HomeMy WebLinkAboutBuilding Permit #987-2016 - 364 JOHNSON STREET 3/22/2014A�l 1� 4W4 Lf-,Nk
Permit
Date Issued:
4
-
BUILDING PERMIT
0
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION f
Date Received
must cowlete all
LOCATION Mexl�l_� hl)c4ile.� 1�7A
Phnl,�'/
PROPERTY 01 ER bo� -e- e4
MAPNOI�
I -as no
..zch;neS1,oPV:!zze ves no
TYPE OF IMPROVEMENT
PROPOSED USE
ev�-
Residential
Non- Residenbal
H New Building
)o"One family
U Addition
Li Two or more family
Ll Industrial
Li Alteration
No. of units:
Li Gornmercial
Kkepair, replacement
U Assessory Bldg
U Others:
Li Demolition
U Other
Fkxxoain VWtlands
Watershed District
e- 614 d
Re
OWNER: Name.- 1 e- e
Address:
I CONTRACTOR Name:
Identification Please Type or Print Clearly)
F /0/1 / "T � �/ Ph(
/V A.'7 alave-11-
Phone:
S___7
F79 771 C1,63
A4
603 �'05- 7,PY
Address:
/ O't J Ae /� .7 ltlq a 3>o 7,6
SupeMsor's Ccnstrixfton Liceisw. 0 7 S 3 J'3' Exp. Date Y
Horr!)!rr!�,roA!srr-_nt L:ccZrse- Ext) Date -
7 4�
ARCH ITECT/ENG I NEER Phone:
Address, Reg. No.
SCHEDULE, BULDING PERMIT. $1200 PER $1000,00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 3 F73e oo 1: E E -. 4S
Check No.: Receipt No.:
NOTE; Persuns contructing with unregistered cantructar3 do not have access to the guarantyfund
SignW,ure crf Signatura oi contracior
Sfi, 4,?6tdf
ev�-
OWNER: Name.- 1 e- e
Address:
I CONTRACTOR Name:
Identification Please Type or Print Clearly)
F /0/1 / "T � �/ Ph(
/V A.'7 alave-11-
Phone:
S___7
F79 771 C1,63
A4
603 �'05- 7,PY
Address:
/ O't J Ae /� .7 ltlq a 3>o 7,6
SupeMsor's Ccnstrixfton Liceisw. 0 7 S 3 J'3' Exp. Date Y
Horr!)!rr!�,roA!srr-_nt L:ccZrse- Ext) Date -
7 4�
ARCH ITECT/ENG I NEER Phone:
Address, Reg. No.
SCHEDULE, BULDING PERMIT. $1200 PER $1000,00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 3 F73e oo 1: E E -. 4S
Check No.: Receipt No.:
NOTE; Persuns contructing with unregistered cantructar3 do not have access to the guarantyfund
SignW,ure crf Signatura oi contracior
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
If t%ORTH
0. -,I-VD 16
4E
I Date Issued : IMPORTANT: Applicant must complete all items on this page I
LOCATION
PROPERTY OWNER
MAP PARCEL:
Print
Print 100 Year Structure yes no
ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Resi ential
Non- Residential
El New Building
El )ne family
0 Addition
El Two or more family
El Industrial
El Alteration
No. of units:
El Commercial
0 Repair, replacement
El Assessory Bldg
El Others:
El Demolition
D Other
io, -Wetla�n s -
I Nl- 1��
n1=QrP1PT1nN
f)F WnRK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
A A.4
I -A%A �
Phone:
Contractor Name:
Email:
Address:
Supervisor's Construction License:
Home Improvement License:
ARCH ITECT/ENGI NEER
Exp. Date:
Date:
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $
FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Sionature of contractor
Plans Submitted. Plans Waived Certified Plot Plan 0 Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
well
Private (septic tank, etc.
Tanning/Massage/Body,A.It F1 Swimming Pools
Tobacco Sales 11 Food Packaging/Sales Fl
Permanent Dumpster on Site n
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature
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
Conservation Decision: Comments
'Water & Sewer Connection Permit
I DPW Town Engineer: Signature:
�0. Located 384 Osgood Street
'0
66 —pa ft n fkS I j!3_t_L!--f-e1'/ i Via t ioA-
N I rA,,-
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.$100-$l 000 fine
NOTES and DATA — (For department use
Ll 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
4. Floor Plan Or Proposed Interior Work
,& Engineering Affidavits for Engineered products
IOTE: 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 And
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
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
10TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doe: Building Permit Revised 2014
Location
No. I
c4' 1— 2 , - I
Check # ;)— I I
Dat;-:�,
TOWN OF NORTHANDOVER
Certificate of Occupancy $—
Building/Frame Permit Fee $
Foundation Permit Fee $ P
Other Permit Fee $—j. -
TOTAL $
Building Inspector
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Massachusetts Home Improvement Sample Contract
This form satisfies all basic requircrocrilsofthe statds.HomlWovmmtContractorlaw(MGL chapter 142AI butdoes oat mcludestandard
language to protect homeowners. Seek legal ad�vice ifnecessary. Any person planning home improvements should first obtain a copy of"A
Massachusetts Consumer Guide to Home ImprovernertV bef6re agreeing to any work on your residence You may obtain a free copy by calling the
Office of Consumer Affairs and Business Regulatiods Ccaisumer hiftinnation Hotline at 6 17-973-9787 or 1-888-293-3757 or on our website.
Homeowner Wormation Contractor h9ormation
Name
&O-zi
A �Xljg�
Comparry Name
11, 4 In Be 6':?5
e ell
o. �e
�/
Street Address (do not use a Post Office Box addf6m)
3 � Y 10k"7_504 Yt-
Ckintractorl Salespersord Owner Name .Of
Cit"Yrown
IV. A4,ve,-
State Zip Code
IN 0 / f3�j__
Busnimms Addr. (.ust .1.& . street addr=)
101t? Mq/n/47W Rd
Daytime Phone
779 271
Evening phone
(7/42
cityrrov-16 . T" Cock.
Pe 117 6) 1P0';"K0_
Mailing Address (it different firoin above)
J�2 gloyr ID or S.S Number
/,,Ett
H1nWMWMM Co&vdw Re"
Expkiftce
The Contractor agrees to do the following work for the Homeowner
pescribe in detail the work to completed, spectf3plog the type, brand, and grade of meterials to be used, we additional shem if
mr) Y
fie 5� f, cz f Ider -4 /21CL-1
W14 d-1 W 5 1A j e- &&.,� /0 4t "I e S
loa4-, W"Ide-""s 6/
Required Permits - The following budding permits am required
and will be secured by the contractor as the homeowners agent:
(Owners who secure their own permits will be
exduded from the Guaranty Fund provisions of
MGL chapter 142A.)
Proposed Start mW Completion Schedule - The following schedule will
be adhered to unless circumstances beyond the contractor's control arise
3 -A
Idt'L114te when contractor will begin contracted work.
i"570/Dte when contacted 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 M
Payments will be made accordnig to the following schedule:
s 70 0 P.-riguncontr-t(nottoexceed 1/3 of the total contract price q[ the cost ofspecial order items, whichever is greater)
by or upon completion of
$ — by or upon co-pletiori of
$ / j4tff upon completion ofthe contracL (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following martenalloquipment must be special S to be paid for
ordered before the contracted work begins m oriter
to meet the coinplefton schedule. (**) $ — to be paid for
NOTES: (*) Including all fin— charges (**) Law requires that any deposit or dawn -payment required by the contractor before work begins may
not exceed the grcater of (a) one-third of the total contract p2i cc or (b) the actual coo of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule
Express Warranty - ban cuuarmwarranW beimoroviiied bitbecentracter? KN*0Yes(al1'- - of thewarranty wait be atbchW to the oDntragft
Subcontractors -The contractor agrees to be solely responsible for completion of the work described regardless ofthe 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 awwrient
Contract Acceptance - Upon signing this document becomes a binding contract under law. UnIess otherwise noted within this document, the
contract shall not imply that arty lien or other security interest has been placed on the residence. Review the following cautions and notices
carefully before sigriing this contract
• Dortt be pressured into signing the contract Take time to read and fully understand iL Ask questions ilsomething is unclear.
• Make sure the conft�wtor has a valid Home Improverrient Contractor The law requires most home unproverrient contractors and
subcontractors to be registered with the Director ofHome hnpmvwmt 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 mmrance company information so thatyou can confirm coverage, or ask to
see a copy of a "proof of insuranW document
• Know your rights and responsibilities- Read the Important Information on the reverse side ofthis form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law -
You may cancel this agreement ifit 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 mad posted, by telegram sent or by delivery, not later than midnight ofthe
third business day following the signing ofthis agreement See the attached notice ofcancellation form for an explanation ofthis right.
DO NOT SIGN THIS CONTRACT IEF THERE ARE ANY BLANK SPACESM
;idmtical cq)ies of Wed and soned- Ore copy sbxdd go tD flit horricowter. The odw ccopy should be kept "e cwtmctor.
'c " 1
ec,—,= 95
paWre Contractor's Signature 61�
Date
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an
alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a
conti-actor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office_qfjgQq�umer Affairs and Business Regulation and the consumer shall be required
submit tAch arbitration as p5ofided In Vassachusetts General Laws, 4pter 142A.
Ho6ejwnees Signature Contractor's Signature
s a apply
NOTICE: The signatures of the partie,�ronly to the agreement of the parties to alternative dispute
resolution initiated by the contractor. T meotner may initiate alternative dispute resolution even where this
section is not separately signed by the es.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer
protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own building permits am automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a
timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the document until all blank sections have been
filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to
be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing
and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of
the contract and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself
to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted woric Withdrawal of funds from said account would require the
signatures of both parties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide, to Home Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787,888-283-3757 or visit the OCABR website at o,,.ibr
If you want to verify the registrationof a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law, contact:
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 8W283-3757 or visit the HIC website at
Go online to view the status of a Home Improvement Contractor's Registration:
.,iij - U11 -.11 . - -, 1, , - , " - . , , - " - - , - I � . I - I
For assistance with informal mediation of disputes or to register formal complaints against a business, call:
Consumer Complaint Section
Office ofthe Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800, 508-755-2548 or 413-734-3114
Version 2.1 - 11/22/2010
&\ 77te Commonwealth ofHassachusetts
Deptaftent ofIndustrialAccidents
I Congress Street, Suite 100
Boston, M4 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciansffllumbers.
TO BE FILED WITH THE PERAffrMG AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Orgwiizafion/IndividuaD: Detvi-d 49 P_ & zn .9
Address: 10LJ 17 /11 -z /?
City/State/Z AlXo4i AIR Phone#:.
60-? S09
Are yo mployer? Cbeck the appropriate box:
e
Type Of project (required):
1.71 anin with
am a employer _LernplWees (M andfor part-time)-*
7. New construction
2.0 1 am a sole proprietor or paitnership, and have no employees working for me in
8. Remodeling
any capacity. [No workers'comp- insurance reTjirodj
9. D Demolition
3.Fj I am a homeowner doing all work myselt lNoworkers' comp. insuiance requiull t
4.n I am a homeowner and will be hiring contnactors to cooduct all work on my propody. I will
10 El Building addition
ensure that all contractors either have waikers' compensation insurance or are sole
11-n Electrical repahs or additions
proprietors with no employees.
12. E] Plumbing repairs or additions
5.Fj I am a general contractor and I Jurve hired the sub-camnictors listed on the attached sheet
13. 0 Roof repairs
Those sub -contractors have employees and have vAxkers'comp. insmanceJ
14. [:]Other
6. n We am a corpmation and its officers have exacised their right of exemption per MGL c.
152, §1(4), and we have no employees. INo wmkers'comp. insurance repired.]
*Any applicant that checks box # I must " fill out tbr section below showing their workers' compeination policy infonnation.
t Homeowners vdw subinit this affidavit midicaUng they are doing all work and then hirc, uutWe contmcM must submit a new affidavit indicating such.
tCimtractors did check this box must MWAW an Wilitional sbcct sN;wing the of the si#>contractors and state vhWw or not those entities have
employees. If the sub -contractors have employees, they must pmvide their workers' comp. policy munber.
lam an employer that isproviding workers'compensadon insurancefor ny enployees. Beldwisthepolley andjob site
information.
Insurance Company Name:
Policy # or Seff-ins. Lie.
14 d 117 .,q vl�a 11.7
6,;7 Expiration Date.
Job Site Address:34t/- ToAq,5�,,7 5t—NA17 dO ' city/state/zip: * A,7 ale, Va._ /V/4- 0 / *9S
Attack a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required underMGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
andlor 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 cerfift under thepains and M ofperjury that the informadonpreviiied above is &ue and correct
Tena es
Sip -nature: Date:
Phone#: 0 7
Official use only. Do not write In this area, to be conWleled by city or town offidaL
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact
Phone M
1.18.2016017AA
insurance Solutions Corporation - Page 2 of 2
BH Insurance
OMC ID 16037416 1/1
------ DATE (MMIDDIYYYI
ACORD CERTIFICATE OF LIABILITY INSURANCE 03/18/2016
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TH18 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE IBSUING INSIURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
iMPORTAWT If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGA11ON IS WAIVED, ub ect 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
oartifloate holdar In Ilou of such enclarGernent(s). ONTACT
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PRODUCER NAM
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60 Westville Road AMMMCRQ-
Plaisbow NH 03865
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PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
CERTIFICATE MAY BE ISSUED OR MAY
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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A
WORKPIka COMPENSATION
R2WC659267
11/4/2015
11/4/2016
AND EM PLOYERS' LIABILITY YIN
E.L. EACH AQC IDENT
$.1 0 00
ANYPP( )PRIETORIPARTNERIEXECUTIVE
ExCLuDE Fy
N/A
............ ......................... . . . ..........
.. ..............................
100,000
OPPiCEPimEN18M
E.L. DISEASE - EA EMPLCYEE
11 I ........... . .....................
(Mand4tory In NH)
jfgs, oesorlbe unper.,
0 0 _r
D SCRIPTION 'ATIO NS below
.......................... . ...................... . ......
E.L. DISEASE - POLICY LIMIT
I ...............
$ 500,000
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 110i, Additional Remarks Schoduls, If more apses Is required)
The workers compensation policy does not provide coverage for David M Degagne
Town Of North Andover
1600 Osgood St
North Andover, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE SXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED,� If, 1w I
ACORD 26 (2010106) The ACORD name and logo are reg Istered marks of ACORD
121
Insurance Solutions Corporation - Page I of 2
1__16*1 a
CC)RO CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD1YYyY)
F 3/18/2016
I [CATE HOLDER. THIS
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT F
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 cortificato holdor Is an ADDITIONAL INSURED, tho po los) must bo ondorsod. If SUBROGATION Is WAIVED, Ojoct 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
cortifloato holdor In liou of such ondorsoment(s).
PRODUCER
Insuramce Solutions CorporaLtion
60 Westville Rd
an Miller, CISR, CPIW
PHONE FA
Ext), (603) 382-4600 WXC. No); (003)362-2034
_NCA�L-.
:kndller@iso-ingurance.com
INSURER(S) AFFORDING COVERAGE NAIC
MED EXP (Any one person) $ 15,000
INSURER A -Merchants 23329
Plaistow NH 03865
INSURED
INSURER B !
David X Degagne
INSURER C: —
1049h Mammoth Road
INSURER D:
INSURERE:
INSURER F i
Pelham NH 03076-2193
COVI=KAUhb tr-m itri%�P%i ra Y PERIOD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIC
INDICATED. N OTWITH STAN DING 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS.
NSR
LTR
A
TYPE OF INSURANCE
X COMMIRCIAL GINFRAL LIABILITY
CILAIW-MAC2 7x OCCUR
ALW6
ClUUM
POLICY NUMBER
ROPTO@7853
EFF
Y
(MMOILD'ofyYy d
11/4/2016
(PO LICY EXP
MMIDDIYYYY)
3.3./4/201-6
LIMITS
EACH OCCURRENCE $ 1,000,000
DAMAGE 500,000
PREM I $EST '(ER F_0N0c'ur'r9nG9) S
MED EXP (Any one person) $ 15,000
PERSONAL& ADV 1NJURY $ rnaluded
Attn: Building Inspector
1600 Osgood Street
AUTHORIZED REPRESENTATIVE
Noxth Andover, MA 0184S
GENERAL AGGREGATE $ 2,000,000
Keith Maglia/KRM
GEN'L AGGREGATE LIMIT APPLIES PER:
F—] PRO-
POLICY JECT 7 LOC
PRODUCTS - COMPIOP AGG $ 2,000,000
Property d8rraa"ir)aI9 limIt $
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per Person)
ANY AUTO HEDULED
ALL OWN SC
'ED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
BODILY INJURY (Per eicoident)
PROPERTY DAMAGE
fPr soddent)
UMBREL a
EXCESS LIAO
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
AGGREGATE
-
DED RETENTION $
OTI-
WORKERS COMPENSATION
I I
TA FR
TUT,
E.L. EACH ACCIDENT
AND EMPLOYERS' LIABILITY YIN
ANY PRO PRIETORIPARTNER/EXECUT1 VE F7
OFRCERIMEMBER EXCLUDED?
(Maridatory IM NH)
If rz, dazcrib' 'n""
D SCRIPTION OF OPERATIONS below
N/A
*OEM BELOW
E.L. DISEASE - EA EMPLOYE
E,L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, AddItIorial Remarl(a Schedule, rMay be attached If more space Is required)
*The insured has purchased Workers' Compensation coverage through the Mk Worker's Compensation Assigned
Risk Pool. We have requested the servicing carrier issue a Certificate of insurance on your behalf.
Agents are not permitted to issue Certificates Of Insurance for Workers' Compensation coverage on
policies issued through the MA Worker's Compensation Assigned Risk Pool.
CERTIFICATE HOLDER
(978)688-9542
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL
ME DELIVERED IN
Town of North Andover
ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Building Inspector
1600 Osgood Street
AUTHORIZED REPRESENTATIVE
Noxth Andover, MA 0184S
Keith Maglia/KRM
;h4ft00=1Jn4AArnRnrnQ0nRATInN
All riahts reserved.
W IV &. I -
ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD
INS026 (201401)
7 0
ACCORV CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY I
1 03/18/2016
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(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 endorsament(s).
PRODUCER
CONTACT
NAME:
INSURANCE SOLUTIONS CORP.
60 Westville Road
PHONE (FAX,
(A/C. No. Ext): AIC No):
E-MAIL
.ADDRESS: INSURER(S) AFFORDING COVERAGE I NAIC #
Plaistow NH 03865
INSURERA: AITIGUARD Insurance Company �2390
INSURED
INSURER B
DAVID M DEGAGNE
INSURERC:
INSURER D:
1049B MAMMOTH ROAD
INSURER E:
1 INSURER F:
PELHAM NH 03076
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDLSUBR
INSR
WVD
POLICY NUMBER
POLICY EFF
(MM/DD1YYYY)
(1POILDSM
LIMITS
GENERAL LIABILITY
I
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DA AGE To RENTED
PREM MISES (E. occurrence)
CLAIMS -MADE F I OCCUR
MED EXP (Any one person) $
F
GENERAL AGGREGATE $
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG 1$
1-1 POLICYF-1, JERC0j F-] LOC
$
AUTOMOBILE
LIABILITY
EMBINED SINGLE LIMIT
. .,d."') $
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
NON -OWNED
HIRED AUTOS F_ AUTOS
PROPER DAMAGE
fP.'..cdZ I) $
I $
F_
UMBRELLA LIAB
IOCCUR
EACH OCCURRENCE $
AGGREGATE !$
EXCESS LIAB
___F7RETENTION
I CLAIMS -MADE
DED $
$
A
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE [Y-]
OFFICER/MEMBER EXCLUDE[ Y
(Mandatory in NH)
N/A
R2WC658267
11/4/2015
11/4/2016
WC STATU- Ir TRI -
191 TORY LIMITS _1 I CE
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEP' $ 100,000
if gs, describe under
D SCRIPTION OF OPERATIONS below
E.L. DISEASE --POLICY LIMIT I $ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
The workers compensation policy does not provide coverage for David M Degagne
Town Of North Andover
1600 Osgood St
North Andover, MA 01845
WADACILLA I IUN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED*
'0 1 "t5-ZU1 U ACURU CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
0
0,1-11ce of Consumer Affhirs & Business Regulation
MEW10ROVEME0 CONTRACTOR
Tpd:
X x-piration' ---5/2 Individual
�DAM NE
DAVID Dt GNE.
1049, MAMMOTH RD UN)T
PELHAM, NH 0376 Uuderseiiiwy
J
VVIvidul U only
License or regijr. j�
before the expiratiow-date. Iffound rOturn to:
-Officq. of'Consqmer.Aff#'rsj
J a ess Regulation
Rd Rusin
Plaza' Sul N
Boston, NUA
01
V it out sigh'a e
ki
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
Li6ense: CS -075353
C onstruction Supervisor
DAVID M DEGAGNE %
1049B MAMMOTH Rl)�—,-,,�,774
PELHAM NH 03676'
Expiration:
Commissioner 08/23/2017