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HomeMy WebLinkAboutBuilding Permit #781 - 36 COLGATE DRIVE 4/30/2012TYPE OF IMPROVEMENT BUILDING PERMIT TOWN OF NORTH ANDOVER ❑ New Building APPLICATION FOR PLAN EXAMINATION 10 ❑ Addition 11 Two or more family y Permit NO: Date Received �9SSgcHus���y ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: Date Issued: ❑ Other 4❑Sep ict t0 Welly �` s EVIPORTANT: Applicant must complete all items on this page D;Wa tersFied District 15Wa`terfSewer CG_ 1Q('"�! '' 6 L®-CATIONS ER—IPR®PERTYO -t Alr"'*i�', yesl ' �ipct ,� • TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family E ❑ Addition 11 Two or more family El Industrial ❑ Alteration ��GV No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 4❑Sep ict t0 Welly �` s f ;©'Floodplain;µ ❑ INetlantls' " D;Wa tersFied District 15Wa`terfSewer DESCRIPTION 1OF WORK TO BE PREFORMED: CGhS�•rvz-4- 0. 600 S/•t 2cK SrS6 PVC. f_)eCtA;n5 a') -+v - 1 Identification Please Type or Print Clearly) OWNER: Name: �� ►�� �: Nc4e— Phone: (of -7 - 44 �.I ea - Address: �� cac,'a �P— Di -/W_ (�j , A. ,Jcver �,.1•...k ,.t,Z''a`.-`..:X.'., 1.jw ;;'.,,yx� f, "`"t'�"`"': �"d-'.�".`°�'- >h:f•� L- ` CO�NTRAGT®Rt, ►Name >-3c�scr • Sup,�erviso�,fsConstructioriLcense C �� R- 4Exps,' Date�,1C� E fa- } S 1 L��� IEXpDate Home Im" rovement L'icenseT�_ V-.'3�`e ►�(.' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. I Total Project Cost: $ FEE: $ C7 Check No.: Receipt No.: NOTE: Persons contracting ith unregistered contractors do not have access to the guaranty fund A. 11,064- Location Go No. --7t/ Date TOWN OF NORTH ANDOVER Certificate of Occupancy $�, Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 11 � 25245 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on COMMENTS (A)-Q-J,,,� 6?-� 0-" flQ^ /00 HEALTH Reviewed on Signature ti CbMMENTS E t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: I Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street �""'��4'?f",�;.`9'i'�`w"1�"d ..�3.-cg{�,{4J`�-' z t FIRE DEPARTMENT aTemp Dumpsti%d site; yes :� ' no v. --� Located at 12MainjSt�eet0 y Fire Department4�ignature/d'ate`} _ _^w . _ a. _ �_. _ 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.$10041000 fine Doc.Building Permit Revised 2008 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 40TE: 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/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 ❑ 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products M ®TE: 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: INSPECTIONAL, SERVICES DEPARfMENTMFORM07 Revised 2.2008 BUILDING & REMODELING CONTRACTOR MASSACHUSETTS HOME IMPROVEMENTS CONTRACT This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973.8787 or 1-888-283-3757 or on our website. Homeowner Information Name Michael and Kimberly Hoye Contractor Information Company Name Joscon Management, Inc Street Address (do not use a Post Office Box address) Contractor/ Salesperson/ Owner Name 36 Colgatebne, 'T)r:ye_ Jonathan O'Sullivan City/Town State Zip Code Business Address (must include a street address) North Andover, MA 01845 185 Atlantic Avenue Daytime Phone Evening Phone City/Town State Zip Code 617-448-1827 Salisbury, MA 01952 Mailing Address (It different from above) Business Phone Federal Employer ID or S.S. Number 603-489-1568 61-1403121 Home Improvement Contractor Reg. Number 159444 Expiration date 4-30-2014 The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to complete; specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.) Construct 625 s/f deck system that will include the following: Demo the existing concrete slab, excavate and pour (8) 12" diameter concrete footings at 4' deep and backfill. Install 2x10 (2) girder system to support the 2x10 floor joists, install PVC Kleer decking with the hidden fastener system, install white Kleer PVC trim around the perimeter of the deck, install rodent screen around the perimeter of the deck, install a 16'x 16' pergola with 30 I/f of bench seats, location TBD. Install (2) 3' wide granite steps, location TBD. All construction related debris to be removed off site. The above scope of work to include all labor and materials. dmm� z r W Cd c� EW c Cl CL Co c A C^ a .�+ 4D C Cn �m O CL E� z coo m O a� s as ti C y OLD V CD ce (� O ®� N =m s C z h� o O C', r W U co V d�N O 9 C/J � o cm W c �cm oa s.o m '4 ca C3.- Z `o as CD .. �C.Co c = m :� 3 F.. ; CLO - C4 ELJ O L c CL= O 'r Z. O LLS ca _ CO2__ s . g0�'O F- t � S e'i�. COO .� OIL E L Z d O y CD ca CD y m m E co CL � O.a �3 ICDc � o Q o a r �Q c c ccc H Z co 0 CL C.3 ND O C C c CLH 0 0 o I x � x W A A as x o v o cn w" r�4 w cn cn c� EW c Cl CL Co c A C^ a .�+ 4D C Cn �m O CL E� z coo m O a� s as ti C y OLD V CD ce (� O ®� N =m s C z h� o O C', r W U co V d�N O 9 C/J � o cm W c �cm oa s.o m '4 ca C3.- Z `o as CD .. �C.Co c = m :� 3 F.. ; CLO - C4 ELJ O L c CL= O 'r Z. O LLS ca _ CO2__ s . g0�'O F- t � S e'i�. COO .� OIL E L Z d O y CD ca CD y m m E co CL � O.a �3 ICDc � o Q o a r �Q c c ccc H Z co 0 CL C.3 ND O C C c CLH 0 Required Permits - The following building permits are required And will be secured by the contractor as the homeowner's agent: (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A.) Proposed Start and Completion Schedule - The following schedule will be adhered to unless circumstances beyond the contractor's control arise. ,_ 4-30-2012.,; Date when contractor will begin contracted work. 5-21-2012 , Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of -.17,044.00 ( ) Payments will be made according to the following schedule: $ 5,681.33' upon signing contract (not to exceed 113 of the total contract price or the cost of special order items, whichever is greater) ,'S'5 68T.33 by or upon completion of DeckFraming.Sysw $0 $0 5,681.34` by _/_/_ or upon completion of by _/_/_ or upon completion of upon completion of the contract. (Law forbids demanding full payment until contract is completed to both parry's satisfaction) The following material/equipment must be special $ 0 to be paid for NIA ordered before the contracted work begins in order to meet the completion schedule.(**) $ 0 to be paid for N/A NOTES: (*) Including all finance charges (**) 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 contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty - Is an express warranty being provided by the contractor? ONo 0 Yes (all terms of the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask'to see a copy of a "proof of insurance" document. s Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. 01 Homeowner's Signature Co"acto 's Signature Date �`- ll� Date Contractor Arbitration The Home Improvement Contractor Law provides ho arbitration action (as an alternative to co homeowners With The same right is not automatically afforded colon) if they have a dispute with a co ht to trate an have to resolve an a contractor, however. tractor. Y dispute he/she has with a homeowner in court The contractor would the Optional clause provided below. This clause would unless both arbitration l l afforded to the homeownerparties agree to The contractor and the homeowner her gyve the contractor the same right to by the Home Improvement Contractor Law, contractor has a dispute concernin hereby mutually agree in advance that in the event the Private arbitration firm which has b this the contractor may submit the dispute to Consumer Affairs and Business Regulation rand the oved by the Secre a arbitration as provided In Massachusetts Ge of the Executive Office of consumer shall be required to submit to such General Laws, chapter 142A. Homeowner's Signature r_ ��2. a Contractor's Signature NOTICE: The signatures of theeI' alternative dispute resolution initiated ba thee apply only to agreement of the dispute resolution even wherecontr this section is not eactor. The homeo Parties to wrier may initiate alternative p sy ately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement other consumer protection laws (i.e. MGL chapter ontractor Law by agreement. However, homeowners may be excluded (MGL chapter 142A) and they choose is not properly registered )may not be waived in an ded from certain n Y way, even own building puts are automaticaly excluded fro lhts if the contractor Home Improvement Contractor Law. escribed Y law. Homeowners who secure their m all Guaranty Fund provisions of the described, in a timet The contractor is responsible for Completing legal rights if the contractorOrkmanlrke manner. Is p g the work as materials. In addition to Homeowners mai' be entitled to other specific guarantees or provides an express warranty Massachusetts c guarantees or warranties provided b h' for workmanship or ' an implied Or warranties provided de y the contractor, all goods sold in An enumeration of other matters on which the homeowner added to the terms of the contract as ton merchantability and fitness for a particular caner and contractor la Purpose: rights. If you haveons g as they do not restrict a homeolY agree may be Formation Hotline (listed below). about Your c°nsumer/homeo wner's basic cons wrier rights, contact the Consumer Execution of contact The contract must be executed in duplicate and should and referenced documents have been attached. not be signed until all blank sections have been filled in or marked until a copy of all exhibits Parties are also advised not to sign the document original signed copy of the contract with a as void, deleted, or not ttachments is to be given to the o applicable. One caner and the other LU L d LU W , LU w w rr= Ch u7 <n J C, n n L X00 �y N N e � � Q Cu n+ ra 3 N Of C%f 1 Q — 1 -- L lh 4 � � 0 M z — 1 -- � G WC J Ll Q L J C � L J /T � o �dWMW �+ � � M /T �dWMW �+ V Q X RENEY, . MORAN & TIVNAN MORTGAGE INSPECTION PLAN a REGISTERED LAND SURVEYORS NAME KIMBERLY M. RICE-HOYE & MICHAEL HOYE bd 75 HAMMOND STREET — FLOOR 2 . WORCESTER, MA 01610-1723' LOCATION 36 COLGATE DRIVE 2* PHONE: 508-752-8885 O FAX: 508-752-8895 NORTH ANDOVER MA co RMT@HSTGROUP.NET A Division of H. S. & T. Group, Inc. SCALE 1 " = 30 ' DATE 08-11-09 O O REGISTRY .ESSEX NORTH =` " G= DEED mm/Pnc;£ 5146/1 16 W BASED UPON DOCUMENTATION PROVIDED, REQUIRED MEASURE- MEMS_ WERE MADE OF THE FRONTAGE AND BULDING(S) SHOWN ON THIS MORTGAGE INSPECTION rr,.. •. PLAN PLAN #3373 o PLAN. IN OUR JUDGEMENT ALL VISIBLE EASEMENTS ARE SHOWN AND THERE ARE 140 VIOLATIONS:li BOOK/PUN OF ZONING REQUIREMENT'S REGARDING STRUCTURES TO PROPERTY LINE OFFSETS (UNLESS OTHERWISE NOTED IN DRAWING 8 ELO�• �'; ''= :` a fl: -_'' 'Ir'.;re WE CERTIFY THAT THE BUILDINGS) ARE NOT WITHIN THE NOTE NOT DEFINED ARE ABOVEGROUND POOLS, DRIVEWAYS., OR SHEDS WITH NO FOUNDATIONS. THIS IS A MORTGAGE T. _-- t SPECUIL Fl0� HAZARD AREA SEE HUD MAP. INSPECTION PLAN; NOT AN INSTRUMENT SURVEY. 00 NOT USE TO ERECT FENCES, OTHER BOUNDARY STRUCTURES, OR TO PLANT - 3. C om 06-02-93 SHRUBS. LOCATION OF THE STRUCTURE(S) SHOWN HEREON IS EITHER IN COMPLIANCE WITH LOCAL ZONING FOR PROPERTY LINE OFFSET ` G FLOOD HAZARD ZONE HAS BEEN DETERMINED BY SCALE AND EXEMPT REOUIREMENTS. OR IS FROM VIOLATION ENFORCEMENT ACTION UNDER MASS. G.L TITLE V0. CHAP. 40A. SEC. 7, UNLESS OTHERWISE NOTED. THIS CERTIFICATION IS NON -TRANSFERABLE _ - v .� IS NOT NECESSARILY ACCURATE. UNTIL DEFINITIVE PLANS ARE SUED BY HUD /WD/OR A VERTICAL CONTROL SURVEY IS THE ABOVE CERTIFICATIONS ARE MADE WITH THE PROVISION THAT THE INFORMATION PROVIDED IS ACCURATE AND IHAT THE MEASURE- PERFORMED, PRECISE ELEVATIONS CANNOT BE DETERMINED. MENTS USED ARE ACCURATELY LOCATED IN RELATION TO THE PROPERTY LINES. COLGATE DRIVE - N 89'13'20" E 130.00' r ------------i I i CERTIFIED TO: KIMBERLY M. RICE-HOYE MICHAEL HOYE 69.53' S 87'54'34" W REQUESTING • OFFICE: SALAS, ALPHEN & SANTOS. PC REQUESTED BY: LOT 19 21,810 S.F.t �= 50.29' N 85'37'00" E i DRANN BY: CPM CHECKED BY: I i i I k I C%4 (0 0 CN In 0 G1. pg U) In .3.0 d > rn Lu -J. :D > C) 0 z z ly- Q Z"') < 0 cc) k I Ro CERTIFICATE OF LIABILITY INSURANCE /y4/0912012 FDATE 4109IM20 2YYY) CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS /IFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. S CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIS►. AUTHORIZED REPRESENTATIVE � PRODUCER, AND THE CERTIFICATE HOLDER. ��iVIPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. tf 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 HUB INTERNATIONAL NEW ENGLAND LLC 299 BALLARDVALE STREET, UNIT 1 WILMINGTON, MA 01887 CONTACT NAME: PHONE FAX (A/C, No, Ext): (888) 661-3938 (AIC, No): f888) 872-8921 E-MAIL ADDRESS: Service.center@travelers.com (888) 661-3938 SV420 700 PRODUCER CUSTOMER ID #: 9199P8138 INSURER(S) AFFORDING COVERAGE NAIC # INSURED JOSCON MANAGEMENT INC INSURER A:TRAVELERS CASUALTY AND SURETY COMPANY INSURER B: TRAVELERS CASUALTY INSURANCE COMPANY OF AMERICA 72 PROVIDENCE HILL ROAD ATKINSON, NH 03811 INSURER C:THE TRAVELERS INDEMNITY COMPANY INSURER D: DAMAGES 0 RENTED Ea occurrence) $ 300,000 INSURER E: INSURER F: X NON OWNED AUTO COVERAGES CERTIFICATE NUMBER: 281758803531001 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. -SR FN LTR TYPE OF INSURANCE ADDL INSR SUBR POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MMIDDIYYYY) LIMITS B GENERAL LIABIITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR X HIRED AUTO 680-3061 N34A-1 1 05130/2011 05/30/2012 EACH OCCURRENCE $ 1 000 000 DAMAGES 0 RENTED Ea occurrence) $ 300,000 MED EXP (Any oneperson) $51000 PERSONAL & ADV INJURY $1,000,000 X NON OWNED AUTO GEN'L AGGREGATE LIMIT APPLIES PER: - POLICY X PROJECT LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP OP AGG 1$ 2,000,000 $ C AUTOMOBILE X X X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BA -4566N615-11 06/05/2011 06/05/2012 COMBINED SINGLE LIMIT (Ea accident) $500,000 I BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE IPer accident) $' $ $. UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under SPECIAL PROVISIONS below NIA UB -230M3062-11 ¢. 10/05/2011 10/05/2012 X ITORY LIMITS OER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000;000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 t DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) FICA I E HULLER SCOTT & LILA HAYNES 74 HIGHRIDGE ROAD BOXFORD, MA 01921 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INI ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (,l` � • A4_1411111 31, © 1988-2009 ACORD CORPORATION. All rights reserved. 4CORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD A & CERTIFICATE OF LIABILITY INSURANCE DATE( 0/21// 201201 YYY) 1 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 HUB INTERNATIONAL NEW ENGLAND LLC 299 BALLARDVALE STREET, UNIT 1 WILMINGTON, MA 01887 (888) 661-3938 CONTACT NAME: PHONE Fax No, Ext): (888) 661-3938 (AIC, No): (ess) 872-8921 E-MAIL ADDRESS: Service.center@trovelers.com PRODUCER C STOME D : 9199P8138 INSURER(S) AFFORDING COVERAGE NAIC # SV420 700 INSURED JOSCON MANAGEMENT INC 72 PROVIDENCE HILL ROAD ATKINSON, NH 03811 INSURER A:TRAVELERS CASUALTY AND SURETY COMPANY INSURER B: TRAVELERS CASUALTY INSURANCE COMPANY OF AMERICA INSURER C:THETRAVELERS INDEMNITY COMPANY INSURER D: GENERAL AGGREGATE $ 2,000,000 INSURER E: INSURER F: $ COVERAGES CERTIFICATE NUMBER: 610087226401492 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVp POLICY NUMBER POLICY EFF (MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS B GENERAL UABIITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR X HIRED AUTO 680-3061 N34A-11 05/30/2011 05/30/2012 EACH OCCURRENCE $1,000,000 DAMAGE A PREMISES TORENTED occurrence) $ 300,000 MED EXP IAny one personI, $ 5,000 PERSONAL & ADV INJURY: $1,000,000 X NON OWNED AUTO GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC X JECT PRODUCTS - COMP OP AGG $ 2,000,000 $ C AUTOMOBILE X X X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BA -4566N615-11 06/05/2011 06/05/2012 COMBINED SINGLE LIMIT $ 500,000 (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY (Per accide DAMAGE $ $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCEH$ AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? 'Mandatory in NH) If yes, describe under SPECIAL PROVISIONS below NIA UB -230M3062-11 10105/2011 10/05/2012X ORY LIMITS O R E.L. EACH ACCIDENT 1 $1,000,000 E.L. DISEASE - EA EMPLOYEE$ 1 ,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) I 1 1Ic r1ULUtr1 TOWN OF NORTH ANDOVER 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. I AUTHORIZED REPRESENTATIVE L� • ���, 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts t i Department of Industrial Accidents ; . Office of Investigations 1. J'1"'� 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):—7TojCcrr MCL1 0 QjY\er\4- =\c. IJ Address: PBS A4 IGv-\ .IL /eve City/State/Zip: cel `s �jt�ti/, P\A pf 9 S k Phone #: 56 9-1 ^ S C), C/6 15� Are you an employer? Check the appropriate box: •I)rpe of project (required): 1. ❑ I am a employer with _ 4. [] 1 am a general contractor and I 6. 0 New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on. the attached sheet. 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity, workers' comp. insurance. g. Building addition [No workers' comp. insurance 5.XWe are a corporation and its 10.Electrical repairs or additions required.] officers have exercised their 3.] 1 am a homeowner doing all work right of exemption per MGL 11.(] Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.n Roof repairs insurance required] t employees. [No workers' 13.[�;Other 1JC,C 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 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. 1 am an employer that is providing workers' compensation insurance for ►ray employees. Below is the policy and job_ site information. Insurance Company Name: �rctVL� eiS CQSuc) �_ in$e.rct�r 2 / Policy # or Self -ins. Lie. #: V IS ` a SOM 3U(oa- 11 Expiration Date: 1 �/ �/ a'ci • .lob Site Address: J� C J- c-Ae— -L11 r`I-vt, City/State/Zip: VJ, ✓' ,, ow I G l� 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 WORT{ 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 cerdfj under the pains and penalt' of perjury that the information provided above is true and correct Signature: J\P, a lj_�L Date:- _ q/a&/1)1 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: