Loading...
HomeMy WebLinkAboutBuilding Permit #592-2017 - 17 QUAIL RUN LANE 5/1/2018 NORTy BUILDING PERMIT OECt LED .6 q�O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: /'"�1 Date Received ��°0RATED yep'`c5 gSSACHUSEt Date Issued: EAPORTANT:Applicant must complete all items on this page LOGA�'Tl�i,�lt � ,-Pram . DD ,mar tr ctur Res bio, ,nntg 'N1PP, �..`PAsCEL` -Ti271 � ONINGDISTR � }��stortr> tnt - rs� _r 14K .< meq,. - f , ` M, achlne Shop�Villa a es: nog TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family ❑Addition [I Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg El Others: ❑ Demolition Other �v�w Welan ">41 a �fer he .D strict +' DESCRIPTION OF WORK TO BE PERFORMED: I n at7l C Identification- Please Type or Print Clearly OWNER: Name: Phone: lP l'1 " S��1 "19 a' Address: A aJJ �-� _� .,+i - ♦ 1 s ems.*�i:"....,3 ^.- +.w.- ",Y xti FE ��.e- trac �...�..ail; Cts t 1 �'► Y1� F ; �.. . _ „ - s .. �• '. '73.x_ r .py«.-x i aic� ,s,� ° r•y y .,r� �.S � w"` '�' z 1 ;.:.w 4l.:, .✓ .i.3�.s ,}. ..- ".^»,s ,� +ay `• �L" t 'S r E . af� �Superv�sorrs onstr0et1on License C S M•` � E. ` Date ..- Ptv��,�xfw,f .^`7��""': .�ii.. PoV. ore- L!ce se? . 3 _< ` , mExp `Date r z ARCHITECT/ENGINEER Phone: Address: 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: $ OSS 1 FEE: $ � Check No.: Receipt No.: I 21 NOTE: Persons contracting with unregistered contractors do not have access t he uaranty fund r lnn'afi m- of Anent/Owner Signature of contractor §i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimn3ing Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS f HEALTH Reviewed on Signature COMMENTS 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: Located 384 Osgood Street F_R� DEPARTMENTS Tem Dumpster site,. ye' s�4, -- Fire�Departmenttsi('�nature/date fir xa -:••.ems mss._.�.`� �.., f .33s.`.., 4Rfi±" 3+fr Si..,�'`i.aL lfdu+�xt= Js.'r:a�-w'is Wi. `rw•`Y,"' ' .'`' COMMENTS.': ;' .. -. ;-a � , , ,��� ��, •� ��% �, Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doe.Building Pemit 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 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/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 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:Building Permit Revised 2014 Location 'I C�Ll vim, "L_`� �? No. f -- 7 o i l Date 111-Z • - TOWN OF NORTH ANDOVER ' W Certificate of Occupancy $ Building/Frame Permit Fee $ `� Foundation Permit Fee $ Other Permit Fee TOTAL $ Check#I /f VBuilding;14pactu NORTIy Town Of 0 : :. - / No. - h ,8",� ver, Mass, ee% COC KICKl WICK y1. x.45 RATED U BOARD OF HEALTH Food/Kitchen PERMI L D Septic System • THIS CERTIFIES THAT ...... .. . . .. ,�� �. BUILDING INSPECTOR *AFoundation has permission to erect .......................... buildings on .......... . ........... .....................� �...... Rough to be occupied as ...... ... ..:1....... .... .. �...................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC1UN 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. From:ll<ate Bargnesi Fax:t9i9)662•1975 To:+13395026345 Fax: +13395026345 Page 2 of 4 1111612016 1:56 PM Federal lD p 05-0405629 RISE Engineering tRiIIA corkractorr R inNo Ho fazas7s y A division of Thitlsch Lagioeering CT Contractor Registration No 62012G R' e' ENGINEERI sbawmut,Canton,MA 02021 CONTRACT 339.502-5197 _.'fFAX 339-502 6345 G-- Page 1 PROGRAM TNA COMMCT 16 ENTERED INTO a£TWEEM RTSE CMA-HES ENOIMEERIIKr AMD TME CUSTOMER FOR MAR AS OESCROW BELOW 2 CUSTOMER PMORE DATE CUBIT WORK ORDEri Kate Bargnesi (617)877-7312 04/08/2016 429984 00002 SERYICe STREET Cn ` aR1MG STREET 17 Quail Run Road 17 Quail Run Road G OERNCE CRY.STATEW 1 aiLLMO CITY.STATS,LP North Andover,MA 01845 L North Andover,MA 01845 ti JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in * concert with the use of special tools and diagnostic tests to assure that your home-will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,anached garages and other unheated areas(windows are not geecrally addressed.) This will require(8)working hours. A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual number of cfm is not guaranteed. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis rill be conducted by the sub-contractor to ensure the safety of the indoor air quality. $680.00 AIR SEALING ADDER: (4)working hours. $340.00 ATTIC FLAT:Provide labor and materials to install a 6"layer of R-21 Class l Cellulose added to(1080)square feet of floored attic space. $1,922.40 DAMMING:Provide labor and materials to install a 12"layer of R-38 unlaced fiberglass batts to(40)square feet for damming purposes. 382.00 ATTIC FLAT:Provide labor and materials to install a 1 I"layer of R-38 Class I Cellulose added to(96)square feet of open attic space. $144.96 ATTIC ACCESS:Provide labor and materials to install(1) easily moved,insulating cover for the attic access folding stair. A small flat surface of plywood will be created around the opening within the attic. This will allow the cover's integral weather-stripping.to restrict air leakage. $237.65 VENTILATION:Provide labor and materials to install(2)insulated exhaust hose with roof mounted napper vent to exhaust existing bathroom fan(s). 5237.50 VENTILATION:Provide labor and materials to install ventilation chutes in(63)rafter bays to maintain air flow. $126.00 COMMON WALLS:Provide labor and materials to install 2"FSK faced semi-rigid fiberglass board insulation to(40)square feet of common wall area, $140.00 BASEMENT CEILING:Provide labor and materials to install(30)linear feet of R-19 unfaced fiberglass insulation to the perimeter of the basement ailing at the house sill. $52.50 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently,for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Sealing measure-s up to the first 5680 and an additional$340 if savings are justified by the auditor. For the safety and health of your home's indoor au quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the wcatherizabDR work is complete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you. Total allowable weatherization incentive is 53.110. 'T From:Kate Bargnesi Fax:(9718)662.1975 To:+13395026345 Fax: +13395026345 Page 3 of 4 11t16120161:56 PM FecWal!D 008-0100639 WSE Engineering :a No 0186 MA . ND 130679 A div 82 or TWetscb EoX1neu1ng CT cattracw ftowalwn ft gain RISE 60,gMWMDh,COMOP,MA 02011 CONTRACT 339302-SI97 .FAX339-502�� .. Page 2 PROGRAM TRieoornRacT a orracaaroeaTwee+Rxe CMA-HES 6MOe If16MIDUMC 0TUMFrRWINflAS oua�coae.Dw EUSIMIt POW DATE OUE"$ TyORItORa61 Kate 13ahpesi (617)877.7312 0410&2016 429984 00002 HOW a1=1 sum MW 17 Quail Run Road 17 Quail Run Road 8==OMSTATkM Oaf aFV.NATE,ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION 590.00 Total: $4,00.01 Program Incentive: $3.110-00 Customer Total: ;843:01. -..... wE AGNEE m9mw To FaRP m sL%va-eX<itPLm w ACCamwcE wren mva spat icATI m&FOR ra salt of *"Nine Hundred Forty Three a 011100 Dollars $843.01 IO�Orr a YPUM!UAMDAMMALVIRMOOgEaR/iD CUWMMAORMTO MW AMO