The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #795-2017 - 16 FERRY STREET 2/23/2017 L t%O R TH �1 (dry BUILDING PERMIT o` s�Eo �6�% I" TOWN OF NORTH ANDOVER o� APPLICATION FOR PLAN EXAMINATION Permit No#: -\ ' ` Date Received �qSs CNUS��5 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION X � Print PROPERTY OWNER NCSM( � // - Print 100 Year Structure yes no MAP PARCEL:_ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid I Non- Residential ❑ New Building One family ddition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other j ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Waters hed'District. ❑ Water/Sewer DESCRIPTION OF WORK TO BE Pq ORMED: �( s ( ` V n ' Identification- Please Type or Print Clearly OWNER: Name: Phone:q •310 S I 1 � Address: �Q FLk1=0JJSk O1 V4 Contractor Name: Vu✓t C, aAi tc Phone: 3 E� • 3'J 13 3 Email: r cLb O►I\ Address: ► C1 3 1 iU� k-136 Supervisor's Construction License: HOZ Slo 2-- Exp. Date: GJ L S I Home Improvement License: Exp. Date: y e ARCHITECT/ENGINEER Phone: Address: Reg. No. x FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ Z ri`'( t .`1 9,) FEE: $ aq-- Check No.: 44Receipt No.: I r�;to NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location i No.--7q5 ' 1 --?UI- Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $� Check#' j �" Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning[Massage/Body 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 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 r Conservation Decision: Comments Vater& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ',FIRE � iD=EPAR_ aTMENTem'T Du mPi steraron sie 1Located atj�l4_ Main�Sf�eet r Fired ~t sig i' t epartmen�l �gnafurVIE R e; _ , NTS__ �COMME, ,. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name 3 P ---- { Doc.Building Pennit Revised 2014 1 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 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 4, 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 Doe:Building Permit Revised 2014 r 1 - NORTH t_ 6 : 1c . ve: � O .� y` � th ver, Mass o II"N. > > COCNtCNlWKK y7' S U BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT ........ .....Q � �� .... BUILDING INSPECTOR . ......... .... ........ .. .. .. . .... ........ ... .......,.. Foundation has permission to erect .......................... buildings on L� PW- 444 .. Rough to be occupied as ............ ��.'.'. ... . � �!!��...1�4.�►Ilk1!!*,..... Chimney provided that the person acceptingthis ermiTShall in eve respect conform to the terms of the application p � p pp 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 Service ................................................................................ Final BUILDING-INSPECTOR- GAS INSPECTOR rOccupancy 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. T a MSE Engineering sm al con ttrit ►ate!tration No 0106 1AA Cotrtro 11121glatratlon No 126979 RISE 60 Shwmut Road,Cantu,MA 0Z02t CF Contractor Re®latrion No820120 I ` 339-SOU335 FAX 339.501.045 CONTRACT 4 PROGRAM Page OMA-IBES anon °cur :a cuaroucti ;�, acaca7mma:tovr �:s aAte Nestor Matias (978)390-5194 �� WCUOaDEa 01/20/201"7 444'720 23902 a¢nvtcE atnxr b Ferry Street owlio stat:eT 16 merry Street e9MM CVMStATE,ZM North Andover,MA Oi845 � � ��cnr,mAT�� North Andover,MA 01845 JOB DESCRIPTION 13ARtt1BR:A D10a°er Door Test'will not be conducted at"'our homer due to the presence Of asbtxtos. Inc nl)d T(JBE I�iRIN'G HARRIER:The following contract is not valid unless accompanied by the Pre-Weathcrizatian!tattier S0.00 inccntivc farm,signed 5y yottr licenst;d electrician,t'latk will not prod>vith this xtnk until v receive a cagy of the faint. --...,._�..� Alk S ALING:Provide tahar and material is seal areas of Your ham a 50.00 performed in cortccn with the use of spccial toils and diagnostic rests to Imurc that Your home Will b ellcagcis work-will be wttlia healthful level of air exchange and imdaarair quality.Aiatcrials to he used In yauthome can include caulks,foams and olrcrgsroducts. Prim2e} areas for scaling include air 1 8e to attics basente�nts,allxitcd garages and Otho unheated erect(wiadoivi arc rwt f,encrolly addressed) This wilt require(8)working hours.A reduction in cubic feet per minute(crm)of air infdtration wS0 occu,but rhe actual number of cfm is not guaualca At the completion of the"cathrrization'York,and at no additiomaJ cost to the homeowner,a Garel blower door andtor combustion safctY MalYsis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. AIR SBALINO:Provide labor and rnnicrials to install !on weathetstri 5680.0(► Q PPing to(Z)door(s)to restrict air isakae, 0,'k4%l!v4lNrj:Provide labor and materiaU 10 install a 12"!flyer ofR-38 unfarvd tibtrgfus baits to(30)Square feet for dammine $116.00 purgc4m riT11C Pt+}7:Provide labor and materials to install a 9"layYr of R-33 Clrsa t Cellulose added to(448)square feet ofopen attict.St) space. S1.0PGS:Provide Irilsor and materials to install a 8 iayxx of R-26 Class 1 Ceflulosc added to(188)squaw feet of slope arra. 567:.90 r1J7'IC ACCESS:Provide labor and mratemats 10 insulate the back of(1)attic hatch with rigid board at R-10 or n cater with the $320.88 �..�..� rcyuircd fire rating.Weatherstrip the perimeter. rVE;'brrlLATl0,V.- NT[1 ATtOh1:Provide!abut and materials to install(4)8"diameter rrtnf vetn(s)to increase vcntilalion in attic areas. The S6o.6n st can be supplied in(circle color)black broom,gray or mill finish. Provide labor and materials to install ventilation chutes in(75)ratkr bays to maintain air flaw, S348.60 Si 87.51) Federal 10 p 0ti-0*M" RISE Engineering Rl Contractor Roghst lion No 8186 MA Contractor Rogistration No JM979 RISEC7 Cornrectar Ragiatratlorn Noti2042t1 EiJGlNtei:RING' GO Shasvmat Road,Canton,stlA 02021 Cr►V i� ! ��L� 339-5024)335 FAC 339-502-6345 Pago 2 PROGRAM RZTMEN f= CNIA-1lEgs S oMANOUeCWWMR F00%V01MM eEacaeam aujow CUSTOMER PHONIC BATE WSWa weatoRoaaa Nestor Matias (978)390-5194 01/202017 444720 23902 SERWn STREET GUM AIME, 16 Ferry Street 16 Ferry Street SOW,=CRY.ST,4MZ& 01MG cnr.araM tv North Andover,MA 01845 North Andover,MA 01845 JOB DESCRJPTION BASEMENT SILLS:Provide labor and materials to install(100)linear feet of R-19 unfaccd fiberglass insulation to the perinKW of the basement ceiling at the house sill. 5145.40 BASEMENT DOOR:Provide labor and materials to in ulale the back of ft bass rnent door leading to lbe buikh:ad with rigid baud at R-10 or greater v ith the required fire rating that meets the sections R-316.5.4 anti 316.6 requircmcats ofbuilding code. Seal,-III edges and seams with FSK tape. 5,110.00 RISE Engineering will apply all applicable,eligible inceolit s to this contract. You will only be billed the Net umoum. Cumxitly, for eligible mcasures,Columbia Lias offers 75%incentive,not to exceed 52,000 per calendar 3W,and an incentive of 10036 for the Air Scaling measures up to the fust 5680 and an additional$340 ifsavings are justifird by the auditor. For the safety and health of your homds indoor air quality,uv will be conducting a blower door diagnostic of the available air flow in your home bola before the work is begun,and atter the wcathcrination work is cornplete.We will also conduct a full assessment of the camhustion safety of your heating system and water heater.This has a value of 590 and is at no cost to you.Total allowable wcatheriration incentive is S3,110, The Permit will be secured by the insulation contractor,at no additional cOSL It is the ltmneownes nespansibility to close out this permit by contacting their municipality at the completion of this work RISE Engineering Federal iD#0ti-0405929 a Rt Contractor Reg nation No elso MA ContractorRaglytratton No 120979 RISCT Contractor Registration NO62o120 ENGINEERING' Gn Sh41VIO It ftftnd,COMM,MA 02021 �t '�` 339-502-6335 F"339-502-04S CO`�T C+1 PROGRAM Page 3 TWO a=ff MCT IS ENSREtt acro nsTVM gM E CMA-HU,s SVOsraEETatioAROXxEeuaToxsatF+Kt KAa CUSTOMM VIOM ORO£R FROME MTC CGE3Tr t Nestor Matins (978)390-5194 0!124/2017 444720 23902. EERY=MEET wWRO aTREET 16 Ferry Street 16 Ferry Street srmrcE cm,OrAT4zo LJl.IKO CITY,eXAT$�t North Andover,MA 0`1845 North Andover,MA 01845 JOB(DESCRIPTION $90.00 Total: $2,841.48 Program incentive: $$2,352.51 Customer Total: $08.87WE AG1tEE t?ti+L6'(1d7 FURtL51 Sr'RiPC£a-Ce°�1r L^cTc tH ACCen1TtJ10E t RTtt A90tT II?EClFiCATIe.'1$.Fen THE SUM 0;: *""Four Hundred Eighty-Eight&87/100 Dollam $488-87 UPOK FG'Ll:ptOPECTIOH ANDAPPROVkt 4YRk7E E::OP1EERp:a.C=rC3tCRAMiEEa TOREMT AMMIT DUEUIFUG„UM"ESTOF 1%Vj LOE GILIROCODUfIIRLX O:1 APR! WWX2 EAU=A.%1ER AYB.a:S RerE E TOit cvr=Allt V.10 m�,As>yw orn auAft&14 Es.FJOHTa OF REec�toar,acx�m sva.wn co»,ytcTOR REe s tusrae:. lr io0 NOT SIGN THIS CONTRACT IF THERE ARE ANY SLAM SPACES i ��t✓ a. AtrnrcItt mmUAE•Asee- UOTE:TRW C0!ABACTVAYDE 1:lU:t`:tA'.•^18Y UalF 48T F.AEGUTEO NasY.:R � { DATE OF ACCEPTAl:G£ n � -f •• 1 7”" �Q ACCEPTA=OF CMVIRACT.71MAAOVE PRICEa,'•F-cGF�ATt:.t:r ANTI COA'CR:D:ip AAe OAYa. DATISFACTMTO UDAMARE HERFOYACCEPTEO,YOUAR�AUTKORtIEU TO UO The WORK Aa SMOFMO.PATIZIM VGULSc VLADE A8 OUTG::®ADOV9 RISEeo Shr~Ref,unk2(tion,MA 0202113394MM4= ENGINEERING �► OWNER AUTHORIZATION FORM 1, N "SrOK mclriczc (Owner's Name) owner of the property located at: .! e s 01roterh► ) (Property Address) hereby authorize 1 r � r6(\ (Subcontractor) an authorized sutmonbactor for RISE Engines fng.to act on my behalf to obtain a bull ft permit and to perform work on my property.This form Is only valid with a signed contract: The Permit will be seamed by the Insutaton cordractor,at no addillwal cos. it Is the homeowner"s responeWly to doss out this permit by an bell ig their munkipallty at the completion of this work. jo fl e*— %^A Owner's ftneftffe Date s.�te The Commonwealth of Massachusetts Department of Industrial Accidents Oits of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers AnQ1,t a t Informattion ___._ P'Please .Print W&I Name (Business/Orgm izWon/Individual): GW1N%trJnS�J6_Ngr\ , \VA, Address: 130 -344 Ci /State/Zi : AW C N r 11A °13� Phone#: $ • S� 34 S 3 Are you an employert Check the appropriate box: Type of project(required): 1.M am a employer with 4. ® I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6 ®New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. [3 Remodeling ship and have no employees These sub-contractors have g, ®Demolition working for me in any capacity, employees and have workers' g. U Building addition [No workers' comp.insurance comp'msmance`l10. Electrical repairs or additions required.] 5. ® We are a corporation and its ® 3.® I am a homeowner doing all work officers have exercised their 11.®Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.[3 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compeasation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must 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. nn Insurance Company Name' "CQ dt 1 tk I My gmaG,l., Co Policy#or Self-ins.Lie.#: VL?_ 3130 3 Z3" Expiration Date: Job Site Address: �Q f�uttM City/State/Zip: Y v I V�N"Uri r 1 (e Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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. Ido hereby eert(fy under the pains and penalties of perjury that the ir4formadon provided above Is true and correct. Si&a '* L Date,• —r Phone#: 'V U 3 • 1 S ko° 3161 Qfflcial use only. Do not write in this area,to be completed by city or town official. lcial. City or Town: Permit/License# 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#: AC RO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMMIArf YY) `'� 1 10/18/2016 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 CONTACT- NAME: NTA TNAME: Meg Munroe MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE (413)536 0804 N,; pppglLF„ss: mmunroe@mjclayton.com 1649 NORTHAMPTON ST.,RTE 5 INSURERS AFFORDING COVERAGE NAICS 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: 94521 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 I TYPE OF INSURANCE A L UBR POLICY NUMBER POLICY EFF MPOMtLDICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR A�TZ_)RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY D PRO- ❑ LOC JECT PRODUCTS-COMP/OPAGG $ OTHER: AUTOMOBILE LIABILITY EOMBIa�NEBLIM D SINGLE IT s ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ Per accident UMBRELLA LIAR [7]OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION �/ AND EMPLOYERS'LIABILITY Y/N /� STATUTE ER" A OFFICER/MEMBEREXCLUDED?ANYPROPRIETOR/PARTNERIEXECUTIVE WA WA WA (Mandatory In NH) MAARP300327 10/30/2016 10/30/2017 E.L.EACH ACCIDENT $ 500,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 emptoyees oWly,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.govitwd/workers-compensation/investigations/. 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. 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 X_ Daniel M.CrO gley,CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD ACOORE0 CERTIFICATE OF LIABILITY INSURANCE DATE Z, M, �a 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 NAME:ONTAC Nancy Usher _ Martin J Clayton Insurance Agency, Inc. PHO E EM). (413)536-0804 1No):(413)534-7874 1649 Northampton Street E-MAIL ADDRESS: P. 0. Box 989 INSURER(S)AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'NSR �—A DL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER LIMnS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE D MA OCCUR DAG TO ENTE PREMISES Ea occurrencs $ 50,000 OL43487F 7/6/2016 7/6/2017 �MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY L, PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLELIMIT i$ (Ee acddentl ANY AUTO SCBODILY INJURY(Per person) $ ALL OWNED HEDULED — — AUTOS AUTOS BODILY INJURY(Per accident) $ I HIRED AUTOS AUTOS D PROPERTY DAMAGE $ Per accident _ X UMBRELLA LIAR OCCUR EXCESS LIAB EACH OCCURRENCE $ 11000,000 B _ CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION t36U028251970 10/18/2016 10/16/2017 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ( STAT UTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E'L' DISEASE-EA EMPLOYE $ H yes,descr ibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached It more space Is required) 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 1200 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD nary and logo are registered marks of ACORD PDMAMbd with OfFactory trial version www.pdff@ptqIyco_m com 4 - 1 Office of Consumer.Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachnsetts 02116 Home Improvement��r Registration Registration: 173410 Type: individual WWI= 10/1/2018 Tr# 291320 KURT GAUTHIER ----- KURT GAUTHIER 119 COUNTY ROAD IPSWICH, MA 01938 Update Address and return card.Mark reason for change. { ❑ Address Renewal ❑ Employment ❑ Lost Card 80A 1 4 20M401 on valid for individual only before the O[Oce of Coasnmer Aftsirs.4k Baau►eas pisiion expiration date. u found return to: HOME IMPRO ENT CONTRACTOR Registretlon� Office of Consumer Affairs and 3410 Type: OfBusiness Regulatioe ; Expirati 8 iruiivlduat 10 Park Plaza-Suite 5170 { '� Boston,MA 02116 (CURT GAUTHIER -r - KURT GAUTHIER 1 I c ae# Of t#r#ddtnujot 011 :t ri Starudat0s t-tiz�ti!4c�. SSL „t t1q?,Sa7 KIUIRT QGAMM" P(?ftx3" u ' tpswkb MA 0190 Gor!tmvtI44q ltt r' Q6i'ti'.i/.ZQt7 z I