Loading...
HomeMy WebLinkAboutBuilding Permit #525-2016 - 24 JETWOOD STREET 10/29/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received vette-s" 06 a t e..':�'•, •_ 6 Om 032 `* n� ocw�c�awK _fie q_ c 4 NSSACH' Date Issued: N� � I IMPORTANT: ADDlicant must complete all items on this page LOCATION 2`4 5--aw s`�" ,(,?�,^ -%, �"'z'✓" Print PROPERTY OWNER!21.".,e �f"Nse-1,111011 Print 100 Year Structure yesn\no MAP PARCEL: ZONING DISTRICT:` Historic District yes Machine Shop Villaae ves TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition , Two or more famil� ❑ Industrial ❑ Alteration No. of units: ❑ Commercial 0 Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other EI -Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: is . l a tP �t yfi e- A-0 n - 4/ r J5�� 7t✓ "o ma^ - 60 & I/S w I A(, l Iota � , H e-Cvse f � rz he oi y Identification - Please Type or Print Clearly OWNER: Name: El/e��%� Phone: 9 4rlrlracc L `� e i �'00C) �.S''7 Contractor Name: Address: M a :791' 4 7 !�--.. Supervisor's Construction License: /G cLL&qe=J_Exp Home Improvement License: ARCH ITECT/ENGINEE Address: Date: , Date / 6 Phone: 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: $� i`7 FEE: $ Check No.: Receipt No.: 2Cic5y1 NOTE: Persons contracting with unregistered contractors do not have access to Oe guaraWpind re nature of contractor -- r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ 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/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 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 VOTE: 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 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 IVU I C5 and UATA — (For department use ❑ Notified for pickup Call Ema Date Time Contact Name Doc.Building Permit Revised 2014 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 Dtiunpster 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: Comme Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osqood Street FIRE DEPARTMENT - Temp Dumpster on, site yes no Located: at 124 Main Street Fire Department signature/date COMMENTS 2 Ems* x J x LL O O cr 0 m N u o LL v' U a %j p Ln Z Z m c O 'O � L.LL L � 0 C -Cc U m LL = O W y Z Z J a L o O_ 0 c LL z O. W N Z •+ u U LY s o CL U Z v N U- O U Lu 0 Z to o CL' LL W OC Q w W ir LL E � CO O Z N v N � N o N O CO 2 Z m cc Z W x LU 1- W a. 5, v v O W O O d Z C I W Q .E m in 0- 0 �+ Wo 0 O cc O CL � �Wa OM C CL O O = Z CD V t/1 N N WAP STANDARD AGEMENT Tenant/Property Owner/Agency Weatherization Agreement I . The Parties to this Agreement are the following: (hereafter Tenant) (hereafter Property Owner), and Greater Lawrence Communi Action Council, Inc. hereafter Agency) In consideration of the mutual promises hereafter stated, the Parties agree as follows: 2. The date of Agency's signature will be the effective date of this Agreement. 3. The Property Owner concFtMand the property located at____ _� currently leased or rented to the Tenant: C UW - the following with respect to L , and a. Enter the premises for the purpose of performing a weatherization inspection. b. Perform weatherization work which the Agency determines in its discretion is necessary and appropriate as a result of the Agency's inspection of the property and in accordance with the appropriate priority list for the tyle of dwelling (See Attachment A). The Property Owner also agrees to permit the Agency and the Agency's contractors to enter both the Tenant's apartment and appropriate common areas of the building for the purposes of accomplishing the weatherization work. The weatherization work will be performed in accordance with the Property Owner's consent as further specified below: (Initial one) _________I consent to performance by the Agency and its contractors of any weatheri7ation work determined necessary and appropriate by the Agency as a result of its inspection of the property. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of the work. or I will provide a consent to performance by the Agency and its contractors of weatherization zted work following my receipt of the Agency's inspection report and a statement of the estimated work and associated value. This additional consent will be attached to this Agreement as Attachment B. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of the work. APR 3 0 2915 9. (*A licable o if Tenant's heat is included in rental pavment and blanks are filled in.) At the e, end of the one (I) year period set forth in Paragraph 8 abovthe rent shall not be raised more than %per year for an additional period of years, and the provisions of 8b and 8c above shall continue in effect for such period. However, the rent provisions of this Paragraph 9 may be waived by the Agency in writing if, and only if, the premises are leased under a state or federal rent subsidy program, in which case the actual rent charged by the owner shall conform to the standards of the rent subsidy program. 10. The Parties agree that the terms of this Agreement are incorporated into any other lease or agreement between the Property Owner and the Tenant, and between the Property Owner and any successor tenant, and if there is any conflict between the provisions of this Agreement and the provisions of such other lease or agreement, the provisions of this Agreement shall govern. However, if such other lease or agreement, including without limitation a lease or agreement under a state or federal rent subsidy program, contains stronger protections for the Tenant, such stronger protections shall apply. I i . For breach of this Agreement by the Property Owner, the Property > > . ner shail Agency in an amount equal to the cost, as certified by to Agency; f the weatherization bmate ials installed and tabor performed on the premises, as well as attorney's fees and court costs. The Property Owner may also be liable for damages to the Tenant in accordance with applicable law; in such instance, the Property Owner shall reimburse the Tenant for attorney's fees and court costs. 12. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor tenant is the intended beneficiary of this Agreement and shall have a right of enforcement_ agency Evelyn Fr Executive SUBTOTALS 2A.INFILTRATION / INSULATION Domestic pipe Hot Water Tank 1st 6' 1 Sill Two Part Foam w/ Fiberglass Batt 64 1" T-max only foam boardPerimeter per IECC& SWS sq. ft. 2" T-max only foam boardPerimeter per IECC& SWS sq. ft. Drape DOOR R-5 or T-max only Tape Joints (Aluma Grip only) per hr. Duct Ins w/ Tape sq. ft. R-5 conditioned space Duct Ins w/ Tape sq. ft. R-8 unconditioned crawl/garage/attic Hydronic pipe insulation to 1" R-5 110 Hydronic pipe ins.1.25"- 2" R-5 Steampipe Ins. 1.25"- 2" iron pipe R-5 Steampipe Ins. 2.5 "- 3" iron pipe R-5 Air Conditioner Meeting Rail Air Conditioner Cover Air Conditioner Cover Special Order SUBTOTALS 21B. INSULATION Open Unrestricted R 49 Open Unrestricted R 38 Open Unrestricted R 30 Open Unrestricted R 20 Open Unrestricted R 10 Restrict FUSloped R 38 Restrict FUSloped R 30 Restricted FUSloped R 20 Restrict FUSloped R 10 R-19 FGB open rafters/walls/kneewalls R-11 FGB open rafters/walls/kneewalls Attic Stairs(stairwell & common wall) Cover Pull Down Stairs Thermadome up to R49 per Site built pull down stairs 2" foam box j ff 6 �46 a.,s - 680 216 TOTAL 204.00 0.00 104.00 0.00 0.00 0.00 0.00 70.00 70.00 448.00 17.70 157.44 0.00 0.00 0.00 0.00 0.00 0.00 420.20 0.00 0.00 0.00 0.00 0.00 0.00 595.34 0.00 0.00 0.00 979.20 0.00 0.00 0.00 334.80 0.00 0.00 0.00 0.00 450.00 0.00 ELIE DEGLOUI- 978-685-7016 24 JETWOOD ST. N.ANDOVER, 01845 LAUDITOR NOTES -_ AUDITOR NOTES 1 3/4 COPPER AUDITOR NOTES SLOPES OVER GARAGE MAY BE FULL Client address city I town contractor 1-WEATHERSTRIPPING/CAULKING QUANTITY Door Kits Q -Lon or Equiv. 4 Door Sweeps (Regular) Door Sweeps (Automatic) 4 Reglaze Windows /In.inch Window.Weathstr Schlegel per side Recessed light cover per SWS. Not a tenmat cover attic sealing 2 part foam aftic sealing 1 part foam 1 basement and living space air sealing 1 part 1 SUBTOTALS 2A.INFILTRATION / INSULATION Domestic pipe Hot Water Tank 1st 6' 1 Sill Two Part Foam w/ Fiberglass Batt 64 1" T-max only foam boardPerimeter per IECC& SWS sq. ft. 2" T-max only foam boardPerimeter per IECC& SWS sq. ft. Drape DOOR R-5 or T-max only Tape Joints (Aluma Grip only) per hr. Duct Ins w/ Tape sq. ft. R-5 conditioned space Duct Ins w/ Tape sq. ft. R-8 unconditioned crawl/garage/attic Hydronic pipe insulation to 1" R-5 110 Hydronic pipe ins.1.25"- 2" R-5 Steampipe Ins. 1.25"- 2" iron pipe R-5 Steampipe Ins. 2.5 "- 3" iron pipe R-5 Air Conditioner Meeting Rail Air Conditioner Cover Air Conditioner Cover Special Order SUBTOTALS 21B. INSULATION Open Unrestricted R 49 Open Unrestricted R 38 Open Unrestricted R 30 Open Unrestricted R 20 Open Unrestricted R 10 Restrict FUSloped R 38 Restrict FUSloped R 30 Restricted FUSloped R 20 Restrict FUSloped R 10 R-19 FGB open rafters/walls/kneewalls R-11 FGB open rafters/walls/kneewalls Attic Stairs(stairwell & common wall) Cover Pull Down Stairs Thermadome up to R49 per Site built pull down stairs 2" foam box j ff 6 �46 a.,s - 680 216 TOTAL 204.00 0.00 104.00 0.00 0.00 0.00 0.00 70.00 70.00 448.00 17.70 157.44 0.00 0.00 0.00 0.00 0.00 0.00 420.20 0.00 0.00 0.00 0.00 0.00 0.00 595.34 0.00 0.00 0.00 979.20 0.00 0.00 0.00 334.80 0.00 0.00 0.00 0.00 450.00 0.00 ELIE DEGLOUI- 978-685-7016 24 JETWOOD ST. N.ANDOVER, 01845 LAUDITOR NOTES -_ AUDITOR NOTES 1 3/4 COPPER AUDITOR NOTES SLOPES OVER GARAGE MAY BE FULL Attic / Kneewal Floor Transition. Dense pack cellulm 0.00 W.S. Hatch Q -Lon or equal 0.00 W.S. & bat Hatch,dam around etc. complete to attic R value 0.00 Kneewall R-12 cell behind Per.Memb 0.00 Open Rafter R-20 Cell. /w poly 0.00 Open Rafter R-30 Cell. /w poly 0.00 Basement Overhead R-19 fiberglass 0.00 Basement Overhead R-30 fiberglass 0.00 Crawlpace Overhead < 4' high R19 0.00 Crawipace Overhead < 4' high R30 0.00 Garage Ceiling cavity filled w/ cellulose 0.00 Wood,Shake,Clapboard,Shingles Vinyl 924 1848.00 Asbestos (single nail) /Asphalt 000 Asbestos (doub. Nail) / Aluminum 0.00 Brick/Stucco 2 hole 0.00 Vinyl over Asbestos 0.00 Multi -layered 3 or more layers 0.00 Drill rough plaster or finish wood plug 0.00 Drill finish plaster 0.00 Test Drill Walls (all 4) 1 67.00 SUBTOTALS 3679.00 2. INSULATION TOTAL 2A.+2B. 4274.34 3. STORM WINDOWS / DEADLITES Plexiglass up to 88 W. Additional per UI over 88" Dead light SUBTOTALS 5. OTHER MATERIAL Ridge vent In ft. Gable Vent rectangular Varipitch Vent Roof Vent 135 (1 sq ft NFV) Large Roof Vent 865 (A sq ft NFV) Small Soffit Vent Rectangular Turbine Vents All Stack Vent Acuvent proper (Must be this product) available @ F Permable House Wrap 6 mil poly on ground Energy Star R-4 Rigid Vinyl Repl 94-101 U.I. 30 AUDITOR NOTES 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 138.00 0.00 0.00 0.00 SUBTOTALS 138.00 6./7. E.C. MATERiAULABOR 4860.34 AUDITOR NOTES I HAS SHORT PROPA VENTS 8a. HEALTH & SAFETY CO detector 0.00 Vent Bath / Kitchen Fan 0.00 Dryer vent w/ exhaust duct Heartland 0.00 Dryer Transition Duct only 1 45.00 Bath fan 50 CFM ( replace exsisitng ) fan only 0.00 Bath fan 50 CFM (new install) with timer 0.00 Bath fan Smart timer 0.00 Blower Door Test Pre Post 1 45.00 EWASUBTOTALS 90.00 8b. REPAIR MATERIALILABOR Basement outside door solild core inc all hardware 0.00 Basement outside door w/ jambs inc all hardware 0.00 Basement outside door site built per SWS inc all hardware 0.00 Door Repl pre hung 32-36" Steel" w / Lite 0.00 Door Repl interior solid core 28-32" 0.00 Door Repi pre hung 32-36" wood"' w / Lite 0.00 Window Replacement w/ SIR less than 1 0.00 Basement Window Repl. Awning/ Hopper 0.00 Basement Window Repl. With a frame 0.00 Lockset ( door) Schlage or equal 0.00 Repair / Refit Door 0.00 Replace Side Stop 0.00 Replace Casing 0.00 Glass Replacement to 64 u.i. 0.00 Glass Replacement per u.i. over 64 0.00 Thermo pane Glass replacement 0.00 Sash Sidelock /Top Replacement 0.00 Threshold (Wood) 0.00 Threshold (Aluminum) 0.00 Slide Bolts / pull handle 0.00 Cut / finish attic-kneewall access 0.00 Cut / close attic-kneewall access 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Permits / Fees (Wap only) 0.00 SUBTOTALS 0.00 TOTAL REPAIR + HEALTH & SAFETY 90.00 GRAND TOTAL WORK ORDER # (A) 5316 4950.34 Any alterations or deviations from the above specifications involving extra costs must be cleared in writing before installation. The Work Order must be complete within 15 working days from acceptance date below: CONTRACTOR/COMPANY: ACCEPTANCE:Company/Contractor AUTHORIZED SIGNATURE: AGENCY APPROVALS: CTI Authorized Signature: 0 AUDITOR NOTES AUDITOR Date Date GLCAC Authorized Signature: Date 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-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia ACORV CERTIFICATE OF LIABILITY INSURANCEDATE(MUMDNYYY) 111. � 10/23/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON' CERTIFlCATE 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 Eastern Insurance Group LLC 233 West Central St Natick MA 01760 Select Dept PHONE (800)333-7234 x66807 FAX 781-586-8244 E-MAILADOBES.seiectvoork@easterninsurance.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Guard Insurance Group INSURED Advanced Energy Solutions Llc C/o Richard Borges 28 Hamilton Rd Peabody MA 01960 INSURER C: INSURER D: INSURER E: 1 INSURER F. COVERAGES CERTIFICATE NUMBER!15-16 Master RFVICIAN NI IMRFR• THISIS 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 A L UBR POLICY NUMBER POLICY EFF POLICY EXPIJIL LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY C.6ARAS*IADE OCCUR EACH OCCURRENCE $ DAMAGE TOR TED PREMISES Ea occurrent $ WED EXP (Any one Person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GENL AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accent $ (P accident) PROPERTY DAMAGE eraccident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? FN (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WC691424 /14/2015 /14/2016 X I WC STATU- OTH- ER EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Lawrence Building Department 200 Common Street Suite 209 Lawrence, MA 01840 AUVKU 25 (2070/05) IN."95 nninnm ni SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Koegel/PKG r terra ?C ©1988-2010 ACORD CORPORATION. All rights reserved. The A(`non name ani! Inn^ ern reniafererl merit* ^f Af`nnn F 0 �... CL o i7 L) �a a O x ° a EL 0 4u r � T3 a o A 41 V U y d o N O dow e� ��+ h w °o NN1 co CM C) q- zn wwt.�M'�ylrn,� , a o G U c o C� o Lwe w to 4p w rn � O W d h L"O .Q z w U 0 p Q m 0 N f6 R O O .Q �1 p, y W 00 Z j < .2 0 = = m 114 Q 00 W R N d F i7 L) �a a O x 4u r � T3 a o N O dow e� ��+ h co CM C) q- zn m �F� � O v t6 o J U Ory Z3 N f6 R O O .Q �1 p, y W 00 114 F Location No.`2 Date Check # U� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee TOTAL $ Building Inspector