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HomeMy WebLinkAboutBuilding Permit #567-14 - 181 FARNUM STREET 1/28/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: r PORTANT: Applicant must complete all items on this page LOCATION._ Print PROPERTY OWNER hiil �tlg� Print 100 Year Old Structure yes n . MAP NO: . b_�Z ARCEL: ZONING DISTRICT Historic District yes n Machine Shop Village yes TYPE OF IMPROVEMENT, PROPOSED USE Residential Non- Residential ❑ New Building jLQ-(e family ❑Addition ❑Two or more family ❑ Industrial V�Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic ❑Well, . ❑Floodplain El Wetlands ❑ Watershed District 0 Water/Sewer [/� ,f Ll� 1/1 /� DESCRIPTION OAF?W RlKdTOr1 BwE�jPERFORMED: / /Y �/•� VpV� L�' 9,k 1./7�AJI�'�/Tf/��NS �.G f/i.�G7 er�7/�(!�/ �L!(J�-- � /A/ .l�1 j.�AJR ��77 Identi cation Please Typ or Print Clearly) OWNER: Name:1'' J1 '46J 1J ���� ,C *Lr Phone: Address: f�� .Q �vh Zr dl�o, irJ(7C�yi2 e'�j�. CONTRACTOR Name: Wil`_. S'rNt�4R Phone:,9?1- Address: f> <.��1 ,��dEJ �t.r2, l�'►,�/ v i ®/��l _ Supervisor's.Construction License: 42STJ� - l /1 aZ 3 Exp. Date:,!±-'&s Home Improvement License: Z/ 9�-__ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:SULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS Qld�$125.00 PER S.F. Total Project Cost: $ 1 ?6 FEE: $ Check No.: I o f J Receipt No.: t � �--- NOTE: Persons contracting 'h unregistered ontractors do not have access to.the giiar my f d Sidnature of Agent/Owner Signature of contractor Plans Submitted LJ Plans Waived ❑ Certified Plot Plan 11 Stamped Plans ❑ Location ! IL iv wo No. r Date o - TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ � _ Foundation Permit Fee $ Other Permit Fee $ �' TOTAL $ Check# 0i �^ 2Y 2612. Building Inspector Plans Submitted ❑ Plans Waived ❑ .Certified Plot Plan ❑ Stamped Plans ❑ _.. TYPE_.OF°.;SEWERAGEDISPDSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swimming Pools ❑ Well ❑ Tobacco.Sales Food Packaging/Sales ❑ Private(septic tank,etc._: Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR-OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM _:-_-DATE REJECTED: DATE:APPR-OVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS R .Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . ti Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer ConnectionlSignature& Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIRE DEPARTI�� iilT "Tem ' Dumpst�r on site yes- no Located at 124iMair, Street: epartme►lfsignature/date `' ''".' .s' ` � ' .' "�-', j i; -� ;r COMMENTS . t -_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. ®NE LITERATURE: Yes No MGL-.Chapter-166 Section 21A--F and G min.$100=$1000.fine NOTES and DATA— For department use El Notified for pickup - Date i S Doc.Building Permit Revised 2010 , I Building Department I The following'is°a-list of-the required-forms to be filled out foe the.appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits l o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.1.C. And/0'r C.S:L Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work o 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 .. o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses a Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 apt),-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doe.Bui4ing Permit Revised 2012 Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 449800.00 m $ - $ 537.60 Plumbing Fee $ 67.20 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 67.20 Total fees collected $ 772.00 181 Farnum Street 567-14 on 1/28.2014 Kitchen Remodel � Town of . t c10RTly- Andover No. Zh ver, Mass SpA cocN�cNew�cw`� S U BOARD OF HEALTH Food/Kitchen PERI T .T LD Septic System THIS CERTIFIES THAT .. .oL. U..V 0 1.ld . ........................... BUILDING INSPECTOR has permission to erect .......................... buildings on .fjr-l......�.^�.�I�.�A,r......&„ . Foundation Rough tobe occupied as .... . .. ..... .... .�........................................................... ....®.................................................... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final so PERMIT EXPIRES IN 6 MONTH ELECTRICAL INSPECTOR UNLESS CONSTRUCTI S S Rough Service ............. ...... .............. .. ............................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. SEE REVERSE SIDE Smoke Det. Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulations Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Nd / Comparrye c1� A�� IF 1 157 0,0f Street Address(do not use a Post Office Box address) Contractor/ person/Owner N City/Town State Zip Code Business Address(must include a streetdr s)f� a. /;//p j Daytime Phone Evening Phone City/Town State Zip Code 2d-L- 9 9 9 ,2 '611— -�9,2 3 Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Home nvp ror CDnh for Reg.Nambu Exuma m date naw regoim the mob home �yy imam,-n* mon mm�b h.re a vilid rrgatratioa•ember The Contractor agrees to do the following work for the Homeowner: (Describe in�ydetail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) 1—ed -o SAA, ja7s,r J,-;a. d,.-//,&-�4 s ASA/^;�odR, A/.,,,W P� i/W 4 /9A �ecN y�iQ/Gr /� t!f611�' fJrSgf1�'�?w /�,9. AA51) >A* ' 0I xv r� Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be VP 6 N excluded from the Guaranty Fund provisions ofDate when contractor will begin contracted work. MGL chapter 142A.) A�;V O '✓! r Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for-the total sum of. 7 () Payments will be made according to the following schedule: $ d e,4pon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ or upon completion of $ / by __L_1_or upon completion of �� �ir�//� �` N f $�dupon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty As an express warranty being provided by the contractor? QKNo❑Yes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617.973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. 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 sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellatiou'fonm for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BL K SPAC S!!! T id copies nand be completed and signed(Inner copy should go w the homeowner.The" be kept corNactor. ztope�_ 4���, eowner's Signa actor's Signature �- j4• -- 1 I - a6 - ( - Date Date s .i Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitratiml firm which has been approved by the Secr I the Executive Office of Consumer Affairs and Business Regulation ah shall be required to sub it to Mch 'tra,�7tprovide4 Massachusetts General Laws,chter2 r 01 owner's Si a o does Signature NOTICE:The signatures of the parties above apply only to the agree ent of the parties to mative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments 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. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at hLtp://www.mass.yov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: hq://db.state.ma.us/homei=rovement/licenseelist.asp 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 508-6524800,508-755-2548 or 413-734-3114 Version 2.1-11/22t2010 9 - Massachusetts-Department of Public Safety f ard of Building Regulations and:Standards ConstructionSupE n•isor Specialh License:CSSL4 123 STEPHEN F JW&kUE 1 Cutting Avenue 495V Woburn MA 01801 W. Commissioner Expiration 04/25/2014 �f: �e. iGar�arr�ararueacl�a``✓G✓,asrae%u f t/' Ofrice d Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR on-, 112799 Type ratto pin 427/2015 DBA WOBURN CONSTRUCTION STEPHEN DELARUE 1-CUTTING AVE WOBURN,-MA 01801• . 0. - Undersecretary - r r .s The Commonwealth of.Massachusetts - - Department of Industrigl 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: d City/State/Zip: JA)6AV AJ 11')* A r 04dPhone#• le?w-f" Are you an employer?Check the appropriate box: Type of project(required): 1.[�l am a employer with � 4• ❑ I am a general contractor and 1 6..❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor orpartner- listed on the attached sheet. 7• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition wonting for me in any capacity. workers' comp.insurance. g• El Building addition [No workers'comp.insurance 5. ElWe are a corporation and its 10.F1 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs required.]insurance re 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. Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached as additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workerscompensation insurance for my employees Below is the policy cancl job site information. -�•''// _ �y Insurance Company Name: 111,6r IJQ/�y,�,�,�if's ' Ch1 s l V Policy#or Self--ins.Lic.#: �%1(3/ Expiration Date: `�f/ ��,QJJ V� / City/State/Zip: IV d Ali d leg2 Job Site Address: , Attach a copy of the workers'compensation Tolley declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of o.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. X do hereby cer fy rie pa s ndpenalties ofperjury that the information provided above is true and correct. Si ature: Date: e-) A I?— (57 2 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.ether - Contact Person: Phone#: s Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their tract ofhire, employees. Pursuant to this statute,an employee is defined as ._ev e ry person in the service of another under any con express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensailon affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is PP p 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permithicense applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in .(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your.cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The CQMTgoaWoaltl ofMassachvsPt�s Departmaat of Industrial.Accidents Office ofIlavestigatioaas 600 WakiVoaa Street Boston,MA 0.2111 Tel#61.7-7.27-4900 0A 406 or 1-87 -.MMS.A E Revised 5-26-05 Fax-4 617-727-7749 WWW.MaSS,g0VMa a ' ACOR® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) M 01/13/2014 PRODUCER 781.729.8770 FAX 781.729.0053 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION John A. Pierce Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 934 Main St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Winchester, MA 01890-1994 INSURERS AFFORDING COVERAGE NAIC# INSURED Robert Swymer INSURERA: The Travelers Indemnity Co 25658 20 Cranston Circle INSURER B: Woburn, MA 01801 INSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YYYY DATE MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS MADE 7 OCCUR MED EXP(Any one person) $ - PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE S �EN'L_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY - EACH OCCURRENCE I$ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION TBI 01/11/2014 01/11/2015 X I ORY U ITS I I ER AND EMPLOYERS'LIABILITY Y/N ANY PROP RIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS perations usual to residential carpentry. Robert Swymer has not elected workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL North Andover, Town Of IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UP . T RER,ITS AGENTS OR 1600 Osgood St REPRESENTATIVES. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE' Kevin Pierce ACORD 25(2009/01) FAX: 978.688.9542 ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD