HomeMy WebLinkAboutBuilding Permit #944-15 - 28 MARBLERIDGE ROAD 5/20/2015U-- t%0RTfj
BUILDING PERMIT
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: 9 Date Received
/if CHUS
Date Issued: ALUI
IAPORTANT: Applicant must complete all items on this page
LOCATION e- IQ 041P ��Ad V
P , t
PROPERTY OWNER 4nolf/
Print 100 Year Structure
MAP,� 7-k PARCEL ZONING DISTRICT: Historic District
Machine Shop Village
�es no
yes no
yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
0�6ne family
El Addition
El Two or more family
[I Industrial
11 Alteration
No. of units:
El Commercial
1�r�epair, replacement
0 Assessory Bldg
0 Others:
El Demolition
El Other
ptic
El -8-e--- El \/Vel I
U,�Ioodbf�in 1i Ian -ds
0 Watershed Distrlct-
,,t
El Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
(I-
IIJ4 14 Lz IVC 6—r J-�-�At
a r / �-
Identification - Please Type or Print Clearly
OWNER: Name: f4At-,- Phone:6/7-S-3:5--,24/f
Adrirpss- " -t
Contractor Narpe: e.",e 5,c,/
E mai I
Add , ress:
Phone: f, 7—
lv� 4�16
Supervisor's Construction Li I cerise: -0.� 0 7 96,4/ 6" Exp. Date: 1-.2 2- /7
Home Improvement License: Exp. Date:
ARCH ITECT/ENGI NEER Me Phone:
Address:
Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
00 6 dC-
,ost: $ 000, FEE: $ to
Total Project C
Check No.: 2 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
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
4, Copy Of Contract
,4� 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
10TE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
10TE: 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
Doe: Building Permit Revised 2014
. n
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans [I
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art F1
Sw"'19 Pool' 11
well
Tobacco Sales 0
Food Packaging/Sales 0
Private (septic tank, etc.
Pennanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature'
CONSERVATION Reviewed on Signature
GOMMENTS
e
HEALTH
COMMENTS
Reviewed on Signature
Zon_�lrig Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_
Pla.riming Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
LOcatea ;Jb4 US900CI 6treet
WM- CAM
`,IR I
1R;TgMqE,-NlJ
��Tl yf� p R) u m 'S 0 br, Z Mhs e - � i��Rb s
Q,
rt 6 n!
XLE
T. 7
4 Main Street-,' emq V
,Ka n
_ 1E
5a"I"i a_%_
a le
1111:315 11 ii,l�� 1: nt s1giWture date',
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 rnin.$100-$1000 fine
NOTES and DATA — (For deoartment use
LI Notified for pickup Call Ema
Date Time Contact Name
Doe.Building Permit Revised 2014
e) C --
Location C29 ged1l, IZOK
No�� v Date
Check # jC2�r
28802
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $
TOTAL $
Lilding Inspector
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Name: JAo(v Lt4r,[c(.je)
-2-9 ft
Buyer(s) Street Address, City,
41
jUlirwain
ill Address
Custom Window and Door Agreement'
taid, [Vb
, caft% 6/7- 83Y- 2-476 - 176- *5'-) 10
Home Phone
MobIle Phone
Buyer(s) herebyjointly and severally agrees to purchase the products and/or services of "MILLWORK MASTERS, A DIVISION OF WOODBURY SUPPLY CO INC."
("Contractor"), in accordance with the terms and conditions described on the front and the reverse ofthis agreement and on the attached specification sheet(s)
collectively, this "Agreement). Buyer(s) hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement.
Total Job
Amount:$5-41 111, 5 7
Depo I Received
Balance at Start of Job (33%):
Balance on Substantial Completion of Job
1122w-%. 'itki 01126.415 , .1 1
Estimated Starting Date:
Estimated Completion Date:
Buyer Initials: Buyer Initials:
Method of Payment Cash— Check— Visa
Discover— AMEX_ Financed App#:
Name on Credit Card:
Credit Card #:
CC Exp. Date:
CC Security Code:
Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that there are no verbal understandings
changing or modifying any of the terms of this Agreement. No alteration to or deviation from this Agreement will be valid without the signed, written consent of
both Buyeqs) and Contractor. Buyer(s) hereby acknowledges that Buyeqs) 1) has read this Agreement, understands the terms of this Agreement, and has
received a completed, signed, and dated copy of this Agreement, Including the two attached Notices of Cancellation, on the date first written above and 2) was
orally informed of Buyer's right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
"MILLWORK MASTERS, A DIV. OF WOODBURY SUPPLY- Buyeds) Buyer(s)
By
Signature of Product Ma nager Signature Signature
vV We- hr
15
Print Name & Product Manager Print Name Print Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE
DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT.
Gani-p2er6r w4t.11ferolir O.Od cerr w4l be 6?jj-r benuzM ownflrj.
W'// tnpo?ct oWoe(5 -(of'yZ. ---IC 40,57- 6-� rh 0 pezrmi;r V 417 LOKrClt C49
COATrOcTor I T19 . 14 Ile-,
&Mir -r 00.11 be PfRce-ot Felar-,to"ryZ3/�2-0/f/ prf6i45 T5,S6#A (407;1 -3/131/2-OT
OCctel d4,1t,) par -1-0 -4nUary inC,(eOY- i5 beTY75
,5 fe-6.41 btyr yeqr ba--�M J
CC, rz, a n -ri / TAevi J*
NOTICE OF CANCELLATION
N0710E OF CWCEUA71ON
Date of Transaction You may cancel this
transaction, withoutany penalty or obligation, within two business
Date of Transaon—. you nweamVIO
trawaction, witlairtanylignakoroblikatIOD, within two 6OW
days from the above date. Ilvou cancel, any properlytraded In, any
days*from the *vO datP- ifyou cancel, anypropffw harry
payments made biryou under the Contract of Sale, and any
payments nude Wyou under the contractof sale, aodany *
wl&14
negotiable I ment executed by you mall bereturned within 14
. negotiabfelknibmimefftexe byyou willhe mimed
days following receipt by the Contractor rSellerl of your
d . ays fiollomiring Wpt by Me. Contractor rSellee) of your
cancellation notice, and any security interest arising out of the
WnWJ13901111196ok, and any security httere5twhing Out If the
.00le
transaction will be cancelled. 9 you cancel, you must make available
transaction will he cancelled.. If yo� canwj, you must make
to the Seller at your residence, In substantially as good condition as
to the Seller at your foidence, In substantialiv as good oDmIlIM's
when reeked I any pods delivered to you under this Contract or
when rem4ved, oygoods delivered to you under this Contractor
Sale; or you may, if you wish, comply with the instructions of the
Sale, or 'you may, W you wish, CRM* with Me in"Iructions Of the
Seger regarding the retuni shipment of the goods at the Seffees
Seller regarding the rptum shipment of the p6d; at the Selle,6
expenseandrisL 9 you do make the goods available to the Seiler
expense and rU If You do make the 90Dds mailable to the S&
does them up WRW 2D days of the date of
and the Seller does not pick them up within 20 days of the date of
and the Seller not Pick
Hattori, may retain lot dispoe of the goods
your Notice of Cancellation,. you may retain or dispose of the goods
without any fortherobligation. If you fag to make thegoods
your Nod- of Cm You
without any krIlor0bligatiOn, If you fall to make the goods
available to the Seger, or I you agree to return the pods to the
available to the SdIer, or if you agree to return the goods to & Seller
Seger and fail to do so, then you remain liable for performanceof all
and fail to do so, ten you remain liable for. perhoamce of all
obligations under the Contract To cancel this transaction, mall or
obligations underthe ContmcL TO cancel Wall or
deliver a signed and.dated copy of this cancellation notice or any
deliver a signed ard dated copy of this cancellation notice or my
other written notice, or send a telegram to Contractor OMIUWORK
other written notke, Or send a telegram to C010actnr 'OU"RX
AM SIM 650 Am WST SASIfUA NH-, B Y NO T LATER THA N
MASW,6MA&WrSrJ%ASMUAfiH", BYNOTLATERTIMN
MIDNIGHTOF . (Date)
MIDNIGHT OF (Date)
I HEREBY CANCEL THIS TRANSACTION.
Buyer's Signature
Date
I HEREBICUCEL THIS TRANSACTIOAL
BuyeesSignature
Date
MILLWORK MASTERS, A DIVISION OF WOODBURY SUPPLY' 650 AMHERST ST, NASHUA JIM 03063 603 990 3212PH / 603 89 3362 FAX
ADDMON4 TERMS AND CONDITIONS
'I" ' "my", and 'me' means each person who signs this Agreement as a Buyer. 'ContractDr`mM50MJULWORKMASW- 'Weandus'mean
both the Buyer, or Buyers if more than one, and the Contractor. 9MILLWORK MASTERS, 650AMHEffrST, AfAsHUANH*is an authorized and
Independent dealer of Marvin and Integrity Windows. You are entering Into a contract with IMIRWORK WSW, 650 AMHERST ST, NASHUA Mr.
Warranties/intended Use: I understand that Marvin Windows and Doors ('Marvin') is providingme with a warrantyin connection with My
purchase. I understand that I should read. Marviffs written warranty for complete details of inywafranty coverage. and that the Marvin warranty is
available for my complete review before . I sign this Agreement. I understand that the Marvin warranty will not be effiactive orenforced while a
balance due remains on this Agreement
Contractoes Promises: Contractor promises to perform all work Ina professional manner and witin industry standards: ontractorwill remove
and transport away from the premises any debris and waste materials that.are generated by Contractor. Contractorshall obtain all building
permits for the work to be performed under this Agre�ement..contmctor shall maintain workers compensation insurance and liability Insurance
during the term of this Agreement
My Promises: I promise to Contractor that (a) I will provide Contractor with reasonable access to my property and the area in which the work is to'
be performed, Including access to electrical outlets; (b) I will he responsible for preparation, mWng, and reinstalling of any materials, personal
property, cars, or equipment as may be needed for Contractor to perform its work, (c) The walls aid surfaces upon which the work is to be
d-gRalaNbl6T6�thEW6�k-b-elfigrOE- dd, (to Wht�n the work ls�'substantially complete, I will pay Contractor the balance
re sou�
due on the purchase price. I understand that 'substantially complete" means the work has been inaterially finished and is functional as Intended;
(e) In the event that I disagree with Contractor that the work is substantially compfete, I agree that I will not withhold more than 10 of the
Agreement price; M If taxes and/or permitting fees are necessary to complete the work, I will pay them unless the law requires Contractor to pay
them; and (g) Contractor may place a. small advertising sign in Buyees yard at the time of installation.
Measurements: I understand that all dimensions referred to I I n this Agreement are considered estimated measurements and used only forthe
purpose of arriving at the contract amount in this Agreement I understand that the actual measurements will be determined duringa follow up
visit by a qualified measurement technician employed by Contractor. I understand that If Contractor must make chan . ges to the estimated
measurements, Contractor may ask me to sign a n addendum to this Agreement
Late Cancellation: I understand that I have 2busine'ss days to cancel this Agreement, as described on the previous Page of this Agreement I
understand that if I want to cancel this Agreement after those 2 business days, Contractor does not have to allow that. I understand that 9 the
Contractor does let me cancel, howeveri I will have to pay to Contractor a late cancellation fee equal to 15% of this Agreement's purchase Price for
Contractor's labor, administrative, and material costs.
DeIaV/Unknown Conditions: I understand that if Contractor determines that Contractor canoOt perform the work according to COntractOrs
normal professional standards, then Contractor cancel this Agreemen4 notify me 1 n* writing itithe cancellation, and return my money to me.
understand that some of the things that could cause Contractor to cancel this Agreement wodd be incorrect pricing, unforeseen structural defects,
or unknown pre-exisfing conditions to my property. I understand that Contractor Is not. responsible for structural or other defects in my property,
and that Contractor's products do not cure those types of problems. I also understand that tle work could be delayed by events that Contractor
does not control, and that is acceptable tome. Some of the things that could cause the work to be delayed would be acts of God, labor stdkes,
inclement weather, material shortages, my inability to qualify for or obtain financin& delays by local government authorities in Issuing or otherwise
approving inspections, Permitting, or other required authorizations for the work.
Late Paym ' ent/Debult: I agree that if I do not pay Contractor any of the money owed when itis due, I can be charged a late fee of 1.5% on the
amount owed for each month the money is owed and not paid. I also agree that if I default on my promises under this Agreement, and Contractor
hlres an attorney to enforce this Agreement, I Will pay Contractor its reasonable legal fees and related costs or expenses, as long as it is legal for me
to do that. I agree and understand that in the event that I do not pay Contractor any of the money owed when it is due, Contractor may have a
claim against me, which may be enforced against my property in accordance with the applicable lien laws, I also understand that If I finance the
work with Contractor or a third party, my separately provided financing documents may include a security interest. I understand that I should read
those documents closely.
Arbitration: The parties hereby mutually agree In advance that should a dispute arise regarding this contract, Contractor may submit such '
dispute to a private arbitration service that has been approved by the Office of Consumer Mirs and Business Regulation, and Buyer(s) shall be
required to submit to such arbitration as provided in MGL c. 142A. The parties further agree that if either Contractor or Buyer(s) submit a claim
to arbitration, (I) the non -prevailing party will ultimately pay the cost of ' the arbitration, In ' cluding reasonable attorney? fees and expenses, (U)
the award of the arbitrator will be In writing and will contain findings of fact and conclusions of law, and (Iii) that judgment to enforce the
award may be entered in any court having proper jurisdiction.
Contractor Signature. Buyer Signature(s):
NOTICE: The signatures of the parties above apply only to their agreement to alternate dispute resolution initiated by Contractor. Owner may
initiate alternate dispute resolution even where this section is not signed separately by the parties.
Interpretation of the Agreement: I agree that this Agreement will be enforced under the laws of the state where the .
work is being performed. If any part of this Agreement is determined to be Invalid or illegal, then I agree that the rest of
this Agreement will still be valid and enforceable. We both understand that this Agreement, and any attachments,
makes up the entire understanding between us about the work Contractor is doing. There are no other oral or written.
agreements or representations on which we are relying. We both agree that any change to this Agreement must be in
writing and signed by both of us. The paragraph headings contained in this Agreement are for convenience only and will
not affect the meaning or interpretation of the Agreement.
Massachusetts Sales Only. Any deposit required under this Agreement to be paid in advance of the commencement of work shall not exceed the
greater of one-third of the total contract price or the actual cost of any materials or equipment of a special orde * r or custom made nature, which
must be ordered in advance of the commencement of work, in order to assure that the project will proceed on schedule. No Final payment shall
be demanded until this Agreement is completed to the satisfaction of the patties. In Massachusetts, all contractors and subcontractors must be
registered by the administrator of the Board of Building Regulations and Standards and any Inquiries about a contractor or subcontractor relating
to a registration should be directed -to- Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, Massachusetts
02116 Telephone: (617) 973-8700. In Massachusetts, the HOMEOWNER Is responsible for applying for and obtaining any and all necessary
permit ting. Homeowners who secure their own permits or deal with unregistered contractors shall be excluded from the Massachusetts
Residential Contractor's Guaranty Fund.
Condensation and Environmental Conditions: Condensation, which can form on or Within walk, siding; tiles, or other surfaces results from pre-
existing conditions In a home and internal or external temperatures. Reducing the humidity in a home will often remedy any condensation
problems. I agree that Contractor is not responsible for condensation or existing or developing spore or mold growth, which can be the result of
condensation.
LUCIANO 030915
Next Gen option
Quote #: NX3CX88
A Proposal for Window and Door Products prepared for:
End Customer:
Judi Luciano+ Brian Seigel
28 Marbleridge Road
North Andover, MA 01845
Phone: (617) 835-2490
Mobile: (978) 435-1461
Shipping Address:
MILLWORK MASTERS,DIV OF WOODBURY SUPPLY
209 FLAT ROOF MILL ROAD
SWANZEY, NH 03446
SCOIT BISHOP
MILLWORK MASTERS,DIV OF
WOODBURY SUPPLY
362 FLAT ROOF MILL ROAD
SWANZEY, NH 03446
Email: sbishop@millworkmasters.com
This report was generated on S/4/2015 2:10:54
PM using the Marvin Order Management System,
version 0002.01.01 (Old). Price in USD. Unit
availability and price are subject to change. Dealer
terms and conditions may apply.
Project Description:
next generation window replacement, originally quoted 04, 14, 2014, now with one lite bottom sash
Featuring products from:
MMVINI*
Wl.d— ..d D.—
AC4:>RL)r
CERTIFICATE OF LIABILITY INSURANCE
DA (MMIDWYYYY)
TE6/2015
1114�
3/2
THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE'CERTIFICATE HOLDER. THIS
CERTIFICATE. DOES NOT AFFIRMATIVELY OR NE13ATIVELY AMEND,.EXTEN I D OR . ALTER THE I COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEJ4 THE ISSUING INSURER(S),' AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE, HOLDER,
IMPORTANT: If the Certificate holder Is. an ADDR 07NA—L INSURED, the p0licy(Ift) Must be endorsed. If SUBROGATION IS WAIVED, subject to
it* terms and conditions of the policy, cedaln policies may require an endorseplant, A,statsinent on this certificate does not, confer rights to the
Certificate holder In lieu of such endomement(s).
PRODUCER
NAMEr a6=if*r Hakala
C"T
M4siall* Insurance Agency
69-A Island.Street, Suite I
PHONE
11"Aft.,d). (603);��2-1810
'41MI
EDUR E-5181, jennh@masiallo.
Keene NH 03431
INSURER(s) AFFORDING COVERAGE NAIC 0
INSURERAOftin Street America Assurance 29939
INSURED
Michael Muchmore
21 Sand Hill Rd
INSURER s.:Libert
,,y Mutual - AR IWC 0071
INSUREC:
INSURER 0
INSURERE:
lwajale NH 03608
[INSURERF:
V*�Iwev numulw%;
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A13OVE FOR THE POLICY PERIOD
INDICATED. NOTNTHSTANDING. ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO. WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1.8 SUBJECT TO ALL THE TEkM8,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE- BEEN REDUCED BY PAID CLAIMS,
11,8111
OR
TYPE Of INSURANCE
ADM
SUOR
POLICyt4ijmsER
POLICYIP
POLICY EXP
10/17/2015
LIMITS
A
OENERALLIASILITY
X COMMERCIAL GENERAL LIABILITY
-1
_j CLAMS -MADE Fx OCCUR
ACnRn 99 1111n4n1mcl
HP718930:
10/17/2014
EACH OCCURRENCE 1 000 j 000
UFMAUL TO RENTED
PREMISES Its b-ccurnumm 500,000
MED eMLAaf — P--) :10,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGRE"TE 2,000,000
iGEN'L AGGREGATE LIMrr APPLIES PEW
POLICY FX� PROT F � LOC
PROouCTscomPioP'AijG S 2,000,000
AUTOMOBILE
LIAMUry
CO
Z=NED SINGLE LIMIT
E�
—
—
ANY AUTO
ALL. OWNED SCHEDULED
AUTOS AUT S
NONMWED
HIRED AUTOS AUTOS
,
BODILY INJURY tPer Person) S
BODILY INJURY (Per ami0ent)
LIMUREL 'LIAS OCCUR
EXCESS LLAIII CLAJMS&MAOE,
-EACH OCCURRENCE $
AGGREGATE $
DED -
F RETENTION$
B
WORKERS COMPENSATION
AND EMPLOYM UASI . LITY YIN
AN P
O�Y INVIETORIPARTNEREXECUTIVE
FIC E SER EXCWDED?
(11118"dalwy In NH)
�r deUrft under
SCRIPTION OF OPERATIONS batow
NIA
5-318-602823-015
3/10/2011S
/29/2016
WC STATU-
LIMITS I O11H
EL, EACH ACCIDENT S 100,000
:EL DISEASE -.EA EMPLOYEE 100,000
EL DISEASE. POLICY LIMIT 4 500.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANSch ACORD M, AdMolull Rwaft Schedule, If man spece to r"ul
SOOPSI.Of Operations: Residential Carpentry - elladow and door instailla"tilon
Sole Proprietor Workers Ccapeneation Exclusion'. Michael Muchmore
t
Millwork Masters
SHOULD ANY,OF TiiE ABOVE DESCRIBED POUCIES 13E CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORUANCE WITH THE POLICY PROV1181IONS.
division.of Wbodi=ry supply
David Wright
AUTWRIZED REPRESENTATIVE
362 Flat Roof Mill Rd
Swanzey, NH 03446
Jwmifer Hak&la/JRN
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CERTIF
2015-05-07 09:00:32 EDT From: Jennifer Hakala
ICATE OF, LIABILITY INSURANCE
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5 /7 /2
.THIS CERTIFICATE IS ISSUED. AS.A MATTER O*F:INFORMATION ONLY AND CO*NFERS.NO- RIGHTS UPON THE . CERTIFICATE�HO . LbER. 'THIS.
TIVE.LY�AMENDI _.E AFFOR
CERTIFICATE: DOESAOT AFFIRMATIVELY O.R.NEGA EXTEND OR ALTER THE. COVIERAG DIED By THE.*IPOLICIES
PE�OW, TIH14�. CE.RTIFICATE. OF INISURANCIE DOES NOT CONSTITUTE A CONTRACT' BETWEEN T.HF_.!*;SUING� IN& PRIER(S), A:UTH.OR,IZ.ED,.
REPRIESIENTATIVE OR PRODUCER,AND THE CERTIFICATE.1116L6112ik.
IMPORTANT:- If the:certifi cats - h6ldee is anADDITIONAL INSUREDj the policAles) must.. be.:endorsed. If SUBROGATION IS WAIVEDj subject16.
the terms'. -a40 .. c6.n,dltloins.,�of th . a C -p . q!6jes may -re I inont;,Ast�tOmeiiton:thi�..6i3r - tific4te-does n6t:66infe(rights tb:thb'
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certlfi cate hoider in. lieu ofsuc,h ondorsement(s),
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maslelio Insurance. Agency
69-A Island.. -Strect,. Suite. 1
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CONTACT e=if er Hakala
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Michael Michmore.
2.1. Sand. M.I'll:.Rd
Walp;ole NH. 03608'
Liberty Mutual AR. VC . 7
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