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HomeMy WebLinkAboutBuilding Permit #515-2017 - 32 SOUTH CROSS ROAD 11/15/2016BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR. PLAN EXAMINATION Permit No#: Date Received Date Issued: OL&I (0' - - LWORTANT: Applicant must c, L 0- 2ATI ONN a LPR0 P 5 1 -R -T". -Ye `ibr! WN'lti M PFA 1413F Mete all items on this page ,4 1001 istructure _4kY PROPOSED USE OR z 0PRI@-T - . Historic : District` Residential Non- Residential -C-n [I One family 0 Addition TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building [I One family 0 Addition D Two or more family El Industrial El Alteration No. of units: 0 Commercial 0 Repair, replacement El Assessory Bldg El Others: [I Demolition El Other Septic El Wel'-­11' 7 D-?in V- "-8116- Flstrh6t- ❑ Water/Sewer e f DESCRIPTION OF WORK TO BE PLK1-L)K118tL): OWNER: Name: Address: ..-Ad.0fess., +�. SuP. et yi$qf? Rpli pe -ion Lice - Nome Im.,,b,t.b Improvement tio PI e Type or Print Clearly' 4//,/- Ph e: id -54!; 02P 71 P-h.&b:; d J/�. Date 1;, ARCHITECT/ENGINEER Phone: Address: Req. No'. FEE SCHEDULE: BULDINGPERMIA$12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. f.,__ Total Project Cost: 6-D, —FEE: $ to ��— Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have- access to I gmara JJ4n d, Signature: of_AgenfiJOwner Signature of confractor' Plans Submitted ❑ Plans Waived Ell Certified Plot Plan ❑ Stamped Plans ❑ IYPB bF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 v U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature. CONSERVATION Reviewed on Signature COMMENTS. r HE4TH COMMENTS Reviewed on Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes A PlannMg Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locat :364 Usgood Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at 124. main Street Fire Department signature/date 1..1-11ZAA- COMMENTF3. -imension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter locati®n, mast or service droprequires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Ices No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine Doc.Building Fennit 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 ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NATE: All dumpster permits require sign off from Fire Department prior o Is it NOTE: Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H. 1. C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation P an Of Propose ork Sprinkl r Plan And Hydraulic Calculations (if Applic. ble) ❑ Mass check Energy Compliance Report (if Applica ❑ Engineering Affidavits for Engineered c s 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 act ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit N 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 ;no 0 E �•T ' i= �u W V ! y J Q W = LL O O QO m N 0 O LL T CL3 41 In O yaj Z Z _J > m LL d' r U C LL W h Z Z > J C C LL HC Z V �� v W ,J W cc L Ln C� LL � w Z Q C7 d' C LL W C W W oc IL i m z OJ L VI CJ O N D J c 0 H _ _ • o :O O : V W q: : a °' : Cl) a Lr) .r _ • z y- O O;CJ E cnQ CD 7 C _ cc Z y ..S.N: O O 0L CL cc > s y _ Cc O c m > v c > a N a Z =a (1).= o X w �. w O E c c 75 CL cm a U o Cl) CD•> o = W J, O: _0 -a 0-Z d m =a) m �: J1 cc O O F- 0r_ Q ea =a .O 2 0 Q6•-3 N w N 4).2 m N L!J C O O Li ' (n = O � N 'Q'=_ O Z ui V Q O .6Q cn �>;� vs O = O w ao0 > ES 2 E _ .0 O Z N O C W Q c •E m m CD O CD V O O cc i a O Q �Q O Z CD U N cv � CL 0 HIC # 174377 Damphousse 2010 I 2015 Roofing �P ttt BestOfSurveysxom A trusted name since 19'38 , • Roofing • Siding;o,Windows 87 Belmont Street • North Andover., MA 01845 P: 978-683-4588 F: 978-685-7446 NAME OF OWNER 4411 10 ADRESS OF JOB zed, TEL.'Ll - OE' 'I We will remove all roof shingles off total roof area, _ layer. Replpce any boards or sheathing at additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. Architectural roof shingle, installed with a limited lifetime warranty. Inst I new ventpipe boot lashings. Waterpro f existing chimney flashing and remove debris. Shin le Col r Rid e Vent Upgrade Wood Sheathing Repair $3.50 per ft. vd We Propose herby to furnish material and labor -complete in accordance witli above specifications, r the suumm "o"f: dollars ($ Payment to be ade as follows J ' J Authorized X Signature /7 NOTE: This proposal maypre withdrawn by us if noVaccepted with in days Acceptance of Proposal - The above prices, specifications and conditions are' satisfactory and are herby accepted. You are authorized to do the work as specified: Payment will be made as outlined above. / Z: Signature_-�. ✓" Date of Acceptance: % Signature v111411",/ L12 HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS (M.G.L.142A) 1. WORK: Provided the Homeowner performs under this agreement, the Contractor shall perform the work on the Property as specified Proposal, attached incorporated herein. The work does not include extraordinary conditions of which the Contractor could not reasonably be aware. If such conditions are encountered, this shall be an additional cost to the Homeowner. Materials selected by Homeowner may have to be ordered or custom made, which items are specified in the Proposal. The Contractor is not obligated to agree to any modifications, extras or change orders unless such items are agreed to in writing by the Contractor. All extras and changes shall be at an additional cost to the Homeowner. Contractor shall perform the work in a good and workmanlike manner using materials consistent with this contract. Lawn or Driveway may be damaged by dumpster or equipment. Due to material shortages Contractor may substitute materials of equivalent grade. 2. PERMITS: If a building permit is required for the work, the Contractor shall obtain same as Homeowner's agent. Contractor is not responsible for any other permits that may be required for the Work, and Homeowner is responsible to determine whether any zoning, planning or wetland related permits or approvals are necessary. Homeowners who secure their own permits or deal with unregistered contractors will not have access to the Guaranty Fund. 3. COMMENCEMENT AND COMPLETION: Homeowner acknowledges the commencement date of the work is fluid, and is subject to numerous factors such as scheduling other contractors, delivery of materials and weather. Contractor and Homeowner shall determine the commencement date of the Work when a more definite determination can be made and shall execute a written acknowledgment of same. The Work shall be substantially completed within 7 days of commencement, except for longer periods as may apply to particular projects as Contractor shall notify Homeowner in the Proposal, and subject to delays for circumstances beyond Contractors control. Notwithstanding, the commencement date and substantial completion date may be extended, and the Contractor will not be liable for delays caused by, labor or material shortages, delays in delivery of items selected by the Homeowner, governmental action, and unforeseen events beyond the Contractor's control, including but not limited to weather, strikes, war, the acts of third persons or the acts of the Homeowner. The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractor's other jobs. 4. PAYMENTS: Contractor agrees to perform the Work and to furnish the materials and labor specified in the Proposal for the amount as stated in the Proposal. Thirty percent (30%) of the total is to be paid as a deposit with the signing of this contract. Upon cancellation prior to commencement of the Work, any remaining deposit will be returned less the costs for materials ordered for which Contractor was unable to cancel. Final payment shall be due upon completion of the Work and Homeowner agrees it may not hold any retainage. Late fees may be applied for late payments. Homeowner shall pay Contractor's reasonable costs of collection, including attorney's fees and costs. Time is of the essence hereof. 5. WARRANTY: For a period of 2 years after substantial completion of the Work the roof will be free of leaks caused by defects in workmanship, but not those caused by ice backing -up or extraordinary weather events, including blizzards, tornadoes, hurricanes or storms of greater than a twenty-five year duration or intensity. Contractor gives no warranties with reference to any materials or equipment installed in the Premises, passes any such warranties directly to Homeowner, and Homeowner agrees to look only to the manufacturer with reference thereto. This limited warranty extends to the Homeowner only and is not transferable to succeeding Homeowners. This Limited Warranty specifically excludes (i) all consequential and incidental damages; (ii) damage due to ordinary wear and tear, abusive use, misuse, or lack of proper maintenance; (iii) defects which are the result of characteristics common to materials used; (iv) defects in items installed or supplied by anyone other than Contractor; (v) work done by anyone other than by Contractor; and (vi) loss or injury due to the elements. There are no other expressed or implied warranties or representations made or given. 6. ENTIRE AGREEMENT: This contract and all documents referenced herein constitute the complete and final agreement between the parties. In the event that any of the provisions of this contract shall be held to be invalid, the remainder of the provisions of this contract shall remain in full force and effect. Two identical copies of this contract have been completed and signed. Homeowner acknowledges receipt of a completed contract signed by the Contractor. 7. HOME IMPROVEMENT REGISTRATION: In accordance with M.G.L.c. 142 A, § 9, Contractor is registered with the Bureau of Building Regulations and Standards Registration No: 174377. Homeowner may verify by contacting the Director at (617) 727-3200, ext. 25205. A Homeowner's rights under the Home Improvement Law (M.G.L.c. 142A) and other consumer protection laws may not be waived in any way. Homeowner acknowledges receipt of a copy of 780 CMR R6 and Massachusetts General Laws chapter 142A, and which are available online at www.mass.gov. Questions may be directed to the Consumer Information Hotline, (617)727-7780. 8. ARBITRATION: Contractor and the Homeowner hereby mutually agree in advance that in the event the Contractor has a dispute concerning this contract, the Contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c. 142A. No lien or security interest is imposed on the Property as a consequence of this contract, but Contractor has the right to record this contract or a notice of this contract, or seek a lien if the Homeowner breaches this Contract. 9. HOMEOWNER COVENANTS: The Homeowner agrees, represents and warrants that (a) the Homeowner grants permission to the Contractor to enter the Property to perform the work as covered by this contract; (b) the Homeowner has funds available to make full payment under this contract to the Contractor upon completion; (c) the Homeowner understands that construction as contemplated by this agreement creates a dangerous condition, and agrees not to enter portions of the Property under construction until the Contractor advises the Homeowner that the construction is completed; (d) Contractor may need use landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and (e) that code requirements may result in roofing nails penetrating through roof decking and will be visible on the underside of some surfaces. The Homeowner indemnifies, exonerates and holds harmless the Contractor from any loss, damage, claim, liability or expense (including reasonable attorney's fees, deposition costs and court costs) resulting from a breach of this provision. Contractor is not responsible for damage to landscaping that will grow back during the next growing season. 10. CANCELLATION: Homeowner may cancel this agreement provided Homeowner notifies the Contractor in writing at the address listed in the Proposal not later than midnight of the third business day following the signing of this agreement. %,CEJ HOMEOWNER�., L/��� ��� DATE: � Shingle: DEPOSIT: �3-5 The Commonwealth of1Mlassachusetts Department of Industrial Accidents 0A Office of Invesdgations J -J 600 ffYashington ,Street Boston, PIA 02111 }Viii3i xzasS gov1lila `workers' Compensation Insurance Affida-dt: Builders/Contractors/Electricians/Plumbers Name Addre X7WIPhone : a%' /•{� 0 Are employer? Check the appropriate box: y am a employer «pith 1. T _ '1an - E]I am a general contractor and I employees (full and/or part-time).' have lured the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on file attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.= 5. (1 We are a corporation and its required.] ;. ❑ I am a homeowner doing all work officers have exercised their myself. [moo workers comp. right of exemption per MGL insurance required.] c. 152, § 1(4), and we have no - employees. [No workers coma. insurance required.l Type of project (required): b. ❑ New construction 7. ❑ Remodeling 8. Demolition 9. Building addition 10.17 Electrical repairs or additions I IZ Plumbing repairs or additions 12. L oof repairs 13.❑ Other *any applicant that checks boxl 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 itire outside contractors must submit a new affidavit indicatine such. Cofll].7C(Oi5 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 -contractor have employes, they must provide their workers' comp. policy number. l am an employer that is pro;,iding ivoricers' colllpellsatiol1 111sul-alzee for illy employees. Beloit, is the policy and job site lllforlllatloll. /1 . e ,7 .4,07 , 6 '17 Insurance Company FAI Policy r or Self -ins. Lic. :04a%" r Zx,' Expiration Date:_ Job Site Address �� �-� City/State/Zi . �, 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 254 of MGL c. 152 can lead to the imposition of criminal penalties of 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. 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 certifIrlin qpr the pains and penalties of perjury that the inforination proided aboue is free and correct -.o Official use onlj: Do not }write in ibis area, to be completed by city or ton n 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 G. Oti3er Contact Person: Phone ACORif CERTIFICATE OF LIABILITY INSURANCE 16,-/ COVERAGES DATE(MWDONM) 11/09/2016 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 CONTACT NAME: Diane LeBlanc DOHERTY INSURANCE AGENCY INC PHONE IAIQ Nm . (978 475-0260 FAX N,; App ESS: dleblanc@dohertyinsurance.com INSURER(S) AFFORDING COVERAGE NAIC9 P.O BOX 1985 INSURER A: AIM MUTUAL INS CO 33758 ANDOVER MA 01810 INSURED INSURER 0: DAMPHOUSSE ROOFING LLP INSURERC: INSURER 0: _ INSURER E: 87 BELMONT STREET : 1 INSURER F.- _ NORTH ANDOVER MA 01845 COVERAGES CFRTIFICATF NIIMRFR• 1111781 oculainW ultuoeo. 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 REOUIREMENT. 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 POLICYNUMBER POLICY EFF M DIYYM POLICY EXP IMMIDONYYVI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S PREMISES Ea occunenco S CLAIMS -MADE EIOCCUR MED EXP (Any one person) S PERSONAL BADV INJURY $ N/A GEWL AGGREGATE LIMIT APPLIES PER: JECT LOC F11POLICY PRO - _ GENERAL AGGREGATE $ PRODUCTS - COMPlOP AGG Is S 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) S NON -OWNED HIRED AUTOS AUTOS PROPERdenTYDAMAGE Par accit S _ S UMBRELLALIAB OCCUR EACH OCCURRENCE $ _ AGGREGATE $ EXCESS LIAO CLAIMS-MADEI N/A DEO I RETENTION S S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I NER OFFIEWMEM EREXCLU ED?ECUTNE WA NIA NIA AWC40070287742016A 04/17/2016 04/17/2017 X I STATUTE OT E.L. EACH ACCIDENT S 500,000 E L. DISEASE - EA EMPLOYEE S 500,000 (Mandatory In NH) It yes. describe under DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT I s 500,OOD N/A DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 101. Addittiml Remarks Schedule, may be attached It more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B. no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in farce 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.govtlwdtworkers-oompensabonf(nvestigationst. 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. 1600 Osgood Street AUTHORIZED REPRESENTATWE North Andover MA 01845 4` 4 I Daniel M. Cra�y, CPCU, Vice President — Residual Market — WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD Client#: 14415 DAMPHOUSSE ACORb- CERTIFICATE OF LIABILITY INSURANCE Y"' MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH ;;;09 6 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency, Inc. P.O. Box 1985 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 21 Elm Street POLICY PIRATIO Andover, MA 01810 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A Western World Damphousse Roofing LLP 87 Belmont St North Andover, MA 01845 INSURER 8: INSURER C INSURER 0: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY PIRATIO OMITS A GENERAL LIABILITY NPP8296488 04/12/16 04112/17 EACHOCCURRENCE S1,000,000 �( COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S100,000 CLAIMS MADE M OCCUR MED EXP (Any one Perm) $5000 AL & ADV INJURY $1.000.000 AGGREGATE $2,000,000 GENL AGGREGATE LIMIT APPLIES PER: TS - COMPIOP AGG s2,000,000 X POLICY JECT PRO LOC F(Eawrident) AUTOMOBILE LIABILITY D SINGLE LIMIT ANY AUTO S BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per person) S BODILY INJURY HIRED AUTOS NON -OWNED AUTOS (Por aociden) S PROPERTY DAMAGE S (Por awdem) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC S ANY AUTO AUTOONLY: AGG $ EXCESSAlMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE S OCCUR F1 CLAIMS MADE S S DEDUCTIBLE S RETENTION S WORKERS COMPENSATION AND WC STATU- OTH• TORY I IMITq FR EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE S OFFICERJMEMBER EXCLUDED? If yes, deschoe under SPECIAL PROVISIONS bebw E.L. DISEASE - POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS Covering operations usual to Damphousse Roofing LLP... Town of North Andover 1600 Osgood Street North Andover, MA 01845 LO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAUL _i n DAYS WRI TEN E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 1E NO OBLIGATION OR LIABILITY OFAbM QND UPON THE INSURER, ITS AGENTS OR AUTHORIZED ACORD 25(2001108)1 of 2 #S34292/M34248 DML 0 AOAD CORPORATION 1988 Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -067560 Construction Supervisor Y a SHAUN M TWOMEY. 61 PATROIT ST ' NORTH ANDOVER MA 01845 CA__ ^^^ Expiration: Commissioner : 1012612017 - Tk T�ooxmzo�zcoeal�i p l�iiaaaaciivaPlta Office of Consumer Affairs & B cmess Regulation HOME IMPROVEMENT CONTRACTOR Registration: =474377_ Type: F Expiration: 21412017 LLP. s A P OUSSE ROOFING-LtP_'C SHAUN TWOMEY', 87 BELMONT ST N. ANDOVER MA 01845 Undersecretary Location 3,:5- Se.71V No. 5/L(-*? 41 7 Check# 313'7 3 118 6 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector