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HomeMy WebLinkAboutBuilding Permit #793 - 37 ROCK ROAD 6/7/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No: 7 429 Date Issued: 6/7 LOCATION PROPERTY OWNER MAP. 210 PARCE TYPE OF IMPROVEMENT New Building Alteration Repair, replacement Demolition Date Received ANT: Applicant must complete all items on this pag, Pr►►ii,. ±F ZONING DISTRICT Historic Distract' .77r7 --77777777777L' Nlachme:Shop PROPOSED USE Residential One famil Two or more family No. of units: Assessory Bldg — Other s Z h Non- Residential Industrial Commercial Others: �Wel;l Floodplain U1letlands Watershed District 3 DESCRIPTION OF WORK TO BE PREFORMED:1 1al e AQA 0�5��� `cam Cow.w�ov� �o��r`n �he� �„no�S�e�r ��� 'Co ct G✓�Y\4Jev1 d I f I oc)Y' I entification PXIe Ty e or Print�Cle rly) OWNER: Name:%Vh �^`"�► .M�.�.�eh Q'Jc1ePhone: ARCHITECT/ENGINEER Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ Q`J FEE: $ v? Check No.: �Receipt No.: 3 y y NOTE: Persons contracting nr g' red contractors do not have access to tl g r fund Si nature of contra Signature of Agent/Owner g ctor L Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ 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 Pian ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco SalesFood Packaging/Sale's Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Sianature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: 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 Doc.Building Permit Revised 2010 Location57 v `,—,(A No. ";�� Date NORTH TOWN OF NORTH ANDOVER ` •i, a Certificate of Occupancy $ ;�%;�,�,s <�• Building/Frame Permit Fee $ y Foundation Permit Fee $ Other Permit Fee $ TOTAL $ t Check # �n 23444 D� Building Inspector CAm m x C m m CO) m v, C � � d yCD n Com! y CD O 'O ar � O CL _• y aC= -0 O O CD CD O CLQ - d CD CCD O CCD C CD y. CD CZ O_ CO) CD � I �Q S D y O 10 Z CD O CD O CCD E cn cn n 0 cn cn cn G� n �l cn O� 0 z cn C O O Z O_ CD O _ m 0 o� c a _ m m C 0 CA C CL O N H CD C13 �� 0 z Mu d y dc ® y y _ Ot CD n ® C7 • co) C2 C. �. =-O y r.► _ ...r CD O S d "►CL CD 0 = m O m O y y W O�m m S �CD Q 2>4 C of O y CO9 'm acft� o?_J CD y C7-0 CL 94 Q d y � L 0 00 = • n A��"C •C C H �m H _ m CD • CD: so GO: o CD 3 m' 0 y p p go m CL -x ?' CD rF �. .. 0 mm O m G x q n n C�: o CD 3 m' ;v y p p go m CL -x ?' n: omCJ "d � Ix w n G x C n C�: a cn 0r- o o, 3 ;v y p p Cil ItPiz -x ?' z "d � Ix w n G x C n O , a M M J H 0 9 4 6s a 0 c Massachusetts - Department of Public Safety Bard of Building Regulations and Standards Construction Supervisor License License:. CS 87851 Restricted to: 00 MICHAEL R NORMAN 10 KELLEHER AVE PLAISTOW, NH 03865 Commissioner Expiration: 9/23/2011 Tr#: 4777 ,,pp�� /:e l°iom►mw�zureal�! a�./jiiaaockiucaetl6 �\ Board of Building Regulations and Standards License or re istratio aI'd f ' A. 'd I 1 HOME IMPROVEMENT CONTRACTOR Registration: 160921 Expiration: 9/10/2010 Trll 274572 Type DBA M.R. NORMAN PROPERTIES:8� pEVELOPMENT MICHAEL NORMAN 10 KELLEHER AVE PLAISTOW, NH 03865 .�'_- Administrator g n v or m m u use on y before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 &7Q Not valid without signature fl' S,< i,.f :fes,;,. "V X;,, Y x jD, 'F". N4.:.... f^•i :A a MA C'S. License:R,.t8FC 51, .VL,,V C#: 16CO21 Project, Address: Judltl ,i: ,;Maarten. Oude La sink :ldsk la«d: - �,� a �atl�•a�ara: 8: a"'or�ir�n�rk �..�t�xaxf . , Reinodefinn, We hereby propose to €tarnish the permits, iisurance lab rf.and materials to complete the'fo lowing badroorn remodeling project as described belown Allowances: 9 $1500 for Vanit es and `f'cyps. v $,5010 far 3,P iece Shower or `F-ub Electrical: Ne -,v Ventilation Fan, S itsl:eS, Outlet Corners, $200.for Lights is plumbing. 334.3 for: Shower Valve s; 4 ead(s), $3W for-Fatacet(e�, Sf-',W for Tellet(s) * Flooring: $3.5€3 per sgift ¢or File - * Slu-mv r Boor: Cust€ mer to pa:r6ase a. Derno.and. Replace E L-fing File Floor and Walls `©. _Neira Tile Floor with f/V Fiber Cement Board. Underlaypienl P- Demo Ex,sting.laluarbMg Drain it3 d Install New r Drairt d, Demo and Replace 1.0 let, vari;y, cow-ite top/sink, custorn fle s- ho ier (12" x 12' Liles) e. ixasst>all new glass shower door (Cr£stomer to Purchase) f. Ne -vv Ventilation Fan g. Sho„ver to have TileFloor (Subtract WU if Shower Base is resireel� fi. Tile Shower t:oha,,T 16n FiNer Cement Board ii1eiEiyment i, f4ew, Double llov.4 Var&, Fauce s ame, Light Bar Abo-ve i. t n L31£f3f3c3itF3. J3G i�t3s'i'£�i i3L $.if needed (Extra charge of $2.50 if applicabl�'� 2. Remodel C'ormmon Baflirooni a. Demo and Replace Exisgrtg Tile IrVall and Shotnxea. b. New Bathtub with filed Shower Walls C. Tiled Shower IATails to Have W” Faber Cement Board U £tderlayment d. New, Toilet e. i' ew. 30" snit r w/'lTcp:andl *'aucP.t f. Hexer Ventilation Fan g. New `file Floor wvith W' Fiber Cement Board Underlavrnerit 3. Ren -tore all debris 4. Faxes Included S. Customer to rernox:e wallpaper and paint walls and ce lhngss a:. Any dan:tape to dry -i. -call .that occurs during removal of ti:.bs will be.repaired b. Walls and. ceilings will rennain undamaged 6. Work to be started within 4 weeks atter signing oft. co�tµacr; %. IiAlork to be completed wiihir 3 -mont s i$ftEi start chat. Allowances: 9 $1500 for Vanit es and `f'cyps. v $,5010 far 3,P iece Shower or `F-ub Electrical: Ne -,v Ventilation Fan, S itsl:eS, Outlet Corners, $200.for Lights is plumbing. 334.3 for: Shower Valve s; 4 ead(s), $3W for-Fatacet(e�, Sf-',W for Tellet(s) * Flooring: $3.5€3 per sgift ¢or File - * Slu-mv r Boor: Cust€ mer to pa:r6ase We hereby propose to ftwnish thepermits,insurance, labor, and materials for tate specifications above €or the som oh ($15,950,00). Sixteen thousand nine hundred fifty dollars Paymentas:Follows: Signing of Contract $1000 Start Bate: $6000 One Bathroom Complete: $2000 Tile Complete on Second Bathroom (before finish plumbing is complete): $5000 Finish_Date: $2,950 All material is guaranteed to be as specified. All work to be completed. in a substantial workmanlike manner according to specifications submitted, per standard practices, Any alteration. or deviation. from above specifications involvingg extra costs will be executed only upon written. orders,: and will become an extra charge over and above the estimate. .All agreements contingent upon strikes; accidents.or delays beyond our control. Owner to carry fire andother necessary insurance. Our workers are fully covered by Workmen 's:Compensation insurance.. If either party commences legal. action to enforce its rights pursuant to.this agreement,, the prevailing party in said legal action sha?t be entitled to recover. its reasonable attorr+ey s fees and: costs of litigation relating to said legal action, as determined by a court of competent jurisdiction. Authorized S:ignatuxe Customer Signature 5/29/2010 5/29/2010: �uHsirk The Commonwe¢lth of Massachusetts Department o f Industrial Accidents Office of Investio ations 600 ff ashind ton Street Boston, M4 U2111, Workers' Compensation Insurance Affidavit: guna s/ )P1icant Information Contractors/Electricians/Plumbers -T1 _ Name (Business/Organization/Indii ideal): ,/ v\ i , Address: to KPAO-t cam. City/State/Zip: Fko 5wwt pla jl Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4, (�` I am Type of project (required);eral (full and/or part-time)* ❑ I contractor and Iemployees ��:n have d the sub -contractors 6 ❑Nevi construction2. am a sole proprietor or partner_listed ship and have no employees the attached sheet 1 7. ❑ Remodeling working forme in any capacity. These _b -contractors have ' 8 ❑Demolition workers com insurance. [No workers' comp: insurance p . 5. ❑ we area corp 9. ❑ Building addition oration required.] 3. ❑ am a homeowner doing and its officers have exercised their 10 0 Electrical repairs or additions .I all work myself. Y [No workers' comp. ri t of ex �OIl P� MGL 11.❑ Plumbing repairs or additions C. 152, § I (4) and we insurance required.] t have no em ees. [No workers' 12-E] Roof repairs comp. insurance required.] 13•7 Other '� °-ny aPpirc^nt that 6e-kq bo•,.'#! IMM! als(, SL! ULC the se'alicm be..,,, t Iiomeowners who submit this affidavit indicating they are d-iz womeas comY�.•a+:oc ...,hcy T !0MtBcton a, workand that chwl; this box must attached an additional sheet showing th-'hire Outside eoatmct= mu.M s rbmii new af�'idavii indicating such. o the name of the s ub-contractors -Tam an employer that is providing workers' and their workers' comp. Pobcy information. compensation insurance information. Insurance Company Name: S4ee for my employees. Below is the policy and 'ob site �� Cc1V��YVJL�eY reyVECC Policy # or Self -ins. Lic. #: Expiration Date: Sob Site Address: Attach acopy of the workers' City/State/Zip: 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 ) fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK penalties of a of up to $250.00 a day against the violator. Be advised that a co ORDER and a fine Investigations of the DIA for insurance coverage verification. PY of statement may be forwarded to the Office of I do hereby certify Official use only. City or Town: ofPer.%ury thiat the information providedabove 4F true and correct Do not write in this arca, to be completed by cixj, or town ffc� Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Tom 6. Other I"ermit/License # Clerk 4. Electrical Inspector Contact Person: Phone #r: 5. Plumbing inspector Information an- d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees: Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association o$ other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintemiance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work =12 acceptable evidence of compliance with the insu=e requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificates) of insurance. Limited Liability Companies (LLC) or. Limited Liability Partnerships (LLP) with no employees other than the members or partners,are not required to carry workers' comp enation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be &tire to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permnit or license is being r eaues*.ed, not the .D--nartmeztt. of Industrial Accidents. Should you have any questions regardirag the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies. should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space- at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a- reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under `.`Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each . year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would Bice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address, telephone.and.fax-number..._.. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Inyesfddations 600 Washington Street Boston, ILA 02111 Tel. # 617-727-4900 e,)1406 or 1-977-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 vww.mass._ aov/dia. JUN -7-2008 09:17A FROM:PHANEUF INSURANCE AG 9783720431 TC:16039742875 P.1 ACORO® CERTIFICATE OF LIABILITY INSURANCE °"00107"""" 010 " 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 CER1IF1cArE OF TIII t1moNGE tJQES IWT t:OMSTriv E A LON'rR4ACT VETYWrEN TWE OMMG fltbUROMS), INMTHOWED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polley(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endoreemen A statement on this certificate dove not confer rights to the certificate holder In lieu ofsuch endorlmnent(s). PRDDucER mumPeher J. Phaneuf Norwood Ins. Agency, Inc.PHONE C/O Phaneuf ins. Agency, Inc. P.O. Box 1296 FAX sa 97B 371311139 MIc - 978 3120431 L Fos: I+Roouct•R Haverhill, Ma_ 01831 INEIIRAFFORDBIOOOVERAOE MAIC M INSUa¢o WSUR RA. NGM Ins. Co. MichaetRyan Norman QBA Norman Properties & Developement 10 Kelleher Ave. Plaistow, NH 03885 I SURats c INStatER c INSURER D INWRERE- INSURERF. COVERAGES CERTIFICATF AIIIMRFR- RFVLCI[]IU 101MRFR- 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. LTR TYPEOFINAURANCE ■YBR NUM6ER ..` POLICPOLICY MOVI EFF POLICY EXP LIMITS A OENaRAL U ABIUrY X I COMMERCIAL GENERrrr^^^A���L'''---UABIL17YPREMISES_('alvc,menee CLAIMS MADE � OCCUR F F CP092417 1129200911292010 EACH OCCURRENCE S DAMAGET S Qarla MED EXP Ar one arson S 10,000, PERSONAL & ADV iNJURY s 500,M), GENERAL AGGREGATE a 1,000.000. GENT AGGREGATE LIMIT APPLIES PER Fp- COMPIOP AGO $ X POLICY PRO.JECT F-1 Loc $ AUTONIDBILE LIABILITY ANY AUTO COMBINED SINGLE LIMB ! (Ea accidenn BODILY INJURY (Per person) $ ALL OWNED AUTOS BODtLV INJURY (Pm eoslderA) S SCHEDULED AUTOS HIRED AUTOS �� PROPERTY DAMAGE (per accloem) S $ NON -OWNED AUTOS E UMBRELLA LUIS HCLAIMS-MAOEAGGREGATE OCCUR EACH OCCURRENCE 8 S EXGEee LUIS DEDUCTIBLE S RETENTION S WORKERB COWENSATIDN AND EM PLOYRU' UAIMLITY ANY PROPRVrCA1PARTNERIEXECUTME YIN OFT- CE"ENBER EXCLUDED? a M I A STA O SO U S _ EL EACH ACCIDENT s Et DISEASE - EA EMPLO S tMandefory,In NN) IIyes, �� under NnmgF -qrrr]Aj PRnv]R L DISEASE - POLICY LIMB F IF] DESCRIPTION OF OPERATIONS 1 LOCATION31 VEHICLES (Atheh ACORD 101, Addhimal Rom rks SchaauK K mon spam Is mqul" Carpentry Town OI North Andover SHOULD ANY of TUE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE 1600 Osgood St POLICY PROVISION& North Andover, Me. 01645 AUTHORIZED REP TATIVE O 1988- 20D A ORD CORPORATION. Ali rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered maraca of CORD FEB -17-2010 12:31 tw. o* P CERTIFICATE OF LIABILITY INSUMNCE PRODUCER INSURANCE SOLUTIONS CORP THIS CERTIFICATE IS ISSUED AS A MAT 60 WESTVILLE ROAD ONLY AND CONFERS NO RIGHTS UP( PLAISTOW, NH 03865 HOLDER. THIS CERTIFICATE DOES NOT (603) 382-4600 ALTER THE COVERAGE AFFORDED BY i NSURED PALE NORMAN INSURERS AFFORDING COVERAGE 9 QUAKER STREET INsuRERa NEWTON NH 03858 INaUAERa: P.001/001 DATE (MM/OWYVV) 211712010 OF INFORMATION THE CERTIFICATE FEND, EXTEND OR POLICIES BELOW. —7MAIC # 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R knwu_ . LLABILJTY MERC{AL GENERAL UABIL'TY CLAIMS MADE E-1 OCCUR LIMIT APPLIES PER. DMOBILE LIABLrry ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-ONINED AUTOS AGE LIABC.ny ANY AUTO EXCESS/ UMBRELLA LI"Wy OCCUR CLAJb4S MADE DEDUCTIBLE RETENTION $ A WORKERS COMPENSATION AND EWC2-315275921 01D EMPLOYERS' UASILfrY 0 PROPRIETORIPA4TNERlEXECUTNr YIN OFFICER/ MEMBER EXCLUDED? jAZ.', ." in NN) Y OTHER COMBINED SINGLE LIMIT $ (Ea aaidenl) SCOY INJURY Per LP -6m) $ BODILY INJURY '(Paracddw) $ PROPERTY DAMAGE $ (Paraccidenil AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY. AGC $ EACH OCCIIRkrhm p e E 1119/2010 1/1912011 � w sraTu orH- E E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ El DISFASF . PAI "i IART a 13ESCRIPMN OF OPERATIONS ILOCATIONS I VEHICLES I EXCLUSIONS ADDED By ENDORSEMENT I SPECIAL PROVISIONS THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR DALE NORMAN Workers Compensation Insurance: Part One of the policy applies only to the Waiters Compensation Law of the State of MA. NORMAN PROPERTIES & DEVELOPMENT 10 KELLEHER AVENUE PLAISTOW NH 03865 ACORD 25 (2009109) CEIt NO.: 6862694 Oeb OarQC"e*wnt 2/17/200 6:37:00 Ax Pagc- L o= L SHOULD ANYOF THE ASOVEDESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAB. 10 DAYS WRITM NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FXWRE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY HHO UPON THE INSURER, ITS AGENTS OR AUTHORIZED .left Eldridge � �,IC{A '�s C�ae _ ®1988 2009 ACORD CORPORATION. All rights reserved. TOTAL P.001 FEB -15-2010 09:58 ACORD,, CERTIFICATE OF LIABILITY INSURANCE PRODUCER 603.382.4600 FAX 603.382.2034 Insurance Solutions Corporation 60 Westville Rd Plaistow, NH 03865 Cynthia St. Amand INSURED Dale Norman 9 Quaker Street Newton, NH 03858-3809 CAVFRACFR P.001 DATE (MMIDDIYYYY) 02/15/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE_ NAIC # INSURER&. Merchants 23329 INSURER B: INSURER C. _ INSURER D• INSURER E: 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER PATE N;;Hlppryyyy DATE MM/DDM Y LIMITS GENERAL LIABILITY BOPI04S301 01/18/2010 01/18/2011 EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea WTFl - $ 500, 000 MED EXP (Any one person) $ 15 000 CLAIMS MADE n OCCUR A PERSONAL & ADV INJURY $ INCLUDE — GENERAL AGGREGATE $ 2,000.000 j! 1 GEfJL AGGREGATE LIMIT APPLIES PER. PRODUCTS_COMP/OP AGG I $_ 2 , 000 , 0O POLICY JECT F LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accidenQ S ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per acadenr) $ PROPERTY DAMAGE S (Per acciderd) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN vEAACC $ AUTO ONLY, AGG $ EXCESS I UMBRELLA LIABILITY i I EACH OCCURRENCE $ I J OCCUR U CLAIMS MADE $ AGGREGATE DEDUCTIBLE - $ RETENTION $ WORKERS COMPENSATIONI OTH_ $ AND EMPLOYERS' LIABILITY Y�' NN LIMITS ER 1 ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? *SEE BELOW ETORY E. L EACH ACCIDENT $ j (Mandatory In NH) If es, dasoribe under q E L. DISEASE - EA EMPLOYEEI $ i SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ I OTHER DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS he 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 ,Talicies issued through the MA Worker's Compensation Assigned Risk Pool. rtFtart�tenre unl nco _...__.. _— Norman Properties ATTN: Ryan Norman 10 Kelleher Avenue Plaistow, NH 03865 ACORD 25 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 01 I ne At rUKu name ana logo are registered marks of ACORD All rights reserved. G IASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING ,: T (Print or Type) AJ 0 /, -rN 4rJDQA1,Mass. Date )AD -2 19 ycl Permit # Building Location 3--1 Li -C, V�� Owner's Name Ace- %+10./11AS SSA Lt GA A N-ao ✓yz- , /14 oa 0 1 j Type of Occupanry_ New ❑ Renovation ❑ Replacement 21-11 Plans Submitted: Yes❑ No ❑ Installing Company Name e-. AE 9 T A .:r -lm MA T A �0 Address i? 0-0A C H m,a ry i-Kf, 111 - 7 H U ni 01 A • U 1 Business Tel Name of Licensed Plumber or Gas Fitter 'X Q A► E P T A - Check one: Certificate O Corporation ❑ Partnership 2--'Firm/Co. 7A A?(--) INSURANCE COVERAGE: I have,Q current obiiity insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. -A Yes lid' No ❑ If you have checked Yes, please Indicate the type coverage by checking the appropriate box A liability insurance policy yid Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the Vn for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 oLaws. BY T%Ietr f License: mber cen u _ or fitter Title er License Number q33� urneyman I ' 010 Installing Company Name e-. AE 9 T A .:r -lm MA T A �0 Address i? 0-0A C H m,a ry i-Kf, 111 - 7 H U ni 01 A • U 1 Business Tel Name of Licensed Plumber or Gas Fitter 'X Q A► E P T A - Check one: Certificate O Corporation ❑ Partnership 2--'Firm/Co. 7A A?(--) INSURANCE COVERAGE: I have,Q current obiiity insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. -A Yes lid' No ❑ If you have checked Yes, please Indicate the type coverage by checking the appropriate box A liability insurance policy yid Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the Vn for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 oLaws. BY T%Ietr f License: mber cen u _ or fitter Title er License Number q33� urneyman I ' J z O W V1 W U LL U. O O w 3 c J W m O Z H r LL N Q O D O r ¢ a O Z Z d j O _J d � m Z 0 0 r W d ca r J r d y� d Q W � W Q y, z in r f5 3536 Date.. ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..... ��.� - ........ . has permission for gas installation %--- Pte! ......... in the buildings„of . /�`3 �!�! ....................... . at..�..%...�: �J. �.` ... ........ North Andover, Mass, Fee r?$ :-r.... Lic. No.. �� ��... t� �.; .:......... . G a�U /"--GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer