The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #1283-2016 - 23 ELMWOOD STREET 6/9/2016 7/+ t✓t, v X r10RTF1 O �t�ec y BUILDING PERMIT _�� e,,:,. °a< TOWN OF NORTH ANDOVER ° : , o APPLICATION FOR PLAN EXAMINATION ;f - a 4 Permit NO: Y"� Date Received 44 o�RATlD IPPt(5 Date Issued: 1,�1 SsgcHuse IMPORTANT: Applicant must complete all items on this page a 2, _ s ki""' -44"MR W-1-W"'t Fz,, u", .n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ,;Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other \NeII \ Uyl a Identification Please Type or Print Clearly) OWNER: Name: 2 n 2 Phone: LA20 Address: p/''.�• z 41, A',14V 1, .s x: 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: $ �1 k�i0Q FEE: $ o Check No.: t5 (®f1i Receipt No.: �l NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i rlat lrie- BUILDING PERMIT o� NoRrH q . + ... gSI.ED ib TOWN OF NORTH ANDOVER c 3� 9y'c 46 APPLICATION FOR PLAN EXAMINATION ` a• 1• Permit No#: Date Received A RgoRcce.Pp, gSSACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes. no 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 qWetlands q Watershed pistrict 0 Water/S"ewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's. Construction License: Exp.- Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: 'r 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: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund `ionat ur mer Signature of contractor <. Location No. 12 �j ` Date l'J • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ �' TOTAL $ r1CoZ^ j Check# 33478 Building Inspector Plans Submitted,[] Plans Waived ❑ Certified Plot Plan ❑ Stasn-fed Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swunmuig Pools El Art ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent 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 Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street roFIRE DEPAR�T�MENET' Ternp mpster'onsite~. est::; s o� =-_ ..-- # Locatetl'at4 Main(;St er etF �" 4Fir�e Departmentsi tem -- Tim Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: (Movement of(Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Buil&ag Permit Revised 201.4 b 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 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) 4� Building pp 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 I i NORTH Town ndover p 0 � Z h ver, Mass I o KI COC NICNEWKK y1' �.QS RATED P,f. �S U BOARD OF HEALTH Food/Kitchen PER IT T D Septic System THIS CERTIFIES THAT ....... .. ' �� . � BUILDING INSPECTOR � . . . ....... .... . V has permission to erect .......................... buildings on ......:..: .... ft T ......................:..... Foundation Rough to be occupied as .......... Aww.'W. ... .... ... ...... .� :......................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION Rough Service .. ....... ..... . .... ..... Final BUILDI. .. NSPEC.... O. R GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Morgan Exteriors LLC 78 Londonderry Turnpike Unit E-1 Hooksett, NH 03106 May 3 2016 Danielle Beaulieu 23 Elmwood St. North Andover, MA 01845 Dear Danielle Thank you for the opportunity to bid on your home improvement project. I would d briefly like to tell you about Morgan Exteriors, LLC and why you should choose us for your remodeling project. Morgan Exteriors protects your property by covering you with $2 million of Liability Insurance. Workers Compensation Insurance covers all of our employees so you are not exposed to any liability. We are registered in the state of New Hampshire and licensed and registered in Massachusetts. Home Improvement Contractors Registration #146964, Construction Supervisor License #CS-092194, and Lead-Safe Renovation Contractor License #LR001659. We are members of the Better Business Bureau (BBB), and the National Association of Remodelers. We have been awarded Angie's List Super Service Award as well as Elite Pro Status with Home Advisors. All of ourwindow mechanics and estimators are certified installation experts, and attend pre-approved on-going training to keep them up to date on the latest technological advances in windows including the local building codes and window specifications. As a legitimate and dependable remodeling company, we maintain these affiliations and credentials to provide you with the highest level of confidence and customer service. With a permanent place of business and over 17 years in the remodeling industry, we take pride in our quality workmanship and specialty services offered to our clients. Very Truly Yours, - Lou Chalifour 978-973-8375 (mobile) 1 Morgan Exteriors LLC Tel: ('603) 895-2092 Fax: (603) 895-1140 Email morganexteriors@yahoo.com Morgan Exteriors LLC 78 Londonderry Turnpike Unit E-1 Hooksett NH 03106 This project has been specified in accordance with local building codes, industry standards and the manufacturer's specification requirements. Certified craftsman will install all work, to insure qualification for the manufacturer's Lifetime warranty. Standard window install consists of: • Remove interior trim stops from the sides and top of the windows. • Care is taken to cut the paint line to minimize chipping of the interior finish. • Expect paint to chip at the joints. Touch up of the interior trim is not included. • Remove the existing wood sash top and bottom. • Insulate an cavities with low-expansion foam insulation where possible. Y p • Remove the parting bead if existing at the sides and top. • Apply Silicone sealant to the interior of the exterior stops. • Insulate the base/sill of the wood openings. • Insulate the head expander of the new window system. • Install the new replacement windows plumb and square. • Screw the new windows to the original wood frame. • Adjust the expander on both sides to remove any bow in the master frame. • Insulate both sides of the new windows with low-expansion foam insulation. This will prevent air movement at the perimeter of the window and reduce any drafts. The insulation also reduces noise infiltration. Interior Finish: • Reinstall the original interior trim. • Caulk the perimeter of the interior with paintable Silicone sealant. • Clean all windows upon completion and vacuum work area when done. • Canvases are used during installation when needed. • Replace any rotted framing lumber at $6.00 per foot. • Replace rotted sills at$70.00 each. 2 Morgan Exteriors LLC Tel: (603) 895-2092 Fax: (603) 895-1140 Email morganexteriors@yahoo.com Morgan Exteriors LLC 78 Londonderry Turnpike Unit E-1 Hooksett, NH 03106 Window Specifications: OKNA 500 Series Insul-Tec Deluxe Glass Type: XR-5 Double-pane with Argon.....U-Factor: .25 XR-9 Triple-pane with Argon.....U-Factor: .19 Remeasure, order, inspect, and install: Qty: 7 Style: Double hung Qty: 1 Style: Slider Qty: Style: Qty: Style: Interior color: white Ext. Color: white Grids: _,_contour flat Wrap exterior trim with aluminum.... Style: PVC Aluminum Color: white Solid UPC Vinyl Construction Will not scratch, dent or corrode like aluminum and wood materials. � Fully Welded Frame and Sash Eliminates separations and air leaks, supplying maximum strength and energy efficiency Foam-Filled Frame& Sash Adds Improved Energy Efficiency Power LiftTm Balance System Smooth Window Operation-Never needs adjustment Full Interlock with Triple Weather-Stripping Provides Low Air Infiltration for Increased Comfort and Thermal Efficiency. This Window has an air infiltration rate of 0.02cfin/ft2 which is 15 Times Less Air Draft than Industry Allowed Air Infiltration Rate of 0.3cfm/ft2 • One Piece Sloped Sill Eliminates Clogged and Frozen Weep Holes-Stops air infiltration and chimney effect drafts. Insulated Extra-Strength Glass Package Increased Strength and Sound Reduction. HeatSeal@ Warm Edge Spacer Guarantees Your Home the Warmest Glass and Least Condensation Possible. • ClimaGuardTm Heat Reflective Coating Keeps Your Home Cooler in the Summer and Warmer in the Winter. This Reduces Heating and Cooling Costs and Significantly Reduces Harmful UV Radiation. This Window has a U-Value of .25 which is the Lowest in the Industry for Double Pane Windows. A- Push Button Spring-Loaded Night Latches Adds Security While Allowing Both Window Sashes to Remain Partially Open for Ventilation. Factory Installed Half Screens Thru Vision Plus Fiberglass Screens are Removable for Convenient Seasonal Storage. 3 Morgan Exteriors LLC Tel: (603) 895-2092 Fax: (603) 895-1140 Email morganexteriors@yahoo.com Morgan Exteriors LLC 78 Londonderry Turnpike Unit E-1 Hooksett, NH 03106 General Details: 1. Dispose of old windows and scrap material. 2. Work area shall be kept neat and clean on a daily basis and returned to normal upon completion of the project. 3. All work shall have a Lifetime workmanship warranty. 4. A Lifetime materials warranty shall be provided upon receipt of final payment. 5. We are a Lead-Safe EPA Certified Renovation firm and follow all lead-safe work practices as required by law. If your house was built prior to 1978 and lead paint is detected on the windows that are being replaced, there will be an additional $75 charge per window in order to comply with these laws. 6. All work will follow local building code requirements and any permits required will be obtained by Morgan Exteriors, LLC. Actual cost of these permits are the responsibility of the homeowner and will be added to the final bill. (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A.). 7. We maintain a current General Liability and Workman's Compensation Insurance Policy. A copy is available upon request to verify coverage. 8. Windows will be installed 4-6 weeks from the day of re-measure and will take approximately 1-2 days to be installed (please add 2-3 weeks for custom colors or tempered glass). Note: These are estimates and time will not be considered of the essence. Special Instructions: DH-PW-DH will be converted to 3 DH's Awning in front will be enlarged and coverted to 2 DH's Awnings on side will be enlarged and converted to a DH All carpentry will be complete and ready for paint (Painting not included) Install 4 pairs of vinyl shutters (included) Color: Black Style: TBD 4 Morgan Exteriors LLC Tel: (603) 895-2092 Fax: (603) 895-1140 Email morganexteriors@yahoo.com Morgan Exteriors LLC 78 Londonderry Turnpike Unit E-1 Hooksett, NH 03106 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 Parts Plaza, Room 5170, Boston Ma 02116 or by calling 617-973-8787 or 888-283-3757. A 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 next page and get a copy of the Consumer Guide to the Home Improvement Contractor Law. 5 Morgan Exteriors LLC Tel: (603) 895-2092 Fax: (603) 895-1140 Email morganexteriors@yahoo.com Morgan Exteriors LLC 78 Londonderry Turnpike Unit E-1 Hooksett, NH 03106 Certifications & Affiliations: Angie's List Super Service Award Winner 2014-2012 Energy Star Retail Partner Elite Pro with Home Advisor New Hampshire Better Business Bureau (BBB) Factory Direct OKNA Window Dealer Factory Direct Authorized Sunspace® Dealer INVESTMENT TOTAL FOR SPECIFIED WINDOWS We hereby propose to furnish all labor and materials in accordance with the above specifications for the sum of: $7,500 Price includes all coupons and discounts. 1/3 Due at acceptance of proposal Deposit received: Date: 05/03/16 1/3 Due at start, 1/3 due on completion Check#: 1167 Amount: $2,500 DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Homeowner's Signature Q�,,, ,� /V' Date 05/03/16 Homeowner's Signature Date Contractor's Signature Date 05/03/16 "You, the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the attached notice of cancellation form for an explanation of this right." Terms and Conditions Since this contract is for made-to-order goods,it is not subject to cancellation other than the inability to obtain financing or proper permits.If you cancel this contract any time subsequent to the third business day after the date of the contract and prior to the start of work.You agree to pay us the difference between our estimate of the cost of material and labor and the amount of the total sale.(Our lost profit)You agree to pay according to the above schedule of payments.If you fail to pay according to the terms above then you must pay a collection cost equal to our actual costs of collection up to 15%of the total amount you owe.Plus attorney's fees and court costs.Any unpaid balances will incur interest charges of 18%annual or 1.5%monthly. 6 Morgan Exteriors LLC Tel: (603) 895-2092 Fax: (603) 895-1140 Email morganexteriors@yahoo.com Morgan Exteriors LLC 78 Londonderry Turnpike Unit E-1 Hooksett, NH 03106 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOU'RE RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO MORGAN EXTERIORS AT 78 LONDONDERRY TURNPIKE UNIT E-1 NOT LATER THAN MIDNIGHT OF 05/06/16 1 HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: Morgan Exteriors LLC Tel: (603) 895-2092 Fax: (603) 895-1140 Email morganexteriors@yahoo.com cl✓1 r0 �s Okna Windows & Doors 215—788-7000 NFR KCI—IG-161-1 r5500DHdx—New Construction Double Hung Deluxe (5500DH—DX) National Fenestration Vinyl Frame Foam Filled•314"Insulated Glass Unit Rating CouncilOa i•Low—E High Pert.Glass with Argon Gas With Grids i Vertical Slider Window — — — — — — — — — — — — — — — — — ENERGY PERFORMANCE RATINGS U—Factor(U.S.11—P) Solar Heat Gain Coefficient 0 ,25 01.27 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance Condensation Resistance 0 ,49 sz Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole product performance. NFRC ratings are determined for a fixed set of environmental conditions and a specific product size. NFRC does not recommend any product and does not warrant the suitability of any product for any specific use, Consult manufacturer's literature for other product performance information. www.nitc.org ENERGY STARQualified Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-092194 Construction Supervisor MARC W COUTURE 42 SHERMAN DR Z RAYMOND NH 03077` r--jZCK CA Expiration: Commissioner 07/17/2017 v �p • a Office of Consumer Affairs and Business Regulation �•'` 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement C ktor Registration Registration: 146964 vt' z _ Type: Ltd Liability Partne t s==° MORGAN EXTERIORS LLC. rl �,4�" rte; Expiration: 6/2/2017 Tr# 265529 MARC ARC COUTURE i,�f -->�• •��= � its{ �---`�" �� ;>• 78 LONDONDERRY TURNPIKE HOOKSETT, NH 03106 =-` v, ;:� `z SCA 1 =�; Update Address and return card.Mark reason for change., w 20M•05N1 Address [] Renewal Employment Lost Card Office of Consumer Affairs Regulation License or registration valid for individul use only ' OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to egistration: ;.: 964 ` WE; piratlonr: Type: Office of Consumer Affairs and Business Ltd ss Re Liability Partne 10 Park Plaza- gulation �-=='--� , Suite 5170 MORGAN EXTERI�, �::,t(� Boston,MA 02116 '1. rid rr : MARC COUTURE •t'�tz-•:;�=;�) 78 LONDONDERRY T`' ,.I'� ; HOOKSETT,NH 03106 j�� a Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): r'1oy--7-A+l�) Address:� 3 City/State/Zip: c1311y.e Phone Are you an employer? Check the appropriate box: Type of project(required): 1.,N I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E] New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 11`l employees. o workers 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that 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-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: Policy#or Self-ins.Lic. #: MOLO(_(A\-A 7s>Z Expiration Date: et P5 116 Job Site Address: 'Z 5 . k M W W ) S'- City/State/Zip: 1J0. 0LM) vt_-?_ y\%4 Gr6 q Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify uF the pains and penalties ofperjury that the information provided above is true and correct. Si nature: Date: (-Q- �z 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#: CERTIFICATE OF LIABILITY INSURANCE 03/30/2016 /YYYY) 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 Paychex Insurance Agency Inc NA Ew PAYCHEX INSURANCE AGENCY,INC. PHONEFAX 150 SAWGRASS DRIVE . 877-266-6850 . 585-389-7426 ROCHESTER,NY 14620 E-MAILESSm Certs@paychex.com AD R INSURERS)AFFORDING COVERAGE NAIC# INSURED INSURER A: NorGUARD Insurance Company 31470 MORGAN EXTERIORS LLC INSURER B: 78 LONDONDERRY TURNPIKE, HOOKSETT,NH 03106 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. NSR TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MMIDDIYYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES(Ea occurrence) $ I = LAIMS-MADE[�� ]�,,CCUR �N MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ r AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY =PROJECT=LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED SCHEDULED BODILY INJURYPerperson) $ AUTOS AUTOS HIRED AUTOS NOOTOSWNED BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) $ UMBRELLA LIAB L__]OCCUR EACH OCCURRENCE $ EXCESS LIAB F71 CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND X WC STATU- OTH- EMPLOYERS'LABILITY MOWC694202 09/15/2015 09/15/2016 1 TORY-LIMITS ER E.L.EACH ACCIDENT $ 1,000,000.00 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? � E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 (Mandatory in NH) I T N/A E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 If yes,describe under _=PRATIC)NA h.1— DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Building Department of North Andover,MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 1600 Osgood St Building 20 Suite 2035 DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY North Andover,MA 01845 PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) @1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD