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HomeMy WebLinkAboutBuilding Permit #788 - 167 LANCASTER ROAD 5/20/2015TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 0 Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION /6 �.C�/1CrcSi�L,' % VO,- / rint, PROPERTY OWNER Print 100 Year Old Structure yes nn MAP NO: i A PARCEL: �I� ZONING DISTRICT: Historic District yesMachine Shop Village yes .TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 00ne family ❑ Addition ❑ Two or more family ❑ Industrial VAlteration No. of units: ❑ Commercial ❑ Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District' 0 Water/Sewer DESCRIPTION O/F/ WORK TO BE PERFORMED: c -A& Gam` 6�Je�-►�P.��-�-. I'll &oo,4- ✓h a � �.�lim� c e'i�V&-dS Cenot" 4W.V &2 e,4, --t1>' i"Ielua(e &,e d f l)�G�SI�-ems , Gr��n r� S' o� d�� f lame C / Identification' Plidse Type or Print Clearly) OWNER: Name: Phone: ArIrI CPS-,- CONTRACTORName: Ian CI�OtL�/)• Phone: c-/7 7{7 Address: ill . tz nee" . _ I�, t�Z/-3 C- Supervisor's Construction License: 6_4� -7 Exp: Date: Home Improvement License: i 3 Ali Exp. Dater 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: $ Z . C3 FEE: $ 2 Vd Check No.: �(% Receipt No.:a69 y� NOTE: Persons contracting with arnregistered contractors do not have access to the guaranty fund Signature�of Agent/Qwner Signature of contract. �--- Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan amp Plans ❑ 4 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 COMMENTS CONSERVATION COMMENTS • HEALTH COMMENTS DATE REJECTED 0 DATE APPROVED Reviewed on Signature Reviewed on Signature QZoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _. - 4 Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Drivewav Permit DPW Tow` ! Engineer: Signature: Located 384 Osgood Street FIRE DEP'iRTMF_NT Termp Dumpster on site yes no Located at'124 Main Street Fire Departineft,signature/date COMMENTS Dimension Number of Stories Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector I Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine NOTES and DATA — (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 No Building Department The fol paving is a list of the required forms to be filled out for the appropriate. permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits a 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 Li 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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) a 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) ❑ 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 ❑ Mass check Energy Compliance Report ❑ 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 app> al 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: Doc.Building Permit Revised 2012 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 24,035.00 m $ - $ 288.42 Plumbing Fee $ 36.05 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 36.05 Total fees collected $ 460.53 167 Lancaster Road 788-13 on 5/20/2013 Finish 50% of basement 5/16/2013 10:44:05 AM 8906 ® 02/02 Acs CERTIFICATE OF LIABILITY INSURANCE DAT5(MM/D01YYYY) 05!16!2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(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 02883-001 pry7p NAME: CT Dupont Insurance Agency Inc a7C0.1o. Ext : (617)376-0795 circ. No.: (617)479-9121 18 Copeland Street Quincy, MA 02169 EMAIL ADDRESS: EACH OCCURRENCE $ INSURERS AFFORDING COVERAGE NAIC INSURERA : A.I.M. Mutual Insurance Company 33758 PERSONAL&ADV INJURY $ INSURED Ian Gleeson NSU E B• EN'L AGGREGATE LIMIT APPLIES PER: OLICY CT MOC Gleeson Construction INSURERC : INSURERD: 112 Faneuil Street Brighton, MA 02135 SURER E I [INSURERF: Ed 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. ILS TYPE OF INSURANCE INSR VWBD POLICY NUMBER POLICY EFF MMNDIYYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED $ PREMISES Ea occurrence MED EXP (Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: OLICY CT MOC PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOSq NON -OWNED AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ UMBRELLA LAB EXCESS LIAB HOCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY P RP ECUTIVEY N o41ICpI��rl�e�R l �Z�i�a��� N InNH) (Mandatory B CIdiII ON u0F OPERATIONS below NIA AWC7025072012012 11!212012 11/2/2013 yyC S X TORY LIAM ITS OER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 11000,000 E1. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER Attention: Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 OSGOOD ST Bldg 20 Ste 2035 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER, MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 0616111 The Commonwealth ofVlassachusetts Department of lndustria[Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0biy Name (Business/Organization/Individual): /d n e-�ees!» Address: j /Z City/State/Zip: 6-,'a AT©n %G Phone #: 1/7 %9 Z 927C Are on an employer? Check the appropriate box: Type of project (required): 1.21 am a employer with � d• ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• ❑Remodeling ship and'have no employees working for me in any capacity. These sub -contractors have workers' comp. insurance. 8. ❑ Demolition g• E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurance ] ired. re q ut employees. [No workers' ME] Other comp. insurance required.] 4Any 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 a're 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. „ Insurance Company N Policy # or Self -ins. Lic. #: Pjk,�-7 C2 _? Z © l 21!!�/ 2ExpirationDate: ///'2. Job Site Address: 16 /l/ /� City/State/Zip: IL)d� 4�e/�� � 41�CC�S 1�.�-� �,. U �r Attach a copy of the workers' compensation policy declaration page �showmg the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of investigations of the DTA. for insurance coverage verification. I do hereby rte under the pains�anndd, RianafirrPl �411 C ofperjury that the information provided above is true and correct. Date: e� - r� use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 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 of 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 enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee 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 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 commonwealth for any applicant who has 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 ofpublic 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 -contractors) name(s), address(es) and phone number(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 notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance 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-insured 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 a reference number. In addition, an applicant that must submit multiple permit/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 orpermit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Cowmoawoalth of Massarh7usetts Department ofIndustdal .A.ccldonts office of Intyestigatiolas 604 Wasbingtoa Street Boston} MA, 02111 Tel # 617-727-4900 at 406 ox 1.-877,;MASSAFB Revised 5-26-05 Fax # 617-727-7749 '{rrirMr_/ ­4X.- _ O O _ cc Q .� 0 (/ E 4. L y 0:as� O = :ova i:-- N rzi.fesm -E o o - > o nWz � ci 1�oo a -5 .yt. n 3 G7 > _ _ `~ CL 0) 0 = m ` c p r.y rn . =o c v _ Q .o t=- o w CL W.2 ZLUw o o u. y morn= o 'a � o m :3 :. 0mc LOw U m o -0 m ,� to m '> :� c J N M O O I- w CLv > h z co Z W w CLX LLJF- LU W CL 0 E JJ�� z .AvA,I, .E :r d O V c� FL O V .CL C V N I -W 0 cm C a Ol- in 22 y U) W W 19 W U) 0 V oC z U . W J W O N Z H N W 1 Z Z LL ? a Q O C7 Q tA z w a' m Q W O J m W LL N v co—C d W L O O Y Z Q (n N N �U1 Q'c 'a U '6 L to U t v Q) y E t to O O- 3 C C O N C O E LL W U LL Q' LL w N LL d' LL m yL.� N V) LL N _ O O _ cc Q .� 0 (/ E 4. L y 0:as� O = :ova i:-- N rzi.fesm -E o o - > o nWz � ci 1�oo a -5 .yt. n 3 G7 > _ _ `~ CL 0) 0 = m ` c p r.y rn . =o c v _ Q .o t=- o w CL W.2 ZLUw o o u. y morn= o 'a � o m :3 :. 0mc LOw U m o -0 m ,� to m '> :� c J N M O O I- w CLv > h z co Z W w CLX LLJF- LU W CL 0 E JJ�� z .AvA,I, .E :r d O V c� FL O V .CL C V N I -W 0 cm C a Ol- in 22 y U) W W 19 W U) GLEESON CONSTRUCTION Ian Gleeson -112 Faneuil St, Brighton MA 02135 Phone 617 416 2712 - Fax 617 782 8975 www.gleesonconstrttctionboston.com - ian.gleeson@yahoo.com CUSTOMER NAME & ADDRESS: 167 Lancaster rd, north andover, 01845 DATE: Mark Thayer 05/12/13 North Andover, MA CONTRACT SPECIFICATION PRICE Finish basement per sketch. Provide labor and materials, except where noted. Building Permit (based on 1.2% of contract amount) 285 Sump Pump - install a .3hp Zoeller pump 1000 Rough Framing Labor - walls and ceiling 3600 Rough Framing Materials - walls and ceiling 2000 Electrical - by owner 0 Insulation 1200 Board & Plaster - plaster skimcoat all walls and ceiling 3600 5 Interior Doors - doors will be supplied 1550 Painting 2000 Carpet Allowance 1200 Floor Install - gym mats (owner to provide mats) 1500 HVAC - by owner 0 Finished Carpentry - door trim, window trim, baseboard - Labor 1500 Finished Carpentry Materials 500 Finished Carpentry - wrap 3 pillars with wood - Labor & Materials 300 Punch List & Cleanout 2000 M isc 1000 Provide access panels and fresh air for mechanicals - where necessary 800 Total not to exceed $24,035 Acceptance of Contra VV V 1 1 � r, Date: C 5/14/2013 Massachusetts - Department of Public SJON Board of Building Regulations and StandMAS� Gbnstruction Supervisor License -License: CS 70495 +M IAN F GLEESON� 112 FANEUILL ST BRIGHTON, MA 02135"` " Expiration: 9/17/2013 ('��nunis�ionrr. Tr#: 395 office of Consumer Affairs & B sines Regulattor'.; HOME'IMPROVEMENTOONTRACTOR' Tvpe 4Registration: X-135405 Expiration_ :!1/2014 Individual IAty: - LEESON i1 i ._ 3 IAN- 112 AN 112 FANEUILLST Undersecretar BRIGHTON, MA 02135;;' y . . /i j J, f ..s -,fl ► 10-1tr1 .9-CtIT 'L '�•\ � � L L � \ r LA \ t \ - �y •`k \ ` r \ L \ wLw\ y L c\ \L' 4 'r \ x L r tL I` ♦\ ` ' �r L`a _ rrL � \\�♦�t• is _ i P� ww.�{�.. ♦\ ` \� `5\ r\y\L \\ ♦YI^J�fn kxy \Ll\Y� tr x. '�'Iv♦ YL \ tl .. w ., v. v ♦ `1 \' ♦y L\' it `\ L ++�•} � y aril- �'x y~L ` L\th rl .. \h 1'Lt, 4 �\x\+\ 4 + w L 4w h L /5 4x`fLP�a��•�y, L\`5 `t `\x•/I \ �1�L\'r4.'r 4\L L \�L xy �\ L �y ' I�.y 1. � �'•. \ \ \ ♦` .\L • t Lt LL�\\ `\ `Lx + \. L \ \ 4 1 \ t x l • r �,. Mtv+ �y��,Aa� a\ t L \xt1L ya, 'L y ti L � `t�,lL x\ t�l•t 4 !� \\ \ \` � r a\\, 1 +.`4 4 \ t \ LL .wk ♦ `x \L y� Lh~v +♦ \ ` . V! \ k 4y \L \\ r L4+.��Ly ♦ . .+ v t+L. v ♦\ \a.. YaYr `♦\L\x .\"a\` h r\+. 4�r ra` t` ♦`\r\ N `r \\\���., `+tw, Cr 1 ♦ +Lx qaui x�ya w4 `. `sC. 1. x h\w r a\\ kir\\\ , \ a.\i \�yrx +4L 9Yd w+yy ♦L` r`�, \ Ln \ `5M. \ \y\\ l • y \ l r.�ax ♦ha 1 \+r ` �♦ 4 , ♦\ \x ♦ 1 tr L + LY\L��l. x'yL ,Lv\ +,\y `,i �'\ L `�-\r ty � 4 \ \ \�L tt�'.`a\ r a w. ♦ xhi +yL, + yL ♦\ y I�y*4 `.+\>�+, �r \�A�,.4.,ti iy xL.,rti i\x\ h\i,`t L Lh '`,LL4' � �, I—i \ 4 \� t ♦ L h�y 'v \ \� 'ti v'\ \ t \ i. a\h.\i .\ 1\w \'� `\ `L .\.\�\�\\lir yi x` \Lv'\t''\� 1r41t ♦L . - ..s -,fl ► 10-1tr1 .9-CtIT ACORO® CERTIFICATE OF LIABILITY INSURANCE `,.►-'" DYYYY) 775/14/13 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 Dupont Insurance Agency, Inc. 18 Copeland Street Quincy, MA 02169 CONTACT NAME: Dianne PHONE FAX 617) 479-9121 tAIC_udi,(617) 376-0795 / No: E-MAIL ADDRESS: Dupontq@quixnet.net INSURERS) AFFORDING COVERAGE NAIC # INSURERA:Main Street America 6/1/13 INSURED INSURER B : Gleeson Construction INSURERC: 112 Fanueil Street INSURER D: INSURER E: Brighton, MA 02135 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVID POLICY NUMBER POLICY EFF M/DDN POUCY EXP MM/DD/YYYY LIMITS A GENERALLIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_1 OCCUR MPP6154B 6/1/12 6/1/13 EACH OCCURRENCE $ 11000,000 DAMAGE TO RENTED $ 500 000 MED EXP (Arryone person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE L IMI T APP LIE S PE R }i; POLICY PRO LOC PRODUCTS - COMP/OPAGG $ 2,000,000 AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS _ AUTOS MBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PPROPaccidERTYent DAMAGE $ er UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yyes describe under DESGRIPTIONOFOPERATIONSbelow / A WC STATU- I JOTH- E.L. EACH ACG DENT $ E.L. DISEASE - EA FUvIPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS !VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is regui red) Job Location: 167 Lancaster Road, N. Andover, MA CERTIFICATE HOLDER CANCELLATION Town of North Andover 1600 Osgood Street Building 20 Suite 2035 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 McGowan t7 1988-2010 ACORD CORPORATION. All riahts reserved- ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: (617) 782-8975 E -Mail: LocatioV No.- Dat r . - TOWN OF NORTH ANDOM9 • CT t"s1) f yo- . O Certificate of Occupancy $ Building/Frame Permit Fee -� Foundation Permit Fee $ Other Permit Fee $ av' TOTAL $ Af Check #-D&J� ti 26417 Building Inspector