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HomeMy WebLinkAboutBuilding Permit #168-2017 - 166 HIGH STREET 8/18/2017 f r BUILDING PERMIT O� taoRr► V �q 1` TOWN OF NORTH ANDOVER �2 y� •6 APPLICATION FOR PLAN EXAMINATION K Permit No#: xm Date Received �4TEDPIPDate Issued: TANT: Applicant must complete all items on this page LOCATIOJ I fjS N56 P r T Print PROPERTY OWNER m()e7hA!'7 Print 100 Year Structure yes no MAP�PARCEL:�� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement - ❑Assessory Bldg ❑ Others: ❑ Demolition 0 Other _-_ a p Septic ll.',r �`.,.❑F oo� �ain�` ®kWe a n []' -0 shed® ,� Water istnct� - DESCRIPTION OF WC?RK TO BE P RFORMED: _ lZJ$gv� C > Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: rc5�oy5o . Contractpr Name:A C'tr -A doh`-T Phone: Email: 4E7 Address: IYD-�b�S �� �.0��� �ZS�r N/t Supervisor's Construction License: Exp. Date: Cf �i1 �l 'T 5/5 � Home Improvement License: � � 1 � Exp. Date: -7 ARCHITECT/ENGINEER Phone: - Address: b Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ L /o 1 /� FEE: $ Check No.: Receipt No.: � 1� I sl NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund • i j I 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 If Applicable) Hydraulic Calculations ( pp ) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. one copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 r' Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ F F SEWERAGE DISPOSAL ewer ❑ Swirn,ni„ Pools ❑ , Tannang/MassageBody Art ❑ g❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ PermanentDumpster on Site ❑ F THE FOLLOWING SECTIONS.:FOR"OFFICE.USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS WEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:.Variance, Petition No: ' Zoning Decision/receipt submitted yes I r Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: ,FIfZE�DE.P.g• Located �.384 Osgood Street n-site�,lye eR¢TMEoVTrTes 4Located jLi;!24 MaiS ., Frey®ep�artmenf4signaure/date �� t w' <, ".� • •} ,, rpt • , .� c s�` �t '-k� "� :�. ��""`-P--��-tea-�� �^--.-� - �,�".�� ? *COMMENT x � i1 Dimension 1 Number of Stories:es: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I ELECTRICAL: Movement of Meter location, mast or service droprequires Electrical Inspector yesq approval of No DANGER ZONE LITERATURE: yes No MGL Chapter 166 Section M—F and G min.$1oo-$1000 fine NOTES and DATA— (For department use) I LI i I A i { I Notified for pickup Call Email I Date Time Contact Name Doc-Building Permit Revised 2014 Location No. — Dateg f • - TOWN OF NORTH ANDOVER ' Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ � Check#�I `'J``q 30747 Building Inspector NORTfy Town q 2 t 6 ndover p oh ver, Mass, !w coc"CNIWrcK y7' W 40_0 �d A�RATEO NP���S S U BOARD OF HEALTH T D Food/Kitchen Septic System THIS CERTIFIES THAT MjDTI -a......�ks � %., ,U. q* ............................... BUILDING INSPECTOR ' Foundationhas permission to erect ....................... .. buildings on .......�.(9744 .. .... Rough to be occupied as ...... l .. .�..... i ...A&F .kftll.t.. Chimney provided that the person accepting this ermi shall in eve respect conform to the terms of the a ication p p p g p p Final on file in this office, and to the provisions of the Codes and By-Laws relating jothe spect' n, Alteration and Construction of Buildings in the Town of North Andover. QAV" (' PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR.- UNLESS NSPECTOR.UNLESS CONST TI Rough Service . ... .. . .. .... . . .. ...... ................ Final BUI ING INSPECTOR 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. I Ln le. pp Con�f�` kction I/We,the owner(s)of the premises mentioned below,hereby contract with and authorize as contractor,to furnish all necessary materials and labor,to install;construct and place the improvements according to the following specifications, terms and conditions,on the premises described below: Owners: David Mushaty Phone: Address: 168 High Street,North Andover,MA 08145 Contractor Information: Apple Wood Construction Inc,64 Noyes Rd,Londonderry,NH 03053 FED ID#45-2837711 HIC#181805 Contractor ID#CS87691 Part I Description Apple Wood Construction,Inc.,will: See attached estimate dated: 5/17/2016 For the above or attached specifications the undersigned agrees to pay the sum of $10,945.00 The Customer agrees to make payment in accordance with the schedule of payment as follows: Deposit on signing agreement $500.00 'Cl a 1 V Start of work $2000.00 Delivery of materials $2500.00 Start of roof $3000.00 Start of decking and railing $1000.00 Upon substantial completion of project $1945.00 Part II Proposed start date:approximately two weeks after issuance of town permits. Proposed end date:Approximately 3-6 months after start of work. Contractor is not responsible for delay,damage or inability to cavy on the work caused by or resulting from strikes, blackouts,fires,accidents,lack of material or any other cause beyond the control of the contractor either before or after the delivery of the material and equipment at the said premises. The contractor is to be permitted to proceed with the specified work without interruption and hereby authorized to do such work as in his opinion is necessary to complete this contract.Plans may need to be altered slightly during construction phase at the contractors discretion. The contractor and/or subcontractors will not enter the house if there are minors present without someone over 18 present with them, INITir'i s.-&[d Londonderry,New Hampshire 603-432-8599 www.applewoodconstruction.net Y' pplA:�k o�od4 Constrlrcti�on Part III This agreement shall become binding only upon the contractor's written acceptance here of or upon the contractor's commencing performance. You may cancel this agreement if it has been consummated by a party there to at a place other than the address of the seller,which may be his main office or branch office by ordinary mail,by telegram or by delivery,not later than midnight of the third business dad following the signing of.this agreement-in-accordance•with----------- - --- _ _ _. MGL c 93 s 48;MGL c 140D s 16 oz MGL c 255D s. Parc 1V The contractor will do all such work in a work-man-like manner. In the event of discovery of hidden damage,it will be charged in a cost plus manner,labor,plus material,plus twenty percent(20016). This amount is due immediately upon completion. The owner(s)agree that in the event of cancellation of this contract before work is started,the owner(s)shall pay to the contractor,on demand,twenty-five(25%)of the contract price plus any material that may have been ordered as it's stipulated damages. Part V The owners)will bear the burden of any penalties or fees associated with delays or litigation necessary to complete this contract and collection of all monies due. Delay in payment of any portion of this contract shall be subject to interest charges of eighteen percent(186/6)per annum. There are no other agreements,understandings,representation or warranties,verbal or otherwise,expressed or implied, which are not contained herein. All additional work and/or materials requested by the owner(s)must be paid immediately. Part VI All home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed tc: Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5170 - Boston,MA 02116 617-973-8700 Part VII x-111 work is watranded for one year after completion date. The contractor reserves the rights to take before and after pictures of the project for use on contractors own website for informational purposes only. INI'ITAI.S:_0CA-.. Londonderry,New Hampshire 603432-8599 www.appiewoodconstruction.net L ppl+eoodk i Constrirti'Ori Part VIII PERMIT NOTICE: a. Any and all necessary construction related permits are the contractors obligation to obtain. b. If an owner secures their own construction related permit or deals with unregistered contractors they shall be excluded from access to the Guarantee Fund. c. Owner must wait for all inspections. If contractor waits for inspections additional charges of$55.00 per hour will apply- Part VM1 This contract is subject to the approval of the General Manager. In Witness whereof,the parties have here unto placed their-hands and seal this day of ::S-OAP— 2016. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. David Mushaty Leon 3antosuosso III,General Manager Date: Dat Londonderry,New Hampshire 603-432-8599 FAipl =' 06d. Gonstr -C on May 17,2016 David Mushaty 168 High Street North Andover,MA 08145 ESTIMATE DECK RENOVATION L Draw:plans needed for approvals. NOTE: If stamped plans are required additional charges will apply. 2. An allowance of$150.00 is included to obtain town permits. 3. Removal of existing: a. Railing b. Decking C. Posts d. Roofing, 4. inspect area—if rot or damage is found additional charges will apply. S. Supply and install five new pressure treated posts. 6. Supply and install YC pressure treated decking under roof 7. Supply and install new rubber roofing to roof and flash as best we can. 8. Supply pressure treated materials and build deck frame 9. Supply and install Aaek standard color decking to new frame 10. Supply and install white vinyl sleeves over posts with caps 11. Supply and install white vinyl railing 12. Supply and install white synthetic boards(triangles)where missing on existing stairs. 13. Removal of all trash due to construction project. TOTAL $10,550.00 NOTES: 1. if inspector makes Us go up and over what is listed above additional:charges will apply. 2. If lead paint is present additional charges will apply to remove. 1 ) Page PpAe' o©cl Construction ESTIMATE SIDE DECK RENOVATION is Supply and install new joists behind stair supports 2. .Supply and install new support if needed 3. Supply and install joist hangerswhere needed TOTAL $395:00 QUOTE VAUD`FOR 30 DAYS i St/A// - 2a. x ENTIRE FIRST FLOOR: • BIG BEAD OF CAULKING BETWEEN CEILING AND WALL WHERE NEEDED-CUT IN WITH BROWN i PAINT • SAND ALL PATCHES AND TOUCH UP WALL PAINT KITCHEN: • FINISH FLOOR • BASEBOARD-NAIL/CAULK/PAINT • ELECTRIC FOR STOVE-SCREW DOWN AND INSTALL-MAKE SURE THERE IS 1%" BETWEEN BOTTOM OF GLASS AND TOP OF CABINETS • INSTALL TOE KICK • IF YOU FEEL CONFIDENT INSTALL REFRIGERATOR PANEL AND CROWN MOLDING • HANDLES/KNOBS: o DOORS-KNOBS-3" UP OR DOWN-CENTERED IN STILE o DRAWERS-HANDLES-CENTER IN MIDDLE OF DRAWER • ADJUST DOORS • INSTALL THRESHOLD IN HALLWAY BETWEEN KITCHEN/FAMILY ROOM FAMILY ROOM: • PAINT BASEBOARD • TOUCH-UP TRIM PAINT WHERE NEEDED • PAINT BIFOLD DOORS FIRST FLOOR BATHROOM: • SECOND COAT WALLS • PAINT BASEBOARD • PAINT DOOR • INSTALL LOCKING HANDLE ON DOOR ENTIRE SECOND FLOOR: • BIG BEAD OF CAULKING BETWEEN CEILING AND WALL WHERE NEEDED-CUT IN WITH BROWN PAINT • SAND ALL PATCHES AND TOUCH UP WALL PAINT SECOND FLOOR BATHROOM: • PUT SHELVES IN CLOSET BEHIND TUB y MASTER: • SAND/PAINT LAUNDRY ROOM • LEVELASTIC FLOOR-BOTH SIDES IF NEEDED IN HALLWAY • DUMMY KNOB ON STORAGE AREA MASTER BATHROOM: • SAND/PAINT TOUCH UP AS NEEDED • RE-INSTALL COUNTER-DON'T HOOK-UP PLUMBING i f BASEMENT: • PAINT DRYWALL IN STAIRWAY • TRY TO CLEAN SOOT • FIX CEILING TILES BASEMENT BATHROOM: • DRILL OUT DUCTWORK AND DUCT OUTSIDE • REPLACE CEILING TILES I� The Commonwealth of Massachusetts F Department oflnclastrialAccidents Meet Congress Sheet,SUUe 100 ` d Boston,MA 02114--2017 .s w�vwrnassgov/clic SY Workers,Compensation insurance Af�.davit:Builders/Contractors/ElectxacianstTlwnbers. TO BE MED WITH THE PHRM[TTIlYG AUTHORITY. A licantXnformation • Please Print Le ' 1 Name(Business/Organization/Individual):i Address: t , city/state/zip:1 6 O� Phone#: � J �'l�J�= c Areyou an employer?Checktlie appiropriate box: Type of project{req red): dia-m.aemployervvithA=employees(full and/or part-time).* 7.• Q New co7istruction 2.Q I am a sole proprletor or partnership and have no employees working forme in 8. 4<emo delitig 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 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs ox.additions propzietors with no employees. 11 plumbing repairs or additions 5.❑I am ageneral contractor and Ihave hiredthe sub-contractors listed onthe attached sheet. 13.'[]Rooff rep airs These sub-contractorshave employees andhaveworkers'comp.insurance.1 6.0 We are a corporation pad ip of�cers have exercised their right ofexemption per MGL c. 14.[]Other 15%§1(4),an4weha9eno.,epiployees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must alsofill out the section below showing their workers'compensation policy information. i Homeowners who snbi iittbz 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 state whether or not those entities have employees. If the sub-contractors have employees, ey must provide their workers'comp.policy number. I am an employer that ispiovidingworkers'compensation insuranceforr my employees'Belo-ly is thepolicy andyob site information. Insurance Company Name: ` Policy#or S elf-ins.lio.#: fn)Cr:R. ion � G Expiration Date: 1 Job Site Address: City/State/Zip. ff � "` Attach a copy of the workers' compolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 ofup to$250.00 a day against the violator.A.copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification.. I do hereby certify under the pains and penalties ofpeiJu y Haat the informationprovided alcove is true and correct. Signature: Date: Phone#-- Official use only. Do not write in this area,to he completed by city or town officiax City or Town: Permit/License# Issuing Authority(circle one): 1.Board of$ealtla 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information. and Instructions � Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their eippr oyees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contra6t bf hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enf6rprise,and including the legal representatives of a deceased employer,or the receiver-or trustee of an individual,partnership,association or other legal entity,employing empl6gees. 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 another who employs persons to do maintenance,construction or repair 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 local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonN�ealth 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 of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out-the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub'corrtractor(s)name(s),address(es)and-phonenumber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees'other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of•Industrial Accidents fbi confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. The 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 required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-iin'sured companies should'enter their• self-insurance license number on the appropriate line. -' City or Town.Officials Please be sure that the affidavit is complete and printed legibly. The Department has-provided 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 permit/license number which will be used as areference number. In addition,an applicant that must submit multiple perp it/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job 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 future permits or licenses. A new affidavit 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts - Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1.877-AIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia =rom:Sandy Gargano FaxID:Santo Insruance Page 2 of 2 Date:8/17/2016 07:53 AM Page:2 of 2 APPLE-2 OP ID: SG DATE CERTIFICATE OF LIABILITY INSURANCE 70811712016 Y 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: .Jason M Mlocek Planright Insurance-Salem PHONE 603-890-6439 a,c No): 603-890-6521 224 Main Street Suite 3C (AIC' Alc No Ext Salem,NH 03079 A DRESS:jason@santoinsurance.com Jason M Mlocek INSURER(S)AFFORDING COVERAGE NAIC A INSURERA:Ohio Security Insurance Co 24082 INSURED Apple Wood Construction Inc INSURER B:Peerless Insurance Company 24198 Leonard Santosuosso 64 Noyes Road INSURER C Londonderry;NH 03053 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 POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMIDDIYYYY MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGICLAIMS-MADE F3(1OCCUR BKS56069602 07/24/2016 07/24/2017 PREMISESOEaoccurrence $ 300,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY a JjECT a LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY O aBINEDtSINGLE LIMIT $ 500,000 B ANY AUTO BA7025198 07/24/2016 07/24/2017 BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIR ED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONX PER O H- AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC7025199 07/24/2016 07/24/2017 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? Y❑ N I A (Mandatory in NH) 3A: MA NH E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Leonard Santosuosso&Lisa Santosuosso are excluded from work comp coverage RE: 168 High St, North Andover, MA 01845 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. 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTA�TIIVVE, 9 / ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD uhclad } � Massachusetts Department of Public Safety ^.� ae ao��nu�ae,�aeal(/z-cc�/T2 Oftice'ot Con umer Affairs&Business Regulation }I Board,of Building REgulatiors and Standards OME IMPROVEMENT CONTRACTOR- I License: CS-087691 Type' egistration'. 761805 . Construction Supervisor r nx� 5/ /2017 Cor oratio x iration `�. oc LEONARD SANTOS�l10SSO III {{ I 64 NOYES ROAD' �}� i `y APPLE WOOD CONSTRUCTION INC. - S , LONDONDERRY,NH 033 '. „LEONARD SANTOSUSSOO - I r t 64 NOYES RD � LONDONDERRY;NH 03053 Undersecretary ` l� t/` u ^^� Expiration: Commissioner 09/21/2057 r �µ.