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HomeMy WebLinkAboutBuilding Permit #183-2011 - 352 CHESTNUT STREET 9/1/2010 BUILDING-PERMIT " 00?Ty TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION *y T z •h Permit N0:.-A;-- Date Received �r �pwreo•f•�a`y�9 �SSACHUS��� Date Issued: () MPORTANT:Applicant must complete a .Ht l-l items �xo-n this-page age WE �{ 4. x_e.- y'�r-rtter.-,',--'.;. '�.•.-.:�-ra - '>•�, �-,s-fem.F-�. . as"'s ���R�T+..iI �%.Y,311?�J-�i�-. ���E�� � dt:�-ria �"^„ '�--�t'�-1'>k�pG ��s`s`,�,�r�'•�s����a�-.�--� ,,,.`- jar.,f.-.,.�G ss�em,,.,, -.. v-a i 5rit�• p�'7-��"'�. '�4-i j�;vwt 'raK?I=caF';�'7":7_-:` r T"�-�'' �'°- „a � .F- � 1 I �'��'�c.'c•�t z-. I. :r+ n4� 'f" 3 4 a�,'' r •-^r4 �4 iten' 1." `f^t � �! a `s-'y��i,4.-PL7Flt'=� �� � 'ri' ,w-^F• $'*'s.� a..Y' a-r ,+ -a--diL�.- �t 1l i ,��n`•P L', c� w � .]'-� � s I- � � 4 F� it •e fih. � e 1 +-1r TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential New Building One family Addition Two or more.family. Industrial Alteration No. of units: ,Is Repair, replacement Assessory Bldg Others: Demolition y Other -r.^c �µ�u iP�i.17 a�t������.�'i.r�7�o�r>n 43..�f n..,,y;yy"yyc"' �J�:1,`>��- V ti +Y..s���t;. S 7fr'✓:! =Sc;.'�x`�:.�c�� ��,�s��'�'it�l*��?�:,a���§� '�''�• ...��s�,r���"a�,^Y�1"`� � �.�. S ������°=���1��s� `a...d"h�t -ck_ '�.: DESC PT?D N OF W RK TO BE PREFORMED: 7}en,LiftFa 'on Please Type,or Print CLearly) c OWNER: Name: S/� l/ Phone: Address: /�' 11 'Oool aTfF�" Y'�fy5•` A�Y, ..i""'°�K' Sn k �3f3' { t �S.c` •J t'j..-s-.' .:.,3:t a FOR c ��'��..���vt� �e' -�x��� 'J,• J9• v".3-'�G� -Y} �-`µ-r{,ty,,��,'r � �� `4�d Y3�� �'k.,�'r.3'4'Y�..-�fX= �._ J�� 0101 IN 1 •moi; 'T"'�"ham ..1�*,+- .1 ,-e r '3 y +s'i' �. -��i--��',1 �� � �,�"-,'�,xr•�€,� �� •�r�,�.���-�yr,�'�'s " .3 _ '-rare.11 �3 - cC -r sr .F C Y Sl F 3 4, •Y Y!f '{a v.iczs+: ...r ar^�+�Q f INN A� I p�Cv -�.�-.��„I q���jrA���1n�' `�.1 C�t�`w �*"-�a� ?' �i' r3u!177,715iYAs- � ,'J^+. �- ca 6 ti €. . � ?S�t'^{+ r�•ry`'�''''r..r sS�:-ss��-fir �s�'7�-'r.-'r� "'`�}i"ir`._',,,�, '.:`*Su`L f`�''.,,K �`st'-hy 1s>� t'a 1 ��.Y �2-,'::. 3lC -''."n ',1 aIC' �Z i aiE? MK 11k v•aaJnrmZ.. ' -.cy'iv zti•T�zr��%`•ts`'- ;"Mn 1t �^ MINOR i- �_3 '." ,L"e-c�- .-- _'r .- •+ r r"+3 ARCHITECT/ENGINEER Phone: 1 4 Address: Reg. No. FEE SCHEDULE:BULDING PER-Mi f:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$123,00 PER S.F. Total Project Cost: $ FEE: Check No.: 110 Receipt No.:2 NOTE: Persons contracting with unregistered contractors do not have a cess to the guaranty fund Sfure # era _ a�uner"'f T _=...- _ _ :.�agratuTefo ra - e�o •,_ Location No. 0% Date D Non?H TOWN OF NORTH ANDOVER f � O f - R A ' Certificate of Occupancy $ CMBuilding/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # f�✓�� 2336 Building Inspector j Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tann ing/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 DATE REJECTED DATE APPROVED• PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature CO •t•r-..t-r r' C Oivii EI I I c7 HEALTH Reviewed on Signature COMMENTS Zoning Baard of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments -Conservation Decision: Comments Ik Wafer& Sewer Connection/signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street f32E ?ATIP. D,ir := e ntte� e � '`.^._.^;':a';.,•P-•=�i1:_.ms:,�-.•`.i=.:�-Vii.=....y.._.T - - •%t:.. ._. : .. .,..._... ...r :. �?,n':.�:.•. ri+_—,_. .,,ate;,-;'_._w..e�,x: - - - - :'�-,rig' :°fT.`:• -_ •t.":i•:2...:-..-;f r - ate. - i r_ ...E_. .,.:.,.....,:.•--,'.`•..:.•f � _-w;a•:. .,-_:_z•�,,. ,,.....1�.-at,..t. _ -Win. - ..n+="' -- - — - - - x.l-l�re�,e "A '1 11: _ =o=_=`'C:;maw= s,•»:±..�'_..-;;;.... :.,_ ,=`•s....0 ... —�.:...._a. .:,..,a'sv.._...:>:_:a - • - - - - '9�=.moi':•-r _ _ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement,of(Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 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 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 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 ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/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 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 11e.mile , rrroposed P tux Plan.. ❑ Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ 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 Doc:Building Permit Revised 2008 ORTH ® o over o�0 V&.. L A. dover, Mass., o LAK 6 COCMIC KE WICK �� o"? TED RTED P.P5 BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR � THIS CERTIFIES THAT.........�� .................................................................................... ,............................................................... Foundation 7 4 has permission to erect..............:......................... buildings on� ...��...�............. .................................�.�.............................. Rough to be occupied a arson accepting e;q........ ... GT.GI.. ....................................................................... Chimney provided that p p g th is permit shall in every respect conform to the terms of the application on file in Final 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 CONSTRUCTION STARTS Rough "..`................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. ' Contract , Tom Quinn Employer ID # (978) 265.2390 , � � -� QUINN's CONSTRUCT40N �� (8,68-Mammoth Road • Dracut, Massachuse kts-01826 Name ` s% ` Dat. �i G Street Add ss(Not Post,O` be Btix) C Job Name S S/ Citv/Town, State&Zipcode AlAD w'0 _ � Job Location Daytime Phone: Evening Phone: Job Phone Mailing address(if differen from,above) ,, t �� Salespemon(s): /lwj 6)Z11111W Contractor Registration M 4?Z7_53 Exp. Date: --3 We hereby submit spa ficatioiis.a stimates for:,41` GO e- A—A'102 19 X/ � G /2UG/� t �� ✓ iLi�C' G�' �'i��,v S �v�E���� :5 Aba CEP 'S /.911�0 f Al The following scheduled will be adhered to unless circumstances beyond the contractor's control arise: Work scheduled to begin: _ _ Expected Date of Completion: _ (Date Contractor Will Be Contracted Work) (Date When Contracted Work Will Be Sustantially Cmpleoted) TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE THE CONTRACTOR EES TO PERFORM THE WORK, FURNISH THE MATERIALAND LABOR SPECIFIED ABOVE FOR THE SUM OF. "includes all finance charges in this amount* Payments yylili be made accordin to the following SCHEDULE: � J � �� $ `ti�po'n signing contract(*Not to exceed 113 of the total contract price OR the cost of special orde I ems,whichever is greater*). $�`By / _or upon completion of $ By_/ / or upon completion of _--__- =� _ -�� l'�-- - - 1 ----_--_- ------ --------------_---__--------------------- $ non completion of the contract('Law forbids demanding full payment until contract is completed to both parties'satisfaction in order to meet the completion schedule,the following material/equipment must be special ordered before the contracted work begins.(-Law requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contractor price or(b) the actual cost of any special equipment or custom made material which must be ordered in advance to meet the completion schedule'): $ to be paid for DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies oft a co/tract should go to the homeowner and the contractor Home Owners Signature: /1�` f1 Date: ' Contractors Signature: /'�*� 5, ..,/ -/--1 //M� Date: You may cancel this agreement if it has been signed by-a-�party thereto at a place other than an address of the seller,which may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of the agreement. Office of Consumer Affairs and usiness Regulation q 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement`C;ontractor Registration Registration: 121604 Type: Individual =_r % Expiration: 5/24/2012 Tr# 293905 QUINN'S CONSTRUCTION .4 THOMAS QUINN 868 MAMMOTH RD. DRACUT, MA 01826 - Update Address and return card.Mark reason for change. -- ❑ Address ❑ Renewal ❑ Employment Lost Card DPS-CA1 0 SOM-04/04-G101216 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation RegistratiorIz—'121604 10 Park Plaza-Suite 5170 Expiration a/24QQ12 Tr# 293905 Boston,MA 02116 Type .,-indivtduai_ QUINN'S CON SFRUCTtON THOMAS QUINN:;;` 868 MAMMOTH RD: DRACUT,MA 01826 Undersecretary Not valid without signature Massachusetts- Department of Public SafetN ' Bo4rd of Building Regulations and Standards Restricted to: 00 Construction Su-pervisor License - i 00- Unrestricted I i IG-1 2 Family Homes License: CS 39732 Restricted to: 00 THOMAS T QUINN 4 868 MAMMOTH RD r� Failure to possess a current edition of the i y `< i Massachusetts State Building Code DRACUT, NIA 01826 •„__ i is cause for revocation of this license. t I -- - Expiration: 3/25!2012 Refer to: WWW.Mass.Gov/DPS ('i�nunisi�uxr Tr#: 18330 co CERTIFICATE OF LIABILITY INSURANCE OP ID BiP DAN`S' QUI»-1 1 02/11/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Francis Provencher Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER.THiS CERTIFICATE DOES NOT AMEND,EXTEND OR 530 Rogers Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lowell MA 01852 Phone: 978-459-8681 Fax:978-454-9343 INSURERS AFFORDING COVERAGE MAIC# INSURED tNamE tA. Penn-America INSURER B. VuinL1's Construction INSURER C. 68 Mammoth Rd. RO)RE t D Dracut MA 01826 INSURER e COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PEMOD INDICATED_NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDiitON 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 SHOYIM MAY HAVE BEEN REDUCED BY PAiD CLAIMS. LTR NS 12 TYPE OF INSURANCE POLICY NUMBER DATE 0ATEWNDDIYrM Lam GENERAL LIABILITY EACH OCCURRENCE $1000000 A x COMMERCIAL GENERALLIABILITY PAC6862247 