HomeMy WebLinkAboutBuilding Permit #467-16 - 27 BELMONT STREET 10/13/2015E
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
�- IMPORTANT: Applicant must complete all items on this page
t%ORTM
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6 .. •'h 6
LOCATION 7
Prin
PROPERTY OWNER AYQi� A `'ia' %� � �✓'�
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
El Other
_
®`1lVerhed D--i�'ner
M-2-V111"
Sewer at. / tr,
_ I
7 DESCRIPTION OF VVUKK I U tit tKr-UKIVItu:
e_melGse,-,Vii` l e4 z -e,.o IViX/6--
'Is/z, Cel _7 5f.D //Y CC ,
ion - Please Type or Print Clearly
OWNER: Name:
Phone:
Pz.
f
Address: ,2 7 �' � �✓
Contractor Name: '� -��� Phone: 17r -- a 9z4---67,3 7
Email:
Address /c�'�s`3 C�/�� L 1 /�'c /Il0 / Jif C%G�-C 1`�✓
Supervisor's Construction License: 02 -2 --Ccs Exp. Date: !1 C
Home Improvement License: 1&12 '3517� Exp. Date: 7/7//
ARCHITECT/ENGINEER
Phon
Address: Reg. No.
FEE SCHEDULE. BULDING PER IT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost:$�;'_5_6 ' FEE: $
Check No.: �� 2 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have acceA to the guaranty fund
Location dYjr
/.
No. Date/0
TOWN OF NORTH ANDOVEA
r
Certificate of Occupancy $
Building/Frame Permit Fee .. $
Foundation Permit Fee $
Other Permit Fee, $
TOTAL $
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
r
Public Sewer ❑
Tanning/Massage/Body Art El
Swimming Pools El
'
- i
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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH, Reviewed on, _ Signature
V
r
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Com
Conservation Decision: Comments
I Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 3 ood Street
x.".:_res4,,
IRE DEPAR,,TE Temp ®umpste`r�bn�sitej.r�est_ ano ;
l o�cated at 1.24 Main Street;µ"
Fire De artment
*'Fr na' ue date �ka
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� k ,E�x'": 'rt•: .:]t�°t' "_. .1 .ajY4 `# " 4�T.{�'��°J�� 4.; 1Xi P f,[`a«3 1;V .. l 4 r
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i
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department
® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4, 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/Cross Section/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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
a� 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2014
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The Commonwealth of Massachusetts
. Department oflndustrialAccidents
�r 1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERIVIITTING AUTHORITY.
Applicant Information �► Please Print LeObly
Name (Business/Organization/Iudividual):
Address: an-�,
,� M,MF VMi���ML
Are you an employer? Check the appropriate box:
le I am a employer with _employees (frill and/or part-time).*
2. ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
#: YW-- eW--i� 73`7
IF] I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.#
6. Q We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no. employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. Fj Remodeling
9. ❑ Demolition
10 Building addition
11. F1 Electrical repairs or additions
12. Plumbing repairs or additions
13. [] Roof repairs
14. they'/,�/41'�
`Any applicant that checks box ##1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit !Ns 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,'tliey 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:_ //Y9
Policy # or Self -ins. Lic. #: 70/�%9�f O foZ !� 0 Expiration Date: �I 1
Job Site Address: c::::Z / 6--t— e�ll G / City/State/Zip: I&P /�%1AQ4:)yeVZ
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA, for insurance
coverage verification.
I do hereby certify nder the pains and penalties ofperjury that the information provided above is true and correct
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and. Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employ's persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill- out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -'contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents fbi confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit.multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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r. , p.s.r .dw. ,;�,.. y,p,,.s...yr� .^:, .Pic .rM+..'T..•ir} "-'7�{*-�^ti:.:+,.r..... "'�" * «P.ft',.. ,A .#.-.. , w-J:l,
Page # of pages
CS # 022680 978-688-6737
HIC# 103358 A. J. Walsh & Sons or
159A .Waverly Road 1-978-912-2853
North Andover, MA 01845
To:
S
Job Name
Job #
Address Job LocationjiP
d
O� /� let_ ,„ ` 0/
t4'� Date f / Date of Plans
Phone # G� � C1 � ! � � FVax/ # Architect
rWe hereby/ submit specfcations and estimates for.
.W -
We propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of:
$ fa `t�1.�, Dollars
with payments to be made as oliows:
w
Any alteration or deviation from above specifications involving extra costs Oil be Respectfully j� /,•�
executed only upon written order, and will become an extra charge over and
above the estimate. All agreements contingent upon sin'kes, accidents, or delays submitted
beyond our cohlrol. Note — this proposal may be withdrawn by us if not accepted within days.
ZfecePtaM So�f 0p00al
The above prices, specifications and conditions are satisfactory and are 4/'. natute
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceptance. Signature
MASSACHUSETTS HOME IMPROVEMENT CONTRACT
This form. satisfies all basicraquuements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not Include tttandard'
language to protect homeowners. Seek legal advice if necessary." Any person planning home tuprovemems should fiisf obfain a copy of "s
Massachusettsticonsumer.guide to home improvement" before agreeing.to any work on yourresidence.' You may obtain -a free copy by calling the
Office of Consumer.:Affairs :and Business Regulation's Consumer Information Hotline at617-973?8787 or 1:888=283-37590 .
Homeowner Information Contractor Information
. d=rat — pray .... . .
Street Address (do riot use a Post Office Hai addre atractor/ S Owner Name
City?own S Zip Code ass A (most include a street address) .
LY
�Daytim P e Evening Phone_-41HIormneone
wn State Zip Code ..
Mailing Address (It different from above) Phone ederal Employer lb or S.S. Number '
y1^JThe Contractor agrees to do the following work forth47�f
Requireld Perurlts - The'fol/lowin7�.u_i11_itj�pcj_jnjts are required
and will be:secured :by the contractor as the'homeownees agent;
(Owners who;secure their own permits will lie
excluded;from:die_,Gnar_anityFund.provisions of
MGLchapter 142A.)
Proposed Start and Completion Schedule - The f6llowmg schedule will
be aajdh t0.11 ile�ss circumstances beyoud:the contractors control arise
v 4Shk when coutractor will begin contracted work
when contracted .work will:be substantially completed..
Total Contract Price and Payment Schedule ,46
The Contractor. agrees to perform the work, furnish -the material and labor specified above for the total sum of (+)
Payments will be made according to the following schedule:
S—JK upon..signmg contract (not to exceed 1/3 of the total:contract price. 4r the cosrof special order items, whichever is.greater)
$by _ / or upon completion of
.j—.
,r/ S by _/ / or upon completion of
0 Q� upon completionof the contract (I.aw forbids demanding full payment until .contract is completed to both party's. satisfaction) .
711e following material/equipment must be special S be paid for
ordered before the contacted work'begins inotde S m be paid for
to meetthe completion schedule.(••)
NOTES: (•) including all finance charges (••) law requires that any deposit or down -payment required by the contractor before work begins m
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of an ry
which must be Y aPecim. W uiPmmt or custom made material
aPaici ordered in advance to mat the completion schedule.
7 xoress Warreari Is as express warranty tela¢ nrovlded by the eontroctor+ No Yes faU terms of the warranty moat be �* s d to rbc contrme�t
Subcontractors The contractor agrees to be solely responsible for completion of the work deserted regardless of the ections'ofany third
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under ihie aereement
Contract Acceptance - Upon signing,this document becomes a binding_ contract under.iaw. Unless otherwise noted within this document, the
contract shall not imply that any lien or other security interest�has been placed on the residence. Review the following cautions end notices
carefully before signing this contract
• Don't be pressured into signing the contract Take time to read and fully understand it As 'questions ifmidething is miclear.
• Make sure the contractor has a valid Home Imurovement ontractor R ¢icrrafi he hiw
requires most home improvement contractors and .
subcontractors to be registered with the Director ofHome lWavemeat Contractdk Registration. You may inquire about.conmictor
registration by writing to the Director it Ashburton Place, Room MI., Boston, MA 02108 or.by.ealling 617-727-3200.or
1-800.223-0933.
• Does the contractor have insurance? Check to see that your contractor is properly insured,
• Knowour
y rights and responsibilities. Read the Important Information on the reverse side of" foiat'end get a copy of the Consumer
Guide to the Home Irdprovement Contractor Law:
You may cancel this agreement if it has been signed at a place other. than the contractor suofinel lace of business,
contracwr in writing at his/her main office or branch office p provided You notify the
by ordinary mail posted by telegram sent or by delivery, not later thea midnight of Oie.
third business day following the signing of this agreement . See the, attached notice of cancellation form for an explanation of -this right
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!!
coo identiml Copies of the Centraet must be Completed mad signed pee copyahmdd so b the the Cthr
Copy mhauW beby the rctor
ntrse.
'r
Homeowner's Signature Contractor's Signature
Date
Date fir'
Contractor Arbitration .
The Home Improvement -Contractor Lawprovides; homeowners with:the righvto-initiate an arbitration action (as an
alteniative to court action) if they. have a.dispute:with.a contractor. The same:tightis nor automatically afforded tort
contractor, bow.ever.:.The: contractor would have.t - resolve any:dispute helshe.Has.with a homeowner in court unless . _. .
both parties agree to, the optional Clause provided below.. This clause would.give the. contractor the. same. right to
arbitration as is afforded to the homeowner.by the Home Improvement Contractor Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract, the contractor may submit the dispute to a.private arbitration firm which has:.been. approved by,
the Secretary of the Executive Office of Consumeit Affairs and Business Regulation and -the consumer shall be required
to.submit to such arbitration as provided In Massachusetts General Laws, chap 142A.
9
o�_- 1
Homeowner's Signature Contractor's Signature
NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution
initiated by the contractor:; Tbe-homeowner.may initiate altnuative dispute resolution even where this section: is not
cPriaretely sierred�+ •thr oart'res; '
Homeowner's Rights
A homeowner's rights unde H
ec-thome'Improvement Contractor Law (MGL chapter 142A) and other consumer
protection laws (ie. MGL chaptef93i - may not be waived in any way, even by agreement! However, homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement•c
Contractor Law. Theontractor is responsible -for completing the work as described, in a
timely and•.:workmanlike:manner. Homeowners.may be entitled to .other specific legal -rights if the ;contractor guarantees.
or provides an. express warranty for -workmanship or materials. In addition to.guarantees or warranties provided by the
contractor, all goods sold in Massachusetts cant' an implied warranty of merchantability :and frtness_for:a particular
purpose. An enumeration of other matters on which:the homeowner and contractor. lawfully agree May be added:to the
terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about
your consumer/homeowner rights, contact the Consumer Information Hotline (listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the document until all blank sections have been
filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to
be given to the owner and the other kept by. the contractor. Any modification. to the ITiginal'contract must be in writing
and -agreed to by both parties. Contracted work may not begin until both parties havereceiveda fully executed copy of
the contract, and the three day recission period has expired.
Accelerated Payments
A contractor may not demand payments inadvance.of thedates specified on the payment schedule incases where the
homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself
to be financially insecure, the contractor may require that the. balance of funds not yet due be placed in a joint .escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the
signatures of both parties.
Additional Information
If you have general questions or.need additional information about the Home Improvement -Contractor Law or other
consumer rights, or if yotr wish-to.,obtam a free copy of "A Consumer Guide to the Home Improvement Contractor
Law,"• contact
Cgnsumier Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
(617) 973-8787 or 1-(888) 283.3757 .
If you want to verify the registration of a contractor or if you have questions or need •additional informatiouspecifiCally
about the contractor registration component of the Home Improvement Contractor Law, contact:
Director of Home Improvement Contractor Registration
Bureau of Building Regulations and Standards
One Ashburton Place, Room 1301, Boston, MA 02108
(617) 727-3200or 1-800-223-0933
For assistance with informal ttrediadtin of disputes or to register formal complaints against a business,'call
Coiisi er`Caimplaint Section
Office of the Attorney General
(617)727-8400
AND/OR
Better Business Bureau
(508)652-4800
(508)755-2548
(413)734-3114
l ®
AC"Rf? CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDD/YYYY)
01/12/2015
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 00775_001
Durso & Jankowski Insurance Agency Inc
198 Mass Ave Suite 1016
North Andover, MA 01845
NQNTACT
A/C. No. Ext : (978)682-5175 F No.: (978) 794-0313
JNA
ADDhSS:
AFFORDING
INSURER A • A.1 -M. Mutual Insurance Company
INSURED
Arthur Walsh
A J Walsh & Sons
55 Pleasant Street
North Andover, MA 01845
INSURER 8
INSURER
INSURER E,
L:UVrKAUt_5 CERTIFICATE NUMBER! RFvlgln I "I111ARFR-
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 REDUCCLEDDC
ILTR
TYPE OF INSURANCE
INDSRe
POLICY NUMBER
yBE�YF�FPAIDppCO�LL�AIIyMSS��.p
MM/DD/YYYY
MPA/DD/YYYY
LIMITS
GENERAL LIABILITY
H��COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
EACH OCCURRENCE $
DAMAGE TO RENTED $
PREMISES Ea cc rr n
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GENT AGGREGATE LIMIT APPLIES PER:
OLICY E O OC
PRODUCTS - COMP/OP AGG $
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY (Per person) $
BODILY INJURY (Per accident ) $
PROPERTY DAMAGE
P r a i nt $
UMBRELLA LIAB
EXCESS LAB
OCCUR
CLAIMS MADE
EACH OCCURRENCE $
AGGREGATE $
RNNETppE7N��TIIONNN $
$
A
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ANDEMPLOYERS�LIABILITY
ANNyy PRRWpP�RR��5E1T(prPARTNEI / XECUTIVE / N
OFFICEWMEMBEREXCLUDED? Y
�(ffManddatory ibbn NH)
D��s Alff ION OF 5PERATIONS below
N/A
AWC-400-7014648-2014A
11/14/2014
11/14/2015
yyC g U 7H
X TORY LIMITS OER
E.L. EACH ACCIDENT $ 100,000,00
E.L. DISEASE - EA EMPLOYEE $ 100,000.00
E.L. DISEASE - POLICY LIMIT $ 500,000.00
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space is required)
The workers compensation policy does not provide coverage for Arthur J Walsh
Town Of North Andover
1600 Osgood 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
A%.vRv co tzui uruo) The ACURD name and logo are registered marks of ACORD
Massachusetts - Department of Public Safety
. Board of Building Regulations and Standards
Construction Supervisor
License: CS -022680
i
ARTHUR J WA ,SO JR
159A WAVERLY- �
N ANDOVER Mak 018�4�
oJ-2 �� r"�� Expiration
Commissioner 06/09/2016
,,i -� Ul��CC4JCCPf7.lCUG'�3 .
�C\ Office of consumer Affairs & Business Regulation
ME IMPROVEMENT CONTRACTOR
r61. egistration: 103358 Type:
xpiration: 7/7/2016 Private Corporatio.
A. J. WALSH & SONS,INC
Arthur Walsh
55 Pleasant St
N Andover, MA 01845 Undersecretary