Loading...
HomeMy WebLinkAboutBuilding Permit #904-14 - 15 MAIN STREET 6/11/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 4vDate Received Date Issued: IMPORTANT: Applicant must complete all items on this page µ: LOCATIONS _ Prin PROPERTY OWNERc r Print 100 Year Old Structure yes 6o MAP NO: `' 0 PARCEL. ZONING DISTRICT: Historic District yes (moi Machine Shop Village yes TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building gOne family 'gAddition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: , Identification Please Type or Print Clearly) 5� _�� �,��-�/ Phone: S'ty OWNER: Name: bib • `1q�3 Address: `6- uw'�_ *_'vys� CONTRACTOR Name: Phone: -q­� 61$ .5-'? Address: t!'zy E Ani Supervisor's Construction License: 07r-2 VR, _ Exp. Date: lV � �5S Home Improvement License: 1:It 1,`4 Exp. Date:- ARCH ITECT/ENGI NEER ate:ARCHITECT/ENGINEER Phone: S`15`1 Address: eyo hReg. 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: $ S_0 5 FEE: $ Check No.: 0� Receipt No.: 1 Lc .t.o NOTE: Persons contra ting with unregiste ed contractors do not have access to the guaranty fund Signature of Age605O / e Signature of contracto Plans Submitted Plans Waived ❑ Certified Plot Plan Stamped Plans - Plans Submitted Plans Waived :.-Certified Plot Plan. Stamped Plans -T70 EOF::S)✓WERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art . . .Swimming Pools ❑ Well Tobacco-Sales -� •FoodPackaging/Sales ❑ Private(septic tank etc. Permanent 0 Dfimpster on THE-FOLLOWING SECTIONS FOR OFFICE USE ONLY `. INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT EI COMMENTS .CONSERVATION Reviewed on l Sieinature�U U�� COMMENTS HEALTH Review on Si nature . COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/S_ignature& Date Driveway Permit `'• DPW To` ;2 Engineer: Signature: Located 384 Os oodStreet FIRE mp'ARTMLAT =`Temp Dumpster on site yes no Located-at;124,Mair; Street -Fire Departme►it,signatare/date M* COMMENTS r ' .-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 DANGERZONE LITERATURE: Yes No MGL.Chapter 966.Section 21A—F and G min.$100=$1000 fine NOTES and DATA— (For department use ® Notified for pickup - Date I Doc.Building Permit Revised 2010 Building Department -` The fol swing i94—list of,the required forms to be filled outfor.:the appropriate permit to be obtained. Roofir;g, Siding, Interior Rehabilitation Permits ❑ ; B,ailding Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/OrC.S.L Licenses ❑ Copy of Contract o 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 L3 Certified Surveyed Plot Plan a Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o__ 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) o Building Permit Application o Certified Proposed Plot Plan o 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 o Mass check Energy Compliance Report Li 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 apw,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:tted with the building application Doc: Doc.Building Permit Revised 2012 Location �6 �—�5A LA--j Q" No. 6 Lk— IL4 Date X011 t I�`i . - TOWN OF NORTH ANDOVER sT Certificate of Occupancy $ Building/Frame Permit Fee $to Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Gilding Inspector Ogden Engineering 978-3E2-12858 p.1 1 I.A'W aENCE H.OGDEN, P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 978-352-8318 fax 978 352-2858 cell: 978-502-5921 July 28. 2014 Mr. Kevin Murphy 169 Boxford Street North Andover,Ma. 01845 (� lE: Couto Residence,Lisa Lase North Andover,Ma.01845 Dear Mr Murphy As you requested 1 visited the site July 23.2014 to review tht installation of the Engineered Materials consisting,of LVLs utilized in the framing of the above project. "These are shov✓n on plans prepared by Steve Foster dated 6j2,'1 4 with the framing shczts certif ed by, me 6!514. Based on the above site visit and based on what I could visibby see. I can certify that to the best of my knowledge the LVLs members utilized in tire framing a5 shown on the drawings are installed properly and rneet the loading conditions of the 8th Edition. of the Massachusetts State Building Code far 1&2 Fwmily Residences All other framing requirements of the dra—,zings and cede, ir:cluding but not limited to materials, naming schedules. blocking, connections, manufacturers installation requirements and other details are the responsibility of the lic:ensced construction supen.-isor responsible for the project. Should you have any gtaestions release do not hesitate to call. Fours truly. a«rence H. Ogden Rf-. Structural 27765 J%� OF May o� w �.,G 9�cA77 0 a T'Ev Fss�aNA-t��,, Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 55,850".,00', m $ - $ 670.20 Plumbing Fee $ 83.78 Gas Fee 100 comm. $� 100:0:0' Electrical Fee $ 83.78 Total fees collected $ 937.75 15 Lisa Lane 904-14 on 6/11/2014 Add 14x18 Room on rear of house NORT#1 Town of 2 E , Andover - 0 No. 904-" Iq I CO, h over, Mass, A- COC LAKI NI CMCWICK �1 7�ADRATED r'4�,`�(5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System � THIS CERTIFIES THAT ..............,:........ BUILDING INSPECTOR has.permission to erect g %.�`—i�fSy,,,; , F............................................ Foundation .......................... buildings ................. Rough to be occupied as ............................ `� � .. /� ............... Chimney ............... a`.............................................................. . provided that the person accepting this permit shall in everyrespect 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 CONSTRUCTION STARTS Rough ... c�1R�r.•:.r/•. . .................................... Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired 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. e Q 98 Forest Street Kevin Murphy • North Andover,MA 01845 • PH:978-688-035 Building Contractor • FAX:978-688-7207 Proposal To: Brian&Sande Coutu 15 Lisa Lane All Horne improvement Contractors and Subcontractors engaged in horn improvement contracting,unless North Andover, Ma 01845 specifically exempt from registration by Provisions of Chapter 142A of the general laws,must be registered with the Commorwveallh of Massachusetts.Inquiries about registration and Status should be made to the Director,Home Improvement Contract Regishation,One Ashburton Place, From: Kevin Murphy Room 1301,Boston,MA 02108.(617)-727 8598 CC: Date: 6/11/2014 Job: Addition Date of plans: 6/14 A chitec Steve Foster Location: Same Section 1-Work Schedule Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified here in writing contractor will begin work on or about 6/15/14. Barring Delay caused by circumstances beyond Contactors control,the work will be completed by 9/30/14.The owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as violations of this agreement. Section 11-Warranty The Contractor warrants that the work fumished hereunder shall be free from defects in materials and workmanship for a period of 1 year following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup,the Contractor shall,at his own expense,forthwith remedy, repair correct,replace,or Muse to be remedied, repaired,or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. Section III-Scope of Work Page 1 of 5 Kevin Murphy Page 2 of 5 Building Contractor 98 Forest Street North Andover,MA 01845 PH:978588-5335 FAX 978588-7207 General Proposal is to add 14'x18' room to rear of existing house. Building permit and certified plot plan will be provided by contractor. Building plans and any structural engineering to be provided by owner. Demolition Existing deck will be removed and disposed of. Excavating Excavation required to install frost wall foundation will be provided. Backfilling and rough grading will be provided. No allowance has been made to relocate any sprinkler systems, underground utilities, removal of ledge, lawn repairs or installation. Any