01/13/10 01/13/11 PREMIA oCcureft e) $50000 CLAIMS MADE ®OCCUR MEDEXP(Anyone person) $5000 PERSONAL SADV INJURY $1000000 GENERALAGGREGATE s2000000 GEMLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPXlPAGG s2000000 POLICY F1 E,ICT El LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMiT = (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY MJURY $ person SCHEDULED AUTOS (Per ) HIRED AUTOS BODILY INJURY s ND"WNED AUTOS (PC U PROPERTY DAMAGE $ (Peraoddent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTWIN EAACC S AUTO ONLY: AGG s EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE s OCCUR FICLAIMS MADE A( RELATE $ i DEDUCTIBLE $ RETENTION S s WORKERS COMPENSATION ) TORYLIMiTS ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTN El EACH ACCIDENT s OFFICERIMEMBER EXCLUDED? � E_—DISEASE-EA EMPLOY $ (Mandatory In NH) tl Yes,descnbe under EA_DISEASE-POLICY LIMIT s SPECIAL PROVISIONS below OTHER . —L DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I OCCLUSIONS ADDED BY 9JDORSEJwLENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO DATE TMEREOF,TH£=Mr.INSURER TMA.OfIrEAVOR TO MAIL 10 OAVS WIZITTEN NOTICE TO THE CERTIFICATE NQL 0ER NAMED TO THE LWT.BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UAB&ny OF ANY IOND UPON THE INSURER.iTS AGENTS OR REPRESENTATIVE& AUIHOR¢ED R TIVE ACID D 25(2009101) (E)004009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NThe Commonwealth of Massachusetts 1 y Department of Industrial Accidents lel E-1 ` rMj;; Office of Investigations 'L 600 Washington Street Boston,MA 02111 =� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrintL/egibly Name(Business/Organization/Individual): Address: �i9``7�(/�/ City/State/Zip: Ar y u an employer?Checkthe appropriate box: Type of project(required): P � 1. I am a em to 4. ❑ I l contractor I ith7lam a generaconor an 6. E]New construction employee full nd/or part-time).* have hired the sub-contractors 2.F] I am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 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 insurance required.]t employees. [No workers' 131-1 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 are doing alt work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 9: o r / Expiration Date: / �r Job Site Address: 1�c C�� ���/�l��s� City/State/Zip:,�� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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. do hereby certify under the pains andpenalties of pei jury that the information provided above is tr a and correct. Signature: Date: Z` Phone#: / ( 3!�AlC� 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'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,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 he sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen-nit 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' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. 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 pen-nit/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"Job 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia :Bonnie Welch FaxID:9784549343 Page 1 of f Date:9/1/2010 01:07 PM Page:1 of 1 i5RMMDATE lDD/YY1'Y CERTIFICATE OF LIABILITY INSURANCE OPID BW (MMI QUINN-1 09/01/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Francis Provencher Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 530 Rogers Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lowell MA 01852 Phone: 978-459-8681 Fax:978-454-9343 INSURERS AFFORDING COVERAGE NAIL9 INSURED INSURER A: Penn—America INSURER B: pRuin" n's Construction INSURER C: 68 Mammoth Rd. INSURER D. Dracut MA 01826 INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TI IE 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSRE TYPE OF INSURANCE POLICY NUMBER DATE(MMlDDlYYYY) DATE(MM/DDIYYM LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000000 A X COMMERCIAL GENERAL LIABILITY PAC6862247 01/13/10 01/13/11 PR'EMISES(Eaoccurence) $50000 CLAIMS MADE XI OCCUR MED EXP(Any one person) $5000 PERSONAL&ADV INJURY $1000000 GENERAL AGGREGATE $2000000 GEN'LAGGREGATE LIMIT APPLIESPER: PRODUCTS-COMP(OPAGG $2000000 POLICY JEa LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO" OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS!UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 71CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION - AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVEF-1E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS "CERTIFICATE FOR WORKERS' COMP COVERAGE WILL BE ISSUED DIRECTLY FROM THE COMPANY WITHIN 2 BUSINESS DAYS" CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Town of N. Andover REPRESENTATIVES. fax (978)688-9542 1600 Osgood St. AUTHORIZED REPRES ATIVE Andover MA 01845 C� ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD