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HomeMy WebLinkAboutBuilding Permit #1134-2016 - 364 JOHNSON STREET 4/27/2016 Of 1►O tlr q < < AAe-4 ,6 BUILDING PERMIT 3: ,�:�. • �'�e��� TOWN OF NORTH ANDOVER ° I 1 APPLICATION FOR PLAN EXAMINATION , s s � Permit NO: Date Received Date Issued: ?Ss�acrws�� IMIPORTANT:Applicant must complete all items on this page LOCATION t_'� Jy'�d�S a-7 S -e e� Al,k, 14411+ tf ` PROPERTY OWNER aC/O'�' -fin Prin;4,r`,j 12 y z Dd,STR,CT : MAP NO: �J PARCEL:fZONING Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-:Residential U New Building 90ne family "ddition U Two or more family U Industrial U Alteration No. of units: U Commercial U Repair, replacement U Assessory Bldg U Others: U Demolition U Other U Septic U Well U Floodplain U Wetlands U Watershed District U Water/Sewer Identification Please Type or Print Clearly) g OWNER: Name !/�� e.,7 P-7 sdy Phone.- Address: hone:Address: 3 (2- O'tih S 0;17 SL /V. CONTRACTOR Name: ate: y" Phone: 603 Fc1,q- Address: / o i�-Jq g j 4(l 19d/7 Q O� Supervisor's Construction License: 0 7 s 3 � 3 Exp. Date: S Home Improvement License: Exp. Date: A?-(9-1,16 " 4 ARCHITECT/ENGINEER Phone: Address: Reg. No. i FEE SCHEDULE:SULD/NG PERMIT.•$1200 PER$10W.00 OF THE TOTAL ESTFMATED COST BASED ON$125.W PER S.F. Total Project Cost: $ FEE: $ _1 — Check No.: 2 Receipt No.: 3 6 1_10 NOTE: Persons contracting unr ed contractors do not have access to the gu ranty fund Signature of Agent/Owner ig ure of contractor &_-,4j� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑' 'Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Z7 I j2blK Signature I COMMENTS (Mtkl nI �)b) G . Ox. 006 Y WON)) �1�. �� �kr���� m�nimU� �n� �u��c , P�(�►crl CPxl�f(� �n O�u(!z �2.�� 11 Z CONSERVATION Reviewed on Si nature VU COMMENTS_ l,J� ,vim 1 O D HEALTH Reviewed on Signature COMMENTS I ,honing Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes panning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREfDEPAR4TiMENT -`Tern ®ump terr�on7�siteyes _ �no µ� LM caedaay e`iD,;epartMMENTI - - _----- 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 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 get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location l� No. �� �� _ ?rA �,P Date -7 r • TOWN OF NORTH ANDOVER .:, Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ , Check# Building Inspector r 1F NORTH .� Wt . 2 � � A. .. - O ti - to No. ZT '� ),APIG- h21 ver, Mass COCHIC641WICK yT x.95 RATED tui BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT PERMt re#J BUILDING INSPECTOR ................. ........................ ..... ...�......."................. ................ has permission to erect .......................... buildings on . ,.� ,,; Foundation ..................... .. ...: ................�:. Rough to be occupied as ....... . ... .................................. Chimney 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ................ .... . r.!:................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required 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. PLOT PLAN NORTHERN ASSOCIATES, INC. "'=X ST. 2ND FLOOR ANDOVER, MA 01810 TEL:(978) 837-3335 FAX(978) 837-3336 MASSACHUSETTS ' Y-2=7 4GOR- DOREEN PRISBY DEED REF . -ATION. 364 JOHNSON ST PLAN REF. ASSESSORS 7 STATE: NORTH ANDOVER, MA SCALE: 1"=40' DATE: 4/20/16 JOB ##: 9� L� I I I I � I o� FI V 1 I O I I o (e' X ZO-) I 38 o PROPOSED DECK I � - y # 364 EXISTING DWELLING azo f ABB07-,T s T TREE JOHM J. • 87 1 d 86'1 141 _ _........ f � 70 g x� a /* f ®I If UO ❑ IN 0 9 VA '"� C8 Q Mvissachnsetts Home Improvement Sample Contract This form satisfies all basic requirements ofthe stab's Home lmpraverricul Contractor Law(MM chapter 142AI bat does not include standard language to prated homeowners. Seek legal advice ifnecessary. Any prion planning home improvements should first obtain a copy of'A Massachusetts Consumer Guide to Home ImprovenumY before agreeing to any work on yam residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumrer Information Hotlinc at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information �} / � D l ICJOJ^ ( �r Shred Address(do not a O&ce Burr J � me ) Connected Salesperson!OwncrName 017-7 pann sideezipCodeBusiness Addtesomeludeaad&=) AAol , �y ! / " C { Evening 0;;, C&0�� Mmh'ng Address(h diffenart from above) Business Phone lFedea EmployerID arS S.Number n---C-66 ra�mpwmteamdaaet.rtmm5er Fapi4m The Contractor agrees to do the folbwmgwork for the Homeowner. (De/ssrn�►bein the rval;t000mpdetedsDedtvmethe type,brand,and guide of to be used,use additional sheetsin ). i 1, , �� 7 C�`vAJ/f�v�'7 i.✓i �7 g -act /�'T '7-,'-' s(j e �/rp,--id v s�-'p �a-�s S c ^e �,-���c� /v.�.d v� der4i15 Q,/Qr ,�►�z r/, Required Permits-The following building permits are required Proposed Start and Coffin Schedule-The following schedule will and will be secured by the contractor as the homwivaces agent: be adhesed to Mess circumstances beyond the contractees control mise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of 17r!46e when contractor will begin contracted work MGL chapter 142A) ,I f Date when contracted work will be substantially completed Total Contract Price and Payment Schedule Si pO The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of Pa will be made according to the following schedule_ upon signing contract(not to exceed 15 of the total contract price or the cast of special order items,whichever is greater) Ser0eby / / or upon completion of DF�G�1 / !'tt.+?�' IV��t J"/t; / 7�Rt�l`r�1�•� $ (� by_/ 1 or upon completion of S��S J C upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following mate iallegoipman most be special $ to be paid for ordered before the contracted workbegins in order to meet the completionsdreddc(—) $ to be paid for NOTES:(')Induding sii fig chmgm C')law..4aiI that any depositor down-paymar required"the contractorbefae work begins may not exceed the gectc of(a)me-third ofdm total cmuactpuez or(b)the acted cost of aagspecial equipment orwstom made material which must be special adaw in advance to meet the completion schedule. ExprereWarranty-Isanaprenwarsaalvbdaearovidsdbythe contractor?M NoflYes(all' of the warranty must besttechedto 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 a8ltcuicat ' 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 sigaing 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 ContractorRegistration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvrmment Contractor Registratiun. You may inquire about contractor registration by writing to the Director at 10 Park Plan,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 • Knowyour rights and responsibrlities. 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 busmess,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 ofthis agu'eanent See the attached notice ofcancellationforna for an explanation of this right DO NOT SIGN PUSTONTRACT BIWRE ARE ANY BLANK SPACESM oidaicdcopiesofine nmabecamptrredsadsWc&oaocapysboaw�to8apa�awoa.nKetheroopyslwatabekqtlryttrcrmVaaor. 11 1? H eowner's Sign Contractors 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)1f 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 be/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 Consumer Affairs and!_40SinesS711cgulation and the consumer shall be required to submit h arbitration as parlvi assach eral Laws 142A t H ees Si Contractor's Signature OTICE:The of es above apply only to the agreement of the parties to alternative dispute resolution initiated tractor. The homeowner may initiate alternative dispute resolution even where this section is not se signed by the parties. Homeowner's Purrs 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 agrcemcak However,homeowners may be excluded from certain rights if the contractor they choose is not property registered as prescribed by law. Homeowners who seem 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 wop.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 sig 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 inciances 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 contimung 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 orif 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 PIaza,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 Horne 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 617-727-8400 AND/OR Better Business Bureau 508-6524800,508-755-2548 or 413-734-3114 Verson 2.1-11/27!2010 License or registri tion'vatid fi� 'ftvidul use only before the expiration date. If found return to: 4?ffice4 of Cons4mer Affgjr�pnd Business Regulation 10 Park Plaza-Suite 5176 Boston,MA1.1 Massachusetts Department of Public Safety �� Board of Building Regulations and Standards License: CS-075353 " Construction Supervisor Not v$Ie{" itltout sigraa e r N DAVID M DEGAGNE ., 1049B MAMMOTH RD, PELHAM NH 03076 : �..n� Expiration: �a �� �ncuea�/o� a uczc cr lG� Commissioner 08/23/2017 �\ Office of Consumer Affairs&Business Regulation MUM ME IMOR®VEMENt CONTRACTOR egistrafion: 178$66 Typd: i xpiration: 5&2 nOlB Individual DAStID DEGAGNE ' DAVID DEGAGNE. 1049 MAMMOTH RD UNIT-6 PELHAM,NH 0376 Undersecretary i J ) ® DATE(MMIDD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 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). 'RODUCER CONTACT NAME: :NSURANCE SOLUTIONS CORP. PHONE FAX AIC o Ex A/C No): 50 Westville Road E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC t/__ 'laistow NH 03865 INSURERA: AmGUARD Insurance Company 2390 NSURED INSURER B: )AVID M DEGAGNE INSURERC: L049B MAMMOTH ROAD INSURER D: INSURER E: _ 'ELHAM NH 03076 1 INSURER F: :OVERAGES 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. tSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS .TR INSR WVD POLICY NUMBER MM/DD MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $____ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE ElOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ _ POLICY PRO 7 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION J WC STATU- OTH- 4 AND EMPLOYERS'LIABILITY Y/N R2WC658267 11/4/2015 11/4/2016 �A' 0 Y L I _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 IESCRIPTION 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 :ERTIFICATE 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 "_6X ©1988-2010 ACORD CORPORATION. All rights reserved. tCORD 25(2010/05) The ACORD name and logo are registered marks of ACORD insurance Solutions Corporation - Page 1 of 2 DATG(MM/DDIYYYY) cC�Rv® CERTIFICATE OF LIABILITY INSURANCE 3/18/2016 'HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS :ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES IELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), I.EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, VIPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to he farms and conditions of the policy, certain policies may require an endorsement- A statement on this certificate doss not confer rights to the :ertlflcats holder In Ileu of such endorsement(s). )DucER Kathleen Miller, CISR, CPIW surances Solutions Corporation PHONG (603)362-4600 A1C No;1609)902-2094 A/C No Ext Westville Rd E-MAIL9kmiller@iso-insurance.com INSURER 6 AFFORDING COVERAGE NAIC i aistow NH 03865 INSURER Merchants 23329 URED INSURER B ,vid M Degagnc INSURER C j49b Mammoth Road IN6URGRDI INSURERE: :lham NH 03076-2193 INSURERF: )VERAGES CERTIFICATE NUMBER:CL1631826091 REVISION NUMBER: PHIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS HE INSURANCEDESCRIBED =,ERTIFICATE MAY BE ISSUED OR MAY PERTAIN XCLUS ONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVEEBEEN REDUCED BBY THEIY PAID CLAIMS.ES HEREIN IS SUBJECT TO ALL THE TERMS, TYPE OF INSURANCE POLICY NUMBER MMlOD/YYYY MM/ODIYYYY LIMITS z X COMMRRCIAL GENPItAL LIABILIT1000 000Y EACH OCCURRENCE $ , 500,000 CLAIM&MADE D OCCUR PREM 13 3 Eeoccurrence ROPIO87853 11/4/2016 11/4/2016 MED EXP(Any one p9mon) $ 15,000 PERSONAL&ADV INJURY $ Included GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 2,000,000 X POLICY 7 JJERCOT LOC Property demege-slnCle Ilmlt $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) III AUTOS AUTOOVVNED PROPERTY DAMAGE $ Persccldent HIREDAUTOS AUTOS $ UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCEGGLIAB HCLAIMS-MADE AGGREGATE $- $ DED RETENTION WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N e E.L.EACH ACCIDENT $ ANY PROPRIETORIPARTNER/EXECUTIVE 9�� BELOW N OFFICER/MEMBER EXCLUDED? /A E.L.DISEASE-EA EMPLOYE $ (Mandatory In NH) IFYros,descnbe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below :SCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional RemarVa Schedule,may be attached Ir more apace is requlred) The insured has purchased Workers' Compensation coverage through the MA Worker's Compensation Assigned isk Pool. We have requested the servicing carrier issue a Certificate of Insurance on your behalf. gents are not permitted to issue Certificates of Insurance for Workers' Compensation coverage on olicies issued through the MA Worker's Compensation Assigned Risk Pool. ERTIFICATE HOLDER CANCELLATION 978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DG CANCELLED CEI'ORt: THE EXPIRATION DATE THEREOF, NOTICE WILL GE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Building Inspector 1600 Osgood Street AUTHORt1FDREPREBENTATIVE North Andover, MA 01845 r