HomeMy WebLinkAboutBuilding Permit #189-2016 - 383 SALEM STREET 8/13/2015 TOWN OF NORTH ANDOVER
�j APPLICATION FOR PLAN EXAMINATION
Permit NO: 0 1�0 Date Received
Date Issued: CJ 7
1<MPORTANT:Applicant must complete all items on this page
LOCATION V2-
Print
PROPERTY OWNER 1�>6u V -d Unit#
Teno cLPrint
MAP NO: ✓ PARCEL: � 7aZONING DISTRICT: Historic District Ypit Machine Shop Village y100 year-old structure y
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
El Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
F! sen/tic. ..1E Well F1 Fi(Indill,J,it: ! t ol ax c s I v_ at xtx e 1►ivract
DESCRIPTION OF WORK TO BE PERFORMED:
E w
I COlul /al-116 14Z S A►.v,�." r>t,/�l l -tea c-r,G'
(Identification Please Type or Print Clearly)
OWNER: Name: Phone: 7�
Address:
CONTRACTOR Name: Eric W.Palm Phone:
3 H><bon tree
Address: Salem MA 01970
a
Supervisor's Construction License: g7 77 7 Exp. Date: LI1Z3Ap 9
Home Improvement License: /`lZCJgrl� Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ FEE: $ 3
Check No.: p
Recei t No.:
NOTE: Persons contracting-with unregistered contractors do not have access to the guaranty fund
Signature of Agent/OWne. , v
S�gnatufe.of contractor;
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pcols ❑
Well ❑ Tobacco Sales ❑
Fo.,d Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Durnpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
�I
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
;7 .1 i
n
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, eased on l=xterior dimensions.
Total land area, sq. ft.:
;i
ELECTRICAL: Movement of Meter location, mist 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 - Date
Doc:.Building Permit Revised 2011 June/mi
I
i
Building Department
The following is a list of the required forms to be filled out for the appropriate {permit to be obtained.
Roofing, Siding, lnterior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses i
❑ 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 Perl
Addition or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
Cole/ Of Contract
❑ r-looi-iCi-osseciioi`iiElevatioii 1`:11an Of Proposed vvor€t Oi-c o 6prin mer l�iafil ;`nC1
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 Permii
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
❑ Mass check Ener Compliance ompllance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permii
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doe: Doc.Building Permit Revised 2008mi
J
Location '
No. / {m Date
• - TOWN OF NORTH ANDOVER
p-4 �
e Certificate of Occupancy $
Building/Frame Permit Fee s
Y Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# j u
` vBuilding Inspector
NORTH
Town of 2 s E ..I/'
Andover
No.
q( h ver Mass
Y LAK.
COC HICHEWICK V�
�,9 DRRTED I.PP�gS
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT JkV4 BUILDING INSPECTOR
. .. � .... ........... Foundation
has permission to erect .......................... buildings on ....
_\ Rough
to be occupied as .....V%......... ...Q / .��►. .. . .'1 ...................................... 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
Service
.............
........... ..... /6 —............................... 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.
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�Fi`.j�3t-;:..._""+__ -:iii-�.Il\v�•[u*-�`��n
Contracts-A-M-L—Son
The Borne Improvement Contractor Lal}provides homeowners tvittr the mnDto initiate �o�ny°tea ded o a
alternative to court action)i=they have a dispute with a c(nttactor. a has R,�h a hameovmrr is cout<tzitless
contractor,however_he contractor would have io resolve any dispute
both parties agree to the national clause provided below.?bis clause tvbild give the contractor the s2tne sht to
arbitration as is affo ed to the homeor,mar by the 33ame Improvement Contractor Lt tY.
The contractor and the homeowner hereby�mutnally agree in advance that in the event the conv-actor has a dispute
concerning this cotriracL the connracibrntay submit the dispute to a private arbitration firm which bas been approved b,
Ire Secretary sucof the utn•.e,pfn•cc,ag.�onsumer s audw Re�tlation and the consumer shall be required
GEireral Lavey than:^<I,--)A
to
to submit h-afbittaion•asprovittes In i+,Iassachusetts -�, r,
Flotneoivne���
Caafractors Si¢naGtra
i< TEC.31:The signatures of the parties above apply only to the aa-eement of the uardes to aitCroatit a dispute
resolution initiated by the contractor_ The homeowner mzy initiate alternative dispute resolution event>>hera this
section is not separately signed by the Parties-
H omeorine s Riffs
A homeottnces rights underthe HomeImprovement ContractorLoxv(MOL chanter 1.'42A)and other consumer
protection latus(Le.MG1,chapter 9,3A)play not be ayaived in any_tu<y>even hi aggis'�ered as gtrescribed byso,r_ers
ma;tie exetuded.fram certaihtig2its iftIie contracts a au choose tically epctuded from di Guaranty tuna provisions os
Homebwnei5 who secure their,otitm bulling pe
the Home Improvement Contractor Law. The contractor is responsible for completing the viorit as described,in a
goods sold in Massachusetts
timely and tvoiltanRuc-manner Hbmea,.6ers may bz enfitleormaien addition suttees-arwarranties
�anteesorptbiddesinetpresslj'a "�tyfarltortmansliip • edw��ofmerehant3iiilityandiitoessfor
provided by the contractor'all cO an implied Ze mabe
a p�¢cular purpose .'t tr enimeratioa oFothstmatters on wbida the homeowner and contractor ITWIlly agr y
added to the terms ofthe cont met as long as they do not resuict a homeott�rer's'basic cbnstinier riehG. If you have
questions about your constuneuhomeo-aiierrraht%contact the Consumerinfbnnation Hotline Listed below).
i.,W_,tie=;o Con rac-
Tile contract must be executed in lubricate and should trot be sued until a copy of all exhibits and reiarenced
documents have been.attached-Parties me also advised not to si-m1 t3ie document until all blank sections have been
tilled in or mai and as void,deleted,ornot applicable. One original signed copy of the contract vA&attachments is to
be given to the owner and the other kmpt by the coatramn Anymadliticadom to the ori_a=nai contract must be in v ri?inQ
and agred to by both parties.Contracted wortcaiay not begin until both parries have rcceived a hilly executed copy of
the contrac! and the three day rescission period bas erred
_reels:ate Via=,.,
A
contractor may not demand gaymertts;im advance of the dales specified on the payment schedule incases when the
eomteoumer de..ms hlmtheisdf to be frirancially insecure. Honeti er,in instances a contractor deems Ititnlhersetf
to be financially insecure,the contractor may require that the baaanca of fim&-not yet due be placed in a joint escrovr
account as a", requisite rte to continuing the contracted worly Vl- dt2t=�21 oFfimds i sold account-would require the
�;gr aturs albot_a parties.
r ddiffonai-Tormation -
Ifyou have aeaeral questions orneedaddthonal mfo�naYon aboutthe Home Tmprovemeni Contactor T a:v or other
consumer agbts,or if;�mn�to obtain a fare copy of"A W-assachusetts Consumer�a tee to?IOme improvement"
contact
Consbrmer?afbnmmon Hb`zine
Office of Consumer Affi r and$tslaess Regulation
!0 earl Pl&-P_Room 3170.Boston MAL 02116
Si7-9��o7d7,���?S3�7S�arvis�titet}Ca�Rt:eb•�ath�:llt�n�t:atass_go.Iocabr/
ormation specrfrcail3
Is you l:crit o veri_r:the rq&Lration of a contractor or if you have questions or need additional inf
about the contz=tor reSmstration comaonent of the Home Improvement Coatactor l ar,eontae-
Ditertor of Rom-_imDrovemerit Contaactu RetsirefloP
Of icw cf Consumer i3 rs and Bt=�'ness Relation
10 Park pl",Room 5170.Boston.IVLh 02116
617-973-n7o7,oSd?�37�art isit the*rC-nzbsite at i W1111n�n,.mass govlb_abrt
Go online-40 rlety the-status of a Homebkoroverned Ca Mapes Registration:-
littt,Udb rtate ma us/h omeimnrovamentAicziiseeiiStasn
For assistance vrdr informal mediation of disputes v-to reg�ster:ormd complaints asainst a business,c.Il:
.onsumer complaint Section
Or+itcr of the 1:ice-rev Gent6
i17?27-3400 . .-
AISMlOR
.3eiter13115itSe55$tSaeaL
SUE-62-800_:0^u=,33254 or i373�-3iz�
Vc�ion 3 i-t rMJ_'Uro
C:onei—=Mr 3 r�* .tiOu
tion(as an
T ii.IiCne Improvement C4n4`dctor LacL provides homeoc��tero�^t?1 the ri�htto initiate.�btise'.;?yIOU afForded o a
aitaniadve to court action)ttthey have a dispute Edi coPtrcto.. same 3'g hue has �b as hfltneQrr3 in coati unless
contracmr.hcwevs� the contractor would itave to res ol J..any v�the COIILTaCtor the Marne_aht to
both parties GwOvB�Ma to the optional clause provnded below.This ciaUe viouid z
eat�
arbitration as is afforded to thehomeorrsierby riteNomeIstrrovemontrmto-IANY.
i ue cnntractt�r and a homeo\vner hereby nuinail;�awe"adronce tn2t in the event the contract has a disputa
concerning this contract, cont ctoe lay ubmitttte dispute to a pavate a*oit;atian firm\;'bicII has been p vefl b.
the Sectztaty of the Executr�� Q a ce consumer ARBIrs ani�ltsmess Redilation and the consumer shah be.rzquirzd
=on as IoiRcled In iilassachusets neral Lath cnaI'
to submit to such aftitiiai` p. ,. P t;
Fome�Signutn'O d
Contractors Sima<atra
i i;.g:i�ie si�aturas of the parries above apply only to the agement of the pariies to alterIIative dispute
resolution initiated by the contractor_11te homeotivner:tiny initiate alternative dispute Z25oluaon eves rJhera this
section;W notseparately limed by thepardes
--
HonicoFane_s_�
A homeormees rights under the Rome uitproveruent Cohtractorl a%"'("'o chanter 142A)and othzr cho O"
protection laves li.e VGi.chapter 93A)pay not be waived in anyvv�=even by agreement.jjot}eva�,. meotr_�era
may Le axet:uied fpm certain iltss if the contractor they choose is notproparly registered praseribed by lava.
Honteo\«ers lvho secure their ovm building peim, are autosatically excluded rsain all Gtatayl}�Bund- sio is as
tine i Iome L-npravemeryt COotrctor Law 1�za coLtractor is raspo:isibier or completing the ghts o�ithe onas ac o ed.in a
dmely and v.or�anlike rmwmc= Hameotaneis may be entitled to Other spesmc le-al=.
� runtees or Prov ides an etprzsz vvar_aIIty for tivorI anship or materials. It;addition io ntees:orZvar aIIt es
orovided by the contLactor-I ail goods sole in hrlassachasetts cam'an implied\natty ofinercltant#bility aaatuess for
a pa-eci,?ar ptuvose A:-i enumeration of othermatters on rrnice the homeotiyner and coat_*actor lay hilly aS�e may be
added to the terms ofthe contract as long as they do not_estic a ltameo\vner's Basic consuu�er dE1t5. i yoL lTai�B
questions aboc t your conSmner�homEOt' —h Ls,contact t_.e Coils urnerL-tformatian Hotline Cl is ad ba!gw)..
iTle contractmustbe executed in duplicate rid sitould notbe sitied until a copy ofall exhibits and referenOd oa
documents ha e been attached.Pa-des am also advised notto sign the document until all bl�sections nav e been
filed in or ra��d as void,deleted,ornotapplicable. One original sued copy o:ine contact mih a aolunenfs iz=i
be given to the osmer and the otharlcept by the cmtzac-M �.nymodttil-a-UOn to the or_pat connactnsttstbe in op inn
and agmed to by both parties.Contractedvrroricmay not bei un dl Guth pard as n�emcelived a fully axeeuted copy or
the coallncL a?d the three day rescission period has e:pire&
A conn-ctor may not d-,mand payments:iu advance of the dates;specti ed an the pa e a contractor
in caves where the
hoeneot.mar oearris hiinfn�elfto be f'li inCIallV insecure, siov+ever itI mstane3'=hers a Cont;actar deems hint/lterself
to be fistaitcially�nsecsre,the cont*aciormayZiliiire thatt=�te balance of;mds notyet due be placed in ajoint eso1:
toceuinasap=are itetacont;nuingtnecontractedwo-r. -jrth&ay.'a?a`nmdst. saidaecountti3ouldraquuatha
s+vnatures;ofboi_a pardes.
a dditionalhfG..-Matioi
If you have genud gae.Wons or needadditional in or=tiai len about to Rome Irstprovemeni Centtactor Lay. e oiler
cog`Der1 ht orifyaa to obtain a a copy of" ifvlassachLens Censtmervuideto Komelmprovem��t„
contact
Consumer
?ifounaYOilH.Odin0
Q, ce of Co nsnmer.cstairs and=usiness IteQulaiion
10 Parltl'la?2 Rocnt51T4;Boston,Ivfa 02116
r'7uT_Pio°u 253-375t
f or �isit�iB OC?�R1�b3r�L Rein:��1:R.•li:rltaa= Cabrl
lf- ou vaattt to verL�:r rhe ra�st a+ian of a contractor ar if you hl-M questions or need ad idonat infoma'don spe:itr�iiy
about thecontactorra str�oncomponento-z"theHomeimnroveaeantCo�actorl�t contact:
DjMCtoTofROMBRIUarOV.-MMitCon actmRP9iStTdtiOP-
Office of Consume.*R.fl"tiir_-and$u-sings Rega adon
14 PaLi-PI^aaRoan~ I Boston;Ithh 02116
617-973-627.07,N00388-283-37557 orzz'it the HIC Tt'ebstte atN7:li''11;:1\.Fila<�bri
Go online to iievi the stn O Gr a dome.iLaprav2sce:w COnttiae bF s tion:-
For
For ssistancew-itinaormal mediation ofdisputes ortarag!sterIformal complains agninct abusiness-caalL-
.�anstz-ee-Complai-:t Section
��Cr 4f ilii�uou-tey C:tter�
a�D/aR
Setter business 3ureae
_oC-52-`�$fl0_�Dirt3]?7�u 4r-'.-Srli=?-�22- VeGion23-It�'_G10
ins
An.
'P
- �Qua►i#ied
1
101", Rim
41,
.51
NFRC 8$Wlm
` Brin"quaUry m Isght.
VINYL DOUBLE HUNG
IMPERIAL LS
Navomigr,vvim Double Glazing.Argon F111.1-ow E.Grids
— — SLL-.4-29-M152-00002
ENERGY PERFORMANCETINGS
U-Factor (U.S./I-P) 'Solar Heat Gain Coeft icient
0 2a
ADDITIONAL PERFORMANCE RATINGS
- - --- ---------------- ----
Visible Transmittance Condensation Resistance
101
hlan.-factu*er stipulates that these raitings conform to applicable NFRC procedures for
detr.minivI,••1r,le product performance. NFRC ralting5 are determined fr.r a fe<ej Pt C.f
<p..-;. _unditions and a stlecifiL prod'1R 5ize. fJFRC doP,-not recommend any prcxtu rt
anu does not warrant the suitability of any product for any;venule it--e.Consult manu`�turer's
literati ore fo,other product performance information.
wAw.nfrc.orq
1318555.050
ni e Comazolzipealtii of assc€e
Depanweat of d eta rzl_&cadeu&
�'®�r� ess S'tr ee,�&jjye.I00
30s"04, 02!Id 20-7
a
www-flzass.B o Jldia
W'orkers'Compensation Insurance Affidavit:Bunders/Cont acto
TO rsl Ie riciaQs/IT[tim
BE FILED TIDE PEPdvffTTUNG AiJ�'Hopjj y. ets.
Aar Iicantfrrfornratiora
Name(Business/O gankationadividual): Ade--wit: w� WL
�f,, �'Iease i�rimg �, •fiI
Address:
.�• . .. :Asaa1
CIt}+/%ate/Zip: - - "
Phone#: 7-0 a 7
Are you n employer?Check the appropriate box:
emplover ndth--'? employees(full and/or parttime).= Type of project(required):
3.n I am a sole proprietoror partnership and have no employees working forrate in ?• Q New construction
any capacity_yq0 workers'comp.insurance required.] .
� Q
?-� a I am homeowner doing all Work mvsei£ Remodeling
[No wort-ers- •comp.insurance required.)t
9• Q Demolition
l.®I am a homernvner and will be hiring contractors to conduct all work on m property. f%ill f U Q
ensure that all contractors either have corkers'compensation insurance o*are sotem Building addition
Proprietor.,with no employees. I I-Q Electrical repairs or additions
d.�I am a general contractor and I have hired the sub-contractors listed on the attached sheet I2'Q Plumbing
These sub-contractors have employees and have workers'comp insurance IJj repairs or additions
6.0lVe are a corporation and its officer have exercised their right ofexemption per MGL c ,L�Rflo-repairs
t 5 §1(4),and wo have no employees.[No�vorlcers`comp_insurance required_ I T Other ?
J
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t Homeoumers tvho submit this affidavit indicating they are doing all cork and then hire outside connectors olim nfor anew affidavit indigtina
*Contractors that check this box must attached an additional sheet shotving _
employees. If the subcontractors have employees,they must provide their the name
suoir�number.tractoand state whether or not those entities has�cI>
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Job Site Address: . ,3 O 3 le
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Policy n�m�
expiratior_.da,,
Failure to secure coverage as required under JVIGL c 152,S25A is a criminon punishable by a fine up to S1,500.00
).
mal violati
and/or one-year imprisonment,as vvell as civil penalties in the form ofa STOP WO
day against the violator.A copy ofthis statement may be
RK ORDER and a fine of up to$250.00 a
coverage verification. forwarded to the Office oflnvestiaations of the DIA for insurance
I do I1ereb1+ca!`46:under then.-��
Ite tttforfr2atYota
Signrovrded ature: ;; .,.._--
above is trite and COMM
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Phone L: -7 I ..
Official Use only: Do not write in tills area,to be C&r feted 8+ci r
P } t} Or t:'nspector
`l—ey of o?.%t_:
merrrtit/�,ice
Essuing Authority(circle one): --
L Board of Health 2.Building Department 3.City/Towtt Clerk �I5fi�Itlanbisr III6.Ztlterg specter
Contact Person:
Rho
ACORV
�- CERTIFICATE OF LIABILITY INSURANCE1 3/3/2015
DATE(MMIDD/YYYY)
THIS CERTIFICATE IS ISSUED ASA 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 Construction
Eastern Insurance Group LLC PHONE
233 West Central St EMatL • (800)333-7234 a
DD
NatickINSu S AFFORDING COVERAGE NAIC#
MA 01760
INSURED INSURER A:Arbella Protection Ins. Co. 41360
Atlantic Weatherization INSURER B-Nautilus Insurance CO
61 Rear Jefferson Avenue INSURER C:
INSURER D:
SalemINSURER E:
MA 01970 INSURER F
COVERAGES CERTIFICATE NUMBER:MASTER 2015 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR TYPE OF INSURANCE Im Am L UB POLICY NUMBER plp EFF MPM7LIC EXP LIMi
GENERAL LIABILITY
DEEAAa OCCURRENCE $ 1,0000
X COMMERCIAL GENE1OCCUR
IABILITY
AA
NNOOUU
OO
WW
dT
A CLAIMS�JIADE 500042816 /20/2015 /20/2016 PREMISES Eaoxurrence $ 50,000
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY $ PRO LOC PRODUCTS-COMPIOPAGG $ 2,000,000
AUTOMOBILE LIABILITY $
COMBINED SINGLE LIMIT
acddent T000000
A ANY AUTO BODILY INJURY Per
ALL OWNED $ SCHEEDULEb 020015871 INJURY(
Person) $
/20/2015 /20/2016 BODILY INJURY(Per accident) $
X HIRED AUTOS AUTOS ED PerOa R tDAMAGE $
X UMBRELLA UAB X PIP-Basic $
OCCUR
A EXCESS LAB CLAIMS MADE EACH OCCURRENCE $ 1,000,000
AGGREGATE $ 1,000,000
DED RETENTION$ 600058654 /20/2015 /20/2016
WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY WC STATU- OTH-
ANY PROPRIETORMARTNERIEXECUTIVE YIN
OFFICERIMEMBER EXCLUDED? El NIA E.L.EACH ACCIDENT $
(Mandatory in NH)
If es,describe under E.L.DISEASE-EA EMPLOYE $
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT $
B POLLUTION LIABILITY PL200378613 0/1/2014 0/1/2015
GENERAL AGGREGATE $1,000,000
ON CONDITION $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if mon:space is required)
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.
1600 OSGOOD STREET
NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE
John Xoegel/PMA
ACORD 26(2010105) C 1988-2010 ACORD CORPORATION. All rights reserved.
INS025 r7mnnsi m The At'nPn nnma=nrl Inn^nru rmnicfonarl mnr6¢of ACARr1
Rightfax N2-1 3/10/2015. 10:11 :37 AM PAGE 7/013 rax St;rvGiL
DAT,aco 0 CERTIFICATE OF LIABILITY INSURANCE ;0: 20� 5
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 THE ISSUING NSURER(S)CA AUTHORIZED REPRESENTATIVE OR PRODIES BELOW. THIS CERTIFICATE OF UCER,AND HE CERTIFICATE HOLDER.NCE DOES NOT CONSTITUTE A RACT BTWEEN
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. K 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).
CONTACT
PRODUCER NAME:
EASTERN INS GROUP LLC PHONE Fax
- ArC No Ed): No
233 W CENTRAL STREET E-MAIL
NATICK,MA 01760 -A DRERg.
INSURER(S)AFFORDING COVE RAGE NAIC&
INSURER A.AMERICAN ZURICH INSURANCE COMPANY
INSURED INSURERS:
ATLANTIC WEATHERIZATION LLC INSURER C:
61 REAR JEFFERSON AVE
SALEM, MA 01970 INSURER D
INSURER E
INSURER F:
O REVIS16i
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 REOUIREMENT, 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.
INSRA0Oq SUB POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE INSR 1WVD POLICY NUMBER D/YYYY orYYYY
GENERAL LIABILITY EACH OCCURRENCE S
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
PREMISE occ ne
CLAIMS-MADE❑ OCCUR - MED EXP(Arty one person)
PERSONAL&ADV INJURY S
GENERAL AGGREGATE S
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPNP AGG S
S
PRO- LOG
' POLICY JEGT MBINED SINGLE LIMIT $
AUTOMOBILELIABQ.ITY accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident)AUTOS $
AUTOS NON-OWNED OPE Y AMAGE $
HIRED AUTOS AUTOS -
S
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$
WORKERS COMPENSATION X WCSTATU- 0TH-
AND EMPLOYERS'LIABILITYY!N Y L
TORIMITS EA
ANY PROPRIETORfPARTNERfEXECUT'VN J A E.L.EACH ACCIDENT $50(),000
OFFICERIMEMBER EXCLUDED? 6ZZUB 03-20-2015 03.20-2016 E.L.DISEASE-EA EMPLOYEE $500,000
(Mandatory in NH) 5B270121
It yes,describe under E.L.DISEASE-POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,"more space Is required)
ERTIFICAT HOLDERO
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
1600 OSGOOD ST CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
N.ANDOVER,MA 01845 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
®1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) The ACORD-name and logo are registered marks of ACORD
S`
Massachusetts -Department of Public Safety
Board of Building Regulations andStandards
Conciruction Supervisor
License: CS487977
ERIC W PALM
3 MLTON ST €1t
Salem MA 01970- =j }
ti
Expiration
Commissioner
0
rr4/23/2016
/Unrestricted-Buildings Of any use group which
contain less than 35,000 cubic feet(991m)of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is rause for revocation of this license.
For DPS Licensing information visit www.Mm.Gov/DPS
' ��e�vru�rrarrerfenll�a�✓hrtr.;.t[rc�r[3e/Lr
_ Office of Consumer Affairs&Business Regulation
= ME IMPROVEMENT CONTRACTOR 4
istration: 142089 Type=
v- piration: 3/12%2016 Ltd Liability Corpo"
ATLANTIC WEATHERIZATION`L:L.C.
ERIC PALM
61R JEFFERSON AVE
SALEM,MA 01970 Undersecretary
License or registration valid for iadividul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
Boston,MA 02116
Not valid without signature