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HomeMy WebLinkAboutBuilding Permit #485-2017 - 39 HIGH STREET 11/8/2016BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR. PLAN EXAMINATION'. Permit No#: 44 0 1-7 Date Received Date IA/ PORTANT: LOCATION PROPERTY` :a must complete all items on this, Print 100 Year§tNcture yes no, S OI MAP PAR GEL ZONINGDISTRICT:.H'istoric, District yes no Machine $11pp Villagg. yq§ no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family 0 Addition 0 Two or more family 0 Industrial 0 Alteration No. of units: 0 Commercial A Repair, replacement El Assessory Bldg 0 Others: D Demolition 0 Other 0 Septic 0 Well El Floodplain [I Wetlands 0 Watershed District 0 Water/;Sewer DESCRIPTION OF WORK TO BE PERFORMED: � r VV - -,Please Type or Print OWNER: Name: Ph J_vo� 10 e CqQ_ I Address: -7 Contractor Name: Phon,e., Address: -_!D3 5-1 C4. Cs Supervisor's Construction, License: 1 Exp. Date: -7 1-7 Home Improvement License'. 1,/ Exp. Date, - _e, t Lic 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: $ 7 -7 FEE: $ i& Check No.: Receipt No..-. NOTE: Persons contracting with unregistered contractors do not have. access to the guaranty fund Sigriatiae Ub h!gr Signature df cohlractor_!11 le�.*E���, ?" Plans Submitted ❑ Plans Waived 01 Certified Plot Plan ❑ Stamped Plans ❑ TYPB-bF 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 COMMENTS Signature. CONSERVATION Reviewed on Signature COMMENTS .HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comm Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Du mpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street no limension 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 DANCER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine 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. r Roofing, Siding, Interior Rehabilitation Permits o 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/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 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 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 Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: 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 l Doc: Building Permit Revised 2014 Location .3 C7 4 ( G l� No. 65r— - �01'7 Check # Q 984-7 31152 r� Date !!- ^ 70f& TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL 4 Building Inspector r L Q w = LL CO C N u — 'D O O LL N v+ -'i y, O_ N Ln W a N z Q J md C O Y C 7 O LL GO 3 O 1' > ci C L U c LL O d N Z z m J L OA 3 O w O LL 0 dui N Z _V F- W J W L w O O 2' u 2!O' N N O LL U Wa N Q L bD O d' to O l.L z Q W 0 W a. LL 41 C O CD O z a+ N i, Ln N N Y O E (n n Vl �; �• m =r .Qcc a. CD ami Q o E * O �. E43� z !• i YO 0 O .u+ .9u W O O L r G0 O �O Ncc - :' ' w L m m m�. 43 m L CCD.a C O O "a cc • � N y Q c O 4) z75 rn O O tm .w�• +. c o> to °a '. Q.CL .� as (D +•� m 0 O tm c r Q L • ujW CO O LL •N H C O W u •E .V a V O O' V CL 0-0 41 N Q 'z N H o " O 1=— t CL0U > 51 F 2 0 O O d z O O Vi .E a � � AW0 �+ d 0 / V=v O CL CL N = Q O 0-0 =z a O ca Q. 1 5 Generations of Boston Roofing 148 Minot St. Dorchester, MA 02122 617.331.5815 i nfo(i!;portanovaroofi ng. com wtivw. portanov� rood ng. com Estimate Date Estimate # 10!19/2016 E455 NORYN Ofa11D 16.1ti0 Town of North Andover ;9- Machine Shop village Neighborhood Conservation District Commission 1600 Osgood Street North Andover, MA 01845 4SSACHUS�t Application For EXCLUSION From Certificate to Alter Certain alterations are excluded from review by the Machine Shop Village Neighborhood Conservation District Commission in accordance with the Bylaw. Applicants for exempt projects must fill out the form below and -submit to the Commission Chairperson (contact info below). Date: d22" Contact Name & Address: Project Address: 31 q1 g zf S `{ '-f fit Project Description (attach additional pages, if needed): 1� y 120c4 regi% �f �� /h �;i�,1� �1a 5'rAl ✓ l Gi% I Exclusion From Review Requested For: ❑ 1. Interior Alterations ❑ 2. Storm windows and doors, screen windows and doors. ❑ 3. Removal, replacement or installation of gutters and downspouts. ❑ 4. Removal, replacement or installation of window and door shutters. ❑ 5. Accessory buildings of less than 100 square feet of floor area. ❑ 6. Removal of substitute siding. W1/ 7. Alterations not visible from a public way. 2� 8. Ordinary maintenance and repair of architectural features that match the existing conditions including materials, design and dimensions. ❑ 9. Replacement of existing substitute doors, substitute siding or substitute windows with new materials that are substantially similar to the existing condition. ❑ 10. Replacement of original fabric windows or doors with substitute windows or doors that maintain the architectural integrity with respect to form, fit and function of the original windows or doors. ❑ 11. Reconstruction, substantially similar in exterior design, of a building, damaged or destroyed by fire, storm or other disaster, provided such reconstruction is begun within one year thereafter. MSV NCDC Pagel Current Chair: Liz Fennessy, 77 Elm Street, Iizettafennessy@yahoo corn, The Commonwealth of Massachusetts . . F Department of Industrial Accidents M = X Congress Street, Suite 100 aBoston, ' - d MA 02114-2017 - www mass.gov/dia ypolkers' Compensation lusuraned Affidavit: Builders/C a Os�xcians/ lumbers. . TOO BE FILED WITH THE PERMITTIN R7�.L7 o en Print 1 Name (Business/Ozgabizaiionadividual): � Q 0 Address:�-�- C Phone #: -7 _ City/State/Zip: - Type ofproject (required)_ Are yon an employer? (heck the appropriate box: e to ees full and/or part-time).* 7. ❑ New'd6nstruction 1� am a employer with_. mp y 2.❑ I am a sole proprietor or partnership' and have no employees Working for me in 8. Remo liti.o g any capacity. [Noworkers' comp. insurance required.] 9. ❑Demolition 3.E] I am a homeowner doing all work myself [No workers' comp. insurance required] t 10 ❑ Building addition 4-❑ I am a homeowner and will be hiring contractors to conduct all work on my property. Twill I1.❑ Elecixical repairs or additions ensure that all contractors either have workers' compensation insurance or are sole bhn xe airs or additions proprietors withnoeniployees. 12.�'P��- g P 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet l3. [� Roof repairs These sub -contractors have employees and have workers' comp. insurance.t 14. Other 6, ❑We are a corporation and ifs, officers have exercised their right of exemption per MGL c. 152, §1(4), and We have no employees. [No workers' comp. insurance required-] *Any applicant that checks box #1 must also fill out the are doing ection all work and thenhire outside w showing their workers' oontractopansators mount submia new affidavit indicating such I homeowners who submit•this affidavit indicating they ?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 providingworkeNs' compensation insurance for° my employees. Below is the policy and job site information. �t � �� C I ��,@ � — Insurance Company Name: VI AJ / � ` ` ©`7 M 7 ExpirationDate, LQ 4; Policy # or Self ins. Lic. #: b 1 v � � F— �/ - City/State/Zip: J ►v4 j &c Job Site Address: Attach a copy of the workers' camp anon policy declaration page (showing the policy number and expiration date). .00 al e by Failure to secure coverage as requireh ascivil to $1,500 naltiesrMOL c. 2inthe form. ofraaSSTOP WORK ORDERIand a fine of up to $250.00 a and/or one-year imprisonment, as w P day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do Hereby certify under tlaepains andpenaltres o fperjury that the information provided above is true and correct. Date: Signature: Official zcse only. Da not write in this area, to be completed by city or town official Permit/License # City or Town: Issuing Authority (circle one):i ector 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. PlumbingInsp 6. Other Phone #: Contact Person-__ Information and. 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 tmstde of an individual, partnership, association or 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 ofthe dwelling house of another who employs persons to do maintenance, 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 xequixed." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for theperformance of public work until acceptable evidence of compliance with the insurance 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 number(s) 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' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial:Accidents. Should you have any questions regarding 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 PIease 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 Iuvestigations 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Oct 2516 02:29p The Insurance Store Inc 6173257892 p.2 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOyYW1 01/14/2016 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(les) must De en ome . if SUBROGA71ONIS 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 enclorsemant(s), PRODUCER NAME THE INSURANCE STORE PHONE(617) 325 - 8952 (FAX A/C, Hol:(617) 325 - 7892 E-MAIL 106 SPRING STREET ADDRESS: INSURER(SIAFFORDINGCOVERAGE NAICit WEST ROXBURY, NUL 02132 INSURER AWESTERN WORLD INSURANCE COMPANY , INSURED INSURER B SAFETY INSURANCE PORTANOVA ROOFING INC DA 0[iCgMMERGAL j PREMISE.(Ee occrlercay 5 100, 000 INSURER C: 50 Elm Street INSURER O: Cohasset MEL 02025 INSURER E: INSURER F: - CUVERAUE5 GERTIFICATE NUMBEK: KLVI51UN NUMdtK; THIS IS TO CERTIFY TEAT THE POLICIES CF 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 WH)CF THIS CERTIFICATE 41AY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES -DESCRIBED HEREIN lo' SUBJECT –0 ALL THE TERMS. EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. L MITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPEOF INSURANCE INSR VVVD POLICY NUMBER IMMMDNYYY) (MM/DDP/YYY) OMITS 120 MAIN STREET ' GENERAL UADILrTY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . EACHCCCURRENCE 5 1,000,000 WILL BE GENERAL UABIUTY , NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. DA 0[iCgMMERGAL j PREMISE.(Ee occrlercay 5 100, 000 a CLaM5MADE 7OCCUR NPP8184354 11/04/15 11/04/16 MED EXP (Anyone peMoN s 5,000 PERSONA_ 6 ADV INJURY S 1,000,000 All rights reserved. G=–NERAL AGGREGATE S 2,000,000 C1 0 CORD CO F/�TION. ACORD 25 (2010105) The ACORD name and fogo are registered marks f ACORD L AGGREGATE'.IMIT APPLIES PER: k.-FOLICYFIPE_.T PRODUCTS-COMP,OP AGG t 2,000,000 LOC E AUTOMOBILE LIABIUtY (Ea ea dent) r 1,000,000 BODILY INJURY (Per person) f ANY AUTO b ALL UTOS, ED X AUTOSSCHEDA_W P.UTCS AUTOS 6238330 05/06/16 05/D6/17 BODILY INJURY (Per aaiden:) $ X I-.IRED AUTOS X NON OS AUTOS $ 100 000 (Per accident) / S UMBRELLA UAe [:TE EACH OCCJRRENCEEXCESS LIAR —MADE AGGREGATE S DEO RETENTION 5 S WORKERS COMPENSATION I Al LL AND EMPLOYERS' LIABILITY YIN 10 TORY LItAITS ER EACH ACCIDENT 5 ANY PROP4IE70R/PARTNERIEXECUTIVEEL OFFICEPUMEMSER EXCLUDEDi N /A EL. DISEASE- EA EMPLOYEE S IMandKAry In NHI If yee- dawibe Inde• DESCRIPTION 0= OPERATIONS Del" — E.L. DISEASE- POLK Y LIM T E I i DESCRIPTION OF OPERATIONS, LOCATIONS i VEHICLES (A—h -CORD 101, Addhlonal Ra .e Schedule. d more zpwe is rryulmtl) ROOFING & CARPENTRY: � CMI IrlI AIa MUL.Ucn CANCELLATION TOWN OF NORTH ANDOVER, BUILDING DEPARTMENT 120 MAIN STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN , NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. " ArUREPRESENTATIVE } All rights reserved. C1 0 CORD CO F/�TION. ACORD 25 (2010105) The ACORD name and fogo are registered marks f ACORD 25 16 02:29p The Insurance Store Inc 6173257892 p.1 ACORO0 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10125/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ann Gallagher goer THE INSURANCE STORE INC. �"E , (617)325-8952 a No: EMAIL ADDRESS:ainsur aol.com INSURERS AFFORDING COVERAGE NAIC P 105 SPRING ST. INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 WEST ROXBURY MA 02132 INSURED INSUR E0.B: PORTANOVA ROOFING INC INSURERC: INSURER D: 50 ELM COURT INSURER E: COHASSET MA D2025 INSURER F: 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 ADDL TYPE OF INSURANCE SUER POLICY NUMBER IAM DDIYYYV I MIA%DDIYYxYV i LIMITS COMMERCIALGEN ERAL LEAS ILITY , MA $ CLAIMS -MADE OCCUR AA R PREM. ES Ea occurrence', $ _ MED EXP (Any one person) S PERSONAL &ADV INJURY $ N1'0` I GEN'LAGGREG.ATELIMITAPPLIEESPER: —. GENERAL AGGREGATE S PRO- ❑LOC POLICY I_' JECT HOTHER: PRODUCTS-COMP/OP AGG S 5 AUTOMOBILELJASIUTY I COMBINED SINGLE LIMIT 3 i I Ea accident ANYAUTO BODILY IN'JUR" (Per person) 3 ALL OV" NEO SCHEDULED AUTOS AUTOS N/A I130DILYINJURY (Per ( $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE. Per accident 3 I S UMBRELLAUAB HOCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS -MADE N/A ' AGGREGATE :5 F—FIDECIT RETENTIONS S WORKERS COMPENSATION�/ AND EMPLOYERS' LIABILITY YIN SPE /� TATUTE ER E.L. EACHACCIDENT $ SOD,DOD A ArJYPROPRIEfOR/PARTNER/-YECUTIVE OFFtCERMIEMBEREXCLUDED9 WA NIA NIA I 6HU68D80784116 10/26/2016 - 10126122017 E.L. DISEASE - EA EMPLOYEE S 500,000 (Mandatory In NH) If yes, describe under E.L. DISEASE - POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS below i N/A DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Addlilonal Remarks Schedule, may be attached I1 more space Is required) Workers' Compensation benefits will 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 MassaMuselts. 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/lwd;workers-compensationJinvestigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED (N town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 main street AUTHORIZED REPRESENTATIVE north andover MA 01845 Daniel M. Crowfey,'CPCU, Vice Prssiden:— Residual Market—'VVCRISMA IV 1958-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD