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HomeMy WebLinkAboutBuilding Permit #117-2017 - 15 HUCKLEBERRY LANE 8/5/2016 NORTH BUILDING PERMIT o�t�LEo gtio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION OR 1eb Permit No#: Date Received �ysswrED CH �5��c5Al1 Date Issued: �IMPORTANT: Applicant must complete all items on this page LOCATION 0S OJAA 61,r 'I L&-Y\k— .1 Print PROPERTY OWNER i(,�SVh Ah /,,�,,� Print 100 Year Structure yes no MAP i ; PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ewe family ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic p 1Nell Floodplain 0,Wetlands ❑' Watershed Qstnct --- —_ _ ,- p VNateTlggwer. DESCRIPTION OF WORK TO BE PERFORMED: rA,r b- oy\' a U lou d. r\ cinMon tom. lS �- Identification- Please Type or Print Clearly OWNER: Name: Phone: 508.3`15 •�H �' Address: S HIV LkJ C 6t Contractor Name: Phone: q1-6 3 Slo • 3y 6 3 Email: r intUlu- •�r l-�-aYvl Address. P O\--)x 344 U,\ q 2`3 Supervisor's Construction License: l�O-L Z' Exp. Date: Home Improvement License: 3 Exp. Date: 1 �O 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: $ 23h 3 1 FEE: $ Check No.: 2A w Receipt No.: 2>6 1 '6'7— NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 aCopy 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) 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 Diy�r�e!�q �q L1 fisio�! J F 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 j 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 i ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 — U r J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanniug/Massage/Body Art ❑ Swununing 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 - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 'Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREDEPARaT�MEN_T� T:,empDumpster onsite�:�yes,�,� ,: ra.�; it. '�•�,no '" ���' 6x_ _� 4Located at 124%aintStreet `, 9 �-� ,�-� '4 �!' •�FireiDepartment4signdture/date, ', `t 'y7=.: i1 t., �:-.+.•} * { } . 4'°'e i `r., '.4 �. 1tfil'^'r t7..�. -t yS+r+...rr � i COMMENTS. 1 Location No. Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 2 Foundation Permit Fee $_� Other Permit Fee $ TOTAL $_ Check Building Inspector s NORTIl Town of t _ �* 6 ndover O �+ ,, h ver, Mass bl� ATO S1 coc"Ic"awK 0 RATE° PP S 1l BOARD OF HEALTH Food/Kitchen PERM T T LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR . . ... .. . ... . . . ej .. ..... . Foundation has permission to erect ............... .......... building on ...1.. ... .. ... .� . �. • Rough • to be occupied as �... �. . .. /. ... �... .... . . . . ... ....�:!:'.+.. Chimney provided that the person accepting this rmit shall in eve res ec nform the terms of thea l...... n p pp Final on file in this office, and to the provisions of the Codes and By-Laws celating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. CA ,`#V.-%'a r ..ft PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION Rough Service Final BUILDING I ti �T6�R 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. RISS B oat�aberiteatteeteB 11,*p NOMOOSMOM mc,abaexarasgiteaemlta Mt9 AD af'della is RISE 6d8bas�Ildt�. ,YAOi mmaimma CONTRACT 3�60R�61d6 FAX ®..�.....,.��. POP 1 =� �svaasr0°0iesiw°is Vam VICE am= -W�mmmqmw Di VUk&AM c (sown OSWM16 435749 mm 15 Hwy Dame is it Low UIFWU ' N North Andover;MA 0184S '� North ALMA 01845 IOU DESCR�'1PION tNtA86 OBiB-t+roposal tbrdeb t sm HBALTit dk SI►t�87'Y:woe�aia�iaawetaadmcp�ocaalam0 moa�daaoe�Oatl�avBf P�n)�(w��l� ObOA)of aoattset=aft Boar ams bcm besmttad is Yauf b=WMMM NEBOS TO BOTALL A HAIR FAN CAPAK E OF 60CFK CON[IIi1J0 MOPgRATMILTUMPANCANBSSEWONAT M TOCMS36NDLM HL OWSUCHFANISAPANISOM LOOKAT6FUM& SQAO HAZARDHABBtEkWafiacidmdW m &malasaaessod6�stmesmtioy+asa�ma.wtesaEmsaoeaeedli�lsaseaati8od res DCtased(bmrbdaa Caamat Rated)rota earte coater a 3•cl�mea spare ae�trmsd the tiattera 6g►mia8 i bt�loet iasalaNw as a dommbwmdmKwbmds =wMbalosmltadaaoesdempmdeImad,eelrtdiamuiaaae=dF&t%w lvmbekmd=& SOAR AMSEAi.a3ti:PsaeidebtborandauI It coud—ofycabwmagdouv oomssaitbt e,Tbb ao&vMbe pad�mad taaonmtoddt dmn®eofepedat000aaaaddb�e/aatmaaemaamtyamrtaEBbetidtvatWat�lasdof airaodamaBeaadiedoaelrdfy.MSaa1affiiolaaneodmmdyoarbomaamaatb fomtanmlalbertuodacta.Fiery memaCorsmHcgiaetadsaab tesa�rmdambummseomaetmdg�gosandvdecrteedee>ooedwes(�vtmdoersaeooetgeeearml�r 'tbiswSlta�na(B)ami3�sgteaars..Arodmotiwiaaobue$ee permimtae(e8a)ara�mBtteadanarSl ocaw�balder eeesoal uL%bw tdeahs is aat V=mataod. Atdeoae woffbeae iraaemeetodr,readtotass�imnotoo:tmtba aid docsaetd4weom6mdw mf r13 * vMbaamdaaaadbydwtoammothewftofdeebeoorasgnft. . Sam ATM ACCESS:P= ckboraadomkififtmfiftR(l)caft, sod, WMfArftWde�feddiR xW&AmM mtemra mi glywao iMbearaaadmoaadltreopesiagwabiamam@c mhvmmftw"wadbhard as eatitstatrlesdmee. s�maa V@IIIIATIOt+L Peosbtebdeerand ameateds mbeset8(2)bm�asbmeslbasewiffimeftueAmledlt�we;rmtmasbemst W7-5D V6NMATIMFtvef&kbw=draaeaetsmbtstdt timmain("mtktbgamambttdaa ftw. Stan c riWAtLV.Bta+eidatnbareeada>aoaaidseabstaeS2'E�EkOalwsittt¢dt boesaiawtmdsreeo(ffiftlageeeoaCartel aommwadttems. seoatlo . it�Tt[VtwRISBBa�q�ratle6m�aeYwr®wbrbabSbsddxltetaamam. Q>Qemij►.fate nwawne;Cobpn4blQasotgdaasieoexi6inoef79layaateaae ftdS%=perakmdasymmdwh, im-1ae at 10016 fordeeAtrSedtogameAmdee BaRS�Memadd0b>�f3t0ita�atej�ttod6ydoe8m� FORAL16Rl�ZmLL:C.afambialiauaaIDabw+�ieraaeettODiaomttramwm�tdiew+at�rmtwaaoikaadaadEodds aatapaevtlhisapeafdSwgmlaeeotbroiteaar8ddemh�aamsv�obs+aeteedd�l�QaQmbarnaaregpram�be�eJnly wn,®on.osno �a,..�,asm.o m�roaua�auwos L a - .. raiaAas AAII�II R11 A �iismv�s�� � � M unan momOONu w SIM M ft% .. d01gf 9 8N1L0� HN0911 MAfAI elAl IAt StBf SOD- if li tlu ApMp op MOP! =11 q +d wm ummpmoIL t�a0007�1��Bp17IIp9ti9f�L �BA�pOR1�QJ110Ry000� '9toL'Ofi i+V 19 8/4 tl '9TOL'16 Sti8i0 Vi'�` V glso�i Sti'8id Vial`�W q�N �D00 &aft 9toi'I" Ltfi6 S�£(8�) qq vM smriw w4a0RTd t Qftd uva Amm 351 el�so�osooml�e r ' RISE0 Ommid Read,Unit21 Carte,MA UM 13324= ENGINEERING OWNER AUTHORIZATION FORA (Owners Name) ^� owner of the property located at / ).e+Iys/" - (Pro ) (PrOerty Address) hereby authorize (Subcontractor) an author>zed subcontractor for RISE Engineering,to act on my beha{f to obtain a bullift permit and to perform work on my property.This form is only valid with a signed contract. The Commonwealth of Massachusetts Depardnent of Industrial Accidents Ofrce of Investigations �y 1 Congress Street,Suite 100 'N Noston,!11A 02114-2017 ►+w .mass.gorldirt Workers'Compensation insurance AffidaNit: Builders/Contractors/Electricians/Plumbers Applicant information t_ Please Print Legibly Name(Businc�s Qr aztuauttn'Indi�iduall: '3 f>kt�'it{.c- tnwl T1 gel �Yom. _ Address: 00 box 314 Ci •1State!Zip: 1 _ vii 1138 Phone n: 9 _'V3 3rt0' 3151a3 Are you an employer''Check the appropriate box: t'A pe or project(required): 1.M I am a cmploycr%kith S 4. 1 am a general contractor and 1 emplo}•ces(full and or part-time,).* have hired the sub-contractors 6.' ®;ecu'consiruetic,n 2.0 1 am a sole proprietor or partner- listed on due attachedSheet. '. Retnodcling ship and have no employees These sub-contractors have S. Demolition \,,,orkinS. for rete to anN capacity. employces and have workers' 9. i3ttildin{*addition [No viorkcr' comp_insurance comp.insurance.- rrquirt:d.] 5- oration and its 1013 Electrical repairs. or additions ® 1i`e arc a corporation I am a homeowner doing all%work otliccrs ha%e exercised their 11.3 Plumbing repairs or additions myself. [No workers comp. right ea`rxetnptio.t +er NSCfL 12.C]Roof repalFs insurance required.] t t:. 152,610l,and we have no employees. [No workers' 13.3 Other comp. insurance required.] apphcim that chccws box=3 mtw also fill out the ztoiun btlou she„urs elate:unr):crs'tort r tc=rt,xt p.�ttat'to,rtnannn -HOntrl7lt^.te:•5 Uho sub-r.this af.5dA%a mdtcarrr th3:c doIng all wars r±r_thm hen outrule con Tactors must,uhmit a nabs a ff LL%it tndicatmr,smh. 'Cotnractors thal check dais note must a..achu an ach'.tuoaal hrrt shuxt^a the rearm or the sub-cuia,:=acts}rs arxi stave xhe-jxr or no< 11(nc rn:tncs kavc rrrtptu)r�. 14 tEtc sub-contra ors have cnnplrnrr,.teem mus:pm,tdr thri. r%vrker,'t.orr t.pohv%aurnbcr I am an emli ver that is providin;q workers'comprmation insurance for my emploree. Below is the polity and job site information. Insurance Companyattte:A�� OL IniQr&,r\,l t („gyp _ Policy=or Self-ins. Lic. rl Il PT V—P.�ooh 3,} ExpirationDate: ,k til 3 a l ikk Job Site Address: T 1�Lkj LbL^,j Lkr-� City State-zip.- ' fV\L6V Cr Attach a copy of the workers'compensation policy declaration page(shocr ing the policy number and expiration date), Failure to secure coverage as required under k diem 25A of W L c. 15-1 can lead to the imlwaition of criminal penalties of a tine up to 51.500.00 and or one-year imprisonment, as+veil as ci%it penalties in the form of a STOP NVORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement urea% be forwarded to the Office of investigations of the Dirt for insurance co%erage �enficalion. I do hereby certify under the pains and penaltics of perjure that the information provided above is true and correct. Signature: ��"�°�t`'e-'l� Date: Phone t': 11 IM 3�'U' 34 Ile _ Official u.ce onl . Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Nsuing Authority(circle one): 1.Board of health 2.Building Department 3.Citvfrow n(,Ierk 4.Electrical Inspector 4.Plumbing Inspector 6.Other mM _ Contact Person: �-•_- Phone;y AC40R"® 7630/2016 (MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 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 Ileu of such endorsement(s). PRODUCER CONTACT NdIIC Usher NAME: y Martin J Clayton Insurance Agency, Inc. PHONE (413 536-0804 FAX (413)534-7874 A/C 419 E,1): ) A/C No 1649 Northampton Street ADDRESS: P. 0. BOR 989 INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harle svi1le NATIO INSURED INSURER B Allied World Natl Assurance Co Gauthier Insulation INSURER C: P.O. BOX 344 INSURER D: INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1663001850 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM D YY MM/D LIMITS R I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADElil OCCUR DAMAGE TO RENTED 50,000 PREMISES Ea occurrence $ X GL43487P 7/6/2016 7/6/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LAB OCCUR EACH OCCURRENCE $ B EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ SE020792125-194985 10/18/2015 10/18/2016 $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ Ifes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) TEI, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSURED(S) ON A PRIMARY AND NON-CONTRIBUTORY BASIS TO ANY OTHER INSURANCE CARRIED BY TEI, UNDER THE SUBCONTRACTORS GENERAL LIABILITY AND UMBRELLA COVERAGE. 30 DAYS NOTICE OF CANCELLATION CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THIELSCH ENGINEERING, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 FRANCIS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. CRANSTON, RI 02910 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014411) The ACORD name and logo are registered marks of ACORD MP't §tbd with pdfFactory trial version www.pdffactory.com AC R V CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/13/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER co'AcNAME: T Katil n Da sh MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE xlk 413 536-0804 FAx N, ADDRESS: kdayshftuclaylon,com 1649 NORTHAMPTON ST.,RTE 5 INSURERS AFFORDING COVERAGE NAICA HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325 INSURED INSURER B: GAUTHIER INSULATION INC INSURER C: INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER: 52708 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR NSR I TYPE OF INSURANCE INSD L WVD B POLICY NUMBER PMNCY YYY ,V_ I MIDI D/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY IEACH OCCURRENCE $ CLAIMS-MADE 7 OCCUR j DAMAGE TO RENTEff- PREMISE Ea occurrence $ i MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JE LOC I PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SIN LE LIMIT $ Ea socident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY Per aWdent $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTYDAMAGE AUTOS fPer accident $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ S WORKERS COMPENSATION x AND EMPLOYERS'LIABILITY Y/N /� STATUTE ERS A OFFICER/MEMBER EXCLUDED?ECUTIVE WA WA WA MAARP300327 10/30/2015 10/30/2016 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,desrnbe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored dally by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.aoviiwdANorkers-oompensafionAnvestioations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF GLOUCESTER ACCORDANCE WITH THE POLICY PROVISIONS. 3 POND ROAD AUTHORIZED REPRESENTATIVE GLOUCESTER MA 01930 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD C�Txe [( 0 )J?J1/0011 e1Y///�fl C J �i/�f1. .1flC ltl,lf' Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173410 Type: Individual Expiration: 10/1/2016 Tr# 257812 KURT GAUTHIER KURT GAUTHIER P.O. BOX 344 IPSWICH, MA 01938 Update Address and return card.Mark reason for change. Address Renewal " 7 Employment Lost Card SCA 1 is 20M-O&II _;,n\— Office of Consumer Affairs&Business Regulation License or registration valid for individul use only before theexpiration date. If found return to: fIOMEIMPROVEMENTCONTRACTOR J$egistration: 173410 Type: Office of Consumer Affairs and Business Regulation % ,Wxpiration: 10/112016 Individual 10 Park Plaza-Suite 5170 N.r Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER 44 ESSEX RD IPSWICH,MA 01938 Undersecretary of vfllid wi out signature Massachusetts.N #m loft me Safety Board Of Suilding Regulations and», ,@# k.%@, "sS % License:CSSL-102 KURT ItCAuTIf \ ° \ P(k 801344 hMA m,» , w bn Co"Itsioner 0&2512017 .