie,_ f ,that the rrrfonnatrosi pro rridedabove is trite and correct Signature: .. _ �->-.�• Date: / Phone r: _ �}Li�� 4fflcia1 Me only: Do rtot write ill tills area,to he cors leted b city P 3, � ortotvri official PermW-01cense r 1 ssuing Autltcrity(t'ircie one): x.Eoasci ofsaltlt 3.t3tsiidiaa Depa:tateiFt .Qther ' Cit'ra,a C'let•1; k. c�lecticai Inspector 5.Plutulzang Inspector Contact Person: Phone r3i Rightfax N2-1 3/10/2015 10:11:37 AM PAGE11VIaDATE ACU D CERTIFICATE OF LIABILITY INSURIS A ANCi►E a31o2015 �iE CERTIFICATE ERTI THIS CERTIHISACERTIF ATE DAS OES or NOTAFMAT VEER OF LIY ORNEGATIVELY ONLY AND CAMEND, EXTEND OR ALTERONFERS NO RIGHTS UPON THE COVERAGE HOLDER. RTIFICATE OF NOT toT AFFORDUINGBy NSUE 'THISRER(S)CAUTHa LOW_ ORIZED REPRESECER'NTATIVE OR PRODUCEREAND TH CERTOIFlCATE HOLDER.CONTRACT BETWEEN THE ISS IMPORTANT. II the certificate holder is an ADDiT1ONAL INSURED,the policy(ies)must be endorsed. It SUBROGATION IS WAN UED 'ES 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 endorsemerd(s). CONTACT PRODUCER NAME: FAX EASTERN INS GROUP LLC PHONE No No Ext 233 W CENTRAL STREET EMAIL NAIGa NATICK,MA 01780 INSURERIS)AFFORDING COVERAGE INSURER A:AMERICAN ZURICH INSURANCE COMPANY INSURER 8: INSURED ATLANTIC WEATHERIZATION LLC INSURER C 61 REAR JEFFERSON AVE INSURER D: SALEM,MA 01970 INSURER E: INSURER F: CO CATE N E V THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME DING ANY REQUIREMENT, TERM OR OF ANY TION I FOR OR OTHER DOCUMENTIWI H RESPECT O WH TAN CONTRACT CH THIS CERTIFICATE MAY BE ISSUED OR MAYIPERTAIN.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. ADD sti POLICY EFF POLICY EXP LIMITS INSR TYPE OF INSURANCE INSR WVD POLICY NUMBER YY) >Sri` � LTR EACH OCCURRENCE S GENERAL LIABILITY 0 TO RENTED S COMMERCIAL GENERAL LIABILITY i „�,jFaoccutte CLAIMS-MADE r� OCCUR MED EXP(Any enapers°n) S PERSONAL&ADV INJURY S GENERAL AGGREGATE S PRODUCTS•COMP/OPAGO S GENL AGGREGATE LIMIT APPLIES PER:PRO- S POLICY JECCT LOC MBINE0 SINGLE LIMIT S dent AUTOMOBILJABLITY a acu LE e00iLV INJURY(Pet person) S ANY AUTOS ALL OWNED SCHEDULED BODILY INJURY(Pet accilent) AUTOS AUTOS SED OPE AMADE S HIREDAUTOS AUTOS S EACH OCCURRENCE S UMBREWILUU3 OCCUR AGGREGATE S EXCESS LIAB CLAIMS•MAOE S DED RETENTION S X WCSTATU• OTH- WORKERS COMPENSATION TORY LN1 ER AND EMPLOYERS'LIABILITY EL EACH ACCIDENT $500,000 ANY PROPRIETOR/PARTNERIEXECUTPJ�YM. - OFFICERMtEMBER EXCLUDED? i r�„N/A 6ZZU6 0$-20-2015 03-20-2016 EL DISEASE-EA EMPLOYEE $500,000 IMandataryln NM 58270121 It yes,desctbe under EL.DISEASE•POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS INE! DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Attach ACORD 101,Addhbna1 Remarks SChedala,a more space is required) r CE Tl C HO R CNC TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE OD ST CANCELLED BEFORE THE EXPIRATION DATE THEREOF, 1600 OSGONOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE N.ANDOVEOD S 01845PROVISIONS- AUTHORIZED POLICY PROVISIONS. AUTXQRIZEDREPRESEI'NTATIVE D 1988-2010 ACORD CORPORATION All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ACORO® DATE(MMmD/YYYIf) CERTIFICATE OF LIABILITY INSURANCE 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 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 endomement(s). PRODUCER CON Construction Eastern Insurance Group LLC PHONE (800)333-7234 FAX 233 West Central St EMAIL o -ADDRESs• INSURERS AFFORDING COVERAGE NAIL# Natick MA 01760 INSURED INSURERAArbella Protection Ins. Co. 41360 INSURER B Nautilus Insurance Co Atlantic Weatherization INSURER C: 61 Rear Jefferson Avenue INSURER D INSURER E Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBERNASTER 2015 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. M1111RTYPE OF INSURANCE POLICY NUMBER POLIDCY EFF NM MPOOLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITYA CLAIMS40ADE ®OCCUR 500042616 /20/2015 /20/2016 PREMISES Fzacwaence $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY Ea eB1NNEO SIN LE LIMB 1-000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED 020015871 /20/2015 /20/2016 AUTOS AUTOS BODILY INJURY(Per accident) S x HIRED AUTOS X NNONNOSWNED PROPERTY OAMA E (Per acride $ PIP-Basic $ X UMBRELLA LIAB IN OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CSS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ 600058654 /20/2015 /20/2016 $ WORKERS COMPENSATION WC STATU- OTH AND EMPLOYERS'LIABILITY ANY PROPRIETORJPARTNER]EXECUnVE Y/NI ER _ OFFICERJMEMBER EXCLUDED? El N J A EL EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B POLLUTION LIABILITY CPL200378613 0/1/2014 0/1/2015 GENERAL AGGREGATE $1,000,000 FAPOLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if 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 IMTH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORtzED REPRESENTATIVE John Koegel/PMA y=s�`�►�..-� ACORD 26(2010105) ®1988-2010 ACORD CORPORATION. All rights reserved. INS029 J9nlflnsm m Tisa ar_ngn norma and Innn nra ranretnrnei mar4e of Ar'.nan Massachusetts -Department of Public Safety 10 M . Board of Building Regulations and Standards Construction Supen-isor Office of Consumer Affairs&Business Regulation License: CS-087977 ME IMPROVEMENT CONTRACTOR Type: t gistrat'on: 142089 ERIC W PALM xpiration: 3/12/2016 Ltd Liability Corpo"i 3 HILTON ST f Salem NIA 019707 ATLANTIC WEATHERIZATION L.L.C. er ERIC PALM Expiration 61R JEFFERSON AVE Commissioner 0412312016 SALEM,MA 01970 Undersecretary Unrestricted-Buildings Of any use group which Contain less than 35,000 cubic feet(991M)Of License or registration valid for individul use only enclosed space. before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www-Mass.Gov/DPS Not valid without signature The Commerce Insurance Company'"' MAPFRE Citation Insurance Companysm 11 Gore Road,Webster,Massachusetts 01570 INSURANCE 508.949.1500www.mapfreinsurance.com February 20, 2016 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MA 01845 I RE: Our Insured: MARGARET T LOPIANO Property Address: 1401 GREAT POND RD 18 Policy#: KX3504 Date of Loss: 02/19/2016 File#: MCAX85-JVHCAO Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. KEITH FITZGIBBONS Telephone: (508)949-1500 Ext: 15712 Sr Claim Representative, Property Toll Free: 1-800-221-1605, Ext: 15712 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. February 20, 2016 CIC 254 (Rev.4/95) MAIL, V10