additional fill will be removed from site. Foundation Poured concrete foundation will be provided as shown on plans. Rough concrete floor will be poured in crawl space. Building All frame, roof, and siding materials will be supplied / installed to match existing / as shown on plans. Ten Anderson doublehung windows will be supplied and installed as shown on plan. Transom will be provided above fireplace. One fiberglass fifteen light single french door will be supplied and installed. Exterior landing/ steps will be granite. Electrical Electrical work required to wire room to code will be provided. Six recessed lights will be supplied and installed. Any surface mounted fixtures to be supplied by owner, installed by contractor. General layout to be approved by owner prior to rough. Heating/Air Conditioning Existing zone of forced hot air heat and air conditioning will be extended to properly heat new room. Insulation Room will have fiberglass insulation supplied and installed to meet code. Plaster Room will be blueboarded and skimcoat plastered.Walls and ceilings will be smooth. Interior Trim/Doors Pre-primed interior trim will be supplied and installed to match existing. Painting Interior and exterior painting will be provided. One coat of primer, and two coats of finish will be applied to all painted surfaces. Kevin Murphy Page 3 of 5 Building Contractor 98 Forest Street North Andover,MA 01845 PH:978688-5335 FAX 978688-7207 Flooring Floor in new room will be tile. Owner to supply the materials. Waste Removal All demolition/construction debris will be disposed of by contractor. Other Allowances Allowance of$3000 has been included to supply/install zero clearance gas fireplace and mantle. 1) Option to widen existing opening to room, and add door unit with transom above, would add$3500. Drawing of door unit will be presented prior to ordering. 2)Option to supply/install bead board ceiling in new room,would add$3000. 3)Option to add arch top window in gable end,would add$1500. Kevin Murphy Page 5 of 5 Building Contractor 98 Forest Street North Andover,MA 01845 PH:9788885335 FAX 978688-7207 Section IV-Price Schedule We hereby propose to fumish material and labor—complete in Accordance with above specifications for the sum of... ... ...... ... ...... ......... ... ....$ 55,850 Payment to be made as follows: Percentage/item Description Amount 1 Permit obtained / deposit $8,000 2 Foundation poured $7000 3 Roof complete $15,000 4 Windows / siding installed $8000 5 Plaster complete $7000 6 Paint/floors complete $6000 7 Job 100% complete $4850 Total 7 $55,850.001 —Notice:No agreement for Home improvement contracting work shall require a down payment(advance deposit)of more that one-third of the total contract price of the total amount of all deposits or payments which the contractor must make,in advance,to order ardor otherwise obtain delivery of special order materials and ecopment,whidrever is greater Contractor: Kevin Murphy 98 Forest Street No.Andover, MA 01845 Registration No: 101874 Section V—Acceptance Acceptance of Proposal—I have read this document and accept the prices, specifications,and conditions stated. I understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified. Payment will be made as outlined above. You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction cancellation must be done in writing DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Signature Date---6 I t l l Lf ,=."ASignature Date i �p ZONING INFORMATION: IP -i 35"E ,i FND ZONING DISTRICT : R3 FND 121.35' * WITHIN WATERSHED DISTRICT - ASSESSOR INFORMATION: LOT AREA N MAP 98A PARCEL 111 25,220 S.F.f 0' b) rn l DEED REFERENCE: o BOOK: 9343 PAGE: 147 r-ri OWNER INFORMATION: 96.7' BRIAN COUTU 15 LISA LANE k 1p NORTH ANDOVER, MA 01845 Prop. 14'x18' FND Z Addition cn ni Ex. Deck to C } be Removed un cn o I ` 14.0' 45.2' W N, 0 0 i m 0' 31.8' EX2 WOOD STORY S7Ru�TQ EE 40.7' i Q UQ � N � 4 R�72s X39. 'Oo � 32.8' R6'23' S74'58'00"W IP s 00 - 69.12' FND LANE I CERTIFY THAT THE STRUCTURES SHOWN WERE LOCATED PLOT PLAN OF LAND BY AN INSTRUMENT SURVEY AND EXIST ON THE GROUND AS SHOWN. #15 LISA LANE NORTH ANDOVER, MASS. jA°F s OF PREPARED BY: JOHN D. SULLIVAN III, P.E. a GMS 22 MOUNT VERNON ROAD No.41686 T BOXFORD, MA 01921 fcr �a�° (9 78) 352-7871 SCALE: 1"=30' DATE: 5/14/14 S f ARCHF ECrUIR W FF43K" WIND BRACING. DBL. 2 X 6 SUPPORT MULLION 2'-8" TYPICAL AT POSSIBLE CORNERS * ALTERNATIVES TW24510 TW 2451 (REQUIRES SKYLIGHT STRUCTURAL ENG.) (ABOVE) AUGIN ,..I - �� CLO.FAN. BRICK PATIO --.� � ! {qgp�/�� z 0 ALTERNATE M2 PAiLii:C ! -r-- ALIGN /i/ --, FIRST FLOOR PLAN STAIRS TO----,, _-T I �� SCALE: 1/4" = 1'-0" FINISH GRADE � 1 F---J /J/ EXISTING .�` WINDOW __ SWITCHES \` RECENTLY INSTALLED RELOCATE EXISTING + I I I j ' (5) D.H. WINDOWS SUMP DISCHARGE I I AS REQUIRED (V.I.F.) \ DOWN F PROPOSED WALLS ALIGN EXISTING BASEMENT �:� I� � y I_� / BULKHEAD I c ENTRYJ ICN 235 ! TW 26510 TW 26510 TW 26510 TW 26510 TW 26510 2-2852 SINK I ALTERNATE # 2: ] o FUTURE I 4- 2'-8" WOOD FRAMED GLASS DOORS. I 1 WINDOWJ I CENTER UNIT = BI-PARTING SLIDING DOOR n CN 13'-4" I XISTIN FIXED END (2) UNITS. I ABLE TRANSOM WINDOW ABOVE. STOVE I NEW SUPPORT BEAM. ILY ROOM = oo I 15'-6"x23'-0" U-) KITCHEN I BREAKFAST HEATH 14'-0" .0" DINING ROOM x16'-8" tr-a"x1a'—a" 23'-10" GAS 12'-10"x14'-6" DNo 0 zV1 U I q N L FFA.si' %� i Vim' FF�__ x I �Lo _ in N2-2'-6"x6'-8" FANFRENCH POCKET DOORS :� I- `` 4°i % % RIDGE BEAM O� (HIDDEN) EXISTING WINDOW ®� wo TO REMAIN C� EXISTING WINDOW {-I FINISH 21INILOOR TTTI RAILINGLLL FINISH IST LOOR •i l FNEW GRADE SIDING TO MATCH EXISTING \"-STAIRS TO FINISH GRADE CRAWL SPACE VENTS ALTERNATE: i MICROLAM BEAM RIDGE VENT 2X100618.O.C. IIINSULAnq,I ASPHALT SHINGLES.MATCH EXISTING. 100 % ICE/WATER SHIELD MEMBRANE. SKYLIGHT AIR SPACE FRAMING CONNECTOR-PLATE TO RAFTER WPICAL EAVU DETAIU CONTINUOUS DOUBLE TOP PLATE FASCIA A 60FFR TO WATCH EXWM DOIELE TROP RATE HEADER 2-2 X 8 TYPICAL METAL DRP EDGE 110EAIATERSHEM TYPICAL EXTERIOR WALL- SIDING ALLSIDING TO MATCH EXISTBrG BUILDING WRAP WINDOW UNIT + 1/P'CDXPLYWOOD SHEATHINO + x 2XSAT18'O.C. Rao RMN AT04 R,ZO INSULATION POLY VAPOR BARRIER 1/P'GINSTYPICAL 9DETAIL* U BILL ANCHORBOLTSAT4+0.R 8/4•T8S PLYWOOD. SILL SAL FOAM PR UATION °p NAIL S GLUE TO FRAMING DOUNA2xSTREATEDSILL CONTwLx=Reeom JOIST FINISH IST FLOOR FINISH GRADE 2 X 12 AT 18.O.C. + (EXISTING) (SLOPE TO DRAIN) CRAWL SPACE INSULATE AT PERIMETER NOTE RIBBON J018T Z VAPOR BARRIER OPTIONAL MTEP DOWN'INTO ADDITON FROM EXISTING. OWNER TO ADVISE Do -' OPERABLE/SCREENED CRAWL SPACE VENTS 2 A16 REBAR — — — PROVIDE CRAWL SPACE TOP S BOT. REMOVE ALL ORGANIC THRU EXISTING BASEMENT SOILS FROM CRAWL 20'X 10' SPACE AREA POURED CONCRETE FOOTING V.I.F.ADEQUATE SOIL BEARING CAPACITY U 0� �o ASPHALT SHINGLES RIDGE VENT SKYLIGHTS ___ ___- _ _ FINISH 2ND FLOOR GABLE END OVERHANG ---- --- _ __ + I.H. "ANDERSEN" WINDOWS GUTTER/RAIN DNERTER �- AT DOORWAY -�- LOCATE STAIRS/DOOR TO AVOID CONFLICT WITH EXISTING CASEMENT WINDOW. FIREPLACE ENCLOSURE - - -- _- -- FINISH 'IST FLOOR FNM GRADE STAIR TO FINISH GRADE Lr L _ O� V O RIDGE VENT SKYLIGHT. "VELUX" FCM FINISH 2ND FLOOR - r FIREPLACE ENCLOSURE D.H. "ANDERSEN" WINDOWS - FINISH 1ST FLOOR :.,. D.H. WINDOW - FINISH GRAM OPEPABUSICREEMM -� / / CRAWL SPACE VEMS RIDGE BEAM O� (HIDDEN) (\n EXISTING WINDOW TO REMAIN i� ' FIXED TRANSOM WINDOW EXISTING WINDOW + FINISH 2N LOOR FM I J.-I I FM RAILING FFH --d . FINISH 193T HLOOR ;;. FMM GRADE SIDING TO MATCH EXISTING FIREPLACE \,-STAIRS TO FINISH GRADE CRAWL SPACE VENTS 0� U" EXISTING WINDOW �0 TO REMAIN FTTJx EXISTING WINDOW FINISH 2N LOOR RAILING LQ FINISH IST LOOR FOM anAos SIDING TO MATCH EXISTING STAIRS TO FINISH GRADE CRAWL SPACE VENTS Sullivan Engineering Group, LLC Civil Engineers&Land Development Consultants May 15, 2014 Town of North Andover Planning Department 1600 Osgood Street North Andover,MA 01845 Re: 15 Lisa Lane, North Andover Watershed Waiver Request—Proposed 14' x 18' Addition To Whom It May Concern; On May 14,2014 I personally conducted a site visit at 15 Lisa Lane to determine the proximity of any wetland resource areas to a proposed 14' x 18' addition in the area of an existing rear deck. There are no wetland resources areas within 325 feet of the proposed work. There was a wetland area to the northeast of the subject site off of Johnson Street that was identified,but was over 325 feet away at the closest point. As such,the b 'lder is seeking a waiver from the Watershed Special Permit application process. If you should have any quest ns or concerns please feel free to tac e. Very Truk' Yo s, „iJ'U"NA 1� � John . Sullivan III,P.E. ' ,_,.:t c� .;,i �w 22 Mount Vernon Road Boxford,Massachusetts 01921 (978)352-7871-Phone 978352-7871 -Fax The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 IN www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lesibly Name(Business/Organization/Individual): Address:_ City/State/Zip: Nv- i,,,.a,,,,,,.�. ►�. G l Phone#: 1;n<�- Are you an employer?Check the appropriate box: Type of project(required): LEA I am a employer with 4. ❑ I am a general contractor and I 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g_ ,Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. C. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 131J Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. C",- ,j w 1 - 60 - I Policy#or Self-ins.Lic. L e _ q!l.2 �l�, 1_ Expiration Date: Job Site Address: kS" k1Q i_ Vlr.4 -e. City/State/Zip: N„ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Y do hereby ertiffy under the pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: l t Phone#: 40k– Of 0 k— 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 - - - i Contact Person: Phone#: AC<JRD® DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 7/17/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WANED,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). PRODUCERN -CT M P ROBERTS INS AGCY INC PHONEFAx aC ND Ext: (978) 683-8073 ac,ND:(978)683-3147 North Andover, MA 01845 1060 Osgood Street ADDREss :sandi@mprobertsinsurance.com RJSURER(S) AFFOROLRG COVERAGE I NAIC# INSURER A:PROVIDENCE MUTUAL INSURED KEVIN MURPHY BUILDING & REMODELING INSURER B:MERCHANTS INSURANCE 169 BOXFORD STREET INSURER C:WARD INSURANCE NORTH ANDOVER, MA 01845 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 13ELOW 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 I ADDL sUBR POLICY EFFP M/LICY EXP LTR TYPE OF INSURANCE INSD VWVD POLICY NUMBER (MWD MDD LIMITS X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1,000 000 CLAIMS-NIADE ®OCCUR I 1 PREMISES Ea occurrence) $ 500,000 ! III MED EXP(Any one person) $ 15,000 A BOPI068945 11/22/12 11/22/13 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY I_t PRCOT- L_I LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITYINGE LIMIT L Ea a"UMcc(dent $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED MCA7013608 0123/13 01/23/14 ! B AUTOS X AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED R RTY D AUTOS Per accident $ $ UMBRELLA LIAR 1OCCUR B EXCESS LIAR EACH OCCURRENCE $ 1,000,000— CLAIMS-MADE CUP9145304 11/22/12 11/22/13 AGGREGATE $ 1,000,000 DED RETENTION$ WORKERS COMPENSATION OTH- $ AND EMPLOYERS'LIABILITY YrN X STATUTE ER ANY PROPRIETORIPAR C OFFICERIMEMBERR EXCLUDTMOCUnVE C)NIA E.L.EACH ACCIDENT $ 500,000 Ifyes,desennbeunder KEWC422467 07/01/13 07/01/14 EL DISEASE-EA EMPLOYE1 $ 500,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it mon:space is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER BUILDING DEPT. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDO",7ER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRES A r rNr ©1988-2013 ACORD CORPORATION. All rights reserved. ACORD25(2013/04) The ACORD name and logo are registered marks of ACORD