HomeMy WebLinkAboutBuilding Permit #917-14 - 172 SUTTON STREET 6/16/2014Permit No#: " 111—
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued: 1
IMPORTANT: Applicant must complete all items on this page
LOCATION`
a. r-•A10
ntPROPERTY OWNER ow U/�� A`GIU�UC. Pe -
JIHL 100 Year Structure yes no
MAP PARCEL: _ ZONING DISTRICT __Historic District yes no
a Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
11Addition
11Two or more family
❑ Industr'aI
❑ Alteration
No. of units:
❑ Commercial
❑ Others!:
❑ Repair, replacement
❑ Assessory Bldg
❑ Demolition
"ther _rA
❑ Septic ❑ Well-
❑ Floodplain ❑ w9flands
❑ Watershed District
11 Water/Sewer
r-OUKIr i PN r
JI Pew l X14/ , ,G v0 a�.
Identia atiq� P) e,ase Typg or P int Clearly
OWNER: Name: /�C-'? G/` AG7th 1911 Pl_ ph"
t3 - PERFORMED:
/C, r 0 1
Address:
Contractor Name!?_p/"(_. �q Phone :�l/
Add ress: J� ..Sru C✓ c >/'� �"```�.." ��� C _—O�1^�7�
Supervisor's Construction License:li•-_ Exp. Oates _,__� !-S
Home Improvement License:
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.
1 �(
Total Project Cost: $__ '/ /_�_� " FEE: $
Check No.: Iv Receipt No.:
NOTE: Persons c tracting with unregistered contractors do not have access to the guarantyfunll
nature of co
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 Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Z Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Con nection/Siqnature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE' DEPARTMENT - Temp Dumpsfer on site yes no
Located at 124 Main Street
Fire Department signatureldate
COMMENTS
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,
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
Its
,�-. ❑ 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
o 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 stampthe decision from the Board of Appeals
PP
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 n2- srza&
No. C� I I —1�
Check W� LA -
27 633
Date Iq
I I I
TOWN OF NORTH ANDOVER
map
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL $
Building Inspector
Deems, Maura
From: Johnson, Adele
Sent: Tuesday, June 17, 2014 4:23 PM
To: Thibodeau, Bruce
Cc: Brown, Gerald; Deems, Maura
Subject: RE: Selectmen's Vote on Waiving of Fees McEvoy Field
Bruce,
The Board lumped all the waiver of fees together in one vote below.
Waiver of Building Fees for various projects at Scholfield Mill, 170-172 Sutton Street
The Board is asked to approve waiving any and all building fees for various projects at Scholfield Mill. These include
several CPA funded projects (roof replacement, window replacement, etc.) and the construction of a small addition
approved as part of the FY15 CIP at the recent Annual Town Meeting.
Waiver of all fees associated with the building of a new Fire Station at Chickering Road and Prescott Street
The Board is asked to approve waiving all fees associated with the building of a new Fire Station at Chickering Road and
Prescott Street. This would include filing fees with the Planning Board and Zoning Board of Appeals as well as building
fees.
Waiver of all fees associated with the Redevelopment of McEvoy Field project
The Board is asked to approve waiving all fees associated with the Redevelopment of McEvoy Field project.
Waiver of Building Fees for new wall openings project at Atkinson School
The Board is asked to approve waiving building fees for installation of new wall openings for interior borrowed light
units at Atkinson School.
Richard Vaillancourt made a MOTION, seconded by Donald Stewart that the Board of Selectmen waives any and al
building fees for various projects at Scholfield Mill, 170-172 Sutton Street, the building of a new Fire Station at—
Zhickering Road and Prescott Road, with the Redevelopment of McEvoy Field project, and for the wall openings pr
at Atkinson School. Vote approved 5-0J
ancourt m
related to the above projects. Vote approved 5-0.
From: Thibodeau, Bruce
Sent: Tuesday, June 17, 2014 3:30 PM
To: Johnson, Adele
Subject: Selectmen's Vote on Waiving of Fees McEvoy Field
Adele,
that the Board of Selectmen waives any and all
Can you provide me with the vote from the last Selectmen's Meeting on the above? Thanks.
Bruce D. Thibodeau, P.E.
Director, Department of Public Works
Town of North Andover
384 Osgood Street
North Andover, MA 01845
Phone 978.685.0950
Fax 978.688.9573
Email bthibodeau@townofnorthandover.com
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The Commonwealth of .tVlassachusetts "
Departmintof ndustyrnlAceiknts '
Office oflnvesiigations
600 Washington Street
Boston, .MA 02111
www.mass govIdla
Workers' Compensation Insurance .Afiiidavit: Baders/ContractorsLElectx ciansqli%mbera
Name Busin
.Address:
_�;-e.1ce4..lYl/*-eooto
City/State[tip;
Are you an employer? Check the all r
1. [] I am a employer with
employees (fuu and/or par- time).*
2. [] I am a solo proprietor or partner
ship and` have no. employe as
working forme in any capacity.
Wo workers' comp. insurance
required.]
3. [] 1 am a homeowner doing all work
myself [No workers' comp.
insuxancerequire fl i
A9.4070,10
- LJ
date box:
4. F] I am a general contractor and I
have hiredthe sub -contractors
listed on the attached sheet I
These sub -contractors have
kers' comp. insurance.
5, We are a corporation and its
officers have exercised.their
xight of exemption per MGL
c. 152, §1(4), andwehaveno
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ]] .Naw construction f
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electriclxepairs or additions
11.[] Plumbing repairs or additions
12.❑ Roofxepairs
13.[] Other
xAny applicantthat checks box#I must also fill outthe section below showingtheir workers' compensationpolicy information.
fHomeownerswhosubmitthisaffidavit indicatingtheybit doingallworkandthenhire outside contractors mustsubmitanewaffidavit indicatingsuch.
TContractors that cheokthis box must attached m additional sheet showing the name of the sub -contractors andtheir workers' comp. policy information.
Z am an employer that is providing workers' cornperasation in ur an fog m employees Blow is the policy anc�job site
�
Insurance Company
uGf >W Hsi, A44
Policy # or Self ins. Lic. M. Expiration Date:
`/2 `�y! Czty/State/Zip: /l/1YG� t
lob Site Address: r
Attach a copy of the workers' comp ensation'Oolicy declaration page (showing.ilze policy number and expirations crate).
h'ailma to secure coverage.as xequiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a
ffmo up to $1,500.00 andlor one, -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER. and a fm.e
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
fInvestigations of the DIA. for ibsurance coverage verification.
Mo liereby cert" zlierkletiainsand enalti perjurytliatilioinformationprovidedabov is ueandcorrect.S7aturc• Data: I
_
Oficial use only. Do not write in tlils area, to be completed by ciiy or town offrcial.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/fwn Cleric 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 demoted as "...every person in the service of another under any contract of him,.
express orimplied, oral or written."
An employeris defined as "an individual, partnership, association, corporation or other legal entity, or any two oxmore
of the f6rQo)ifij engaged in aJoint enterprise, and including the legal representatives of a"deceased employe, .or the
p, association or other legal entity, employing employees. Howeverthe
receiver orirustee of anindividual,partnershi
owner of a dwelling house having not more than three apartment �and who resides'therein, or the o coupant of the
dwelling house of aizothex who employs persons too maintenance, consinz`ctioiz ox repair wort on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes."
MGL chapter 152, §25C(6) also states that "every state or local lic-�nsvag.agency shall withhold the issuance or
reziewal of a license or permit to operate a h6iuess or to construct buildings iii the comm' 'Ok wealth fox fizzy
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 beenpresented 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-conixactor(s) name(s), address(es) andphonenumbex(s) along with their ceztificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members orpartuers, arenotrequiredto carryworkers' compensation insurance. IfanLLC orLLP doeshave
employees, apoIzcyis xequired. Be advisedthatthis affidavit maybe submitted to the Department of Industrial,
Accidents fax con%xmation of iusuxance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed 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. SO -If -insured companies should enter their
self insurance license number on the appropriate line.
City or Town Officials
Please be sure, that the affidavit is co plete," andpriited legibly The Department has provided apace at•ihe bottom
of the of fk vit for you to, fill out in the event the Office ofh ve9tigatioiis has�to cohtact you reprt kg the applicant.
Please be -sure to � in the permit/Hcense number whichwill be'tMed as a r&xenc6 nu &,r. 7n. addition "an applicant
that must submit niultiple permit/lieense applications is any given year, deed only"s'ubmit one affidavit indica tg:curxent
policy information (if nece'ssaiy)` and.umer "Yob Site Address" the applicant should vwxite "all locations in M: (city or
towiz)" copy of the affidavit that has been officially stamped or marked by the city ox town may be provided to the
applicant as proof that a valid affidavit -lion on izle for iuiuxe p exmits or licenses, Anew affidavit must be fitted out each
Year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture
(i.e. a dog license orpermit to burn leaves eta.) said person is NOT required to complete ibis affidavit.
The Office of Investigations would like to thank; you in advance fox your cooperation and should you have any ctuestions,
please do not hesitate to give us a call.
The Department's address, telephone aizd ft number: 4 �.
1
Tho.Tho.CQ ox w�a t Z o aSsachv Pts �' `• '' .
• (.�f�ec o�Tn.�eSii�a-�xQu� '
60 WasW-agtm
Boston., 02111
TQ1. # 617-727-4.9-00 e-406 Qx 1 -877 -
Revised 5-26-05 `ay, # 617"727-7749
' �vt�'.�tas�,g4?vfclia
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To Zbigniew Mrorzka (MDMENGINC@yahoo.com),
Santilli, Ray
Z
See attached roof shingle color selection
Please verify "Pewter Gray" = color selection shown on the chart
Drip edge metal should be mill finish
fy
Ray santilli to prepare a p.o. and send to you M1'
i
i
A permit is required but the permit fee is waived.
Call me Tuesday 6.10.14 to coordinate schedule
Steve foster
Pleas: note the Massachusetts Secretary of State's office has determined that most emailsto
and from municipal offices and officials are public records For more information please refer
to: http:/A%m.sec.state.ma.udpre/preidx.htm.
Please consider the environment before printing this email
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i
ROOFING SHEET METAL CONTRACTOR
[ - ML7.L!J.!\/,�.
51 Sawmill Road, Dudley, MA 01571- MDMENGINC@yahoo.com - (Phone) -508-949-1616 - (Fax) -508-949-3176
Data: 06/02/2014
Regarding: Schofield Mill -172 Sutton Street -North Andover, Ma — Shingle Roof Quote
Attention: Stephen E. Foster— Facilities Director
A cost proposal for the above referenced project follows:
1. GAF Timberline 40 year shingle - $1,920.00
2. GAF shingle starter - $60.00
3. GAF shingle cap - $80.00
4. Ice & Water at rake, eave, ridge - $780.00
5. 301b felt - $80.00
6. % inch CDX plywood - $740.00
7. F5 drip edge - $84.00
8. Cobra ridge event - $120.00
9. Roofing Nails - $30.00
10. Plywood Fasteners - $160.00
11. 3 pipe boots - $48.00
12. Copper step flashing - $60.00
13. Existing Material Disposal - $580.00
Material Total - $4,742.00
14. 5 men x 8 hours = 40 hours x $60.66 (Roofing Wage) _ $2,426.40
15. Workers Comp/Liability Insurance = $2,426.40 x 42% _ $1,019.08
Labor Total - $3,445.48
Material + Labor Total - $8,187.48
16. M.D.M. Engineering Inc. Overhead & Profit - $8,187.48 x 15% = $1,228.12
Grand Total - $8,187.48 + $1,228.12 — $9,415.60
I
Zbigniew Mroczka
Pr s� ident
M.D.M. Engineering Inc.
Rightfax C3-1 3/5/2014 4:38:16 AM PAGE 2/002 Fax Server
."` CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/ODIYYYYI
nwy
T VIFICATE 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. D THE CERTIFICATE HO DE .
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 and endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME:
PHONE
FAX
O'CONNOR & COMPANY INS
PO BOX 1458
(A/C, No, Ext):
(AfC; No):
i
E-MAIL
DUDLEY, MA 01571
ADDRESS:
29GBF
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED
INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY
INSURER B:
MDM ENGINEERING COMPANY INC
INSURER C:
INSURER D:
51 SAWMILL ROAD
INSURER E:
DUDLEY, MA 01571
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 6 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS.
INSR
ADD
SUB
POLICY EFF DATE
POLICY EXP DATE
LTR TYPE OF INSURANCE
L
R
I
POLICY NUMBER
(MM\MXYYYY)
(MMDDIYYYY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
Is
HCOMMERCIAL GENERAL LIABILITY
CLAIMS MADE ❑ OCCUR.
(RENTED $
REMISES
REMISES (Ea occurrence)
ED EXP (Any one person) $
ERSONAL & ADV:INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
ENERAL AGGREGATE $
POLICY F] PROJECT ❑ LOC
RODUCTS - COMP/OP AGG $
AUTOMOBILE LIABILITY
COMBINED SINGLE $
ANY AUTO
LIMIT (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULEAUTOS
(Per person)
BODILY INJURY $
(Per accident) i
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
i
UMBRELLA LIARHO
CCUR
EACH OCCURRENCE $
AGGREGATE $
r
EXCESS LIABCLAIMS-MADE
DEDUCTIBLE
$
$
RETENTION $
A WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY YIN
UB -4777P402-13
06/042013
Oa/04/2014
XWC STATUTORY OTHER
; LIMITS _
E. L. EACH ACCIDENT $ 1,000,000
ANY PROPERITORMARTNERIEXECUTIVE a
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
N/A
E.L. DISEASE - EAIEMPLOYEE $ 1,000,000
DESs, deserlbeCRIPTION OFunder
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONStLOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
120 MAIN STREET IN ACCORDANCE WITH THE POLICY PROVISIONe7,
AUTHORIZED REPRESENTATIVE
NORTH ANDOVER, MA 01845
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPOIRWTI 7N."• Afffl hts reserved.
Rightfax C3-1 3/5/2014 4:38:16 AM PAGE
2/002 Fax Server
I
i
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
TM&OMIFICATE 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
ORP ODUC R D HE CER i TE 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 and endorsement A statement on this certificate does riot confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME:
PHONE
FAX
O'CONNOR & COMPANY INS
PO BOX 1458
(AIC, No, Ext):
(A1C, No):
E-MAIL
DUDLEY, MA 01571
ADDRESS:
29GBF
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED
INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY
INSURER B:
MDM ENGINEERING COMPANY INC
INSURER C:
INSURER D:
51 SAWMILL ROAD
INSURER E:
DUDLEY, MA 01571
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS O CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TEAM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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
ADD
L
ISUB
R
POLICY NUMBER
POLICY EFF DATE
(MmomyYYY)
POLICY EXP DATE
(MM1DD\YYYY)
LIARS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 7 OCCUR.
DAMAGE TO RENTED $
REMISES (Ea occurrence)
ED EXP (Any one person) $
ERSONAL 8 ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
ENERAL AGGREGATE $
POLICY F] PROJECT F]LOC
PRODUCTS-COMP/OPAGG $
AUTOMOBILE LIABILITY
COMBINEDSINGLE $
ANY AUTO
LIMIT (Ea accident)
_
BODILY INJURY $
ALL OWNED AUTOS
SCHEDULE AUTOS
(Per person)
BODILY INJURY $
(Per accident)
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
DEDUCTIBLE
$
_
RETENTION $'
A
WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY YIN
UB -4777P402-13
08/04/2013
06104/2014
X I WC STATUTORY OTHER
LIMITS
E. L. EACH ACCIDENT $ 1,000,000
ANY PROPERITOR/PARTNER/EXECUT[VE E:]
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
WA
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
It yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIRESTRICTIONSISPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
120 MAIN STREET IN ACCORDANCE WITH THE POLICY PROVISIOI
AUTHORIZED, REPRESENTATIVE
NORTH ANDOVER, MA 01845
v \h !
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 1988-201 D ACOFID CORPOF{ATFUR. • A1lTrg'nts reserves.
4a i
Massachusetts - Department of Public Safety
'+Board of Building Regulations and Standards
Construction Supen icor
License. CS -072493 /r
ZBIGNIEW MROC°ZKA i,
51 SAWMILL RD.`
DUDLEY MA 01TS71
L"i .�jt. JI
,��,,,� �y j"" Expiration
Commissioner 09/06/2015
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