Loading...
HomeMy WebLinkAboutBuilding Permit #798-2017 - 37 WAVERLY ROAD 5/1/2018 � BUILDING PERMIT o NORTH 1 ��t0R A6A"O TOWN OF NORTH ANDOVER ` o APPLICATION FOR PLAN EXAMINATION 70 Permit No#: �"�, Date Received \ � Q <ocwi� 1• gDRA rED/.4p` CHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER l PrP 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ edition [I Two or more family ❑ Industrial - Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑Well ❑ Floodplain p Wetlands ❑ Watershed District 0 Wafer/Sewer DESCRIPTIpN Ofi WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: ��/ �� Phone:q 6S- ZL4 Address: �'3 'J Contractor Name: �) Phone: '(PJ 3 S-10 3M Email: 1'Yl i lCA Address. C)QQX 3 V1 Superviso(s Construction License: [ O7-S- 2 - Exp. Date: Home Improvement License: 1 3 Exp. Date: C) ti ARCHITECT/ENGINEER Phone: 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: $ FEE: $ Check No.: J Receipt No.: ew) NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments `Conserv tion Decision: Comments Wata& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEQ PEAR MENT T,;emp`®umpste or n R4T,.ye 11-' Lo t at 124 Main Streets Fie De -am.entnt sigg atur�e/teYz µ�•-a"i`�..�,•'p-fie,.-, • �' . w..:- %+:`' t� +�,`- z e3 s, '. .'�,�5 •3 9�. ''- � ti .. i v•. •�• COMMEN�TtS _ `' i 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 I Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses 16 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 4, 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 No. -71 t1 -as( Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ � " Foundation Permit Fee Other Permit Fee TOTAL $� � 1 f IJ- Check r Check#D}( l� . 6 0f Building Inspector NORT#i Town of t _ sAndover No. All � Zti T , LANA h ver, Mass, A_ Coc"ICNlwic" 7.9 q�RATEO s U BOARD OF HEALTH Food/Kitchen PERMIT T LD cr Septic System THIS CERTIFIES THAT ........... - V � �N ��SV1�k� �GN� BUILDING INSPECTOR .............................................. ....... ................... has permission to erect ........ 3 W lo V er f17- Ot b. Foundation ...... , ............ buildings on .................. ......... ......... Rough to be occupied as k 30 At % #1 C of#. / V #,I,.y 0V Chimney p ........... ...............................................�............. .................. 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 START Rough IService Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. f e 1 j i RISE L,ngiilcerilt Federally#o5-0405529 Rl Contractor Registration ado.i�6 MA Contractor Registration No 120979 RISE CT Contrnctor Reglsstntion No 520120 ENGINEERING- 339-502-5197 �han'mut Road.f'nntun,T�i:i 1120^1 339-:tie-5197 FAX 331)-502-6345 CONTRACT Page # pi2<J(.RAki ' THIS 0PRACT IS EJURED WTO SETWEVi RISECi:�- , . . AAD IME CIJSr0!,,ZR For,E•v^RH AS DE&cmaEo BEIow CUSTWE.4 .. PHOfi;E DA.tE i CUE'IT w Steven Dll'.IiLti°' � t`fgRNORUEft SERVICE STREET (978)685-12471(978)685-1247101i3t)r201'r 444587 ?860? ulasvc 37 Wav rley Road sre,EeT a7 Waverley Rtmd SERVICE CITY.STATE,IJP BtLLIM CITY,STATE,ZIP North Andol'el', MA0#$:15 North Ando ver. ?NIA 01941 JOB DESCRIPTION FH AIJRIC,:prat provide labor and materials to seal,,reds ot'�'otrr honle'-t�atinst tsmsfetul.excess air Ic ha,e, flu",nnrl:101 he rl m 4culccrt 1+ilh tflc u,e oI's#Tcual tools and dia�nnsttc tests tit,=sure(it'.11 your hr>tne it he!cif with a he lit}tiit?leltl o! ngc and indoor•lir qualit llaiusals fo be used t+ < sI et;u tiuntc e n tnefelde caulks,titatns attd otticr product;. 