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HomeMy WebLinkAboutBuilding Permit #768-16 - 1520 Forest Street 1/4/2016I 7(� Permit No Date Issued: / BUILDING PERMIT TOWN OF NORTH ANDOVER. APPLICATION FOR PLAN EXAMINATION'. Date Received RTANT: Applicant must complete all items onAhis FiirnC'­'a- 4- 0 v .vim\ 3� y� LOCATION r FC'1 man C l s PROPERTY OWNER _ Print 100 Year Structure, yes no MAP �d PARCELC�ej_ ZONING DISTRICT: Historic District yes no Machine Shop Village ,yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ' Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 11 Well ❑ Floodplain ❑ Wetlands [I Watershed' District Water/Sewer DESCRIPTION i �� L ��� 0 0 A I n It s �_ OWNER: Name:( Address: I 6D, D K TO: BE PERFORMED: n Print Clearly Phone. Contractor NameXMPPhone: ��U�J VVV -7 Address,5In� (&rK M n� � r In m D50< '` Supervisor's Construction License. C J - )q ubb(p Exp. Date:.,. Home -Improvement License: 51-1 z4-73_Exp. ....�. - ARCHITECT/ENGINEER Phoney ; V. Address: Reg.: No. FEE SCHEDULE: BULDING P IT: $12.00 PER $1000.00 OF THE TOTAL ESTIMA TEU COST BASED ON $925.00 PER S.F. Total Project Cost: FEE: Check No.: l (� 7 .� Receipt No:.:::._ NOTE: Persons contracting with unregistered contractors do not havewcess o toVaranbju Location Na fF� /� Date•— TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ' Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming 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 COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Signature Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r, Planning Board Decision: J Conservation Decision: Comments Comments a Water & Sewer Con neCtion/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locatea 364ysgooa -street ,FIRE DEPARTMENT - Tern'p bumpster on, site yes Located at 1241Main•Street Fire Department signature/date 'COMMENT Dimension Number of Stories: Total square feet of floor area, based on ''xterior 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 DA I A — (t -or department use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Perinit 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 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) o 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) VBuilding 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 o 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 Client#: 1076769 FENCEUNL1 ACORDTM CERTIFICATE OF LIABILITY INSURANCE M/DDN 1/04DATE (M1/0412016 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 USI Insurance Services LLCONE 3 Executive Park Drive, Suite 300 Bedford, NH 03110 855 874-0123 CONTACT NAME: g55 874-0123 FAX PIC, No, Ext : AIC, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Safety First Insurance Company 11123 INSURED The Stove Shoppe The Commons, 25 Indian Rock Rd., Route 111 INSURER B : INSURER C INSURER D PERSONAL & ADV INJURY $ Windham, NH 03087 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR EACH OCCURRENCE $ PREMISES (ERENTED occccu ence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY JECT LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident _ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A AND EMPLOYERS' LIABILITY WORKERS COMPENSATION ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? FN—] (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A X FPP4050457-MA 8r CT 1/01/2016 01/01/201 X PSTATUTE ER OTH- E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Waiver of Our Right to Recover from Others Endorsement per form WC 00 03 13 is attached to the policy. GBJ4JRil Town of North Andover, MA 120 Main Street North Andover, MA 01845 ACORD 25 (2014/01) 1 Of 1 #S17009823/Ml6828479 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SCLCA Deems, Maura From: Stove Shoppe <info@stoveshoppe.com> Sent: Tuesday, January 19, 2016 11:02 AM To: Deems, Maura Subject: permit cancellation Good morning! Our customer Joe Francis located at 1520 Forest St. Ext in North Andover, MA has cancelled his order. We are no longer installing his HST Clydesdale wood insert and wish to have the permit pulled by us ca shelled. The customer is aware that if he chooses to go forward with another contractor, they must obtain a new permit. Permit # 768-2016 Thank you! Kendra Walsh Scheduling Coordinator Fences Unlimited & The Stove Shoppe 25 Indian Rock Rd Windham, NH 03087 603-537-0555 x 15 iR CA: r L J uj Z u. O co L u Y O 0Q7 LL E a0+ v In CL N N z z m O O A-+ c6 3 O LL do 7 O d' T aJ E .c U c0 C LL O N z Z mCA J d j O d' t0 c LL O N z V W J W t4Y = O CC • j> 0) (n m c LL 4 O a Z 7 O OC M O LL z uj a W 0 W LL i O m Q z d 4z In v O. N rrwwn V1 o • �. t6 O V J r a m r <v W �• .6- o r= 16.y+ u < �• o Q r vQ `i C cu M � tNG° 10ccE y J � � N = o o tm o� 0 •0 E � o c o - Noc ami . cr- CLIO as _ � m 0 O U) 1c c __ L cc 'a 0 C o O O N N N0CC LJLJ m W O •a +�•+ O O " M Li •� .Q w C O VE C L O O. Q �7 N N) -0 •0 = 0 9 W O o 0 Z � CD 0 � ' O '- 0 N m CL t O �+ v O `�oCL a CL 0)a o c �CL O a) = Z O V N C CL U) 0 O` r a Cl) Z 0 m y/ Z coo Z V W a Z w O �L) �w LU 9 W O o 0 Z � CD 0 � ' O '- 0 N m CL t O �+ v O `�oCL a CL 0)a o c �CL O a) = Z O V N C CL U) 0 S A L E S O R D E R THE STOVE SHOPPE 25 INDIAN ROCK ROAD, ROUTE 11 WINDHAM, NH 03087 Phone #: (603)537-0555 Fax #: (603)537-0556 BILL TO 135646 Joesph Francis 1520 Forest St Ext North Andover, MA 01845 PHONE #: (978)660-6234 CELL #: ALT. #: P.O.#: TERMS: Cash SALES TYPE: Work Order TAG #: DATE: 12/11/2015 ORDER #: 27232 CUSTOMER #: 135646 CP: Steve B LOCATION: 1 STATUS: Pending TECH: Mario B SHIP TO Joesph Francis 1520 Forest St Ext North Andover, MA 01845 PAGE: 1 YEAR I MFR I MODEL NUMBER DESCRIPTION VIN/SERIAL # MILEAGE/METER 1: INSTALL CLYDESDALE Tech: Steve B [ ] MFR PRODUCT NUMBER DESCRIPTION ORD SOLD B/O PRICE NET TOTAL HST 8491-0020 CLYDESDALE 8491 WOOD 1 0 $3,999.00 $3,999.00 $3,999.00 INSERT -BROWN ENAME S/N: 12304 **** HST SALE HearthStone Sale 1 0 ($300.00) ($300.00) ($300.00) **** LAB25 Install Wood Insert w/ Full 1 0 $0.00 $0.00 $0.00 Liner LAB LABOR COST 6 Labor Cost for Install 1 0 $660.00 $660.00 $660.00 NEC L6351K-R6 6" X 35' Liner, Insert Kit 316 1 0 $981.53 $981.53 $981.53 SS, 30 Degree Offset w/ A Typ ROC 6DP Damper Plate 6" 1 0 $44.95 $44.95 $44.95 RUT 76C Silicon CLEAR High 1 0 $13.50 $13.50 $13.50 Heat10.3oz Cartridge LAB note 1 0 $0.00 $0.00 $0.00 ********NOTE********** LAB NOTE 1 These parts represent a 1 0 $0.00 $0.00 $0.00 typical install LAB NOTE 2 However other parts may be 1 0 $0.00 $0.00 $0.00 require. PER Permit Permit & Processing Fee 1 0 $125.00 $125.00 $125.00 **** CUSTOMER PICK-UP CUSTOMER PICK-UP 1 0 $0.00 $0.00 $0.00 ****NO SALES TAX**** Parts Job 1: $5,523.98 Subtotal Job 1: $5,523.98 Thank you for your business! All material must be paid in full at time of pick up or delivery Please note that if you are using our installation services all materials and labor must be paid in full at time of installation. If the installation takes more than 1 visit $250 may be withheld until the job is complete. TOTAL PARTS: $5,523.98 TOTAL LABOR: $0.00 TOTAL EXTRAS: $0.00 SUBTOTAL: $5,523.98 TAX: $0.00 ORDER TOTAL: $5,523.98 12/11/2015 PMT VISA: 160365 $1,000.00 BALANCE REMAINING: $4,523.98 S A L E S O R D E R PAGE:2 THE STOVE SHOPPE 25 INDIAN ROCK ROAD, ROUTE 11 WINDHAM, NH 03087 Phone #: (603)537-0555 Fax #: (603)537-0556 Picked Up By: PHONE #: (978)660-6234 CELL #: ALT. #: P.O.#: TERMS: Cash SALES TYPE: Work Order TAG #: DATE: 12/111/2015 ORDER #: 27232 CUSTOMER #: 135646 CP: Steve B LOCATION: 1 STATUS: Pending TECH: Mario B Pmt VISA AUTH #: 160365 XXXX-XXXX-XXXX-0425 Credit $1,000.00 SIGN X BUYER AGREES TO PAY TOTAL AMOUNT ABOVE ACCORDING TO CARDHOLDER'S AGREEMENT WITH ISSUER L. c s, o =t 0 S N C fl' � O Q � nj °i ac 9� nc aj rt N O n� a � pasul a:)eldaii j pUelpoll 83 Oss :) In}o f T fD ou n M tA n) r -h yM-11OF mD,,,p2Zv+n 9 I Z 9,>, D n 2 m zo"o' a513v+�o do 'a 'a z_Om3CC 55'&=— *m y ay Do ZZ�CAO mono zomm m-WTZ�n a0CAnO psi 5d ��DODOG m T Q= 0 m C-0 W Z q TH a 11 X--JmOT -_ z m T. 0 700 '<mmm-v T � G m m Nq w A or; k> ' 00-o -'0 dx= dnnD 3 1 W Wa �n?* O ° ° 1 n„Sl � 3 S— ° Tnnwxw @= i^ vC:$714� 4w � G N< W d w >nocr > 7 O w `c G d J dQS N 3 d n o (� " o n '- N D ao�n F w o3: O n �' d°o��. o n o A O n[ N p d d io iii Dam z n N W 7 M N 7 d °p S '3 0 3 y A A .% W o�Da A 3 O C O O p O' w A 7 A N O N N O-� '^ C O j l -n' n a n `� <3; -0 v �D d `° 03. a 3 8+ n 01? rnoo 3 ' c 3 v° x » _. �e z N N rD o c Di -M 3 o o w ' - o - o 3: rmx 33 11'} 'i c° o c o c c '. w N N N � O W ooJ v' rnv�v+AA w N OHO OOJJJ o+ v. v�v,A d �! 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Ncnz a �- n^ 000j 030 ;° - �» ocG �m The Commonwealth ofMassccchusetts Department of IndUstrialAccidents N I Congress Street, Suite 100 _ Boston, MA 02114-2017 www mass.go v/dia Workers' Compensation insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH TRE PERMITTING AUTHOMY. Please Print Legib rl Applicant Information A iA Name (Business/Organ`izationftdividual): it I Address: -7 0?0�"T- Phone#: �Cr 3) V p �3 city/State Are you an employer? Chec the appropriate box: Type of project (Tq%aired): eIo full and/or part-time).4' m ees am a employer with p Y ( `l. 0 New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. [] Remo delirig any capacity. [No workers' comp. insurance required.] 9, ❑ Demolition IF] I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 ❑ Building addition 4. [JI am a homeowner and will be hiring contractors to conduct all work on my property. Iwill that all contractors either have workers compensation insurance or are sole 11 [] Electrical repairs or additions ensure _...., _ . - ... proprietors with rio eiilployees:- 12. [] 1Rlumbing repass -or additions._ _ -- 5. ❑ I am a general contractor and I have hired the sub-cointractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 13, E] Roof repairs 14.V�Other ia { 14169 -4 6.E] We are a corporation and ifs offeers have exercised their right o£ exemption per MGT", c. comp. insurance required.] 152, § 1(4), and we have no, employees. [No workers' *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 - t that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, tliey rinust provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information.— Insurance Company Name: Policy # or Self ins, Lic. #: ('1�! 6-00 0 3'2- ExpirationDate Job Site Address: 15 �L Q aCity/State/Zip: /fir v declaration page (showing the policy number and expiration date). Attach a copy of the workers' compensation policy 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 ciyamenalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the viola. A copy of this ss emen , maybe forwarded to the Office of Investigations of the DIA for insurance I do hereby c ify err a d p alt s ofper jury that the information provided above is true and correct. p I, Si nature: 2 Date- 1 `I Phone ff: Official use only..Do not write in this area, to be completed by city or town official. City or Town: Permit/License V Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: /DATE A� " CERTIFICATE OF LIABILITY INSURANCE (MMIDDIYYYY) 12/11/2015 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(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 FIAI/Cross Insurancef�ON 1100 Elm Street Manchester NH 03101 CONTACT g NAME: Judith George CIC,CPIA,CPIW o EM. (603) 669-3218 AIC No; (603)645-4331 E-MAIL eor a@crossa enc com ADDRESS: Jg g g Y INSURERS AFFORDING COVERAGE NAIC # INSURERA:Continental Western Ins Co INSURED Fences Unlimited, Inc. Mis-Bec of NH, Inc. dba The Stove Shoppe The Commons at Windham 25 Indian Rock Road, Suite 19 Windham NH 03087 INSURERB:Union Ins Co dba Berkley Property & INSURERC:Granite State WC Manufacturer's INSURER D: INSURER E: INSURER F : C()VFRAnl7R CERTIFICATE NI)MRFR-16-17 All- NH WC RF_VISION NIJMRER- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FxI OCCUR CPA0311123-15 1/1/2016 1/1/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 250,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JPRCOT I LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 AI-Owner/Lessee/Contractor-A $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS NON -OWNED HIRED AUTOS AUTOS CAA0311124-16 1/1/2016 1/1/2017 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ Pea PERTDAMAGE Uninsured motorist property $ 25,000 A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CUA0311125-16 1/1/2016 1/1/2017 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED RETENTION$ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N� (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC012014000032 (3a.) NH All officers included 1/1/2016 1/1/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE_- POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) %,MM I IrIk A I r r1VLLlCK GANGtLI A I IVIV For Informational Purposes Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE J George CIC,CPIA,CPI q ' ' ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 /?m4n1t gl!- _62 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration MIS -BEC OF N.H. INC. KEN SZYMANSKY 25 INDIAN ROCK RD. SUITE 19 WINDHAM, NH 03087 )PS-CA1 0 50M -04/04-G101216 ✓{2C U/ O'It7/II2092cI/PQ�Gl2 O�ii (�LQb6Q�LCCdP.�6 Off, ce of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR >_ Registration:,; ---15,447$ Type: Expiration 311412017 Private Corporation, MIS -BEC OF N H INC KEN SZYMANSKY' 25 INDIAN ROCK 1213 WINDHAM, NH 03087 Undersecretary t' 0 State of N GAS FITTERS", P ? NAME: KENNET'. Z ENDORSEMENTS HST DATE ISSUED: 01/09/2014 EXPIRES: 02/29/2016 mpshire LICENSE # G F0700998 Registration: 154473 Type: Private Corporation Expiration: 3/14/2017 Tr# 262169 Update Address and return card. Mark reason for change. Address ❑ Renewal 0 Employment [-J Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS -096606 ,.- r r S 4V KEN T SZYMANS�Ky 27 TICKLEFANCY r SALEM NH 03079 Y Expiration Commissioner 02/25/2016