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HomeMy WebLinkAboutBuilding Permit #481-12 - 25-27 WILEY COURT 12/16/2011Permit NO: 4,41 ._ / 17 Date Issued: /4( TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received RTANT: Applicant must complete all items on this LOCATION 10 t, eo u,, ' PROPERTY OWNER 1/l I I'" SSm, int Unit # Print MAP NO: _,6S PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE 0� 6 vet IqA Residential Non- Residential ❑ New Building krOne family Phone: ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ilrRepair, replacement ❑ Assessory Bldg ❑ Others: 0 Demolition ❑ Other i �tSeptic� q`We11► ElY141 dplaint 0 Wetlands; C IT Wa ershedlDistnct3 a ❑,Water/Sewer. Lr OUmr 11UIN Ur w UK1L 1 U bh FEE -P UFdME : Qe -�bok 6 qtr exis-in� skin5(c, A r i (Identification Please Type or Print Clearly) OWNER: Name: U�! 1 [(, &m gm t 4h Address: 0�1 l l)I�@�,, COyrk 0� 6 vet IqA D iW CONTRACTOR Name: & T6 (D VU I6y ``l /l s Phone: G 8 3 g q 2 o Address: Z,06 Suf -t-6 _ &+T-ee+ �J p ('% /\A rl ,b\s q Supervisor's Construction License: a( C( 3 '�_ C6 Exp. Date: (-)--I(_13 Home Improvement License: ( 0 14 S-6 � Exp. Date: -7-/L+-- 12 ARCH ITECT/ENGINEE Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ o0o °J FEE: Check No.: / �%..�� Receipt No.: 0yeft" NOTE: Persons contracting with unregistered contractors do not have access to t11tu ignatur_e�of�Agent/©wner� =Signature of'cont�actorf 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 DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: fi Pianning Board Decision: t Comments Conservation Decision: Comm ing Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street yes no 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 ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 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 ❑ 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: Doc.Building Permit Revised 2008mi Location>S-- %_2 / No. ��/ — /2- Date �/1 t�//� AORTq TOWN OF NORTH ANDOVER • OL 9 o Certificate of Occupancy $ !'•O��s•o �`�� sS�cNusEt Building/Frame Permit Fee $ 7s1C • 00 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # / 24888 112�� Building Inspector 49 z 0 w w a T co O CD ■ L O Z CD CL O CO) G C I Com_ CO) p 'C C CO) CD .7 m m O OD CL co 3.a a� O C O m o a a cma CO.) S 'O o4-9 civ ■Q v_ O C CD CL V h C CL .0 C CO2 is LLI U) uj W W 09 ujW c o as c a CD c� u o a A U _cis w Q" w°' w W w°' cn w to C4 cz w w N rA cn o cn z 0 w w a T co O CD ■ L O Z CD CL O CO) G C I Com_ CO) p 'C C CO) CD .7 m m O OD CL co 3.a a� O C O m o a a cma CO.) S 'O o4-9 civ ■Q v_ O C CD CL V h C CL .0 C CO2 is LLI U) uj W W 09 ujW c o as c CD V C., •n C .' Jt C ev � m c o C CD Ea c •= v o c. y E :.o m p p CD CL E G: y • G: m m m y �... ' 23 -a C y C O p E m _Q� m O m N C-1 Z V ' A 2-6- O. p Ql C a. m p �� � o = m ~ 2 ~ m W C O=..'p 2 S AD �� V m.y C:33 �p O W cm GO 0. co p � a y�� O _ 0 4"m�m� z 0 w w a T co O CD ■ L O Z CD CL O CO) G C I Com_ CO) p 'C C CO) CD .7 m m O OD CL co 3.a a� O C O m o a a cma CO.) S 'O o4-9 civ ■Q v_ O C CD CL V h C CL .0 C CO2 is LLI U) uj W W 09 ujW DAVID CASTRICONE, PRES. M-".fi"tj CASTRICONE ROOFING & SIDING INC. IYAO/ ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 In North Andover 978-683-3420 In Boxford 978-887-6147 . In Haverhill 978-374-7314 I/we the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and conditions, on premises below described: Owner's Name.......K.Y. .e... ...................................7777........ Te one #... n17:S .D..te.............. State .�......t3 . )f..e./....Job Addres..... a...... ...................//L'y.. (S Specifications: .................................... ................ .... 777 7 ............................................:....... ........... .... . .. ....... A)].....�..... rs . 1.ktlf..tP�..:l�%� .......4.�....�L.U.I.I�S.� /r ..... .!.11...... 1zL.1... ...... .........J a 1. .b...lT.l�. �,iC..... s.�oJ.ax . bP.�.....td�...•P f .. ... 7777 ../.`...... ..............1..` l.Q�r�..1.�t>.tlre�........................................... .......................................... .77 7:7M....:............................. 1.,b.e.................... y aYiVPJYES... ........................................................................................................................ ............................................. ............ ................ Two Year Workmanship Warranty (Not Transferable) Manufacturer's Warranty as specifie anuI eturer The co ractor agrees to perform the work at d %pJsh the materials specified above for the SUM $..... •Q ............. •• I ayable .t„3.0..t0.12.......... on ....i -. ......... Payable........ 77= .............. on ......... .7777-:................ &balance payable on completion of 'oh - Owner or Owners are not responsible for Property Damage or Liability whi e job is in operation. Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust h attic or other living spaces). Items in attic may need to be covered by homeowner. All materials arc property of contractor. Any dumpster placed by contractor is for his use only. Upon completion ofabove work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall he paid by the owncr(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shalt be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. Property may be subject to mechanic's lien if unpaid. It is further agreed that this contract may be assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are) the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s). There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to the Office of Consumer Affairs and Business Regulations, Tel. (617) 973-8700. Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction - related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A Approximate starting date of work ................................................. Completion date ......................................................... Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES This contract may be cancelled, without penalty or obligation, within three business days of the below -referenced date. Mail or deliver a signed and dated notice or send a telegram to Castricone Roofing & Siding Inc, 200 Sutton St., No. Andover, MA 01 9845. IN WITNESS WHEREOF, the parties have hereunto signed their names this .. 7777 f ..Ll_., 20..1.'.... Accepted: Signed. ............................... .............................. ner Signed...................................................................... Owner David Castricone, President The Commonwealth of Massachusetts Department of Industrial Accidents LV Office of Investigations k9i 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly n Name (Business/Organization/Individual): ( tgsL<~/C t) /Ve5 RUQF e N<r - Slb/M(.1` A-1C Address: �,2 G CS Su -rn - �X , T S(_11 r& Z2-(- City/State/Zip: L(City/State/Zip: No, A /V eco y ' _ kA 0/ eclf Phone #: 97f f e3 3'Id Are you an employer? Check the appropriate box: Type of project (required): Q I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 6. New construction !. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10. El Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.tg Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. FI Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ k K U S Policy # or Self -ins. Lic. #: M10 QJ q Lb 9 2 -13 Expiration Date: 'Z - 273 - / -1 Job Site Address: C) � l�J 3( u 0J )Kt City/State/Zip: N — Adef , NA Q t 6 / Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the s �ndpena es ofperjury that the information provided above is true and correct. Siznature Date: Phone #• 97 Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone M Deltarinrent of Puhlic Jafet� Buar(1 of Buil(lin', Rc�,ulatiun.:uul 5tan(I:u•(1 Construction Supervisor Specialty License License: CS SL 99358 Restricted to: RF,WS DAVID CASTRICONE 31 COURT STREET NORTH ANDOVER, MA 01845 �� Expiration: 12/16/2013 ( "uuuuis.ir,uw' Tr -9: 7924 /A, 6" ��A /.I rUCr.c:�uJet(J _, Oflit'e orCuusumer:U'Lrirs & L3u�incss Regulation HOME IMPROVEMENT CONTRACTOR F f:t Registration:104569 T ype: Expiration: 7/14/2012 Private Corporatio DAVID CASTRICONE ROOFING, SIDING 8 David Castricone 200 SUTTON ST SUITE 226 _ NORTH ANDOVER, MA 01845 ,� Undersecretary �l:u.a\Ittt.ctt. - Uclrtrinu•nl ori Pul?1ir �af(•t� Buart) ni Bttiltlin� Ilc�trl:rtiun.:utt; � , License: Cs 105611 JONATHAN MACLEAN 33 ERRY ROAD SALISBURY, MA 01952 cam— �- �� Exp ration: 4/24/2014 ,:uinn..i��nrrTr_ 105611 Town of North Andover of NOk71� p Building Department o H � 27 Charles Street A Nor<h Andover, Massachusetts 01845 19z ti (978) 688-9545 Fax (978) 688-9542.E 7 �R�reo SSHCHUS��� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c,l 1, sl50a. The debris will be disposed of in /at- /' z' � at:/'z'-�- E (f, {S' Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. A&VRHCERTIFICATE OF LIABILITY INSURANCE D1YNYY) 9// 9/2019/2011 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an AMONAL INSURED, the policy(in) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, cartaln policies may require an endorsement. A statement on this eartlflcate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willows Insurance Agcy 51 Cochichewik Dr North Andover K% 01945 INSURED ..._. _.... •- DAVID CASTRICONE ROOFING & SIDING INC 200 Sutton St Suits 226 NORTH ANDOVER MA 01945 o amu: 979 -475 3414 ---- . _ ,jFt c, No), __....._ MAIL �R__....__._._ - OMER IQ I. INSURER(S) AFFORDING COVERAGE suRFA A Maiden S»ecialtY Ins Co suRER k: SURER C WWR 0: .._.._ SURER 9; L.UVLKA ass CERTIFICATE NUMBER:CL119906255 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, EXCLUSIO_N_$ AND CONDITIONS OF SUCH POLICIES. LIMITS_ SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSA % SUeR LTR TYPE OF INSURANCE _ POLICY NUMBER t1C1 EPF MPMtoo "y ---' UMRa GENERAL I.MILITY EACH OCCURRENCE 3 100_0_000 tXOOM11 1.CIAL GENER�AL LIABILITY IS —.50000 A cLAY,L4MADE I x OCCUR 00031600 9/06/2011 /6/2012 MED EXP An ane even 3 1000 "' - - PER.gONAL 6 AOV INJURY 3 1000000 GEMLAGGREGATE LIMIT APPLIES PER AUTOMOBILE UABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS I_ NON -OWNED AUTOS UMBRELLA UAB HI OCCUR eI`CBSS LIAe cLA1Ms DEDUCTIBLE AND EM PLOYERB' UABILM Y ! N ! OFF ERMEMANY BERR EXCLUDEDD7 ECIVE OE D I N I A ro (MMetery In NN) OESCROMON OF OPERATIONS I LOCATIONS J VEHICLES (Attach ACORD 101, Addltonal Remarks Slenedule, R Isere ApeM N regUlMd) GENERAL AGGREGATE 1 200000_0 PRODUCTS - COMP/OP AGG j 1000000x S 3 _ COMB NI EDIS NGLE LIMB (� ecddenl) BODILY INJURY (Per penon) S BODILY INJURY (Per aceidmi) $ PROPERTY DAMAGE (Per acclaent) 3. s _ s EACH OCCURRENCE_ _ 3 DISEASE . EA EMPLOYE _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Castricone Roofing 6 Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. Cdatricone Roofing 200 Sutton street Suite 226 AUTHOMMUPRUKhMATIVE N Andover, MA 01945 4WORD ACORD 25 (2009109)IN5023(2ooeve) 988. The ACORD name and logo are registered marks CORPORATION. All rights reserved, Ac"RoP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 9/23/2011 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 AnTrm w Tmrw •Tr rrwr nr�n IMPORTANT:•Tff ther�wcertificatennnwir holderw�n n Is an ADDITIONAL INSURED, the poIicy (Ies) must be endorsed. It 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 CONTT NAME: Eastern Insurance Group LLC – Main PHONE PAX AC. C Na : – 233 West Central StreetMAIL Natick MA 01760 ADDRESS: INSURED 31969 David Castricone Roofing & Siding Inc 200 Sutton Street #226 North Andover MA 01845 COVERAGES CERTIFICATE NUMBER: 21 41 631407 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. INS Lin ADDLISUOR mocn AnA/GLY EFF n r r r P�I�Y rgXP mi r r GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 7 OCCUR EACH OCCURRENCE $ PREMI S a rr nce $ MED EXP (Any oneperson) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 7 PPO LOC PRODUCTS - COMP/0P AGG $ $ AUTOMOBILE X LIABILITY ANY AUTO ALLOWNED SCHEDULED X AUTOS AUTOS NON-OWNE D HIRED AUTOS X AUTOS BCNGCV /1/2011 /1/2012 Ea accltlerq 1000000 BODILY INJURY (Per person) $20000 (Per BODILYINJURY(P$40000 PROPERTY DAMAGE Peraccldenl $ UMBRELLA UABOCCUR EXCESS LIAB HCLAIMS-MADE EACHOCCURRENCE $ AGGREGATE $ DED 11 RETENTION _ $ g WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) Ile describe under DCRIPTION OF OPERATIONS below N I A C003989723 9/23/2011 9/23/2012X WC STATU• OTH- E.L. EACH ACCIDENT $100000 E.L. DISEASE - EA EMPLOYE $100000 E.L. DISEASE • POLICY LIMIT $500000 ----•••••–•--•–•�•�••�•�•.��– �. I._„—cot—ownAwnu,u,,Acomonoinemamsscneauie,nmorespaceIsrequire(l) CERTIFICATE HOLDER CANCELLATION Castricone Roofing & Siding Suite 226 200 Sutton 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 0 1988.2010 AC( ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD I rights reserved.