HomeMy WebLinkAboutBuilding Permit #034-14 - 24 LANCASTER ROAD 7/10/2014 I
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BUILDING PERMIT
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TOWN OF NORTH ANDOV7N)nO
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APPLICATION FOR PLAN EXAM 4VPermilrNO:,_. • Date ReceiveJ
Date Issued: 1
�9SS�CHUS
IMPORTANT: Applicant must complete all items s on this page
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pp 2t
s
s '10
44,
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
W# ❑ lertd l�r i ,
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DffCe COWEV I,IM 014 + F-V I ST-'1 WCC pclr-
DF,,N0LJ-r1b"
OQPYG<. 13
Identification Please Type or Print Clearly)
OWNER: Name: LV- LSaWM�4 Phone: 310 4182- 7220
Address: 2� LAN
Name: N j(J+-'t* p1P_-,D,4WEJD Phone: q79 352 �;
Address: ? � L, A-y
CP 1 r:14 a 8 a�
Supervisor's Construction License: 05 45c,5 Exp. Date: 1
Home Improvement License: Exp. Date:
143�I"�
ti
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: $ 10, *(,o. 20 FEE: $ k C�0 -
Check No.: XK r! Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fun
gnature of Agent/Ow_ r _* � -ig_nature of contractor
T
T1y
BUILDING PERMIT 0* NORAOR ,6,q'tio
TOWN OF NORTH ANDOVER 3? y,".'`' OL
APPLICATION FOR PLAN EXAMINATION
Permit:Io#: u Date Received �QA�RATEO.PPy�S
gSSACHU`��
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 ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No. "
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with-unrz istered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor - �T�
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art ❑ Swiimning 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
CANNING & DEVELOPMENT Reviewed On 7 Signature_
COMMENTS
CONSERVATION Reviewed on Si nature
COMMENTS
XALTH Reviewed on 717//q Signature
�COMMENTS �--
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
r
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
i
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
v
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
24
LI Notified Notified for pickup Call a
Date Time Contact Name 1
t
Doc.Building Pen-nit 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
o Building Permit Application
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
o Certified Proposed Plot Plan
E3 Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
a Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2014
Location ,{24
No. G "1 r7 Date
. - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# <LS;2-��
I V J Building Inspector
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ND LANDSCAPE INC.
Kelly Ashlon 978.3 i 2.i400 C:508.9 30.5 10 3
17:978.3�2.8874
2 Martel Way,GcorgetoNxii,MA
W W W.NDLANDSCAPE.COM MTI,mUed tosslbili6s...
Factrao'rdinary 4Zesults!
F NORTH
own of E _ ndover
0 -
No. F� _
It#-(
h ver, Mass, 1 c7
w GOC NIC Nl WKN
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A°RA rE o 01Pa���S
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT 1,s.�.........., r,�„��,,, BUILDING INSPECTOR
....................... .... ..........................................
.N
has permission to erect .......................... buildings on .......... �............ `r►kYl�♦ ...... ..........
Foundation
r r . Rough
to be occupied as ........ ........ ...��illi lf...... ...... � ........... .. ..1!........ Chimney
provided that the erson acce din this permit shall i
p p p g p a n 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 INfi40NTH5 ELECTRICAL INSPECTOR
UNLESS CONSTRUC ST S Rough
Service
............ ... ......... ............................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinty 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.
p RuTI
CERTIFIED FOUNDA TION PLAN
LOCATED /N No.At-ADOMP MA
a
SCALE: / a o' DATE nZs 43
Scott L. Gi/es R.L.S.
50 Deer Meadow Rood
North Andover,Mass,
L.aT 19 -
24
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SG _
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1�5S,00�
LAN CA 5T F-2 . 1!4AD
/ CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE-
THE OFFSETS OF THE SU/L DING/NSPEC TOR ONLY
WOWIV COMPLY AND SUCH USE/S FOR THE
� H
THE ZONING DETERMINATION OFZON/NG
! AIMS OF CONFORMITY OR NON-CONFOfi'M/TY GI L
P ;l
yNN WHEN CONSTRUCTED. �f•� to��
s CISTE�
U/L T.
The Commonwealth of Massachusetts rsRintTForn
Department of Industrial Accidents
Office of Invesdgations
' I Congress Street,Suite 100
Boston,MA 02114-2017
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Avulicant Information Please Print Legibly
Name(Business/Organization/Individual): ND Lm ZSC r F Ne.
Address: 2 MA1Z-rM \"A
City/State/-Zip: d- 01833 Phone#: 9-78 M2 5400
Are you an employer?Check the appropriate box: Type of project(required):
1.0 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. New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity, employees and have workers'
msurance.x 9. ❑Building addition
[No workers'comp.insurance comp.
required.] 5. E] We are a corporation and its 10.[1 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t C. 152,§1(4),and we have no
employees. [No workers' 13.0 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.
lContractors 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: A CQ t�SQLOS
Policy#or Self-ins.Lic.r#: . r4 WC/20202045:24-- 00 Expiration Date:
Job Site Address:E4 LA Y C EPRO, City/State/Zip: �Y j 161845
5
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.
I do hereb cern under the ains and enaldes o e u that the in ormadon provided above is true and correct
Phone M
Oficial 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#•
NICnotal J. D991NxDr"o 976.352.5400
MANURLJ.Desauz IJR. LAIrI LW-"E. INCWWW.NDLANDLC"X.CQU
Tune 18,2014 PURCHASE AGREEI1IEti r
contract No.-5091 (V.0)
B atton Residence
24 Lancaver Road.
Ncfzth.Andovcr, 0184
Deck Demolition
Demolition,ofexisting deckforbelowrlistedeconstructoon_
Machine work
I>Umping
General labor
TOTAL $699.95
Deck Construction
Pro-vide proper footing and rebuild pressure treated with decking and handrail systems as w,ell as
steps_
Wood deck
Demolition&disposal
Machine work
Carpentry
Cement for footings
General labor
Truclang
Dump fees
TOTAL $11.7,6625
CUSMNa2 APPP-L-VAL
ND REP�s1:5t 41-XrIVE
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5'-4"
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H�3
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iPnac r.rs-ae:-mw
EXISTING DECK
13'-0" REVISIONS:
I
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NONE
biU
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Of
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11'-2" Z
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HOUSE
H OUSE SHEET
1
SHEET 1 OF 3
09
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y oma
z
LEDGER moz
4"x 4"POST FLASHING F i
TIMBER TECH
icn"°w
RAIL SYSTEM
PHpIE k318-J93-l2M
SUB FLOOR
AZEK DECKINGaroT/ana�
7"S EP REVISIONS:
I_
LEDGER LOCK FASTENER 16"O.C. 2"x 10"JOIST
DOUBLES 12'-2"x 10"PRESSURE TREATED 16"O.C. 2"x 6"SILL
2"x 10"P.T.
RIBBON
SCALE:
JOIS HANGER NONE
P.T.2"x 10" w
U
LEDGER 10"FOUNDATION w
0
V)
w
Of
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SIMPSON JOIST HANGER 0
Ofm
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SHEET
2
SHEET 2 OF 3
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x 6"P.T.POST m o s
i=ns
:.IIHGS,ER R°
SIMPSON
ILi 4"X 6"POST BASE wwxc nz a�e:ezx
��c�ay�oawns
mm.713A-
REVISIONS:
13 -REVISIONS:
o[SfAwnp�:
z"REBAR
8"SON IT TUBE
SCALE:
NONE
uj
i 48" BELOW GRADE z
w
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ujZ
0
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m
SHEET
3
SHEET 3 OF 3
C
North Andover MIMAP July 7, 2014
200 SLUE RIDGE RD
104.D-0153 104.D-0154
104.D-0151 / 104.D-0152 -
170,
'Blue Ridge Road.
158'
147 208' 180 LANCASTER RD
104.D-0170
065.0-0185
210 BLUE RIDGE RD104.D-0172 198 LANCASTER RD
10 LANCASTER RD 104.D-0171
l� N
N
104.D-0180
--� J 104.D-0169
104.D-0173
R1 L
24 LANCASTER RD 104.)-0168
31 LANCASTER RD
104.D-0167
k
104.D-0179 104.D-0174
N
�•r
36 LANCASTER RD
0
104.D-0166
'Zjf
` 104J)-0175 104.D-0165
104.)-0178 54 LANCASTER RD
\065.0-0176 90 LANCASTER RD
—Rail Line Wetlands Zoning
Interstates r:Exempt Lands Busine s 1 District
_I O Busine s 2 District Hod—tal Datum:MA Stateplane Coordinate System,Datum NAD83,
SR ®Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack
Businei 4 District NORTH Valley Planning Commission(MVPC)using data provided by the Town of
Roads 0 Gener Business District Of ° •4 North Andover.Additional data provided by the Executive Office of
Ci Easements O Planne Commercial Dev ? 1',, '���00 Environmental Affairs/MassGIS.The information depicted on this map is
`.l Corrido Development Dist 3. L for Tannin purposes only,It may not be ad
❑MVPC Boundary O Corrido Development Dist p _ to planning r �° R Y equate for legal boundary
definition or NO
Interpretation,THE TOWN LI NORTH ANDOVER
C3 Municipal Boundary O Corrido Development Dist N 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
ZoningOveda Industri I 1 District #
y f THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
::Industri 2 District
B Adult Entertainment •Q Industri 13 District i ,�, {� OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
Q Downtown Overlay District tF o ��� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
Q Historic District 0 Industri I S District • •^••^•••+
®Water Protection Reside ce 1 District THIS INFORMATION
Reside-2 District
O Parcels a R—ide ce 3 District SSACHUS�
r:Hydrographic Features de ce 4 District
--Streams 1"=100 ftde ce b District
•de ce 6 District
--ge esidential District
North Andover MIMAP July 7, 2014
0 '"BL RID E D x "
i D 153 L04 D Jill.
IMr' }F r`•`..:'+"t'qy"t ".+X'�Y c., "''� I� 'Y
•(te. t�
d--ge'Road
.L
ry
1 8 A TER Ink
1 `l iH RID E D 1 `Ol r2 f,
, d ` 8
10 LAN.A$�TER RD
u1
�� .D=0'180 „ "
u.24 L -AS D 10 D—Oi68
-s
0
31 LA 'C -TER 104 D-0167
p,
10 .D—01 9
1 .➢— 1
6 LA A GE RD
10 .D-01 $ � 54 LANGA"Sf R R'D
�
5 I
0 'S 0-0176LAN�AS RD >
Interstates
—I
SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
- Roads Meters Data Sources:The data for this map was produced by Merrimack
NORTH Valley Planning Commission(MVPC)using data provided by the Town of
r Easements Ot tt�a '6
ILD qO North Andover.Additional data provided by the Executive Office of
0 MVPC Boundary ? �� *� O Environmental Affairs/MassGIS.The information depicted on this map is
Parcels F _ 1 for planning purposes only.It may not be adequate for legal boundary
definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
t • THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
• t ,�, * OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
o�w �� • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
SSACMUSe
1"=100ft ��°
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
J Boston, Massachusetts 02116
Home Improvement Contractor Registration
Reqistration: 143817
Type: Private Corporation
Expiration: 8/4/2014 Tr# 230240
N.D. LANSCAPING, INC.
NICHOLAS DIBENEDETTO
2 MARTEL WAY
GEORGETOWN, MA 01833
Update Address and return card.Mark reason for change.
Ej Address 0 Renewal ❑ Employment E] Lost Card
SCA 1 Co 20M-05/11
License or registration valid for individul use only
Office of Consumer Affairs&Busi ess Regulation
before the expiration date. If found return to:
ME IMPROVEMENT CONTRACTOR
Wgistration: 143817 Type: Office of Consumer Affairs and Business Regulation
piration: 8/4/2014 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
N.D. LANSCAPING,INC.
NICHOLAS DIBENEDETTO
2 MARTEL WAY
GEORGETOWN, MA 01833 Undersecretary Not valid without signature
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
ConstrUction Supervisor
License: CS4054585
```
NICHOLAS J DIB
10 CROSS RD "4
BOXFORD MA 61921
ti i tir.
Expiration
Commissioner 07!08/2018
Unrestricted-Buildings of any use gwup which
contain less than 35,000 cubic feet(991nt)of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS ucensins information v[sit- www_Nbss.6cnr/#iP5
v7H ---
CERTIFICATE
4 11 : 37 9782234038 Consoles-Insurance :2172 P. 001/002
CERTIFICATE OF LIABILITY INSURANCE ;J.j2�4""'
ICATE. IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
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(iss) must be endorsed. If SUBROGATION IS WAIVED, sut)ject 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 cull Conlin
Nicholas A Consoles Insurance Agency IAc PHONE (998)223-4037 FAX (37e)223-4030
153 Andover Street Unit 111 gaileconsolesinsurance.om
SUE 8 AfFOFtPI G COVERAGE NAIC A
Danvers DSA 01923 SURLRA;Bat et IDI3111raUce Com aA
INSURED INSURER B:
N D Laudocaping, Inc. JNSUC:
2 Martel Way INsurte p:
INSURER E:
Geor etown MA 01833 I Su F:
COVERAGES CERTIFICATE NUMBERXaater Cert 2014-2015 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE PEEN 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 DESCRIBFD HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR I A NOT
LTR TYPE OF INSURANCE POLICY uMBER 142168= pDLICY x LIMITS
GENERAL LIABILITY EACH OCCURRENCE 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES IEA 00 D E "1511D.
100,000
A CLAIMS-MADE OCCUR MAOOlBS10 1/1/2014 L/1/2015 MED EXP(Any one persom 01000
PERSONAL C ADV INJURY $ 11000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 21000,000
POLICY ]( PRO- LOC $
JECT
AUTOMOBILE LIABILITY MBIN
'10 SINGLFLIMIT
1,0001000
A ANY AUTO BODILY INJURY(Per person) $
ALLOWNED X SCHEDULED 6221419 1/1/2014 1/1/0015 BODILY INJURY(Per accidanl) $
X HIRED AUTOS X AUTNONOS
ED R a R AMAGE $
X UMBRELLA LIAO X OCCUR EACH OCCURRENCE $ 51000,000
A EXCESS LIA6 CLAIMS-MADE AGGREGATE $ 5,000,000
D I X I RETE TIO 101000 K00001565 1/1/2014 1/3/2015
WORKERS COMPENSATION WC STATU- OTH-
ANO EMPLOYERS'LIABILITY YIN �Y llkl
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? NIA
(Mandatory In NMI E.L.DISEASE--FA FMPI_OYF4$
If yYes.describe under
0.SCRIPT10N OF OPERATIONS 0e10w E.L.DISEASE -POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks 6cneduls,It more space Is regWred!
Re: 24 Lancaster Road, N. Andover x& The Workera compenaation certificate will be issued by Acadia
insurance company under Policy # Wc2o20oo452401, effective from 1/24/14 to 1/24/15.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE PIESCRI09P POLICIES 09 CANCE1.4E0 RFFORE
THE EXPIRATION PATE TH9REOF, NOTICE WILL OF P9WV9RED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
Building Dept. AUTHORREDRI;PRESENTATIVE
120 Drain street
N. Andover, DSA 01845
Anthony consolon/Gcon
ACORD 25(2010/05) U 1888-2010 ACORD CORPORATION. All rights reserved.
IN5025(2otoo5).o, The ACORD name and logo are registered marks of ACORD
07/08/2014 11 :38 9782234038 Consoles-Insurance 4t2172 P. 002/002
Acv CERTIFICATE OF LIABILITY INSURANCE DATE(MM1pD/1'YYV)
7/8/2014
THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TMS
CERTIFICATE DO ES N OT AF FIRMATIVELY 0 R N EGATIVELY AM END, E XTEND 0 R ALTER T HE C OVERAGE AF FORDED B Y T HE P OLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURE R(S), A UTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must Im endorsed. If SUBROGATION IS WAIVED,stlDject 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 Berkley Assigned Risk Services
Consoles Nicholas A Insurance Agency Inc AM
PriuNt
153 Andover St 208 A1C.No.EXl 800 634.4589 AIC.Nd. 866 215-8116
ADORFSS: PoIicySarvicasftQrkI0yri5lc.com
Danvers,MA 01923 INSURER S1 AFFORDING COVERAGE NAIC a
INSURER A:
INSURED N D Landscaping Inc INSURER B:
dba:Grassmaster Plus INSURER C:
2 Martel Way INSURER D:
INSURER E
Georgetown MA 01833 IN6URER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS I$TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 AFFOROFD BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THF.TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LI ITS SHOWN MAY HAVE BEEN REDUCED BI PAID CLAI S.
L TYRE OF INSURANCE INSR WVD POLICY NUMBER MMrDb1YYYY MMIODIYYYY ICY ExP
LIMITS
GENFIRAL LIABILITY EACH OCCURRENCE $
DAMAGE 0 RENTEp $
COMMERCIAL GENERAL LIABILITY PREMISES a nnn r rn
❑ CLAIMS-MADE Q OCCUR ❑ q MED EXP(AAV nnnperson) $
PERSONAL 8 ADV INJURY $
GENERALACGREr3ATE
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $
-
POLICY JECPRO7 LOG $
AUTOMOBILe LIABILITY E6 accidenl $
ANY AUTO BODII.Y INJURY IP&rparson) $
ALL OWNED SCHEDULED AUTOS $
AUTOS 1:1BODILY IKJURY n urc nn
HIRED AUTOS Q NON-OWNEO PROPERTY DAMAGE $
AUT06 ac
Par cldenl
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEP U RETENTION$ $
WORKRAS COMPENSATION WC STATU- ❑ OTH-
AND EMPLOYERS'LIABILIYY YIN TO V I-I I s
A NY R
A OFFICE MEMBEREXCLUDED?7(EcuTIVE NIA ❑ VVC•20.20-004524.01 1/24/2014 1/24/2015 El EACH ACCIDENT 1000000.00
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 1000000,00
If Yee,UescriD6 Under
DESCRIPTION OF OPERATIONS peluw F.L.DISEASE-POLICY LIMIT 1 aa0aoa.00
DESC IPTION OF OPERATIONS I LOCATIONS I VEHICL 6(Aflacf ACO p tot,aadlllonal Rema**Schedule,jl more space ie requi(ed)
Election Category Election Status Name All Entities/Insureds:
Officer Include Nicholas Dibenedetto N D Landscaping Inc
Officer Include Manual DeSouza
CERTIFICATE HOI--DER CANCELLATION
FAMORIZEDREPRESENTATIVIE
OULD ANY of THE ABOVE OESCRIE3E0 POLICIES BE CANCELLED BEFORE THF
Town of North Andover,Bldg Dept PIRATION DATF THEREOF, NOTICE WILL BE DELIVERED IN
120 Main Street CORDANCE WITH THE POLICY PROVISIONS.
North Andover MA 01845