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Building Permit #482-14 - 247 BRIDGES LANE 10/15/2015
BUILDING PERMIT TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION * - Permit NO: !� Date Received Date Issued. LOCATI IMPORTANT: Applicant must complete all items on this page MAP NO:/PARCEL: ZONING DISTRICT: Historic District yes Machine Shoa Villaae ves no TYPE OF IMPROVEMENT PROPO$F.0-USE Res,00tial Non- Residential ❑ New Building One family ❑ Addit*!pn ❑Two or more family ❑ Industrial ❑ AI ation No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer �� Identification Please Type or Print Clearly) OWNER: Name: Address: CONTRACTOR Name: Address: Supervisor's Construction License: Home Improvement License: Phone: Exp. Date: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING 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 t guaranty nd Signature of Agent/Owner i Signature of contractor Location l — Date 4f Check #q� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1 Building Inspector 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. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS HEALTH COMMENTS 0 DATE APPROVED DATE REJECTED DATE APPROVED Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ' Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 nu 1 co ana UA I A— (ror aepartment use 1 Doc.Building Permit Revised 2012 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/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 ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) • Copy of Contract o 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 E L CL y L U) M O d ai m C cm _ .O N O z O Q J O G i Z CO G CD Z W w CL W H W CL v .�N It Aq O Fdw O 0 H = z V W J W O x Ln z z a LL z Q N 0 (DCL Z o z Z u W � N ui O G 5% m W LL EJ N N m C d W a N Y ? .2 > Z O y V1 r0 C) 4) V t c LS U t N — , E to to_ 3 _ i O O Q 7 O C C 7 > @ C C 7 N d' .L �' U LL LL K (A LL W LL m V) V) LLO Ln E L CL y L U) M O d ai m C cm _ .O N O z O Q J O G i Z CO G CD Z W w CL W H W CL v .�N It Aq O Fdw The Commonwealth ofMassachusetts Depardnemoflndu &&1Acdden& O, f ke of Investigations kvi 1 Congress Streely Suite 100 Boston, MA 0211¢2017 www -mass gov/dia Workers' Compensation InsuraneeAifidavit Builders/Contractors/Electricians(Pknmbers DDlieant Tnfnimm a4in,n Name 03udne&organiza6on&&,,iduW)- t til c L-0 10 Z 19 Q �� F ,t I Address: 10", � l--E•c1(d'/- ,4- City/State! �jt/D �+ r� �J - i 90/Phone # t - L - 3 `/9 - -,4,;? Are you an employer? Check the appropriate box: I .IL I am a employer with C) -L 4. ❑ I am a general contractor and I TYPO of project (required): employees (t'uA andlor parte).* 1 ❑ I am a sole pmprietor or have hired pre sub. -contractors listed on the s• ❑ New construction partner- ship and have no employees attached sheet These gab-cantwtors have 7. ❑ Remodeling 8. ❑ Demolitionworking for me in aay capacity. employees and have workers' No workers' comp. mstnaare comp. instrtance.t 9- ❑ Building addition required-] 3. [1 I am a homeowner doing all work 5• ❑ We are a corporation and its ofricers have exercised their I0.❑ Electrical repairs or additions myself [No workers' comp.neht of exemption per MGL 11. plumbing ❑ g repairs m additions insurance required.] t c. 152, §1(4), and we have no 12 .❑ Rogfz+epa� employees. [No workers' 13- ther442L comp- ��� required.] *Any applicant char chccks box RI must also till out the section below showing their workers' compensation policy information. t Homeawnccs who sabmkft affidavit indicating they are doing all wodc and then hire outsides must submit a new affidavit indicat, sack ICan¢actars that check this bar must attached as additional sheet thowiag the name of the sub-CMM=tots mod state wbetheror not tbow Mel Lave emploYas. if the sub-contradms have employees, they most provide their worloers' comp. F�eY�ber. 1 am Wz employer dhotis providing zborkers' c0nrpetrsat90lr insurance for »ry employees Belo is the policy mjob ssi�tte infonnatiorL InstG uance Company t: � �'t� �-s Policy# or Self -ms. Lic. #:— 90 - 003 5O C-- AM. imitation Date: S - Sob Site Address: Citylsbte)zip.R, Attach a copy of the workers' compensation policy diel tion page (showing the policy number and expiration date). Fa"u're to secore coverage as required under- Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to 50.00a d and/or one-year later. Beadv as well � civil penatties in the form of a STOP WORE. ORDER and a fine Of up to $250.00 a day against the violator. e advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,lhe1d ppt� of peu3, that the nrformation provided above u true and correct Official use only. Do not tvnte ix this firers to be comrZded by cfij, or town ,0jWgL City or Tour: Permit/License # Inning Authority (circle one): 1. Board of Health 7. Building Department 3. City/Town Clerk 4. Eleetrical Inspector 5. Plumbing inspector 6. Other Contact Person- Phone #: Aug.2Q.�015 01:03 PM ValpakNH 6034322522 PAGE. 2% r 1N/11iaANIAA6RR - f:t noa fhrt�aa � conhny(d • . �nr; ' itf)wsrr�rl�rl p"p,ti P�'dvtDlldfliQ��aZDfPs CarpArxtr kmd,tum(ntb IIa Cepa as. Nrob►uN Mh IFS Ueoar:¢itt " nttScoHt7ucT4,l,ItuenIg. _. p'lrrft.oa�0oao,r,..�,eMsvo�re�, , �duY0`614t�-20_&�lyalwmilt.�-.,._w `r�-fes' �+ �,. UTD'u�l1t1U• 1tt'iq MtiO/ ......Al�.rr� it +rte NLWrotn,�_•..,.._... MOOporalhty LLCr'!yrWtgQp—......�,.`___ Utldarulonds ihei lhlt �► ••,`�`� ugun meet 12) wam brlr� )larfvrmodr ine (7) wetkr waaieroalrta„i, 4wtglr array RaVlaAtt ofhfs dGr+l t to o.n� hi lansaatloaaDt a titin m1 of thDpromrues rabd by �t�w R��Imsd. Owher tla19 0! Ihla iraaf b1s on q� ,lrru Y Vias prrnr to n” Maht of thaou" doy 4 fir t (roan t)t►NQ1q1gNYtsleO"TRACTIr1'1191tvAIM VMI NYAALL NKNPWith v(f)oopleDafaosttFD!ltrllenforrura plalnf gthistl� ethn• �rrx sDACC•6. IRtluda bland NatDs Odty}r N'atrru to bpyort (1) Ro "1 49`1 Hit#Avroumallt if any of the 1pti,•.rr Iris �pMod t4rmsro qtr axtoDf at than avalla6lc Intormatlon an loft hlank_ yop eYa 011ptlodtua w ' AO'�TrlrrStMt tiro dnw o Adad for the wrdlnaod gniptlR• �S)Yeu yntarrytlD vDyerltAotuil� PYOfrhta, Alrtp " +^sY a• ontlUod to m9afvo a poRral rstra4 at Iho finana a;tld balem nov al arlaeq 11IN Agre.morKr MI' h Iriybt r ambrmutty VRiMTybut prem(aaL Dr oOMMIt Uny broub ar the "gay tD rrr►o.parn aooda purcbyrey Uhdur thla AQAalrthSt..(S) YOU 1Mhy aRet:ol tl�rs � ��� Tho caller me Obltar, orovldett yw netlly tha rerlor ntftio p �Y i t tA�AV i°t beep Mobs al htv Dm!n at[iae orbraneh OIf1aD Df raUlsrCr6do.e9itltlodtnrll,wh7i=laahall>:apetlrvrl netkl t 4"i °ftleownagryfR"thoA widuh tiro kuyer Dtpna thq tar than mldnit!!rt or8+r Itllra QR19eoar !11�.,nent by Soa Iha aaremyyryRO per( of F tIQ, akdaglnd 8ana.y tad rlgyherWay Ols Whtetr ►spalaiar+djdal(Yerlrtha! noitllado. otr=It+tb ferltt tar rq "Pil cutin of bUyar�a rtph[:. tittlode Iti)and Bain: only): vwAtrr eoknuvrltntg9R reewpt of regblrrd contraotara RDp�railan aR�t L eratin 4aarti trottaumnr wluohtlon mrtarla�. % �.,...� tPwOot'irr11i1R�sJ V MNR WN IV; prom CNN YELLOW. atwmo 5 f9 '��i'd ZZ92ZE6£09 R-PivdT+IA rid 60sZT STOZ'bZ•bnv 2 CERTIFICATE OF LIABILITY INSURANCE=DATEmYY) 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: c the ions f th holder is an App(T(0 INSURED, the p0licy(ies) must be endorsed If SUBROGATION IS WANED, subject to the terms and conditions of the Policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Mackintire Insurance NAME Melissa Pflug Agency Inc PHONE .(5Q8)366-6161 I FAX 11 nest Main Street EMAIL Al N,. 1508) 366-5202 ADD melissaP(imackintire.com ncat ULuugn MA 01581-1931 nrouttuta M-9— COVERAGE { NI INSURED INSURERA Netherlands 124171 Nelr_Dro Operatirig LLC "SURER a ldbe Mutual/Peerless 24138 26 Cedar St. INSURER C Acadia InsUrallCe CO _ r . INSURER D: I Woburn ba 01802 INSURER E • I COVERAGESCERTIFICATE NUMBERiaster 14-15 -15URER i IS TO CERTIFY THAT THE POLICIES 7F INSURANCE LISTED BELOI-I HAVE INDICATED. 4NOICATEO. NOT1fA REVISION NUMBER: BEEF! ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD rHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER, DOCUMENT 80'1WIT1 RESPECT Tp'NHICH THIS CERTIFICATE ISSUED OR MAY PERTAIN, THE AND INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, O EXCLUSIONS ANG CONDI TIONS OF $ITCH POUGIES. LIMITS SHO`LW MAY HAVE BEEN REDUCED -BY PAID NSR i LTR i TYPE OF INSURANCE IAODLISUBRI 11 iix N POUCY NUMBER CLAIMS. - � FOUCY EFF ; MGltOp � POItCY EXP t ( A:M I COERCEN IAL GENERAL. t.Uie[LITv 4 I - ))3Ig I U)AITS 1 AOCCUR i t ! ISErCH Z. UD), DOGP j 85E95?7 Ij 1 DAMRGE MISESIEaa eaterLt< I S 1G0,000 J i 132/33/2034�?2/3Z/2015 ( t7(P (Art I fAtD (Anyone VersnFi S ) I ijENM fiC17RCCil1 E USIt i h�I,It:S PLR: iPERSONALaAOVe,IURY IS 1,000,000 POLICY '' P=0 t `! rc< I LOC i i L GENER4LAGG.REGATE 1 S tt 2,000,000 r IOTHER: ( {?iiODUCTS-COMPIOPAGC-I5 2,000,000 10.UTOMOBILE UA91Lf i'f A i iAwgtlTD j ; COSIBINED SWSL E LtktR L�adenI) Is 1,000,000 , �AFw OK5NE0I SCI•r••'DLILED AUTOS ( I 8D0!LY ikJURY jeer PII S IX �F : c 0m com�� -n ZX>O DOT 1 � ou D> 0 Zz u i r r n mCD X S �m 'a o m p J N ap Ln CD co co a M A L / Ia �, _r n O O .1 • t c ' ' o m CS Nm CD m Q -/�1 to ♦ ♦ N t r=. O yo C- 2 i y C3 n n oT -:- N � Z 1 3 -� n n 0m com�� -n ZX>O DOT 1 � ou D> 0 Zz u i r r n mCD X S �m 'a o m p J N ap Ln CD co co a I L / Ia �, _r n O O .1 • t O a•, N C7 � to f�aCDCDjo t r=. O� C- m i y 1 I L / Ia �, _r N to o rnoa.L 7 O� C- m i y TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ` Date Issued: L�1_� d IMPORTANT: 're 4,17 Date Received must complete all items on this MAP NO: /0 • h PARCEL: 00 ��ZONING DISTRICT: Historic District yes Machine Shop Village yes 0 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial WRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other "� a' Septic9 ❑IWelh _ ®iFloodp [Wetly ds �s ®WatershedtIDistrict ` , 1L.--02 { " r/sewer_ DESCRIPTION OF WORK TO BE PERFORMED: Id ntification Please Type or Print Clearly) OWNER: Name: eCa Phone: - P -Was Address: ,,2 ` Li Jge5 Lk, /Ifo 1qtkU-Qr- A CONTRACTOR Name: Mn Phone: Address: J Supervisor's Construction License: (f, j — ��j �(Q�L 0 Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMI fT:r$12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 7�� `©� FEE: $ !�Z2 Check No.: ` 5q4�,- Receipt No.:� -c7 Q) NOTE: Persons contracting_u{th unregistered contractors do not have access tR the juaranty fund � Plans Submitted ❑ Plans Waived ❑ TSE OF sECertified Plot Plan ❑ Stamped PI RAGE DISPOSAI, Public Sewer ans ❑ Well . ❑ Ta"11n9/MassageBody Private se ❑ Tobacco ❑ Swimmg pools � ptic tank etc. Sales 0 ❑ ❑ Permanent Dumpster on Site Food Packaging/Sales 0 I THE FOLLOWING SECTIONS F INTERDEPARTMENTAL SIGN OF OFFICE USE ONLY OF - U FORM PLANNING & I)EVELOPMEN r COMMENTS CONSE --" RVA7-ION Reviewed COMMENTS HEALTH RevieWed COMMENTS DATE REJECTED E APP ❑ DAT ❑ ROVED Zoning Board Of Appeals: Variance, Petition No: Planning Board DecisioZoning Decision/receipt submitted yes n: Conserv Comments afion Decision: Wafer & Sewer Co Comments nl]eCtrpn/Si nature 8, Date DPW T.°�'� Engineer: Signature: Drivewa Permit Looe DR-p.14RTiV1ENT - Tem D t 124 Maw Street Pan ester on site yes Located 384 Osgood Street Fire Department signature/date no COUNTS 4® riance or spec he apo" �tiol• u all cases 1 eat per10 is the building applica hat the a ubed with austbe $ per�tReai$ed2��$n� Dcc: Doc�u�dmg U Doc:.Building I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ElTYPE OF SEWERAGE DISPOSAI, Sta mped Plans ElPublic Sewer ❑ Well (se ❑ ❑ Ta�1g/Massage/Bod y Art El Swimming pools ❑ Private Tobacco Sales ptic tank, etc El Food Packa Permanent Dumpster on Site Elging/Sales ❑ THE FOLLOWING SECTIONS FOR OFFICE INTERDEPARTMENTAL SIGN OFF U FORM E ONLY PLANNING DEVELOPMENT DATE REJECTED ❑ DATE APPROVED COMMENTS ❑ CONSERVATION Reviewed COMMENTS HEALTH Reviewed COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Zoning Decision/receipt submitted yes__ Comments Conservation Decision: Water &Comments Sealer Connection/s, iginature &Date DPW Town Engineer: Signature: Drivewa Permit FIRE DEPARTMENT Temp Dempster on site Located 384 Osgood Street Located at 124 Fire Dep�nMaw Street Yes ent si no gnature/date COMMENTS n all Cas eat pexioa'"the buuQ...n teat the aPP fitted with nustbe subju . tRevised2008mi ` pen� poc: DocB�ding Doc:.Bul Location No. — Date NORTFr TOWN OF NORTH ANDOVER F R Certificate of Occupancy $ sMus `�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 <- —`3/9" Check # 23790 Building Inspector G' z M Cd c c m c c • O L C y ' � O :vV a C m m : m C :t G • Co m r-. C CO O • = CD CD a E E .00 c cO u a m c � v :gym o • �ce v, g 3 ._ M-0 c� AmHo at. A m m = CL 0 4WD :E O m �Z c � o � a Q L y m C = ma :mOZo : LL m �N•aZ c0 mC f- "A �E ca -o co, .y wLU m o®Ec N a m 'C Oca .fl Z eO N �O F- z saL.m E a h Z y O i y c Om CD m a m G a c 'c N CD O Z 0 s 0 U O W O CD L O O v Z a, O N C cm I C C ca p� E mm CD 0 CD CL~ +=+ CD O� 0 0 coO L Cl a CL �a ca C o 0- CcC v J .O O Z ts CL V N O C C C h 0 � x x z_. GQ u w° Cl),� J) U w wa a w° w°' v U w W w°' x W wSd C2 cit w 0 w°' co w x w v a rA ° z cn Q ° cn c c m c c • O L C y ' � O :vV a C m m : m C :t G • Co m r-. C CO O • = CD CD a E E .00 c cO u a m c � v :gym o • �ce v, g 3 ._ M-0 c� AmHo at. A m m = CL 0 4WD :E O m �Z c � o � a Q L y m C = ma :mOZo : LL m �N•aZ c0 mC f- "A �E ca -o co, .y wLU m o®Ec N a m 'C Oca .fl Z eO N �O F- z saL.m E a h Z y O i y c Om CD m a m G a c 'c N CD O Z 0 s 0 U O W O CD L O O v Z a, O N C cm I C C ca p� E mm CD 0 CD CL~ +=+ CD O� 0 0 coO L Cl a CL �a ca C o 0- CcC v J .O O Z ts CL V N O C C C h 0 � TRAVELERS J One Tower Square, Hartford, Connecticut 06183 RENEWAL CERTIFICATE COMMON POLICY DECLARATIONS POLICY NO.: I-680-198C5708-PHX-10 t ti CONTRACTORS PAC ISSUE DATE: 08-27-10 BUSINESS: CARPENTRY 0 0 0 0 0 m 0 0 0 0 n 0 0 U INSURING COMPANY: THE PHOENIX INSURANCE COMPANY 1. NAMED INSURED AND MAILING ADDRESS: CHRISTOPHER J. DAVEY 545 SHARPNERS POND ROAD NORTH ANDOVER MA 01845 2. POLICY PERIOD: From 10-08-10 to 10-08-11 12:01 A.M. Standard Time at your mailing address. 3. LOCATIONS: PREM. BLDG. OCCUPANCY NO. NO. 01 01 CONTRACTORS ADDRESS (same as Mailing Address unless specified otherwise) 545 SHARPNERS POND ROAD ANDOVER MA 01810 4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING COMPANIES: COVERAGE PARTS AND SUPPLEMENTS INSURING COMPANY Businessowners Coverage Part PHX 5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse- ments for which symbol numbers are attached on a separate listing. 6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions. POLICY POLICY NUMBER INSURING COMPANY DIRECT BILL 7. PREMIUM SUMMARY: SUBJECT TO AUDIT Provisional Premium $ 2,389.00 Due at Inception $ Due at Each $ NAME AND ADDRESS OF AGENT OR BROKER COUNTERSIGNED BY: L� CHARLES A SLEE AGCY INC HG582 �avld E. _3azt&tt P 0 BOX 6 Authorized Representative MARBLEHEAD MA 01945-0006 DATE:.�a • �p�y IL TO 25 08 01 (Pagel of 01 ) Office: BOSTON SOUTH MA DOWN TRAVELERS J One Tower Square, Hartford, Connecticut 06183 RENEWAL CERTIFICATE �u1 COMMON POLICY DECLARATIONS POLICY NO.: I-680-198C5708-PHX-10 CONTRACTORS PAC ISSUE DATE: 08-27-10 BUSINESS: CARPENTRY INSURING COMPANY: THE PHOENIX INSURANCE COMPANY 1. NAMED INSURED AND MAILING ADDRESS: CHRISTOPHER J. DAVEY 545 SHARPNERS POND ROAD NORTH ANDOVER MA 01845 2. POLICY PERIOD: From 10-08-10 to 10-08-11 12:01 A.M. Standard Time at your mailing address. 3. LOCATIONS: PREM. BLDG. OCCUPANCY NO. NO. 01 01 CONTRACTORS ADDRESS (same as Mailing Address unless specified otherwise) 545 SHARPNERS POND ROAD ANDOVER MA 01810 4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING COMPANIES: COVERAGE PARTS AND SUPPLEMENTS INSURING COMPANY / Businessowners Coverage Part PHX Y 1 n__ O O 5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse- 0 ments for which symbol numbers are attached on a separate listing. 6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions. POLICY POLICY NUMBER INSURING COMPANY 0 0 o— DIRECT BILL r 7. PREMIUM SUMMARY: SUBJECT TO AUDIT Provisional Premium $ 2,389.00 Due at Inception $ Due at Each $ NAME AND ADDRESS OF AGENT OR BROKER COUNTERSIGNED/ BY:: CHARLES A SLEE AGCY INC HG582 JbavirI3. -Sad&tt P 0 BOX 6 Authorized Representative MARBLEHEAD MA 01945-0006 DATE: ad IL TO 25 08 01 (Page 1 of 01 ) Office: BOSTON SOUTH MA DOWN AIM TRAVELERS J One Tower Square, Hartford, Connecticut 06183 RENEWAL CERTIFICATE COMMON POLICY DECLARATIONS POLICY NO.: I-680-198C5708-PHX-10 CONTRACTORS PAC ISSUE DATE: 08-27-10 BUSINESS: CARPENTRY INSURING COMPANY: THE PHOENIX INSURANCE COMPANY 1. NAMED INSURED AND MAILING ADDRESS: CHRISTOPHER J. DAVEY 545 SHARPNERS POND ROAD NORTH ANDOVER MA 01845 2. POLICY PERIOD: From 10-08-10 to 10-08-1 1 12:01 A.M. Standard Time at your mailing address. 3. LOCATIONS: PREM. BLDG. OCCUPANCY NO. NO. 01 01 CONTRACTORS ADDRESS (same as Mailing Address unless specified otherwise) 545 SHARPNERS POND ROAD ANDOVER MA 01 81 0 4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING COMPANIES: COVERAGE PARTS AND SUPPLEMENTS INSURING COMPANY Businessowners Coverage Part PHX 5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse- ments for which symbol numbers are attached on a separate listing. 6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions. POLICY POLICY NUMBER INSURING COMPANY DIRECT BILL 7. PREMIUM SUMMARY: SUBJECT TO AUDIT Provisional Premium $ 2,389.00 Due at Inception $ Due at Each $ NAME AND ADDRESS OF AGENT OR BROKER COUNTERSIGNED BY: CHARLES A SLEE AGCY INC HG582 avid-S.2azt[it P 0 BOX 6 Authorized Representative MARBLEHEAD MA 01945-0006 DATE: �.aa app IL TO 25 08 01 (Page 1 of 01 ) nnoo„ Office: BOSTON SOUTH MA DOWN iA► TRAVELERS J One Tower Square, Hartford, Connecticut 06183 RENEWAL CERTIFICATE COMMON POLICY DECLARATIONS POLICY NO.: I-680-1 98C5708—PHX-10 a CONTRACTORS PAC ISSUE DATE: 08-27-10 BUSINESS: CARPENTRY r 0 0 o� 0 0 0 0 0 0 0 0 U INSURING COMPANY: THE PHOENIX INSURANCE COMPANY 1. NAMED INSURED AND MAILING ADDRESS: CHRISTOPHER J. DAVEY 545 SHARPNERS POND ROAD NORTH ANDOVER MA 01845 2. POLICY PERIOD: From 10-08-10 to 10-08-11 12:01 A.M. Standard Time at your mailing address. 3. LOCATIONS: PREM. BLDG. OCCUPANCY NO. NO. 01 01 CONTRACTORS ADDRESS (same as Mailing Address unless specified otherwise) 545 SHARPNERS POND ROAD ANDOVER MA 01810 4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING COMPANIES: COVERAGE PARTS AND SUPPLEMENTS INSURING COMPANY Businessowners Coverage Part PHX 5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse- ments for which symbol numbers are attached on a separate listing. 6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions. POLICY POLICY NUMBER INSURING COMPANY DIRECT BILL 7. PREMIUM SUMMARY: SUBJECT TO AUDIT Provisional Premium $ 2,389.00 Due at Inception $ Due at Each $ NAME AND ADDRESS OF AGENT OR BROKER COUNTERSIGNED BY: �/�r CHARLES A SLEE AGCY INC HG582 �alJid-S. _Sa'LtL£tt P o BOX 6 Authorized Representative MARBLEHEAD MA 01945-0006 DATE: �,�� • ap( IL TO 25 08 01 (Page 1 of of ) Office: BOSTON SOUTH MA DOWN TRAVELERS J One Tower Square, Hartford, Connecticut 06183 RENEWAL CERTIFICATE '. COMMON POLICY DECLARATIONS POLICY NO.: I-680-198C5708-PHX-10 CONTRACTORS PAC ISSUE DATE: 08-27-10 BUSINESS: CARPENTRY U INSURING COMPANY: THE PHOENIX INSURANCE COMPANY 1. NAMED INSURED AND MAILING ADDRESS: CHRISTOPHER J. DAVEY 545 SHARPNERS POND ROAD NORTH ANDOVER MA 01845 2. POLICY PERIOD: From 10-08-10 to 10-08-1 1 12:01 A.M. Standard Time at your mailing address. 3. LOCATIONS: PREM. BLDG. OCCUPANCY NO. NO. 01 01 CONTRACTORS ADDRESS (same as Mailing Address unless specified otherwise) 545 SHARPNERS POND ROAD ANDOVER MA 01 810 4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING COMPANIES: COVERAGE PARTS AND SUPPLEMENTS INSURING COMPANY Businessowners Coverage Part PHX 5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse- ments for which symbol numbers are attached on a separate listing. 6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions. POLICY POLICY NUMBER INSURING COMPANY DIRECT BILL 7. PREMIUM SUMMARY: SUBJECT TO AUDIT Provisional Premium $ 2,389.00 Due at Inception $ Due at Each $ NAME AND ADDRESS OF AGENT OR BROKER COUNTERSIGNErDBY: /'C CHARLES A SLEE AGCY INC HG582 �avi�! 2. -SQTtwtt P 0 BOX 6 Authorized Representative MARBLEHEAD MA 01945-0006 DATE: V., -d - apf 0 IL TO 25 08 01 (Page 1 of of ) Office: BOSTON SOUTH MA DOWN 77 TRAVELERS J One Tower Square, Hartford, Connecticut 06183 RENEWAL CERTIFICATE '► COMMON POLICY DECLARATIONS POLICY NO.: I-680-198C5708-PHX-10 CONTRACTORS PAC ISSUE DATE: 08-27-10 BUSINESS: CARPENTRY INSURING COMPANY: THE PHOENIX INSURANCE COMPANY 1. NAMED INSURED AND MAILING ADDRESS: CHRISTOPHER J. DAVEY 545 SHARPNERS POND ROAD NORTH ANDOVER MA 01845 2. POLICY PERIOD: From 10-08-10 to 10-08-11 12:01 A.M. Standard Time at your mailing address. 3. LOCATIONS: PREM. BLDG. OCCUPANCY NO. NO. 01 01 CONTRACTORS ADDRESS (same as Mailing Address unless specified otherwise) 545 SHARPNERS POND ROAD ANDOVER MA 01810 4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING COMPANIES: COVERAGE PARTS AND SUPPLEMENTS INSURING COMPANY Businessowners Coverage Part PHX 5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse- ments for which symbol numbers are attached on a separate listing. 6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions. POLICY POLICY NUMBER INSURING COMPANY DIRECT BILL 7. PREMIUM SUMMARY: SUBJECT TO AUDIT Provisional Premium $ 2,389.00 Due at Inception $ Due at Each $ NAME AND ADDRESS OF AGENT OR BROKER COUNTERSIGNED BY: CHARLES A SLEE AGCY INC HG582 avid E. 2a'ztftt P o BOX 6 Authorized Representative MARBLEHEAD MA 01945-0006 DATE: �,a-a . �( D IL TO 25 08 01 (Page 1 of 01 ) Woo„ Office: BOSTON SOUTH MA DOWN ialk TRAVELERS J One Tower Square, Hartford, Connecticut 06183 RENEWAL CERTIFICATE COMMON POLICY DECLARATIONS POLICY NO.: I-680-1 98C5708-PHX-10 CONTRACTORS PAC ISSUE DATE: 08-27-10 BUSINESS: CARPENTRY INSURING COMPANY: THE PHOENIX INSURANCE COMPANY 1. NAMED INSURED AND MAILING ADDRESS: CHRISTOPHER J. DAVEY 545 SHARPNERS POND ROAD NORTH ANDOVER MA 01845 2. POLICY PERIOD: From 10-08-10 to 10-08-11 12:01 A.M. Standard Time at your mailing address. 3. LOCATIONS: PREM. BLDG. OCCUPANCY NO. NO. 01 01 CONTRACTORS ADDRESS (same as Mailing Address unless specified otherwise) 545 SHARPNERS POND ROAD ANDOVER MA 01810 4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING COMPANIES: COVERAGE PARTS AND SUPPLEMENTS INSURING COMPANY Businessowners Coverage Part PHX 5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse- ments for which symbol numbers are attached on a separate listing. 6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions. POLICY POLICY NUMBER INSURING COMPANY DIRECT BILL 7. 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ANDOVER, MA 01845 (978) 975-3736 LIC. #034690 HICR #110256 PROPOSAL SUBMITTED TO PHONE DATE (3� 9 �=1��-baa S /S' Zoll STREET JOB NAME ,:7?�r Gh CITY, STATE and ZIP CODE JOB LOCATION DATE OF PLANS I I JOB PHONE Or PropoSP hereby to furnish material and labor — complete in accordance with specifications below, for the sum of: Ol/1 /!2b �`7C �r O� Gvll2/�$ dollars ($ �ayment lobe made as foil s: aft 6 � 7o 54^01`&d' -5� All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from specifications be Authorized -low involving extra costs will be executed only upon written orders, and will become an Signature extra charge over and above the estimate. All agreements contingent upon strikes, acci- dents or delays beyond our control. Owner to carry fire, tornado and other necessary Note: This pr0 wrawny us ay be insurance. Our workers are fully covered by Workman's Compensation Insurance. withdrawn bif not aCCep ed within days. We hereby submit specifications and estimates for: ... .... .... _............. ........... ...... _...... F�....... .... ... .... .... .... ... .... ........ _... .... .... ....... ... .... .... ... _ __.... __ ..... ... .......... .... ... _... _... _ ...... .... .... ..... .... .... ... .... .... �n?�c G✓C! /<!j'� /N��L /pie .. ............... _.. _.. ....... ......... .. . �. ��s � . �e ���G,. r /rte GY.. -��aw�.��.�s ..........._ .. Acceptance Of Proposal— The above prices, specifications � and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance:�t. �, o 0 Signature or nebs.com