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HomeMy WebLinkAboutBuilding Permit #796-2017 - 292 CANDLESTICK ROAD 2/23/2017lzt BUILDING PERMIT TOWN OF NORTH ANDOVER 1 APPLICATION FOR PLAN EXAMINATION Permit No#: '� 11 Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Zq 2 o rtc4 C S%1`�.Qr� o Print PROPERTY OWNER 'Si1 yhT n Print 100 Year Structure MAP_PARCEL: I�2 ZONING DISTRICT: Historic District - Machine Shop Village TYPE OF IMPROVEMENT ❑ New Building ❑ dition AMAlteration ❑ Repair, replacement ❑ Demolition ❑-.Septic ❑ Ami �Cs<_6_II�_q. PROPOSED USE Residential Wone family ❑ Two or more family No. of units: ❑ Assessory Bldg — ❑ Other Non- Residential ❑ Industrial ❑ Commercial ❑ Others: ,vvCuAgyb L DESCRIPTION OF WOR TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: _S�O ,-� .- Phone: Address: 1� _L r r„ ►--r I t_,, 1 ( L n rJ Contractor Name: Addres \*\°-�I.L -:_�% yes no yes no ves no Supervisor's Construction License: Exp. Date: Z 5 Home Improvement License: `-A-3'41',-) Exp: Date:_I,�-I-1 I l ARCH ITECT/ENGINEE Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $_Z� u- �� (Q� FEE: $ . Check No.: Receipt No.:3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund TOWN OF NORTH ANDOVER -Certificate of Occupancy $ Building/Frame Permit Fee $ �� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1 T' Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/Massage/Body Art ElSwimming 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 Reviewed ori Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments I Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: t_ocatea juv4 usgooa Street FIRE DEPART EM NT - Te p"�®, um exon sit yes, Located at 124 Main Street_z• ` `;41 Fire Department eig ature/date' �COMMENTS � •�' ��- .� .� ����,. -� � .� � ����- � � r�. , � .� 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 i MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For dwartment use) r� ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 44 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 6 ' I 4. Building Permit Application ,4. Certified Surveyed Plot Plan 4. Workers Comp Affidavit � Photo Copy of H.I.C. And C.S.L. Licenses 4. Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4 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 r. Photo of H.I.C. And C.S.L. Licenses 4 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 0 _ 0 = F- J W Il O O O m � U Y O LL a) N v Q (n 0 U d Z Z '' m C O Mai O 7 LCL t 7 0 K C E :E_ U t0 I_L O W Z C7 Z J d L bbM =3 LL. O W H Z J (aj u J lJJ bo N mL oC O F w H ? Q (D by H Z W Q w W LL O z Q �7 0 Y O O � C Ir- Jv W O h c •v o4c, P % cn J d Lm a cn > � w cc O �.c c it U rn U) Q c N O Z O Q y tm — N p p O o a> > .o = �® c o H ` C O = O C Q L ca .0 = as = Q "amp cD!— p cn v m SLJJ 0 0 0 Li AujC N C O Q� O I - _ V = v O LU U m 0-0 Q �j�•N F-1 N N > J a o U) O .- CLOG > N O z O 0 W Q t/1 .E m m � 0 cc Q a CA 2-0 O�a _v CcJ O = Z O U cc cc r_ U) 0 s Federal ID # 05-0405629 RISE Engineering RIContractor Registration Nosi$G MA Contractor Registration No 120999 RISECT Contractor Registration Nofi20120 60 4haw (nut Itoari, C:antmi, �G1 113031 CONTRACT �dtl TRACT 339-5024)33.5 i�,11334 :>f13-G3d5 Page 1 PROGRAM TMS CONTRACT IS 04TERED PATO DCTvEEtr FUSE CNIA-HES EtOR:nEiR!:GASO THECUSTOMER rest WORK AS DEECRICIF31 U°LOY! CUSTOMER PIMA ONiE CUEnT a WORK ORDER Stephen Karcia (978)314-7376 01/16/2017 45695 23904 LERWCE STREET 011.1.146 STREET _ 392 Candlestick (toad. 292 Candtestick- Road ` s t , f 9ERYICE (3TY, STATE, ZIP Ott.UR6 CITY, STAT£. ZIP ......... North Andover. MAO 1845 North Andover. MA 111345 , z fV JOB DESCRIPTION PHASE: ONIC-Ptopabal Cor this calendar yc;m fi0.0i? I1rV'.,ARD BARRM-k- We have idenfifted that Iheie a/rc res s -,ed light. present in your home. imless the reccs;sed lights arc ccrtificd as iC•tilted i Insulation Ccrilact Rmctl) v+c still ercau: a .. aTL~und lit%: fixtutc In using, trlicr^_l,'ts_ Malmo 3miulai:i F)5 a a daJ111111nl: ii1:';Cri;ll. fliry lniul.lfir it g"tel ZIC fella((%ta z9.iti'4,4 U3e Etfj Ind el T_?jd Cat ilicti +t(licit cf+linin r+ _iti )..-:.liiz alit Rt?S fY insulated Alit SEALING( Provide labor and materials to seal agent, Of %our home apinst wasteliul. cess air leakkLm This work will be pertitnncd in colleen with the use ofspcciid tools and diagnostic tests to assure that your (tome will be Jell with a ficahthtid level of air exchange and indoor air quality. Materials to be used lo seal your home can include caulks, foams and other products. Primary areas for staling include air leakage to attics. bwt cntents, attached garages and other unheated areas (windows are not generally addressed,) '17ris will require ( 12) workin (tours. A reduction in cubic feet per minute Writ) of air infiltration will occur. but the actual number of efin is not guaranteed. At file completion ot'thc wcathcriYadon wort;, and at no additional cost to the homeowner, a filial blo%%cr dovr andlor Combustion salcn° an:tl}iis will he conducted by the sub -contractor it, enure iiic lately of the indoor air quality, S LM_O.00 KN,EFWAI.i.S Provide labor anti materials to instal ri',id hoard ai P -I t) iN srcatcr with the required fitr rating to ( I i 5i =quart feet df knecliAl arca, $45-1.30 KNVI:tt'AI.h. I.1,C) iR: Provide labor and Inateriafs it, install a •f" la) cr of R-14 Class I Cellulose added to i t 12) squats Iecf of open kncc+vall klub. S134,40 :'.'f-rIC +t`CCi "&. Novicic 12hot and inweiials its install t 11 easih moved. in,:ulating cov'sr fo. the attic sr s lblding stair. A salail Itat surthce n1'pl}wood +ci11 he created around the rv(xning within the anis. 'This win aloes the covers integral wcathtsr- stripping to restrict tit Icaka:_e. A111C \i'U'SS'Provide labor and materials to insulars the hack Of the attic door with rigid board at R-10 or erealcr with the ` re4mred fire raiiila, and Act![ tit:: cd, -`i :\ith --Scathes,ril?pitl w r:itritl air S110.00 r17 1'IC AGl'C_5S: Provide labor :end materials to make f1) temporary access to an attic area. The opening will be closed with ulallcriak similar to chase existing. f=inish sanding cute( paimin.- is not included. $170.00 VFNTII .,XTI0N: Provide labor and material, to install (1) irnulatnl exhaust lose with roof tnounted flapper rent it) exhaust cx191ing hathrrem t n(5). tiroan traockl d 6.16 or equivalent, RISE Engineering 60 Shawniut (toad, CaeNm. 1.IA 02021 ENGINEERING 33'9-502-Ci335 FAN 339-4024335 Federal ID # 050405629 RI Contractor Registration No 8186 MA Contractor Registration No 120979 CT Contractor Registration No620120 CONTRACT VENTILATION: provide labor hathri vnt mH(s+_ .IOI3 DESCRIPTION materials to install i I I imulated r¢h:sttst hnsc with naofmont ucd clapper vent to exhaust future CCl vl i(r� 4ti';4i_t 4 F'r�+Yid 1 i rand aratcrial, to install i_td ?t+oral .t3 It-lfl nr err:ucr is ith th required tore ratio!" it., l 128> _quare fret of conuilun .sail tress R1SF: Gnginecrint twill apply all applicable. cli_ible incentives to This cisrttract. You, will only ire billed the Net amount. Currently. for Cligih{e measures, C'iilunlbia Lias olkm 750,1. incentive, not to cxCCcd $40001W calendar year. and an incentive of 100".6 for ,be Aii 5T along measures lip Ito the fits! sbi;o -ind an aildhiona4 S; 4+> if �:avinps -C justified by the auditor. F'or the safety and health ol'your home's indoor air quality, we will lie Llinductiny' a bluffser door diagnostic of the aenilable air lint in your home both before the work is begun, and alio the teralhcrrr�ttitm work is complete. We Will alsis conduct a loll asst ssmenl of die ctKnbustion a lfctI of %t+ur hcatnlg. System and water heater. This has a value of S%t and is at no cost to +xou. Total allotwable tveatitrnraritui incenti%v is -5?. i in. '[lie Petniil twill be .wc urcd by the inst latiun contractor. at nts additional cxt t. It is the h—co lm rices responsibility to close out this pennit by contacting their municipality at the completion of this Work. Sl 13.75 `;F 15.75 5492.90 Page 2 liltOGRAM CMA-11ES EE`TIUSE' �A D CUSTOMER OF-WHREDBEL071 CUSTOraER Stephen hareta FNOtiE DATE cuenra WORK ORDER (978)314-7376 01r'10f2017 44-5695 23904 SERVICE STREET nfLt.It:G STREET 292 Cattdlestick Read 292 Candkst ek Rmd SERVICE CITY. STATE ZIP OILLPRI CITY, STAT- TjP North Andover. MA 01845 North Andover. MA 01 Sas VENTILATION: provide labor hathri vnt mH(s+_ .IOI3 DESCRIPTION materials to install i I I imulated r¢h:sttst hnsc with naofmont ucd clapper vent to exhaust future CCl vl i(r� 4ti';4i_t 4 F'r�+Yid 1 i rand aratcrial, to install i_td ?t+oral .t3 It-lfl nr err:ucr is ith th required tore ratio!" it., l 128> _quare fret of conuilun .sail tress R1SF: Gnginecrint twill apply all applicable. cli_ible incentives to This cisrttract. You, will only ire billed the Net amount. Currently. for Cligih{e measures, C'iilunlbia Lias olkm 750,1. incentive, not to cxCCcd $40001W calendar year. and an incentive of 100".6 for ,be Aii 5T along measures lip Ito the fits! sbi;o -ind an aildhiona4 S; 4+> if �:avinps -C justified by the auditor. F'or the safety and health ol'your home's indoor air quality, we will lie Llinductiny' a bluffser door diagnostic of the aenilable air lint in your home both before the work is begun, and alio the teralhcrrr�ttitm work is complete. We Will alsis conduct a loll asst ssmenl of die ctKnbustion a lfctI of %t+ur hcatnlg. System and water heater. This has a value of S%t and is at no cost to +xou. Total allotwable tveatitrnraritui incenti%v is -5?. i in. '[lie Petniil twill be .wc urcd by the inst latiun contractor. at nts additional cxt t. It is the h—co lm rices responsibility to close out this pennit by contacting their municipality at the completion of this Work. Sl 13.75 `;F 15.75 5492.90 RISE Engineering Federal ID # 05.0405629 RlContractor Registration NoMS ?AA Contractor Registration No 120979 CT Contractor Registration N0620120 ENGINEERING' GU tiflaTSBTut Road. C.'nntTln, Jts\ 02021�������� 319-502-61335 FAX 339-5112-6345 Page 3 PROGR NM C\ A-11 E5 TWO COtrrRACr Io ENTERED cno errgEEN Rens ENGRUMiG AND THE CUS70fan FOR Vr4Xw AS OESCRI$£B SELN,7 STOI.'ER Stephen Kareta PHONE CAiE CLIENT WORK ORDER (978)314-7376 0111612017 445695 23904 SERVICE STREET BILLING STREET 292 Candlestick {load 292 Candlestick koad SERVICE CITY. STATE, LP North Andover. MA 01545 BILLING CtTY. STATE. ZIP North Andover, NIA 01545 .JOB DESCRIPTION Slxi.00 T otal: $2,946,65 Program incentive: $2,487.49 Customer Total: $459.16 WE AGREE HERESY TO FURNISH SERVICES - COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS FOR THE SUJ.: OF "Tour Hundred Fifty -Mine 11% 161100 Dollars $459.16 UPOtt FRl4L MSPECTTOM MM APPROVAL OY R13E EHGI :TERIJJO. CUSTO!,Zg AGREEN TO REMIT AMODUTOUE ItJ FULL. MTERE5T OF I': V"LL BE CHARGED MONTHLY O'J ANY UJIPAID 0AWICE AFTER Sa DAYS. SEE REVERSE FOR ",!PORT4NT IIJFORt! ATION UN GUARANTEES, RIGHTS OF RECISION, SCHEDULING. A',JD CGT;TRACTCR REWSTRATIOIJ. / - DO NOT SIGII THIS CONTRACT IF THERE ARE ANY BLANK SPACES-— AUTHORLl:G SJGR:ATUP,E • R �� Emm�ace:r"a yv /` 1:L> CeitRT A ..s:f+7t„�;CE ~3' } R,�? 3 it; 7!G1 fJOTE:TItS CONTRACT MAY DE YATIipRAVNL BY US IF:JOT EXECUTEOYflTNL'I DATE OF ACCEP(AriCE , �^ 3a ACCEPTANCE OF CognV.CT • THE ABOVE PRICES, SPECWICAt10NS AND CONINTCONS ARE DAYS, ASSPPECWI D PAYMENT ALL eE MADEAS OUTLINED ABOVEE AUT{i0A1ZED TO 00 THE VIQAK The Commonwealth of Massachusetts Department of IndustrW Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 W www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers li ant Information �` Please Print LWQ_11 Name (Business/organizadon/Individual): �� lY1$U� u iifan I \y,,$, Address: °C • 6 BOX '34q Ci /State/Zi : 10 JW i U\ r1 1A X1313 Phone #: 1 �u • 34 6 on an employer Check the appropriate box: AWl Type of project (required): 1 am a with employer _�[ 4. ® I am a general contractor and I 6. � New construction employees (full and/or part-time). � 2. ® I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. Remodel' 7. ® � ship and have no employees These sub -contractors have g, ® Demolition working for me in any capacity. employees and have workers' comP • i ce't' 9. [3 Building addition [No workers' comp. insurance 5. ® We are a corporation and its 10.0 Electrical repairs or additions required.] 3. ® I am a homeowner doing all work officers have exercised their 11.1] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL c. 152, §1(4), and we have no 12.® Roof repairs insurance required.) t employees. [No workers' 13.[] Other coma. 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. $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 providing workers' compensation insurance for my employee& Below is the pollcy and fob site information. Insurance Company Name: Policy # or Self -ins. Lie. #: �1,� 3 O O 3 -Z*"+ Expiration Date: 4 3o i„Q 11: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,504.40 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cen fy under the pains and penalties of perjury that the information provided above is true and correct. Date: I1 - nu --,Y. Q -Prt4 • 3 ao' l m -s Official use only. Do not write in this area, to be completed by city or town offlcial. 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#: Aco:Rn� CERTIFICATE OF LIABILITY INSURANCE JDATE(MM/DD/YYYY) � 10/18/2016 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 pollcy(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 Iieu of such endorsement(s). PRODUCER MARTIN J. CLAYTON INSURANCE AGENCY INC CONTACT ­ NAME: Meg Munroe PHONE 413) 536-0804 -A No A�DORESS: mmUnrOe 111 Cla ton.com 1649 NORTHAMPTON ST., RTE 5 INSURER(S )AFFORDING COVERAGE NAICS INSURER A: ACADIA INS CO 31325 HOLYOKE MA 01041 INSURED GAUTHIER INSULATION INC INSURERS: INSURER C: INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER: 94521 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. ILTR TYPE OF INSURANCE ADOL UBR POLICY NUMBER POLICY EFF OADYM MPS Y EXP Antm LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO R PREMISES Ea occurrence $ CLAIMS -MADE E� OCCUR - _ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS - COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY Per accident $ ( ) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident)$ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE NIA AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' _ X STATUTE ERH LIABILITY Y / N E.L. EACH ACCIDENT $ 500,000 A OFFEC ICER/MEM EREXC EXCLUDED? WA WA WA MAARP300327 10/30/2016 10/30/2017 E.L. DISEASE - EA EMPLOYEE $ 500,000 (Mandatory In NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 2003 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/twd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845y - Daniel M. Crawley, 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 DATE {MMIDWYYY1r) AC40RV ® CERTIFICATE OF LIABILITY INSURANCE 8/12/2016 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 pollcy(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 NAME CT Nancy Usher Martin J Clayton Insurance Agency, Inc. PHDNEEM): (413)536-0804 No): (413)634-7874 1649 Northampton Street E-MAIL ADDRESS: P. 0. Box 989 INSURERS AFFORDING COVERAGE NAIC # Holyoke MA 01041-0989 INSURERA;Nationwide Mutual -Harleysville NATIO INSURED INSURERB:Allied World Nati Assurance Co Gauthier Insulation INSURER C: P.O. BOR 344 INSURER D : INSURER E: _ IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NI IIISRF12•CL1663001ARn QC1/ICIl1AI IJI IM112C113. 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. ' ILTR TYPE OF INSURANCE A DL S BR Am POLICY NUMBER POLICY EFF POLICY EXP LIMITS R COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR EACH OCCURRENCE $ 2,000,000 AMAA DREMI 0 R Ncur 50 000 PREMISES Ea oculrenoa�$ r _ MED EXP (Any one person) $ 5,000 OL43487F 7/6/2016 7/6/2017 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: R POLICY PRO- JECT [7] LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 Is OTHER: I AUTOMOBILE LIABILITY4 ANY AUTO BI I LE LI IT $ Ea accident BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS accident Per BODILY INJURY $ ( ) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident R UMBRELLA LIAB 1 OCCUR EACH OCCURRENCE $ 1 000 000 AGGREGATE $ 1,000,000 B EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ EBU028251970 10/18/2016 10/18/2017 WORKERS COMPENSATIONPER TH- AND EMPLOYERS' LIABILITY YEN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A STATUTE I ER T E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) H ea, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 $ UESCNIP [ION Or OPERATIons / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Town of North Andover 1200 Osgood Street North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sullivan/MEG ©1918-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014(1) The ACORD name and logo are registered marks of ACORD MMrM&W with pdfFactory trial version www.pdffagtoll.cor -1 ; i 2Q 2 C a i 9 N F tv M ` \ kP .-P t .'s 12 4 'm .j fg 40 IN RISE ENGINEERING E ff;crtncv cl .eI'E:i:f d. 60 Shawmut Road, Unit 21 Canton, MA 020211339-502-6335 www.RISEengineering.com OWNER AUTHORIZATION FORM I. e Name) owner of the property located at: (Property Address) SCI . _ f9-!✓ 1%Q 11'�.�' - --h+<� - b t p tiS : � t 4, (Property Address) hereby authorize (n 0�1 rAi t an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. Owne s ignature Date 6.2016