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HomeMy WebLinkAboutBuilding Permit #745 - 220 BOXFORD STREET 6/2/2006Of NOR7p e � SSACHUSE Permit NO: Date Issued: LOCATION PROPERTY O MAP NO TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION IMPORTANT: PARCEL: TYPE AND ITSF, OF BUILDING Date Received: 2 U must comi) ete ail items on this L, Print 9 ( ZONING DISTRICT: HISTORIC DISTRICT YF.S fl TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family ❑ Two or more family No. of units: ❑ Industrial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: Phone: Signature ' Address:( slL-�C� : S 11��C�/7iG� &Ce-41-� CONTRACTOR Name: Phone: Ro inS lav Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $10.0 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost :$ % x10.00=FEE:$ Check No.: 3 Receipt No.: Page I of 4 f Location �r l� .�'yxd sl— No. Date 6—.2-40(, TOWN OF NORTH ANDOVER ?aw L Certificate of Occupancy $ Building/Frame Permit Fee $_ Foundation Permit Fee $ " Other Permit Fee $ TOTAL $ Check # 2 Building Inspector TYPE OF SEWARGE DISPOSAL i wmmn SiPools M ❑ Tanning/Massage/Body Art ❑ g Public Sewer Well Tobacco Sales ❑ Food Packaging/Sales 11F1Permanent Dumpster_on Site Private (septic tank, etc. -- --- Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne k&tj Signature of Contractor Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS DATE REJECTED ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other D TE REJECTED CONSERVATIO COMMENTS . 6 1 NG f Iawt:�� tzho I W HEALTH COMMENTS f/ Zoning Board of Appeals: Variance, Petition N Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Water & Sewer connection signature & date DATE APPROVED DATE APPROVED X71-' DATE REJECTED DATE APPROVED ❑ 5 j� Comments Comments Temp Dumpster on site yesno_ Fire Department signature/date Building Permit Approved and Issued by: Page 2 of 4 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided DIMENSION Number of Stories: Total land area, sq. I: TInTRQ o„A r)ATA —'For department ncel Total square feet of floor area, based on Exterior dimensions. -Pie -- CAO 'j 01 v o W Ct (-7.ec, J Page 3 of 4 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC. Jan.2006 L 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Page 4 of 4 �N F -o C= < w c o � � Q CD CD CDco o c CD _ = cD w o CD o — Z:::r — CD O G Q CO w o CD Cw`C 7 C _ CD Q cCDD Q, w O � O CD _ N O Q CD C7 C7 cD O CD w w = con w CD CD CD CD � _ CSO Fn O = c w = O w C w CD � CD cv cn CD c - = C C c� -6 D c X CD - CD CD = w Ey- C:) 0 CD C CD T -M w _ c w O E C X It: m� F 4-7 q3 R -o C-� C-) --q o Q, CD = Q w CD c CD cD CD - = Z= CD CQD w = E _ CCD o r-- 7:3 C/) CD CD C/) CO C O_ O Q w w m cnCD=_M w COD C cn Q Q O CD w CD X —CD �-a w cm w w = _-(C:) _ = C, O w p Q O R N C CCD C - p QM CD c C C M Cn X Q w OO C) C) CL, O CD <- ci,� <n c -)w = o = CCD Q O V • � C- � CD ( � �> 1 a, CD w c W CD O C cr 4 C7 e e e e e I� m m m m m m O roll 0 3 B °�° eOOo M o o 2 a 0� eao o_ Q� CCCCCC o o� am =� aQ o� O CL iD G M- '� = eo � rr a o 3 o ee a ao 00 In J .A 00 cn m C r H I nn o Q -C ' V CD CD oov,��oovF N xm $� o ,..o m ea o ea Cq e i o D x x x x x x "' - o u s. o o eo '� o m a V' l„ o w w In cn Ln Ln Cie G7 Ost R �S^��C 7 .moi —1 wor.�r�rai.? o, .0 3 0 �I I. N ewem �V 0 r --I In o e, go 10 0o�a0410000 D wa-h C.L ��u O }os� o mo �4 IL m HCl) N 0 s Go eca Go ' e SL cc `v e cl 0m� m m m m y m N m M y C ._ W d CACD C7 MZ y 06 0 C2. � O co) a� � o d CDCL O cr I CD cD o CD mm a. C.O co) co �O y C I C2 CO)CD O CD Z oCD CD0 0 s FA 1� cn VJ n O VJ t O ��0 m z dy 5 my =mom m n O ymaC M =r C m N0. CI o y �( H 3 'o O : C, 0 z C.31 O ti Cf U, mom: �:j :r chg. 0— Ir � Cs 3 4!!^ fl1 y CZ d Q O � c W D. CD< y m O� JE N � C, ao w C=D o to n�O CD H d .Oi. r ^. � 0 : o, Cy . CA -� _ --I CD omi 0 0 roz oil tztz °� o�v °� 5 A Ctf w a c Z w oGn �- �7 w a7 r z �^ n C/)� O_ x eD d I N 0 7 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: o�! A Date Received ��5 /✓ �c Date Issued: r w,LOC-ATIONi `71 R,, , 0 TANT:'Applicant must complete all items on this pag fA :1 Print _ L ZONING_ DISTRICT:__ Histone :District TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial ep;ir,rep ace Assessory Bldg Others: DemionOther . - —dt Sep c UVell, n Floo plain.- Vlletlands E - y� Watershed Dtstict< Water /Sewer ' DESCRIPTION OF WORK TO BE PREFORMED: RPYV" 0 �� + Q-�e ole e i3ccz ti.YvJct,-j OWNER: Name: Please Type or Print Clearly) .0 1 \NOiV-- Phone- ?chi Address: CONTRACTOR; °Nara�e:,f'l i32c�ic. _ P1 1/ Phone A Ass � _.� � y ddre_ - t� Supervisor>s Constructiornheense: J 1�7 _ - �'Y r:1_ n7�C" I L ! J ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING RMIT. $12.00 IJIR ,$10000..00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project I FEE: $ Check No.: I NOTE: Persons Keceipt_NO.:_ 1 unregistered contractors do not have access to :tor. 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: Building Permit Revised 2008 Location No. t Date ^ f r , Ir Check # / 5-6 26624 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer. Con nection/sia nature & Date Drivewav Permit DPW Town Engineer: Signature: �CO.M z PAT+MENTF 7e' mph umpster on s tee yes Located 124Aain.Stfeet Osgood Street a' - -..3.= tea-. 'r -� -,�,.: ,�. •.i. �artmentAsigna. d1date L - Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 Doc.Building Permit Revised 2010 m m X m y m CO) mm _v C � n O CD Z mo N p O CL a)IWr• CL�•N .a o vCD CL % CD — CD CD o CD CD O N• C• ♦D I � v O Z CD 0 0 VIOL O CD a CD lot 0 3, ti Vf 3 O V1 - co O j ( < o��o =T O T O U=) CD X O T T = :0T O T o j n ? 3 :m x O pCp s T O j a A O Q. n N M 'D n LA T O d __op z O _? -a T m m m -Zi 0 3 y .�► �D m m m 00 0 0 a, V C W H m 0 O N � C v z Z to m 0 H o CD W N CD 0 0 o to 0 3 '. Cl) CCD W CD �- Z E -4 o CO r m y rn .0 Cl) C o=�,: �q r 0 oo� .-r 0 M o �� N OU)' Z>< � i CL cf)< 0 CL CL < y �M U)��� C� �iD_ o �) _ �0 cno CD � cc r. 0o CD CD :3 , UDD C CN v : rto c _. z: C' = _ Do yCDM m c 0 0 °_r O o 0 _ = = CL Vf 3 O V1 - co O j ( T > 6l =T O T O N (D CCD m X O T T = :0T O T j n ? 3 :m x O pCp s T O j a N M 'D n LA T O d __op T m m m -Zi D � m n -i O m m m 00 V C W H m 0 � C v z Z to m 0 H o n m 3 O D v O T m m _ C CD 04 J i' ow 0 C fDol MOYNIHAN-NORTH READING LUMBER, INC. "QUALITY BACKED BY A DESIRE TO PLEASE" 164 Chestnut Street FEIN:04-2261995 North Reading, MA 01861Contractor Reg No.: 978-864-3310 / 781-944-8500 W W Exp. Date: — /_/_ I Salesperson(s): /— Salesperson(s): i, HOMEOWNER INFORMATION Name StreetAddress ( Not P.O. Box) M AyJ6y ao,,4 tW 0> e.VS " City/Town State Zip Code 13 ) /f — ?,_14 — LA, 1� r> Daytime Phone Evening Phone Mailing Address (if different from Street Address) WORK TO BE PERFORMED AND MATERIALS TO BE USED Moynihan -North Reading Lumber, Inc. agrees to perform the work set forth in Exhibit A for Homeowner and to use such materials in connection therewith as set forth also in Exhibit A, attached hereto;and made a part hereof. I I • ' ' The following schedule shall be adhered to unless circumstances arise beyond Moynihan -North Reading Lumber, Inc.'s control: Work scheduled to begin: _/_/_ Expected date of completion: May be based upon arrival of special order material TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Moynihan- North Reading Lumber, Inc. ar/ees to per o,rm the work, and furnish the material and labor set forth in Exhibit A for the Total Contract Price of: 2l(which amount includes all finance charges). Payments shall be made by Homeowner according to the following payment schedule: $ 1124-2, Initial deposit upon signing this Contract (the initial deposit shall not exceed the greater of one-third (1/3) of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom Orders as set forth below). $� by—L--/—or upon completion of delivery of materials $ by -4—t --or upon completion of install $ upon completion of the Contract In order to meet the completion schedule set forth above, the following materials/equipment must be special ordeget`b'"efo're"e,G ntract work begins, for a Total Cost of Special/Custom Orders of $ t e paid for building permit $ to be paid for 4,;N . -nn K uY1 %A.t"f $ """"'"""' to be paid for DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Mo nihan-North Reading Lumber Inc. Homeowner's Signature Date Contractor Dat -%r /tom / (� 1� (i /)_ By: Dale Fuller Homeowner's Name (Printed) Installed Sales Coordinator You may cancel this Contract if it has been signed by a party thereto at a place other than an address of Contractor, which may be its main office or branch thereof, provided you notify Contractor in writing at its main office or branch by ordinary mail posted, by telegram sent or by delivery, no later than midnight of the third business day following the signing of this Contract. See attached notice of cancellation for an explanation of this right. See reverse side for additional Homeowner Terms and Conditions 1057 -NR 1/11 White - Office Yellow-'Sales/Service Pink - Customer Page 1 of 5 HOMEOWNER TERMS AND CONDITIONS The following terms and conditions are an integral part of this Contract between Moynihan -North Reading Lumber, Inc. ("Contractor's and Homeowner. 1. All payments are due upon presentation of billing, and a late charge of one and one-half percent (1'/2 %) per month will be applied to past due charges. Homeowner shall pay Contractor court costs, attorneys' and paralegals' fees, and any other expenses incurred in the collection of past due accounts. 2. If Homeowner is borrowing money from a construction lender to perform the work, Homeowner represents that the construction loan fund is sufficient to pay Contractor and any other contractors performing work on Homeowner's property. Homeowner irrevocably authorizes Contractor to communicate directly with the construction lender regarding payments and loan balances, and authorizes the construction lender to make payments directly to Contractor. 3. Homeowner shall be in default if it breaches any provision of this Contract; if any warranty or statement to Contractor in connection with this Contract or Contractor's extension of credit to Homeowner is false or misleading when made; if any statement to a lending institution in connection with financing for this Contract is false or misleading when made; or if Homeowner becomes insolvent, makes and assignment for the benefit of its creditors, or files or has filed a petition for bankruptcy. 4. If the Total Contract Price includes allowances, and the cost of performing the work covered by an allowance is either greater or less than the allowance, then the Total Contract Price shall be increased or decreased accordingly without the need for a signed Change Order. Unless otherwise requested by Homeowner, Contractor shall use its judgment in accomplishing work covered by an allowance. 5. If Contractor agrees to do any installation work, Homeowner will procure at its expense and before the commencement of work hereunder "all risk" insurance with construction, theft, vandalism, and mischief endorsements attached, the insurance to be in a sum at least equal to the Total Contract Price. The insurance will name Contractor and any subcontractors as additional insured. If the project is destroyed or damaged by accident, disaster or calamity such as fire, flood or storms, Homeowner shall pay for work done by Contractor in rebuilding of restoring the project as extra work. 6. If Homeowner defaults under any of its obligations under this Contract, Contractor may: Stop work until any payments are received or defaults are otherwise cured. Terminate work upon seven m days written notice and recover as damages, at its option, either the reasonable value of the work performed through termination, or the balance of the Total Contract Price plus any other damages including reasonable attomeys' and paralegals' fees Contractor suffers as a result of the default. 7. Contractor shall be excused for delay in completion of the Contract caused by contingencies out of its control, including acts or delays of Homeowner or other contractors, acts of God, labor trouble, acts of public agencies or inspectors or public utilities, extra work, breaches of this Contract by Homeowner, problems obtaining materials from suppliers, or other contingencies unforeseen by Contractor. Under no circumstances will Contractor be liable for monetary damages caused by delays as set forth above. 8. If Contractor encounters unforeseen conditions that were not reasonably anticipated by Contractor, Contractor shall call the conditions to the attention of Homeowner and the Total Contract Price and schedule will be adjusted by the extra work necessitated thereby. No installation, plumbing, electrical, flooring, decorating or other construction work is to be provided unless specifically set forth herein. In the event Contractor is to perform the installation, it is understood that the price agreed upon herein does not include possible expenses incurred in addressing hidden or unknown contingencies found at the jobsite. In the event such contingencies arise and Contractor is required to furnish labor or materials or otherwise perform work not provided for or contemplated by Contractor, the actual cost of such additional unexpected work plus fifteen percent (15%) thereof will be paid by Homeowner. Contingencies include but are not limited to: inability to reuse existing water, vent and water pipes, air shafts, ducts, grilles, louvers and registers; the relocation of concealed pipes, riser, wiring or conduits, the presence of which cannot be determined until the work has started; or imperfections, rotting or decay in the structure or parts thereof necessitating replacement. 9. Homeowner shall be responsible for the coordination of any work performed by itself or other contractors, and shall be responsible to have the work site ready for contractor to proceed. If installation is involved, with its work through the completion date. Any work performed by Homeowner or other contractors shall not hinder Contractor's schedule. Contractor does not warrant any work performed by Homeowner or other contractors not working for Contractor as its subcontractor. 10. Homeowner understands that some products described in this Contract may be specially designed and custom built, and as such Contractor will take immediate steps upon execution of this Contract to design, order and construct those items as set forth herein. Except as provided on page one of this Contract, this Contract is not subject to cancellation by Homeowner. 11. The delivery date, when given, shall be deemed approximate and performance is subject to delays caused by strikes, fires, weather conditions, acts of God or other reasons not under the control of Contractor, as well as the availability of the product at the time of delivery. Once the delivery date is determined, Homeowner agrees to accept delivery of the product(s) within one (1) week. 12. The risk of loss, damage or destruction, shall be upon Homeowner upon the delivery and receipt of the product. If Homeowner is not ready to accept the product, the delivery payment will by made as agreed upon and an extra storage fee of Fifty Dollars ($50) per week will be charged. 13. Title to the items sold pursuant to this Contract shall not pass to Homeowner until the full price as set forth in this Contract is paid to Contractor. 14. Contractor agrees that it will perform this Contract in conformity with customary industry practices. Homeowner agrees that any claim for adjustment shall not be reason or cause for failure to make payment of the purchase price in full. 15. This Contract sets forth the entire understanding of the parties. Any and all prior contracts, agreements, warranties or representations made by either party are superseded by this Contract. NOTWITHSTANDING PARAGRAPH 4 NO CHANGES SHALL BE MADE TO THE WORK DESCRIBED OR TO THE CONTRACT PRICE UNLESS AND UNTIL HOMEOWNER AND CONTRACTOR SIGN A WRITTEN CHANGE 1057 -NR 1/11 White - Office Yellow - Sales/Service Pink - Customer Page 2 of 5 o- ✓�ie �ammom,�uea�C�i a�✓llaaazc�iva�Li'. Office of Consumer Affairs & Bdsiness i<egue"tion HOME IMPROVEMENT CONTRACTOR = �- Registration: 1.71474 Type: P Expiration:, 3/21/2014 Mm Individual N ARSENAULT .;-. i SHAWN ARSENAULT.:.=,'; 105 HAMILTON L'rEOMINSTER, MA 01453'x' Underseeretary i1( i�+lassachuseit= --P0ati; 2i1:. ; P_iOiiC S Board o; Building Regulations a^d S'andards C'onstructl»n & 3 Famik _ice-nse CSFA-106031 VIM SHAWN ARSENAAULT t :: 105 HAMYLTON STREET Leominster MA 61453 08/24/2016 G R',miss;O-T of ' ARSEN-2 OP ID: NB s --'E CERTIFICATE OF LIABILITY INSURANCE RATS ! vtMfDDNW'1t 03101113 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(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 978-534-5133 Anderson, Bagley 8r Mayo 978-534-9385 Insurance Agency, Inc. 44 Main Street, P. 0. Box 360 Leominster, MAGI 453 Richard M. Bagley CON NAMEACT PHONE FAX Arc No E_t : arc, Nati: E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC 9 NSURERA: Charter Oak Fire Ins Company 25615 INSURED Shawn Arsenault INSURERB: Travelers Indemnity of America 25666 INSURER C: Travelers 105 Hamilton St 1 st FL Leominster, MA 01453 INSURER D INSURER E EACH 0 CCU RR ENCE $ 1,000,000 INSURER F: B THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTH E 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. ILTR TYPE OF INSURANCE INSR %kVD POLICY NUMBER (MMIDDIYYYY) MMIDDIYYYop— Y LIMITS GENERAL LIABILITY EACH 0 CCU RR ENCE $ 1,000,000 R E 300 000 occurrence) SES Ea occurrence $ _ r PREMISES B X COMMERCIAL GENERAL LIABILITY 16805583M546ACJ12 08/01/12 08/01/13 MED EXP (Any one person) $ 5,000 CLAIMS -MADE � OCCUR PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMPiOP AGG $ 2,000,000 EO .cddentNED SINGLE LIMIT 500,000 POLICY M JjECT LOC AUTOMOBILE LIABILITY $ BODILY INJURY (Per person) $ A BA -8672A678 -12 -SEL 08/26/12 08/26/13 ANY AUTO ^:NNED SCHEDULED BODILY INJURY (Per accident) $ PROPERTYDAMA.GE $ Per accident AUTOSx AUTOS NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB HCLAIMS-MADE DED RETENTION $ $ YJCSTATU- OTH- WORKERS COMPENSATION TORY LIMITS ER C AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVE Y t N IHUB6890875713 04/02/13 04/02/14 E.L EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100 000 OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L DISEASE POLICY L!MIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHCLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) -1 1- ^Arr unr nro CONr:FI I ATICIN © 1988-2010 AuURD CORPORA I iON. All ngnzs reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD ^NOTICE THE EXPIRATION DATE THEREOF, WILL BE DELIVERED IN ACCORDANCE INITH THE POLICY PROVISIONS. Moynihan Lumber Co. 164 Chestnut Street North Reading, MA 01864 AUTHORIZED REPRESENTATIVE Richard M. Bagley © 1988-2010 AuURD CORPORA I iON. All ngnzs reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD I Moynihan Lumber of Beverly, Inc. 82 River Street P0. Box 509 Beverly, fJA 01915-0509 (978) 927-0032 FAX: (978) 927-8668 El A A &` . MOYNNAN LUMBER CO. Moynihan North Reading Lumber, Inc. 164 Chestnut Street P.O. Box 128 North Reading, MA 01864-0128 (978)664-3310 (781)944-8500 FAX: (978) 664-0872 Moynihan Lumber of Plaistow L.L.C. 12 Old toad P.O. Box 1160 Plaistow, NH 03865-1160 (603) 382-1535 FAX: (603) 382-1935 Su'c tn.tractor'WTO'rkers' CanlPensation Waiver 0 ., hereby acknowledge that I, as an independent contractor, have been asked by Moynihan Lumber Co. to provide it with a Certificate of Workers' Compensation Insurance coverage for myself. Based on the exemption provided by the Workers' Compensation Insurance coverage for myself because I am a sole proprietor without employees. Therefore, I hold Moynihan Lumber Co. and it's related organizations and the Arcadia Insurance and or Self Insured Lumber Business Association, Inc. totally harmless for any injuries or cost of injuries incurred by myself because I have voluntarily chosen to exclude myself from coverage by engaging the exemption provided under the Workers' Compensation Laws. I have taken this option of my own free will. SIGNATURE I i DATE: White: Moynihan Yellow: Installed sales Pink: Contract Form# 1103 2006 O >0ZZZ O _ � 00 M Cp D CD O r °ate' m 0 C m ]�l Z 70 m Q a -0 = p R p N N O O W A a O O O