Loading...
HomeMy WebLinkAboutBuilding Permit #257-2017 - 15 WRIGHT AVENUE 9/9/2016 m4 %10RTy BUILDING PERMIT aF�.�VED ,6�q•0 TOWN OF NORTH ANDOVER '`- APPLICATION FOR PLAN EXAMINATION 000 _ 70 1 " * Permit No#: > 11 Date Received `"0RAr gSSgCHU5��4 Date Issued: I PORTANT: Applicant must complete all items on this page 1 LOCATION 1 G\AT WL (� Print PROPERTY OWNER �71U_D ss-(:;) Print 100 Year Structure yes no MAP 10 PARCEL:&�3 ZONING DISTRICT: 76 Historic District yes n Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Add'tion El Two or more family El Industrial ❑A ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 WIelI ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: RE-y-'a4a L. Identific�}'on- Please Type or Print Clearly OWNER: Name: `D �yS Phone: l as b �7 Address: t `IST NO , J w2 Contractor Name: otj ���� cc`^��Qo Phone: Email: C O Ac\Ws_ C (f) \l A 14p _ CC) _. Address: M O1 c,— I \A %C o A.81 Supervisor's Construction License( S " Qj T? 3Y Exp. Date. a� ao Home Improvement License: \_7 k c(CIS Exp. Date: ►J ld o10 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: $ �J 0 'per FEE: $ Check No.: /�`I'� Receipt No.: 3687 NOTE: Persons contracting with unregistered contractors do not have ac esst guar ty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 1 TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ �i Well ❑ ❑ Tobacco Sales Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Diunpster on Site ❑ 1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS i 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 *FIRE DEPARaTMENT ,TE rnp Aster onsite:;.;yes, .� gno '.f t LocatedJat��12�4iIVlainrStreet , . � e�Depart hent signature/d COMMENTS, I I 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 p N® DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4 Building p Permit Application 4 Certified Surveyed Plot Plan 4 Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract i 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 prig-r 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 ° 4 Workers Comp Affidavit ,4. 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 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 Location ^� u No. -0/1- 7" U , Date ! �� • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ s Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# d Building Inspector NORTH q own Of t aAndover h ver, Mas A- C OCN CAA,... 7a A0 ArED 001V (5 7S U BOARD OF HEALTH Food/Kitchen PERM . IT LD Septic System THIS CERTIFIES THAT............ .............................�5.. ....................i ......................" BUILDING INSPECTOR 15 has permission to erect .......................... buildings on .. 0.11t . ,.... .6..e �l�R. Foundation • � Rough . . . *.I. to be occupied as ........ ..... ......... .... ................................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION Rough Service .. ..... ... ..... ................... ........ ....... Final BUILDIN NSPE TOR 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. Ronald Finocchiaro 187 Old Gage Hill Road Pelham, N.H 03076 Fred Russo 15 Wright Ave. No.Andover,Ma.01845 Bathroom Remodel Ron Finocchiaro is responsible for the following bathroom remodel at the address of 15 Wright Ave No.Andover Ma. The remodel consists of full demolition with no structural changes. The following is a job description of all work to be performed. Job Description A. Full demolition of bathroom walls and ceiling, flooring and fixtures. B. Bath tub stays with refinish at the end of job. By the homeowner. C. Bathroom existing window unit stays with new trim. D. Insulate exterior wall E. Install %"blue board with plaster finish smooth ready for paint. F. Install %" cement board to floor area for the install. G. Install %" cement board to tub area walls with rubber membrane. H. Install floor tile supplied by home owner and grout floor. I. Install (2) arched shelves into tub area for soap products. J. Install stone tile to tub walls with border glass tile. K. Seal stone tile with sealer. L. Install tub glass door unit supplied by home owner. i OP ID: LANK CERTIFICATE OF LIABILITY INSURANCE FD09/08ATE /2016Y) 09/08/2016 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). CONTACT PRODUCER Phone:978-688-6921 NAME: Macdonald&Pangione Insurance Fax:978-688-5350 PHONE FAX 104 Main Street WC, lc No Ext): AIC No North Andover,MA 01845 E-MAIL Michael Pangione PRODUCER CUSTOMER ID#:RONAL-6 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Ronald Finocchiaro INSURER A:Preferred Mutual Ins Co 15024 295 Merrimack St INSURER B:Safety Insurance Company Lawrence, MA 01843 INSURER C: INSURER D: 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 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 ADL SUB POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY BOP 0100 71 59 14 11/15/2015 11/15/2016 DAMAGE T RENTED PREMISES Ea occurrence $ 100,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JECT PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TDRY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F—] N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Evidence Of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Osgood St ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Continue M. Install new vanity and top supplied by home owner. N. Install vanity mirror and cabinet supplied by home owner. O. Install new closet door unit supplied by home owner. P. No work inside closet. Q. Install new base board along wall area 4-1/2" colonial. R. Install new 2-0 x6'8" masonite 6 panel RHswing door unit. S. Install towel bars and TY holder supplied by homeowner. Plumbing Segment P1. Disconnect existing plumbing fixtures. P2. Remove 5' section of heat unit. P3. Install new water supplies to vanity and toilet fixtures. P4. Install new tub valve. P5. Install new 5'section of heat unit with cover. P6. Install vanity fixtures,and hook up existing toilet unit. Electrical segment E1. Remove existing fanlight unit. E2. Move GFI outlet and relocate. E3. Install vanity light supplied by homeowner. E4. Install new fan/light unit vented. E5. Install new light fixture supplied by home owner. 10 All items listed above are in the total construction cost of$10,550.00 Any unforeseen or additional work is subject to a change order agreed by both the contractor and the home owner. Building permit cost is not in the contract and is additional charge. Payment schedule Bathroom remodel $109550.00 Deposit to start work $59375.00 Payment plastering segment $39175.00 Final payment on final inspection $2,000.00 eowner Ron Finogkhiaro D.B.A �x�s�INq W IN VU 3 FF �x�sTsN� TSG oINI Q oo w �t G 1�T AVL No �., ��� r'1A01%45 �" �q�t SCAA,(,V, The Common vealth ofMcsso,e- iusefts Department ofl adusirialAccidents 1 Congress Sheet,Suite 100 - Boston,MA.02114-2017 t www mass.g'OyfdZa Workers'CompensatiollJusurance"davit:Bwilders/ContractorsiBigctdeiaZts/Plwabers- TO BE Mn VTM TE PERTATTmrGAVMORUY. ApjLheanthformation. • Please Print iegal Name(Business/Organization/Indivtdnal): Address:— City/State/Zip: �4� �A,�• N 1a .(�;0.7( Phone#: . . Areyou an employer?checkf a apprlopriate box: Type of project(regmretl): 1.E]I am mployer itt employees(:M andlorpart-firne). 7. N coxistraction 24amasole propdetororparinershii andhavenoemployeesworkN9forme in 8. elnodelffig any capacity [Na workers'comp.insurance required] 9, El Demolition I R I am a homeowner doing all work m self[No workers'comp.dMoranca required.]' 10 Building addition 4.QIamahomeownerandwMbehi:ingcouraetorsfoconduct2llworkonmyproperi3r- Iwilt 11 xe airsor.adclitions ensure&at all contractors either have workers'compensation ir�,ranee or are sole L-1Electricalp proprietors wi$rno employees. 12:[(Plumbing repairs ox additions 5.FJ I am a general contractor and Ihave hired the sub-contactorslisted on the affached sheet. 13:Q Roof repairs These sub-contractorsliave employees andbaveworlters'comp-in�x -- • 14. Other 6.Q We are a corporation.pnd#q of yprs have exercisedfirek right of'mmption perMW,c. andwehaveno.empIoyees.WP workers,comp.insuranceregmred.] 'Any applicanttbat chad'ksbox-Al must also mil outthe seciionbelow showingtheirworkers'compensaiionpolicymfonnalion. iHomeowners-whosffid Iiiffairdavitindicafingtheyare doing all workaudthea re outside contractorsmustsiintanew affidav>Lmdicatingsuch_ tcontrartois,thatch5cLilLis:b' m' mu�st.$. MBP.Ta�dditional sheet showing the name of the sub-contractors and sate whether oznoLthose entities have employees. ifthe sub-coniradbrs have Employees,Ey must pravidet7ieir workers'comp.policy number. I curt art employer t1i at as pYo�iazg-pt'arket's'eampensadan insurance for Orly ernpl�yees'Below zs the policy acid job site infoirnatian. � Insurance Company Name: Policy or Self-ins.Iia.#: h ExpirationDate: Yob Site Address: Lb P,l V N • ry n-� City/,State/Zip: '6 • ©� .Attaciz a copy ofthev grkers' coon Mationpoj%i declaration page(showing thepolicynumber and expiration date). Failure to secure coverage as required under MGI.c. 152, §25A is a criminal violation punishable by a fine up to$1,50 0.00 and/or one-ye rdsomnant,as well as civil penalties i:a.the form of a STOP WORg ORDER and a line of up to$250-00 a day again e vio t or.A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage rificatio Ido here aepain randpenaities afpetjirq tfzat the infoxmafionpro>sided ba;� is/rue and co ect. Si afore: Date: Phone#: OfficiaZ arse onry. .po not-wwzte in this area,to be completed by city or town official I City or Town: Permit/License# Issuing AuthoritE -(circle one): i 1.Board of Health Z.BuffdingDepartment S.City/Town Clerk 4.Electrical Inspector 5.Plumbinglnspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 1.52 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 bf hire, express or implied,oral or written." Aro,employer is defned as"an individual,partaersllp,asso ciation,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiver-or trastee 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 anotherwho employs persons to do maintenance,construction or xepair 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 to cal licensing agency slaalz withhold the issuance or renewal of a license or permit to operate a brashness or to construct buildings in the commonwealth,for any applicant who lias not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any ofits political subdivisions shall- enter into any contract for the performance of public work unfit acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fzll•out the workers' compensation affidavit completely,by checkingthe boxes that apply to your situation and,if necessary, supplysub=contractors)name(s),address(es)and•phonenumber(s)alongwiththeir certi eate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)withno employees'otherthanthe members orpartaers,are notrequiredto canyworkers' compensationinsarance. If au LLC orILP doeshave employees,a policy is required. Be advised that this affdavitmay be submitted to the Department of•7n.dust dal Accidents for•confirmation ofh=ance coverage. Also be sure to sign and date the affidavit. Tlie 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'are reggpd to obtain a workers' compensatioil policy,please call the Department at the number listed below. Self-iissured companies should'enter their self-insurance license number on the appropriate line. City or Town Ofcials Please be sure that the affidavit is complete and printed legibly. The Department hasprovided 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 pmmit/license number which will be used as arefereace number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current poli6y information(if necessary)and under"lob 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 proof that a valid affidavit is on file for fntare permits or licenses. A new afidavit 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 (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department ofIadustdalAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617.727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ACO® r ATE(MM/DDIYYYY) C00 CERTIFICATE OF LIABILITY INSURANCE 09/08/2016 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(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 endorsement(s). PRODUCER CONTACT NAME: Kim Landry MACDONALD& PANGIONE INSURANCE AGENCY AICD No. o Ext: (978)688-6921 AAc No: E-MAIL @p'm In ADDRESS: Kim s.net 104 MAIN ST. INSURER(S)AFFORDING COVERAGE NAIC# NORTH ANDOVER MA 01845 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: RONALD FINOCCHIARO INSURER C: INSURER D: 187 OLD GAGE HILL ROAD INSURER E: PELHAM NH 03076 INSURER F: COVERAGES CERTIFICATE NUMBER: 83328 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 ADDL SUBR POLICY EFF POLICY EXP LTR POLICYNUMBER MM/DDIYYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY 0 PRO- JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ ,rTDED I I RETENTION$ r $ WORKERS COMPENSATION X PER STATUTE ORH AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? I NIA1 NIA NIA AWC40070343902016A 04/08/2016 04/08/2017 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be 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 daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. 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. Osgood St AUTHORIZED REPRESENTATIVE -� ' C ts`D North Andover MA 01845 t J` Daniel M.Cr oi ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts -b partrhent:of Publi&.Safety 4:, Burd cf.Buil4ing Regulations and Standards`. C nstructibn Superiijur Y u License: CS-07734$ f RONALWE FINof!C IUAR 295 MERRIMACK S7"' � Lawrence MA 01$43 i 4 � 11 y✓ jJ .; `1 Wyk i 'Expiration Come issioner.. 07/23/2016' a C��e eco-�7�r»noz�aecc�� a�C� a�iac�c�te�� License or registration valid for individual use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation n: — Registratio ' 171995 Type: 10 Park Plaza=Suite 5170 fir Expirations -,5/j-(:(/-2a-1_8 Individual Boston,MA 02116 RONALD FINOCCHIAROAt RONALD FINOCCHIARQ { 187 OLD GAGE HILL R{1 — '� PELHAM, NH 03076Undersecretary Not valid without signature i 9/8/2016 Details The Official Website of the Executive Office of Public Safety and Security(EOPSS) Mass.Gov Home State Agencies uemotgraphic Information Full Name: RONALD E FINOCCHIARO, JR Owner Name: ip ucenseAaaress inTormation City: Pelham State: NH ipcode: 03076 IC,oLintry: Urted, tates icense inTormation License No: CS-077344 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 7/26/2016 Issue Date: Expiration Date: 7/23/2018 License Status: Active Today's Date: 9/8/2016 Secondary License Type: Doing Business As: atus Change Reasory IP License ftiewal rerequisi a inTormation No Prerequisite Information Close Window © 2011 Commonwealth of Massachusetts Site Policies Contact Us i http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license_id=266294& 1/1