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HomeMy WebLinkAboutBuilding Permit #1015-16 - 275 DALE STREET 3/29/2016 vk4y BUILDING PERMIT TOWN OF NORTH ANDOVER to " o APPLICATION FOR PLAN EXAMINATION 4 - Permit NO:do /6 Date Received " �4,.� - • �A�TeD♦��.(5 Date Issued: 9SSACNus�t IMPORTANT:Applicant must complete all items on this page LOCATION 21 '_� � S� Print PROPERTY OWNER KVI 1< 4 -t C_4-11:\SSS PPMA'tyt�; ` Print MAP NO: C/ 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 gAlteration No. of units: 0 Commercial 0 Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑Other ❑Septic ❑Well ❑Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer / 2—W'T�\l.L(-\-I%O'N pIr k)-tW i7l<Oty% -Dho',Z l C o'ivS;0�Vr.-A1t0Iy )17 1 X f:k0.1 I=►y i 9NW0(�'r W INH %. PO:S I S of- CSE (_Aiv'biNf, Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: ) I to Address (4 ► 7 iaSWr— f.I : Rb . Nocn-k nti-i r 0&4 Supervisor's Construction License: Exp. Date: Home Improvement License: i�� i Exp. Date: i ti ARCHITECT/ENGINEER IAN Phone: Address: I 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: $ 7 �� Check No.: C?' / Receipt No.: 2 /7-1- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature of Agent/Owner Signature of contractorD-1 Location No. ' ` / Date �` y • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ o Other Permit Fee $ TOTAL $ Check# {r " ' 172 r �y Building Inspector .? iJ i I G 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 PLANNING & DEVELOPMENT Reviewed On , Signatur6a Off' J i COMMENTSiJ (� 1,t�rjG�1'1C� U�� N(A e c o _SQL � ►�" r CONSERVATION Reviewed on Signature COMMENTS j I HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes I i Planning Board Decision: Comments Conservation Decision: Comments A A Water & Sewer Connection/Signature& date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street - FIRE DEPARTMENT - Temp ®urnpster on site yes n© WL Located at 1►24 Main S reet Fire Departmen si.g . ature/date C®MMEt�JTS 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-$1000 fine NOTES and DATA— (For department use) �I ❑ Notified for pickup Call Email Date Time Contact Name € F Doc.Building Permit Revised 2014 r -i c1ORTH . I . E : :. .c . . ve' 'o No. � Z LAK! h , ver, Mass, 3 �� COCMIC"9WICKE a• BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ........ .. ....................................... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ........../......................... ....................................... Rough to be occupied as `.�....>` 7 /fa'`d ��� ��G�.. ............................................. Chimney . ............................................................. provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO/ STARTS Rough �' Service ......... :.. . ��. . .:: ............................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Occupancy Permit to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. i` Massae isetts Home Im rovement SaInide Contract "isformswafiessubado ofthe"d"'Home7mprovem'dCwtmcpo l— GL Language to prv"cd hommwue>� (M chapeer 142A�but does not include standard Mass dmwb�a.�e.I � �YP�PI»�gbomo embefmeolsshonldfmobtamacowof"A Offtce of Consam�Aff*s and �' agtt:eingto anywmiron Ymwresidence.Yonmayobtain afree°oN by mUingthe ads Cmmm='ni onHodine nt 517.973-R7g7 or i-88&283-3957 or on om wehsbe.. °$ouipqwaer I> olation Contractor Information N Le �ZT SnatAd&=(do=use armtomeeikxaddrmI OwnerName M1 i Mfg ; LOA slue `` ZAP` ZUM=Addmss(maat➢ebnteasbaetaddress) U Dayt®ePhone �' gygomgtp V" RZ t�A Or6LIS c wr— q iSmug Zip Code MBAddrsa(IIditiaeatfromaboSe) Ens,aeasl •/• - �(,C Fedeaetfimptoye+•ID➢rS.S.N➢mber i� omewaovro �taP�emavateaegrtoober Hge�mdme The Contractor agrees to do the fopowbtgvvorkfortbeHomeowuer. L�1 aksMbeindetaIItbeaodttocompleted apecifymgtherype,)nand� andg�adeofmmeTialsuobe ased M additional ci+eecc if )!'���w F�E��J�` €evve 12e�red Permits-The ionwfto�pe amrexlafied Proposal Start and Co sod vnIl be second by the canharb6a as thehomeowpots aged be adhered to mpletion Schahile-the inIIowing schedole will (Owners who secmn their&vn permits will be clanstrIces b j and the ms's coah,,l arise eseinded from the Guarani'Amd provisions of , Date when contractor will MGL chapter'142A.) 44 begin camhatiedweric ;i IS I(j Date when cmilracted wmkwM be sabstantiany completed. Total ContractPrux and Paymerit;Schedale The contawtor agreestoperformt'he'wor>Sfinnish the mateoaland labor specifedabove for ffietatalsum at Payment;will be made a-Mftgt4Mowing 11hftk (� $te_upon signing eoahaet(not to exceed W ofthe total conhadprice Qc the ofspecial order items whielteveris greater) s _ by or Upon completion of by orupoacompletkinof upon completion the coftaa (lawfo&&demanding fiill Pa9mcet Ohl oonhad is c®pletedto bo8i patty's satisfaction) UM JbHowing . ocdemdbefnih. s tobepaid fa, to medtbe completion schedui� ) $ to be paid for NOTES:(hlacludmgall fmanee (n)1•aflaprastat anydepositar Whwh m➢stbmicbegins may ye oft(a)oneadoftbetomlcamBctpmceor(b)t.acetal .f., equMmentor made mand special m?&vd in advanceio ngett�comptettvn schanda �CpLess Warr➢➢h.-TS an er➢rK ".,.e...,;, _ . IE m➢v� tr.v}#. Subcontractors ao�l �No Yes fall terms vu. Me comrawaa agrees to be solely nle ` t �h Yoffie ➢m �/-b-&WWr i dbythe4dwraetor.Thecontracmr rPlehoaofthevwrkd ain essofthese&=Ofanythhd a I daffier agrees to be solely—Poasible for all paymenft to all sabc onhactm hr Co htractAcceptaace-Ujx m sigmrtg' ft doammmt be a &MliarO �9i�resthasbba�placedamtheresc notedwitha,fhisdocaam,4 he Ilowi ig cent w and notices i. �_—Dadtbc-Pr ssa cdimn • • `jam ° Malresmetbeebnanctag' COnaactTaietime toxeadandfaTgtmdestanait S3kgtto I 1!aridl3omeTMMIT0ent a ifsa�iimgistmelee. sabce admi b s to be xegti lwuh the Drrector of8ame 3mprovemeat Coatrs � mOsthame impmvemcet c�gm g and Vd'emgtothe at 10 PazkPlazk ROM° Do conhadorhave msmancap Askthe C {or s5I70, vtor Boston,MA 0211��617-_973.&7g7 nhe abont800nL -37 . see a copy ofa`woofofh,,a doe^doc�aent ce�P�YintaumationsothatyoncancbnSna—'-Mm•askto ° Guide to the Hosni Read the ° fnfea®atioa on tttereveese side ofthis �a i and copy ofthe Consumer Yoamaycancelthisagn m�tifith sbora34pedataplaceoI II rs the third tiogathis/ItermairOfficeorbranchofficebymdinm9marl adotsnerntalplaceofbasiness,Providedynanotitythe dayEoIlowingfie siguiagof8vsegceemurt See Ereattachednotioeoceacel[atuatfrnmfm notlatertbmmmidniglrtof8re DO NOT SIGN TS CONTRACT TF THER>,A ' offfiisright T.ota�at Orme x�cbee � oaN„tJILEP-E �--- ANY11111-11 ES ACES►jr -'tre��ya�,umrmpeym,,,°a� ss, s Stgoapue r Dei ! ' .Date i j S .�0 Building&.Remodeling Adam Brien CSL 104428 417 Waverly Rd. HIC 168512 North Andover, MA 01845 LLC 978-479-1526 3/7/16 adambrico@gmail Ahren Lippman 275 Dale St North Andover MA 01845 Job Description: Construction of front entrance "Portico" design to mimic picture sent. New Front entry Door. • Supply and install materials to construct "portico" roof. Posts to be 4"x4" Fur lagged to granite landing. All work performed to MA building code. • Posts to be wrapped with "Versetek" PVC material • All trim to be PVC, "Versetek" • Roofing and siding to match • Underside of roof to be PVC, wainscot style • Installation of light from center of ceiling and removal of side sconce utilizing existing switch location. Light to be supplied by owner. • Installation of front entrance door. Door selected and ordered previously. Door surround insulated. Interior trim installed to match. Exterior trim to be incorporated into portico details. All exterior trim to be `Versetek". Door handle to be removed and re- installed. • All debris disposed off site • Permit Fees included • Paint not included Total contracted cost$8,900.00 First payment of$4000.00 is due at the beginning of construction. Balance is due at completion Any extra work resulting from unforeseen problems will be priced accordingly on site and be done with written approval. BriCo is not responsible for anything that occurs on site that is not directly involved with the construction of this project. BriCo, Building and Remodeling is a fully licensed and insured LLC company. License numbers are provided in the header above and current insurance documentation upon request. All subcontractors must carry the appropriate license and insurance to perform work in the state of Massachusetts. The contractor agrees to perform this work in a competent and skillful manner according to standard industry practices, and all work performed shall be subject to final approval by Owner. All work to be done incompliance with Massachusetts building code. BriCo, takes on full responsibility of all necessary inspections. . BriCo, warranties all construction related to this project for two years after completion. Dated: 1� Signature of Owner: t Signature of Contractor: Any unforeseen work or necessary repairs found during this project to be brought to the owners attention as soon as possible. Any extra work resulting from unforeseen problems will be priced accordingly on site and be done with written approval. BriCo is not responsible for anything that occurs on site that is not directly involved with the construction of this project. BriCo Building and Remodeling is a fully licensed and insured LLC company. License numbers are provided in the header above and current insurance documentation upon request. Dagle Electrical Construction Corp. JOB P.O. Box 760982, Melrose, MA 02176 SHEET NO. CF Tel: 800-379-1459 / Fax: 781-937-7678 CALCULATED BY DATE E-mail: dec@deccorp.com CHECKED BY DATE Local 103 IBEW www.deccorp.com SCALE I , i i .. I I- i 1 � r ` - , �- II �4_Y_R�t�l�hly f I - - - I i I i I - - - - 3 - --I---I-- -.. I I ' I. - J +rtel!-> r _ __.---� -� -- _..i__.Vv SAY, 1 -- ----� - i a i r ` I I ; 1171 1 t l i North Andover MIMAP March 29, 2016 o- 64.tF- 03, " 064.0-0027 fr4.0-0030 244 DALE ST 242 DA E S � � �• r:. 40 DALE S, �� f 064: 0.28 — �� 1 r� cx- I! f' r - 064.0-0077 275'DALE ST i' 6` 259 ALE 5 0 MVPC Bo Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, —I Meters Data Sources:The data for this map was produced by Merrimack —SR MQRT1f Valley Planning Commission(MVPC)using data provided by the Town of Roads �f �y North Andover.Additional data provided by the Executive Office of i Easements ,r ��� r�•��Q Environmental Affairs/MassGIS.The information depicted on this map Is Parcels3 _ L for planning purposes only.It may not be adequate for legal boundary f 'Adefinition regulatory Interpretation.THE TOWN NORTH ANDOVER MAKES NOOWARRANTIES,EXPRESSED OR IMPLIED,CONCERNING i • THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY • -s „{t OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT o* t ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF •; 1>,,�0�w�{j THIS INFORMATION 1SSACIf1Js� 1"=52 ft - ° The Commonwealth of Massachusetts Department of IndustrialAccidents = 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 PERMITTING AUTHORITY. Analicant Information Please Print Letaibly Name(Business/Organization/Individual): i U,O 2�k_J t- 1')t k) t`»AFA &N 6- Address: y1'1 WAY w qty Rb City/State/ZipANICUA AWI �-K MAnl$ Phone#: `177 LA19 Are you an employer?Check the appropriate box: Type of project(required): lQ I am a employer with—Lem employees full and/or Part-time) 7. E]New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.❑1 arh 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 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance t 14.0 Other T0Tl CIS i fo;VT a L 6.F-1 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.] *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. tContractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: 11�`,t Policy#or Self-ins.Lie.#: -7 Pa U R' -`'161 1'r, a Expiration Date: y lq \1( Job Site Address: " �4� �1�1_ �T City/State/Zip: t\W-OO JZ MR 0 i16LIS Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). j 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: �� Date: 2, 116 Phone#: 51 1 4-11 1 S 2 G 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#: � r �` F i, i � � ' r � , � �. ' � / \ � ao ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 3/8/16 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 endorsemen s. PRODUCER CONTACT Konnie Phifer Michaud insurance PHONE 978 683-767 1 FAx No): (978) 794-5409 105 Haverhill St E-NIAIL Methuen, MA 01844 ADDRESS: Konniephifer@michaudinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Northland Insurance INSURED INSURER B: BRICO Building & Remodeling LL INSURERC: Adam J Brien INSURER D: 417 Waverley Rd INSURER E: N Andover, MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADDU SUER POLICY EFF POLICY EXP LTR TYPEOFINSURANCE VWvD POLICY NUMBER MIDDAY MMIDDIYYYY LIMBS A GENERAL LIABILITY WS201172 4/13/15 4/13/16 EACHOCCURRENCE $ 1,000,000 X COMMERCIAL GENERALLIABILITY DAMAGE TO RENTEDcurrencel $ 100,000 CLAIMS-MADE Fx1 OCCUR MED EXP(Ary one person) $ 5,000 PERSONAL&ADV.IWURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,0 0 GENTAGGREGATE LIMITAPPLIES PER PRODUCTS-OOMP/OPAGG $ 2.000,000 POLICY JECTPRO- LOC $ AUTOMOBILE LIABILITY COMBINED S(Ea c dart)INGLE LIMB $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS _AUTOS a accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICE RIMEMBER EXCLUDED? NIA E.L.EACH ACgDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is regri red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ahren Lippman ACCORDANCE WITH THE POLICY PROVISIONS. 275 Dale St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Konnie Phifer ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: (978) 685-2549 Fax: (978) 258-6953 E-Mail: konniephifer@michaudinsurance.com Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/08/2016 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). ONT PRODUCER NAMEACT Trudy Lawler MICHAUD INSURANCE AGENCY PHONE _ (978)685-2549 Fac No: E-MAIL ADDRESS: trudylawler@michaudinsurance.com 105 HAVERHILL ST. INSURERS AFFORDING COVERAGE NAIC# METHUEN MA 01844 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: BRICO BUILDING&REMODELING LLC INSURERC: INSURER D, 417 WAVERLEY RD INSURER E: N ANDOVER MA 01845 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 35808 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD MM/DD LIMBS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE D OCCUR DAMAGE TO RENTED PREMISES Ea occunence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JE T LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X SPER TATUTE ETH- AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 7pJU64618P50715 04/19/2015 04/19/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwdtworkers-compensationriinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ahren Lippman ACCORDANCE WITH THE POLICY PROVISIONS. 275 Dale St AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA @ 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 and Business Regulation t` '10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 168512 Tvpe: LLC ` Expiration: 3/1/2017 Tr# 262883 BRICO BUILDING AND REMODELI NGLLC(4"� _ , ADAM BRIEN ; , j4! . 417 WAVERLY RD NORTH ANDOVER, MA 01845 4�rUpdate Address and return card.Mark reason for change. SCA 1 Co 20M-05/11 Address Renewal [:] Employment Lost Card -. - --�ie�am��w�ruuec�l�a��,aaaa�uaeCta Office of Consumer Affairs&Business Regulation License or registration valid for individul use only WOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: '•.9.68512 Type: Office of Consumer.Affairs and Business Regulation Expiration 3f1E2017 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 BRICO BUILDING AND REMODELING LLC ggi ADAM BRIEN �� ` 417 WAVERLY RD F '01 r NORTH ANDOVER,MA 01845 Undersecretary Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS404428 ADAM J BRIEN 417 WAVERLY ROAD North Andover NFA 01845 • Expiration Commissioner 05/12/2016