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HomeMy WebLinkAboutBuilding Permit #448-16 - 204 COVENTRY LANE 10/8/2015 BUILDING PERMIT 0&1t%10RRTFr bgtio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ?o# ey Permit No#: Date Received A A �l 0 T. '4 � SSgcHus�� Date Issued:-412 ""� IMPORTANT: Applicant must complete all items on this page LOCATION 20 � 1. Q l� L.. Alf � ��{� � A k�� '�V�t` I PROPERTY OWNER 7 Igo ' Print 100 Yeas Structure yes no MAP PARCEA/31 ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: � � �l✓Ut � V1� 0 Gl CJ�/U� 7 T f,1 l�LI �� Identificatio - Please T e or Print Clearly ip 41 OWNER: Name: �W 0 /'1A 1 Phone: Address: - _ m Contrac or Na e:l'q l t4 A1,445 ((1116640� Phone: Email , kt t � G C.��1 OGZt Address: aC N JAD Supervisor's Construction License: Exp. Dater Home Improvement License: Exp. Date: 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: $ Q f L FEE: $ `� Check No.: ✓ Receipt No.: NOTE: Persons contracting w h unr istere contractors do not have access to t e guaranty fund L Ignature of Agent/Owne � 2 Signature of contractor Location d 61 V,4" &U,1b, No. Date • TOWN OF NORTH ANDOVER Certificate of OccupancyAw $ p Building/Frame Permit Fee yen � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# �J Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL i 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 PLANNING & DEVELOPMENT Reviewed.Qn Signature_ COMMENTS CONSERVATION Reviewed on /OA 15- Si nature J COMMENTS HEALTH Review n_ Signature COMMENT c Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIDE DEPARTMENT Tem .uD,um ster on site yes no P P _ . ._ . -.� Located,at 124'Maini 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) OJ4 ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 1 I 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 o Building Permit Application o Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li 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 o Photo of H.I.C. And C.S.L. Licenses o 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 o 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 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 F NORTH Town of E �. Andover p �' `� to > > �` h ver, Mass O oQ SA cOCN�CHlwK�t y7' 7,9�R�ITEo r'Pp'�,�5 U BOARD OF HEALTH Food/Kitchen PERMIT T. LD Septic System THIS CERTIFIES THAT Hl A� BUILDING INSPECTOR ... ..................................... . .�. .��/.ll...................................................... has permission to erect . buildings on �/� 'r Foundation ......................... ..� ....4..L1.��.`:. .......f`(yir.... ....... Rough to be occupied as ............. .. (... . ..........I` ....A. ....r�. !�!:1 ..... .. .............. 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 3V PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TA 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. NORTH Town of . � EAndover 0 No. h ver, Mass o OI COC KIC N�WICK y�. A�R�TED S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT �.�.oL 1BUILDING INSPECTOR has permission to erect g Foundation .......................... buildin son ......(,..C.1!��. .......1401 ... .. . ... . .^ ....,. Rough to be occupied as ............. ..a(...�. ..........1"�.6ov. ....r�. .✓.!'fid..... .. ........ 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 3-D PERMIT EXPIRES IN 6 MONTHS ELECTRICALINSPECTOR UNLESS CONSTRUCTION TA 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. r �. TT X21 AREA=43,560 S.F. =1.0000 AC. 30' �v1 p ` STORY 0 STORY M_ irlc[� O N #204 N I za clq I 1 / =150.00' GUVENTRY LANE "I HEREBY CERTIFY TO SALEM FIVE MORTGHGh COMPANI PLOT PLAN LLC & THOMAS RINGLER THAT THE DWELL/AVG fS LOCATF'D ON THE LOT AS SHOWN AND THAT IT DOE: UNFORM IN WITH THE TOWN OF NORTH ANDOVER ZONtN(' REGULATI(IVS I GARDING FURTHER CERTIFY STHAT THItS bWELFROM STREETSLIN( i5 /OTS o NORTH ANDOVER, MA LOCATED IN THE FEDE ,L HAZARD �,REA SHOWA ON FEMA COMMUNITY 0098 000 DATED DRAWN FOR JUNE 2, 1993 r THOMAS RINGLER • Ta •- TP := 4, CALE =50' DATE: APau 1' 2011 STEPHEN Lk S. THIS PLAN F ,W RPOSES NO t,'Oh MERRIMACK ENGINEERIN(: SERVICES BOUNDARY DET ```BOUNDAR' OQRMATIOr �I66 PARK STREET TAKEN FROM EXIS?`1 -.. ECORDS M27 97 ANDOVER MASSACHUS ETT: oI110 The Commonwealth of Massa chusetts z Department of IndustrialAccidents »= s 1 Congress Street,Suite 100 Boston,MA 021142017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le6b Name(Business/Organization/Individual): ��O(`l/�S I U bL Address: 6 AJ /? Z...A M q City/State/Zip: Vo OPA A A) Q VER Phone Are you an employer?Check the appropriate box: Type of project(required): 1.FJ I am a employer with employees(fiill and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9 Demolition 10 ❑Building addition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions • 5.❑I 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.# Q 6. We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.�Other /A )4V Q U All ❑ rP , . , gh P 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] �� Z *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors tbat check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-coniractors have employees,they must provide their workers'comp.policy number. lam an employer that is pioviding workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 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 do hereby certify der the pa' and p alties of peijury that the information provided above is true and correct. signafore: l� Date: 0a Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town, Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: � v 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 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 i 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 cavy 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 foi•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 yoii'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 contactre ou g y regarding the applicant. Please be sure to fill in the permitilicense 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 ACOO 100/7//7/20155 CERTIFICATE OF LIABILITY INSURANCE DIDDIY �� 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 Christopher Kennedy Farquhar & Black Insurance Agency PHONE ('781)599-2200 FAX No:(781)581-3940 85 Exchange Street - Suite 101 ADDREs :Chris@FandBInsurance.com INSURERS AFFORDING COVERAGE NAIC# Lynn MA 01901-1475 INSURERA:Penn-America Insurance CO. INSURED INSURERB:Safety Indemnity 33618 Hyde Brothers Contractors INSURER C: 76 West Park Drive INSURER D: INSURER E: Wakefield MA 01880 1 INSURER F: COVERAGES CERTIFICATE NUMBER:Thomas Ringler 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 IN L SUER POLICY NUMBER MM/DDY MMIDEFF D Y EXP LTR IYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE I—XI OCCUR PAV0062800 /14/2015 /14/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 }� POLICY PECTRO- LOC $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident 500,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED5;71 SCHEDULED 5021390 9/18/2015 9/18/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS n AUTOS Per accident Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE — N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,It more space Is required) 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. Thomas Ringler 204 Coventry Lane North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Marian Cruz ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn95 ron1nw ni Tho Af`npn nnma nnA Inn^gra ranicfarad mnrlre^f Arnion A657R©O CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDWYYYY) 10/07/2015 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: N the certificate holder Is an ADDITIONAL INSURED,the poilcy(les)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 NAMONCT E Marian Cruz FARQUHAR&BLACK INSURANCE AGENCY INC. 99-2 781 5200 _____..........T_—i in c PHONE No): E4WE�; marian@fandbinsurance.co _._...._. _._....... 85 EXCHANGE STREET-STE,101 INSURER(S)AFFORDINGCOVERAGE__...._�._._.___ NAiCk LYNN MA 01901 INSURER A: ACADIA INS CO 31325 INSURED INSURER e: .._... ....... ......__......_ HYDE PHILLIP INSURER C: DBA HYDE BROTHERS GENERAL CONTRACTORS INSURER D: 76 WEST PARK DRIVE INSURER E WAKEFIELD MA 01880 1 INSURER F COVERAGES CERTIFICATE NUMBER: 4256 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. fNSR TYPE OF INSURANCE_....................._�ADOLL R -�. POLICY NUMaER I.ICY EFF blyrm M L ICY EXP LIMBS L COMMERCIALGENERALWa1LRY EACH OCCURRENCE S O_RE. ..._....._-__ CLAIMS-MADE OCCUR PREMISES tEs oawrenoej,,,,,,,,_3 MEOEXPt one.Derson) S__ ............ i PERSONAL&ADV INJURY NIA S .........._....m. I _ GENm.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY JECT !- LOC ( - PRODUCTS-COMP/OP AGG _S OTHER: S AUTOMOBILE LIABILITY I .fEa at)INCL LI i S CCiden ANY AUTO _ BODILY INJURY(Per person) $ ALL OWNED r SCHEDULED AUTOS AUTOS N/A (BODILY INJURY(Per accident) S NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS accident)..___,_,___...,_„_ I S UMBRELLA LIAI OCCUR ! i EACH OCCURRENCE S EXCESS UAB CLAIMSMAOE! N/A AGGREGATE S_ DED I I RETENTION $ WORKERSGOMPENSATIkJ I X STATUTE ERH i A �AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNER/EXECUnVE Y f N E.L.EACH ACCIDENT s 500,000 OFFICEMMEMBEREXCLUDED? NIA wA NIA WC202000521901 03/12/2015 03112/201$ - (Mandslnry In NH) ' I E.L.DDISEASE-EA EMPLOYFE1 S 500,000 Hdescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT i S 500.000 i N/A DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(ACORD 101,Addllionai Remarks Schedule,maybe attw*W N mon space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits 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 above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gaWlwdMrorkers-compertsationrinvestigationst. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thomas Ringlet ACCORDANCE WTH THE POLICY PROVISIONS. 204 Coventry Lane AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniell t an .Crc&*y,CPGU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD