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HomeMy WebLinkAboutBuilding Permit #674-2017 - 247 BRIDGES LANE 12/28/2016XIWIy Jo�, Lr Permit N0: W4— 2,0q Date Issued: I I t 1, LOCATI / BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINA Date Received KTANT: Applicant must complete all items on this PROPERTY OWNER k, MAP NO: PARCEL: •• q p©RTH� pF Q 2-o �ON1NG DISTRICT: Historic District Machine Shop Vil yes no yes no r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building E One family _ Addition Two or more family i Industrial I- Alteration No. of units: ❑ Commercial -- Repair, replacement ❑ Assessory Bldg ❑ Others: )(Demolition C Other Septic 0 Well Floodplain 11 Wetlands 0 Watershed District 0Water/Sewer C) %A t4f_^, ur +t> ",A -C -C �C>p til Vl_ q -i- -fit. 1-c s + i Identification Please Type or Print Clearly) OWNER: Name: C�rt`Cny MG Phone: Address CONTRACTOR Name: Phone: Q?$ 629 "2r�-L Se�.rWdb tr� L4wd�"t Address; Supervisor's Construction License:, Exp. Date: C S -� 067 6Ci.0 aA20 [ k gl Home Improvement License: l S$ 1 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BUL Mf PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Co s FEE: $F7 Check No.: 1�' Receipt No.: 1 NOTE: Persons contractingw1 unregistered contractors do not have access to thearan fun Signature of Agent/Owner Signature of contractor see o , x Location �2 q? av tdq0a /V. No. fJ%Ct ' ��'� Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $,, Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check # c if thC._ A "I :? � �� U Building Inspector CD � Z CD 0 �r CL > 0 00 D Ccr� 0 CD 0 CO CD U) CD 0 OwJ 10 a F 0 CD CDa U) CD U) 0 0 CD 0 CD 0 Z m cn m z M ic Z Cl) O .. °, CD N O (o O W cm Q CD to 0 CA 2. o=�o d = -. < CDCD * to CD 0 T �' 0 m 0•s=r-C vi �' x 0 T 5' o O — a 0 m W D• U) 0 T 0 n �p �D 2 �o CL 0 rt H ZD H A O N rt M m r m r N M m 0 O Ln 0 0 U rD 0 0 W � =5 � * O 7p► T �' Vl � ;uT c �' x 0 T 5' A s rD 0 o T o � N D Ln N Ln 0 0 U rD 0 0 W � =5 � T X 0_ T �' Vl � ;uT c �' x 0 T 5' A s rD 0 o T o � N D Ln N T 0 n rt '-� o rn D m H ZD H A O m r m r N M m 0 r C Z �+% N m 0 � w C C H 0 3 s rD Z W G O = D m _ Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Client: Megrath, Kathy Property: 247 Brigdes Lane N. Andover, MA 01845 Operator: BWHITE Estimator: White, Brian Business: PO Box 328 Lawrence, MA 01842 Type of Estimate: Water Damage Date Entered: 11/29/2016 Price List: MAEM8X NOV 16 Labor Efficiency: Restoration/Service/Remodel Estimate: 2016-11-29-1414 Date Assigned: Home: (978) 682-0025 Business: (978) 688-2242 x 13 E-mail: bwhite@servprooflawrence. com Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Bathroom 2' 6" .2„ �n aih Closet 1D M N N 1 � 2' 8" -q Door DESCRIPTION Bath Closet 2016-11-29-1414 Main Level 64.69 SF Walls 71.01 SF Walls & Ceiling 0.70 SY Flooring 10.17 LF Ceil. Perimeter 2'6"X6'8" Height: 8' 6.32 SF Ceiling 6.32 SF Floor 7.67 LF Floor Perimeter Opens into BATHROOM QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 1. L ear out non -salvageable the tloor & bag for disposal 6.32 SF 2.88 0.10 18.30 (0.00) 18.30 ' 2. Tear out non-salv underlayment & bag for disposal 6.32 SF 1.24 0.04 7.88 (0.00) 7.88 3. Clean floor -Heavy 6.32 SF 0.50 0.00 3.16 (0.00) 3.16 4. Apply plant -based anti -microbial agent 6.32 SF 0.23 0.02 1.47 (0.00) 1.47 5. Tear out baseboard 7.67 LF 0.38 0.00 2.91 (0.00) 2.91 ) Totals: Bath Closet 0.16 33.72 0.00 33.72 �- 6' 7" -� T 6, 1E��4 -_ v Bathr6 i2'2" -B h Closer 6" 5" Door Window Door Bathroom 182.67 SF Walls 224.22 SF Walls & Ceiling 4.62 SY Flooring 28.50 LF Ceil. Perimeter 2'6"X6'8" YX4' 2'6"X6'8" Height: 8' 41.55 SF Ceiling 41.55 SF Floor 23.50 LF Floor Perimeter Opens into HALLWAY Opens into Exterior Opens into BATH -CLOSET DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 6. Tear out non -salvageable tile floor & bag for disposal 41.55 SF 2.88 0.62 120.28 (0.00) 120.28 7. Tear out non-salv underlayment & bag for disposal 41.55 SF 1.24 0.23 51.75 (0.00) 51.75 8. Clean floor -Heavy 41.55 SF 0.50 0.03 20.81 (0.00) 20.81 9. Apply plant -based anti -microbial agent 41.55 SF 0.23 0.10 9.66 (0.00) 9.66 10. Tear out baseboard 23.50 LF 0.38 0.00 8.93 (0.00) 8.93 11. Remove Toilet 1.00 EA 21.57 0.00 21.57 (0.00) 21.57 2016-1.1-29-1414 12/28/2016 Page:2 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 DESCRIPTION CONTINUED - Bathroom QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 12. Remove Vanity 2.50 LF 6.47 0.00 16.18 (0.00) 16.18 13. Remove Sink - single 1.00 EA 16.19 0.00 16.19 (0.00) 16.19 14. Air mover (per 24 hour period) - No monitoring 10.00 EA 24.95 0.00 249.50 (0.00) 249.50 2 for 5 days Totals: Bathroom 0.98 514.87 0.00 514.87 D 6" [Lund, cy-s 2 --0 1 Door DESCRIPTION Laundry Room 136.22 SF Walls 159.97 SF Walls & Ceiling 2.64 SY Flooring 21.33 LF Ceil. Perimeter 5'2"X6'8" QUANTITY UNIT PRICE Height: 8' 23.75 SF Ceiling 23.75 SF Floor 16.17 LF Floor Perimeter Opens into HALLWAY TAX RCV DEPREC. ACV 15. Tear out non -salvageable tile floor & bag for 23.75 SF 2.88 0.36 68.76 (0.00) 68.76 disposal 16. Tear out non-salv underlayment & bag for disposal 23.75 SF 1.24 0.13 29.58 (0.00) 29.58 17. Clean floor - Heavy 23.75 SF 0.50 0.02 11.90 (0.00) 11.90 18. Apply plant -based anti -microbial agent 23.75 SF 0.23 0.06 5.52 (0.00) 5.52 19. Tear out baseboard 16.17 LF 0.38 0.00 6.14 (0.00) 6.14 J 20. Tear out wet drywall, cleanup, bag, per LF - up to 2' 16.17 LF 2.90 0.39 47.28 (0.00) 47.28 tall 21. Washer - Extractor - Remove & reset 1.00 EA 98.56 0.00 98.56 (0.00) 98.56 22. Dryer - Remove & reset 1.00 EA 28.51 0.00 28.51 (0.00) 28.51 23. Air mover (per 24 hour period) - No monitoring 10.00 EA 24.95 0.00 249.50 (0.00) 249.50 2 for 5 days Totals: Laundry Room 0.96 545.75 0.00 545.75 2016-11-29-1414 12/28/2016 Page:3 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Hallway Laundry Room throom I'�-5.2•'x'4' �T xT Hal iL't 1 F2'6„4 3' - Door Door Missing Wall - Goes to Floor Door DESCRIPTION 106.89 SF Walls 141.89 SF Walls & Ceiling 3.89 SY Flooring 24.33 LF Ceil. Perimeter 216'1X618" 51 211 X 61 811 YX6'8" 21 611 X 61 811 QUANTITY UNIT PRICE Height: 8' 35.00 SF Ceiling 35.00 SF Floor 11.17 LF Floor Perimeter Opens into BATHROOM Opens into LAUNDRY -ROOM Opens into Exterior Opens into Exterior TAX RCV DEPREC. ACV 24. Tear out non -salvageable the floor & bag for 35.00 SF 2.88 0.53 101.33 (0.00) 101.33 disposal 25. Tear out non -salt' underlayment & bag for disposal 35.00 SF 1.24 0.20 43.60 (0.00) 43.60 26. Clean floor -Heavy 35.00 SF 0.50 0.02 17.52 (0.00) 17.52 27. Apply plant -based anti -microbial agent 35.00 SF 0.23 0.09 8.14 (0.00) 8.14 28. Tear out baseboard 11.17 LF 0.38 0.00 4.24 (0.00) 4.24 29. Air mover (per 24 hour period) - No monitoring 10.00 EA 24.95 0.00 249.50 (0.00) 249.50 2 for 5 days 30. Dehumidifier (per 24 hour period) - Large - No 5.00 EA 71.22 0.00 356.10 (0.00) 356.10 monitoring 1 for 5 days 31. Containment Barrier/Airlock/Decon. Chamber 64.00 SF 0.64 0.28 41.24 (0.00) 41.24 Totals: Hallway 1.12 821.67 0.00 821.67 1 J Door Door DESCRIPTION 1..- 15'8" 4 Storage 41.7.33 SF Walls 61.4.50 SF Walls & Ceiling 21.91 SY Flooring 56.33 LF Ceil. Perimeter 216"X6'8" 21 611 X 61 811 QUANTITY UNIT PRICE Height: 8' 197.17 SF Ceiling 197.17 SF Floor 51.33 LF Floor Perimeter Opens into Exterior Opens into LIVING_ROOM TAX RCV DEPREC. ACV 2016-11-29-14'14 12/28/2016 Page:4 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 CONTINUED - Storage DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 32. Dehumidifier (per 24 hour period) - Large - No 5.00 EA 71.22 0.00 356.10 (0.00) 356.10 monitoring 1 for 5 days 12.33 SF 0.45 0.05 5.60 (0.00) 5.60 33. Content Manipulation charge - per hour 0.50 HR 38.50 0.00 19.25 (0.00) 19.25 34. Clean floor 98.58 SF 0.34 0.00 33.52 (0.00) 33.52 35. Apply plant -based anti -microbial agent 98.58 SF 0.23 0.25 22.92 (0.00) 22.92 Totals: Storage r-3' 5"-i Door DESCRIPTION 0.25 431.79 0.00 431.79 Closet Height: 8' 96.67 SF Walls 12.33 SF Ceiling 109.00 SF Walls & Ceiling 12.33 SF Floor 1.37 SY Flooring 11.67 LF Floor Perimeter 14.17 LF Ceil. Perimeter 2' 6" X 61811 Opens into LIVING_ROOM QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 36. Tear out wet non -salvageable carpet, cut & bag for 12.33 SF 0.48 0.05 5.97 (0.00) 5.97 disp. 37. Tear out wet carpet pad and bag for disposal 12.33 SF 0.45 0.05 5.60 (0.00) 5.60 38. Apply plant -based anti -microbial agent 12.33 SF 0.23 0.03 2.87 (0.00) 2.87 39. Clean floor -Heavy 12.33 SF 0.50 0.01 6.18 (0.00) 6.18 40. Air mover (per 24 hour period) - No monitoring 5.00 EA 24.95 0.00 124.75 (0.00) 124.75 1 for 5 days Totals: Closet 0.14 145.37 0.00 145.37 2016-11-29-1414 12/28/2016 Page:5 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 -9'- 7' K -A'-rK 2 ce 3' 10' co H2(Y-1 set iscr ing Ro_ L IuU taus ]fRet v oc T L4' + 17 6" f-17' 10" -r Door Door Door Missing Wall Door Door Door DESCRIPTION Living Room Height: 8' 603.33 SF Walls 291.70 SF Ceiling 895.03 SF Walls & Ceiling 291.70 SF Floor 32.41 SY Flooring 72.42 LF Floor Perimeter 90.42 LF Ceil. Perimeter 11911 X 61811 Opens into CLOSET -2 61 1111 X 61 811 Opens into H20 -CLOSET 2161' X 61811 Opens into CLOSET -3 31911 X 81 Opens into OFFICE 11 1011 X 61811 Opens into CLOSET -UNDER 21 611 X 61 811 Opens into STORAGE 21 611 X 61 811 Opens into CLOSET QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 41. Dehumidifier (per 24 hour period) - XLarge - No 5.00 EA 101.25 0.00 506.25 (0.00) 506.25 monitoring 42. Air mover (per 24 hour period) - No monitoring 35.00 EA 24.95 0.00 873.25 (0.00) 873.25 7 for 5 days 43. Tear out wet non -salvageable carpet, cut & bag for 291.70 SF 0.48 1.28 141.30 (0.00) 141.30 J disp. 44. Tear out wet carpet pad and bag for disposal 291.70 SF 0.45 1.28 132.55 (0.00) 132.55 45. Apply plant -based anti -microbial agent 291.70 SF 0.23 0.73 67.82 (0.00) 67.82 46. Clean floor - Heavy 291.70 SF 0.50 0.18 146.03 (0.00) 146.03 47. Content Manipulation charge - per hour 3.00 HR 38.50 0.00 115.50 (0.00) 115.50 48. Tear out tackless strip and bag for disposal 25.00 LF 0.78 0.14 19.64 (0.00) 19.64 , 49. Remove wet suspended ceiling tile and bag for 80.00 SF 0.36 0.35 29.15 (0.00) 29.15 disposal ; 50. Tear out and bag wet insulation - Category 3 water 80.00 SF 1.14 0.35 91.55 (0.00) 91.55 Mice droppings, Totals: Living Room 4.31 2,123.04 0.00 2,123.04 2016-11-29-1414 12/28/2016 Page:6 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 t-3' 6" loset?G - Li CUndel I s 1 3' 4,� 1 a -. Door DESCRIPTION Closet Under Stairs 173.11 SF Walls 200.61 SF Walls & Ceiling 3.06 SY Flooring 23.17 LF Ceil. Perimeter 1'10"X6'8" Height: 8' 27.50 SF Ceiling 27.50 SF Floor 21.33 LF Floor Perimeter Opens into LIVING_ROOM QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 51. Air mover (per 24 hour period) - No monitoring 5.00 EA 24.95 0.00 124.75 (0.00) 124.75 1 for 5 days 52. Tear out wet non -salvageable carpet, cut & bag for 27.50 SF 0.48 0.12 13.32 (0.00) 13.32 disp. 53. Tear out wet carpet pad and bag for disposal 27.50 SF 0.45 0.12 12.50 (0.00) 12.50 54. Apply plant -based anti -microbial agent 27.50 SF 0.23 0.07 6.40 (0.00) 6.40 55. Clean floor - Heavy 27.50 SF 0.50 0.02 13.77 (0.00) 13.77 56. Content Manipulation charge - per hour 0.25 HR 38.50 0.00 9.63 (0.00) 9.63 Totals: Closet Under Stairs 0.33 180.37 0.00 180.37 Closet 2 3, 6_ toset2 N -2� �„ Door DESCRIPTION 65.67 SF Walls 71.48 SF Walls & Ceiling 0.65 SY Flooring 9.67 LF Ceil. Perimeter 1'9"X6'8" QUANTITY UNIT PRICE Height: 8' 5.81 SF Ceiling 5.81 SF Floor 7.92 LF Floor Perimeter Opens into LIVING_ROOM TAX RCV DEPREC. ACV 57. Air mover (per 24 hour period) - No monitoring 5.00 EA 24.95 0.00 124.75 (0.00) 124.75 1 for 5 days 58. Apply plant -based anti -microbial agent 5.81 SF 0.23 0.01 1.35 (0.00) 1.35 59. Clean floor - Heavy 5.81 SF 0.50 0.00 2.91 (0.00) 2.91 Totals: Closet 2 0.01 129.01 0.00 129.01 2016-11-29-1414 12/28/2016 Page:7 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 s ,o H2O Closet Height: 8' - ^3 6 T 5.00 EA 24.95 0.00 124.75 (0.00) 1 I 159.22 SF Walls 32.67 SF Ceiling H3ox 191.89 SF Walls & Ceiling 68. Tear out wet non -salvageable carpet, cut & bag for 10.50 SF 32.67 SF Floor 0.05 CRA, (0.00) 5.09 disp. p b a 1 3.63 SY Flooring 18.75 LF Floor Perimeter 10.50 SF 1 25.67 LF Ceil. Perimeter 4.78 (0.00) 4.78 70. Apply plant -based anti -microbial agent .wing Room 0.23 0.03 2.45 (0.00) 2.45 Closet 3 10.50 SF 0.50 0.01 5.26 (0.00) Door 6' 11" X 61811 Opens into LIVING_ROOM DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 60. Air mover (per 24 hour period) - No monitoring 5.00 EA 24.95 0.00 124.75 (0.00) 124.75 1 for 5 days 61. Apply plant -based anti -microbial agent 32.67 SF 0.23 0.08 7.59 (0.00) 7.59 62. Clean floor - Heavy 32.67 SF 0.50 0.02 16.36 (0.00) 16.36 63. Tear out wet drywall, cleanup, bag, per LF - up to 2' 18.75 LF 2.90 0.46 54.84 (0.00) 54.84 tall 64. Tear out and bag wet insulation 37.50 SF 0.64 0.16 24.16 (0.00) 24.16 65. Tear out baseboard 18.75 LF 0.38 0.00 7.13 (0.00) 7.13 i 66. Containment Barrier/Airlock/Decon. Chamber 64.00 SF 0.64 0.28 41.24 (0.00) 41.24 Totals: H2O Closet 1.00 276.07 0.00 276.07 m Closet 3 Height: 8' 1 87.33 SF Walls 10.50 SF Ceiling 97.83 SF Walls & Ceiling 10.50 SF Floor 1 1.17 SY Flooring 10.50 LF Floor Perimeter 13.00 LF Ceil. Perimeter Door 2' 6" X 6' 8" Opens into LIVING_ROOM DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 67. Air mover (per 24 hour period) - No monitoring 5.00 EA 24.95 0.00 124.75 (0.00) 124.75 1 for 5 days 68. Tear out wet non -salvageable carpet, cut & bag for 10.50 SF 0.48 0.05 5.09 (0.00) 5.09 disp. 69. Tear out wet carpet pad and bag for disposal 10.50 SF 0.45 0.05 4.78 (0.00) 4.78 70. Apply plant -based anti -microbial agent 10.50 SF 0.23 0.03 2.45 (0.00) 2.45 71. Clean floor - Heavy 10.50 SF 0.50 0.01 5.26 (0.00) 5.26 Totals: Closet 3 0.14 142.33 0.00 142.33 2016-11-29-1414 12/28/2016 Page:8 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Closet 4 �r Closet 4 `e a N S 1 iset Under S We Door DESCRIPTION Height: 8' 98.00 SF Walls 12.83 SF Ceiling 110.83 SF Walls & Ceiling 12.83 SF Floor 1.43 SY Flooring 11.83 LF Floor Perimeter 14.33 LF Ceil. Perimeter 21611 X 61811 Opens into OFFICE QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 72. Tear out wet non -salvageable carpet, cut & bag for 12.83 SF 0.48 0.06 6.22 (0.00) 6.22 disp. 73. Tear out wet carpet pad and bag for disposal 12.83 SF 0.45 0.06 5.83 (0.00) 5.83 74. Apply plant -based anti -microbial agent 12.83 SF 0.23 0.03 2.98 (0.00) 2.98 75. Clean floor -Heavy 12.83 SF 0.50 0.01 6.43 (0.00) 6.43 Totals: Closet 4 0.16 21.46 0.00 21.46 7' 8"-. �1 Close) 4 3 R" a a Pndei Office a '� jl 1 y 11'8" a• Door Missing Wall Door DESCRIPTION Office Height: 8' 319.33 SF Walls 127.13 SF Ceiling 446.46 SF Walls & Ceiling 127.13 SF Floor 14.13 SY Flooring 39.08 LF Floor Perimeter 44.08 LF Ceil. Perimeter 2' 6" X 6' 8" Opens into Exterior 3' 9" X 8' Opens into LIVING_ROOM 2' 6" X 61811 Opens into CLOSET_4 QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 76. Tear out wet non -salvageable carpet, cut & bag for 127.13 SF 0.48 0.56 61.58 (0.00) 61.58 i disp. 77. Tear out wet carpet pad and bag for disposal 127.13 SF 0.45 0.56 57.77 (0.00) 57.77' 78. Apply plant -based anti -microbial agent 127.13 SF 0.23 0.32 29.56 (0.00) 29.56 79. Clean floor -Heavy 127.13 SF 0.50 0.08 63.65 (0.00) 63.65 80. Content Manipulation charge - per hour 1.00 HR 38.50 0.00 38.50 (0.00) 38.50 Totals: Office 1.52 251.06 0.00 251.06 Total: Main Level 11.08 5,616.51 0.00 5,616.51 201.6-11-29-1414 12/28/201.6 Page:9 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Job DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 81. Add for personal protective equipment (hazardous 3.00 EA 8.67 1.37 27.38 (0.00) 27.38 cleanup) 0.00 7,298.54 82. Equipment setup, take down, and monitoring (hourly 6.00 HR 46.14 0.00 276.84 (0.00) 276.84 charge) 83. Haul debris - per pickup truck load - including dump 3.00 EA 160.57 0.00 481.71 (0.00) 481.71 fees 84. Asbestos test fee - full service survey - base fee 1.00 EA 380.00 0.00 380.00 (0.00) 380.00 85. Asbestos test fee - full service survey - per sample 7.00 EA 50.00 0.00 350.00 (0.00) 350.00 86. Negative air fan/Air scrubber (24 hr period) - No 2.00 DA 72.99 0.00 145.98 (0.00) 145.98 monit. 1 for 2 days during demo 87. Add for HEPA filter (for negative air exhaust fan) 0.10 EA 190.28 1.09 20.12 (0.00) 20.12 Totals: Job 2.46 1,682.03 0.00 1,682.03 Line Item Totals: 2016-11-29-1414 13.54 7,298.54 0.00 7,298.54 Grand Total Areas: 2,510.47 SF Walls 824.26 SF Floor 0.00 SF Long Wall 824.26 Floor Area 1,350.50 Exterior Wall Area 0.00 Surface Area 0.00 Total Ridge Length 824.26 SF Ceiling 91.58 SY Flooring 0.00 SF Short Wall 914.43 Total Area 159.17 Exterior Perimeter of Walls 0.00 Number of Squares 0.00 Total Hip Length 3,334.73 SF Walls and Ceiling 303.34 LF Floor Perimeter 375.17 LF Ceil. Perimeter 2,510.47 Interior Wall Area 0.00 Total Perimeter Length 2016-11-29-1414 12/28/2016 Page: 10 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Line Item Total Material Sales Tax Replacement Cost Value Net Claim Summary for Dwelling White, Brian 7,285.00 13.54 $7,298.54 $7,298.54 2016-11-29-1414 12/28/2016 Page: II Line Items Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Recap of Taxes Material Sales Tax (6.25%) Clothing Sales Tax (6.25%) Storage Tax (6.25%) 13.54 0.00 0.00 Total 13.54 0.00 0.00 2016-11-29-1414 12/28/2016 Page: 12 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Recap by Room Estimate: 2016-11-29-1414 Area: Main Level Bath Closet 33.56 0.46% Bathroom 513.89 7.05% Laundry Room 544.79 7.48% Hallway 820.55 11.26% Storage 431.54 5.92% Closet 145.23 1.99% Living Room 2,118.73 29.08% Closet Under Stairs 180.04 2.47% Closet 2 129.00 1.77% H2O Closet 275.07 3.78% Closet 3 142.19 1.95% Closet 4 21.30 0.29% Office 249.54 3.43% Area Subtotal: Main Level 5,605.43 76.94% Job 1,679.57 23.06% Subtotal of Areas 7,285.00 100.00% Total 7,285.00 100.00% 2016-11-29-1414 12/28/2016 Page: 13 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Recap by Category Items Total % APPLIANCES 127.07 1.74% CLEANING 347.10 4.76% CONTENT MANIPULATION 182.88 2.51% GENERAL DEMOLITION 1,717.31 23.53% PERMITS AND FEES 730.00 10.00% HAZARDOUS MATERIAL REMEDIATION 19.03 0.26% WATER EXTRACTION & REMEDIATION 4,161.61 57.02% Subtotal 7,285.00 99.81% Material Sales Tax 13.54 0.19% Total 7,298.54 100.00% 2016-11-29-1414 12/28/2016 Page: 14 Z ,N 31.92 ►--1101 I8 I r-� ►i a cz O N 00 N N _d2tft*_. —Authorization to Perform Services and Direction of Payment Customer Name: Cathy Mcgrath Loss Address: 247 Bridges LN City: Insurance Company: North Andover Self Pay Date of Loss: 11/27/2016 State: MA Zip: Claim Number (if available): 01845 16120865 The undersigned Customer, being the building owner, owner's representative, or resident, authorizes the Provider identified below to perform any and all necessary cleaning and/or restoration services on Customer's property located at the property address above, and with respect to items that need to be cleaned at a remote location to remove and clean such items as necessary. Customer authorizes Self Pay Insurance Company, herein referred to as "Insurance Company," to pay Provider solely and directly for that portion of the work covered by Customer's insurance policy. If, for any reason, Customer receives a check from Insurance Company made payable to Customer, Customer agrees to pay Provider immediately upon receipt of the check. In order to expedite payment to Provider, Customer hereby appoints Provider as attorney-in-fact, authorizing Provider to endorse Customer's name on Insurance Company checks or drafts, and to deposit Insurance Company checks or drafts for Provider services. Customer agrees to pay Customer's deductible in the amount of $ $0.00 that applies to this claim. If any amounts owing to Provider for Provider services are not covered by insurance, Customer agrees to pay those amounts to Provider within fifteen (15) days of Customer's receipt of invoice. It is fully understood that Customer and its agents, successors, assigns, and heirs are personally responsible for any and all deductibles and any costs not covered by insurance. Interest and finance charges will be charged at the maximum allowable by law, or at 1.5% per month, whichever is less, on accounts over thirty (30) days past due. Time is of the essence. Customer agrees that Provider is working for the Customer and not Customer's insurance company or any agent/adjuster. Property Owned By: Remarks: Cathy Mcgrath I HAVE READ THIS AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT, INCLUDING THE TERMS AND CONDITIONS OF SERVICE ON THE NEXT PAGE HEREOF, AND AGREE TO SAME. Customer Reviewed Customer Information Form: O Y ON Customer's Signature: Printed Name: Cathy Mcgrath Date: E-mail Address: 12/06/2016 Provider's Signature: Franchise Legal Name: d/b/a SERVPRO® of: Date: Contractor License #: ©SERVPRO® INTELLECTUAL PROPERTY, Inc. ALL RIGHTS RESERVED FE -051707 1.0 Each SERVPRO'� Franchise is Independently Owned and Operated. KEJO CORP The Andovers 12/06/2016 28000 05/16 Authorization to Perform Services and Direction of Payment Terms and Conditions of Service READ CAREFULLY Note: This Contract includes a limitation of liability and limitation of remedies. 1. SERVPRO® is one of the largest nationwide Cleaning and Restoration Franchise Systems in the United States. The SERVPRO® Franchise owner identified on the front of this Contract (the "Provider") is an independent contractor who agrees to perform the services identified on the front of this Contract (the "Services"). Client agrees to purchase, receive, and pay for the Services pursuant to the terms and conditions of this Contract. Servpro Industries, Inc., the Franchisor, is not a party to any agreement with Client, is not a guarantor of the Provider's Services, and is not subject to liability arising out of such Services. 2. Provider's performance of the Services is limited by, among other things, the pre-existing conditions and characteristics of the premises, material, fabrics, furniture, and/or other items. PROVIDER EXPRESSLY DISCLAIMS ANY RESPONSIBILITY OR LIABILITY FOR ANY PRE-EXISTING CONDITIONS. Client shall retain responsibility and shall be liable for all effects of and costs necessary to correct such conditions, including, byway of example and not limitation, the conditions identified below: (a) Provider may, in its sole discretion, pre-test materials for removability of spots or stains; dye or color fastness; shrinkage; fading; adhesive breakdown; or other problems. It is not always possible to determine these conditions in advance. PROVIDER DOES NOT GUARANTEE SPOT OR STAIN REMOVAL AND COLOR FASTNESS OR PREVENTION OF SHRINKAGE, FADING, OR ADHESIVE BREAKDOWN. (b) Provider DOES NOT GUARANTEE that wall and ceiling cleaning will restore the original color to painted surfaces. (c) Not all fabrics are conducive to cleaning. Provider shall use reasonable efforts to advise Client of any adverse effects which may be reasonably foreseen due to the nature of the fabric or material involved. PROVIDER DOES NOT GUARANTEE THAT SUCH MATERIALS CAN BE CLEANED OR THAT THERE WILL BE NO ADVERSE EFFECTS FROM ANY ATTEMPT TO CLEAN SUCH FABRICS. (d) A variety of materials are used in the manufacturing, upholstery and/or installation process. These materials include backing, lining, tacks, or other unknown substances that may cause discoloration or other adverse effects to the face material. Client acknowledges that it is impossible to determine when such adverse effects may occur and PROVIDER DOES NOT GUARANTEE AGAINST SUCH ADVERSE EFFECTS. (e) Client acknowledges and agrees that mold is commonly found throughout the environment and that it is impossible to eradicate mold. PROVIDER DOES NOT GUARANTEE THE REMOVAL OR ERADICATION OF MOLD. (f) Client acknowledges and agrees that limited photographs or video of the damage and cause may be made solely for work process and insurance claims purposes. 3. PROVIDER SPECIFICALLY DISCLAIMS ANY AND ALL OTHER WARRANTIES AND ALL IMPLIED WARRANTIES (EITHER IN FACT OR BY OPERATION OF LAW) INCLUDING, BUT NOT LIMITED TO, ANY IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE OR ANY IMPLIED WARRANTY ARISING OUT OF A COURSE OF DEALING, CUSTOM OR USAGE OF TRADE. THIS CONTRACT PROVIDES FOR THE PROVISION OF SERVICES AND DOES NOT PROVIDE FOR A SALE OF GOODS. 4. Limitation of Liability: IN NO EVENT SHALL PROVIDER, ITS OWNERS, ANY OFFICERS, DIRECTORS, EMPLOYEES, OR AGENTS, FRANCHISOR, OR AFFILIATES BE RESPONSIBLE FOR INDIRECT, SPECIAL, NOMINAL, INCIDENTAL, PUNITIVE OR CONSEQUENTIAL LOSSES OR DAMAGES, OR FOR ANY PENALTIES, REGARDLESS OF THE LEGAL OR EQUITABLE THEORY ASSERTED, INCLUDING CONTRACT, NEGLIGENCE, WARRANTY, STRICT LIABILITY, STATUTE OR OTHERWISE, EVEN IF IT HAD BEEN AWARE OF THE POSSIBILITY OF SUCH DAMAGES OR THEY ARE FORESEEABLE; OR FOR CLAIMS BY A THIRD PARTY. THE MAXIMUM AGGREGATE LIABILITY SHALL NOT EXCEED THREE TIMES THE AMOUNT PAID BY CUSTOMER FOR THE SERVICES OR ACTUAL PROVEN DAMAGES, WHICHEVER IS LESS. IT IS EXPRESSLY AGREED THAT CUSTOMER'S REMEDY EXPRESSED HEREIN IS CUSTOMER'S EXCLUSIVE REMEDY. THE LIMITATIONS SET FORTH HEREIN SHALL APPLY EVEN IF ANY OTHER REMEDIES FAIL OF THEIR ESSENTIAL PURPOSE. Some states/countries do not allow the exclusion or limitation of incidental or consequential damages, so the above may not apply to you. 5. Should Provider bring legal action to collect monies due under the Contract or should the matter be turned over for collection, Provider shall be entitled, to the fullest extent permitted under law, to reasonable legal fees and costs of any such collection attempt, in addition to any other amounts owed by Client. This attorney fee provision shall not be effective or enforceable in jurisdictions where attorney fee provisions are made reciprocal or invalid by operation of law. Consent is hereby given for filing of mechanic's liens by Provider for the work described in this contract on the property on which the work is performed if Provider is not paid. 6. Any labor, materials or other work beyond that identified in this Contract shall require a written amendment to this Contract and will result in additional charges. 7. Any claim by Client for faulty performance, for nonperformance or breach under this Contract for damages shall be made in writing to Provider within sixty (60) days after completion of services. Failure to make such a written claim for any matter which could have been corrected by Provider shall be deemed a waiver by Client. NO ACTION, REGARDLESS OF FORM, RELATING TO THE SUBJECT MATTER OF THIS CONTRACT MAY BE BROUGHT MORE THAN ONE (1) YEAR AFTER THE CLAIMING PARTY KNEW OR SHOULD HAVE KNOWN OF THE CAUSE OF ACTION. 8. A failure of either party to exercise any right provided for herein shall not be deemed to be a waiver of any right hereunder. 9. CLIENT AND PROVIDER EACH WAIVE THEIR RESPECTIVE RIGHTS TO A TRIAL BY JURY WITH RESPECT TO ANY AND ALL CLAIMS OR CAUSES OF ACTION (INCLUDING COUNTERCLAIMS) RELATED TO OR ARISING OUT OF OR IN ANY WAY CONNECTED TO THIS CONTRACT AND AGREE THAT ANY CLAIM OR CAUSE OF ACTION WILL BE TRIED BY A COURT TRIAL WITHOUT A JURY. 10. If any provision of this Contract is found to be ineffective, unenforceable or illegal for any reason under present or future laws, such provision shall be fully severable, and this Contract shall be construed and enforced as if such provision never comprised a part of this Contract. The remaining provisions of this Contract shall remain in full force and effect and shall not be affected by the ineffective, unenforceable or illegal provision or by its severance from this Contract. 11. No modification, termination, or attempted waiver of this Contract shall be valid unless in writing and signed by the party against whom the same is sought to be enforced. SERVPRO° Franchisees are always looking for motivated employees. SERVPRO's individually owned and operated franchises offer a variety of positions including crew chief, production technician, marketing representative, administrative assistant, and many more. 28000 05/16 Each SERVPRO'' Franchise is Independently Owned and Operated. POLICY NUMBER: ENVP016006-00 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES, OR CONTRACTORS -- COMPLETED OPERATIONS This. endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Sn"Frn If F Name Of Additional insured Person(s) Or Organization(s): Location And Description Of Completed Operations Any person or organization for whom you are performing In respect to any location where the Named Insured is operations when you and such person or organization have performing "your work." agreed in writing in a contract or agreements effected prior to the date your operations for that person or organization commenced, that suchperson or organization be added as an additional insured on your policy. . I Information required to complete this Schedule, if not shown above; will be shown in the Declarations. Section it - Who Is An Insured is amended to include as an additional insured the person(s) or organizations) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, In whole or in part, by "your work" at the location designated and described in. the sched- ule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". CG 20 37 07 04 © ISOProperties, Inc.,. 2004 Page 1 of I De Commonwealth of Massachusetts _ Department of ndust'ialAceidents F I Congress street, Sure 10 0 d 02114-2017 - - Boston, MA www mass.gov/dia •b:/f M 5J'L '"'ii • yea kers' CompensationbsuranceAifidavi�t:B�aiiders/CO.A.U' OsBIT'. cicansl lumbers. TO BEAD WIMTHEP� -Di—ea Vrinf Name (Business/Ozgabization/Individua�: Address: g l0`t Ph -no#: q 78 City/Slate%dip: ..._ ecktIie a . ro rlate box: Type o project (required). Aro You an employer. CJz PP P 1 am a employer with— MPoyees (full and/or part-time)-- 7. ❑Naw"donsitv.`ciaon e in 8. Remo del7�ig IQ I am a s ole proprietor or partnership ana�e no employees vvorlang form� any capacity. [Noworkers' comp. insurance required.] 9. [6Demolition e oworkers' comp. insurancerequired] t 10 0 Building addition 3.� lam ahomeowner doing all workmys 1£ [N ¢.Q I am a homeowner and wM be hiring contractors to conduct all work on my property. I Will 11.❑Electrical repairs or additiorLs ensure that all contractors either haveworicere compensation insurance or are sole b re airs 0 additions proprietorswithno employees. 12.Gj_Plturi- Stag rep *s I am a general coniaactpr and I have hrredthe sub -contractors listed onthe attached sheet 13'.[]Rbofrepair� These sub -contractors have employees and have workers' comp• �uanee 0 14, Other 6.n We are a corporation and rf 3. officers have exercised their right of'exemption per MGL c. 152, §1(4), and vie l7avz no employees. jNo workers' comp. insurance required.] licy information; *Any applicant that checks box 4I must °1 eys doing tion all work andihan hire outside w showing their -workers' contracttors moust sabmit a new affidavit indicating such. ' Homeowners who submit tins affidavrt g shoat showing fihe name of the sub -contractors and state whether or not Ehose errtii}es have tContractors that check this bol. must attached an additional t prom their workers_' comp. policy number. employees. If the sub -contractors have employees, they mus p p em to ees. Below is t/ie policy arzd job site lam an employer' that is providingworkeNs' compensation insr�rance for my Y information.,/� Z l C h Insurance Company Na�n.e: M Q (D '� ` g� G- 0 3 _ Expiration Date, t Policy # or Self -ins. Lic. #: W City/State/Zip: AD (r �- to � � - Job Site Address: A Ctach a copy of the workers' compe. ation policy declaration page (shog the policy number and expiration date . Failure to secure coverage as rto $1,500.00 equixed underMGL alties2xn§ih2e f rmis aofiamSTOP WORK ORDERpunishable and a fine ofup to $250.00 a and/or one-year, imprisonment, as well as civil p ainst the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance day ag coverage verification. the ains andpenalties ofperjury that tTie information provided move is true and correct': X d ere y c p i/) — 77 _4WD_ Official rase only. Do not7vrite irz t7zis area, to be completed by city or town o ffzcial. • Permit/Liceuse # City or Town' )[Ssuj gAuthority(circle-one):actor S.Plnmbingxnspector 1. Board of Health 2. Building Drtoz epaent 3. City/Town Clerk d•. Electrical Xnsp 6. Other Phone #- Contact Person- WHITKE1 OP ID: PI ACORO® CERTIFICATE OF LIABILITY INSURANCE PDATE(MMIDDNYYY) 11/11/2016 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(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 endorsements . PRODUCER Stanley McDonald Agency 1101 MainStreet Onalaska, WI 54650 James R. Mc Donald CONTACT James R. Mc Donald PHONE FAX Arc No Ext); 608-788-6160 Arc No; 608-788-7012 EMAIL ADDR SS: X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR INSURERS AFFORDING COVERAGE NAIC # INSURERA:Rockhill Insurance Company 28053 03/01/2016 INSURED KeJo Corporation dba Servpro of Lawrence See Note For Named Insured INSURER B: The Federal Insurance Co. 20281 INSURERC;ACE Property & Casualty 20699 INSURER D : PO Box 328 INSURER E : Lawrence, MA 01842 INSURER F: COVERAGES CFRTIFICATF NI IMRFR• RG\/ICl/1A1 All IMP= THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. /LTR TYPE OF INSURANCE DDL D SU D POLICY NUMBER MMDDS ITf MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR ENVP016006-00 03/01/2016 03/01/2017 EACH OCCURRENCE $ 2,000,000 ETO RENTED occurrence) $ 50,000 PREM GEES MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JEST LOC GENERAL AGGREGATE $ 3,000,00 PRODUCTS - COMP/OP AGG $ 3,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea.accident _ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 11000,000 AGGREGATE $ 1,000,00 C EXCESS LIAB CLAIMS -MADE M00798617 01/14/2016 01/14/2017 DED I X I RETENTION $ 10000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N/A PER 0TH - STATUTE E E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ B Property Section 670-66-47 03/01/2016 03/01/2017 B Crime 670-66-47 03/01/2016 03/01/2017 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder Is Additional Insured Per Attached CG 2037 (07104) And CG2010 (07/04) A.T.I.M.A. Policy#ENVP016006-00 TOWNNO3 Town of North Andover Building Department 120 Main Street North Andover, MA 01845 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 .Ali" ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD ACOORGIr CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 12/22/2016 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(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 Dabney CollierPHONE c/o Collier Insurance 606 S. Mendenhall; Suite 200 CONTACT NAME: g01 529 2900 FAX (901) 529-2916 AIC No Ext): ( ) AIC No EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # Memphis, TN 38117 INSURER A : American Zurich Insurance Company 40142 INSURED Adams Keegan, Inc. 6750 Poplar Ave Ste 400 INSURER B INSURER C INSURER D: Memphis, TN 38138 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 16TNO09858085 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL I D SUBR WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE F7 OCCUR DAMAGES( RENTED PREMISES Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ PRO ❑LOC JECT PRODUCTS -COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ AGGREGATE $ 4EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PRO PRI ETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A WC 56-11-865-03 12/01/2016 12/01/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 Location Coverage Period: 12/01/2016 12/01/2017 Client# 2410 -MA DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) KEJO Corporation dba: SERVPRO of Lawrence Bi only those co -employees Weekly Coverage is provided for of, but not subcontractors 8 BLAKELIN ST to: Lawrence, MA 01842 Town of North Andover Building Department 120 Main St. North Andover, MA 01845 (:ANC:tLLA I IUN 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs & Business Regulation %,HOME IMPROVEMENT CONTRACTOR j;..4'r`_'' Registration: 158271 T YPe: tis ii Expiration: 12/31/2017 Private Corporation KEJO CORPORATION SERVPRO OF LAWRENCE, ET ALS. GREGG WHITE 8 BLAKELIN STREET LAWRENCE, MA 01841 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without sipnalin•c Massachusetts Department of Public Safety Board of Building Regulations and Standaras LicenseCS-067690 -anstrur:tnon 5,�per.�ser GREGG M WHITEg r 4 CHATBURN RD WINDHAM NH 03087 ^-� ✓f-- Expiration —omm ss;cner 02/20/2018