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HomeMy WebLinkAboutBuilding Permit #701-15 - 18 LYMAN ROAD 3/4/2015Permit N0: 9-q,( r Date Issu LOCA BUILDING PERMIT Y TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Date Received .g TANT: Applicant must complete all items on this A 3 9�7.�L 0 Kf C Print PROPERTY OWNER ft e du Print /� MAP NO: PARCEL:V��-- ZONING DISTRICT: Historic District yes(-no Machine Shop Villaqe yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne 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 Identification Please Type or Print Clearly) OWNER: Name: W \ 0- ((_ �J (-a I Address: l 1) CONTRACTOR Name: Address: Supervisor's Construction License: Home Improvement License: Un �(k ti,� 3 �o 5;J #, Phone: � (1 � 335 Phone: `) � D t ' C _S— (� laa y\-) xp* a we )_ 0 , 01 Exp. Date: zK 0 `115" 1A1 10lr� f ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST rSED ON $125.00 PER S.F. Total Project Cost: $ 02� (off FEE: $ .� _Izq Check No.: .Vg_Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guara fund Signature of Agent/Owner Signature of contracto � J T BUILDING PERMIT' " V TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received 71 4 - Date Issued: aF a� ADRATED TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition 0 Other ❑Septic E Well 0 Flgodplain ❑Wetlands ❑ JNatershed District ❑ Water/Sewer . DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: 'Phone: Address: w ; Supervisor's Construction License: _ _.. __ Exp. Date:, Home Improvement License: _ T _ Exp. ARCHITECT/ENGINEER Phone:!�-;aY .; Address: Reg. No -!,: FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED,COS:T BASED ON $125.00 PER S.F=_ Total Project Cost: $ FEE:.: $ Check No.: Receipt No:: NOTE: Persons contracting with unregistered contractors do: not. ave access to the guaranty J x4nd gnature of Agent/Owner= Signature of contactor, 1" f?� 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 Doe: Building Permit Revised 2014 4 y Plans Sub,nitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ j7y_ F 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 Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS 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: Y - _ _ Located 384 Osgood Street FIRE DEPARTMENT Hemp �Dum_pster on site - 'L•ocated,at 124-Min,aStreet yes. -- = ti no ,Fire IDepartment;signature/date__ COMMENTS E _, - - --i Dimension Number of Stories: Total square feet of floor area, based en Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop:requi.res approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Pennit Revised 2014 Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 24,265.00 m $ - $ 291.18 Plumbing Fee $ 36.40 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 36.40 Total fees collected $ 463.98 18 Lyman Road 701-15 on 3/4/2015 Finished Storage Space in Basement Complete Basement Remodeling BAalrmMENT IV1NG 5-YSTEMS-1 ax Basement Living Systems of New England, LLC 11 Sixth Road Woburn, MA 01801 781 937-9000 Name Address L M u rV Phone Contract Sketch WALLS APPROX LN FT S COLOR GREEN BOJ RD or P 11 TE ED WALLS TRIM COLOR W V WINDOWS (e m t f ) 6 PANEL DOORS 30" �_ 32" L 36" BIFOLD DOORS 30" 36" 48" 60" EXTERIOR STEEL DOOR CEILING APPROX SQ FT STYLE VVMStJ✓I (U SOFFITS APPROX SQ FT # POLE WRAPS ELECTRIC PACKAGE: SUB PANEL OUTLETS: STANDARD _L GFI / DEDICATED 6" RECESSED CAN LIGHTS SWITCHES _3 PULL CHAIN LIG PSMOKE DETECTOR CABLEJACK INTERNETJACK 8' BASE HEATERS WITH WALL THERMOSTAT _ OTHER FLOORING APPROX SQ FT 4l� STAIRS C i` 1c�- On/ DEMOLITION SIGNATURES: DATE REMARKS REPRESENTATIVE HOMEOWNER O O .� O _ m .a Cl) > CL • CL O m n O 0 0. 0 z c =r =r � y O O — Q m •'► -% =4 S O N CD 'a CD _ C (Q to Q O l rt �� ° J O � rt C7 W � ID CD C CD -0 r. � c0� ss oo� a :tom rt rt `•� C o ss ' N fA O 0 = Q Q2. o = Q. < CD N O O ..+ < � O O CD CD W�CIP CD 'I J -% 0 'N% w =, � rt O ° =r C CD CD 5C ° .. 0 N o 0, ' =: DCD ma n� � _rt a1 O O O Q , N Ln W T TVI X v T ;Q T n x T V7 T 0 (D rr (D K O C j (D •n m D z j w O C D N vZi j p) r)s O C m m C �_ H M p) O C 3 C j y � O C O C a O O 2 z vZi v � O a fD 'B 0 3 O O n S fD 3 W D X O 2 m x U) O n CD CD O Z CL C--) rrn rn = �o CO)CL c c� N 0 --I m •� O May Z� O v CD VVI MQ O fi �• C V/ Cl cr CD CD OZ'S 00Oo3 CD V)Z CL v U) CD —� _ O CA CO CD S O o0 -0 Z CD O r' O 70 c CD z CO) C n O O O .� O _ m .a Cl) > CL • CL O m n O 0 0. 0 z c =r =r � y O O — Q m •'► -% =4 S O N CD 'a CD _ C (Q to Q O l rt �� ° J O � rt C7 W � ID CD C CD -0 r. � c0� ss oo� a :tom rt rt `•� C o ss ' N fA O 0 = Q Q2. o = Q. < CD N O O ..+ < � O O CD CD W�CIP CD 'I J -% 0 'N% w =, � rt O ° =r C CD CD 5C ° .. 0 N o 0, ' =: DCD ma n� � _rt a1 O O O Q , N Ln W T TVI X v T ;Q T n x T V7 T 0 (D rr (D K O C j (D •n m D z j w O C D N vZi j p) r)s O C m m C �_ H M p) O C 3 C W p j y O C O C a O O 2 z vZi v � O a fD 'B 0 3 O O n S fD 3 W D X O 2 m x c v c Champion Home Improvements of New England, LLC Phone: 781- 937-9000 11 Sixth Road Woburn, Ma. 01801 Home Owner CAJ �%(,�� Phone Address: Lam( Vy\ u n IU Jf V -y LLUJ-�- , & �5 Email 1. Agreement Date �� qt 4. Deposit tD y 2. Contract Sum)_ (p , 5. Due at Commencement yo 3. Source of Funds 1.�� i. LLL 6. Due upon Completion RJ Uy 7. Completion Schedule: Work will begin approximately on o2 �y and will be completed within weeks. Contractor is not responsible for delays due to a change in the scope of work, and other factors out of his control such as weather, utility failures and inspector's delay. Homeowner must provide a clear and safe path from parking location to project entrance. 8. Scope of Work: Work to be performed in accordance with contract sketch. Any changes to agreement must be written with homeowner's and contractor's signatures. Any additional work mandated by township to be priced at fair market value; labor and materials. Contractor will leave premises broom clean daily. 9. General Provisions: Contractor provides all labor and material to complete work unless otherwise stated. Contractor responsible for obtaining all necessary licenses, required permits and inspections. All work will be completed in compliance with codes and applicable laws. 10. Warranty: Contractor's warranty for labor will extend for a period of twelve months from date the work is completed. Customer must give contractor written notice within warranty period for any claim. Customer shall have no other remedy against contractor for warranty claim for loss or damage caused by intentional or negligent acts, loss or damage caused by acts of God or any other consequential damages. 11. Payment: Payment of the price is due by customer in full upon the terms set forth in this contract. In the event that the contractor declares the project complete but the customer determines items for "punch -list", it is agreed that the customer may be entitled to withhold 5% of the total contract price until such items are completed. The contractor has the right under Massachusetts and New Hampshire Lien Laws to use your home as security for payment for this agreement. 12. Remedy For Breach: If customer breaches this contract, contractor shall be entitled to recover the greater of liquidated damages in the amount of twenty percent (20%) of the total contract price, or such actual damages as the contractor may prove. In the event that the contractor cancels this contract, a written notice will be sent within thirty (30) days of contract date and all deposits or monies on account will be promptly refunded to customer. 13. Arbitration: Customer may contact the contractor with any questions or complaints regarding the contract. All disputes and claims between customer and contractor concerning this contract which any party believes cannot be resolved informally, including without limitation any warranty claims, shall be resolved by binding arbitration conducted by a single arbitrator under the auspicious, rules and procedures of the American Arbitration Association and in accordance with the applicable federal and state arbitration statues. The arbitration shall be held in the city or county where the premises are located. No discovery shall be allowed except as may be agreed to in writing by the parties. Either party may demand arbitration, and the arbitrator's final award shall be issued within ninety (90) days after the service of the arbitrating demand on the other party. It is agreed that all arbitration costs shall be bourne by the party that does not prevail. 