Loading...
HomeMy WebLinkAboutBuilding Permit #911-15 - 33 BEECH STREET 5/13/2015BUILDING PERMIT `� �� ����, TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: 1 ' 1 / Date Received Date I IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Tc_.0 c k t Print 100 Year Structure yes no MAP 0-_Y,� PARCEL_ ZONING DISTRICT: Historic District yes 9 Machine Shop Village yes o 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 qtncf. Septic 0 -,We'll _ D Floodplain TM }❑ Wetlands El V�/atershed ®is titer/Sewer - . DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: 'C" -tA_ , Phone: " T% IM - o q 6 Address: 33 Contractor Name: t J10 t r-A__� Email: Address: Phone: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ .30 l)y FEE: $ '4 6 ,.i7 o Check No.: ' ��%/ Receipt No.: (P(, NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Ae, Location No. 6* Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee $ A TOTAL $ Check# 20- /61� -1 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan( Stamped flans ❑ TYPE OF SEWERAGE 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 o U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS ERVATION Reviewed COMMENTS HEALTH COMMENTS ature --�, J/r Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments t Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street RT 11ilENT TGtx rx �z r -r -r FIRE DEPA,�+tt ;`rnD'umpsteroncsite��� �._ i 4 .e �,yL .> a •b .s. m.,- r�_ . f-� y, a �7,. �. �ted a# 1�241111ainiStie2, e�DRepart�ment�sgn�atur,�e/date � gt, � 4 � �� r~ Di menslon 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 DANCER ZONE LITERATURE: Yes No MGL -Chapter -466- Section 21A. -F and G min.$100-$1000:fine NOTES and DATA — (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department -The fo4iowing'is.4list of,the r_equired.forms to be filled out-for:the appropriate. permit to be obtained. Roofiv,g, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit Li Photo Copy Of H.I.C. And/O•( C. S`1 Licenses u Copy of Contract o Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Li Building Permit Application L3 Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses a Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) Engimeering_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) o Building Permit Application o Certified Proposed Plot Plan a 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) a Copy of Contract a 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 apu.�al 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: Doc.Bui?ding Permit Revised 2012 l00 w 02 w- --__.0 .G�. cqc 1 CD cn cn -� N bl o n O y��od o O CD to,si -ti W F m (D j� esu � � � �m Q- �cD-2 u I -n cn m w W , CL 00 w N � ,tz 0) �p '00 4 N Uti m m n 70 rr m -.4 M m � O O m m m 0 m OZ D O r Wa,-, CDW ��CD cc n� O Q V N, —I DO :-, cn r� c2 2 CO �' I-�� K � _��� �1 D CJ CD m= -r �' S' S o cn CD CD o 0- �m0 XCO -n-,D �• m Q m �o w�� �zG7 n T O c 0 � m�� vn r- ca cn CA v �_-y v O O� c'S t7 � NCD 0c) ��� CD Cn 61zsa �( co � wQ�� �r m cn (D Z-< �cr) OW v N p CCD D W z 'n CD (� � 7 r 2 ii a 90i o o w w CD Qo = o �� O' O n� > w CA) cn w m z C7 N O CD�— tv CD Z m o o CD 177 CD Q CD � '� D i X �= 0 D :3 p (1) Qo p r ,. 0 C v C � CD n Z N CD O CLO CL a D cc v' O vCD CDQ � ii — (D CCD O CD O y• CO C I � v O Z CD n �- O CD O CD < 0 O -v o --qN O �, < C MU Af� N C cD. m CD 0 0 n O of -, r 3 c Z O =rN N O N Cl)N W CD '0 N O 2 ` C CD n to N Q r _ O 2)00 W ••" CCD<D _ CDD -0'rt r CL —i p CQ• * < y.� CO 3 CD O 0' cn *" - z CD c0�� c- D m N �. N Q C C = N Ir a- y O N O O CD NCL CD N r N r fu -con * * O :=r ti 0 0 Z _ O O rw .� CD CD p x Fes. H CCD %► �� I� - CD �S s C1 N aCD C CD- @ •a +� O ci 2) oCL � v v E/) 3 O (D 0 O N N OZ co C j m v�^ M y m T O' cu Z7 O = S DF Z M A 0 T 3' 6r (n xT O d00 S m m 7000 y rn Z N m 0 �' A O 000 =r C z Z H m 0 rm (") 3 7 A O ? T O 7 Q cu O 3 mw N m n Ln -C N 3 T O Q n = W 0 v O Tr m x y ic n0 M Z C v' �• � � Z O C7 X� O Z W z 0 Z Cl) m O < 0 O -v o --qN O �, < C MU Af� N C cD. m CD 0 0 n O of -, r 3 c Z O =rN N O N Cl)N W CD '0 N O 2 ` C CD n to N Q r _ O 2)00 W ••" CCD<D _ CDD -0'rt r CL —i p CQ• * < y.� CO 3 CD O 0' cn *" - z CD c0�� c- D m N �. N Q C C = N Ir a- y O N O O CD NCL CD N r N r fu -con * * O :=r ti 0 0 Z _ O O rw .� CD CD p x Fes. H CCD %► �� I� - CD �S s C1 N aCD C CD- @ •a +� O ci 2) oCL � v v E/) 3 O (D 0 O N N OZ co C j m v�^ M y m T O' cu Z7 O = S DF Z M A 0 T 3' 6r (n xT O d00 S m m 7000 y rn Z N m 0 �' A O 000 =r C z Z H m 0 T O' NC: (") 3 7 A O ? T O 7 Q cu O 3 C v M Z N m A 0 N m n Ln -C N 3 T O Q n = W 0 v O Tr m x Q4 Y nvrH - TOWN OF NORTH AND OVER - b�;�t =a OBFICE OF - ' Q e ZdOD Dsgood StreetBttff ft20,•Suite 2-0 6 7R��R'Shrn F4H�y.�r7 - - • XbithAndovor° -Massachusetts 01845 �sascuus�� • Gerald A.13rovm - Telephone (978) 688-954-5 Inspectoro Buildings - Fax (978) 688-9542 . - No�Eow�E�.•L�CEr��� �NEzv.�Tro�r - B III G PEPMT AWLICATION - • pleaseprinf •• . DATE: �( L'3 l i s- . SOB LOCA ON: Number StootAddresg Nlap/Zot Name .. 13ome??hone Wo&Maone PRMSENT .i AUNG ADDRESS 7, Code The current exempfion for `$omeowners" was extended to iu&1610 owner-occupied ditUings to two units -or :ess an d to allow such 1?omeo;7ner3 to engage anhire vho does notpossess a 1icMise, provided that tTie owmr acts as sapervisor). State30, ding (Code Sectior�.108.3.5.1) DBFMI.TION OFROMEOW.t`7 R Persons) wha c�Wns aparcel ofland on Which Itelshe resines or intends to reside, an wJlich there is, or is xnfended to be, a one or two family stmctures. A. persona. Who constricts more that ohne home in a twoyearperiod shall not be mmsidered a ho�meowr�er, The undersigned "homedwner" assumesresponsz'biliiyforcompliances With tha StateBuilding Code and other .Applicable codes, by Jaws, n&s andzegulations. The undersigned "homeowner" ceriiRes that helshe understands the Town Of Xbrffi A.ndoverlbilding De�a ,,,Lt xnmim"m iuspeotion procedures and requirements and that helehe will comply with;said pzocedures and requirements, . HOMEOWNMS SIGI*NATM APPROVAL OF BU,Ir,DXNG OEF.ICIAL RaYised 7.2009 FonnRomeowners Esx&apticm BOARD OF.A.PPEAM 688-9,541 CONTSEKVAMN 688-9534 23EALTH 688-9540 PT1. f.NNIPjG 6$8-9535 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.$10041000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks TOTE: Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application 4, Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: 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 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 1 , Date Received Date Issued: IMP RTANT: Applicant must complete all items on this page LOCATIO PROPERTY OWNER - Print 100 Year Old Structure yes - MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Q,a� Machine Shoq Villaae ves 4aw1 TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building tbOne family D Addition ❑ Two or more family ❑ Industrial 'SAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 4.1 s i--, Q h., vK #- 2A iD e: i r +r,- . t - Identification Please Type or Print Clearly) OWNER: Name: �: R -v 64� Phone: S-\tb - 6t3 - 2.�6 "t 1 Address: 33 e -e c�% P CONTRACTOR Name:�4w�w _ Phone: q1 64(6 3 Address: C(i 9 �?! +' e s r S'—t--T- Supervisor's Construction License: 05-3 012t °\ Exp. Date: bIZS ( 16-'_ Home Improvement License: _ —11-k Exp. Date: b Vv -t 46 ARCHITECT/ENGINEER tVt) t�r-e 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: $ FEE: $ k�`� Check No.: Receipt No.: NOTE: Persons contrac ing with unregistered contractors do not have access to the guaranty fund Signature of Agent/OvvnerY}1.,. t Signature of contracto s Plans Submitted FE Plans Waived Certified Plot Plan ❑ Stamped Pla J 2 O a m -C \m O LL E ate+ U Q {%j O U ta/l z Z o m - C ,O Yi -0 7 LL L b.0 cu C U N LL O W to z Z m J d tE UO O w (0 LL O W Vf z u W LU -C :3i C u (n f0 LL O U a H Q t j CC _ m LL Z W Q ui G LU LL v m O z V �..� N Y (n r L E%l O CO 2 Z m CD Z cn NW w X LU LU CL V O W Z in 0 --Plans -Subm itted ❑ Plans Waived ❑ Certified Plot Plan El Plans El TYPE -OF ';SEAM,RAGEDISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swimming Pools ❑ Well ❑ Tobacco Sales Food Packaging/Sales ❑ Private (septic tank, ete._ ❑ .. - _ =Permanent Dempster on Site ❑ =THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM _ DATE REJECTED: - DATE:APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS :CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments 1 i Conservation Decision: :Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osg FIRE DEPARTRENT Temp Dumpster on site yes no Located'dt124,Main Street- -Fire treet.-Fire Departineiitsignature/date`' - .< COMMENTS ood Street -�;� /�� /IV,, Location :2 :2 No. �32zr Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $& � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # J U Building Inspector r L n TVTw` �I F- uai LL D G' a ca Y y \ai O O LL v Ln ++ fl. V1 0 Wa Z z Z Q J ca c O .2 m c 7 LL b0 7 cc T N E U _ LL 0 F U a kn Z m J a bq 7 C _ LL 0 U a H (aj W W bD � OC > V) _ N LL OC U d Z Q bD �cb d' _ LL W Q W W LL O) L m Z cu v Ln OJ 0 e 0 V) 71M O a y t N y _ 7 cn d CD m 0 tm .O N O 0 Z O Q J O F. CD z W w CLx LLIr G a O LLI IL Z a 0 �m .ti w ��e tpa��zma�zcc eat/ a� cojacl eJel6 Office of Consumer Affairs & Busihess Regulation IF0OME IMPROVEMENT CONTRACTOR egistration: 101874 Type: xpi ration: 6/A/2016 Individual KEVIN MURPHY Kevin Murphy 98 FOREST ST.. N. ANDOVER, MA 01845 Undersecretary I I Massachusetts - Department of Public .Safety . Board of Building Regulations and Standards i Construction Supervisor License: CS-053099��'' KEVIN W MURPOV UU41 98 FOREST STNorth Andover Na 01 c Expiration 06/29/2015. Commissioner 98 Forest Street Kevin Murphy n • North Andover, MA 01845 • PH: 978-688-5335 Building Contractor • FAX: 978-688-7207 Proposal To: Michelle Roche 33 Beech Ave North Andover, Ma. 01845 From: Kevin Murphy CC: Date: 9/25/2014 Job: Roof / Repairs / Tree damage Date of plans: None Architect None Location: Same Section I - Work Schedule All Home improvement Contractors and Subcontractors engaged in home improvement contracting, unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered with the Commornveaflh of Massachusetts. Inquiries about registration and Status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108. (617)-727 8598 Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified here in writing contractor will begin work on or about 9/22/14. Barring Delay caused by circumstances beyond Contactors control, the work will be completed by 10/15/14. The owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as violations of this agreement. Section 11- Warranty The Contractor warrants that the work fumished hereunder shall be free from defects in materials and workmanship for a period of 1 year following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. Section 111- Scope of Work Page 1 of 4 Kevin Murphy Building Contractor 98 Forest Street North Andover, MA 01845 PH: 9784588-5335 FAX 97BS8B-7207 Page 2 of 4 General Proposal is to repair alll damage caused by fallen tree. Building permit will be obtained by contractor. Demolition Entire front of existing house will have roof shingles removed. Damaged ceilings / walls will be gutted as required. Building Miscellaneous roof trim and sheathing will be repaired / replaced as required on front of existing house. New thirty year architectural shingles will be supplied and installed. Color to be determined. All roof edges and valleys will have ice and water sheild supplied and installed. Seamless aluminum gutter will be replaced. Insulation Any water damaged insulation will be removed / replaced as required. Plaster Ceilings in four rooms, and second floor closet, will be blueboarded and skimcoat plastered. Interior Trim/Doors Crown molding around ceilings will be replaced as required. Painting All damaged interior ceilings / walls / trim will be painted. One coat of primer, and two coats of finish will be applied to all painted surfaces. Waste Removal All demolition / construction debris will be disposed of. Kevin Murphy Building Contractor 98 Forest Street North Andover, MA 01845 PH: 978,688-5335 FAX 978588-7207 Section IV - Price Schedule Total Page 4 of 4 We hereby propose to furnish material and labor — complete in Accordance with above specifications for the sum of ..................................... $ 14,100 Payment to be made as follows: Percentage/Item Description Amount 1 Permit obtained / Demolition complete $3000 2 Roof / Plastering complete $8000 3 Job 100% Complete $3100 3 $14,100.00 "Notice: No agreement for Home improvement contracting work shall require a down payment (advance deposit) of more that one-third of the total contract price of the total amount of all deposits or payments which the contractor must make, in advance, to order andlor otherwise obtain delivery of special order materials and equipment, whichever is greater Contractor: Kevin Murphy 98 Forest Street No. Andover, MA 01845 Registration No: 101874 Section V — Acceptance Acceptance of Proposal — I have read this document and accept the prices, specifications, and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction cancellation must be done in writing DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Si9 nature ��4 �c DateqtzAll�j Signature Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IV 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name (Business/Organization/Individual): Address: S e I Or City/State/Zip: I.iu p ,,.�,e w�. t M.� u kY, 4-5 Phone #: �o b b - T3 3 Are you an employer? Check the appropriate box: Type of project (required): 1:W I am a employer with 1 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors t 7• -KRemodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 10.n Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.[] Roof repairs required.] insurance re f employees. [No workers' 131J Other comp. 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 aie 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 their workers' comp. policy information. lam an employer that 1s providing workers' compensation insurance for my employees. Below is the policy and job site information. 11 Insurance Company Name: GIA r d4 ��..,5 cJr ow-QJ� c I 11 Policy # or Self -ins. Lie. #: WZ�7 VCb SID 04A. Expiration Date: Job Site Address:3 3_I1�� I City/State/Zip: Nv 4 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A 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 ceMfy under the pains and penalties of perjury that the information provided above is true and correct. 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 #: �'► � CERTIFICATE OF LIABILITY INSURANCE 6/25i 014 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 POLICES 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 M P ROBERTS INS AGCY INC 1060 Osgood Street North Andover, MA 01845 CAMONTACT Sandi Munroe N PHONE g78 683-8073 FAX (978) 683-3147 ooRES& san i mpro ertsinsurance . com INSURERS AFFORDING COVERAGE NAIC# INSURERA: MERCHANTS INSURANCE INSURED KEVIN MURPHY BUILDING & REMODELING 169 BOXFORD STREET NORTH ANDOVER, MA 01845 INSURERB: GUARD INSURANCE INSURER : INSURER D: INSURER E: INSURER F: COVFRAGFS CFRTIFICATF Nl1MRFR- RFVISION KIHMRFR- THS 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. NSR LTR TYPE OF INSURANCE UL I -K Y POLICNU E MMI POLICY EFF I TIL CY EXP UMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 0 OCCUR REMISES E occurrence) $ 500,000 NED EXP one person)$ 15,000 BOPI068945 11/22/1311/22/14 A PERSONAL &ADV INJURY $ INCLUDED GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY JEa [] LOC PRODUCTS -COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILELIABILITY COMBINEDSNGLELIMIT $ Ea accident 1,000,000 BODILY INJURY (Per person) $ ANYAUTO MCA7013608 1/23/14 1/23/15 A AUTOS NED X SCHEAUTODULED BODILY INJURY (Per accident) $ NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS dent UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ r r A EXCESS LAB CLAIMS -MADE CUP9145304 11/22/1311/22/14 DED I I RETENTION WORKERS COMPENSATION X PEROER AND EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 500,000 B ANY PROPRIEfOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) KEWC527844 07/01/14 7/01/15 E.L. DISEASE - EA EMPLOYEE $ 500,007 Ifyes, descrbeunder 500,000DESCRIPTION OF OPERATION I E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101, Additional Remarks Schedde, may be attached if more space is reqtAred) CFRTIFICATF Hol IIFR rAMr r=l I ATInK1 TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 OSGOOD STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. I L AUTHORIZED REPRESENTATIVE M N ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD