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HomeMy WebLinkAboutBuilding Permit #383-14 - 181 FARNUM STREET 10/23/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: v Date Received 4'" 7 Date Issued: I POR T!Applicant must complete all items on this page - -., LOCATION Print PROPERTY OWNER Print 100 Year Old Structure yeCno MAP NO:/ d7 PARCEL: ZONING DISTRICT: Historic District yeMachine Shop Village ye TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial i?Kepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic []Well ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: f1wip AAJD WOc5'1 e.40 Identification Please Type or Pri}t Clearly) OWNER: Name: ?',A[!� ��15�� ZAL�o�1� Phone: Address: CONTRACTOR Name: p Phone: (q/ Address: l CrJ Supervisor's Construction License .' Exp. Date: Home Improvement License: /10?79 Exp_ Date:___f'"A "7- /tJ7 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ fid d FEE: $ °. Check No.: Receipt No.: NOTE: Persons contract' ath ungiste co Tactors do not have access to t my nd Signatureof-Agent/OW er Signature of con_tractoc - N -- Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Sta ped Plans ❑ Location 1 t t A N1 Date • • TOWN OF NORTH ANDOVER e Certificate of Occupancy $ n Building/Frame Permit Fee $ aC� k Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# C� 27034 Building Inspector Plans Submitted-❑ Plans Waived ❑ .Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGEDISPOSAL Public Sewer ❑ Tanning/MassageBodyArt 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 l DATE REJECTED DATE.APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature i 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 Tow;: Engineer: Signature: Located 384 Osgood Street �= FIRE DEPARTMf_IVT -'Temp Dumpster on yes no Located at 124 Mair, Street Fire Departiner4sig_ re/ date-' COMMENTS x 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 - Date i f Doc.Building Permit Revised 2010 Building Department _ The foliswing is a 1i'st ofthe required forms to be filled out-for the appropriate permit to be obtained. I Roofing, Siding, Interior Rehabilitation Permits I ❑ 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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) j ❑ 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 cas,s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apr).,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.Buil, Doc. �img Permit Revised 2012 . NORTH Town of E 11Andover 0 - 1 " No. h , ver, Mass, O LAME COC NICNEWICK reo V S U BOARD OF HEALTH Food/Kitchen P E Septic System THIS CERTIFIES THATMIT ... lot0, C BUILDING INSPECTOR .... ..... ........................................................................................... 11 11 ...... has permission to erect .......................... buildings on ...1. .1....TAr�V►wl,..sc..................... Foundation Rough tobe occupied as ..... P ....... .........m. ....................................................................... 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU NATS Rough 6Service ......... ............................................................. 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. SEE REVERSE SIDE (Massachusetts-Oepactment of:Public Sa€ety Board of Building`Regulations aid Stastcards -� Canstruet�€�a Sulierrisor Site€talo_ �` �3-� � License:CSSL-101123 STEPHEN g;t1LARIIEIF 1 Cutting Av ►ne Woburn MAr--01801 °3l.•�.,•, �e '� Expiration C3mrraissiinea 04125/2014 � �lze tparta���araroecc�l�a�`V[ ae�ttael�4 Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR s. egistration. 712799 Type ;d pirabon =412712015, DBA , J. WOBURN CON$TRUCTtON • STEPHEN DELARUE r l 4CUTTING AVE � .�. � 4 WOBURN,:MA 01801_ Undersecretary 977' Dv,, 4J4 7, 7-W /14C I q, e ci T 7W `j°� f X/Z,0 71-9s T-Tomi.e I -rovememJ Saan ' Re Contra et This i'oiV,-Psatisfies all basic�etiuirements oi'the state's Nome Improvement Contractor Law language to protect homeowners. SeeIc Iegal advice if necessary. An (MGL chapter 142A),but does not include standard Massachusetts Consumer Guide to Home Improvement"before agreeing person oxlcon.home xe h3 ice.You ma obtainvenlents should s free i a b paltar' Attie Office of Con sumer Affairs and Business R egulation's Consumer lnfomationHotline at 6.ourres deucel )73-8787 or 1-888-28a-3157 a re on ovyb baiting ' ]�o eo�val.e>t' o>rm�.tnoln. •Cont>Nac�:o><JC>�f®n�l�a.�,•ioz>, Name ' Company Name K wt .S Strect.Address(do notuse a vostultceBox address ) Contractor/Sales erson/OwnerName Ry orsn City/Town S ate Zip Code 26,95A Business Address(must includ .a street address) /�D•1���a�,r � .ding 6/gam- � A1� Dayt,mePhone EveiungPhone ,� ' " 9 Eddrees �� � City/Town SffZip CodeMailing (It differentfrom above) �� �Q N Business Phan d' �ederal Employer ID or S.S.Number Hamermpmvement'Contmetorltez.•Number �xpirntandnte xnwrc��irrs tbatmastJiomc improvement cantractars ImVe n valid rcgistrntion numLcr The Contractor agrees to do the following work for the Homeowner: ()Descnbe in detail the worlcto completed,speciiyingtbe type,brand,and grade of materials to be used,use additional she ii'necessa Required Permits-The following building permits ate-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 S=x re their own permits sill be excluded from the Guar=ty Fund plroyisions of LI�/,3 M- G]L chapter 142A.) P8 when contractor will begin contxactedwozlc. I� :!— Date when contracted work will be substantially completed. Total Contract Price a ad Payment Schedule The Contractor agrees to Perform the wozlc, Garnish the material and labor speciZed above for the total sum,of _ �� "J-60 •66 Payments will be made accozdingto the following schedule; 30 S�- � �,�56�6 6' () a � upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,Whichever is greater) —A� �_by l 1 oz upon completion of S' Zog e by / ! or upon completion of �Q ® �' $ A ��� upon completion of the contract. (Law forbids demanding full payment until contract is completed to both 's sat` • P�•3' ).stiction) . The following material/equipment must bespecial $ ordered before the contracted work begins in order to be paid for to meetthe completion schedule.(N'-) to be paid for NOTES.(*)Including all finance charges(*,i')Law requires that any deposit or down payment rcquired by the contractor before worlcbegins 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 advande to meet the completion schedule. Rx LessMran -lsanea resswarrant behiz Providedb the contractor? No 1:1-yes all termsofthewnrran mastbentttchedEothecontract Subcontractors-The contractor agrees to b.e solely responsible for completion ofthe work described regardless ofthe actions of my third party/subcontractoxutilizedliythe contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and aborunderthis a Bement Contract Acceptance-Upon signing,this document becomes abinding contract under law. Unless otherwise noted within,this document,the contrast shall not implythat any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. C Don't be pressured into signing the contract.Take time to read and fuliy understand it. Ask questions if something is unclear. o ake sure the contractor has a valid Home 7m roveme-.t Contractor Rer4stration, The law me imovement subcontractors to be registered with the unector of.Homue Improvement Contractor Registration. Y maires most y>nqu eabout contractor contractors and registration by writing to the-Director at 10 Par1CPlaz8,Room 5170,Boston,MA-02116 or by calliug.617-973-8787 or 888-283-3757. C Does the contractor have insurance? Ask the Contractor fox his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insuzance"document. o Know your rights and responsibilities. Read the Important Infolmationon the-reverse side of this form and eta Guide to the Home Improvement:Contractor Law: g copy of the Consumer You may cancel this 4.greement if it has been signed at a place other than the contractor's normal place of business,provided you no' the contractor in writing at his/her main office or branch office b ordin ttfy third business day followin the signing Y ary mail posted,by telegram sent or by delivery,not later than midnight of the g gning ofthi.s agreement. Seethe attached notice of cancellation form for an explanation ertha right. ID® T'NIG:N T-M- S CONTRACT IF TB ERE ARE ANSI J�1G 4Sigg7niatur, s ofthe contractmust be completed and signed. One copy should go to the Ilomeo,vner. The other eopy�'s1t0iild ba lcep b�yttliiLj�contractor. I omeowner' Contracto s Signature 'Date . Date i Conf racto:r Arbitmition The Home Imp%ovement 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 automatrcall contractor,however. dto a' The contractor would have to resolve any dispute he/she has with a homeowner in court eu�7 unless both parties agree to the optianall clause provided below. This clause would give the contractor the same xi ht to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. g • 1 The contractor and the homeowner hereby concerning this contract;the contractomutually agree in advance that in the event the contractor has a dispute the r may submit the dispute to a private arbitration fum which has been approvebe required irby Secretary of the Executive Of xc f ConStuner to sub, Affairs and Business Regulation and the consumer shall o st arbitrati s.p• 'ded InMassachuseits General Laws, chapter 1 A., Home Met's SrgaatLtre NOTICE- The or's Signatoze The signatLtres of the parties above apply only-to the agreement of the pax-ties-to alternative 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 L4.w'(MGL chapter 14.2A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way, even,by agreem may be excluded from ent. however,homeowners certain rights if the contractor they choose is not properly registered as prescribed m ow I-Iomeowners who secure their own,building permits are automatically excluded from all Guaranty Fund provisions of the home Improvement Contiactor-Law, The contractor is responsible forcompleting the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other sp cin legal rights if the contractor guarantees or provides an express warranty:for workmanship or materials. c addition to provided by the contractor, all goods sold.in.Massachusetts Garay an implied warranty 01f guarantees hant bility and.fitness for a Particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree maybe added to the te=s of the contract as long as they do not restrict a hom eowmr's basic consumer rights. If yott have questions about your consumer/homeowner rights, contact the Consumer In-folmatiOn Hotline(listed below), Execution of Contract The contract must be executed in du licai;e and should not be signed until a copy of all exhibits and referenced documents lave been attached. 1'aa tiesare,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 modi_ficatio�n,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 fally 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 himlherself to be financially insecure. However,in instances where a contractor deem account to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a j oint escrow accou t as a prerequisite to continuing the contracted work, Withdrawal signatmes of both.parties. of Cztnds from said'account would require the Addition-4 Bforxm.ation .If YOU have general questions or need additional inforivation about the Horns Improvement Contractor Law or other constuner rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home 7xnaw or other contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,RO6=5 170, 02116 617-973-8787,'888-28s-3757 or-visittthe OCABRwebs twat 11ttp v.mass: Dov/ocabr/ 7f you want to verify the registration ofa contractor about the contractor registration compoor if you have questions or need additional information specifically component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registxation Office of Consumer Affairs and-Business Regulation a 617-973-8787, 888-283-3757 o visit the I-UC website�at�02j16 wvvw.tnass roy/nr;,1„I Go Online to view the status of a Home Improvement Contractor's Registration: , 1��://db.s•tate.ma.t�s/IaoTneirzr rovelx�ent/]icenseelist.as Tor assistance with infonxaal mediation of disputes or to register formal complaints against a business,nr ss, call: Consumer Complaint Section Oface of the Attorney General 617-727-8400 AND/OR ; Better Business Bureau S08-6S2-4.800,508-:755-2548 or 4.13- 734-311.4 The Commonwealth of Massachusetts - Department of Industrud Accidents Office of Investigations 600 Washington.Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electrcicians/Plumbers Applicant Information Please Print Leaibly Name(Business/Organi'zation/fn.dividual):_ST ��/�'� Address: City/State/Zip: J6ALgii 1i9 6/90 l Phone#: 417" Are you an employer?Check the appropriate box: Typo of project(required): 1.[a I am a employer with + _ 4. ❑ I am a general contractor and 1 6. ❑New construction employees(fulland/or part-time).* have hired the sub-contractors 2.❑ I am a sole,proprietor orpariner- listed on the attached sheet.t �• ❑Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, []Building addition [No workers'comp.insurance 5. F1We are a corporation and its 1011 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing allwork right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.Q Roof repairs insurance .re uiredemployees.[No workers' required.] 13.0 Other comp.insurance required.] xAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they 2Ee doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy antijob site information. , Insurance Company Name: wxmix,�."c //lf� 61Y21 Policy#or Self-ins.Lie. Expiration Date: Job Site Address:/,& /9wWoMK7. D01fF,,f City/State/Zip:,f/i AoJO61W a/94tr Atiach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or oner-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. Ido hereby certlounder t pains andvenala s of perjury that the information provided above is true and correct. Si afore• Date: I3 Phone#: G 7 �'� g l `� r 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 Ph nn a�#• Information and Instruct ions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhiw,- express or implied,oral or.written." An employe�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 ox 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"Neitherthe commonwealthnor any ofits 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'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates)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 maybe submitted to the Department of Industrial Accidents for conflm ation of insurance 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. 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 pemut/license number which will be used as a reference number. In.addition,an applicant that must submit multiple permit/license 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license of 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 Tike 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 Co oaawealt� of Massachusetts Departweiat of Industrial.Accidents Ofaee of Iavestigatiolas. 600 Washington Street Boston}MA all X 1. TO,#617-727-4900 ext 406 Qz 1-877 MASSA'F Revised 5-26-05 Fax#617-727-7749 Client#: 20510 WOBURNCONS s DATE(MM/DD/YYYY) v,PCORDTM CERTIFICATE OF LIABILITY INSURANCE 9/24/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 'tI ERTIFICATE 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: HUB Int'I New England (WILSB) PHONE 978 657-5100 FAX ac No Ext): AIC,No): 978-988-0038 299 Ballardvale St E-MAIL ADDRESS: Wilmington, MA 01887 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers Indemnity Co of Ameri INSURED INSURER B Woburn Construction INSURER C Stephen Delarue d/b/a INSURER D 1 Cutting Ave. INSURER E: Woburn, MA 01801 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 CONTRACTOR 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 INSURANCE ADDL SUB POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES ERENTED occu ence $ CLAIMS-MADE F-1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY RTYDAMAGE $ HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION UBSB475986 0912512013 09/25/2014 WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? FN� N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION Stephen Delarue SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1 Cutting Ave ACCORDANCE WITH THE POLICY PROVISIONS. Woburn, MA 01801 AUTHORIZED REPRESENTATIVE fGC>z .9C C:400~- ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S992666/M992503 DKO04 I