14. Cancellation: Under Federal and State Law you have up to three (3) business days to cancel this agreement. Comments: Signatures Owner: Contractor: n Print: A %, CL �I�-' c( Date: Print L Sti 1—k a G r,. �' h I,Date: HOMEOWNER HOMEOWNER //Y' �/+/ l L/_/ ) Complete. Basement Remodeling Basement Living Systems Name 4' i arc, 1.1 Qd,� address an of N />1- BASEME� 1 Sixth Ro dLC plid , Lu/ r -L1 V I N GSYSTEMS`, Wobum, MA 01801 Phone " 781 937-9000 �br` Contract Sketch o Litt"`. wU�4�- Av . 1n4Ll5}1c P' 4 . q ESLS WALT. SYSTEM GREEN BOARD WALLS SOFFITS AND POSTS LIGHTS COLOR � WALLS APPROX W FT �REJp ELECTRIC PACKAGE: SUB PANEL GREEN 80) RD or WALLS J n <F UTLETS O: STANDARD _L Gn / DEDICATED TRIM COLOR U,iVt M �f-'��(A 6" RECESSED CAN LIGHTS 7. SWITCHES WINDOWS �e tw / PULL CHAIN LIG 6 SMOKE DETECTOR M 6PANEL DOORS 3V 32" _L 36" CABLEJACK INTERNETJACK 81FOLD DOORS 30"_36"_49"_W_ B' BASE HEATERS WITH WALL THERMOSTAT ___0 EXTERIOR STEEL DOOR OTHER J� 1 CEILING APPROX SQ FT U STYLE 1'�T Yid S1l'11+1 �� FLOORING APPROX SQ FT l/ I- A '1 SOFFITS APPROX SQFT NPOLE WRAPS C Ad- 06.1 DWOUTLON �u b lie STAIRS r . SIGNATURES: DATE REMARKS REPRESENTATIVE / - / /v •! HOMEOWNER //Y' �/+/ l L/_/ ) Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS422200 DOM mC G RICO r� 405 CARDINAL I N TYNGSBORO MA ,o _ Expiration Commissioner 05/20/2016 CITY OF BOSTONX19029 BOARD OF EXAMINERS r' - MAYOR ` �^ Martin J Walsh - - {SAY uCENSEOTQ TAKE CH F F S A i/d/1B�E�0 Nt AQ. fja+isrl4W23f13 Mass 4r I BOARD 0= EXAVINERS ffice of Consumer Affairs R Business Regulation 5 OME IMPROVEMENT CONTRACTOR CHAMPION HOME-Ih NEW ENGLAND LLC DOMINIC RICCI ; 11 SIXTH ROAD WOBURN, MA 01801 Type: Supplement Cs OF Undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 1 Congress Street, Suite 100 ` Boston, MA 02114-2017 5 ` www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print V'Le2ibl/y / Name (Business/Organization/Individual): (,(K n l� L�/j -( f/¢J /u (, L[„ t/ Address: 8 Is. i �( LA e Uay) L l'n , 0 ( �'0I Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. [X I am a general contractor and I employees (U] and/or part-time).* T have hired the sub -contractors 2. ❑ I am 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. employees and have workers' [No workers' comp. insurance comp. insurance.: required.] ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 3)4", Type of project (required): 6. ❑ New construction 7.] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F] Electrical repairs or additions 1 LE] Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *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 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. _ A Insurance Company Name: �{-,- -(/L-j _A d (m n /1 d -P_ /4-oit,/1 k Policy # or Self -ins. Lic. #: ►) f� (, U 11 % 6 v Expiration Date: Job Site Address: y ^ �- GQ - City/State/Zip: 1 VU/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 nder the pains andpenalties ofperjury that the information provided above is true and correct Signature:ylyti (2S 4 Date: f Yd 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 #: lllk O CERTIFICATE OF LIABILITY INSURANCEF2/27/D27/ 201/DDIY5�5 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: Deborah Stanhope Elliot Insurance Agency A Division Of PHONE(603) 497-4143 IF XAX No•(603)497-2521 Eoo a :dstanhope@elliot-ins.com Stanhope Associates, Inc 11 North Mast Street Goffstown NH 03045 INSURERS AFFORDING COVERAGE NAIC# INSURERA:MSA Group 29939 INSURED INSURER B :Travelers ROBINTONS REPAIR & REVOVATIONS LLC INSURER C: 9055 35TH WAY N INSURER D: INSURER E: GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JrCT PRO LOC PINELLAS PARK FL 33782-5951 INSURERF: COVERAGES CERTIFICATE NUMBFR:CL1522701938 RF\/ICInM All IM01=0 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDL Im SUER POLICY NUMBER EFF MMIDDPOLICYIYYYY EXP MM DDY/YYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR B38358 /25/2015 /25/2016 EACH OCCURRENCE $ 1,000,000 AMAGE TO RENTED PDREMISES Ea occurrence $ 500 , 000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000 , 000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JrCT PRO LOC PRODUCTS - COMPIOP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTntDAMAGE $ 14DED UMBRELLA LIAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBEREXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 6KUHSH26093819 /9/2015 /9/2016 WC STATU- OTH- E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYE$ 500,000 E.L. DISEASE - POLICY LIMIT I $ 100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) (;I --K I IFIGA I t HULUtK GANL,tLL.A I IUIV Champion Basement ACORD 25 (2010/05) INS025 (201005).01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Lavallee/LAVALL ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OP ID: LO ACORV* CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDNYYY) 02/17115 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 '4CONSTITUTE 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 P_ hone: 781.935-8480 DeSanctis Insurance Agcy, Inc. Fax: 781-933-5645 100 Unicom Park Drive Woburn, MA01801 CONTACT NAM PHONE Ra No M ADDRESS: ooucER TO RID M BASEM-1 INSURERS AFFORDING COVERAGE NAIC I INSURED Champion Home Improvements of New England, LLC New England, LLC. 11 Sixth Road Woburn, MA 01801 INSURER A: Senecit insurance Company, Inc. 10936 INSURER e : Carrier Will Send Certificate INSURER c:The Commerce Insurance Company 34754 INSURER D: INSURER E : INSURER F : COVFRAGFS CFRTIFICATF NIIMRFR• 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 TYPE OF INSURANCEPOLICY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. vim POLICY NUMBER FF M D POLICYEXP D LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY C AIMS -MADE a OCCUR BAG1020696 03123114 .03123/15 EACH OCCURRENCE $ 11000,00 DAMAGE TO RENTED PREMISES Ea occurrence $ 1 OO,OO MED EXP (Any one person) $ 5,00 PERSONAL &ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRO LOC X POLICY JECT PRODUCTS - COMPIOP AGG $ 2,000,00 $ C AUTOMOBILE X X X X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS ' HIRED AUTOS NON-OWNEDAUTOS HCPD up to $70k BBXZ59 07!17/14 07117/15 COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ UMBRELLA LU1B EXCESS LU18 HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? a (Mandatory in NH) It yes, describe under WeOF OPERATIONS below N I A MA-CERTIFICATE TO BE SENT CERTIFICATE DIRECT FROM CARRIER 03/27114 03/27115 X WC 0TH IT R ER E.L. EACH ACCIDENT $ 100,00 E.L. DISEASE - EA EMPLOYEE $ 100,00 500 OO E.L. DISEASE - POLICY LIMIT $ r DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Evidence of Coverage. t%CDTICl/-ATC Lill) 111=0 CAWRFI I ATInkl - CREDIMI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Marc Credi THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 18 Lyman Rd. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988.2009ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑ Addition ❑ Two or more family ❑ Industrial U" Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer a ` e U Identification Please Type or Print Clearly) OWNER: Name: V \ G., f(, U ed Address: l b CONTRACTOR Name: U1-\ �- C� Phone: �-k i'I - 335, oa-J 3 Address: p Supervisor's Construction License: xp. Date: Home Improvement License: Exp. Date: 10 y�UU ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED DD7 J COST ASED ON $125.00 PER S.F. Total Project Cost: $ o2 (� FEE: $ G�- Check No.: 519Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund, :ure:of Agent/Owner' Location 6a- �^ No. 1/5 . Check # 28543 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit. Fee Other Permit Fee TOTAL Building Inspector