'rtritnsn --tor". ee iltllg include-air hat,WIN ttt,ttuc,,basements.alt tc?ted.!:era e•and ruhe:r uniteatcd arc: >,s{critldoxs are not general}t• .. ad.i 1 ins stiiN Tcquirt{21 norkinr houn.:A rtcituctierslfn cubic lett per minute.tctinl ttl':tir infiIIIalion ,ill ocs:in.but the tantunher ofcfm is not guaranteed. At 1110 ctnnplction of'file weatheriz:nion++ori:.and ai va additional cutis to file 6onlcoltncr,it filial hloner dour sattty:male+is will he conducletl I,the uh-contractor to ensure the sauv cifthe indc4+r air eluili(�•. andf(,r combustion AIR SEA}),\Q i'rctviee lahir and mafcri:ll>to hlstall t?-loll taeatherstri t tiro< : , 5170.0[1 I i e utd:i dooriWeep It?i_f det,tri.s i to regricl air le ikas to 1'1 N I ILA 11()'s4*:11rat•i+le lahot and materials to mmall f 13 exhaust how uith%%4111 ntouuled liapper,ent tta celr:(t4t cxiatin 5160.00 efwtrnc clothe,dn,Cry,l. BASEMENT DOOR:#'roYide I:tltelr anti nl:nerrals tib Insulate lite back of the ba_u:mcut hoar lcaelim,to 1 S I t}.(its at R-10 of greener With Ilse required fire rating that tttcei the sctfians R ';i#t_�.3:tnd, ,b re(#ttirctncttth nt�tatti}t tigtccltkrl ti�:1;all cllzI c:'and yearns�eifh#CA tape tis 1f100 Federal 10#05.0405629 RISE Engincering RI Contractor Registration No 8186 MA Contractor Registration No 920979 RISE C7 CDntnctor Registration No 629920 GO 5hatl�mut Road.Canton.NIA 02021 �q ENGINEERING' COF�TKCT 33'I-502-5I:)? FAN 339,51121-045 Page 2 PROC'PAN-1 TNS CONTRACT tS ENTERED INTO BETWEEN RISE CNIA-lI ES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUS iOM,En PHO1:E DATE CLIEI:T a WORK ORDER Steven Dickey (978)685-1247 01530/2017 444587 28602 SERVICE STREET BILLING STREET 37 Waverley Road 37 Waverley Road SERVICE CITY,STATE,ZIP HILLING CITY,STATE,ZIP North Andover. MA 018415 Not71h Andover,MA 01845 JOB DESCRIPTION f2I51 tateinccring vsiti apply all applicaflh,clicilTle inccntit^cs to this clhntrset. 1'r+tl Vk If anh he hiti;lt the tc l anrtuInt. :"urr.nli _ kireligible measures.Cuttlmhia Gtts OMr;75"it incentive.nl+t tear.ani an inwilive of 1001%far the Air tieating ineastites tip to the tint Sf,M and an additional S3,40 It sa ings fireJustified h� the atidiutr. For the saluv Mid health of ,our honlc:s indoor air qualm,ire kilt lie c(uxlucting a blolier thlor diaLnustic 140110 available stir tlo%% in your home bath betilre the stork is Ileum and after lite tleathcri�atioa%%ork is complete.We will also conduct a!full ak"osfnclft of the Combustion;afet%of}'our hest6t s-,slem and%Natcr healer. thus has a value of S90 alio is at no cost ib)oil. The Pennit will lie sc c irett by file insulation con(racior.•this ha:':I value of S7?and is at nu cleat to%tltl.Ii i til h=,tne�tniter's rc4ponsibih(1 to close out leu,;perillil 11% comacong(heir laullicipaiiip at the eomplelion of this teorl,: Fowl uNotsabic wCathcrization incentive is$3.185. S 1 ii5.of) Total: $755.00 Program incentive: $690.00 Customer Total: $65.00 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFtCA'nONS.FOR THE Strict OF *'*Sixty-Five&001100 Dollars $65,00 UPON I`.!µ.1 ^r`zCTi)N AND APPROVAL BY RI">E EI-G s1EERN.G.CI1RT0`l.ER AGREES TO NEVVT AMOUNT DUE It!FLU:L.!NTEREST(IF 1� WII.L t;F:CHARGED SIOWHLY ON A:'Y UNPAI BALANCE AF TER 111 DAYS.SEE REVERSE FOR IMPORTANT 01FORIAATION ON GUARANTEES,RIGHTS OF RECISION.SCHEDULING,AND CONTRACTOR REGISTRATION. f AUTH 51GHATURE•FUSE EnClncriclgC115T0!1CR ACCEPTANCE NOTE:THIS CONTRACT MAY BE WTHORAWN BY US IF NOT EXECUTED tYnHIN DATE OF ACCEPTANCE ACCEPTA%\-E OF CO.'-;TRACT-THE ABOVE PRICES,SPECLFICAT[C!:S AND CO1NrITIO!S ARE 30 DAYS. SATISFACTORY 10 US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE VIORK AS SPECIFIED.PAYMENT WLL BE MADE AS OUTLINED ABOVE MSE _ 60 Shawrnut Road,Unit 2 Canton, MA 020211339-602-6335 ENGINEERING' www.RISEengineering.com OWNER AUTHORIZATION FORM 1, --- f YTF R I a f1 F W O C c:1t I R RO (Owner's Name) owner of the property located at: a r7 WAV>_RLcY RDAD (Property Address) (Property Address) hereby authorize t{ ( �Vvs vj Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. Ther Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. i O ner's Signature / Z/Z 20j �7 Date 6.2016 The Commonwealth of Massachusetts Department of Industrial Accidents O,face of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 Ulp- www.mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaa lcantinformatiion Please Print Legibly Name(Business/organization/Individual): i X64 `Y wk X1.Nom I ,V�--- A.ddress: Com•6 BOX -34N Ci /State/Zi : ` SW is V\ N�1 01413.5 Phone#: (i _14 g Are LOU an employer Check the appropriate box: Type of project(required): 1.Lf 1 am a employer with_ .� 4. ® I am a general contractor and I 6 ®New construction employees(full and/or part-time).* have hired the sub-contractors 2131 am a sole proprietor or partner- listed on the attached sheet. 7. ®Remodeling ship and have no employees These sub-contractors have $, ®Demolition working for me in any capacity. employees and have workers' 9. [3 Building addition [No workers' comp.insurance comp.insurance� required.] 5. [3 We are a corporation and its 1013 Electrical repairs or additions 3.® I am a homeowner doing all work officers have exercised their 11.®Plumbing repairs or additions [No workers' comp. myself. right of exemption per MGL 12.®Roof repairs insurance required.] t c. 152, §1(4),and we have no 13 ®ether employees. [No workers' comp.insurance required.} *.Any applicant that checks box#1 roust also fill out the section below showing their workers°eompensadOn policy h&v maoion. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employe" Below is the policy and}ob site information. Insurance Company Name- kra i t �Q almL 0 = Policy#or Self-ins.Lie.#: ? 3 O C) 3 Z, Expiration Date: © 30 to 1 17 Job Site Address• �' ln.)��2( �Ac�-C City/State/Zip:.- Attach ity/State/Zip:IAttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,w 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby een fy under the pains and penalties of perjury that the b formation provided above is true and correct. Sign Lc�,�- I Phone#.x -;t A --,15 10-~3`f 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 G.Other - Contact Pe =: Phone#: AC RLJ � CERTIFICATE OF LIABILITY INSURANCE DATE(MMIU/Y"10/18/2016 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: it the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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). PRODUCERONTACT MARTIN J. CLAYTON INSURANCE AGENCY INC NAME' Meg Munroe PHONE : (413)536-0804 ,V No: EMAIL ADDRESS: mmunroe@mjclayton.com 1649 NORTHAMPTON ST.,RTE 5 INSURERS AFFORDING COVERAGE NAIC# HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325 INSURED INSURER 8: GAUTHIER INSULATION INC INSURER C: INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 94521 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 AFFORDEDY B 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. I�Tp TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP J=WVD POLICY NUMBER MMOD MM4) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE FIOCCUR DAMAGETO E PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Is acadent ANY AUTO BODILY INJURY(Per penton) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ $ UMBRELLA As OCCUR EACH OCCURRENCE _$ EXCESS LUIB __HCLAIMS-MADE N/A AGGREGATE $ DEO I I RETENTION$ $ WORKERS COMPENSATION v PER OTH- AND EMPLOYERS'LIABILITY Y/N /� STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED7 WA WA WA MAARP300327 10/30/2016 10/30/2017 — (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 ff yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits wilt be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy In force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA X31988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AC<>RE0 CERTIFICATE OF LIABILITY INSURANCE s/iaOD oD� 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 pollcy(les) 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 CONT C Nancy Usher Martin J Clayton Insurance Agency, Inc. PONE (413)536-0804 FAX A/C (413)534-7874 1649 Northampton Street E-MAIL P. 0. Box 989 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville NATIO INSURED INSURERS Allied world Natl Assurance Co Gauthier Insulation INSURER C P.O. BOX 344 INSURER D: INSURER E: _ IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1663001850 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, IEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NS" A L SUBR T TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS R COMMERCIAL GENERAL LIABILITY 211% ' EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE I—XI OCCUR _5WWG_ff TO RENTED PREMISES Ea ocam ce $ 50,000 GL43487F 7/6/2016 7/6/2017 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 JECT 0 PRO-ECT F LOC POLICY PRODUCTS-COMP/OPAGG $ 2,000,000 X OTHER: AUTOMOBILE LIABILITY COMBINED SINGLELIMIT Ea_accidentt Is _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED — AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS AUTOS NED APROPERTY DAMAGE AUTOS Per accident $ X UMBRELLA LIAR HOC EACH OCCURRENCE $ 1,000I000 B EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ 8BII028251970 10/18/2016 10/18/2017 $ WORKERS COMPENSATION AND EMPLOYERS'LUIBILITY Y/N i STATUTE ER ANY PROPRIETOR/EXCLUDED? E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) If yes,desaibe under E.L.DISEASE-FA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1200 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marcs of ACORD PUPtAftmd with pdfFactory trial version VVlntw_ndffartnn/ mrrl u _ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Mass ac tts 02116 Home Improvement or Registration Registmfian: 173410 Type: IndIviduai Expimilon: 10/19018 Tit 291320 KURT GAUTHIER KURT GAUTHIER . a 119 COUNTY ROAD IPSWICH, MA 01938 Update Address and return card.Mark reason for change. f (i Address [] Renewal D Employment D Lost Card BOA 0 20M4Wil , df° O"EO °�'cua� ! on valid for individual e only before the 0fVw of Coasmner Affairs&Basanese Regadstion d us HOME IMP ENT CONTRACTOR expiration date. If found return to: ! 3410 Type: Office of Consumer Affairs and Business Regulation Expirall >y 8 individual 10 Park Plaza-Suite 8170 Boston,MA 02116 KURT GAUTHIER w a KURT GAIJ'THIER `` ��`• ,� �' t r�3i1-S2'#�4i#$f4' ia '�13i"�'t8'lkRCn&Of Public Safet'Y /�g{�� tYa JCUW it GA1tZ'!l" P.UL Max 344J f 1pslkb 01.A @! r itkist}nTi:ls lt;+i�¢;i w l? 0