HomeMy WebLinkAboutBuilding Permit #050-2016 - 2303 TURNPIKE STREET 7/10/2015 NORTH
BUILDING PERMIT ,.CUE. b�tio
TOWN OF NORTH ANDOVER �2 y
APPLICATION FOR PLAN EXAMINATION y,0
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Permit No#: Date Received
SSA
CH USE
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Date Issued: 119
IMPORTANT:Applicant must complete all items on this page
LOCATION ,�Z3 O-3 —rcz--z-�of Xnz S
Prin
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PROPERTY OWNER (.3/.O-e.
Print 100 Year Structure yes no
MAP PARCEL: bt�l 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
❑AI ration No. of units: ❑ Commercial
I'Aepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition 0 Other _
! ❑ Septic El Well ❑ Floodplain D Wetlands p WatershedtDistnct,
DESCI,IPTION OF WORK TO BE PERFORMED:
dentification- Please Type or Print Clearly
OWNER: Name: uo� Phone=
Address: T�1iry sK— S
Contractor Name: 4-A � u'""t hone:
Email: L. Qc
Address:
Supervisor's Construction License: . Exp. Date:
Home Improvement License: f 2, 3 4:�::, d Z Exp. Date: 13--20/
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 07 FEE: $ lo-�2—
Check
.Check No.: � %ZG13 Receipt No.: Z9aLA5
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
�Si�Tnathre of_Agehu wnor= Eianaf PrP o: __ _
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. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENT'S
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
0
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
ti` �Y`""`.""T f.: t' r t a: -' w. *) L•yag•}.Fw. •�•v -.. .+`^ ,, ��'"_,.Pa.
FIRE'�1 ERp�ARaTMENT Tem Dum sterpon site!� es = s t �:�
Located at 1P24 Main Streets .
s_. 3-.+, � iw^` {` i� •� 4
Fire DeP13 tmentisignafureldateY
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t ,,! ,sP'+;�t"'4? r �Y t -.'Y'j—a'--"+t'-�+w•.w+�ry. ^X.ea•,r i `#,_
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t 7 '`'' 7.�. c _s ''r 3
vi�.► t L [x t... � �_ r�S` •�' 't '* i 1s � N♦ ti♦4 '� °': 'fa s ` •:�a c 9�"".
�.... _,:__... ..,._ �_ ...c ._..�_ '. _ .,.�« _,..�...�_��_o.,.:•t ,..:.pati,•
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Motor locati®n,,anast or service drop requires approval of
Electrical Inspector Yesy' 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
F
Doc.Suilding Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
4: Building Permit Application
4. 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
4. 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
4. 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
Doe:Building Permit Revised 2014
Location L � u� r-i�� It -�► .tee_
No. 2o Date
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
• Building/Frame Permit Fee $ `J
k Foundation Permit Fee $
Other Permit Fee $
_ a
TOTAL $
i'
Check#
f� v
Building Inspector
r '1 NORTH
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COC NICNl W.CN '-
�d A04ATED Okf' ki
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BOARD OF HEALTH
RM LD Food/Kitchen
PE T Septic System
THIS CERTIFIES THAT .................'�........ .. ....... .. .................................. .................. .
. . ,, BUILDING INSPECTOR
.,R.3.0 �.....1 We� 1 ,,,, ,.t Foundation
has permission to er t .......................... buildings on .... .......... ... ..................... g
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I�c 1� S-fir � �{c.
to be occupied as ... .�.��. `. .1 .Imit
�......... ..................................... ........1......................... ..,....... Chimney
provided that the person accepting this 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-Law rel�tholcmjet
spection Al ration and
Construction of Buildings in the Town of North Andover. ow PLUMBING INSPECTOR
�,�l
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 TH ELECTRICAL INSPECTOR
UNLESS CONSTRUCT 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.
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PRO-DESIGN BUILDERS.com I.
Builder License # 43550, HIC# 123602 P.O. Box 4223, Andover, MA 01810
Phone 978-475-2999 Fax 978-749-9402 lenniesaltz@verizon.net
Customer: Melanie Dube
Address: 2303 Turnpike St. North Andover
Phone:// /0 7 7S' /-- Cell Phone: sem'-975-2695 - 978-305-3966 4.
Fax: Email:
The Owner represents that he/she is the Owner of the premises located at 2303 Turnpike St. North. .
Andover, MA and the Contractor relying on such representation agrees to furnish and the Owner
agrees to pay for the following:
DESCRIPTION OF WORK
Build 112' Pt deck Frame and install one white 6 ` x 6/8 Vinyl sliding door, install a
total of 18 VitylvTilt-in insulated low e glass Silver line by Anderson,insulate window weight
pockets also install 7 cellar with hopper style Vinyl windows, cover casing with custom white G
aluminum Install new kitchen cabinets with _granite c un erops, new floor Bamboo or equal
owners choice install Vinyl siding color choice �' stall fanfold 3/8" insulating board {
underlayment, cover fascia, rakes with custom aluminum tri . Option Vinyl siding front of
garage and right side additi nal 3,250 Attached cost sheet dated June 15, 2015
Total Job Price Sales Tax; N/A
R ou
Down Payment $20% �° U U Balance $ �
Terms of Payment: Progressive `
e:
* We are not responsible for any pre-existing violations including any unforeseen rot! ..... ;
Cost to replace rot would be about $16.50 up to 1x8 per lineal ft., 1/2' plywood @ $14.50 a sq ft.
* Any changes to the scope of work will be executed only upon signed change orders.
f.
* Customer agrees that by signing this agreement, customer is hiring PRO-DESIGN BUILDERS to ,
perform the above described work.
* The customer agrees to make payments as per payment schedule. If customer fails to pay, customer
will be responsible for interest at 1.5% after 10 days, reasonable attorney fees and costs incurred by
PRO-DESIGN BUILDERS to collect these amounts.
* Changes to this contract must be followed in writing and signed by both parties and will be governed
over this contract.
s
4
Delays beyond PRO-DESIGN BUILDERS control such as acts of God, abnormal weather, delays by
owner, or other contractors, labor or market disturbances, acts of civil authorities, or crime shall cause
an extension of time to complete the contract and adjustment in the contract price allowing for storage
charges, etc.
* All job is Materials are fully warranted by MFG ... Pro-Design Builders will service all any
issues with installation if necessary within one year after which MFG warranties will apply..
* All work to be done in a workmanship manner with upmost attention to construction standards and
state codes.
*
Service work and preventative maintenance outside.one year will be billed on a time and material
responsible for
annually. PRO-DESIGN BUILDERS will not 'be p
basis and is recommended ann y
consequential damages. Clerical errors are subject to correction.
* Job to be started 10 days after permit and to be completed in 40 days.
* Unit pricing is subject to change if the proposal is not accepted in its entirety. PRO-DESIGN
BUILDERS scope is limited to items on proposal.
* This proposal is subject to the terms shown on the face hereof including any additional.sheets
*** The customer may request their deposit back within 3 days if they decide to cancel the job.
We,the undersigned, have r u tood and agreed to each of the provisions of this contract
Leon d tzman/PRO-DESIGN BUILDERS tOer
Date Owner
Date
i
The Commonwealth of Massachusetts
Department oflndustrialAccidents
µa. . _ d 1 Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dna
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le 'bl
Name (Business/Organization/Individual): L
Address: (_5
City/State/Zip: hone#:
Are you employer?Check the appropriate box: Type of project()required):
1. am.a employer with C/ employees(full and/or part-time).* 7. ❑New construction
2.Q I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 ❑Building addition
4.Q1 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.Q Electrical repairs or additions
proprietors with no employees. 12.[]Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors 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,%ey 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: _ A103,
Policy#or Self-ins.Lie.#: V� ��,�TS,�� 1� �/S Expiration Date:
Job Site Address: 3 � �/ S City/State/Zip:/�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 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 unde z a' a d p alties o perjury that the information provided above is true and correct.
Si afore: Date:
i 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#:
i
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(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=contractor(s)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 carry 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 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-iiisured 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
7/08/2015 23:33 FAX 9789577230 CLOUTIERINS 0 001/001
CORDa►TE(MrroaYYYYI
CERTIFICATE OF LIABILITY INSURANCE 7i9 15
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 13Y THE POLICIES
BELOW. THIS CER1'IRCATE OF INSURANCE DOES NOT CONS-I TUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE=HOLDER,
IM RTANT: if the certificate holder Is an ADDITIONAL INSURED,the policy(ias)must be endorsed. if SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies ney require an endomemenL A statement on this certificate does not confer riots to the
certificate holder in lieu of such andoreemen
PRODUCERypere MsaQa>!i Alli son
Cloutier Insurance Ag®noy HONE 57- 1 IAI . (978) 957-7230
1996 La]t:eview Avenue - mallison@insurer.com
Dracut, MA 01826 iNsgFCM)APFORotNocovERAGE NAIcu
INSURERA:ATLANTIC CASUALTY
INSURED "--- I INSURERS
Leonard F Saltzman INSURERC'
DHA Pro-D®sign Builders I,asuRERp;
5 Hillcrest Road IN6UR$
Andover, MA 01610 INMR6i F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMISD 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,
MIR
AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - _
i TI2R TYPE OF INBURANCN ADOL gvign U9Rp Ucr NUxeER PxuDD/Y �a�rrrY LINTS
A GENERALLIABILITY L117001830 7/13/14 7/13/15 EACHOCCURRENCE $ 1 0 0,000
DAMAGE TO 6 � 0
X COWERCIAL GENF PAL LIABILITY AREMMES(F�
CLAIMS-MADE I�I OCCUR MED W WM ore eeram g 5,000
PERS ONAL&ADV INJURY a _1,000,000 -
GENERAL ROGREGATE
,000,000GENERALROGREGATE S 2,OOO,OO
GEN'LAGGREGATELIMITAPPLIES PER PRODUCfs•COMPlOP AGG $ OOO OOO
POLICY PR - LOG 8
AUTOMOBILE UABIUTY Ea exJcllf>i3 LIMIT S
ANYAUIO BODILY INJURY(Par ponon) S
ALLOWNED SCHEDULED BODILY INJURY(Per wddanl) S
AUTOS AUTOSPROPS GE
NON-OWNED er sod Y 9
HIRED AUTOS _AUTOS
g
T;WA OGCUR EACNOccuRRENCE
Sg
CLAIMS-WADE S
DED RETENTION h S
WC STATU-i
wORK06 COMPENSATION OTH-
QR.ILLWATS --
ANO EMPLOYERS'LIABILITY Y I N
ANY PROPRIETORIPARTNER/EXECUTIVE NIA E. E0.CMACCIDENT
OFFIC=RMEMBER EXCLUDED?
@eerdamry In NH) E.L. ,yQEABE•gq EMPLOYEE lB..,_
Ify BS d'*Vibe under E.L.DISEASE-POLICY LIMIT
Dh8C 1 'n N OF OPERATI N bele-
' DESCIRIPTION OF OPERAMONS/LOCATIONS I VEHICLES (Aunh ACORD 101,Addidwial Ra rm"S nedWa,If mom spam Is regLdmd)
CERTIFICATE HOLDER CANCEI-LATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TME EXPIRATION DATE INCREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
1600 Osgood Street:
N.AndOver, MA 01845 AUTMOR¢EpREPResENTATIVE `
Im
m 1989':20-10 ACORD CORPORATION, All rights reserved-
ACORD 26(2010105) The AC ORD name and logo are registered marks of ACO RD
Phone: Fax: (978) 688-9542 E-Mail:
Rightfax N2-1 7/10/2015 6 : 49: 34 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
44
T. F0IFIC TE 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 and endorsement. A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
CLOUTIER INS PHONE FAX
1996 LAKEVIEW AVE (A/C,No,Ext): (A/C,No):
E-MAIL
DRACUT,MA 01826 ADDRESS:
73LYS INSURER(S)AFFORDING COVERAGE NAIC q
INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA
SALTZMAN,LEONARD DBA ALL PRO DESIGN BUILDERS INSURER B:
INSURER C:
INSURER D:
PO BOX 4223 INSURER E:
ANDOVER,MA 01810 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.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MNhDD\YYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
CLAIMS MADE [—]OCCUR. PREMISES(Ea occurrence)
MED EXP(Any one person) $
k_� PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY EDPROJECT LOC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
(Per accident)
NON-OWNED AUTOS PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $
A WORKER'S COMPENSATION AND x M WC STATUTORY OTHER
EMPLOYER'S LIABILITY Y/N UB-0609N493-15 06/10/2015 06/10/2016 LIMITS
ANYPROPERITOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? WA E.L.EACH ACCIDENT $• 100,000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SALTZMAN,LEONARD.
---------------
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
1600 OSGOOD STREET IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENT g VE
N ANDOVER,MA 01845
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
CEJ/ze �a�rr�rra�aareall/i o,'C�/ daczcalc!!a f'- :�' k*reaw
Office of Consumer Affairs&Business Regulation
1 Massachusetts -Department of Public Safety
Board of Building Re0ula4l6ns'and Standards`"
OME IMPROVEMENT CONTRACTOR
egistration �HA2 Type: C $#14k►15 � ��r f
Expiration: 1f Private Corporation; Llcehse .CSwW"0
All Pro Design Builder$ l LEONARD F SAL v
5 EUL•L.t=REST
V
Leonard Saltzman � f. �AndoverMA 018
0
P.BOX 4114/5 Hillcrest
51 X
Andover,MA 01810 " ► \�
Undersecretary �
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expiration
Commissioner 08/1912015
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