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HomeMy WebLinkAboutBuilding Permit #1032-2016 - 364 JOHNSON STREET 4/1/2016 pORTIi 1 4 ` BUILDING PERMIT TOWN OF NORTH ANDOVER 2-6 APPLICATION FOR PLAN EXAMINATION a � Permit NO: I Date Received "°. . + • Date Issued: I �ss4C ORTANT: Applicant must complete all items on this e LOCATION 3 6 q V 411-'7 S 41100 S'��'�-�� /gy' A�O V f,' P9k Print ,p PROPERTY OWNER �a►/'-e-e vi Print MAP NO: 01% PARCEAI� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Nan-Residential Li New Building u One family Li Addition u Two or more family U Industrial KAlteration No. of units: U Commercial KRepair, replacement U Assessory Bldg U Others: U Demolition U Other U Septic U Well u Floodplain u Wetlands U Watershed District U Water/Sewer '�W l�Ll�`� IV�"o'�' %!'1 ,$`fJ1'I/'"�,'0'l`7 !1 �t,�-' l,✓���Qa e�� SCJ e srZ/7 �QY�''v` C ,17 4 V e d 141 f? /` O Identification Please Type or Print Clearly) OWNER: Name: ,e-e, /`s Phone: Address: 6- I 01,4,/ S 61,7 51 zy, Andv vP� A CONTRACTOR Name://�J Phone: &0,7 S 03- Address: / 157 '/-p,& Ad 10-e A a,-,7 N l� 0301-1;114 Supervisor's Construction License: Exp. Date: o Home Improvement License: 7 8 Exp. Date: s- / ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$12500 PER S.F. �+ Total Project Cost: $ .S ® 0 . ® 4 FEE: $ Check No.: Receipt No.: I NOTE: Persons contraco* vg-w'h unregistered contractors do not have access to guaranty fu d Signature of Agent/Owner ignature of contractor l r Plans Submitted D Plans Waived ❑ Certified Plot Plan [I - 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 Dmmpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS 4 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments a k Wafter& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: a Located 384 Osgood Street �X,IRE��DEPARtTMENiT Temp Dumpstertoii site> lyes ono _ M a ltLocated at1�2'.4'MamSfreet4 ��irbeDepartmentsgnature/date F"` z 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses 4. 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 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 getthis recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location. i n. _✓_ No. �` `-, c, Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $11— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector r -i NORTH.q +0 _ . W' '.. . c . . ve. . No. _ s hve r, Mass I o , I2-A4o COC.4 IC14 1WIC1, _�• R4TEO P,vp y 11 BOARD OF HEALTH Food/Kitchen PER LD Septic System • THIS CERTIFIES THAT BUILDING INSPECTOR ............ .. ...... .......,�.. ... .................................. .................... has permission to erect buildings on �. .... �� !.5Foundation Rough to be occupied as ..� J .... .....31 . �'. ..� v' !...�. ...��..�1.!!!�roe, Chimney ...... ...d.... provided that the person accepting this permit shall.in every respect conform to the terms of the application Final 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 'VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough Service G ............... .. . ........ . .. .. ....................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Buildinz 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. Massachusetts Home Improvement Sample Contract This form satisfies all basic requacmeds of the states Home Impravemeat Ca>mactor law NU chapter 142AI butdoes not include standard langaage to protect hommoi nw& Seeli bWA advice if nece€sary. Any person planning home improvemerds 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 Contractor Information Name ICompany Name OCa tJf d 0 1✓ G 4 ,2 Sfreet Address(do not use a Post Office Bac ) Contractor!Saimpersaid Owner Name CiVrownstate Tp Code t Address include a streetaddian) J Daytime Phone Evening Phone own state Zip Code 7 71— 0/6_ VA 565, 7c �tS v/ct 766 6 ?'P Mailing Address(It different from above) Business Phous Faleral Employer ID or S.S.Number Easr�pwae[c.eewag trmee rxprrrt aree rs:�ear�a� The Contractor agrees to do the following work for the Homeowner. (Describe in detail the work to completed,specifying the type,brand,and g_iade of materials to be used,use additional sheets ifneassarvJ Required Permits-The following building permits are requited Proposed Start and CompkUm Sdwdde-The following schedule will and will be secured by the contractor as the hameawnces agent: be 7amstckca�s beyond the contractors control arise (Owners who secure their own permits will be //excluded from the Guaranty Fund provisions of /// when contractor will begin contracted work- MGL orkMGL chapter 142A.) W�l 46D., when contracted work will be substantially completed. Total Contract Price and Payment Schedule �.p The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of ` (•) Payments will be made according to the following schedule: $ ?000 upon signmg contract(not to exceed 15 of the total price or the cost of special order iittems,whichever its greater) U'i $ G' by_/ /_or upon completion of,zz�p ✓, $ by_/ /_or upon completion of $ 040 upon completion ofthe contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment mbe special S to be paid for ordered before the contracted wade begins in oder to meal the completion whedole.(**) $ to be paid for NOTES:(*)Including all finance cbmW(**)Lawrequa that any deposit ordown-paynxnt regmred bythecontrader befae work begins may not exceed the greater of(a)ate-send of the total ventrad pries or(b)the acl®l cost of'eryspeciat egmpmad or—tan made material which must be special ordered in advance to meet the completion schedule. fires wamrrty-is an emreu waevaam idea aravYei 6vthe eaamaBer? 11 Yes raUaeraw of thewarranty moor[ie 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 imder this aweement Contract Acceptance-Upon 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 Hone 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 Plate,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 • Know your rights and responstbilifim Read the import=hfferrusation 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 contractors normal place of business,provided you notify the contractor in wri at his/her main office or branch office b mail telegram sent or deli not later than midnight of the tuna Y arlorztY 1���' � tiY �', Gh third business day following the signing ofthis agreement Seethe attached notice ofcancellation form for an explanation ofthis right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two identicil copies ofihe co and sued.One copy sbualdgo to me hameownc.The alba copy should be kept by the contractor. r H eowner's Signature Cormactor's signature Date 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 contractor,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 of ConsugppAlffliiii and Business Regulation and the consumer shall be required to sub husetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE:The sign of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. 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 are 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 bath 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 work. 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 - If you want to verify the registration of 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 617-973-8787,888-283-3757 or visit the HIC website at Go online to view the status of a Home Improvement Contractor's Registration: For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-9400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-7343114 Version 2.1-1 1/22/2010 Addendum A 364 Johnson street North Andover -install new 6'wide Anderson vinyl sliding patio door leading to deck -Eliminate windows on each side of new slider -Replace back window in sunroom with Anderson double hung vinyl window -Eliminate front sunroom windows and install 2 side by side Anderson double hung window units -Replace vinyl siding on sunroom -Patch and sand interior walls as required -Move electric as required/install light next to new slider as required by code -Re route and modify baseboard heat to allow for sliding door access -Remove all job related debris The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,AM 02114-2017 www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/ElectricianslPlumbers. TO BE FILED WITH THE PERAHTTING AUTHORITY. Applicant Information Please Print Let biy Name(Businessforganizationandividuai): Qq,yi-;C� M e Address: ©IV ` -A City/State/ZipA-/ Gn i AIR 030;;' � Phone#: Are yo n employer?Check the appropriate box: Type of project(required): 1. m a employer with_employees(full andtor part time)_* 7. Q,New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in S. remodeling any capacity.[No workers'comp.insurance required.] 9. 3.0 lam a homeowner doing all workmysel£[No workers'comp.mm suncerequired.]t Demolition 4.F1I 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 11.[_Wlectrical repairs or additions proprietors with no employees. 12.[ ILS 5.E]I am a general contractor and I have hued the sub-contractors listed on the attached sheet 13. oof repairs These sub-contractors have employees and have workers'comp.insurance) 6.0 Weare a corporation and its officers have exercised theirright of exemption perMGL c. 14.0 r 152,§1(4),and we have no employees Wo workers'comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'eompansatioa policy infommtiont° t Homeowr errs who submit this af£ndavitindicating they are doing all work and then hire outside contmetors must submit a new affidavit indicating such $Contractors that checkthis box must attached anaddit fond street showing the name of the subcontraetorsand state whetlreror not those entitns have employees. If the sub-contractors have employees,they must provide their workers'comp.policy mnnber. I Iain an employer that is providing 3vorkers'compensation insurance for n.y employees Below is the policy and job site information. Insurance Company Name: /)'f q ay/11 L/f S rrr r 7 c-e (�p Policy#or Self-ins.Lie. Expiration Date: l -- al Job Site Address:_34�51;' T01295or7 5 — a(-, ti's' City/State/Zip:All Attach 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 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 cern under thepains and enaNes ofperjury that the kformadon provided above is true and correct: Si afore: �` Date: (0— A: Phone#• 6�e,7 Q 8 7 -;k.- 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: ■ insurance Solutions Corporation - Page 1 of 2 ■ ■ ® DATE(MM/DDA'YYY) CERTIFICATE OF LIABILITY INSURANCE 3/18/2016 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 poll s)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 doss not confer rights to the certificate holder In Ileu of such ondorsement(s). I' �RooucER Kathleen Miller, CISR, CP IW PHONE (603)362-4600 FIC No): Insurance Solutions Corporation (603)382-2034 A/C No Ext 60 Westville Rd ADDRF06;kmiller@isc-insurance.00m INSURER a AFFORDING COVERAGE NAIC;F Plaistow NH 03665 INSURERA Merchants 23329 INSURED INSURER e David M Degagne INSURER C: 1049b Mammoth Road INSURER D INSURERE: Pelham NH 03076-2193 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1631826091 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 ECERTIFICATE MAY BE ISSUED OR MAY PERTAIN,XCLUSIONS AN CONDITIONS OF SUCH PO ICIES..LFIINSURANCE AFFORDED POLICIES HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS SHOWN MAYHAVEBEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER MM/DOMYYY MM/OOM(YY AWL LIMITS LTR 1,000,000 X COMMCRCIAL GENERAL LIABILITY EACH OCCURRENCE $ j� CLAIM&MADE F}{ OCCUR UAAQ' 500,000 -PREMISES Ea Occurrence $ ROP1087663 11/4/2016 11/41/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ Included GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 7 X POLICY IECOT F—]LOC PRODUCTS-COMP/OPAGG $ 2,000,000 Property damaoe-sln0le Ilml[ $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON�OVvNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Peracdden[ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS MADE AGGREGATE $ $ DED RETENTION WORKERS COMPENSATION 11 P1357ATUTE ER AND EMPLOYERS'LIABILITYYIN $ ANY PRO PRIETORIPARTNER/EXECUTIVE ygs E.L.EACH ACCIDENT eBLow OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ F ae,dezcribe under E.L.DISEASE-POLICY LIMIT $ IDESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES (ACORD 101,Additional RemarUs Schedule,may be attached If more space is required) *The insured has purchased Workers' Compensation coverage through the MA 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 CANCELLATION (9-18)688-9542 SHOULD ANY OF THE ABOVE D!!BCRIDED POLICIEB DG CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL CE DELIVERED IN Attn: Building Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Keith Maglia/KRM Q 1968-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD INS026(201401) ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MMfDD1YYYY) 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 endorsement(s). PRODUCER CONTACT NAME: INSURANCE SOLUTIONS CORP. PHONE FAX A/C No Ext): AIC No): 60 Westville Road E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURERA: AmGUARD Insurance Company 2390 INSURED INSURERB: DAVID M DEGAGNE INSURERC: 10498 MAMMOTH ROAD INSURER D: INSURER E PELHAM NH 03076 1 INSURER F: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBERMM/DD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE __ $ COMMERCIAL GENERAL LIABILITY DAMAGE (RENTED PREMISESS Ea occurrence) $ CLAIMS-MADE FIOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTYDAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC STAT% OTH- AND EMPLOYERS'LIABILITY Y/N R2WC658267 11/4/2015 11/4/2016 TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 O(Mandatory BERNH)EXCLUDED? N/A E.L.DISEASE-EA EMPLOYE $ 100,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below , E.L.DISEASE-POLICY LIMIT $ 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 CERTIFICATE HOLDER CANCELLATION Town Of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 Osgood St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover, MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ' �1e Qp'o�»unw���'C/�.cr�dccclucap� Office of Consumer Affairs l�Business Regulation ME iF�IORG)VEMENT CONTaRAO T OR 7 TYp&: r gistraiioru: ,; 76$66 - = ;�iratirin:.4 5125%2 16 Individual- DAVID DtOAGNE. :-Y PELHAM,NH 0376 Underseerf$ary License or regisf'ra`Iloasaiid 1v: t0vidul use only before the expiratioufdate. Iffound r0turn to: 4?€9'ccqof Cons enipr.Afjrs agd$.usiness Regulation id Paik Plaza-Spite 517(f A Boston,MAS 1.-:6-- A x Liot v9ti :�yithisirf sig- ` e < �v - Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-075353 ' Construction Supervisor ikt IN nEi. h DAVID M DEGAGNE 10498 MAMMOT14 D�- = PELHAM NH 03076 =. 4 "^^ Expiration: Commissioner 0812312017,