HomeMy WebLinkAboutBuilding Permit #098-14 - 19 YOUNG ROAD 7/30/2013 i
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received � ems/
Date Issued: !
/Nk,�
IMPORTANT: Applicant must complete all items on this page
LOCATION
PROPERTY OWNER /1 ,-- /Print
Print
MAP NO*6 o PARCEL: ZONING DISTRICT: Historic District yesno
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Re, ' Non- Residential
New building 40n;1 7
familywor more family Industrial
Alteration No. of units: Commercial
epair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Ide tificatio Pie se Type or Print Clearly)
OWNER: Name: & � Phone
Address: Ovi✓�- /l0
CONTRACTOR Name: ' Gu — " ` Phone;
Address: J
Supervisor's Construction License:_ / Exp. Date: Z I
Home improvement License; 7 Exp. Date; Z� /
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: $ , 30-D, -- FEE: $
� 1-1 Check No.: Receipt No.: (.pj
NOTE: Persons contracting with unregistered contractors do not have access t u nd
ignatur_e of Agent/Owner ignature of contract
Plans Submitted
Plans Waived Certified Plot Plan Stamped Plans
T E GE 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
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
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature&Date Driveway Permit
a
DPW Town Engineer: Signature:
t Located 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use)
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
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/Crossection/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
Doc: Doc.Building Permit Revised 2008
Location / / YotA
No. % _ Date
r
• - TOWN OF NORTH ANDOVER
•
Certificate of Occupancy $
Building/Frame Permit Fee $SOU
` Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# 7/7c
Buiilding Inspector
Enter construction cost for fee cal - North Andover Fee Cakulation
Construction Cost
$ 105300.00 m
$ - $ 123.60
Plumbing Fee $ 15.45
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 15.45
Total fees collected $ 254.50
19 Young Road
098-14 on 8/1/13
Bath Renovation
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NORTH
own of t Andover
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No. 2 _09� - 14
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ver, Mass,
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COC
Nl WICK y1.
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BOARD OF HEALTH
Food/Kitchen
PERMI LD Septic System
THIS CERTIFIES THAT < < BUILDING INSPECTOR
........... ..................... ........ ........... .................... ........... ............
..... .. .... ....
has permission to erect buildings on � ,,..,...., Foundation
O 4" 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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION S ARTS 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.
SEE REVERSE SIDE
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
UV www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
Name(Business/OrganizatiorAndividual): t-✓t� rL �; L�%
Address: Z-q 1A)'✓l U
City/State/Zip: /0�k Phone#: /�� ��� —7y ,
Are yojx an employer?Check the appropriate box: Type of project(required):
1.W4ni 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 sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
workingfor me in an capacity. orkers'comp.insurance. 9 `
Y p t5'• Building addition
[No workers' comp.insurance 5. We are a corporation and its
requrred.]
officers have exercised their
10.❑Electrical repairs or additions
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.❑Roofrepairs
insurance required.]t 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.
T Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit anew affidavit indicating such.
#Contractors that check this 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 and job site
information.
Insurance Company Name:. /''�t�C�i / �/•'
Policy#or Self-ins.Lic.#: �� ��'�D ��— Expiration Date: �.�
l
Job Site Address: 8 City/State/Zip: "
Attach a copy of the workers'co ensationpolicy 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 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 DTA for insurance coverage verification.
Ido hereby cert!under t e ains enalties ofperjury that the information provided above is true and correct. -
Sig-nature: Date:
Phone#: j/ k-j CJ Y�� ✓
Offccial 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#:
i
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 of hire,
express or implied,oral or.written."
An employeiis 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'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 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 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 Depar4�ent has pr6vided 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 in 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. 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 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 GomMonwealthofMassachvsetts
Department of Industrial Accidents
Office ofInvestigatlons
600 Washington Street
Boston,MA 02111
Tel,#617-727-4900 ext 406 or 1-877�,MASS.A.FE
Revised 5-26-05 Fax 4 617-727-7749
_ v�ww.n�ass,govld�a
w
TWOMEY & LEGARE
CONTRACTING INC .
"Couldn't your home use a little TLC?"
Specializing in residential additions
87 Belmont Street, North Andover, MA 01845
HIC #136779
North Andover- 987.685.7447 Facsimile- 978.685.7446
EXHIBIT B
Proposal/Specification
Homeowner: Matt& Liz Gabree Contractor:Twomey&Legare Contracting, Inc
19 Young Road 87 Belmont Street
No Andover, MA North Andover, MA 01845
(978) 685-7447
The following is a description of work as discussed.
• Renovation of new Bath
1. Demo- strip drywall from walls in bath area and
rip up floor to sub floor.
2. Leave tub,and protect it the best we can.
3. Insulate exterior walls to code.
4. Wire new bath to code. 1 GFI plug,Install fan/light combo, and vanity light.
Fixtures by owner.
5. Existing plumbing to remain in same location.Install new shot offs to sink and toilet.
6. Remove bath window,and frame up a smaller Harvey awning unit.Repair exterior siding.
7. Use customers extra siding to match as close as possible.
8. Blue board and plaster on ceilings and walls. Smooth walls, sand swirl ceilings.
9. Install new bath fixtures,all fixtures by owner.
10.All painting by owner.
11.Match all new interior trim as close as possible.Install 3/8 inch bead board panel 40 inches up
wall.With chair rail detail on top.
12.Install tile on floor and walls in tub area over cement board..Tile and grout by owner.
13. Contractor r_ onsible for all permits and inspections.
Sign Date
Allowance Page
Bath fixtures to purchased by owner
1. Sink and faucet.
2. Tub with drain assembly.
3. Shower valve.
4. Toilet and seat.
5. Towel bars, TY holder.
6. Medicine cabinet.
7. Vanity light.
8. Fan light combo.
9. Tile for floor, and tile for shower also grout.
Project Total and Payment schedule
Y
Exhibit D SY"
Job Total $1060.00
Balance
r> ). 0>
st
1 signing of contract $3,000.00 $7,9M.00
n
2d The day work starts $3,000.00 $4,9W.00
3rd Completion of plumbing
Electrical roughs $4,000.00 $9$6'00
4thSubstantial completion of
project and fmal sign off. $ 0,01-V6
Sign Date � `
HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS(M.G.L.142A)
1.WORK:Provided the Homeowner performs under this agreement,the Contractor shall perform the work on the Property as specified Proposal,attached
incorporated herein.The work does not include extraordinary conditions of which the Contractor could not reasonably be aware.If such conditions are
encountered,this shall be an additional cost to the Homeowner.Materials selected by Homeowner may have to be ordered or custom made,which items are
specified in the Proposal.The Contractor is not obligated to agree to any modifications,extras or change orders unless such items are agreed to in writing by
the Contractor.All extras and changes shall be at an additional cost to the Homeowner.Contractor shall perform the work in a good and workmanlike manner
using materials consistent with this contract.Lawn or Driveway may be damaged by dumpster or equipment.Due to material shortages Contractor may
substitute materials of equivalent grade.
2. PERMITS:If a building permit is required for the work,the Contractor shall obtain same as Homeowner's agent.Contractor is not responsible for any
other permits that may be required for the Work,and Homeowner is responsible to determine whether any zoning,planning or wetland related permits or
approvals are necessary.Homeowners who secure their own permits or deal with unregistered contractors will not have access to the Guaranty Fund.
3. COMMENCEMENT AND COMPLETION:Homeowner acknowledges the commencement date of the work is fluid,and is subject to numerous factors
such as scheduling other contractors,delivery of materials and weather.Contractor and Homeowner shall determine the commencement date of the Work
when a more definite determination can be made and shall execute a written acknowledgment of same.The Work shall be substantially completed within 7
days of commencement,except for longer periods as may apply to particular projects as Contractor shall notify Homeowner in the Proposal,and subject to
delays for circumstances beyond Contractor's control.Notwithstanding,the commencement date and substantial completion date may be extended,and the
Contractor will not be liable for delays caused by,labor or material shortages,delays in delivery of items selected by the Homeowner,governmental action,
and unforeseen events beyond the Contractor's control,including but not limited to weather,strikes,war,the acts of third persons or the acts of the
Homeowner.The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractor's other jobs.
4. PAYMENTS:Contractor agrees to perform the Work and to furnish the materials and labor specified in the Proposal for the amount as stated in the
Proposal.Thirty percent(30%)of the total is to be paid as a deposit with the signing of this contract.Upon cancellation prior to commencement of the
Work,any remaining deposit will be returned less the costs for materials ordered for which Contractor was unable to cancel.Final payment shall be due
upon completion of the Work and Homeowner agrees it may not hold any retainage.Late fees may be applied for late payments.Homeowner shall pay
Contractor's reasonable costs of collection,including attorney's fees and costs.Time is of the essence hereof.
5. WARRANTY:For a period of lyear after substantial completion of the Work the roof will be free of leaks caused by defects in workmanship,
but not those caused by ice backing-up or extraordinary weather events,including blizzards,tornadoes,hurricanes or storms of greater than a twenty-five
year duration or intensity.Contractor gives no warranties with reference to any materials or equipment installed in the Premises,passes any such warranties
directly to Homeowner,and Homeowner agrees to look only to the manufacturer with reference thereto.This limited warranty extends to the Homeowner
only and is not transferable to succeeding Homeowners.This Limited Warranty specifically excludes(i)all consequential and incidental damages;(ii)
damage due to ordinary wear and tear,abusive use,misuse,or lack of proper maintenance;(iii)defects which are the result of characteristics common to
materials used;(iv)defects in items installed or supplied by anyone other than Contractor;(v)work done by anyone other than by Contractor;and(vi)loss
or injury due to the elements.There are no other expressed or implied warranties or representations made or given.
6. ENTIRE AGREEMENT:This contract and all documents referenced herein constitute the complete and final agreement p g t between the parties.In the event
that any of the provisions of this contract shall be held to be invalid,the remainder of the provisions of this contract shall remain in full force and effect.Two
identical copies of this contract have been completed and signed.Homeowner acknowledges receipt of a completed contract signed by the Contractor.
7. HOME IMPROVEMENT REGISTRAT(W In accordance with M.G.L.c. 142 A,§9,Contractor is registered with the Bureau of Building Regulations
and Standards Registration No: Homeowner may verify by contacting the Director at(617)727-3200,ext.25205.A Homeowner's rights under
the Home Improvement Law(M.G.L.c. 142A)and other consumer protection laws may not be waived in any way.Homeowner acknowledges receipt of a
copy of 780 CMR R6 and Massachusetts General Laws chapter 142A,and which are available online at www.mass.gov.Questions may be directed to the
Consumer Information Hotline,(617)727-7780.
8. ARBITRATION: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 such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs
and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c. 142A.No lien or security interest is
imposed on the Property as a consequence of this contract,but Contractor has the right to record this contract or a notice of this contract,or seek a lien if the
Homeowner breaches this Contract.
9. HOMEOWNER COVENANTS:The Homeowner agrees,represents and warrants that(a)the Homeowner grants permission to the Contractor to enter the
Property to perform the work as covered by this contract;(b)the Homeowner has funds available to make full payment under this contract to the Contractor
upon completion;(c)the Homeowner understands that construction as contemplated by this agreement creates a dangerous condition,and agrees not to enter
portions of the Property under construction until the Contractor advises the Homeowner that the construction is completed;(d)Contractor may need use
landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and(e)that code requirements may result in
roofing nails penetrating through roof decking and will be visible on the underside of some surfaces.The Homeowner indemnifies,exonerates and holds
harmless the Contractor from any loss,damage,claim,liability or expense(including reasonable attorney's fees,deposition costs and court costs)resulting
from a breach of this provision.Contractor is not responsible for damage to landscaping that will grow back during the next growing season.
10.CANCELLATION:Homeowner c 1 this agreement provided Homeowner notifies the Contractor in writing at the address listed in the Proposal not
later than midnight of the third burin s da fol w' g the signing of this agreement.
HOMEOWNER: DATE: 1? /-3
f� >� � DEPOSIT: �� ��
Rightfax C2-2 1/16/2013 5 :01 :57 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
T TIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TIS
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 and endorsement. A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
DOHERTY INS AGENCY INC PHONE FAX
PO BOX 1985 (A1C,No,Ext}: (A1C,No):
E-MAIL
ANDOVER,MA 01810 ADDRESS:
22YhOC INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: TRAVELERS INDEMNITY CO.
TWOMEY&LEGARE CONTRACTING INC INSURER B:
INSURER C:
INSURER D:
PO BOX 366
INSURER E:
NORTH ANDOVER,MA 01845 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
6 IS TO CERTIFY THAT THEPOLICIESOF INSURANCE LISTED BELOW HAVE BEEN I ED 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 POLICES. LIMBS SHOWN MAY
HAVE BEEN REDUCED BY PAID CLAIMS.
MSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (NNItDD%YYYY) (MMUD0IYYYY) UMTS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
CLAIMS MADE M OCCUR. EMISES(Ea occurrence)
NED EXP(Any one person) $
GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL&ADV INJURY $
ENERAL AGGREGATE $
POLICY
1:1 PROJECT C]LOC ODUCTS-COMPIOP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
(Per accident)
NON-OWNED AUTOS PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKER'S COMPENSATION AND X WC STATUTORY OTHER
EMPLOYER'S LIABILITY YM UB-0290M994-12 09M82012 09/18/2013 uMITS
ANY PROPERITORIPARTNERIEXECUTIVE
OFFICERAAEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ 500,000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
T yes,describe under
OESCRIPnON OF OPERATIONS below E-L-DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIRESTRICTIONSMPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENT
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
Clien -13298 TWOMEY6
ACQRD.. CERTIFICATE OF LIABILITY INSURANCEora UMONYM
PRODUCER 12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Doherty Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O.Box 1986 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
21 Elm Street
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW-
Andover,
ELOWAndover,MA 01810 INSURERS AFFORDING COVERAGE MAIC#
INSURED INSURER A: Arbella Protection Ins Company
Twomey&Legara Contracting,Inc.
PO Box 366 INSURER B.WSURERC.
North Andover,MA 018455 INSURERC.
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.
.
LA
POLtCYF�FECTIVE POLICYEXPIRATION
!TR NSR TYPE OFINSURANCE POLICY NUMBER DATE IMMIDWY1 DATE iMMIDDIMLIMITS
A GENERAL LIA6IUTY 8500043255 06122112 0612213 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGETORENTED $100,000
CLAIMS MADE 51OCCUR MED EXP(Anyano person) s5.000
PERSONAL 8 AOV INJURY $1,000,000
GENERAL AGGREGATE S2_000.000
GENT AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG S2,000,000
x POLICY ;ECT F1 LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE uIIT
ANYAUTO (Ea accident) S
ALL OWNED AUTOS
BODILY INJURY S
SCHEDULEED AUTOS (Per Person)
MIRED AUTOS
BODILY INJURY S
NCN•OWAE D AUTOS (Per amdenn
PROPERTYDAMAGE $
(Pet accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO
OTHER THAN FAACC S
AUTO ONLY: AGG S
EXCESSIUMBRELLALIABILITY EACHOCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE
S
RETENTION S $
WORKERS COMPENSATION AND NC STATU• I DTH.
EMPLOYERS'LIABILITY TORY LIMIJS ER
ANY PROPRIETORJPARTNERIEXECUTTVE E.L.EACH ACCIDENT $
OFFICER(MEMSER EXCLUDED? E.C.DISEASE-EA EMPLOYEE S
It yes.dest ibe under
SPECIAL PROVISIONS belaw E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Covering operations usual to Twomey&Legare Contracting,Inc...
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPMATION
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
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED SE A
ACORD 25(2001108)1 of 2 #tS28467IM28466 DML o CORD CORPORATION 1968
r
Niassachusetts- Department of Public Safct}
4 Board of Buildinip Regulations and Standards
�►-� Construction Supervisor License
License: CS 67560
SHAUN M TWOMEY `
61 PATROIT ST
N ANDOVER, MA 01845
Expiration: 10/25/2013
t'omauissiuner Tr#: 4913
f Massachusetts -Department of Public Safety
Board of Building Regulations and Standards.
Construction Supervisor
License: CS055108 "
DOUGLAS J LEgAVE L"`
79 GARY AVE s
HAVERR LL Mk 01830
a 1 11 141 1
Expiration
Commissioner 09/02/2014
Ulze cY�a�zz��zarrrueazu�a�C%r�aJ:(ac�uJe(�J .
Office of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
egistration: 136779 Type:
expiration: -8/26/2014-. Partnership
TWOMEY+LEGARE CONTRACTING INC.
SHAWN TWOMEY
87 BELMONT ST.
N.ANDOVER,MA 01845 Undersecretary