MOWNFULL.NMMMOFI%MLeECNYIOwwom yc"# r U.a•MD. AFMUDAVILKEREVB=Ponnwa"A RUSi0R1M TmoN ewpjMTEEB.RMRIIaOFSIcmftac"aoLLN mocamTnAc 0RRER1l1RAym 00.NOT SION Yh08 CON MCT WnMtrMN BLANC SPACES . aIaNATURE-ruin .. �ccevTAase avt�nw.eoNtrM►rrru►recwmoRAww�ruAw«oTaucuruDwmaN ..... . asaFAocMANee T°oNr°fTOCO"uET n WZA&0WrA OPOCIVATIMIJOCCUOITKMAN 30 *A" iRewDRa as aPaeaaED.PATreNT sal ee aADn Aa ausuxEo Aaova ". —A n d From:Kate Bargnesi 7 Fax:(978)662.1975 To:+13195026545 Far +13395026345 Page 4 of 4 1111612016 1:56 PM n ?D co 0 oa RISEt' 60 Shawmut Road Unit It 2!Canton,MA 020211339-602-6336 ' ,` wt+vw,RlSEengtneertrtg,com OWNER AUTHORIZATION FORM Kate Baragnesi (Owner's Name) owner of the property located at: 17 Quail Run Road, North Andover, MA (Property Address) (Property Address) Merrimack Valley Insulation t 23A Sullivan Rd hereby authorize Billerica,MA 01862 (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. rOwne s Signature Date ►�U�' The Commonwealth of Massachusetts Department of Industrial Accidents 04 Office of Investigations ' 600 Washington Street r' Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/lndividual): Merrimack Valley Insulation Corp. Address: 23 A Sullivan Rd. City/State/Zip: Billerica_, MA 01862 Phone#: 978-888-3495 Are you an employer?Check the appropriate box: Type of project(required): 1 1. X❑ I am a employer with 18 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E] New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' insurance.t 9. E] Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.[:1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.X❑ Other Insulation comp.insurance required.] :Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 5Star V3 AAIC American Alternative Insurance Policy#or Self-ins.Lic.#: V9WC749118 Expiration Date: 6/18/2017 Job Site Address: 1-1 ►1 P City/State/Zip:N,Rnd0O;er MA M++- 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 under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 8-888-349 Oficial use only. Do not write in this area,to be completed by city or town offwiaL 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#• J The Commoumealth of—Massa. set's Lem—:Lmeut of ladust ii?~~ Accidals + 0,,Rce of Tnveszigatim..s fOC w,enol St Bost0a,!tf�fl27il 1 vivn;z_mggs.g-w eia -Workex's Com-pensation nsuianl;e davit: BtsI�ersl�;ou sc�o `' �eCiIRCi I�Iu?+DezS AP- IC nlatio-a�fo�--anon—Pi.ease�'r_j�.3e==blr -I4amne(E-usines!©r,an�ai': �Iac�. 40 oi-.vieual[O?-tvuer.^ 2rMi.ate 1f�Eta; L��S�tEms'7u CCtZ�_ 5_c€di ess_ _Q:-�, A City/S te�i�:`'�I+ � ic3 �i,� cii��r phone.. a�•`��-� s- 0 g5 s Are you an employee— -kreyou the hom.eot uer' Check the appropriate umber- I. �a_rn aI?a�tiployer sit aL eii icyee5 f tan , raan tee. i aetar or p�z-tTieash_p ci C zo e�p_Q;es fort �aQ_ >ie in any capacity- am-m-a sole propr 3. _ 1 ain a homeown—ar doing a^.iI`=Fork m-sel (NiQ vorku=compeassuOB msurance recydred-) -;_ �at�L a_aeltierai cont amr 13c�a ht1 rC' J e s-iu-c(IP.i a_ct,a. �cZLei''i oII�e 3iia^c ed shev I i-These Coaltrae.oTs have i-Qrkeis comp-iisuraIICa--ad r nz:ve atmehed a^opy D=weir tIL_j -� S 817E 3 coT�G'��L?6L---ad9 iGca .417?tr2T�li?.G�- 12)S'P %of a~:_emP- on per 'FGT.C.1552§111 ! C4,1,:id we have-.a employees �Q T'orken:QT.ap.iB�rmice required-) _ i t7 n av icant um,cheCi3.aMi;!W.! -21750 Til out the Set-J05 Ceio..51owirm their F:orl--:yr C"i.L-17.soliev in=ormation. j tii�!�tiit!>?ilC3�i�atzci=. i o Contr.ctors'Imt:Cern tlti5 bu nausr aia2Cl an ddifipr—il sheet siiorRri`tie a1me of 1:2 cotnperisaiioa nolley,ittf.b=rG lum_ i =ane OF project(required): Giieck appropriate= i 6. New-- 'L?c COUST- oon _R L_�i J�: ?_i _ p iz� r, u 1 Ln c add:, m t 10. `_`-beet-n-cl 11- P1.umb. t� .£3Qs 13_ if 0tzei- :TAT9cJaL�G.., t str:as empib zr tfmt is pre idiom rmi err cuinumsaaou itn-umnec for otc_npIotee s. Below is the policy S job sire info_ insur"an-ce company4�e: pliCjr 0r 3e3 ss'is ' tLa ti C._ i>on Dale" -o13 S_t�c Address: ttacii a cop aiworkees coctnen54tion polio-declar .tior.pagelshn Angruie colic•rzumier and a piratiott dafe. FmIum c"!SeG1:-.:CQVeY2 as�-_t±tii?Q under Sectioa.252',of i`r.!c_15?`moi lead to the.`aTC05i Q7�T!T1t ac ialt-as of a iaite R!=Q SLAG.00 Ind-*Qr fl:ie er Sipi isoZF:]z;,'tt, S"mil a5 ci;til p-anald-s in the fol m o?a 'TOP 1WORK GIRDER andl•..:~ti�o i ptQ�a('i_oil..Q.;���il�the zOlauQiz BeadviiieQ Chet8 copy of th:5 :aa ernentt uta;be fQr>.r8rded to the Office of iu:esdgations 01-the DTA Qr iosarance LQ�tei y�e r�ri�catioa_ c do lierebv Lai ttmn Lr-der Z?e pa-Ins m-ldDei_!a71ii�CJI p�CiL`` ibu clic ia-fG-m:iedoh urm ided 2FD:m is triiie w d mrX1_ Dete: OffR cia't 1m- o l _ Do a(}=C iie in CIMS --ma-to be complete . v city oi-town i ficial_ i 1.-iCv l.lr im::'.t v'��'• :_: _svvu v . i - t issu iia__-R._�I-t ori _(C?'swell=Q?ze I. Board o:Heath -_uuudiner DR'== 3_ Ci__n i:r!'m i^.teit -_Y.iecidcal Plumb&Gas 6_ Oilier t t Contac_Person: (-print:.) °Lone i Ac©® CERTIFICATE OF LIABILITY INSURANCE DA 11/07/20 g 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), AUTHORED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poficy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,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 Carolyn A Coughlin Charles J Coughlin Insurance FAX 14 DinleyStreet PHONE _ (978)957-3588 Arc No: MAL P.0.Box 10 ASS: Carolyn@(wughlinins.com Dracut,MA 01826 INSURER(S) AFFORDING COVERAGE NAIL# INSURERA: Northland Insurance Company 24015 INSURED Merrimack Valley Insulation Corporation Joseph A.Ryan,Jr. INSURER B: Safety Standard 39454 23A Sullivan Road INSURERC: Torus Specialty Insurance Company A0159 N. Billerica,MA 01862 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 ADDL SUBR POLICY EFF POLICYEXP LTR TYPE OF INSURANCE INSD WVQ POLICY NUMBER D/YYYY) Amppryyyyi LIMITS A COMMERCIAL GENERAL LIABILITY WS274182 01/21/2016 1/21/2017 EACH OCCURRENCE S 1,000,000 CLAIMS-MADE F�I OCCUR DAMAGE TO RENTED 1 Q0 000 PREMISES Ea occurrence) $ MED EXP(Any one Person) S 5,000 PERSONAL&ADV I W URY $ 1,000,000 GENL AGGREGATE U MIT APPU ES PER GENERAL AGGREGATE $ 2,000,000 PRO- J POLICY 0 ELOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ B AUTOMOBILE LIABILITY 6205006 11/25/2015 11/25/2016 COMBINED SINGLE DNIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ AWNED UTOS ONLY AUTOS ULED BODILY INJURY(Per accident) $ HIRED N I NONOWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ C UMBRELLAUAB OCCUR 87593L161AU 01/21/2016 01/21/2017 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED 1 I RETENTION S 0 $ WORKERS COMPENSATION PER OTt+ AND EMPLOYERS'LIABILITY Y f N STATUTE ER ANY PROPRETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E_L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S F1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Reworks Schedule,may be attached if more space is required) Insulation Installation 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,Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andowr,M A 01845 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD MERRVAL-03 UUEJE CERTIFICATE OF LIABILITY INSURANCEDATE(IAPNDDIYYYY) 6,020'16 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 PiMEND, S(TEND 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. It SUBROGATION IS-UIIAIVED,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: Automatic Data Processing Insurance Agency,Inc PHONE _ FAX 1 ADP Boulevard AIC.No EM : I AIC,No): Roseland,NJ 07068 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC K INSURERA:5Star V3"C American Alternative Insuran. INSURED Merrimack Valley Insulation Corp INSURERS: _ 23a Sullivan Rd INSURER C: _ North Billerica,"MA 01862 INSURERD: -- - - ----- _ �`'--- INSURER E _ I INSURER F: —.^---- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 1S TO CETZTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO vilHIGH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- SRTYPE OFINSURANCE' L" ADDL SSUER;'- -- --- + POLICY FBF POLICY 7 - -- LTR tNS1 RIU�Np1 POLICY NUMBER I b1lNDD1YYYY h1hUDD/EX'P'1 1161frs GENERAL LImi-rrI, EACH OCCURRENCE I S COIIMERCIALGENERALLL49ILITY OAAA' t PRELI1SESjEaoccunznc] t S _ r— —� FT :CLAIMS-MADE OCCUR. 1 7 r,ED EXP(Any one person)_i 5 _ i lLj __— i i PERSONAL S ADV INJURY S k�Etli,I'L GENERALAGGREGATE I5 AGGREGATE U67ITAPPLIES PER: i !PRC - (� ! {PRODUCTS-CONIPJOPAGG S POLICY ,IECT I 1 LOC HOP.IOBILELIABILITY I ! I COMBINED SINGLE LIMIT Ea accident S ANY AUTO 8001LY INJURY(Perpersnn) LSALL OWNED SCHEDULED AUTOS AUTOS i BODILY INJURY(Per accident)j 5 f NON-0WNEOI I I PROPERTY DAIAAGE HIRED AUTOS AUTOS ( j i Peracid..-nU 5 . — UtABRELIA LIAR OCCUR ; + EACH OCCURRENCE 5 I EXCESS LIAR C4ilMS IhAOEi ! S t DEC) P.ETENTION S AGGREGATE s WORKERSCOf1PENSAT10N x WCSTATU- OTH- i AND EMPLOYERS'LIABILITY Yf N ! TORYLmn's I ER A I FS•lY PROPRIETORIPARTNEtIEXECUTArE ❑ V9WC749118 611812016 6/1812017 F-L EACH ACCIDENT — 5�----1,000,000 OFFICER!!/EMEE?EXCLUDED? Y NIA — — '- I(Mandatory inNH) E.LDISEASE-EAEMPLO S 1,00'00 t If Yes,describe under I 0 RfPTTOMOFOPERATIONSbemi g E.LDISEASE-POLtCYUfLfI S 1,000,00 { ! I 7 DESCRIPTION OF OPERATIONS I LOCATIONSIVEHICLES(Attach-ACORD 101,Additional Remarks Schedule if more space is required) I 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 Andoier,Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andoter,MA 01845 THORIZED REPRESE14TATIVE 1 ©1988-2010 ACORD CORPORAT ION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered-marks of ACORD f Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home ImprovemerrtContractor Registration Type: Corporation Merrimack Valley Insulation Corp Registration: 180506 Ecpi rati on: 11/23/2018 23 A Sullivan Rd o Billerica, MA 01862CC a V Update Address and return card. Mark reason for change. SCA 1 0 2OMF-05111 ❑ Renemroi E-1 rmpinyment I-1 1 nSt�`arri�_ ,per CJJre �panznzanrueall�a���Gaaaa�r�le� -\ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only Type: Corporation before the expiration date. If found return to: Ciegistration Expiration Office of Consumer Affairs and Business Regulation ® = 80506 11/23/2018 10 Park Plaza-Suite 5170 _= Boston,MA 02116 Merrimack Valleyffi lation=Corp Joseph Ryan 4- c- ; 23 A Sullivan RdV�� Billerica,MA 01862=F .. Undersecretary � Not v id ithout signature ttiassachusefts-Oepa.=r=tent at Pubtic Safety Bcard of Bui;din g _tIciaa<,n s a S Z:n d ard C 4 11:S�i3 ilL lilifi.Tii�Il.s I�tS :Cense. CS-075541 JOSEPH A RYA-N.: �. 200 Kmg Raft Dr_A-Dt:201 _ Lynufield MA 01-940 h Cor :sssore: 02/04/2017