HomeMy WebLinkAboutBuilding Permit #803-2017 - 193 GRAY STREET 2/27/2017441 `7 BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION'-*
Permit No#: -P3 Date Received /7' 9-oI7
Date
TYPE OF —IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
-g One family
[I Two or more family
No. of units:
El Industrial
[I Commercial
0 New Building
[I Addition
)KAlteration
El Others:
El Repair, replacement
El Assessory Bldg
11 Dolition
0 Oth.er
,
g] w,at-d'i Wsfti6-i-
Wo-pepup qell t -
A.i 4:
DESCRIPTION OF WORK TO BE PERFORMED:
Doieia/
OWNER: Name:
Identification - Please Type or Print Clearly
od�g ..—Phone: P-5-
C 5;�� /1/, d1j'C'el-
Address:
' C
iaFf►r' q%` -
3
bto( Name: bh, 7
j
,
upervisbr-s, @Ab "s ruction
License_
pQvemp-nt-L'eenset,
IT 75
PHbmeImDater
ARCH ITECTIE NGI NEER A Phone:
Address:
. 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: $ FEE:
Check No.: y Receipt No-:
N:)TFI Jpe acting with unregistered contractors do no4,bave. access to the guaranty fund
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Location i r
No. 91t^ — P[7 i Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ i
Building/Frame Permit Fee $ 1'1 2,�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
r
Check #
Building Inspector
Plans Submitted
Plans Waived Certified Plot Plan ❑ Stamped Plans ❑
TypE bF SEWERAGE DISPOSAL
Public Sewer ❑
Tannmg/MassageBody Art ❑
Swimming Pools ❑
well ❑
Tobacco Sales - ❑
Food Packaging/Sales ❑
Private (septic tank, etc. 1'
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Z �U C Sign atu
COMMENTS �c,2� c� . _ `1"°7 vc 5 iJ S �liQ ¢-� + lod t/
6 l fj� k5 o /jq j f q (C-- Mrd 6f 0
F Zoning Board, of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
a Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
(
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT'- Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signatureldate
COMMENTS
-)imension
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.,Tequires approval'of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
r
Roofing, Siding, Interior Rehabilitation Permits
--7❑ Building Permit Application
,;6 Workers Comp Affidavit
��❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
,7❑ 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.1. C. And C. S. L. Licenses
❑ Copy Of Contract
o Floor/Cross Section/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)
• Building Permit Application
• Certified Proposed Plot Plan
• Photo of H.I.C. And C.S.L. Licenses
o Worker' Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
❑ Copy of Contract
act
• Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
DOTE: 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: Building Permit Revised 2014
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
1,6 OM
m
$ -
$
19.20
Plumbing Fee
$
2.40
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
2.40
Total fees collected
$
124.00
194 Gray Street
803-2017 on 2/27/2017
finish attic and basement started by others
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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 Regulation's Consumer Information Hodine at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner information Contractor Information
Name. -
med M/5�ir�
Company
IG ge dik-
Street;Add s (do not us& Post Ogee Box address)
Contractor/ Salon! Ower Namd
Q� jSttaaten Zip Code fBusiness
PO,__ A Z"
Address(must irnc ude at addJress)�Q—
/ /—// { r t � V / 0
Daytim one(/,►G JJjj �� Evening Phone {r/�
74
City/r tate Zip Code
Maili ddress (I different from above)
Business Phone Federal Employer ID or S.S. Number
/
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Ln ngNrotYst most home
Imptovemntmneutoniavc
s
•sad ngNttatlon ezm6 er
name �vr�r$pg.Nm�er
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The Contractor agrees to do the following work for the Homeowner.
(Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.)
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: ;beadhered to unlesscircumstances beyond the contractors control arise
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work.MGL chapter 142A.) 'i /,
when contracted work will be substantially completed.
Price and Pavment
The Contractor agrees to perform the work, furnisb the material and labor specified above for the total sum of: P27V /"' ,t (•)
Payments will be made according to the following schedule: g"ellp '
$ upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater)
$ by / / or upon completion of
%�$_M by _/ /_ or upon completion of
Vs upon 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 S to be paid for
ordered before the contracted work begins in
to meet the completion schedule.(*•) $ to be paid for
NOTES: I-) Including an finance charges (••) taw requires that any deposit or down -payment required by the contractor before work begets may
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of airy special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
Express o- Is an atiren warrantyi r 'd by the n o? N ll terms of the wr n a e thea to the
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 trader this a> reement
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 fort 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 contractors 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 cancellation font for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two identical copies of the contract must be completed and signed One Dopy should so to the homemvner. The other copy should be kept by the cmlr. rotor.
.'\
Homeowner's ignan Contractor's Signature
�-;L�'z 7a017017
Date Date
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 arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbi t' n as provided In Massachusetts General Laws, chapter 142A.
omeownees Signature Contractor's Signature
NOTICE: The signatures of the parties above apply only to the agreement of the parties 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 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). tf',
Execution of Contract
The contract must be executed in du licate 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
they 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 http://www.mass.gQv6ocabrt'
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 HRC website at http://www.mass.pov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
hqp://db.state.ma.us/liomeimprovement/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
508-652-4800, 508-755-2548 or 413-734-3114
Version 2.1 -11/22/2010
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Property Information
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Property 210/107.13-0012-0000.0
ID
Location 169 GRAY STREET
Owner MFT REALTY TRUST
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MAP FOR REFERENCE ONLY
NOT A LEGAL DOCUMENT
Town of North Andover, MA makes no claims and
no warranties, expressed or implied, concerning
the validity or accuracy of the GIS data presented
on this map.
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Gray Rd
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Property Information
I
Property 210/107.13-0012-0000.0
ID
Location 169 GRAY STREET
Owner MFT REALTY TRUST
//4J
rY.tyay�•;C� �� •i~9 T`/C
to
p
I 0AGVSI 0,
3°
? .1 `r j KrJipk Ride 40 l �. 1" = 772 ft
._ 2 - v �_�� 1. a .tGS .t�L. Teti„a of Use
a:
MAP FOR REFERENCE ONLY
NOT A LEGAL DOCUMENT
Town of North Andover, MA makes no claims and
no warranties, expressed or implied, concerning
the validity or accuracy of the GIS data presented
on this map.
Map Theme Legends
FEMA Flood Zones
0 FIRM Panels
— Cross -Sections
• • Coastal Transects
— Limit of Moderate Wave Action
Q Coastal Barrier Resources System Area
--- Base Flood Elevations
Flood Hazard Zones
I% Annual Chance Flood Hazard
Regulatory Floodway
Special Floodway
Area of Undetermined Flood Hazard
(
0.2% Annual Chance Flood Hazard
Future Conditions I% Annual Chance Flood
Area with Reduced Risk Due to Levee
FEMA Map Service Center
03/09/2005 WED 18:03 FAX 17812709406 Litchfield Company --�4 D'URSO, JUNE, Z003/004
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03/09/2005 WED 18:03 FAX 17812709406 Litchfield Company D'URSO, JUNE [?] 004/004
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Ae Commonwealth of Massachusetts
Department of Indust ial.A.eeldenis
{ 1 Congress Street, Siaite 100
Boston, 3" 02114-2017
c wyww mass.govldia
`0vnrlrerson' Compensati7nsuxanceAfidavit:Br�1d ACn AirT�-rORITY. cians/'lumnbers.
J.N-,LMUi jouzuiww...b—
Address:
r',
�oPhoneCity/siate,Mp: e ofproject (recf'ecl)Areyou an employer?tlie appropxiatehox:employees (fan andlor pari time).'.❑ I� 'd6nsi4dtlOn
1.❑Iamaeniployerwitb.______--.— p mp eesVaorlong for S. �Re7nodeXiiig
2. Imnasoleprop=ietororpartaershi andhaQenoe loy 9 Demolition
any capanii r IN•oworkm' comp. instuance required.]
BE oworkers' comp, insuraucerequired] ` 10 ❑ Building addition
3.Q I am. aho nwwner doing allworkmys if jN
4.❑IamahomeownerandwMbehiringcoutractorstoconduct altwork
onmyproperty_ IWM ILEJElectdcalrepairsoradditions
have workers' compensation insurance or are sole 2
ensurethat all confractbts eiiher1,UPng repairs or additions
proprietors with. no •enpibyees• - R__1 l�:bi
5.❑ I am a general contractor and Ihave hiredthe sub-coiftwtos listed onthe attached sheet
J 3. [l Rb6frepairs
Thesesob-contract ors have employees mdhavewarkers' comp. insuran 14.M Other
6.❑we area corporaiion-aud ris ofEicevs have exarcisedtheir right of'exempiionperMGL c.
152, §1(4), aud'weavo hno employees. L"o workers' romp• insurance required ]
cJrsbbx Ininstalsofill out thesecdonbelovtshowu3.gth irworkers' compensationpoficyinformation
Auy apphca that chg . all work andthenhire outside contractors must submit anew affidavit indica5ng such
i Homeowners who submit this affidavit indcatingthey are doing
?Contractors that checkihis bo must aitazhaci ha additional sheetshowingthename of the sub -contractors and sfafewhefiher ornotfiiose enttlies ave
employees. Ifthe sub-couEractors have employe
es, theymustpro.ade their workers' comp- pohcy number.
am an em loye� tliatisproWdingwo,-ke-ts' compensation inszirancefor my employees. Below is t/iepoliey all
site
f p
information.
Insurance Company
Policy # or Self -ins. Lxc. #:-
Expiration Waz
City/State/Zip:
Job Site Address: the policy number and expiratio�o date)-
job
a copy oftheworkers' compeWaffoRpolicy declaration page (showing P y
Failure to'secuxe coverage as required underMGL c. )s i the form ocriminal OP WORK ORDER and a fine o£n§25A is p to X250.00 a
and/or one-yeaC hnPris°nmen well as civil penalties xu
day or onagain-St the violator. A copy s this statement may be forwarded to the O ce of Investigations of the DIA for insurance
Gowidgu VGl1.u.vu.__- -
X �o iies'el7 certify under= the -Tains anclpenct'des ofperjury that the infor7nadon p.^ovz e
Si atam ..
of use only. Do rzotrvrite in tills cr'ea; to h-, completed by city or toren official
Ferxnuit/License #
City or Town'
sgAathoxity (circle one):eetor
].Board of Realth 2. $nilding Department 3. City/I'o vvn Clerk 4. B+lecirical Xnspector 5. Plumbing Znsp
6. Other
Phone #-
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fox:heir employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of bite,
express or implied, oral or written."
An employer is d'efuied as "an individual; partnership, association, corporation or other legal entity, or any two or more
Of the foxegoing engaged in a joint enferprhe, and including the legal representatives of a deceased employer, or the
xeceivbfor, :`rusted Qfan individual, partnership, association or other legal entity, employing emplbyeeg. .However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of tb:e
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 b6 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
applicaxttwhd has not produced acceptable evidence of compliance with the insurance coverage req &ed."
Additionally, MGL chapter 152, §25C(�) 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 ofthi chapter have been presented to the contrading authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxesthatapply to your situation and, if
necessary, supply stzb=contractor(s)name(s), address(es) and phonenumber(s) along with theircertificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partaexships (LLP) with no employees other than the
members or partners, are not required to catty workers' compensation insurance. If an LLC ox LLP d6es have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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
Iudustrial:Accidenis. Should you have any questions regarding the law or if you are required to obtain a workers,
compensatioii policy, please, call the Department at the number listed below. Self-insuredconipaniesshoWdenter their
self insurance license number onthe 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 Off ce of Investigations has to contact you regarding the applicant.
Please be sure to fill in the p ermii/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 m.ay b e provided to the
applicant as proof that a valid affidavit is on file for fuitire permits or licenses. A new affidavit must be filed out each
year. Where a home owner or citizen is obtaining a license or permit nat 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877 MA.SSAFE
Fax # 617-727-7749
Revised 02-23-15 www:mass.govldia
A� �® CERTIFICATE OF LIABILITY INSURANCE
ATE
02123/2017 MMIDDIYYYY)
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.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT Susan McDonald, CISR
NAME:
Fred C. Church, Inc.
41 Wellman Street
AIC No): (978) 454-1865
AIC NNo Ex : 978 3227140 FA
E-MAIL smcdonald@fredcchurch.com
ADDRESS:
Lowell, MA 01851
(800)225.1865
EACH OCCURRENCE $ 1,000,000
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A : Peerless Insurance Company 24198
INSURED Michael W. Auclair
INSURER B:
INSURER C :
57 Fairlawn Avenue
Haverhill, MA 01830
INSURER D:
INSURER E
INSURER F :
MED EXP (Any one person) $ 5,000
COVERAGES I CERTIFICATE NUMBER: 60907 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL
SUBR
POLICY NUMBER
POLICY EFF
MMIDDNYYY
POLICY EXP
MMIDDNYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED 50,000
PREMIS ES Ea occurrence $
CLAIMS -MADE a OCCUR
MED EXP (Any one person) $ 5,000
PERSONAL 8 ADV INJURY $ 1,000,000
A
CCP8353190
11/20/2016
11/20/2017
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2.000,000
POLICY PRO LOC
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident $
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED i SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Per accident
HIREDAUTOS NON -OWNED
AUTOS
L
$
I
UMBRELLA LIAR
I
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAR
CLAIMS -MADE
DED RETENTION $
$
WORKERS COMPENSATIONSTATU-
OTH-
AND EMPLOYERS' LIABILITY YIN
TWC Y IT R
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? ❑
N I A
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYE $
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
ran
ULK 1 IFII;A It MULUtK UANUtLLA I IUN
Town of North Andover
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town Hall ACCORDANCE WITH THE POLICY PROVISIONS.
North Andover, MA 01845
AUTHORIZED REPRESENTATIVE �J
... 31898 AOQn7 . _s83642 n 4ns4_'JA4A Arnon rnconDATinr.r All ...r.� .., .a
c rvWitt ----- ....... �.. ...
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
141
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CSFA-064781
Construction Supervisor 1 & 2
Family
MICHAEL W AUCLAIR
57 FAIRLAWN AVE
HAVERHILL MA 01830
_ l— /� , . Expiration:
,,&A lJ�� 0512012018
Commissioner
✓fZ( �CL9J7/l7tdY[�CCY.IG`I 6�G-��CL(j66ClCfL000BG� !
Office of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
;Registration:.'] M875
Expiration:_ _-3%27J01.7 Type:
Individual
MICHAEL AUCLAIR- .:
'= V`- ` ,1
MICHAEL AUCLAIR
57 FAIRLAWN AVE.
HAVERHILL, MA 01830
Undersecretary