HomeMy WebLinkAboutBuilding Permit #243-2016 - 1483 SALEM STREET 8/27/2015 BUILDING PERMIT of p►ORT01 q
STEED /6
TOWN OF NORTH ANDOVER �? 5 '_ 0
APPLICATION FOR PLAN EXAMINATION
Permit No#:_��J ` Date Received ��
Date Issued: Z 7
��SSACHUSE��y
IMPORTANT: Applicant must complete all items on this page
LOCATION. 1 y 8 3 Sa 14-1&1 S
LitPROPERTY OWNERT�1en1
Pnnt�- 100 Year Structure yes no
-& --MAP
_..PARCEL..- dU�� ZONING DISTRICT : Historic Districf yes- no
Machine Shop Village yes no_-.
TYPE OF IMPROVEMENT PROPOSED USE
Resi tial Non- Residential
❑ New Building One family
❑Addition 0 Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ElOther
0 Septic tic ❑Well, - -
p ❑ Floodplain ❑Wetl'ancl ❑ Watershed District
O Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
3�e� CQ��r�I ds� HtTI C `
Identification- Please Type or Print Clearly
OWNER: Name: Tho ma A Phone: 4�R 83S
Address: 1
Contractor Name: r;� (art Phone: X78-7Nq l4/3
Address: 6 / 2 �L:! - U.AA v2._ ..SCJJeO
Supervisor's Construction License: Exp Date:..__
-
Home Improvement License -140- q Exp Date:_LL. 3,71
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.
Total Project Cost: $_ a/ad FEE: $ 2�0
Check No.:_ ///R6 . 2-9
Receipt No.. 2
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner -�"�`� —� -racto-
- _�ignature of contracto, ,�..,;G�'�y
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
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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
,Hydraulic Calculations (If Applicable) s
❑ 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 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
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
_ TYPE OF SEWERAGE DISPOSAL
Public Sewer ElTanning/Massage/Body Art ElSwimming Pools El
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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
J
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
4
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE' DEPARTMENT Tern- ern Dumpster on site yes
Located at 124,Main Street
Fire Department 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.$100-$1000 fine
NOTES and DATA— (For department use)
� f
❑ Notified for pickup Call Email
Time Contact Name l
Date
Doc.Building Permit Revised 2014
Location
No. d7 3 Date &/2
• -{ TOWN OF NORTH ANDOVER
• ��fi�D t�y4 .
Certificate of Occupancy $
Building/Frame Permit Fee $3d-
-
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
I
Check#
Building Inspector M
2coo,2 5 9
r--
NORTH
Town of '
Andover
° h ver, Mass, �I
coc"Ic/1l WICK y1'
S
U BOARD OF HEALTH
Food/Kitchen
PER T LD Septic System
i
THIS CERTIFIES THAT �. .
BUILDING INSPECTOR
.. . .... ...... . .......... . .
' 3 �. ...............C Foundation
has permission to erect .Ah
............ buildings n .. .. ........ ............
' � ��� ��� � . ............ Rough
pp,,,,�� ScQ
to be occupied as ........ ................................. !► 11 .... ..... Chimney
....... .
provided that the person accepting this permit shall in every respect conform to the terms of the applicai46n
p p g 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 IN6 ON ELECTRICAL INSPECTOR
UNLESS CONSTRUC ST 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.
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-----------------
Contractor ArbitG ation
The Home Improvement Contractor Lata 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,hotWever 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 saute richt to
arbitration as is afforded to the homeowuerby the liome Improvement Contractorlaw.
The contractor and the homeowner bereby mptuany agree in advance that in the event tate contractor has a dispute
concerning this contract:the comiactoetiiay submit the dispute to a private arbitration firm which has been approved by
the Secretary of the E"&,e.Qffice a �onctimer Affair;and Business Regulation and the consumer shall be required
to submit such.arbitraiias p v de In Massachuset`s General Laws,chap�ter 3 2P�
Homeowner's Signature Contractor's Sknature
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 wbere this
section is not separately signed by the parties.
Honeownees Rights
A homeownees rights under the Home Improvement Contractor Law(NIGL chapter 142A)and other consumer
protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by aereement However,homeowners
may be excluded from certain rights ifthe contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their o,,-,m 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 destari'bed-in a
timely and workmanlike manner. Homeowners may be entitled to ot=ter specific legal rights if the contractor
guarantees or provides an express'vananty for won tmanship or materials. 7n addition to guarantees or warranties
provided by the contractor ail goods sold in Massachusetts catty 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 homeo"z'ee's basic consumer nights. If you have
questions about your consmnerlhomeotvner rights,contact the Consumer Warmation Hotline(listed below.).
tE5ecution of Contract
The contract must be executed in du�te 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 marlmd as void,deleted,or not applicable. one original signed copy of the contract with attachments is to
be given m the owner and the other kept by the contractor. Any modification to the original contract;oust be in waiting
and agreed to by both parties.Contractee work may not begin until both parties have received a fully executed copy of
the contract,and the three day rescission period has expired:
_cceler atec PI-vs,s3s
A contractor may not demand pavmentsin advance of the dates specified on the payment schedule in cases where the
homeowner deems him/tierself to be financially insecure. However_in insttmces where a contractor deems himilimelf
to be financially insecure the contractor may require that the balance of fimds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted wort;,.Vrithdrat=gal off unds fvm said account would require the
simatures of both parties.
Additional-formation
If you have general questions Or need additional reformation about the Home Improvement Contractor Law or other
consumer rights,or ifyou wish to obtain a free copy of"!1 Iviassachusetts Consumer Guide to Dome Improvement"
contact
Consumer Information Hotline
O nce of Consumer Affair and Business Regulation .
10 Park Plaza,Room 3170,Boston,MA 42116
617-$73-707,8884 83 37�r orAsit the 0CA3Rv.ebsite at hrtn_fhta:Rtcmas aoy/oeabrl
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 Ctmtractor LM.
Director of Home improvement Ctuuiactor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,IVDA 02116
617-97327-07,989-293-3757 or visit the EUC'vebsite at hits-/h'nim°mass sow/ocabrl
Go online too view the status of a Home Improvement:Contractor's Registmdom-
bari.//db staiema.us/homennnI vemenUlicenseelistam
For assistance with informal mediation:of disputes or to register formal complaints a-Pinst a business,call-
(-'as isurner
all:(ortsumer Complaint Section
Office of the Attomev General
617-7277-9400 _
AND/OR
Better Business Bureau
40S-652-4$40,:50U-755 2548 or 413-734-3134 veMian Zi-1 t Flo
The Commonwealth oflMlassczchusetts
z . Department oflndlustrialAccidents
1 Congress Street,Suite 100
Boston,MA.02114-2017
F
www.mass go-v/dia
Workers'Compensation Insurance Affidavit:Builders/ContractorslEleetricians/Plumbers.
TO BE FILED WITH TBE PERMITTING AUTHORITY.
-applicant Information Please Print Le0bb TT
Name(Business/Oxganization/fudividual): 4+ j6
Address:
City/State/Zip: Phone A(4
Areyou an employer?Chee'kthe appiopxiate box: Type of project()Vequired):
1.[Skg�aemployer with employees(fulland/orparttime).* 7. New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3-E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10E]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12_Q Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c.
14.[..�-8'ElZer TNS
152,§1(4),and we have nu employees.[No workers'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 fiave employees,they rimst provide their workers'comp.policy number.'
X am an employer that is pidviding workers'compensation insurance for my employees.'Below is'the policy and job site
information.
Insurance Company Name: V�,j L L� —
Policy#or Self-ins.Lic.#: ExpirationDate:_, ,Z,6
Job Site Address: I q 6 3 (-e_vv,.- City/State/Zip: • j4n/o& (,14A _1
Attach a copy of the workers' compensation-policy declaration page(showing the policy number and expiration elate).
Failure to secure coverage as required under MGL o.152,§25A 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
X do hereby cert.fy under the pains andpenalties ofpeijury that the information provided above is true and correct.
Signatures �� � �- Date: L5^
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): i
1.Board of Health 2.Building Department 3.City/Town Clerk. 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
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 person in the service of another under any contract of Mre,
express or implied,oral or written."
An,employer is defined as"an individual,partnership,association,corporation or other legal entity,ox 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 of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
.Alpplicants
Please fill-oat.the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)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 fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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"axe regtured to obtain a workers'
compensatioil 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(if necessary)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 may be provided to the
applicant as proofthat 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
Ge.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.# 617-727-4900 ext. 7406 or 1-877-UNSSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Rightfax N2-1
3/10/2015 10:11:37 AM PAGE "111.}101 '-G^
DATE
AC lERTIFICATE OF LIABILITY INSURANCE 03102015
INFORC
THIS CERTIFICATE ISISDOES A ATTER Of ATIVEMY ORNNEGATIVE YONLY ANDCONFERS AMEND, EXTEND OR A TERNO RIGHTS UPONTTHE COVERAGE
HOLDER. THIS CERTIFICATE DOES NOT
EN
AFFORDED BY THAUTHORIZED ZED THISREPCERTIFICATE
OR PRODUCEREAND THE CERTIFICATE HOLDEITUTE A R RAS BSE
THE ISSUING INSURER(S),
must be endorsed. It
IMPORTANT: If the cera conditionser is an of the policy cercelnNAL 1policResDmay rthe equire(lan)endorsemoft statementn this certifica a does
subject to the terms
not confer rights to the certificate holder in Hsu of such endorsement(s).
CONTACT
PRODUCER NAME: FAX
PHONE No:
EASTERN INS GROUP LLC AlCa N
233 W CENTRAL STREET E-MIll AIL
NATICK.MA 01760MAIC s
INSUREfl1S)AFFORDING COVERAGE
INSURER A:AMERICAN ZURICH INSURANCE COMPANY
INSURER B
INSURED
ATLANTIC WEATHERiZATION LLC INSURER C-
61 REAR JEFFERSON AVE INSURER D:
SALEM,MA 01970 INSURER E:
INSURER F:
B R
C
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED
1 ABOVE FOR THE POLICY PERIOD
INDICATED.
RESPECOTO WH CH THINS ANY CERTIFICATE MAY E ISSUED OR MAY EQUIREMENT, TERM OR DIPERT IN,THE
CONTRACT OR OTHER DOCUMENT
INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AN
CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS
ADD SU POLICY EFF POLICY EXP
INSR OF INSURANCE ADD SU POLICYNUMBER (MM/DDPIYYY
E O N OCCURRENCE S
TYPE EACH
1 LTR �—
GENERAL LIABILITY pAMAGE TO RENTED S
1 rr
COMMERCIAL GENERALLIABILITY MED EXP(Arlt'one perso^) S
CLAIMS—MADE OCCUR
PERSONAL 8 ADV INJURY $
GENERALAGGREGATE S
PRODUCTS-COMPIOPAGO S
GEM AGGREGATE LIMIT APPLIES PER: $
PRO- LOC MB ED SINGLE LIMIT $
POUCY JECT
AUTOMOBRE LIABILITY a aera
ead
- BODILY INJURY(Per Person) $
ANY AUTO $
SCHEDULED BODILY INJURY(Par accident)
ALL OWNED
AUTOS AUTOS E AMAGE $
NON-OWNED $
HIREOAUTOS AUTOS
EACH OCCURRENCE S
UMBRELLALULB OCCUR AGGREGATE S
EXCESS UAB CLAIMS-MADE S
DED RETENTIONS X STATU- OTH-
WORKERS COMPENSATX)N TWGORY LIMITS EA
AND EMPLOYERS'LIABILITYYIPI EL EACH ACCIDENT $5QD,000
ANY PROPRIETORIPARTNERIEXECUTIV
OFFICERMIEMBER EXCLUDED? NIA A 6ZZU6 03.20-2015 03•ZO-2016 E.L.DISEASE-EA EMPLOYEE $500,000
(Mandatory in NH) 3B270121 EL.DISEASE-POLICY LIMB $500,000
II yes,dewibeunder
DESCRIPTION OF OPERATIONS below
DESCRIPnON OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Sehedule,H in space is reAuirad)
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I
CE TI IC HO CNC O
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
EXPTHE
1600 OSGOOD ST NOT CEUWIILDATE THEREOF,
CANCEED LBBEEFORE ODELIVERED NIRATION ACCORDANCE WITH THE
N.ANDOVER,MA 01845POLiC O�yONS-
Y PR
ALTIHORfiEDREPRESENTALIVE
®1888-2010 ACOiD CORPORATION Ali rights reserved.
ACORD 25(2010105) The ACORD.name and logo are registered marks of ACO D
A00REPCERTIFICATE OF LIABILITY INSURANCE F
DA7E{MM/DDMfY1�
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(fes)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terns 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 CONTA
N ME:CT COT18t r11CtlOn
Eastern Insurance Group LLC PHONE (800)333-7234 FAX
233 West Central St Enaa
ADDRESS-
INSURER(S)AFFORDING COVERAGE NAIC#
Natick NA 01760 INSURER A:Arbella Protection Ins. Co. 41360
INSURED INSURER B Nautilus Insurance Co
Atlantic Weatherization INSURER C:
61 Rear Jefferson Avenue INSURER 0:
INSURER E:
Salem MPS 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.
INSR POLICYEFF POUCYEXP
LTR TYPE OF INSURANCE POLICY NUMBER MM D MMIDD LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY
A CLAIMS MADE a OCCUR 500042816 /20/2015 /20/2016 PREMISES Ea occurrence $ 50,000
MED EXP Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000
POLICY X PROLOC $
AUTOMOBILE LIABILITY681 aeDISINGLE LIMfT S_ 1,000,000
A ANY AUTO BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED 020015871 /20/2015 /20/2016
AUTOS AUTOS BODILY INJURY(Per accident) S
X HIRED AUTOS X NON OWNED PROPERTY DAMAGE
AUTOS Per acadent S
PIP-Basic $
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIAS CLAIMS41ADE AGGREGATE $ 1,000,000
DED RETENTION$ 600058654 /20/2015 /20/2016 S
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE YIN
OFFICER/MEMBER EXCLUDED? ❑ NIA EL EACH ACCIDENT $
(Mandatory in NH)
If yes,describe under E.L.DISEASE-EA EMPLOYE $
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB I$
B POLLUTION LIABILITY ZPL200378613 0/1/2014 0/1/2015 GENERAL AGGREGATE $1,000,000
EA POLLUTION 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 WITH THE POLICY PROVISIONS.
1600 OSGOOD STREET
NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE
John Noegel/PMA
ACORD 25(2010/05) m 1988-2010 ACORD CORPORATION. All rights reserved.
INS025 r�mnn5�m Tho Af:nPn name and innn arm rmniefarad marke of AtIns?n
L e
Public safc y
_acsrse: CS-087977
EMC W PALM = `
3 HILTON Sr O
Salem MA 01970 l'
CO3mm4.S5:10nes 0412312016
UnresWcbed-Buildings of any use group which
contain less than 35,000 cubic feet(991M)of
enclosed space.
r
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation ofthis license.
for UPsucensinginformationvWt www•Mass.Gov/OPS
Office of Consamer Affairs&Business Regulation
laWegi
ME IMPROVEMENT CONTRACTOR
stration: 142089 Tie=
iration:.. 3/4212016 Ltd Liability Corpo`
ATLANTIC WEATHERiZ4TION LLC-
ERIC PALM
61 R JEFFERSON AVE
SALEM.MA 01970 Undersecretary
License or registration valid for individul use only
If found return to,.
before
the expiration date.
Office of Consumer Affairs and Rosiness Regulation
10 Park PIM-suite 5170
Boston,MA 02116
vv
out signature
_ Not valid with sign