Loading...
HomeMy WebLinkAboutBuilding Permit #1153-2016 - 20 HAWTHORNE PLACE 5/4/2016 L NORTH BUILDING PERMIT TOWN OF NORTH ANDOVER - p APPLICATION FOR PLAN EXAMINATION *y )16 "nh 'nJ Permit No#: Date Received AT t, ACHUS 14 Date Issued: I ORTANT: Applicant must complete all items on this page LOCATION - Print PROPERTY OWNER W t' 0 k Q vn FAr- a Print 100 Year Structure yes no MAP PARCEL M1 ZONING DISTRICT: Historic District yes no - Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential ❑ New Building m,6ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Othern -- - ' ❑;,Septic., ❑WeU ❑ Floodplain. ❑Wetl""ands ❑ Watershed District ❑;\IV�terlSewer _ = .� ,. n n_n �.._ _ A . _. _ � _ �,, - - DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly 8-p 10� OWNER: Name: W � ,'O-v. FN, G Phone: ci7�-10 Address: -,)O 4-0,w' Place DIM- 'Contractor otSYS'Contractor Name: S� �1 ��a�'`� Phone: Email: W r �-� tia l ,Cm Address: 3s� 6 ver- r► 4 o f (1 Supervisor's Construction License: 10JL6(.3 Exp. Date: 08//.)-,40/7 I-� Home Improvement License: 3g.Sbq Exp. Date: ly aoi7 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: $ FEE: $ a •� Check No.: Receipt No.: X032-7 NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund _ _ r J ,r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ElTanning/Massage/Sody 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 PLANNING & DEVELOPMENT Reviewed On_ Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Pl nning Board Decision: Comments Cot;servation Decision: Comments Wafter& Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: f�F REDEP,�gRrTMENT emDu y - 3� Osgood Street T.� 4 IiL�ocated at;�1�2,41<IVIaa, Sfr t'. `p mpstt Cfk(. its �Y�e%- » Q^ Located �no� et ___.. �_. ee - = p i Fr,�e�[Departrnen��s`i E.-w,-.� �gna�ure/date T Dimension Number of Stories: Total square feet of floor area, based on EBderior 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: lies No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA,— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 z.:. r 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 aCopy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: 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/Cross Section/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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 Locations-11� No. Date � r .tt rf /_!/,� � � � � • - TOWN OF NORTH ANDOVER . x Certificate of Occupancy $ _ Building/Frame Permit Fee $ Xd -- Foundation Permit Fee $_rt_ Other Permit Fee $_ TOTAL $ Check# f �t ��i�'• Cc's-'-�; Building Inspector" / 14ORT11 own o ndover o : :. - M No. h ver, Mass o� 7 ,/- coc"ICN[WKK yq. 7,�s R�1TE� ►'P�,��(5 U BOARD OF HEALTH Food/Kitchen PERMI Septic System THIS CERTIFIES THAT ..� ,,,,,,,,,,, BUILDING INSPECTOR ................. .... ..... ........... ' ........ ....................... . . . Foundation has permission to erect ................... buildings o N p. ....... l .......... . . ........ . ..� .......��. ... " Rough to be occupied as ..... .. .....& .... .� .. .. ..... . .. .cr......l�,rs ................... Chimney provided that the per ccepting this permit shai.every respec�onform 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 LD Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TIO Rough Service • ... ..... . .. .. .. .... . ... ........ Fina BUILDIN SP TOR GAS INSPECTOR R '� B Occupancy Permit Required to Occupy uildin� 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. FREE ESTIMATES PROPOSAL Construction Supervisor Lic.#CS102663 FULLY INSURED H.I.C. Reg,# 138569 WMGHT ROOFING-GUTTERS AND HOME IMIPROVEMENT All Types of Roofimg& Gutters 350 BERRY STREET . NORTH ANDOVER, MA 01845 TELEPHONE: 97$-657-2247 PROPOS UBMITTEDTO PHONE r DIXfE�/ ran' ?81- Sao- 31() br� STREET JOB NAME 1 LOCATION CITY,STATE AND nZIP CODE^' s JOB START DATE �!' r �VI /11/4 019(45 d,35t a , ds'0406 a SP (S f 11 A a O V Q-C- 3 --Talc �f - bk CJkt`jac.e r\ all uav��S F �rKeS, �Q� vin b©o�l'S (�). Hca Mawr h �� 3 � t i TQ- i e �arcj"- .P �h rt s ► x �at` I =�affe,r n; ��3Q 0 t ` �o �'tx if >� once W1114 a--o&e-&. is c i'p Q V f, r 2�laces iii► t 1. ,\Quj ca'p. avks ko u [ awav j debit°s -fb LL 8 `7 Lo . S rA��t q.tf. 030'7q G Q st-,'C.hatrud land ;f 1. - & A( We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:$ 5-750,00 Payment to be made as follows: All material is guaranteed to be as specified.All work to be completed in a substantial workmanlike Authorized manner according to specifications submitted,per standard practices.Any alteration or deviation from above specifiicationsinvolving extra costs Will beexecuted only upon written orders,and will become an Signature extra charge overand above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance.Our workers are fully NOTE: This proposal maybe covered by Workmen's Compensation Insurance.Nonpayment by agreed party may result In litigation withdrawn by us if not accepted within days. with penalties including court cost and compensation both real and punitive. Acceptance of Proposal - The above prices, specifications and V conditions are satisfactory and are hereby accepted,making this a valid contract. Signature You are authorized to do the work as specified.Payment will be made as outlined. Date of Acceptance: .)�a / 020 Signature WRIGHT GUTTERS 350 Berry Street No.Andover, Ma 01845 Homeowner Information Contractor Information �,^e t Company\a:ns ` ,�j Sue,_tAe&ccs(do mtusoaPest08ic-BoxAddress) Contractor/Sate,pe .✓O"T..C::am.e a0 dal- �'horne Place Scoft-- City:`ro'M seta Zip Ccie 3wiressAddres>(—'•'tircic•?:a Via?:rens) l4. Inc u�✓ . �+ 0�ByS" 350 B 2r DaytirnePhcao Ever3n311hore cayfro:,n t5!ate Zip Code 978-'M-0100 Sri-f')YL- N, A► Ao-b.- Mdq - 006- lfai:?ng Add:ess(Iteifferentfremabo-re) Bu5ir. PhoneV'76 lFcdor4lEm loyer1DotS.S.Number a s lr:.tlei.^tTJFG�:trL^.:J:::f S':�.:v tiT.� '•��_.nt±tJ ranreiuin'zttaCALc.6 4///9 - OJ7 :r:.id re attain s.-:e: f 'rhe Contractor agrees to do the following tvorkfor the Homeownert (Describoindetai�e;;t�kYoeonpleted,spttifyirgtlte!ype,b:and,ezdg:adsofmateris:slobeusci3,a_eaddi;ioral=meets;fre.�;sxvJ ,� o o © o v er(`n (air "� -a(b CA rJ11- `I 3�"A l.S. i /� S� SF-'(L GC'�'c�iE(i� Prop 3$al e CF Required Permits-1he.fotowing building pert.its are regaired Proposed Start and Completion Schedule•TILe following schednlo wit( and will be secured by ti a contractor as t to t oreo•s�eis agent: bo zdi erg to adless circtun5tances oeyo 3 t;e contactei s control ' (Owners who secure their own permits will be exeluded from the Guaranty Fund provisions of Datewhelwntrzctcrp:ittbe&lLtcantrectedwcrc. IAGL chapter 142A..) Dara;vltea ccntrac:ed wcr will be sobstenlialIy completed. Total CdntractFrlce and PaymentScbedule TteContractoragreestopetformthework,titmishthematerialandiaborspecifiedaboveforthetotalsumop 45"750.00 (•) Payments tiviltb\a tuzde accor3iag to dta fellc••.ti;ng sc?::cule: s d.bOQ 0th 11p07 ngnaig Co;-; ac:(not to tAc'ei I1�L•T�1i�:O!I CvuL-azt price r,�-C,a c„st of specil eider itexs,4viicLever is grezter} S i nao`QQby 1 l_ otupoacompletion uf _ r S00,00 by _/ / or upon comple ion of. � I S_ 50,Ot7ttponconpletionafthecantrzct. (Lawrrbidsdemandtngitllpaymentantitcoxitsactiscemplated±obotitparty'ssarisfzcuoa) r T.z`c:lomngma*.- a'e aipr..:;:tm t -`n! cdemibefo:a t::a ccn!c-;tedwarlcbe 3inord:r NOTES:(*)bicicdiagall finance cbarges(11)Wvrc'Jits1Wany deposit ordot,a•payrncntrequired bythe cormactorbefo:evnod bepsrnay rotexceedtho;roaterof(a)ono-:htrdoftho totaleoniractprieeor(b)theaaualcostofa yspzciateq ipre terc temmadein terial t,hi:br.,tstbss� zic:deradinedva:..csarettthecomp:e:icarr::eduls. Er--- Fxn r Va • an -Is a ex ress,v.r ntv Wait ,ided the cont•tot r V. ,Yes hill terms of h %,Aymntyrnust banttachgd to the contrnctl Subcontractors-31=contractor agrees to be sole.y responsiblo far congpletlon of the tvork described regardless of tha actions oftay third n rty(subceatraCort:ti;izedbytL:econtrcctor. Vie contractor fistiteragrees tobesolely respomiblo'Or all pa}xentstoall su;;coctrac:ors for rnatarials acd laborurder this at:-eament Contract acceptance-Upon signing;this docrtmeat becomes a binding contract under law. unless ot'rerwise noted within tis coc=eat, coritractsaallnot imply that any lienero8tersecurityiuteresthasbnaplac:don.tasresidence. Reie.vthe follut%iagcautions and notices careRtllybefore signing US contract. • Doncbepressuredintosigaingtirecontract•Talofimotoreadandfullytwdersiandit. Ask gees?Iensifsa uettdngisttnciear. • %fako a valid Hoaaolmyrovenrient Contractor ReRistration. The law reqnh:es most home improvement contractors ard subcontractors to be registered with the Director ofHome Improvement CentractorRegistration. You may inquire about contractor xegistration by writing to the Director at 10 Park PIaza,Room 5170,Boston,MA 02116 or by catling 617.973.8787 or 888-283-3757. • Does;thacontractor have inscrauce7 Ask the Contractor forhisinsttrarcecompanyinformationsothatyo:teaneonflnneoveraga,oras.ctc. see a col;y of a"preo£o£in suranc�'dccunear. • ICno.v}our r g tts and re pensibilitles.Read the Important Information on the reverse side aft'ris fort and get a copy of,!w Cccsmzxr Gtilde totL•e Hcc::eItaptovemcat Contractar Law, You may cancel titin agreement is it has been signed at a place other than the contractors normal place of husiness,provided you notify t.a Ltbird ontractor is writing at ltisrhermaia office or branch office by ordinary mail posted,by telegram seat or by dclivey,not later than initial gltt of the business day following the signing ofthis agreement See the attached notice of cancellation forst for an explanatloa oftr(s right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES! Tr:ai..rti:Et;apEseftL:c:..�et7stb:.-sp:e.dz-.lsf�.td.Oa.c;pyrc.a3,a'o:.....-_.at-..'7.'ae�:urr;.y s.//_//a••ac. � 57�.r- ,,�.-. X� � Hbnleowner's S.CiggnSignature ontrac,is Siature Date �� /�� Data The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 r www massgov/dia • WPorkers'Compensation Insurance Affidavit:Builder>ti/Contractors/Electricians/Plnmbers. TO BE FILED WITH THE PERAUNflNG AUTHORITY. Please Print Le 'bl APPAKUt Information Name(Business/Organization/Individual): I h t LA S Address: City/State/Zip: n( Al �oy�r ►9 0(SV Phone#: r2,FJ u an employer?Check the appropriate box: Type of project(required): em to ees full and/orpart-time).* 7. ❑New'construction am a employer with P y ( am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling ny capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q 1 am a homeowner doing all work myself[No workers'comp.insurance required.]t 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.[]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12,[]Plumbing repairs or additions 5.�1 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 14�er p 0 ��5�' 6.Q We are a corporation and its.officers have exercised their right of exemption per MGL c. kP�Q `�'�a,,;,r.1--0 0 f 152,§1(4),and we have no employees.[No workers'comp.insurance required.] /� " _71 *Any applicant that checks box must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ched an additional sheet showing the name of the sub-contractors and state whether or not those entities,have #Contractors that check this box must atta employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C_s - 3 S- 3$ a 7- 0 s Expiration Date: 93� a0(6 Policy#or Self-ins.Lic.#: �)J `f,� e Job Site Address: p� G�W T��rR� G�C Q City/State/Zip: G�V P�( A 0 18 s n policy declaration page(showing the policy number and expiration date). Attach a copy of the workers'compensatio Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I v hereby cern under 14 A pal a d pe es of perjury that the information provided above is true and correct. Date: .Simstore: Phone#: 9.7 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): L ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ther Phone#: tact Person, 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 employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver'or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(l)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-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 anLLC 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 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 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 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-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ® DATE(MMIDDIYYYY) A�RL> CERTIFICATE OF LIABILITY INSURANCE j 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 poltcy(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 T A SULLIVAN INSURANCE AGENCY INC NAME:CONTACT 135 MERRIMACK ST PHONEFAX METHUEN, MA 01844 E-MA_a Extl*IL A1C No ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation 33600 INSURED INSURER 8: SCOTT WRIGHT DBA WRIGHT GUTTERS INSURER C: 350 BERRY ST INSURER D: NORTH ANDOVER MA 01845 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 26890575 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 TYPE OF INSURANCE ADDLISUSR' POLICY EFF POLICY EXP LTR POLICY NUMBER IM MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 DAMAGE TO RFNTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) S PERSONAL&ADV INJURY S GEN 'L AGGREGATE LIMIT APPLIES PER - - GENERAL AGGREGATE S POLICY JECT _LOC PRODUCTS-COMPIOP AGG S OTHER: — S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ^_;ANY AUTO BODILY INJURY(Per person) S ALL OWNED r SCHEDULED ; BODILY INJURY(Per accident), S AUTOS IAUTOS l `PROPERTY DAMAGE I (HIRED AUTOS 1 NON-OWNEDAUTOS I Per accident - S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESSLIAB I CLAIMS-MADE: { AGGREGATE S DED RETENTIONS $ A WORKERS COMPENSATION ! WC5-31 S-387187-015 9/30/2015 19/30/2016 �/ PER STATUTE EH - T AND EMPLOYERS'LIABILITY YIN' I ANY PROPRIETORIPARTNERIEXECUTIVEE.L.EACH ACCIDENT 5 100000 OFFICER/MEMBER EXCLUDED? �'.N I A ! i(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE'S 100000 If yes,describe under DESCRIPTION OF OPERATIONS below !E.L.DISEASE-POLICY LIMIT S 500000 f 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. THE WORKER'S COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SCOTT WRIGHT. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 26830575 1 1-387187 1 15-16 WC I .lagadesh059C.Av Z:,iber[ymucual.cor.. ; i =age 1 of 1 05/04/2016 15:06 9786817775 TASULLIVAN PAGE 02/02 ACQR& CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNWY) 05/04/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPO.I THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVER I,GE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 3SUING INSURER(9), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les) must be endorsed. If$I1GROGATION 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 C NTA T N Thomas Sullivan T.A. SULLIVAN AGENCY INC. FHON 9.Rzfl; (ale)681-e200 E MArI. 'µms AbbRF9s : ann(�tasUlllvanja cn ,Cor' 135 MERRIMACK ST, INSURER(SlAFFORDING'OVERAGE NAZCA METHUEN _ MA 01644 INSURER A; LM INS CORP w 33600 INSURED INSURERS: _ SCOTT WRIGHT INSURERC: _ ~^ DBA WRIGHT GUTTERS wsuREaD; ... _ 350 BERRY ST .,INSURER r NORTH ANDOVER MA 01845 1 r~SURER F; COVERAGES CERTIFICATE NUMBER: 50118 REV 31ON NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N/IAED 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 6E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HE'IEIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN6R TYPEOFIN9URANC@ POLICY EFF POLIC POLICY NU MBER D1YY1'Y LIMITS COMMERCIAL GENERAL LIADTLITY FACT OCCURRENCE S _ CLAIMS-MADE 71 OCCUR 1 i;g•Eg_tEa ocwrtenee>� & ME4 XP Ly one peLavn) s NIA PERI iJNAL&ADV INJURY s P L AGGREGATE LIMIT APPLIES PER: GENI 7ALAGGREGATE $ _ � PR4 POLICY i JKOT 71 LOC I PRO'NCTS-COMPIOP AGG S �.. OTHER: I $ AUTOMOBILELIAaILITY 'UM DINED SINGLE LIMIT E Ra gidenil _ ANY AUTO BCDI.Y INJURY(Per person) $ALL W� _ AUTOS CD SCHEDULED LTO$ N/A BODI,Y INJURY(Persccldant)i S HIREDAUTOS aIOJTOS N-CWNED PRi01`.FTY DAMAGE S erin e I UMBRELLA LIAR1-1 OCCUR FACI OCCURRENCE $ _ – EXCE95LIAS I j CLAIMS-MADE N/A AGGI:EGATE $ op I I RETENTIONS $ �y wORKERSCOMPENSATION AND EMPLOYERS'LIABILITY Y N X_;TA,T,L TE ERH A OFF CANyPERPMEM ER EXCLUDEDT gcUTIVE NIA N/A NlA VVC5315387187015 09/3D/201 J 00/30/2016 E.L.E ACH ACCIDENT a 100,000 IMandetory In NN) C.L.[ISEA$E-EA aMPI,OYt:E $ 100,000 Ir eB tleaerlee under DrnA1P71ON OF OPERAT ONS below E.L.[ISEASE-POLICY LIMIT S 500,000 N/A I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Addltlonal RCTarka Schedule,moy ho ottoanaq IT more apses Is requlrodl Workers'Compenastion benefits wilt be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 S.no suthc izatlon I.,given to pay claims for beneflte to employees in States other than Massachusetts If the Insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy In force on the date that this certificate was Issued(unless the expiration date on the at Ove policy precedes the Issue data of this certificate of Insurance), The status of this coverage can be monitored dally by accessing the Proof of Coverage-Coverage Vertfic Itlon Search tool at www.mass.govnwdAvorkert-Compensallon/Investigatioris/. Sole proprietor hes not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCR 3ED POLICIES BE CANCELLED 9EFORE THE EXPIRATION DATE THEREOI', NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PRi'VISIONS, 1500 Osgood SI.BLDG DEPT Bldg 20 Ste 2035 AUTHORIZED RF.PRESENTATNE North Andover MA 01845 Daniel M.Crq�oy,CPCU,Vice Pres dent—Residual Market—WCRIBMA ®1966-2014 ACORD I'.ORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 10- Massachusetts Department of Public Safety ; Board of Building Regulations and Standards License: CS-102663 Construction Supervisor SCOTT W WRIGHT,, 'r e 350 BERRY ST �.�� ' NORTH ANDOVER M` 0,1844': 1�/�►Z'� CA— Expiration: Commissioner 08/12/2017 I Unrestricted-Buildings,of any use group which contain less than 35,000 cubic feet(991M )of enclosed space. Failure to possess a current edition of the Massachusetts . State Building Code is cause for revocation of this license. For OPS Licensing information visit: www.Mass.Gov/f)PS . ,,.y �3 Office of Consumer Affairs&Business Regulation y4-1 OME IMPROVEMENT CONTRACTORON a� Aegistration: •138569 Type: V, i, 'Expiration: 4/14/2017 DBA WRIGHT GUTTERS SCOTT WRIGHT 350 BERRY ST. NO.ANDOVER,MA 01845 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without gnature