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HomeMy WebLinkAboutBuilding Permit #829-15 - 280 MIDDLESEX STREET 4/21/2015Llr f �10RT11 q BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION + Permit NO: k Date ReceivedLT I Date Issu ' I I IMPORTANT: Applicant must complete all items on this page LOCATION iG�G��Qs2yc Print PROPERTY OWNER J'`% 6L^ L --l) Lu.S �GL �rGLtZC.a yes no e yes no TYPE OF IMPROVEMENT PROPOSED USE Print MAP NO: 00 PARCEL / ZONING DISTRICT: Historic District ❑ Addition ❑ Two or more family Machine Shoo Vi yes no e yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building R One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial R,Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer au- .- �aA�,A s�00 OWNER: Name: / )61t - Address: c�'S O `/)/4,0 FF—c-ONTRACTOR Name: Identificaation Pleasse� Type or Print Clearly) g,rVJ ZOU-�J Ph( Address: Supervisor's Construction License: a. UbLe / h �� / � I,,,- , Phone: 60 3 4o Home Improvement License: /3 -23q, 5 Exp. Date: c Exp. Date: ARCHITECT/ENGINEER Phone: Address: 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: $ Check No.: ? _7:: Receipt No.: NOTE: Persons contracting with u►f-egistered contractors do not have access to the guaranty fund nature of I gnature of contractor BUILDING PERMIT %-E° •a; ti� TOWN OF NORTH ANDOVER o - APPLICATION FOR PLAN EXAMINATION _ Permit No#: Date Received cAreo Issued: IMPORTANT: Applicant must complete all items on this pag .Y_70"F51— f�`.0 F nth +ra JUTAP` �PAf2"CES _ �ZONIN Gi Dl YES snot. +f10� 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 ❑ Other ❑� ec 4WeIP, ��F1®otlp.lain _f ❑V11 nds _ — _ e'tla IWate`she str a. _� ..''i �rWafer/*Sewer �__ - DESCRIPTION OF WORK TU tit PtMI MlVltU: Identification - Please Type or Print Clearly OWNER: Name: _ - Ph Address: �� Phone: X -,':a 7r .� r - I —: EAdtlress.� Supeneiso'saConstkucton ILicense M_ _ -- ._..�Exp'.I Date _ -- tLlr aJ'F;-a—_P.`_.rePA'a Kt11,Eincneot aiyvtl' AtAt'Ax- ARCHITECT/ENGINEER. 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. Total Project Cost: $ EE: $ . Check No.: Receipt.No : --NOT-E:---- Persons -contracting -with -unregistered contractors t- do-nohavawceess-to-the-guaranty-fund- - he-guarantyfund-_ Si natureontractor Signatures©f Ager t/®,wner � , .g : - Date -- Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. . Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit a 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan-'amped Plans ❑ .. FT7Y7PF.,'6F.Q-FWERAGE 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 COMMENTS Reviewed On Signature, CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: tPlanning Board Decision: A Conservation Decision: Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: _. Located 384 Osgood Street PARiTMENT =Temp ®urnpsteron siteyes --_ �124;lMain�Streel Comments --�-- a u„ V • -b Dimension Number of Stories:________ _ Total square feet of floor area, based on Exterior~:;dime 'nsions_ _. . Total land area, sq. ft.: = ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE I LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Permit Revised 2014 r Location No. O 2 —1 Date+ TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $& a -- e Foundation Permit Fee $ r_ Other Permit Fee $ TOTAL $ Building Inspector o % O 23 2 O y, < p- in CD CD CL 0 0 O r0r rf n /r p, C OHO �C m CSD W n O y p (j) m N CD 0 CD 2 = C.p -r CQ• N fy O O �• S n CD p CD -0 rat • 0 co � �,..� CD O y to Z CD •CD O�':�:s rt O (DD =rQ ai n �. C C1 o O CO O C CL = to Q O CDCn a)CD Q 0 W� CDr=- y a1 'CD � CD O o .••�• � �� '1 zr = CD %P x A .)CD ,►'C? I CD �S J C1 N 0 vCD C aa)i o N N co T :;O T 0 Z7 v T SCI t1 n TJ T VI T O O O O C � OT. O rD O OC OCC j. 7 Q N n OCC CD 0 ;z CD C7 Z Z y C m 0-0 ;tZ -0 M F f� rrn G o'b CLyc m D co b 0O �' '—� �O� m Z x vCD �o 3 cn� CDS o C ;om C W C _ O O 0 CD O CD O 0ZE o CD Z O y �• VI''_^^ CO CD I o O z cn o0 _0 Z iq D H v 0 O cZi CD z ch: : O M: x CD O 70 o % O 23 2 O y, < p- in CD CD CL 0 0 O r0r rf n /r p, C OHO �C m CSD W n O y p (j) m N CD 0 CD 2 = C.p -r CQ• N fy O O �• S n CD p CD -0 rat • 0 co � �,..� CD O y to Z CD •CD O�':�:s rt O (DD =rQ ai n �. C C1 o O CO O C CL = to Q O CDCn a)CD Q 0 W� CDr=- y a1 'CD � CD O o .••�• � �� '1 zr = CD %P x A .)CD ,►'C? I CD �S J C1 N 0 vCD C aa)i o N N co T :;O T 0 Z7 T SCI T n TJ T VI T O O O O O OT. O rD O OC OCC j. 7 Q OCC OCC C7 Z m a N O G m b '—� m 3 ' C C W O c o a o z D H '- O LA x m O m m m D n r- 0 0 0 _ O � Is �-qw ow 0 e BRUSSARD GENERAL CONTRACTORS, INC. 27 PRISCILLAWAY PELHAM, NH 03076 TEL. 603.635.7008 FAX. 603.386.6009 4/21/15 Louis and Kathleen Capobianco 280 Middlesex Street North Andover, Ma 01845 Re: Roof and Front Porch Following price covers all labor and material to: Remove existing roof and replace with timberline architectural shingles. Replace existing porch, frame will be pressure treated with composite deck. Estimated time of completion is May 8, 2015. Job Complete: $13,500 Contractor Homeowner The Commonwealth of Massachusetts M Department of IndustrialAceidents X Congress Street, Suite 100 Boston, MA 02114-A17 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: 02 7 pris "a& City/State/Zip: doyh ,i NH OWi6 Phone #: 663&3S 900f Are you an employer? Check &e appropriate box: Type of project (required): LN I am.a employer with 100 employees (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.] 3. r] I am a homeowner doing all work myself [No workers' comp. insurance required.] t 9. ❑ Demolition 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E] Building addition ensure that all contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. ` 12. [l Plumbing repairs or additions 5..NI 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 17U0 P_,?J - f 6. ❑ We are a corporation and its officers have exercised their right of 'exemption per MGL c. 14. ®Other ��&I `yiC / 1 mployees. [No workers' comp. insurance required.] 152, § 1(4), and we have no eired.] ( *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-coriiractors have employees, they must provide their workers' comp. policy number. I din an employer tfiai is pi'ovidiing workers' compensation insurance for my employees ' Below is the policy and job site information. Insurance Company Name: (,1� J;ISU44_1t2 Policy # or Self -ins, Lie. #: if ji Expiration Date: Job Site Address: O�iiV lel � � Jk City/State/Zip: /�&A R40-YPO� pa Ql�� 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. do hereby certify under thepains that the information provided abovg is true and correct. Phone #: �� 7� �✓ l�C te' �'� ��� tY� 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 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 commoniyealth 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 for confirmation of insurance coverage. Also he 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' compeusatioj! 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 bum 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 I IMG-1374jpg (JPEG Image, 2048 x 2048 pixels) -Scaled (40%) https://web.mail.comcast.net/service/home/—/?auth=co&loc=en—US&... olr I WOW; A, TRIBOIS? 119RIVER, ROAD NUROWMAO"MAr ()16(;o I 1 of 1 4/18/2015 5:22 PM vire (pa��vrrrarrraca�� a�C��iraaaa�«aelfd Office of Consumer Affairs & Business Regulation OME IMPROVEMENT CONTRACTOR egistration: _ 137349 Type: Expiration:._ -10/30/2016 Private Corporatie BRUSSARD GENERAL-CflNT 1NG STEPHEN BRUSSARD __1"-`-- 27 27 PRISCILLA WAY PELHAM, NH 03076 Undersecretary ACOR 1 0 � CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 3/4!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 CHOICE INSURANCE AGENCY INC 376 SUMMER ST FITCHBURG, MA 01420-0310 NCNTACT AME: PHONE FAX E cMAIL Ext): A/c "° ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA: LM Insurance Corporation 33600 INSURED DOUGLAS MERCIER INSURER 8: EACH OCCURRENCE $ DBA ECONOMY CONSTRUCTION INSURERC: INSURER D: 232 PATRIOT DRIVE PELHAM NH 03076 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 23695041 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. IICY TR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER EFF MM/L DY/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADEOCCUR PREMISES (Ea occurrence)_ $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑PRO- ❑ JECT LOC GENERAL AGGREGATE $ PRODUCTS -COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY Per accident ( ) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICERIMEMBER EXCLUDED? ❑Y N / A WC5-31S-386689-014 8/11/2014 8/11/2015 PER OTH- STATUTE ER EACH ACCIDENT $ 100000 E.L. DISEASE - EA EMPLOYE $ 100000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 500000 . --F, DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. THE WORKERS' COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR DOUGLAS MERCIER. This certificate cancels and supersedes all previously issued certificates, only as they relate to workers' compensation coverage BRUSSARD GENERAL CONTRACTING 27 PRISCILLA WAY PELHAM NH 03076 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 J ll LM Insurance Corporation v VV e ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ACC)RO CERTIFICATE OF LIABILITY INSURANCE `..1 7MMIDDfYYYY) 3/2/15 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(es) 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 Choice Insurance Agency, Inc. 376 Summer Street Fitchburg, MA 01420 CONTACT NAME: C. DiPaoli PHONE 978 343-4853 pX N60978) (978) 345-1007 E�naL ADDRESS: eter@ Choice -insurance . COm I GENERAL LIABILITY y INSURE S AFFORDING COVERAGE NAIC# INSURERA:Main Street America Assurance 29939 5/13/14 INSURED INSURER B: Doug Mercier DBA Economy Construction 232 Patriot Drive Pelham, NH 03076 INSURERC: INSURER D: INSURER E: 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MIDDY POLICY EXP MM/DD/YYYY UMTS A I GENERAL LIABILITY y MPT5404E 5/13/14 5/13/15 EACHOCCURRENCE $ 1,000 000 X COMMERCIAL GENERAL LIABIU DAMAGE TO RENTEDTY REM --E$ Eaoccurrenc $ 500,000 CLAIMS -MADE MED EXP (Arty one person) $ 10,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OPAGG $ 2,000,000 _71 PRO- LOC POLICY I—xi kcT $ AUTOMOBILE LIABILITY CO OMBINED�SINGLE LIMIT $ BODILY INJURY (Per person) $ ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ ( ) NON -OWNED HIRED AUTOS _ AUTOS PROPERTY DAMAGE $ eraccideM $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE _ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N___1_TORYJJMITS E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE N / A E.L. DISEASE -EA EMPLOYEE $ (ManOFFICER/MEM If tes es glory in NH) yydescribe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is regli red) Brussard General Contracting 27 Priscilla Way Pelham, NH 03076 ACORD 25 (2010105) Phone: 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 Baker © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Fax: E -Mail: brussardcrc@comcast.net RRUSS-1 OP ID: WC A " CERTIFICATE OF LIABILITY INSURANCE DATE1210 DIYYYY) TYPE OF INSURANCE z�a4tla 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(les) 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 978-975-1300 Segreve & Hall Insur.Assoc.lnc 305 North Main St 978-975-7596 Andover, MA 01810 NAMEA'T R N . Ext);IE mac, Nol: E-MAIL ADDRESS: _ INSURER(Si AFFORDING COVERAGE NAIC If I I 71/04114 INSURERA:Arbella Protection ins. Co. 41360 I EACH OCCURRENCE 15 1,000,00( INSURED Brussard General Contractors Inc I INSURERB:Guard Insurance -- INSURER C:_ 27 Priscilla Way Pelham, NH 03076 INSURER D: INSURER E - i INSURER F I.UVr-KAGE6 CERTIFICATF Nt1MRFR• 0MA01n41 \I/Is1nCn. 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. M R LTR TYPE OF INSURANCE + POU CY EFF POLICY NUMBER i MMIDO i POLICY EXP ! MIDDNYYY 1 ` LIMITS A I GENERAL LIABILITY X COMMERCIALGENERAL —�LIABILITY 1II_�`� CLAIMS -MADE �� OCCUR j I I I 71/04114 ' _NT`-- 1 11/04/15 j I EACH OCCURRENCE 15 1,000,00( -- PREMISES Eaocamence 5 300,00 MED EXP (Any one person) 5 5,00( PERSONAL & ADV INJURY 1$ 1,000100 I j3 GENERAL AGGREGATE $ 2,00D,00 [GENL AGGREGATE LIMIT APPLIES PER: POLICY F-1 PRO- L� JECT ' PRODUCTS - COMP/OP AGG S 2,000,0010 i ! ! i 1 is AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS 17 AUTOS NON -OWNED I I HIRED AUTOS H 1 + I ! r I j I COMBINED SINGLE LIMIT {Ea acadent S BODILY INJURY (Perperson) S !-- BODILY INJURY (Per aaidentl S (Peracatlent PROPERTY DAMAGEi s ,s EACH OCCURRENCE 15 I i !Ii B i umaRELLA LiAe I OCCUR M l EXCESS LU1B —ACLAIMS-MADE DED 1 RETENTIONS 1 WORKERS COMPENSATION i AND EMPLOYERS' LIABILITY I ANY PROPRIETORIPARTNER/EXECUTNE YIN OFFICERIMEMBER EXCLUDED? ,NIA (Mandatory in If yes, describe under DESCRIPTION OF OPERATIONS below f( f i r I , I Ij I 1 ' 1 I I BRWC563080 12/01/14 I ! 12101/1S j ' i AGGREGATE Is is WC STATU- OTH IT RY UMITS E L EACH ACCIDENT S 500 (D L___ , _ EE.L.DISEASE - EA EMPLOY S 500,000 F I DISEASE - POLICY LIMIT S 500,00( j I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) r`CDTICIr`ATC LJAI Non 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 v,aoo-wIV Aq UhU,J WKPL1KATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD