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Home My WebLink AboutBuilding Permit #887-15 - 19 CANDLESTICK ROAD 5/6/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page Ir. ATIONt PROPERTY OWNER'_ 1�,CX � � ��1Ck1(Y1 r - 4 Pnn11 �_; OO Year Old,St uc ure nom iMAP+NO1PHRCELf' tfZONWG DIS3TRICT� _'_ _sHiston District yes =no, IIVlachne:Shop Village gess non TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building YOne family ❑Addition ❑Two or more family ❑ Industrial `'Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D Septic> ❑Vl/ell ❑F dplain ❑Wetlands aim ❑ 'V1/atershedJYM 'District ❑Water/Sewer.. _ DESCRIPTION OF WORK TO BE PERFORMED: o.�(X 1Ca l'11Y�C�l� S'��t Identification Please Type or Print Clearly) OWNER: Name: 2 A\'WDL-�: 1 Phone:g1�•16al°Tis {Address: 0� C' CONTRA4C#T®R Name jp� } r{�O(jFir1G, _ $PhoneT�-41 2 � F ,x ,�„ "'y �.v f s �.3�.�.v �."�`�'.� —may #_ •± � �,"� F�� I�C' ��t�71 �l N c- - �Superviso�YsConstructloritjicense �j\�( Exp.. rDate �Uo� `Home�lm.pro�ementsLicense; �aQ;_a��- 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. Total Project Cost: $ ] �tC�C"�� FEE: $ Check No.: & 7 3 Receipt No.: 'Ifl2c� 7 3 NOTE: Persons contracting with unregistered contractors do not have access to anty fund 9 ; -- y Signature of AgenUOwner S� nature of.contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ _. =. . �. —�:,7,.. ,. y a a,Ra — A /� Location I A f G (�� No.. ( � Date �� ' TOWN OF NORTH ANDOVER �� s• • "I • a Certificate of Occupancy $ ` - Building/Frame Permit Fee $ � - - Foundation Permit Fee $ J _ Other Permit Fee $ -N .. TOTAL $ Check#�� .. -� } �>t t .. �, utl ding Inspector _ . .-:: :; . ... , r r;le Plans Submitted❑ Plans Waived El Plot Plan El Stamped Plans El _. =OF=SEWEIZAGEDiSPOSAL- - Public Sewer ❑ Swimming Pools ❑ Tanning/Massage/Body Art ❑ - 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 DATE REJECTED: DATE.APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes PI-nning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTMENT =`Temp Dumpster on site s-. no Located-at 124 Mair, Street-- -Fire bepartrner'it-signature/date Lr= G' 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 DANCER Z®NE 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 Doc.Building Permit Revised 2010 Building Department -rhe foliowing is--a:list of the required.forms to be filled out for the appropriate.permit to.be obtained. Roofing, Siding, Interior Rehabilitation Permits u; Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work a Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks La Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o 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 ❑ Photo of H.I.C. And C.S.L. Licenses ❑ 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 - a Mass check Energy Compliance Report o 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 apn,,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building permit Revised 2012 NORTH Town of �.. 1 E 1, ndover No. * -_ - h ,� " �t h ver, Mass, COC LAKS NICM1WICK ORATED JkV' �S S U BOARD OF HEALTH PERMIT T Food/Kitchen r a.� Septic System THIS CERTIFIES THAT ..,•�..��. ,. v .�.�A.. �............................... BUILDING INSPECTOR ................................... .... has permission to erect buildings on ..I � S�« P............... Foundation Rough to be occupied as ............ ...... ...... ..... ..... .... ... .... ....... ....................................... Chimney provided that the person acceptin his permit shall in every resp 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 EXPIRE 6 M THS ELECTRICAL INSPECTOR UNLESS CONST I S Rough Service ........ ................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. �T7// //r (",5 " G EIN#51-050-3313 Haverhill MA 978.374.9224 MA Reg.HIC#149221 ' Lawrence MA 978.687.7339 MA Lic.UCS#78130 Hampton NH 603.929.9224 BBB. Single-Ply License#1711 oofing Hampstead NH 603.329.8200 _.. Sc nc X1932 7Q, Toll Free 1.888.SOS.ROOF 265 Winter Street Haverhill MA 01830 /( Licensed -Insured *Factory Trained ::Factory Certified y � l Name: �t ZL� � 1� Lt1l�I1G1al( Date: 57 Telephone9'�I �( '/_5 Alt.Telephone: Email: Billing Address: j CC�.� o 4 City: Ah)' f f4 4y"A"'(f. f- State: /71C." Job Address: City: J State: Scope of Work Strip and Re-roof ❑Re-roof Approximate Roof Area: ❑ Prepare for re-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. ❑ Remove existing layers of shingles down to roof deck and dispose of in a legal fashion fro the job site. ❑ Inspect wood deck,if we discover any rotted wood,replacement will will performed at*$-5. per LF for roof deck boards.If substantial deck rot is discovered,re-sheathing of roof deck can be performed at*$ 1 . per SF.If individual sheets are found to be rotted/or de-laminated,removal,disposal and replacement will be performed at*$ I%�C2 per sheet.If any trim boards are rotted, replacement will be performed at*$ f per LF for new pre-primed pine.Inspect siding at oo e and all flashing behind siding,if we discover any damaged flashing or siding at the roof line,replacement will be performed at*$�G`� If wood deck,siding,and flashing is sound,we will re-nail any loose wood to rafters,s eep deck,and prepare for roofing. El1 Install 8"drip edge to all rakes and eaves. Color 2�I Pi ❑ Apply ice&water shield(UNDERLAYMENT)as per manufacturers'specifications and/or ❑ Apply premium(UNDERLAYMENT)to the balance of the exposed wood deck. ❑ Re-flash all plumbing stack pipes,and any roof penetrations as required and dictated by good roof practice to ensure water tightness. ❑ If upon inspection,we discover chimney lead to be worn or deteriorated,replacement will be performed at*$ M D t Z ❑ Install a new: Year ❑ Traditional Architectural ❑ Designer Color JOFPV ❑ Furnish and Install a new shingle over style ridge vent system ❑Soffit vent system*$ ❑ All debris generated by Lambert Roofing Co.,Inc.will be cleaned up and disposed of from the job site in a legal fashion.Under no circumstances will the watertight integrity of`the building becompromisedr- Special Notes r t' v� ��.! G� C1f.4,•E UPON COMPLETION AND PAYMENT IN FULL,ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF�L YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND?i-2YEARS HONORED AND ISSUED BY SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$ `O d� o .S *Denotes potential additional costs above the total estimated price. / o nL TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE The Contractor agrees to perform the work,furnish the materials and labor specified above for the total sum of:$ � (*) (Dollars) Payment will be made according to the following work schedule: $ deposit upon signing contract $ by_/_/_or upon completion of $ upon completion of contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) 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 or by delivery,not later than midnight of the third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES Acceptance of the Contract Proposal Home Owner(s)Signature(s): Date: S /2/—po5 Contractor's Signature: Date: .la rtroofingxom (Please see reverse side) Company Insurances TGLRC Inc.DBA Lambert Roofing Company will provide certification of insurances,demonstrating that we are fully insured for worker's compensations, general liability,automobile liability and an umbrella policy.This documentation will be sent through the US mail to the above named party if not already provided. TGLRC Inc.dba Lambert Roofing Companyaees to: • Commence the described work on or about • Complete the described work in approximately days. • Not be held liable for delays due to circumstances beyond our control. • Not be held liable for any damages to landscape and or fixtures due to circumstances beyond our control. • Not be held liable and not covered under the workmanship warranty,for pre-existing conditions including but not limited to: • Mold and or wood rot,defective,faulty,rotted or worn building counterparts such as,but no limited to:siding,roofing,masonry, plumbing and windows,all of which may jeopardize the watertight integrity of the structure. • Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. • This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inc.DBA Lambert Roofing Company and the Homeowner/Business Owner or Agent. Permits A building permit may be required to remove and replace your roof.It is our obligation to secure these permits if required as the home owner's agent.Note: Homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c.142A. Accelerated Payment 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. Payment Terms A finance charge of 1.5%a month(18%per year)will be added to all invoices on the 31'day.All legal and or collection fees will be paid by the binding holder of this contract. • The law requires that any deposit or down payment required by TGLRC Inc.dba Lambert Roofing Company before work begins may not exceed the greater of- 0 1/3 of the total contract price or: 0 The actual cost of Special or Custom made materials which must be special ordered in advance to meet the completion schedule. Arbitration The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this .contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business gulationAnd the consumer shall be required to submit to such arbitration as provided in MGL c 142A. Owner: Date: Contractor: Date: Contractor Registration All home improvement contractors and subcontractorsmustbe registered,any inquiries about a contractor or subcontractor relating to a registration should be directed to: Contractor Registration: Director of Home Improvement Contractor Registration Board of Building Regulations and Standards One Ashburton Place,Rm.1301 Boston,MA 02108 (617)727-3200 Home Improvement Contractor Law: � Consumer Information Hotline Commonwealth of Massachusetts Office of Consumer Affairs and Business Regulations 10 Park Plaza,Rm.5170 Boston,MA 02116 (617)973-8787 For assistance with informal mediation of disputes or to register formal complaints against a business,cats: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 Cancellation You may cancel this agreement if it has been signed by a parry thereto at a place other than an address of the seller,which may be in the main office or branch thereof,provided you notify the seller in writing at the main office by ordinary mail posted,by telegram sent or by delivery,no later than that midrd o the third business day following the signing of the agreement. INITIALS The Commonwealth ofMassachusetis Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Conti°actors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgmi'zation/Xndividual): O' 1 Address: , (ps i nA-e-r S - City/State/Zip:��W_) \\� Ma 01(3 Phone#: C)"29 Are you an employer?Check appropriate box: Type of project(required): LR I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a soleproprietor orpartner- listed on the attached sheet. 7• E]Remodeling ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance. 9. (]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.El 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 wehave no 12.❑Roofrepairs insurance v required.] employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section bel6w showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they 27re doing all work and then hire outside contractors must submit anew 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,poldcy and job site information. Insurance Company Name: �} ra- aa'�� Policy#or Self-ins.Lie.#: -cit 09 Q� 'a'J i4 ExpirationDate: Job Site Address-_g _City/State/Zip: 0YV—C 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 cero un ' s and dties ofperjury that the information provided above is true and correct. - Si ature• Date: Phone#• ` n 6. ��A • ct:a 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other -- Phnna.ffi 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 defined as"...every person in the service of another under any contract ofhire, express or implied,oral or.written." An employeY 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 employes." 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 ofits 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 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-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 notrequired to carry workers'compensation insurance. If an LTC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 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 permit/license applications" any given year,need only submit one affidavit indicating current Policy information(if necessary)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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum 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 Co oAwealth of1\4-assa eft sPtls 73epaftent ofladustdal Accidents Office of I11vestigatiolm 600 Washtngtou Street Boston?MA.021 Z Z -617-72 -4900 est40' az 1-877 MA.SUFF Revised 5-26-05 Fax 6X7-727-7 749 AC< CERTIFICATE F DATE(MWDONYYY) ice-- O LIABILITY INSURANCE 04/01/2015 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 t7AMEACT Jerrold Rameras ALLAN INSURANCE AGENCY INC. PHONE ( 745-5905 FAx -rikLAIC,No.r .(978) 745-5483 63 1/2 Jefferson Avenue 2nd Floor E-MAIL.ADDRESS.Jerrald(Rallaaiasurance.com P.O. BOX 511 INSURER(SI AFFORDING COVERAGE NAIC S SALEM MA 01970-0511 INSURERA Assoicated Ind Ins Co INSURED INSURERB:SafetV Insurance Co TGLRC INSURER c:National Union Fire Ins Co. dba: Lambert Roofing Co. INSURERD:Ace American Insurance Co. 265 Winter Street INSURERE:Ace American Insurance CO. Haverhill MA 01830- INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. D U POLICY EFF POLICY EXP tLlR TYPE OF INSURANCE POLICY NUMBER MMID MM LIMITS GENERAL LIABILITY / / / / EACH OCCURRENCE g 11000,000 X COMMERCLWL ENERAL LIABILITY / / / / PREAMIS 5 aoxurrence _& 50,000 A CLABAS-14ADE FX-1 S102B029 11/12/2014 1/12/2015 MED EXP(Any oneperson) $ 11000 X Per Project Agg / / / PERSONAL EADV INJURY S 11000,000 f / / / GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER / f / / PRODUCTS-COMPIOP AGG S 2,000,000 POLICY X PRO- LOC / / i / g AUTOMOBILE LIABILITY / / / / OMBINEDSINGLE LIMIT 11000,000 B -ANY AUTO / / / / BODILY INJURY(Per person) S IALL OWNED X SCHEDULED 6203819 ! 'AUTOS AUTOS / / / BODILY INJURY(Per acci;Ienl) S X HIRED AUTOS XN AUTNON-OWNED 7/16/2014 716/2015 PERTY DAMAGE P — $O dordi X UMBRELLA UAB X OCCUR BE18430331 / I / / EACH OCCURRENCE $ 51000,000 O EXCESS LIAB CLAIMS-tl•.ADE 1/12/2014 1/12/2015 AGGREGATE 9 51000,000 DED RETENTION S WORKERS COMPENSATIONIM1IC STATU- OTH- ANO EMPLOYERS'LIABILITY X ANY PROPRIETORIPARTNERIEXECUTIVE YIN / / / 1 OFFICERIMEMBER EXCLUDED? � NIA E.L EACH ACCIDENT E 11000000 D (Mandatory in NH) 686217B-2E09875-2-14 ASA 2/22/201412/22/2015 E It .L DISEASE-EA EMPLOYE S 1,000,000 yes,describe under DESCRIPTION OF OPERATIONS be!aw / / / / E.L DISEASE-POLICY LIMIT S 1,000,000 W Worker's Compenstaion NH S62UB-81381311-6-14 *IH 12/22/2014 2/22/2015 seme!;misas 1,000,000 F-,Izyabove 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule.IT more space i3 requlredl CERTIFICATE HOLDER CANCELLATION TGLRC Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION HATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. dba Lambert Roofing 265 Winter Street AUTHORggREPRESENTATNE Haverhill MA 01830- 9%•'_ ` 1 �� ^ ACORD 25(2010105) C 1988-2010 ACOR ORPORATION. All rights reserved. f INS025(2c1W5J 01 The ACORD name and logo are registered marks of ACORD CS-MI30 RICHARD J UMBSRT 265 WffMR STHEET KwerhM MA 01$30 Office.of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Reglstration: 149221 Type: Private corporation Expiration: 12MO15 Tr# 248813 T.G.L.R.0 dba Lambert Roofing Company RICHARD LAMBERT 265 WINTER STREET HAVERHILL, MA 01830 Update Address and return card.Mark reason for change. n Address E] Renewal C3 Employment F1 Lost Card