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HomeMy WebLinkAboutBuilding Permit #234-2017 - 1401 GREAT POND ROAD 9/6/2016 V �7 I � J BUILDING PERMIT �, o�No oT" 1ti 1 TOWN OF NORTH ANDOVER 32 `- Y_ .V6 APPLICATION FOR PLAN EXAMINATION ~ '° 4 Permit No#: Date Received gSSACHUs�� Date Issued: ® A6 �� IMPORTANT: Applicant must complete all items on this page LOCATION / int PROPERTY OWNER � `omaJC- 7 O an� Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial gAffe'ration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain 0 Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Vial de ti icatio - Please Type or Print Clearly OWNER: Name: Phone: Address: 1 G—ea'{' C4,�l jQ Contractor Name: Enc W.Palm Phone: Email: 3 HiM S',ee Address: Salern MA 0197 Supervisor's Construction License: 379 -7 '7 Exp. Date: q Home Improvement License: /'I Z05 y Exp. Date: 3/f7, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. c Total Project Cost: $ a-?(fU�- FEE: $ Check No.: 1 2 CO67 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th a1 my fund t 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 4 Building Permit Application 4.. 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 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 4 Certified Proposed Plot Plan . Photo of H.I.C. And C.S.L. Licenses 4,, 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 I ECC Energy code 4 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 Doe:Building Permit Revised 2014 L Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: i 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) I i ❑ Notified for pickup Call Email i Date Time Contact Name Doc.Building Pennit Revised 2014 - - - r Plans Submitted F] Plans Waived-11, Certified Plot Plan ❑ Stamped Plans El TYPE OF SEWERAGE DISPOSAL Swimuning Pools Public Sewer 11Tanuing/Massage/Body Art El ❑ I Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ ' Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ � THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS I . fi i CONSERVATION Reviewed on Si nature K M k COMMENTS i HEALTH Reviewed on Si nature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments n Conservation Decision: Comments Wafter & Sewer Connection/Si--nature&Date Driveway Permit Town Engineer: Si DPW Tow nature:g g Located 384 Osgood Street _ ,FIRE DEPARATMENT Tempgoumpster � Located at-;124fMainfStreet _� E FireDgpartrrierit Signature/date: f ,E a Cq)MMENTMS._ - Location 1/ r'"✓L'rt ' No. Date��4b • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#.1 57 ff ~ - Building Inspector L NORTI� Town of ? ? _� s ndover O ";' to J_ A R. No. _ t - C�b � � zti h ver, Mass, coc«ic"awKK �'1. �— �•9 A°RATED �Pa �(5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ...;4 .,.., ,,. BUILDING INSPECTOR . . . . .�. .......................... ..... �,� ..... . .. . Foundation has permission to erect .......................... buildings on ..�'Q.:I...�Si�r.�,il� .. .,l�,��1.. �'jf� ................ Rough to be occupied as ..�i�, wR••!'�,/•�'�!�. .................................................................. 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 6THS ELECTRICAL INSPECTOR UNLESS CON �"W"W"o S Rough Service .. ....... . .......... ............TP�E6CT .... ... Final BUILDING 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. IV Wsachusets This fimm �I®me r�ve�neSt Sam Ie�anact t�EgOabsa �ooftltestatrsHome7mprovem �xorLaw erGnidetoHttm.2,Lew g��r•Ro1rPc+saaplaonin a ter142A),6utdoCsnat�dudestaatfasd OffrceofC4asvmerq aadB¢uneQg onb Caro 4 ao° tigto 3onrreside�¢oey�5bo��tobiana auYwodt® may obtain aim cuPl'�A $oIDeavwmn i, o RUDD fngo�OBgotlineatb17A73,S787ari-888-2833757oron� gthe Name Cantmetor�¢OyTbaNOR V lGlo{'l(�p�L ComPmYlVame Street rets(oaotnseaP atfrce8���? Ct h Cartn-mtmiSal` r•:nen G Citytloiy S e BusiAean �� plrtrs�r`•v�e cde ���vllll hyo �,► [ 19ap AaltimeFhone �� J EbrniuS Phase Cityllawn State Mailing Address(itdiffcreot Zip Cade �nm above) $usurers Phone fedaat F.mpla q!j 11, S Ivmnbc +Shtratm�atara �,/ /�JaB-HC3s �'r+-.�i�. TEre Contsacto;aP, ey to do tbefallawio ^� /%2-V`.' er 311 L/,O (Aeseifieindet;itUr_wodrtacorapl S:vorEcfo=tbeSam�wn � j (�SPecif'ins the tSPAhraad,and vadeaf?trarm'ralstobe"G �u-d.IMaddiliD'f�I JiccE ifn } t2eguired 1"�'ntits-?'uefollowin �� IC.�h�C �-ti�l 7-'l� and Will be seemed by the coatractorasghnd�hehomommer F- r °I- ✓I'TiH1si� �/ (Owners"whosecurethei,arm ehomaavme°s Pn=Wto tartdCoagdegonS�ed�e-U0fo90win excluded f-am °" Pea-M$sem jt �a�etedto,mless �ndthecontta�+sCODUW l swM e ?�dG,c�a the GL,aaanty Fe P,6 i Oels of control arise pter 142A.) --�_ Date xdt®contractor wit begin a, d wort. rolat Cootract l'sieeand ewheo contracted wart;wi716e onnarxoragrsmYmeatSrhedaie The � nYcompleted Frrforat tSc tvarh,ftani�the PapmcntswillbemadeatxDn,jo to c°ataadiabnrs-aiiiedabmr g thefo6o ihetnial man of S _ �ngschednle: [� ' U6nII Stgruag conlra�[not to . ext-d 1,6ofthe total contract 5--- --- by I price_r theca order' or noun aomafa5on of ��9+hicbevta•isgr�} 9 io, orS ` mon completion of "i �-upon completion ofthecontract rnefollecyn [Eawfurbrdsdemandmgf.M �ora�Man� m� `--� Pa3'rnentrm canttactis PletcdtattothPattY'Sszfistactian) . COtAFt2tionSched le(oa) IV07Ls.-m InclAwAg att _ far no:exceed lheg-EL,O f a "1e4wrs UcA any d�rsit osdm:a R�eai naaerAr&eforen xntchmasthe Y O'der,cd in contract Pficu,ar(b�the actual mxttbecomptrh'onschedale. can�bySP�eNiPmetttarar#ambvu�n� Gram?larrsA -LSA madematerir3 Snbcantrcctor-2hecaatrajor rrAatvb3 ectad eon thetra esto P 1-1PioQYes nrS r Ma rials tractor:181iz:9[rythe eon y Poa4b!efarcam letioaofthecsod dg a_uxe>7arranfvMrdba.-radhetmtheranb3 �_ dlabartutderthkamcen,a,t iltecaatrattorf�era � soJetyresFansrbefoq'aaT soFthe ntioasofedtolmy yd onhnctAcceptance- contract shall notim i Upon sigujn"this do��b J2 Payments to all subconbWom� carefully before sj PYthscOat ubact.o-othersecarit)rgu ihabinding onn= et law U�� fining this can msidenc�RcvievitEe fop oted within Ibis do o crtmerrt;the Dont to �gcoudonsandnotices ° i+ha1:e�Pr'�-staect the into sig�g the pnbacZ 1'�ye . subcoatrctorsta regist`-- eanr Contr -and R Di Ast,4,,,q,,fsometltiogisnnotcar f m s*sa6onbyxritiagtoihel)ire-to Di�torofHom0T��rsriCo 3bel<•wregvL smasihame ° Aces the cantrcior' r at f 0 Pam? ard p; ltaom 5170,Rn o n trT �s¢anan Yon may inquire oonnactors and see a cop y ofn,dao �nMM;; Ask the Cuntraotrrr IWA 02126 or quire about contractor Knowyottrrid��A � document. for =''umatxcompanyinf �g6179734787or888-283-3757 sgaastbrTities.12ead o On so tlratyon can can Guide to the Rome.la Lhe;hnn�t �co�+age,orayk to tmoveme tComcforLaw fn mationontheravetsesideoftbisfaomandgetacoPyatheC You mal'cancel�a Consumer peerneatifitlrPs bei et contractarinwritmgathislhrrmnino �gnedataplaceotha _ third businessd. foIIo%mgthegPbg f,-braacl2ofttcebyordh madpo,4bYtllm-1 Memofbtt�a�natjalwthm ear> H entsee theaitacbednoticeof un�DtorbydeliydreT"Mt� ,-Pimord-M �° onforanfnraanightoftheT� $�gi�ag, 3!B� ten Tbeet�rcpy.` dbe�ptb Homed:ssrer's Signature 4 Date 3 1 CoatrarxarsSign.tn,e O g13� Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an altemative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a 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 homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the con forK the dispute to a private arbitration firm which has been approved by the Secretary of$5E�e (,i Q3 ��ii'Cdfller Affairs and Business Regulation and the consumer shall be required to submit to such a>i ati5asr P-% achusetts General Laws,chapter 142A. AnaMAM7 TV U Homeowner's Si ConfMcM197igna6ire NOTICE:The signatures of the 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,homeowners may be excluded from certain rights ifthe contractor they choose is not properly registered as prescribed by Iaw. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty far workmanship 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 lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in dnrolieate 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 owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of 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 him/herself to be financially insecure. However,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 placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of frmds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Pura Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at httn:/Av4Env mass Qov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-233-3757 or visit the HIC website at litw:/h%,ttRv.mass.sov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration:- httn://db.state ma.us/homeimprovement/licenseelistasn For assistance with informal mediation of disputes or to register formal complaints against a business,tail: Co c. omplaint Section Of$ce` f Attorney General 617-727-8400 AND/OR Better Business Bureau 508-6524800._508-755-2548 or 413-734-3114 Version 2-1-1 12211010 The Commonwealth of Massachusetts Fg Department of Industrial Accidents Office of Investigations IF 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Alsi i 1 itlicri euii,LLC 61 R Jeilorsor- Avenue Address: S;jlen Nn 1107 City/State/Zip: Phone#: Cj 7�' 7,IW- Fr1 q 3 Are yo n employer?Check the appropriate box: Type of project(required): 1. Im aa employer with j/ 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, []Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. re uired. 5. We are a corporation and its 10.F1 Electrical repairs or additions 3 E] I m a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E] Roof r pairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13. ther :2Zz..SL.& X ell—) 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. Contractors 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: Z_C4 Yr GG. Policy#or Self-ins.Lic.#: !:r627 0 /Z / Expiration Date: 31201! 7 Job Site Address: A Pcv1 dlCity/State/Zip: Ada-l _ 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 $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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: �','_ t(rl'Q Date: �I3 Phone#: 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#: ••"� �-' <'�' [.i 4Ji Gv1V O.JY GY 1117 t_r%%zL. G/UVG raA 04:111-VC.1, CERTIFICATE OF LIABILITY INSURANCE DATEtMM/Ito TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. T CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRE O PRODUCER. D H FCHOLDER. IMPORTANT:If the certificate holder is en ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subje he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rig he certificate holder in lieu of such endorsemen s. PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 W CENTRAL STREET (A/C,No,Ext): (A/C,No): NATICK,MA 01760 EMAIL 22MLW ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURED I INSURER A: AMERICAN ZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER e: INSURER C: 61 REAR JEFFERSON AVE INSURER D: SALEM,MA 01970 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED HAM M ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY'CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE LR MTS BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LTS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. ' NSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF NSURANCE L R POLICY NUMBER (MMIODIYYYY) INMOD%YYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE F-1 OCCUR. 3AMAGE TO RENTED $ REMISES(Ea occurrence) EXP(Any one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL&ADV INJURY $ POLICY [:]PROJECT�LOG E NERAL AGGREGATE $ RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS i (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION$ $ A WORKER'S COMPENSATION AND , WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-5B270121-15 0320/2016 03/20/2017 X LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE I OFFICERIMEMBER EXCLUDED? WA E.L EACH ACCIDENT $ 500.000 (MandatorylnNH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUE TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. C CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER } SHOULD ANY OF THE ABOVE DESCRIBED POUCIESBECANCEL'm 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. [AUTHORIZED REPR A YE N.ANDOVER,MA 01845 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD lega-2010 ACORD CORPORATION. All rights reserved. 1 AR" CERTIFICATE OF LIABILITY INSURANCE C /DD,YYYY, 3//9/29/2 016 THIS CERTIFICATE IS ISSUED AS A M�TTER 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 isan 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 endorse, ent(s). PRODUCER CONTA T NAME: construction Eastern Insurance Group LLC PHONE (800)333-7234 FAX C Not 233 West Central St AD AIE INSURER S AFFORDING COVERAGE NAIC# Natick MA 01760 INSURED INSURERA Arbella Protection Ins. Co. 41360 INSURER B NautlluS Insurance Co Atlantic Weatherization 61 Rear Jefferson Avenue INSURERC:INSURERC: INSURER E: Salem ' 01970 INSURER F: COVERAGES CERTIFICATE NUMBERMaster 2016 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 MPOLICY EFF WDDnrfM MP�pCY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $_ 1,000,000 X COMMERCIAL GENERAL LIABILITY ENTED PREMISES Ea occurrence) $ 50,000 A CLAIMS-MADE a OCCUR 500042816 /20/2016 /20/2017 MED EXP(Any one person) $ 5,000 X CONTRACTUAL LIABILITY PERSONAL&ADV INJURY S 1,000,000 X CG0001 10/01 FORM GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO El LOC $ AUTOMOBILE LIABILITY Ea COMBINED SINGLE LIMIT 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ATOX SCHEDULED 020015871 /20/2016 /20/2017 AUUTOSS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ PIP-Basic $ X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000 A DEEXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 D RETENTION$ 10,00 600058654 /20/2016 /20/2017 $ WORKERS COMPENSATION WC STATU- I OTH AND EMPLOYERS'LIABILITY ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? ❑ NI A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L DISEASE-EA If yes,describe under EMPLOYE $ DESCRIPTION OF OPERATIONS below ( E.L.DISEASE-POLICY LIMIT $ B POLLUTION PL200378614 0/1/2015 0/1/2016 EA POLLUTION CONDITION $1,000,000 f GENERAL AGGREGATE $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/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 WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, NA 01845 AUTHORIZED REPRESENTATIVE John Koegel/SNE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(9ninnss m Tho e(`nPn narrro anA burn aro rnniafomri marka of Ar non Massachusetts Department of Public Safety Construction Supervisor Board of Building Regulations and Standards Restricted to- License: CS-087977 Unrestridfied-Buildings of any use group which contain Construction Supervisor less than 35,000 cubic feet(991 cubic meters)of . enclosed space. ERIC W PALM 3 HILTON ST SALEM MA 01970 ; ..nnFailure to possess a-current edition of the Massachusetts Expiration: State Building Code is cause for revocation oflliis ficense. Commissioner 04/23/2018 OPS Licensing information visit WWW.MASS.GOVIOPS J�r.Y%rt)lllJtr+P7t.rF/ of t�f.r;�rrr/r,;grf License or registration valid for ind'nridull use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:- d , ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Busmen Regulation egistration: 142089 Type: 10 Park Plaza-Suite 5170 }r xpiration: 311212618Ltd Uabliily Corpor Boston,MA 02116 ATLANTIC WEATHERiz.ATION-LLC. • FJ2iC PALM 61 R JEFFERSON AVE �✓G �t-_.cam-\..ter - SALEM,MA 01970 .... rse�cretary Not valid without signature f i, I