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HomeMy WebLinkAboutBuilding Permit #305-2016 - 169 ANDOVER STREET 9/9/2015 BUILDING PERMIT NORTlt S.1L8G 6 �� .16 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: V� � Date Received `3 '1/4Q°Rwre° gssac►+us�� Date Issued: I IMPORTANT:Applicant must complete all items on this page LOCATION \�Dq �n1-w �+- Print PROPERTY OWNER Print 100 Year Structure (yesJ no MAP 00 PARCEL: ZONING DISTRICT: Historic District no Machine Shop Village s o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building &One family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRI TION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Y02 (gym l P Y Phone: (o 171- a(01 (.0i Address: D Contractor Name: Phone: Email: 1 Address: b2 Supervisor's Construction License: C3" I?� Exp. Date: &' 0"1 l Home Improvement License: \401'aAa\ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST�B,[A,SED ON$125.00 PER S.F. Total Project Cost: $ ` � : �a � FEE: $ 14` Z rr�� Check No.: jld Receipt No.: �Z NOTE: Persons contracting with unregistered contractors do not have access to th ty fund i Signature of AoPnt/Owner Siqnatu-[e-of contractor Location 4, r _ Date i' k TOWN OF NORTH ANDOVER t } ` r4 Certificate of Occupancy $ t Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ k Check#W Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i F OF SEWERAGE DISPOSAL Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Pack � ❑ aging/Sales ❑ Private(septic tank,etc. Pelm hent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS i i CONSERVATION Reviewed on Signature COMMENTS i i HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments I Wafter& Sewer Connection/Signature& Date Driveway Permit ' DPW Town Engineer: Signature: I - _ _ FIR E�DEP'AR�T�MENT =_TernpDurim ster o_n te_ ,yes - ` �+ - `-` Located 384 Osgood Street Located at 'p I� tri _ FireiDepartmentfsignafure%d'a`fe 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) I I i I �I it I i U Notified for pickup Call Email i i Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products 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 4. 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 j 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 Ci^rinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products i IN 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 t Doe:Building Permit Revised 2014 ,. I NORTH To' wn t ,, No. �(�S —ZQ * _ o - h ver, Mass, _ct '9A COCNICHt w1c. . S R�TEO I�P��.(5 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System . L 11K �./ THIS CERTIFIES THAT ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR .............. ......It ..............�' .........�...... rr--GG � Foundation 'I has permission to erect .......................... buildings on ....�.IQ:1..... !�`ffF ...�1� ........ .................. Rough to be occupied as ..... Vccin .....�..... ............... ..r .......iw......�L .�� .................. Chimney provided that the person this permit shall in eve espect conform to the terms of thea application 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 CONSTRUCTI T Rough Service ............... .... ...... ............................................. Final BUILDING 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. T. EIN#51-050-3313 br Haverhill MA 978.374.9224 tue MA Reg.HIC#149221 Lawrence MA 978.687.7339 'or MA Lic.UCS#78130 Hampton NH 603.929.9224 BBB. Single-Ply License#1711 M"- O. Hampstead NH 603.329.8200 minim' ' .- e%r�i1932 �p, Toll Free 1.888.SOS.ROOF 265 Winter Street Haverhill.MA 01830 Licens d -Insured ::Factory Trained *Factory Certified Name:- Date: z 545 Telephoner 1-7 vie b t�'Alt.Telephone:: Email: /� ,,/� Billing Address:����j��„� City:_ L�/ter �. A'n QMLa ' State: /1 t6,- Job Address: City: State: Scope of Work Strip and Re-roof ❑Re-roof Approximate Roof Area: ❑ Prepare for re-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. ❑ Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the'ob site. El Inspect wood deck,if we discover any rotted wood,replacement will will performed at*$ 5 5 per LF for roof deck boards.If substantial deck rot is discovered,re-sheathing of roof deck can be performed at*$ 1 2-0 per SF.If individual sheets are found to be rotted/or de-laminated,removal,disposal and replacement will be performed at*$ per sheet.If any trim boards are rotted, replacement will be performed at*$ per LF for new pre-primed pine.Inspect siding at roof line and all flashing behind siding,if we discover any damaged flashing or siding at the roof line,replacement will be performed at*$ 2- .If wood deck,siding,and flashing is sound,we will re-nail any loose wood to rafters,sweep deck,and prepare for roofing. ❑ Install 8"drip edge to all rakes and eaves.Color , ' ❑ Apply ice&water shield(UNDERLAYMENT)as per manufacturers'specifications and/or ee�) ❑ Apply premium(UNDERLAYMENT)to the balance of the exposed wood deck. ❑ Re-flash all plumbing stack pipes,and any roof penetrations as required and dictated by good roof practice to ensure water tightness. ❑ If upon inspection,we discover chimney lead to be worn or deteriorated,replacement will be performed at*$ ElInstall a new: '-'L"- Year ❑ Traditional Architectural ❑ Designer Color ❑ Furnish and Install a new shingle over style ridge vent system ❑Soffit vent system*$ ❑ All debris generated by Lambert Roofing Co.,Inc.will be cleaned up and disposed of from the job site in a legal fashion.Under no circumstances will the watertight I integrity of the building be compromised. Special Notes y/ 1 r o t[ CO, (-1,� L7 I UPON COMPLETION AND PAYMENTYN FULL,ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A RIOD OF� YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$ *Denotes potential additional costs above the total estimated price. TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE The Contractor agrees to perform the work,furnish the materials and labor specified above for the total sum of:$1I ' I . (*) (Dollars) Payment will be made according to the following work schedule:i $_._deposit upon signing contract $ by_/_/_or upon completion of $ upon completion of contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram or by delivery,not later than midnight of the third business day following the signing of this agreement.See attached notice of cancellation for for an explanation of this right. I DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES ptance of the Contract Proposal Home Owner(s)Signature(s): v Date:�/aLzl Contractor's Signature: Date: C) / .lambirtroofing.com (Please see reverse side) company Insurances TGLRC Inc.DBA Lambert Roofing Company will provide certification of insurances,demonstrating that we are fully insured for worker's compensations, general liability,automobile liability and an umbrella policy.This documentation will be sent through the US mail to the above named party if not already i provided. _ TGL Inc.dha T amben Roofing Compmy aaxees to: �,, r Commence the described work on or about�' r` • Complete the described work in approximately J*; days.' • Not be held liable for delays due to circumstances beyond our control. • Not be held liable for any damages to landscape and or fixtures due to circumstances beyond our control. • Not be held liable and not covered under the workmanship warranty,for pre-existing conditions including but not limited to: • Mold and or wood rot,defective,faulty,rotted or worn building counterparts such as,but no limited to:siding,roofing,masonry, plumbing and windows,all of which may jeopardize the watertight integrity of the structure. • Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. • This contract is the complete contract unless a signed Change Order has been executed be TGLRC Inc.DBA Lambert Roofing Company and the Homeowner/Business Owner or Agent. Permits A building permit may be required to remove and replace your roof.It is our obligation to secure these permits if required as the home owner's agent.Note: Homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c.142A. Accelerated Payment A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure.However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal of funds from said account would require the signatures of both parties. PaMentTerms A finance charge of 1.5%a month(18%per year)will be added to all invoices on the 31'day.All legal and or collection fees will be paid by the binding holder of this contract. • The law requires that any deposit or down payment required by TGLRC Inc.dba Lambert Roofing Company before work begins may not exceed the greater of- 0 1/3 of the total contract price or: 0 The actual cast of Special or Custom made materials which must be special ordered in advance to meet the completion schedule. Arbitration The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business egulAgon and the c sumer shall-be required to submit to such arbitration as provided in MGL c 142A. Date: Owner: �� •�' r 2 ! f Date: Contractor: contractor Registration All home improvement contractors and subcontractors must be registered,any inquiries about a contractor or subcontractor relating to a registration should be directed to: Contractor Registration: Director of Home Improvement Contractor Registration Board of Building Regulations and Standards One Ashburton Place,Rm.1301 Boston,MA 02108 (617)727-3200 Home Improvement Contractor Law: Consumer Information Hotline Commonwealth of Massachusetts Office of Consumer Affairs and Business Regulations 10 Park Plaza,Rm.5170 Boston,MA 02116 (617)973-8787 For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 Cancellation You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be in the main office or branch thereof,provided you notify the seller in writing at the main office by ordinary mail posted,by telegram sent or by delivery,no later than that midnight of the third business day following the signing of the agreement. INITIALS The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: �LQej in4-pf - City/State/ZipA` NR,Y 11 )1 Ma0)yU,3l�hone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4<fIlrant a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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 Name: Policy#or Self-ins.Lic.#:__IrYLW(JJ.A "a(_, 4� -,�—�C.t Expiration Date: J Job Site Address: �Q1/el^ 5� City/State/ZipO. ft dner Mc 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. I do hereby certify and pa' of perjury that the information provided above is true and correct Signature: Date: Phone#: Official 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#: A CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 08/13/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jerrold Kameras N ALLAN INSURANCE AGENCY INC. PHONE (978) 745-5905 FAX LAIC No).(978) 745.5483 63 1/2 Jefferson Avenue 2nd Floor E-MAIL P.O. BOX 511 .Jerrold0allaninsurance.com SALEM MA 01970-0511 INSURERS AFFORDING COVERAGE NAIC9 INSURED iNSURERA:Associated Ind Ins CO TGLRC INSURERB:Safety Insurance CO INSURER c:National Union Fire Ins Co. dba: Lambert Roofing Co. INSURERD-Ace American Insurance Co. 265 Winter Street Haverhill MA 01830- INSURERE:Ace American Insurance Co. � INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: WI THIS IS TO CERTIFY THAT THE POLICIES INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTIFICATE MAY ISSUED INDICATED NOTTHSTANDING ANY REQUIUI REMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS AND COO NDITIONOR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, TIONS OF SUCH POLICIES.LIMITS SHOWN MAY INSR HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICYNUMBER POLICY EFF POLICY EXP GENERAL LIABILITY MMIDRM!YYI JMhLqgfY= LIMITS EACH OCCURRENCE $ 1,000,000 X COMMF.RCIALGENERALLIABILITY / / PR MI •a encs S 50,000 A CLAIMS•MADE F0 OCCUR y kES1028029 11/12/2014 11/12/2015 MED EXP An one person) S 1,000 X Per PzO jeCt Agg / PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER / / / /l , 7 PRODUCTS-COMPIOP AGG $ 2,000,0 00 POLICY }[ PRO- / / / / LOC S AUTOMOBILE LIABILITY / / / / COMBI ED SIN LE LIMIT sac Kent 1 000 000 B ANY AUTO 130DILY INJURY(Per person) $ AUTOS ED X A,70SUIED Y 203819 7/16/2015 T/16/2016 8001LYINJURY(Paraccident) S X HIRED AUTOS X AUUTOSWNED / / / / PROPERTY DAMAGE Por accident) s X U MBRELLA X OCCUR Y 618430331 1/12/2014 11/12/2015 AR EACH OCCURRENCE S 5,000,000 C CLAIMS-1.DE / / / / AGGREGATE $ 5,000,000 RETENTION$ WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY X NIC STAT,- 01'H- ANY PROPRIETORIPARTNERIEXECUTIVE Y/N li D OFFICER/MEMBER EXCLUDE07 N❑ NIA / / / / E L EACH ACCIDENT $ 1 000 000 (Mandatory in NH) GS62UB-2609875-2-14 MA 3/25/2015 03/25/2016 i7 yes describe rider E L DISEASE-EA EMPLOYE $ 1 000 000 DESCRIPTION OF OPERATIONS bebw / / / / EL DISEASE-POLICY LIMIT S 1.000,000 W Worker's Compenstaion NH 6S62UB-SD81311-6-14 ?m 12/22/2014 12/22/2015 same Imi;s as 1,000, ,000,000 / / / / policy above 1,000000 000 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) I I CERTIFICATE HOLDER CANCELLATION TGLRC Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. dba: Lambert Roofing 265 Winter St. AUTHORIZED PRESENTATrIVE Haverhill MA 01630- 1. 1 l� `�. J ACORD 25(2010/05) ©1988-2010 ACORD C RPORATION. All rights reserved. INS025(201005Ioi The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODNYYY) 0611612015 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 policOes)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 00571-004 NaIJACT D Francis Murphy Insurance Agency Inc eULQ�fo.Ex ; (508)422-9277 200 Main Street E� (508)422-9914 Marlborough,MA 01752 ADDRESS: Ic INSURED A.I.M.Mutual Insurance Company Golf Construction Inc 63 Depot Street JOURER C, Milford, MA 01757 INSURER I N 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. TG TYPE OF INSURANCE 110 R POLICY NUMBER MM/DD F MNVD�i LIMITS ERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g DAMAGE TO RENTED $ CLAIMS-MADE a OCCUR P a c i e MED EXP(Any one person) $ PERSONAL&ADV INJURY $ AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ OLICY RO- OCPRODUCTS-COMPIOPAGG $ EMOBILE LIABILITY ANY AUTO COMBINEgddED SINGLE LIlm MB $ ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS I HIRED AUTOS NON-OWNED BODILY INJURY(Per accident) $ AUTOS PROPERTY DAMAGE $ UMBRELLA LIAR OCCUR $ EXCESS LIAB EACH OCCURRENCE $ CLAIMS MADE R�QEDg M RNETETN�TpIONN $ AGGREGATE $ gANe ERM�PpL�OIYEURSRE�pL1gR7ILryIETRY/ � WC gTq — a ----- I /ll OFFICERIMEMBER EXCLUDED?ECUTIVEI,��YILL�..��L X TORY LIMIT• OLT — - - (MandatorylnNN) u NIA AWGI00-7032568-2015A 6/3/2015 6/3/2016 E.LEACHACCIDEN7 S 500,000.00 Yy@9s,.dda� �ya�4�d E.L.DICEASE-EA EMPLOYEE $ 500,000.00 DESCRIPT ON OF 9PERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION LRC 265 Winter Street Haverhill,MA 01830 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 REPRESENTATIVE1988-20 ACORD 25(2010105) The ACORD name and logo are registered marks of ACORDACORD CORPORATION.All rights reserved. CW8130 I�L•1 RICSAM J LANPW 265 WIIt1 M STREET H"Uta MA 01030 52w.11.8 • p6l0y�018 Office.of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 149221 Type: Private Corporation EmIrstion: 12WO15 TO 24013 T.G.L.R.0 dba Lambert Roofing Company RICHARD LAMBERT 285 WINTER STREET HAVERHILL, MA 01830 Update Address and return card.Mark reason for change. Address 0 Renewal (j Employment 0 Lost Card