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HomeMy WebLinkAboutBuilding Permit #799 - 1679 OSGOOD STREET 5/31/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / ` Date Received Date Issued: IMPORTANT: Applicant must complete all items on this Daae LOCATION ((0:29 OS(0001) S -s- \ Print 4� PROPERTY OWNER ,Q 0 ,,k -L Print MAP NO: �PARCEL: ZONING DISTRICT: Historic District yesGno Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition �(two or more famil 0 Industrial 0 41 ation NO. of units: 2 0 Commercial Pl�epair, replacement ❑ Assessory Bldg 0 Others: 0 Demolition ❑ Other 0 Septic 0 Well' El Floodpl'a h, 0 Wetl'andss u WatershJoistrict 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMS j / 1 �es u2 >✓aC 4,e,<-) cwt wA- ( �_ C u1 c O'L4 �✓� ! �c (c E� L c, [ A -t-0 env cz S ; 8-s ti L 1✓ D (Identification Please Type or Print Clearly) OWNER: Name: Address: 1(-771 S<' t rin "1'78 -(?Y6 -7 1 &� CONTRACTOR Name: AN0-� "\JUi�L15L-C / VA� Phone: Address: S 4iev a S .e tLi> L4,�✓ c_e. r PU- o t s4i 3 Supervisor's Construction License: `� q 2 1 Exp. Date: Home Improvement License: i S3 to to b Exp. Date: ARCHITECT/ENGINEER Phone: \z -I2, ),-?- ARCH ITECT/ENGINEER , Address: Reg. No. ---------------_ _-__---� -- ---- -. _---.--_- - - - - .._..- - - - -_7 ---- FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ Check No.: 0*61 NOTE: Persons cont Receipt No.:—� do not have access t Signature of Agent/Own- r _ Signature.of•cont�acto 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 DATE REJECTED El DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street no 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 - Date Doc:.Building Permit Revised 2008mi 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/Crossection/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 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 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: Doc.Building Permit Revised 2008mi Location �� (�� J No. Date e� L?/ TOWN OF NORTH ANDOVER Certificate of Occupancy $ ..� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �y 24i0 `� Building Inspector m 0 z ON W o i� -u ti wo CO cin o r r bc p w° on g2 U —ti w x v W �'' :3 ao' Cd w x w U a W °° V) i� w p x °° ao' is w w w v o z cn Q o cn V O O 2 O CD O co L Cl :..7 Z CD fl. O CO) C C cm o M. •� as c m m co ° c co 0 co 0 o rO, O N a O v C.i Ca o civ v .fl JCD C1 C Cc Cc C Z � CL ;= O C C r-. A :..y $ a co o r+. 0 y C* v rn E \J: a CA H tm y y a �_ y ca CO O O � h 'E m . r C LC.3 L� m mac ' y m1= :.�:...- .o CD c CM CD c :o dC.0 �:•vcm m N Z r C2 i O C � v d y m C Q = m a'r o O N ~ aO+ y m .2 co O Z co C y=_. ED O �.: oc 3 �E CZt C cis CCD .y Z o ® 0®gym 5 Vo c' m o a = �_0.CL- eyv `_ mom 2 V O O 2 O CD O co L Cl :..7 Z CD fl. O CO) C C cm M. •� m m co O co 0 co 0 o Cc a Ca o civ v .fl JCD Za C Z � CL c C C _c CN C 4-4 4,4 E- uj ,t - W > ■ Co Lr) CN 0) (Y) 0 0 0, x of C) 15 W (1 < w Z w c! 0 —j —J W Lj W \�\ C 0 4) u 2 > U) . z w \ . , Z \\^/� } _3 CO < Lo f§\ \\� . .. 2A.INFILTRATiON / INSULATION Domestic pipe Hot Water Tank ist 6 Job Number 3M7 DATE Sill tnsufadon R-19 CF Client 0.00 Sill Two Part Foam wt Fiberglass Baft adder city! towrr 0.00 Drape Perimeter R-5 Anch. Sq. It. contractor 0.00 1.WEATHERSTRIPPINWCAULKiNG QUANTITY TOTAL Door Kts Q -Lon or Equiv. 2 86.00 Door Sweeps (Regular) 1 15.00. Door Sweeps (Automatic) 1 22-00 ReglazeWindows /ln.inch 0 0.00 Wtndow.Weathsir Schlegal per side 0 0.00 Attic/Basement bypass sealing marubr 1 60M Attic sealing with 2 -part foam manft 1 75.00 SUBTOTALS 0 258.00 2A.INFILTRATiON / INSULATION Domestic pipe Hot Water Tank ist 6 0 0.00 Sill tnsufadon R-19 CF 0 0.00 Sill Two Part Foam wt Fiberglass Baft 0 0.00 Drape Perimeter R-5 Anch. Sq. It. 0 0.00 Drape DOOR R-5 Anch. 1 44-00 Tape Joints (Aluma"orM per hr. 0 0.00 ouct insulation S Tape In, It_ 0 0.00 Rigid Foam Board Anch. 1- 0 0.00 Hydronic pipe insulation to 1' R-5 0 0.00 Hydronic pipe ins.1.25 -1.5' R-5 0 1100 Steampipe Ins. toi.W iron pipe R-5 0 0.00 Steampipe Ins. 1.5*- 2" iron pipe R-5 0 0.00 Steampipe Ins. 3" iron pipe R-5 0 0.00 Air Conditioner Meeting Rad 0 0.00 Air Conditioner Cover 0 0.00 Air Conditioner Cover Special Order 0 0.00 SUBTOTALS 44.00 2B. INSULATION Open Unrestricted R 49 O 0.00 Open Unrestricted R 38 240 336.00 Open Unrestricted R 30 0 0.00 Open Unrestricted R 20 O 0.00 Open Unrestricted R 10 O 0.00 Restrict FLISloped R 30 390 549.90 Restrict FUSloped R 20 0 0.00 Restrict FUSloped R 10 0 0.00 R-19 FGB open raRerstwalisR ovewaft 0 0.00 R-11 FGB open rafter ilwallslbeewalis 0 0A0 Aiiic Stairs(stairweil & common wall) 1 130.00 Cover Pull Down Stairs Thermadome 0 0.00 Site built pull down stairs T foam box 0 0.00 19 -Apr i 1 John Holland 1679 Osgood St North Andover Heat Quest AUDITOR NOTES l Flash Chimney on outside of house I- AUDITOR NOTES I F- AUDITOR NOTES I P Attic 1 Kneewal Floor Transition. Dense pack cellulose 0 0.00 W.S. & bat Hatch R-19 /Q -Lon or= 0 0.00 W.S. & bat Hatch R-30 /0 -Lon or = 0 0.00 Kneewall R-12 cell behind Per.Memb 0 0.00 Open Rafter R-20 Cell. /w poly _ _ _ 0. _ 0.00 Open Rafter R-30 Cell- AN poly 0 0-00 Basement Overhead R-19 fiberglass 0 0.00 Basement Overhead R30 fiberglass 0 0.00 CravApace Overhead < 4 high R19 0 0.00 Crawlpace Overhead < 4 high R30 0 0-00 Garage Ceiling cavity filled w/ cellulose 0 0.00 Wood,Shaka,Clapboard,Shingles Vmyl 0 0.00 Asbestos (single nail) / Asphalt 0 0.00 Asbestos (doub. Nati)/ Aluminum 794 1746.80 Brick/Stucco, 0 0.00 Vinyl over Asbestos 0 0.00 Mufti -layered 3 or more layers 0 0.00 Drill rough plaster or finish wood plug 0 0.00 Drill finish plaster 2 3.62 Test Drill Walls (all 4) 0 0.00 SUBTOTALS 276$.32 2. INSULATION TOTAL 2A.+213, 2810.32 S. STORM WINDOWS 1 DEADLITES Pladglass up to 88 W. 0 0.00 Additional per Ul over OW 0 1100 Other (Negotiated Price) 0 0-00 SUBTOTALS 0.00 5. OTHER MATERIAL. Ridge vent In ft. 0 0.00 Vents Gable rectarigular 0 0.00 Varipitch Vent O 0-00 Vert Roof 135 (1 sq ft NFV) Large 0 0.00 Vent Roof 865 (.4 sq ft NFV) Small 0 0.00 Vent Soffit Round 0 0.00 Vent Soffit Rectangular 0 0-00 Turbine Vents All 0 0.00 Stack Vent 0 0.00 Propa Vent 0 0.00 Permable House Wrap 0 0.00 Vapor barrier 0 0.00 Energy Star R-4 Rigid Virryl Repl to 73' U.I. 0 0.00 Energy Star R-4 Rigid Vinyl Rep] 74-W U -L 0 0.00 Energy Star R-4RWid Vinyl Repl 84.50' U.I. 0 0.00 Energy Star R-4 Rigid Vinyl Rep[ 94-101 U.I. 0 0-00 SUBTOTALS a-00 8.17. E.C. MATERIAiJLABOR 346ti.32 rage t AUDITOR NOTES AUDrCOR NOTES I AUDITOR NOTES 1 Sa. HEALTH & SAFETY Basement outside door only Basement outside door w/ jambs Door Repl pre hung 3236" Steel" moor Repl Interior solid core 28-37 Dow Repel pre hung 32-M wood— Window Replacement w/ SIR less than 1 Basement Window Repl. Awning/ Hopper Basement Window Rept With a frame Vent Bath i K►tchen Fan Dryer vent wl exhaust duct Heartland Dryer Transition Duct only Blower Door Test Pre Post SUBTOTALS Sb� REPAIR MATERIALILABOR Lockset ( door) Schlage or equal Repair / Refit Door Replace Side Stop Replace Casing Glass Replacement to 64 u.L Glass Replacement per u.i. over tad Sash Sidoloc k Prop Reptacement Threshold (Wood) Threshold (Aluminum) Slide Bolts Plug Plate Cover Out / finish attic-kneewatl access Cut / close attio-kneevuail access Labor Rate Hours Perrrrits / Fees (Wap only] SUBTOTALS TOTAL REPAIR+ HEALTH & SAFETY GRAND TOTAL WORK ORDER # (A) 0 0 0 0 0-- 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Any alterations or deviations from the above specifications involving extra costs must be cleared in writing before installation. The Work Order must be complete within 15 working days from acceptance date below: CONTRACTORfCOMPANY: ACCEPTANCE:ComparWContractor AUTHORIZED SIGNATURE: AGENCY APPROVALS: CTI Authorized Signature: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 85.00 0.00 0.00 M00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0..00 0.00 0.00 0.00 MOD 0.00 85.00 315$.32 Page 3 AUDrfOR NOTES PRE 3975 I AUDITOR NOTES I Date Date GLCAC Authorized Slgnaiurw Date Greater Lawrence Community Action Auditor. Phone: _ ao -- 14,71 Job # Date: y Y l Client First : __— k -N � Last: q, z �1 Address. j `2 g o 1st f r5 .2nd fir third fir CityJ�©r i ,�Co cIG� Zip Code n Phone 1 R 7 - iQR( - Phone 2 - House Type., Cape Ranch Split 1 lamC2: f:�m3 fam duplex other Victorian olonia Tenement T -STK 426 T T -AIR 53.6 °F Siding Type: Wood Viny Alum Asb Single Asb Dble Condition Good Fair . Poor Vinyl over Asb T111 Brickl Stucco Asphalt Comments: Roof Type- Roof Material Gable �!*pFlat Gambrel Asphalt late Rubber Tar & Gravel Condition Good Fair Poor Heating System Manufacturer: - HWSt FHA Space Heater it Gas Electric Woo Pellet Coal Pipes Insulated: Yesf0 Treated Ducts: Yes fo Domestic Hot Water Tank Gas Oil Electric Tank less Gallons Temp Setting Amb CO. Stack CO: Add 6 Feet of pipe wrap YES / NO Comments: Efficient Excess Air Stack Temp Primary Temp Oxygen CO 2 CO CO Air Free Draft Flame Color Age Ambient CO Date referred Referred to HWAF C'mnfea Raarlinn Time: 10:40:38 M rime: 04/14/11 Fuel Oil 2 16 7.4% CO 14 ppm Eff 83.3 % CO2 10.1% T -STK 426 T T -AIR 53.6 °F EA 51.2 % CO (0). 22 ppm ifferential Pressure -0.07 inwc r co I vv Ambient CO Readings: Stove ^0 Oven n Broiler o _ Dryer Tient 1(7 0-5 docj -57- Doors 5ifloors n.- To Baseme mom..�����i� r■s�s� i� i� iii ��� Fire place Space Heaters Blower Door Knob and Tube Location Pre Post YesNO Date Inspector called Locations Condition Reason not doing Blower Uoor Air seaiing Client r ��.` rr)_s ori �` Windows] Direction O _ -.. ■��i■■iii■■■■■■■ ■ ■■e■■■■■■■■■■■■ ■■■e■■■■■■■�■■■�� MOMMEM MEMO ` ■■■ �■■■■■■■■■■■■ �■■■■■■■■ �■■■■■■■■,■■■ MEMO ��■�■■■■■■■■■■■■ -- - O Client i G-7-9 0,-5oAci Basement Conditioned' Unconditioned Asbestos Yes No Location Basement Overhead Garage Overhead Sills Drape perimeter Crawl Space Done Steam Iron 112 inch 4 In 1 inch 1 114 inch 91112 inch 2 inch 21/2 in Done Yes No Measurments Crawl space Dirt floor Existing R Added R ISQ- deet Pipes steam t Ducts Mastic seams hrs Square footage Basement Airsealing Basement Door Drape Repair Caulk Kit & Sweep Client I CI 9 n"Sacc>d i Walls Floor Plan tX Comments 3D fi Exterior wall ut 98'x A = 78 Exterior wall 2nd X interior wall X ISt � 2nd 3rd Sq Feet Common Adj Total Please indicate: unheated Common /////// ..... i ei1�K.3 C, Lo (! Client Attic Loose Wool or FIG 2.2' Cellulose 3.6 FIG or Wool baits 3.2 Vermlcutife 2.3 Vents ll ype Size Location Amount Present Attic Air Sealing Notes Needed Insulation Existing R R Added Square Feet Notes Unfloored C V f� Floored L 0 Al I Slopes Kneewalls Kneewall Floor Flat Roof Hatches Weatherstrip and Bats Cut And Close Attic Walk up ' T -Dome Cut and Finish Kno es No Storage to move Yes No Recessed Lights Cheeks Attic Air Sealing Notes AS t AJ C V f� I.siC/ V L 0 Al I G C Q y JS 0 C? L v L3 E m O V U3 m o a apt is 401 Z — C m a a a ° Q b ° CP Q ZO L: V a Z w CZ a m U3 o ° is 401 — C a a Client Nance Attic Inspection Form Mandatory for all Attic Insulation Jobs Job # Date Section A.- To be filled out by. WAP auditor during initial interview with client Are there any recessed lights in this dwelling ? YES NO Don't Know Locations: Section B: { To be rifled out by auditor upon inspection of the ceiling area beneath the attic 9 Recessed Lighting Fixtures Other potential Heat producers Section C: Number of recessed lights Furnace flues Other heat Producers Total Guards needed To be completed by the Insulation contractor at the time of installafFon. Should agree -with Section B: Section D: To be signed by insulation contractor after completion I have installed guards. Contractor Date ; signed Section E I To be signed by the weathedratfon client: I agree that the number of insulation guards indicated have been installed as noted above. I have received the notice to the client that was attached below Signature: Date: =------------------------_--------------------------------------------------- Detach here and give to Client Notice to Weatherization clients: The purpose of the insulation guards is to ensure that your dwelling is in compliance with the National Electric code .The insulation used meets all Federal test spefrcations. However since insulation retains heat; it is essential that heat producing sources be protected. For this reason it is important that the Insulation guards not be removed altered or covered. Be sure to use insulation guards if you install new recessed light fixtures or some similar fixture Also be certain not to obstruct any affic ventilation devices. Address.- Contractor ddress; Contractor Depth Level OK No Hatches OK No Air sealing OK No Comments GLCAC INC, In Progress Q C Deport Date Inspector Attic Access Venting Bath vent OK No OK No OK No Work Additional Measures Added By Inspector _ -I Missed by auaGtor NVU11% Vruer iu lie cnangea res No Basement General Heat Lass Air sealing OK NO Door Kits OK NO Chimney -oK NO Sweeps - OK - NQ Pipe Wrap OK NO Locksj% ker OK No Ducts OK NO Caulking in OK NO sills OK NO Caulking out OK NO Dryer Vent OK NO Glass OK NO Dryer Hose oK NO Glazing OK NO __ .. Comments Work Additional Measures Added By Inspector _ -I Missed by auaGtor NVU11% Vruer iu lie cnangea res No Walls Windows 1 Hole OK NO Installed OK No Dense Pack OK No Caulked in OK No Plug & Patch OK NO Caulked out oK No Density OK NO Dead Lights OK No Work Additional Measures Added By Inspector _ -I Missed by auaGtor NVU11% Vruer iu lie cnangea res No 1 05/31/2011 07:44 19785212751 ANTHONY&MALCOLM INS PAGE 01/02 :AC�DM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) CObUCER 0S/31/2011 (978)373-5623 FAX (978)521-2751 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INTHONY & MALCOL.M INSURANCE AGCY., INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3 SO. CENTRAL ST, HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR BRADFORD, MA 01835 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Allan VeT eux, 7r. d/b/a INSURERA: Phenix Insurance Co. Heat Quest Insulation Company LLC INSURERO; Safety Insurance 5 Shawsheen Rd. INSURERC: The Hartford _ Lawrence, MA 01843 INSURER D: INSURER E; THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE F ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHI MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEI POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. JSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRAT101 GENERAL LIABILITY CPP0713253 12/27/ZO10 12/27/2011 COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR A GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC AUTOMOBILE LIABILITY 5021421COM01 12/26/2010 12/26/2011 ANY AUTO ALL OWNEO AUTOS B X SCHEDULED AUTOS X HIRED AUTOS X NON -OWNED AUTOS GARAGE LIASILITY I ANYAUTO EXCESS/UMBRELLA LIABILITY OCCUR FICLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND 6S60UB9609 L39010 11/08/2010 11/08/2011 EMPLOYERS' LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If Ves- describe undar Or=SCPJPTION OF OPERATION$ / LOCATIONS /VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS insulation C C _ ceurtFl I AT1r%kl Town of North Andover Inspectional Services 1600 Osgood St. Bldg. 20 Suite 2/36 North Andover, MA 01845 ACORD 25 (2001108) FAX: (978)688-9542 OLICY PERIOD INDICATED. NCTWITIISTANDING CH THIS CERTIFICATE MAY BE ISSUED OR (MS, EXCLUSIONS AND CONDITIONS OF SUCH 1 ^� LIMITS EACH OCCURRENCE $ 110001005 DAMAGE'f0 I Fa RENT nrrED -RFMISF_R nrnnae S , 50 000 MED EXP (Any one person) $ 51000 PERSONAI. B ADV INJURY S 1 000, 000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG S 2,000,000 COMBINED SINGLE LIMIT 3 (Eo accidnnl) 1,000,000 000.000 BODILY INJURY $ (Per person) BODILY INJURY S (Per accldenl) PROPERTY DAMAGE $ (Por mccldgm) AUTOONLY-EAACCIDENT $ OTHER THAN EA ACC S AUTO ONLY; AGG 3 EACH OCCURRENCE $ AGGREGATE S S $ $ WC STRTU- OTH- LIMLT9ER E.L. EACH ACCIDENT S 1,000 000 E.L. DISEASE. - EA EMPLOYEE $ 1.000 , 000 F„ L. DISEASE - POLICYLIMIT $ 1, ow, 000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 OAYS WRITTPN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSe NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES AUTHORIZED REPRESENTATIVE / Frederick Malcolm Ir /1A ®ACORD CORPORATION 1988 1 05/31/2011 07:50 19785212751 ANTHONY&MALCOLM INS PAGE 01/02 �AC�DM CERTIFICATE OF LIABILITY INSURANCE DATE 05/31/2011 ODUCER (978)373-5623 FAX (978)521-2751 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION INTHONY & MALCOLM INSURANCE AGCY., INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3 SO. CENTRAL ST, HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR BRADFORD, MA 01835 AFTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIL # INSURED Allan VeT eux, Jr. d/b/a IN$URERA: Ph, Insurance Co. Heat Quest Insulation Company LLC INSURER 0, Safety Insurance 5 Shawsheen Rd. INSURER c: The Hartford Lawrence, MA 01843 INSURER D: INSURER E; THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE F ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHI MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEI POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. VSR JADEYLTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATN)I GENERAJ. LIABILITY CPPD 713253 12/27/2010 12/27/2011 COMMERCIAL GENERAL LIABILITY CLAIMS MADEXI OCCUR A GEN'L AGGREGATE LIMIT APPLIES PER; POLICY PRO- JECT LOC AUTOMOBILE LIABILITY 502142 1COM01 ANY AUTO ALL OWNED AUTOS B X SCHEDULED AUTOS X HIREDAUTOS X NON -OWNED AUTOS GARAGE LIABILITY ANYAUTO EXCESS/UMBRELLA LIABILITY OCCUR FICLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MF,MBER EXCLUDED? If yes, deearibo under SPECIAL PROVISIONS below OTHER OESC PTION OF OPERATIONS / LOCATION$ /VEHICLES / insulation Town of North Andover Inspectional Services 1600 Osgood St. Bldg. 20 Suite 2/36 North Andover, MA 01845 ACORD 25 (2001108) FAX: (978)688-9542 L390 ADDED BY ENDORSEMENT /SPECIAL PROVISIONS 1 OLICY PERIOD INDICATED. NOTWITHSTANDING :H THIS CERTIFICATE MAY BE ISSUED OR ,MS, EXCLUSIONS AND CONDITIONS OF SUCH LIMITS EACH OCCURRENCE $ 11000,000 DAMAGETOED RENTED _REM1Pw errurnnpe S 50,()00 , MED CXP (Any One per■on) S S, 00 PERSONAI, $ ADV INJURY S 1 000 , 000 GENERAL AOOREGATE $ 2,000,00 PRODUCTS - COME/OP AGO S 2,000.00 COMBINED SINGLE LIMIT S (Ea aooidnnl) 1 000 ' 000 BODILY INJURY $ (Per person) BODILY INJURY $ (Per accleenl) PROPERTY DAMAGE $ (Por accldenl) AUTOONLY-EAACCIDENT $ OTHER THAN EA ACC S AUTO ONLY; AGG S EACH OCCURRENCE $ AGGREGATE $ $ $ WC STATU- OT11- Llm)28 E.L. EACH ACCIDENT S 1,0001000 E.L. DISEASE - EA EMPLOYEE S 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 SHOULD ANY OP THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEfY, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, IT$ AGENTS OR REPRR3ENTATIVES, AUTHORIZED REPRESENTATIVE / Frederick,Malcolm Jr./JA� OACORD CORPORATION 1988 Name (Bi Address: Sv �A-nw� Co /U CI City/State/Zipk�Am_ 5(,V_, AA(Zl i_tl_j phone #: f -n 561 60 '7 Arg you an employer? Check ty appropriate box: ' The Commonwealth ofMassachusefts c ,P, Department oflndustr'ialAccidents =" P• �4 �. � Office of Investigations = ? ; ;•,i a u 600 Washington Street ~` Boston, MA 02111 workers' comp. insurance. www.massgov/dia Workers' Compensation. Insurance Affidavit: Builders/Contractors[Ellectricialns/Flumbers Name (Bi Address: Sv �A-nw� Co /U CI City/State/Zipk�Am_ 5(,V_, AA(Zl i_tl_j phone #: f -n 561 60 '7 Arg you an employer? Check ty appropriate box: 1. PNJ am a employer with C,11 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2111 aim a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We. area corporation and its required] officers have exercised their 3. ❑ I aim a homeowner doing all work right ofexemption per MGL - inyself. [No workers' comp. c. 1'52, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [( Demolition 9. ❑ Building addition 10.❑ EIectrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roofrepairs -(S�>� 13.Other 15t/ i. -Huy appscant rnat cnecKs box 91 must also tilt out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and thep hire outside contractors must submit anew affidavit indicating su-,��� tContractors that check this box roust attached an additional sheet showing the name of the sub -contractors afid their workers' comp. policy information. I am an employer that & pro viding workers' compensation insurance for my employees. Below is the policy and job site information. ' • t _ Insurance Company Name: S Policy # or Self -ins. Lic.#:c S�s O U a �' C—,Q 9 L- Expiration Date: [ L, Job Site Address: �7� l o s `CJ' PSiJ `� - City/State/Zip i D _ t t vc yid, 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 maybe forwarded to the Office of Investigations of the DIA foxjinsu^coveyftge verification. I do hereby r ofperjury that the information pro vided4ove ' true and coi neck Date: 5 / 3 I Official use only. Do not write in -this area, to be completed by city or town ofjIcial City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone