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HomeMy WebLinkAboutBuilding Permit #315-14 - 240 CHARLES STREET 10/3/2013 ` Ott,.,.., ,6o BUILDING PERMIT Fr , 1. ... 4 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION I n b Permit NO: �� Date Received Date Issued: I ORTANT:Applicant must complete all items on this page LOCATION Z40 CiS 'CEE'T" Print PROPERTY OWNER 11;,4, 6VJR NLe Sm ITP4Y 15T�rc.T /'�''�•� Print Shop MAP NO: 1 L PARCEL ZONING DISTRICT: Historic District yes no Machine Sho Villa ge yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: KCommercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other ❑ Septic ❑Well 0 Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer ft,mo Ye- /,-Aw lP­r_-Ol ffc, Res @ �o N f t to ic�0 } IZI vJMW-E ISUt U)I N(a AAM _rPS Identification Please Type or Print Clearly) OWNER: Name: GR i-eNCE S►lfiarzv ,�t&cl­ Phone: q7b - ($51612- Address: C,*K Les 5TMz-"Vr AN00vI6t_ MJJ 0 t 64-5 �� �� CONTRACTOR Name: Phone: ,- tl '77- 307.7 Address: 2►b IZ1c kUT1 t�►�, - Qu�N�Y , 0?Ab9 Supervisor's Construction License: Exp. Date: Cs-053494- of Z 2014- Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:SULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ � _ 22D. `a FEE: $ � D59 .-b-b Check No.: 1tcl(001 Receipt No.: Ci 49 NOTE: Persons contracting with unreistered contractors do not have acces the guar my d i nature of Agent/Owner Signature of contractor KPRofic. 296 Ricci V Driv6 . Oul ,MA 02169 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION_ — Print_ .PROPERTY OWNER - Print� 100 Year Old Structure yes no MAP NO: _ _ _ PARCEL: _._.= ZONING DISTRICT: Historic District yes no Machine Shop Village yes _ no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition 11 Two or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: [],Demolition ❑ Other ❑ Septic ❑Well El Floodplain ❑Wetlands Watershed District ❑Water/Sewer_ - - - DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: a _- CONTRACTOR Name: .. _ Phone: Address: . Supervisor's Construction License:_ _.,.v �... Exp. Date:. - - Home Improvement License: _ _ - _ _ _ Exp. °pate:- _ 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 unregistered contractors do not have access to the guaranty fund ;Sgnature:of Agent/Ovurier. Slgna u of.contractors _ {� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan 0 Stamped Plans ❑ PPP- .✓' In \� Locatio "TC) �6vdes S1� -'l No. �� Date ® - TOWN OF NORTH ANDOVER 0 ED 0 Certificate of Occupancy $ Building/Frame Permit Fee $,X1561A r„ Foundation Permit Fee $ - Other Permit Fee $ 1 TOTAL $ i Check# 2694 9 //Building Inspector v Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE:OF%SEWERAGEDISP.OSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc,. ❑ - Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED .. DATE.APPROVED PLANNING & DEVELOPMENT ❑ ❑ 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 p !Nater& Sewer Connection/signature& Date Driveway Permit DPW'To`v;2 Engineer: Signature: Located 384 Osgood Street FIRE DEP,ARTiVM-L-W -Terrip Dumpster on site yes no Located at 124 Main Street -.Fire Deparfine7t signature /date" d COMMENTS i -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 El Notified for pickup - Date I Doc.Building Permit Revised 2010 i Building Department The fol Ewing 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 Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apo,-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 r � µORT -c ve- /y _ . w: .. . 1 h ver, Mass &c6ber 2013 .Q cocHcHewcx 1 �as RATED PPp`,`�5 L! BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .OtoCker.. .�!!!r�!!�. ....�� .� NAWC�......... BUILDING INSPECTOR ... ..... . . .... Z4. .. k a} .. Foundation has permission to erect .......................... buildings on ... .... .... ............ Rough to be occupied as mie ..A mcco e.. l.. kM k&rjwh%« ; ... . Chimney �. .............. ..... .. ...!. . provided that the person accepting this permit shall in every respect conform to the terms of the applicatio 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. R°ugh Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT - N STARTS Rough Service .......... ......�/�..04101111111�........................ 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. 11 1 SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.rnassgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers .Applicant Information Please Print Learibly Name(Business/Organization/lndMdual): p i, Address: 21- Q,%-Cc lv l t on-w-e-. City/State/Zip: Q\ow c7 M 0 u 6 Phone#: 7 Are you an employer?Check the appropriate box: Type of project(required): LJK I am a employer with g 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time)x have hired the sub-contractors 2111 am a sole proprietor or partner- listed on the attached sheet.? �• Remodeling ship aud'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, F1 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 L Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12. Roof repairs 64414c e-•w+> insurance required.]t employees.[No workers' 13-ElOther comp,insurance required *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they tie 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 their workers'comp,policy information. I am an employer that 1s providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name% 1tkN �T-AF'flaN nlS, C- Policy 4 or Self-ins,Lie.M w I t t52- 10 Expiration Date: 05 1r, 7,&14- Job ,&1Job Site Address: Z d C --5 57vet-T City/State/Zip: Attach a.copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required der Section 25A of MGL 0.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one year im isonment,as well-as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 qpMA_ he viola . Be advised that a copy of this statement maybe forwarded to the Office Xof Investigations ofsurance verage verification. I do hereby certify der tl naldes ofpe • that the information provided above is true and correct. Signature: Date: Phone 4: G l7 30-1 ? 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 o£Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instr diolmS . 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 j oiut 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,§250(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 ofpublic 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-contractors)name(s),addresses)andphonenumber(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. D e advised that this affidavit maybe 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-theaffidavit-is-complete-aadprintcdlegibIy: TheDepaitmenfhasprovidedaspaceattfieboitom 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 pemiit/license number whichwill 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. Anew affidavit must be filled out each year.Where a homeowner 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number; Tho GQmMonw(Wth of Massarhwefts Mpartmout of l dustdal.Acezdexita OfAce QUAYeWigatiolu 60G Washijgtoxa Stmt Boston,MA,02111 Tel,#617-727-4900 0A 406 or 1-87MASS.AFB Revised 5-26-05 Fax#61.7"727;7749 Rdess�Chuse%s-Dep�r hnt of pui- 4 ' Board df.8uildtng Reguf4fg4s;and Stanch is k Cgjw tructjon Supcnlsgr • � z �Ctnse: C$-059843 DEAN B BURSE '" ��'' k WELLESLO MAr 0248 , t GommisrCof, # Exp rn.y g y.: O7�a014 i GREATER LAWRENCE SANITARY DISTRICT RICHARD S.HOGAN,EXECUTIVE DIRECTOR LAWRENCE ANDOVER THOMAS CONNORS MORRIS GRAY Jr. JOSEPH R.QUARTARONE JOHN MGEE NORTH ANDOVER ANDREW W.MAYLOR METHUEN CONTRACT RAYMOND DMORE SALEM,N.H. JOHN A.CRONIN FOR MICHAEL J.LYONS Furnishing and Installation of TREASURER Replacement Roof for Conference Room, Kenmore Building &TPS BuildiMJA-PE KUSJr- THIS CONTRACT IS DATED September 25 , 2013 by and between KPR Inc. , with a place of business at Quincy, MA (the "Contractor") and the Greater Lawrence Sanitary._District, a body.politic and corporate under c. 750 of the Acts of1968, as amended, operating a regional wastewater treatment facility with a place of business at 240 Charles Street, North Andover, Massachusetts 01845-1649 (the"District"). WHEREAS, the District desires to retain the services of the Contractor to replace the Roofs for Conference Room, Kenmore Building &TPS Building consistent with the terms and conditions described in the attached Invitation for Bid and Bid Specifications which are made a part here of and incorporated herein by reference, and all other services contained in the Contractor's proposal which is incorporated herein by reference. WHEREAS, the Contractor is willing to perform such services for the District as an independent contractor on the terms set forth below and, in accordance with such terms, furnish said services; NOW, THEREFORE, in consideration of the covenants and agreements mutually to be observed and performed, and for other valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows: TERM This contract shall be in effect beginning September 25. 2013 and shall expire on December 31, 2013. 240 CHARLES STREET • NORTH ANDOVER,MASS.01845-1649 TEL:978-685-1612 FAX:978-685-7790 b. SCOPE OF SERVICE The Roof Replacement is described in the Specifications (Attachment 1) and shall be provided in accordance with all requirements and specifications which is made a part here of and incorporated herein by reference. The Contractor Shall provide qualified personnel for the purposes of installation. Contract Price - Payment Terms The contract price shall not exceed $88,270.00. The District will make payment of one-third of the project cost after all equipment is delivered to the District site and the second one-third payment shall be made at 50% completion of the project. The remaining one-third payment shall be made thirty-five (35) days after completion of the project. Completion of the project shall be determined when all work is deemed satisfactory by the District and a warranty has been furnished as provided in Section 1.08 of the attached Specifications and Scope of Work. Waiver of Workers Compensation and Unemplovment Compensation Benefits It is agreed that the Contractor and Contractor's employees, agents, servants or other persons whose conduct the Contractor is responsible for shall not file any claim nor bring any action against the District for any workers compensation or unemployment benefits and compensation for which they may otherwise be eligible as a result of work performed pursuant to the terms of this contract. The Contractor shall submit to the District certification of Workers Compensation coverage, which shall contain a provision that the coverage cannot be canceled without prior notification to the District. The Contractor shall not cancel said Workers Compensation coverage without ten (10) days written notice to the District. The Contractor is retained solely for the purpose of and to the extent set forth in this contract. Contractor's relationship to the District during the term of this contract shall be that of an independent contractor. The Contractor shall have no capacity to involve the District in any contract nor to incur any liability on the part of the District. The Contractor, its agents or employees shall not be considered as having the status or pension rights of an employee; provided that the Contractor shall be considered an employee for the purpose of General Laws, Chapter 268A(the Conflict of Interest Law). The District shall not be liable for any personal injury to or death of the Contractor, its agents or employees. 2 ACC> CERTIFICATE OF LIABILITY INSURANCEDATE(Mm)DNY" I 9/30/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomeme s. PRODUCER CONTACT NAME: The Driscoll Agency, Inc. PHONE -681M567 a c wo:7 81 93 Longwater Circle E-MAIL P.O.Box 9120 ADDRES Norwell MA 02061 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA--Continental Inamnce Co. 35289 INSURED 2092 INSURER B-Nati EmIns Co of Hartford M478 KPR, Inc. INSURER cContinental 216 Ricciuti Drive INSURER 0- Transp-ortation Insurance Co. Quincy MA 02169 INSURER E: —J INSURER F- COVERAGES CERTIFICATE NUMBER:1980290175 REVISION NUMBER: 7— THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWn`HSTANDING 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. ILSSR TYPE OF INSURANCEDL SUBR POLICY EFF POLICY EXP IN POLICY NUMBER MWDWYYYYI (MWDDNYYYI LIMITS A GENERAL LIABILITY 01082071765 15/2013 Sh512014 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY D SEI) I PR MMI ES Ea r $100,000 CLAIMS-MADE F1 OCCUR MED EXP(Any one person) $15,000 PERSONAL 8ADV INJURY $1,000,000 1 GENERAL AGGREGATE 52000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO JECT F7 LOC1 $ B AUTOMOBILE LIABILITY SAP2086857924 15/2013 /15/2014ED�INGLE LIMIT I Ea auxidumtL_ S1 000 000 ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) $ HIRED AUTOSX NON-OWNED PROPERTY DAMAGE $ XIAUTOS Per accident $ I C X UMBRELLA LIARX OCCUR 01098409971 /15!2013 15/2014 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X I RETENTION$10 000 $ D WORKERS COMPENSATION AC4021132906 /15/2013 /15/2014 XSTATU OTH- AND EMPLOYERS LIABILITY Y/NER ANY PROPRIETOR/PARTNERIEXECUTNE I E.L.EACH ACCIDENT $1,000,000 j OFFICERIMEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I F-L DISEASE-POLICY LIMB I$1 000 000 A Inland Marine C1082071765 15/2013 /15/2014 LeasedlRentO Equip $50,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) RE:Removal and replacement of Conference Room,Kenmore Building and TPS Building roofs. The Greater Lawrence Sanitary District is included as Additional Insured for Automobile Liability on a Primary Basis for the conduct of the (Named)Insured,but only to the extent of that liability. The Greater Lawrence Sanitary District is included as Additional Insured for General Liability and Excess(Umbrella)Liability,as required by a See Attached... CERTIFICATE HOLDER CANCELLATION 30 days except 10 for non a ment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Greater Lawrence Sanitary District ACCORDANCE WITH THE POLICY PROVISIONS. 240 Charles Street North Andover MA 01845 AUTHORIZED REPRESENTATIVE 1 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD .rr AGENCY CUSTOMER ID:2092 LOC#: ZAAC66WO ADDITIONAL REMARKS SCHEDULE Pagel of 1 AGENCY NAMED INSURED The Driscoll Agency,Inc. KPR,Inc. POLICY NUMBER 216 Ricciuti Drive Quincy MA 02169 CARRIER MAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE signed,written contract,or agreement with the Named Insured. Notice of cancellation provision is 30 days,except 10 days applies for non-payment of premium. ACORD 101(2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD