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HomeMy WebLinkAboutBuilding Permit #1202-2016 - 33 EDMANDS ROAD 5/17/2016 O* NORTy q A0 BUILDING PERMIT -'T,U TOWN OF NORTH ANDOVER. APPLICATION FOR PLAN EXAM INATTGN,.t-s = * „ � _ e Permit No#: 1lam'` Date Receive:ct ,TE,SPP`cy �SSACHu`''�I( Date Issued: t) IMP RTANT: Applicant must complete all items ones-cage LOCATION ST ® Pnnt PROPERTY OWNER�dgt-. Go(. -7,�, Print '-100 Year Structure yes rt MAP 2D PARCEL: _ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ArOne family ❑Addition ❑Two or more family El Industrial ElAlteration No. of units: ❑ Commercial XRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition - — - ❑ Other - ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identificati n- Please Type or Print Clearly i,�hr S � ER: Name: ni Phone: t/[`� OWN _. Address: 3-1 F[FI Contractor Name: j Phone: Email: 1 I Address: Supervisor's Construction License: �:� - as�s'��l Exp. Date: 4- Home Improvement License: /y�7aZZ Expo.. Dates. �'/� l 7 ARCHITECT/ENGINEER Phone:-- ' Address: Reg- No.. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATES $125.00 PER S.F. Total Project Cost: $���� FEE: $ Check No.: ` 1 Qf J Receipt No.: _ NOTE: Persons contracting w' z unreg' tered contractors do not have:accessao;tlieguaramy fund I-A Location �� ('' No. 2 C'Z f Date . - TOWN OF NORTH ANDOVER r Certificate of Occupancy $ Building/Frame Permit Fee $1t:ZS' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# � i J t3 Z Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS a Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Os ood Street FIRE 1741 MEN �t ;TempA,ump� ster-yonvsjr p� ,yes Located at`;1�24Mam#Street ,Fir�etDepartmen signature/elate 'i • ."`.=�"'.1. ,ted. i* " -- - .. - -�-- - .-z _ .�_-» _. ,. 2 rd�i•rx�• COMMENTS •, r,, .t ; I L 1 Dimension Number of Stories: Total square feet of floor area, base(kdn,Uderior dimensions. Total land area, sq. ft.: ELECTRICAL Movement of Deter location, wast or service droll-regwres 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) ® 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 IS OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit 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 Arid Hydraulic Calculations (If Applicable) 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 �I 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 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 r 'I NoRTM ' c ver O t^ ver, Mass, Y 1. toc NitnFwItK � A�4ATEO S U BOARD OF HEALTH PERMIT LD Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR Foundation haspermission to erect .......................... buildings on ..3.5... .. ... ..... • •••••••••••••••�' p Rough 04it I• �• ..................... Chimney to be occupied as .......... .... ... ........... ................................................. that the person acce tin his permit shall in eve respect conform to the terms of the application Final providedp p g p every 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION RTS Rough .C.;,a:,~^:........................... Service ...... .... Final 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. Page No. of Pages x � Supervisor CS 068461 • Fully Licensed & Insured Home Construction Reg.#146722 • �i Keefe �uSETTs Roofm sT�o3 North ReaCWI& MA 1920 A.MM1.1 uthorized coy ® 978-276-3043 RMUM 1u.1ev CertainTeedW ol PROPOSAL SUBMITTED TO PNONE 9 DATE / IWXAIa (� CiC STREET JOB NAME s CITY,STATE AND ZIP CODE JOB LOCATION - We hereby submit specifications and estimates for: Recommended Optional (Included in price) (Not included in price) Rip& Remove all shingle debris from roof&job site: Z1 layer ❑2 layers tl ❑3 layers or more Repair/or Replace any roof decking; not to exceed 50sq.ft. f Install 8"aluminum drip-edge/and rake-edge along entire perimeter.Choice of mill 0or brown Install ICE&WATER underlayment along horizontal eaves,valleys,sidewalls and sky-lights&chimneys V Install premium base sheet underlayment between roof deck and roofing shingles 15 Ib.felt❑30#.felt • Install 25yr CertainTeed/GAF/IKO traditional -tab roof shingles ❑30 year Install CertainTee GAF KO architectural YLifetime roof shingles *See manufacturer warranty policy for more details V Install new aluminum vent-pipe flange (s) •� Chimney(s)-counter-flash and re-step existing flashing ❑Cut& Install new lead flashing Ridge-vent/exhaust vent with low profile design, hidden by shingle caps ❑Soffit-ventilation ❑ Roof louver-vents • Seamless style aluminum gutters-custom fabricated at job site ❑downspouts • Other O'Keefe roofers will properly dispose of all roof debris in our own dump truck. *Please Note:All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear-off Price includes all items above that are checked only/others may be priced separately upon request. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: 6 b Total price not including options. dollars($ J-F�)G Payment to be made as follows: 30%deposit required upon delivery of materials.Balance due in full upon day of completion. Please make all payments out to Michael O'Keefe,21 Francis St., No. Reading, MA 01864 Late charges of$50 per week for all outstanding bills due upon day of Authorized completion. Signature . -z -Accepting proposal means agreeing to the terms of the enclosed binder Note:This proposal may be contract. withdrawn by us if not accepted within days ��_-�-_ e The Commonwealth of Massachatsetts F Department oflndustrialAccidents d I Congress=Street,Suite 100 - Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Elee.tricians/Plumbers. TO BE]FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib Name(Business/Organization/fnclivi(ival): Address: City/State/Zip: Z,0.4 Phone#: a'?L' (5q3 Are you an employer?Check the appropriate bo Type of project()Vequired): 1 tA:�am a employer withemployees(full and/or part-time).': 7. F1New construction ! 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t ❑ [�4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑Electrical repairs or additions proprietors with no employees. 12.F]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13Roof repairs These siib-contractors have employees and have workers'comp,insurance.$ 6.❑We are a corporation and its of iicers have exercised their right of exemption per MGL c. 14.F1 Other 152,§1(4),and Nye have no employees.[No workers'comp.insurance required.] t: "Any applicant that checks box#1 must aisd fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,tiey must provide their workers'comp.policy number. Iain an employer that is providiiig workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: ��/ Policy#or Self-ins,•Lie.#: +VW C ZjgV - 4!�©17'?Y d 0`Y 4. Expiration Date: -�6i Job Site Address: �) `�trl�bQ�' �Gl.. City/State/Zip: c— Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under.lie pains and penalties peijury that the information provided above is true and correct. s � Sign 0: Date: Affrl Phone#- 99W 17t% dY3 Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'coi isation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." ` An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work,until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and•phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also 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 Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensatioiii policy,please call the Department at the number listed below. Self-insured companies should'enter-their ' self-insurance license number on the appropriate lane:. City,or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"fob Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia L6� /2016/TUE 03: 39 PM A&K FOWLER INSURANCE FAX No, 9786642209 P, 001/001 llo® CERTIFICATE OF LIABILITY INSURANCE DATE`MMI°DIYYYY> 5/11/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CER7IFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: HONEFAX A & K Fowler Insurance AIC No Ext: (978)664-0366 AIC No): (978)664-2209 200 Park St. E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC A North Reading MA 01864 INSURERA:Western World Insurance INSURED INSURERS: O'Keefe Roofing LLC INSURERC: 21 Francis St. INSURER D: INSURER E North Reading MA 01864 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1591110313 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBRITYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP LTR MMIDDIYYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE XX OCCUR PREMISES Ea occurrence) $ 50,000 UPP1404384 9/8/2015 9/8/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY F PELT 11 LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Workers Compensation cert E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N!A (Mandatory in NH) to follow separately. E.L.DISEASE-EA EMPLOYEd$ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance verification Please refer to actual policy for all other terms, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main St. ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Nicole Orlanzo/NMO ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) AY/17/2016/TUE 03: 41 PM A&K FOWLER INSURANCE FAX No, 9786642209 P. 001/001 � o DATE A6OZ CERTIFICATE OF LIABILITY INSURANCE (MM/DDlYYYY) 05/11/2016 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 policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCERNT CO NAME:A T Nicole OrlanZo BYETTE INSURANCE AGENCY INC. A",°NN tet: (978)851-6678 AM Ne: E-MAIL ADDRESS: nicole@akfowlerins.com 200 Park St. INSURER(S)AFFORDING COVERAGE NAIC# North Reading MA 01864 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: OKEEFE ROOFING LLC INSURER C: INSURER D: 21 FRANCIS STREET INSURER E: NORTH READING MA 01864 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 51968 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR POLICYNUMBER POLICY YYYY POLICY EXP LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _UAMATE_7 CLAIMS-MADE FIOCCUR PREMISES Ea occuRENTErrrence $ MED EXP(Any one person) $ N/A PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY F—]PRO- � LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accidenl ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCI DENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A NIA N/A VWC10060178842015A 10/12/2015 10/12/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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 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.govAwd/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. 120 Main St. AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniel M.Crowley,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 Office ofConsumerAffairs& Business Regulation Massachusetts Department of Public Safety `rJ.f�r�/rrJnYYJ 1<}F� t ;OMEIMPROVEMENTCONT Board of Building Regulations and Standards 1=� egistration: CONTRACTOR �' Ex 146722 T License: CS-068461 Expiration: 5Lfi,1/2017, ype: _r DBA Construction Supervisor EEFE CONSTRUCTION NjICI MICHAEL J OKEEFE 21 FRANCIS STREET 21 RAS O'KEEFE NORTH READING MA 01864 ` NORT.8 4E�STREET, ,)ING, MA 01864 _ Undersecretary l Expiration: Commissioner 02/24/2018 Construction Supervisor License or registration valid for individul use only Restricted to: before the expiration date. If found return to: Unrestricted -Buildings of any use group which contain less than 35,0 Office of Consumer Affairs and Business Regulation enclosed space0 cubic feet(991 cubic meters)of 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid wit ut sign ure Failure to possess a current edition of the Massachusetts State Building din Code is cause for revocation of this license. se. DPS Licensing information visit: wWw.MASS.GOV/DPS i 6