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HomeMy WebLinkAboutBuilding Permit #341-2016 - 326 CHESTNUT STREET 9/16/2015 O BUILDING PERMIT oF11,or 6'�ti TOWN OF NORTH ANDOVER 3� APPLICATION FOR PLAN EXAMINATION * - Permit No#: Date Received Q ��SSACHU`-+���h Date Issued: aIMPORTANT:Applicant must complete all items on this page } L•OCATION, Print PROPERTY OWNER /t Citi,t'l (3"�l ( l - 1'�O a j�-� Pnnt 100 Ye9�Structure4 _ yes ,, o MAP..DPARCEL: y �?�� ZONING DISTRICT- -.Nstoric,Distnct' yes no. Mach e,Shop;Village yes o' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building r4-Plne family ❑Addition ❑Two or more family ❑ Industrial &-Aiteeration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑Well q Floodplain 0.1Netlands _ ❑~Watershed District Water/Sewer,'' # ; DESCRIPTION OF WORK TO BE PERFORMED: - >; Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor'Nam41d : '- Phone:.2?-,? Email: c �" � _. .._ Address:. r.° Supervisor's,Construction License:" fC/ y�l Exp Date �` a. ... . _. -:Homp,IMproyement Licenser Exp Date l ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PEROT.$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 access to the gu ranty fund Signature of Agent/Owner Signature of contractor Location � '� No. �' Date E tp 7 . = TOWN OF NORTH ANDOVE71 _r Certificate of Occupancy $ Building/Frame Permit Fee $c3t�"" r ' Foundation Permit Fee $ ' f7if:1BCR£Ntt0. Othex.Permit F e �, $ r v e TOTALS' Check#,5 ! Y. r uilding Inspector � U,) Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swira ning 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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature k y COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE:tDEPARTMENT =: .emP Dumpster,.onsite ,yes, . nog R FiireDepartment signature/date',.,z_ COMMENTS,. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) a 1 i ❑ Notified for pickup Call Email j 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 o Floor Plan Or Proposed Interior Work a 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 L3 Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o 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) a 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 o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report o 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 Doe:Building Permit Revised 2014 1 �10RT11 T . w: . _ t c . ve, ,*. . No. OW Alt h ver, Mass, 0 �QO COCKICKIWICK �1,9s0 Arso P1P�`,�q5 U BOARD OF HEALTH Food/Kitchen PERIT T D Septic System THIS CERTIFIES THATN �� 6 Q.1 ! �� BUILDING INSPECTOR ............... ............................ .,.. ,.. ......... ......... .... ........ ........ .... .... ........ .. �t Q� has permission to erect .......................... buildings on .�.�o... Foundation Rough �.....�........................... Rough to be occupied as ................................................ .. d ............... ............... Chimney . provided that the person acceptin this permit shall in every respect 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRIJJN ST S Rough Service ...... ...... ......... ..................................................... Fina BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. r , V NORTH W� ' z 1 � : ve.0 - - .r No. I I *y ,t -IF T Z � o �.'@ h ver, Mass, 2ooK COCNIC"t-CN A0R^teo S U BOARD OF HEALTH Food/Kitchen PERNIT T LD Septic System THIS CERTIFIES THAT ........ �� 9 &A t...� `,b BUILDING INSPECTOR ........ . ............................ ..,. ...I..... ......... .... ........ ........ .... .... ........ .. �� Foundation has permission to erect .......................... buildings on . ...%1W .... ..... ........................ Rough to be occupied as .......... ..... ... e. tl. ..................................................................... Chimney provided that the person 1ccteptiTnthis permit shall in every respect 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHAS ELECTRICAL INSPECTOR UNLESS CONSTRU N STAP Rough Service ...... ...... ......... ...... .... .................. . ................... BUIL.DING. INSPECTOR. .. Fina - GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. KEVIN A.GALIZIO 53-260113 1683 JAYNE A.GALIZIO 326 CHESTNUT ST. e r!/C®Shield' NORTH ANDOVER,MA 01845 DATE d , e� PAY 10111E'� R / C G;c Ip a ORDER OP Jo Y ----- DOLLARS lJ BANK NO TM ANDOVER,MA Ot$1 �, �._ c•. �� iF MEMO I 1:0 1 b 3 260 31: b00 38 L 6 L sill 1613 Specialist gg e g, R. `� die ii 4'Y a cq a;, Coq atf 978--3-V;(;-'Q, I. 4` i-,} 4$-^t's 1$ ia.` O B S r'$Y k .�.,i l"�..3i .�c.,B�:i LM )4 i Y 5`." eir�F7'EY'E2t33..V}5g.»s, Date: October 27,2014 Customer: Kevin Galizio Re: Roofing Proposal Project: 326 Chestnut St n� �lt�S North Andover, Ma • Description of work area: Entire house excluding bac .of m in house. • Install tarps from roof to ground to protect landscaping,then, remove existing layers of asphalt roofing and dispose of properly. • Inspect all sheathing for rotted wood. If new plywood is needed it will be installed at $1.875 per s.f. If roofing boards are needed it is an additional charge of$3.75 linear foot as needed for labor and materials. ' Re-Nail deck to ensure proper installation. • Install 6 feet of GAF Weather watch Ice&Water Shield to all eaves. • Install Grace Tri Flex Synthetic paper to remaining exposed areas. • Install heavy duty 8"drip to all rakes and eaves.Color to be:TBA • Install GAF Pro starter course to all eaves over drip edge. • Install a GAF Timberline Architectural Shingle per manufacturer's specifications.All shingles will be nailed using 11/4" nails.Color to be: Install GAF cobra Ridge vent and capped with GAF Hip and Ridge Caps. • Install all new pipe flanges to all pipe boots. • Work site will be cleaned on a daily basis and all area will be gone over using a magnet to pick up all the nails. a1 • Twin Metals will furnish manufacturers System Plus lifetime material defects warranty,as well as a 15 year non-prorated workmanship warranty that entitles homeowner for coverage to include all labor, materials and disposal cost. • Twin Metals is responsible for pulling all permits to complete the job. • Twin Metals will supply customer with a Liability and Workers Compensation insurance certificate prior to any work being performed. • Twin Metals is NOT responsible for debris that might fall into the attic. Please cover any valuable items. • Any changes to the specifications will be executed on a written change order and will become an extra charge above and beyond the original contract price. Any siding that needs to replace will be an additional charge. • All jobs to be started approximately 14-21 days after the signed contract. (Pendine weather conditions) $8,360 Total Job Cost **Eight Thousand Three Hundred Sixty Dollars Any questions or concerns please call me at 978-663-2563. Thank You, Tom Gordon Twin Metal Rep: date: **ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are satisfactory and hereby accepted.Twin Metals is authorized to do the work as specified_ Balance is due upon completion. Please make checks payable to:Twin Metals. ** Price is good for 30 days only anq includes all applicable Oiscounts.� Authorized Signature: date: ��l The Commonwealth of Massachusetts zDepartment oflndlusiWalAccidents d I Congress Street,Suite 100 Boston,MA.02114-2017 F www raass.govldza Workere Compensation insurance Affidavit:Builders/Contractors/FIectricians/Plumbers. TO BE FILED WITH THE kER10HTTING AUTHORITY- Applicant Information % Please Print Legib Name(Business/Organizattonllndividual) ' Address: Y/ (1°i'r City/State/Zip: �lC'�il C/f 2 Phone#: Areyou an employer?Checkthe appropriate box: Type of project(gquired): 1. amaemployerwith employces(full and/orparttime).x 7. [1 New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. F1 Remo delirig any capacity.[No workers'comp.insurance required] 9. �j Demolition 3.Q 1 am a homeowner doing all work myself,[No workers'comp.nisurance required]t 10[]Building addition 4_❑lam a homeowner aadwill behiring contractorsto conduct all work on my property. Twill ensure that all contractors either have workers'compensation insurance or are sola 11.[�Electrical repairs ox additions proprietors withm employees. 12..❑PlipbWopairs or additions 5.Q 1 am a general contractor and I have hued the sub-contractors listed on the attached sheet. 13.ff5oofrepaits These sub-contractors have employees and have workers'comp.instrance.t 6.Q We are a corporation and its officers have exercised their right of'exemption perMGL C. 14.❑Other 152,§i(4),and we have no employees.[No workers'comp.insurance required.] "Any applicant that checks box 41 must also fill.out the section below showing theirworkers'eompensationpoliey information. i Homeowners who subniif this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such. lCoalractors 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. .tarn an employer thatispr'ovidingworkers'compensation insurancefor my emplayees'.Below is thepolicy andjob site information. �+ Insurance Company Name-4.1-1 A R itu',f — Policy#or Self-ins.Lic.#: C— 40 7a 30C J Expiration Date: J/ �7 Job Site Address:� J City/State/Zip: Attach a copy of the workers'compepsation•policy declaration page(showing the policy number aniration 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 fox insurance coverage verification. Ido Iaereby ' un a__ _ ai a alties ofperjury that the information provided above its true aJnd correct Si na Date: Phone# ��?I- ® �0'/XC) Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitlLicense# Issuing Authority(circle one): i 1.Board of Health. 2.Building Department 3.CityJTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: m Information an 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,asso ciation,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 applicantwho 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 0-out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub'contractoi(s)name(s),address(es)and•phonenumber(s)alongwiththeir 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. B e advised that this affidavit may be submitted to the Department of Ifndustrial Accidents fox 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 Accidenis. 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-imurauce license number on the appropriate line. City or Tovm 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/licensa applications in any given year,need only submit one affidavit indicating curTent policy information(if necessary)and under"Job Site Address"the applicant should write"all to cations 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 proofthat 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 1.00 Boston,MA 02114-2017 Tel#617-727-4900 ext.7406 or 1-877-MASSAPE Fax#617•-727•-7749 Revised 02-23-15 www.mass.gov/dia TWINM-1 OP ID:RR CERTIFICATE OF LIABILITY INSURANCE DATE(M 02/033120120YYY) 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(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 Lisa Foster Sullivan Insurance NAME: 163 Main St. Ap°N;E ;978-686-2266 AIC No,978-686-6410 North Andover,MA 01845 E-MAIL Foster Sullivan Insurance LLC ADDRESS:llariviere@fostersuilivangroup.com INSURER(S)AFFORDING COVERAGE NAIC 9 INSURER A:THE HANOVER INSURANCE COMPANY 22292 INSURED Twin Metals Inc INSURER B:MERCHANTS INSURANCE GROUP 12775 86 Billerica Ave Unit 6 North Billerica,MA 01862 INSURER C:MARKEL INSURANCE COMPANY 38970 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. /LTR TYPE OF INSURANCE POLICY NUMBER MMIDDr� MMIDD POLICY P LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY OHN4850163 01119/2015 01/19/2016 PREMISES Ea o=rTencel $ 300,00 CLAIMS-MADE I A I OCCUR MED EXP(Anyone person) $ 5,00 PERSONAL A ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GFN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY 7XJ PROT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ng $ 1,000,00 B ANY AUTO MCA7015114 05/21/2014 05/2112015 BODILY INJURY(Per parson) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X AUTOSWNEO PARACG DAMAGE $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,00 C EXCESS LIAB CLAIMS-MADE OBW5114114 01/19/2015 01/1912016 AGGREGATE $ 2,000,00 DED I RETENTIONS $ WORKERS COMPENSATION WCSTATU- TH• AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECITTNEYa NIA E.LEACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE•EA EMPLOYE $ H describe under DESCRIPTION OP OPERATIONS below EL DISEASE.-POLICY LIMIT s A RENTED/LEASED HN4850163 01/19/2015 01/1912016 LIMIT 120,00 QUIP FROM OTHERS DEDUCT 1,00 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 1e1,Additional RemarloF I -7� CERTIFICATE HOLDER I VCELLED BEFORE c DELIVERED IN Twin Metals 86 Billerica Ave Unit North Billerica,MA 01862 rights reserved. ACORD 25(2010105) The ACORD name and log TWINM-1 OP ID:RR CERTIFICATE OF LIABILITY INSURANCE DA02JO312015TE 17 02!0312015 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 CONTACT LISA Foster Sullivan Insurance NAME: 163 Main St. PHONE,E,1;978.686-2266 (Alc No:9T8-686.6410 North Andover,MA 01845 E-MAIL Ilariviere ostersullivan rou .com Foster Sullivan Insurance LLC ADD s: 9 P INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:THE HANOVER INSURANCE COMPANY 22292 INSURED Twin Metals Inc INSURER q;MERCHANTS INSURANCE GROUP 12775 86 Billerica Ave Unit 6 North Billerica,MA 01862 INSURER c:MARKEL INSURANCE COMPANY 38970 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 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. INSADDL SUER I LTR TYPE OF INSURANCE POLICY NUMBER MMIDONYYY) (MMJDD1YYYYl LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A ]!rMERCIAL GENERAL LIABILITY OHN4850163 01119/2015 01/19/2016 PREMISES Ire owxTence $ 300,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,00 PERSONAL d ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGG $ 2,000,00 POLICY X PRO' LOC $ CT F _1AUTOMOBILE LIABILITY CEOs eBINE eDISINGLE LIMIT $ 1,000,00 B ANY AUTO CA7015114 05/21/2014 05/2112015 BODILY INJURY(Per person) $ ALLOWNED X SCHEDULED BODILYINJURY(Per aaident) $ AUT AUTOS OS X HIRED AUTOS X NON.OWNED PROPERTY DAMAGE $ AUTOS PER ACCT $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,00 C EXCESS LIAB CLAMS-MADE OBW5114114 01/19/2015 01/1912016 AGGREGATE $ 2,000,00 DED I I RETENTIONS $ WORKERS COMPENSATION I WC STATU- TH AND EMPLOYERS'LIABILITY YIN ITORY LIMITS ANY PROPRiETORIPARTNERIEXECUTNE❑ MIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUG (Martdatory in NH) E.L DISEASE-EA EMPLOYE $ N yes,desc ft Under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ A RENTEDILEASED OHN4850163 01119/2015 01/19/2016 LIMIT 120,00 QUIP FROM OTHERS DEDUCT 1,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Twin Metals ACCORDANCE WITH THE POLICY PROVISIONS. 86 Billerica Ave Unit (North Billerica,MA 01862 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ACORE) CERTIFICATE OF LIABILITY INSURANCE DATE 03/225!2016/201rrYY) 5 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 06106-001 CONTACT Hays Companies PHaMENEo-�: (612)333-3323 AIC.No.: 80 South 8th Street EMAP #7 ADDR SS: Minneapolis,MN 55402 URER(S)AFFORDING COVERAGE i NAIC(t INSURERA: A.LM.Mutual insurance Company 33Z5 — INSURED INSURER 6: Surge Resources — — -- INSURER C 920 Candia Road Manchester, NH 03109 SOT�+D --- INIIURFA 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. ISR TYPE OF INSURANCE ISM POLICY NUMBER NNIID�Y F a1n obi y LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDS PREMISES Me coc hence CLAIMSMADE OCCUR MED EXP(Any one pemon) S PERSONAL 6 ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO OLICYECT OC AUTOMOBILE LIABILITY COMBI EO SINGL LIMIT $ _ (Ea accident) ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) S HIRED AUTOSNO�WNED PR PERTY § $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS MADE AGGREGATE 3 DED I I RETENTION$ S )US iRAITi�RA X T$tfii��'S °,zk A 6Wl€pg;Mg6It6EC'T1`EM NIA AWC400 7030053-2014A 11/1712014 11/17/2015 EL.EACH ACCIDENT $ 1,000,000.00 (fibriddatoorryIIn HH) EL.DISEASE-EA EMPLOYEE $ 1,000,000.00 DESCRIPTION OF OPERATIONS blow E L DISEASE-POLICY LIMIT S 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space is required) WC coverage applies to MA employees only RE:Evidence of Coverage.This policy covers those employees teased by Twin Metals through Surge Resources Inc,Manchester NH 03109 CERTIFICATE HOLDER CANCELLATION Surge Resources 920 Candia Road SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Manchester,NH 03109 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration -- _— Registration: 174281 - , Type: Corporation Expiration: 1123/2017 Tr# 2626x9 TWIN METALS, INC. -� THOMAS GORDON { 154 NEWBURY ST. w DRACUT, MA 01826 Update Address and return card.Mark reason £or Chang Address Renewal Q Employment Lost C CA 1 0 2OM-05111 �e �orrn�na�zcueall� oo�C�2�czc�ir.�ael�i fti;,e of Consumer Affairs & Business Regulation License or registration slid for individul use only E IMPROVEMENT CONTRACTOR before the expiration date. If found return to: F Type: Office of Consumer Affairs and Business Regulation istration: 174281 10 Parr Plaza -Suite 5170 xpiration: 1/2312017 Corporation Boston,MA 02116 WIN METALS, INC. HOMAS GORDON X54 NEWBURY ST. G� --- ---- - iRACUT, MA 01826 Undersecretary Not valid without signature I 0 Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supen icor SpecialtN License:CSSL'105991 �� THOMAS GORDON 154 NEWBURY STREET Dracut MA 01826 Expiration Commissioner 07/09/2017 v .COMMONWEALTH OF MASSACHUSETTS vwwm BOARD: ,: SHEET FETAL WORKERS I S5Ul:S: THE F0LL0W1N'G'11 CU;SE ; A5 A MASTER. <t1N ESTR I CTED IV TITO MAS E GORD.ON W 154 NEAURY ST MAW MA 01826-5733 V ce of Consumer Affairs&Bpm sess Regulation E IMPROVEMENT CONNTRACTOR istration: 1774281 Type: irati. 1!23!2015 Corporation WIN METALS,INC. THOM GORE T ON EWBURY ST. g DRACUT,MA 01826 Undersecretary