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HomeMy WebLinkAboutBuilding Permit #356-16 - 28 PHILLIPS COMMON 9/18/2015 BUILDING PERMIT OF NORTft q [LED +bt TOWN OF NORTH ANDOVER 6 APPLICATION FOR PLAN EXAMINATION A. Permit No#: Date Received 0 4TED yea"c5 / gSSACH►15�� Date Issued: 01 I PORTANT:Applicant must complete all items on this page LOCATIONd Print PROPERTY OWNER Q sc ct_ C��T�9�N Print 100 Year Structure yes no MAP -�� PARCEL: 6 ZONING DISTRICT: Historic District yes n Machine Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Resid ial Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 3 Set x (Nell i � FI'©tl lad n'§ R11 Wet antls y®11Nate:shed D:istrlctti r ,5 Water/'Sevue�- .,: � �"•_�a -,� ��*� �. ��� � d, '� 4s D� SCRIPTION OF WORK TO BE �RFORMED: ,y S. en ification- Please Type or Print Clearly OWNER: Name: X0)s CR,r C C-P ,e Phone: Address: ' Contractor Name: /�2G �/ �' Phone: '9 7f�e� "EZ3 Email Address: l�3% (�t�/91� L. �/ /2Q' /��o ��►<� a X713 Supervisor's Construction License: 6)2- � Exp. Date: �� if Home Improvement License: �a3 ��� Exp. Date: a l� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING P MIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acces o the guaranty fund -- _ f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools. ; ;El- well ❑- Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS w CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS I ZoningB of Appeals:Board pp als:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street .,,.,.,-.� •_,,..�„}-.�""`..,..:".w.." `CP°Y3.ti".rY.•'°.°.,kL:w:#t?'xi� 5 s 'a.•^v S 4 .«+, v +.sx- ..cs v ,FIRE D�EP,ARdTMENT Temp'Demp�°ster on si W, $yesVt, no 1 1• in •1 ; �a8z� � t y < ' { y 5T4 "�4L.yryt�xxruY # # ft Fgire Depa�rtment Signa re/clate� >�� � � Ii , , 4 , W':kwxaq;ts� p t t e + if_ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of dieter 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.$10041000 fine NOTES and DATA— (For department use) ® 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 4. Building Permit Application 4. 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 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 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 OTE: 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 Locatio t� �Gir►n��s--. "07 Date . - TOWN OF NORTH ANDOVER . � Certificate of Occupancy $ Building/Frame Permit Fee $19-3- r r Foundation Permit Fee $ Other Permit Fee $ a i TOTAL $ Check U. 79 Building Inspector . . . r � NORTN Town oj E ,, Andover to No. _ ® L.K. h ver, Mass, COC MICN�WKN ADQ�TED S U BOARD OF HEALTH PERM T LD Food/Kitchen Septic System THIS CERTIFIES THAT ........ ....0 �"Now BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ... ...... .�.� a .e .V.. Rough to be occupied as .................... . .... ...... ......... � .......................... !l .. ................... Chimney provided that the person accepti this permit shall in every r ect 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 e PERMIT EXPIRES IN ONRICAL INSPECTOR UNLESS CONSTRUC I STRough Service .......... ..... .... .......Al.. ................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final dY No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. BurnerStreet No. Smoke Det. MASSACHUSETTS HOME IMPROVEMENT CONTRACT This form,satisfies all basic mquirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners Seek legal advice((necessary.'Any peison•planning home#nprovements shouldfiraf obtain a copy of"a Massachusetts;consumer guide to homeimprmcment"before agreeing to any work on yourriestdenct.You m�obtain-s free coP Y by'callimg the Office of Consumer Affairs and Business.Regulation'a Consulter lnformadon Hotline at617-9738987 or 1+8882834757. . . . Homeowner Information -Contractor Information name . _ pany ame' Street Address(do not use. .P.ostOffice Ad - � ox aOwner N GSty/foav S 1p Cod -I iusiness Address(must include a street address) . CZ�3lc�-tQ� v-- / Daytime Phone EveniaSPhodt- ,) � /� state Zip Code ryfIown.(/ tlee_I�Q�G wt ,f) /j-q!5-: Mailing Address(]t different from above) Phone ederal Employer ID or S.S.Number Law nq-imam mwt tgmeim. Acme iCoetraetor sea?hmher -PaPveri000�.;': -. P.o�have e n:ebesaeem®w /u ..JU(J �Cs+ The Contractor agrees to do the following work for the Horneo ner:_ :'. I 11 aqui 11 Petntits The following buil permits aro required Proposed Start and Complefli Schedule-The fdllowmg schedule will and will bcseeuredby the contractor as the'homeowvnees agent; be adhered to unless circumstances beyond the contractors control arise (Owners w*secure their own permits will be excldded>from:the:GuarantyFuad'provisionsof /s/ a re when contractor will begin contracted work MGt chapter 142A:) Jt�Date when contracted .work will be Substantially completed Total Contract Price and Payment Schedule v The Contractor.agteos to perform the work farnish Ute material and tabor specified above for the vital sum of- Payments fPayments will be made according to the following schedule; (� upomsigeung contract(not to exceed 1/3 of the totatoontract price.91 the cost;of spetial order items,whichever is..greater) $ by or upon completion of $ T'T or upon completion of Lqob $ [ upon completion of the contract (1AW forbids demanding full payment until.cwntract is complete d boll to party's.satisfaction) The following mater a equipment must be special S to be paid for ordered before tliecontractad work begins inorder S to be paid for to Meetthc,completion schedule.(••) NOTES:(')Including all finance charges(•-)Law requires that any deposit or down-payment required by the coonactor before work begins may not mceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special.equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express warranty Is an exyress warranty bein¢.nrovided by the contractor! No Ves (aLterma of th• .. :.. luid Subcontractors The Contractor 8 h aamceee f m!hfid nl grins m be solely responsible for completion of the work described regardless of the actions of any f Party/subcontractor utilized by the contractor. The contractor further agre materials and labor under this aereement e$to be solely responsible for all payments to all subcontractors for Contract Acceptance Upon signing,this document becomes a binding.contract under-law. Unless otherwise noted within this document the carefully before signing this contract contract shall not imply that any lien or other security interest�has been placed on the residence. Review the following cautions and notices • Don't be pressured into signing the contract Take time to read and£ally understand it-Ask' • -Make the contractor h a valid HomeImprovem nt on .R questions mositst home improvement is Meat' subcontractors to be registered with.the Director ofHonre0 law uires mom home improvement contractors and. Improvement Contraetot Regishratio& You may inquire about.eonaactor registration by writing to the Director it-One Ashburton Place,Room 1301,.-Boston,•MA 02108 or 1-800-223-0933. bY:�ling 617-727-3200 or • Does the contractor have insurance? Check to see that your contractor is properly insured • Know your rights and responsibilities. Read the Important Information on thereverse side of this foim'and Guide to the Home IMprovement Contractor Law: Bet a copy of the Consumer J&Mbusinwss7da s agreement if it has been signed at a place otherthan the contractries normal place of business,provided you the g ai his/her main office or branch office by ordinary mail s notify ollowingthe si m of this a po te by telegramsent or by delivery,not later than midnight of the.S� 8 gm=cnt.See the attached notice ofcancellation form for an explanation of.this rightO NOT SIG S CONTRACT IF THERE ARE ANy BLANKSPACES!!! ml pnsofmn et be toeopleted sed aiyOed.One copy,abouldosothe i twmeowna.The other copy sfwuW be kept by the eopnaetor. Ho � e meowner's ' St rote Contractors S tore Dau ,Date Contractor Arbitrslion The Home Improvement,Contractor Lawprovides homeowners with therighvto4nitiate an arbitration action(as an altemahve 10 conR acttoti)if they have a dispute with a contractor. The.same rightis jjb automatically afforded to*a contractor,however.-:'The:contractor would have:tQ resolve any_dispute helshe.ltas 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 concerrtin this contract,the contractor may submit the dispute to a.private arbitration firm which has been.approved by, the Sec of the Exec v Office of Consumet Affairs and Business Regulation andthe consumer shall be required to b it o o p vided In.Massachusetts General Laws,ch 142A. 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::The homeowner:may initiate alternative dispute resolution even where this sectio.4 is not separately srgned#ry':thn es: :'. Homeowner's Rights A homeowner's rights undec'the.Home'Improvement Contractor Law(MGL chapter'142A)and other consumer protection laws(Le.MGL chapte`93A)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 Contractor Law. The contractor is responsrble for completing the work as described,in a timely and workmanlike.:mannei. 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 carry an implied warranty of merchantability,and fitaess_fora particular purpose. An enumeration of other.matters on which:the homeowner and contractor lawfully agree 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 dupjicate 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 griginal 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 the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances wheme.a.contracwr deems him/herself to be financially insecure,the contractor may require that the.balance of funds not yet due be placed in-sjoint 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 you v�nsh=tQ.obtain a.fcee copy of"A Consumer Guide to.the Home Improvement.Contiactor Law,"•contact Cgnsumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or I-(888)2031757 If you want to verify the:aegistration of a contractor or if you have:questions or need additional information specifically 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)727-3200 or1-800-223-0933 For assistance with informal iirediation of disputes or to register:formal complaints against a business;call ... Coiisure er''Complaint°Section Office of the Attorney General (617)727-8400 :AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 roPpool Page# of pages CS # 022680 1 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 159A Waverly Road 1-978-912-2853 North Andover, MA 01845 Proposal Submitted To: p ti Job Name Job# - .d .7'.✓i'�.",� �I'{,!%(� �•�.1d''5��. -..<'�.,�.,l.r "1,� �.w g a.p4., f,.e,.r Address Job Location Date { , Date of Plans Phone# ` Fax# x Architect �I j We hereby submit specifications and estimates for. } i/��tx;.:.L��"'4,.w' {....i+'�,✓ ""'✓' .p�$i"4'�,:�t:,�.wj r ��a-./�a^�`tee�.-'?P' --�'��'.�.,�t.r^"". �c'� �ity..� d.4..� •�.`/:}'�'c... - �t�',,:...-� J fi r -+!",�L�!«� fY. � � ,1 ';f t: R•G�_.+ ���t� ��fC'.C.ao`+`,,f.yy.-�'' § f°�,ff�„�,, ....,.n�'' lEf�...�fb't�.r*,, .t 9„FM"t`F'.+✓LAr._„.N' Y6 r' .l.-yy'ee}.!fA n c+F.+'` ..rL'�'{°''.�''`.,� �y'�.st'c PY../r C• '�v..L,�.l+�t,�'7.ef.`'1 .,Y .{....w-kc'!' } r.'.�::Y6�,,,�” -`,+"r .r"A..efe.,._ ;t,..o+�...3 dC ,� .i' :� ���...,i�..+� f„���”-���''"_...r •-f_.k�w�SY..•- �. i.:°'',}'€_,M _'�t�..`?''k:er ,.s :ae.�,'�. �� .�:s..�. —.`l� ..a?�� %—��s.,k�I f �'» 2,.,,, ,f.orf 4n r�✓Z-9� `� fei,!:� 'P' ..,'i F....:P�:.✓w r'.�r'd ,J{ ��-r. �.,'�.t?.'1,1 • t r i .c r ,:l.ragf Com::? r r .'�'. �;� -�yl`.{..PS"� /'`F..t�. „,r' .€ r''f�' - ° }`'r,°'.r`..1 .yCi d'=¢: -tr.,C.,.✓ 4 44 ,?t 't," z �.'.'„•:`'",C3 jn1�s�r' 1 i I , f 1 i ''^fit s' f.w_f"/.�. .._.�`.4[.A°.r+"^'�` i.,4.d..'s.'S+F "'i�.•�w1.R�-'�`r.� .w. ,..i��=.. i'",:/"p' t,.J9+'srA'F e�'.Vs, �.(`�, {,..+'" .......... We propose hereby to famish material and labor—complete in accordance with the above specifications for the sum of: 12 f Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully d Y executed only upon writien order,and wfil become an extra charge over and f, ' above the esUinate.AN agreements cordingent upon strikes,accidents,or delays submitted beyond our cdhirol. Note—this proposal may be withdrawn by us not accepted within days. r;4.c�•�. �,� -17-2- T 7�2. ` The above prices,specifications and conditions are satisfactory and areSignature hereby accepted.You are authorized to do the work as specified. f€ Payments will be made as outlined above. ` Date of Acceptance. Signature The Commonwealth of Massachusetts Department oflndustrialAccidents 1 F a X 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. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: 1s^�� �� 4_/ A& City/State/Zip: /W ANO dy-e–< /99- Phone#: 73 7 Are you a ployer?Check the appropriate box: Type of project(required): 1. I am a employer with mployees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.FJ I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 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 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13. oofrepairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14'❑Other 152,§1(4),and we have nq employees.[No workers'comp.insurance required.] I *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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 p/'oviding workers'compensation insurance for my employees.'Below is the policy and job site information. > �i Insurance Company Name: Policy#or Self-ins.Lie.#: 7 'Ycf 2'4 !2, ao1 Expiration Date: 11/_r ' Job Site Address: ­Zk P,�14ZX45 C?.li�,� IfIn/ City/State/Zip: AJA-.�Ma0YA 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 DTA,for insurance coverage verification. I do hereby certify under tthepains and penalties ofperjury that the information provided above is true and correct. Signature: 6wy� A/a/4Dater3— Phone#: 9/7 Y–—6 7 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#: 0 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 l=ire, 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 employs 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 foi•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-MA.SSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia From: 01/12/2095 14:48 #151 P.013/016 a® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/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). 'RODUCER 00775-001 5Ha4'1ACT Durso&Jankowski Insurance Agency Inc / 8%.Ext: (978)682-5175 .No.: (978)794-0313 198 Mass Ave Suite 1018 North Andover,MA 01845 Fdghss: A.I.M.Mutual Insurance Company —33758 NSURED Arthur Walsh _IUMFR R! A J Walsh & Sons INSURER C, 55 Pleasant Street North Andover, MA 01845 INSURER INSURER E, 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 REDUCEDC BY PAID CLAMS.pp TYPE OF INSURANCE INDSR Bp POLICY NUMBER MM1DO/YYYY MW&I EXW LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISESancel CLAIMS-MADE ❑OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPIOPAGG $ __]POLICY RCO- OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ — A119 accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOSNOTOSWNED PROPERTY DAMAGE $ Wer i nt UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE S yypRD��E}p�g Cory RETENTION S $ AN�NyyD ERRM��PLR9��YEEETTRpps€NLpIpaRBT1�N4nRr/EX yy�,��I x ,DRY I,a, - 1 I OETR A OFFI9MM-MBER EXCLU�ED9 ECUTIVEI�7 N I A AWC-400-7014648-2014A 11/14/2014 11114/2015 E.L,EACH ACCIDENT $ 100,000.00 (Mandatory In NuunrH)) u E,L.DISEASE•EA EMPLOYEE S 100,000.00 D�S�`RIF� M OFUPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) The workers compensation policy does not provide coverage for Arthur J Walsh CERTIFICATE HOLDER CANCELLATION Town Of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDREPRESENTATIVE ©1988-2010 ACORD CORPORATION,All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD d r 4 :. : . . �� ' .. - .. - 5$. � ? . 11 s:: 1.. t i ] - - - - .— wa 'Y �' .. - i �': _ • • - - K. d iY ai aCyxaaacuida';q y . Off ce of Consumer Affairs&Business RegulationI I E ¢-' ME IMPROVEMENT_.CONTRACTOR I ist ration: TYPe 9 0 558`• xpiration: J1 Prdvate Corporat�pr ---_, j, A.J.WALSH&SON _� �$� ��; j a r _ I Walsh �. . .. Arthur Was p'' /E7 55 Pleasant St1. ,,r �R ,8, N Andover,MA 01845 p � Undersecretary {: I I �: . r ' . X � . :x17,; \ - . ,I''i , ,� ,� � 1. . . . . . :': , -- K-� w <� 1. : - . . . - MassacheJsetts -Department of Public Safety. _ Board-of Building Regulations and Standards Construction Supervisor j4 License: CS-022680 ., ARTHUR J WAIM - ' ',�. ,Z. 159A WAVERLY iD a A' I N ANDOVER MA 01 . .1 yy' 1� 1. - � I , -.-, I.;—'... . „/,,, j '�'Q�� Expiration Commissioner 06/0912016 . � � --...'. :�."-..-% -- - :�;��:� ,'--""1'11,1-” - , -�'�:' '�-;'.'--"�' ' : �. �!'.:'--.V�� I � . -1. . � 1. "- . — —�'��:�.......... '.''. ...." — - ,:, - "" . .'. , - . . - .. : . - - . ' '. - . ..'' . - , -'.'.-' -. �. - , ' '.-, �. --- , " � i� ;: : - 1. -- -'.. . -- -' ' . " . . I —, — r � -."' '. 11- . 1 . - .. ' . �, �.-- � , . � '- -­--'�.� .'% -..'.--z'.'-""--, . -- . - - 111 - ' — � . . .--- . , , , , . - - - ., " I ,, .-.--'-.-- .-'-.- e- � .: .. .� 11'- . I.. �-1. ,I I � '- ''*' , .I :''.,��".,r'""'-,--��.�-. ..'�'. !-I .- , -1 .1 I . . : .'..?--' � , J'- w �. . . ..