HomeMy WebLinkAboutBuilding Permit #995-2016 - 39 MAIN STREET 3/23/2016BUILDING PERMIT T&ORTH
ED
AW -4 �P TOWN OF NORTH ANDOVER C
0
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
C US
Datelssued:
IM�'ORTANT: Applicant must complete all items on this DaRe
LOCATION .79 M19JAJ '57-1
Print
PROPERTYOWNER 60'e-Ic- C,#/e.&f-,::;kJ.
Print 100 Year Structure
MAP PARCEL: ZONINGDISTRICT: Historic District
Machine Shop Village
WS n o
no
yes 0
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building-
[I One family
0 Addition
0 Two or more family
0 Industrial
0 Alteration
No. of units:
VCommercial
[WIRepair, replacement
0 Assessory Bldg
11 Others:
El Demolition
00ther
El Septic El Well
0 Floodplain El Wetlands
0 Watershed District
[I Water/Sewer
DESCRIPTIOri OF WORK T09� PERFORMEQ:
VIAIrz-- co--/a—Z 07
aw 5;on C- - Y/ hz�
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name:
Email: -7a-L"c
Address: P ?
I=/ -
Phone: 4/9J-- -74-14Y-9
ver;z-c4--,
^/ I *-%/,
i ^c -
Supervisor's Construction License: 0 46 Exp. Date:
Home Improvement License: /,?� 22 F Exp. Date:
ARCH ITECT/ENGI NEE
Address:
Phone:
ork
FEE SCHEDULE. BULDING PERMIT. $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ -,71, -7�f 0 , — FEE: $ 2-15�-n
<04 -
Check No.: U --, Receipt No.: 5bA46(
NOTE: Persons contracting 11 71th—unregistered contractors do not have access to the zuaratrtv funW
P lans Submitted 11
Plans Waived 11 Certified Plot Plan 0 Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Ir
Public Sewer El
Taming/Massage/Body Art
Swirn'n'n Pools El
well El
Tobacco Sales
Food Packaging/Sales 11
Private (septic tank etc. El
Pennanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature.
COMMENTS
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
2 Planning Board Decision:
Comments
Cqnservation Decision: Comments.
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
F� fR7E:,, 1, J,
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COMM�-NTMS
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
MGL Chapter 166 Section 21A —F and G min.$100-$l 000 fine
01 10% Ir r- C. -1 r% it Ir A E:�*- rjdMnnrfMdMnf lmi-1
.No,
C-10 O"U Lj
-el 7,
0 Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
--------------------- - --
4 Building Permit Application
iL Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable) '
Mass check Energy Compliance Report (if Applicable)
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
DTE: 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. 2c, Date
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $2�L,--
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector
Twomey & Legare Contracting, Inc.
87 Belmont Street
North Andover, Ma 01845
Office: 978-685-7447
Fax: 978-685-7446
twomeyandlegare@verizon.net Date 3/17/2016
Name of Owner
Rolfs Pub
39 Main Street
North Andover, MA 0 1845
Provide and Install New Harvey Classic windows to the Front and Right side of building as discussed with owner, Color: BRONZE
Windows to have Low E and argon gas to meet energy star requirements.
Windows to have 5/8" window grids between the glass. BRONZE
Front of building :
4- new replacement style double hung windows installed, caulked. insulated, new bronze exterior metal coverage.
1- 117" mulled window unit 29" double hung. 581, picture window 29" double hung, window to have tempered glass as required near
stair location.
1- 117" mulled window unit 29" double hung. 58" picture window 29" double hung.
Right side of building:
7- new replacement style double hung windows installed, caulked. insulated, new bronze exterior metal coverage.
Siding Specs:
Strip Existing vinyl siding off Front and right side of building and dispose of.
Install new 3/8" foam insulation board over wall areas on front and right side of building. ANNAH WICKER
Provide and install Certainteed Mainstreet 4/4 vinyl siding over insulation board. Color To Be : SAV
New soffit to be vinyl 12" SABLE BROWN
All aluminum trim to be color: BRONZE
Contractor to obtain permit for work
Contractor to dispose of debris.
Above is the specs for window and siding work -
Job Total is $ 21,380-00
First payment on signing = $ 9,000-00
We hereby propose to furnish material and labor - complete in accordance with above specifications, for the sum of:
Total:
Payment to be made as follows:
Authorized Signature*
NOTE: This proposal may be with rawn by us if not accepted within days
Acceptance of Proposal - The above prices,
specifications and conditions are satisfactory and are hereby
accepted. You are authorize I to do the work as specified. Signature:
Payment will be made as out ined a )ove. 4 -
Date of Acceptance: A Signature:
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//Twomey& Legare Contracting, Inc.
87 Belmont Street
North Andover, Ma 01845
Office: 978-685-7447
Fax: 978-685-7446
twomeyandlegare@verizon.net
Date 3/17/2016
Name of Owner
Rolfs Pub
39 Main Street
North Andover, MA 0 1845
ve�
Second payment completion of one side $ 9000.00
Substantial completion of job = $ 3380.00
We hereby propose to fumish material and labor - complete in accordance with above specifications, for the sum of.
Total:
Payment to be made as follows:
Authorized Signature:
NOTE: This proposal may be wilrawn by us if not accepted within days
Acceptance of Proposal - The above prices,
specifications and conditions are satisfactory and are hereby
accepted. You are authorized to do the work as specified.
Payment will be made as outlined above.
Date of Acceptance:,
Signature:
Signature:
Page 2
TWOMEY & LEGARE CONTRACTING INC.
HOME ]IMPROVEMENT CONTRACT TERMS AND CONDITIONS (M.G.L.142A)
1. WORK: Provided the Homeowner performs under this agreement, the Contractor shall perform the work on the Property as specified Proposal, attached
incorporated herein. The work does not include extraordinary conditions of which the Contractor could not reasonably be aware. If such conditions are
encountered, this shall be an additional cost to the Homeowner. Materials selected by Homeowner may have to be ordered or custom made, which items are
specified in the Proposal. The Contractor is not obligated to agree to any modifications, extras or change orders unless such items are agreed to in writing by
the Contractor. All extras and changes shall be at an additional cost to the Homeowner. Contractor shall perform the work in a good and workmanlike manner
using materials consistent with this contract. Lawn or Driveway may be damaged by dumpster or equipment. Due to material shortages Contractor may
substitute materials of equivalent grade. Contractor to leave site Broom Clean, any additional cleaning by owner.
2. PERMITS: If a building permit is required for the work, the Contractor shall obtain same as Homeowner's agent. Contractor is not responsible for any
other permits that may be required for the Work, and Homeowner is responsible to determine whether any zoning, planning or wetland related permits or
approvals are necessary. Homeowners who secure their own permits or deal with unregistered contractors will not have access to the Guaranty Fund.
3. COMMENCEMENT AND COMPLETION: Homeowner acknowledges the commencement date of the work is fluid, and is subject to numerous factors
such as scheduling other contractors, delivery of materials and weather. Contractor and Homeowner shall determine the commencement date of the Work
when a more definite determination can be made and shall execute a written acknowledgment of same. The Work shall be substantially completed within
days of commencement, except for longer periods as may apply to particular projects as Contractor shall notify Homeowner in the Proposal, and subject to
delays for circumstances beyond Contractor's control. Notwithstanding, the commencement date and substantial completion date may be extended, and the
Contractor will not be liable for delays caused by, labor or material shortages, delays in delivery of items selected by the Homeowner, governmental action,
and unforeseen events beyond the Contractor's control, including but not limited to weather, strikes, war, the acts of third persons or the acts ofthe
Homeowner. The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractor's other jobs.
4. PAYMENTS: Contractor agrees to perform the Work and to ftimish the materials and labor specified in the Proposal for the amount as stated in the
Proposal. Thirty percent (30%) of the total is to be paid as a deposit with the signing of this contract. Upon cancellation prior to commencement of the
Work, any remaining deposit will be returned less the costs for materials ordered for which Contractor was unable to cancel. Final payment shall be due
upon completion of the Work and Homeowner agrees it may not hold any retainage. Late fees may be applied for late payments. Homeowner shall pay
-Contractoes-reasQnable�-c�asts-of collection, -including attorneys fees and costs. Time is of the essepce hereof -
5. WARRANTY: For a period of 2 years after substantial completion of the Work the roof will be free of leaks caused by defects in workmanship,
but not those caused by ice backing -up or extraordinary weather events, including blizzards, tornadoes, hurricanes or storms of greater than a twenty-five
year duration or intensity. Contractor gives no warranties with reference to any materials or equipment installed in the Premises, passes any such warranties
directly to Homeowner, and Homeowner agrees to look only to the manufacturer with reference thereto. This limited warranty extends to the Homeowner
only and is not transferable to succeeding Homeowners. This Limited Warranty specifically excludes (i) all consequential and incidental damages; (ii)
damage due to ordinary wear and tear, abusive use, misuse, or lack of proper maintenance; (iii) defects which are the result of characteristics common to
materials used; (iv) defects in items installed or supplied by anyone other than Contractor; (v) work done by anyone other than by Contractor; and (vi) loss
or injury due to the elements. There are no other expressed or implied warranties or representations made or given.
6. ENTIRE AGREEMENT: This contract and all documents referenced herein constitute the complete and final agreement between the parties. In the event
that any of the provisions of this contract shall be held to be invalid, the remainder of the provisions of this contract shall remain in full force and effect. Two
identical copies of this contract have been completed and signed. Homeowner acknowledges receipt of a completed contract signed by the Contractor.
7. HOME IMPROVEMENT REGISTRATION: In accordance with M.G.L.c. 142 A, § 9, Contractor is registered with the Bureau of Building Regulations
and Standards Registration No: 136779. Homeowner may verify by contacting the Director at (617) 727-3200, ext. 25205. A Homeowner's rights under
the Home Improvement Law (M.G.L.c. 142A) and other consumer protection laws may not be waived in any way. Homeowner acknowledges receipt of a
copy of 780 CMR R6 and Massachusetts General Laws chapter 142A, and which are available online at www.mass.gov. Questions may be directed to the
Consumer Information Hotline, (617)727-7780.
8. ARBITRATION: Contractor and the Homeowner hereby mutually agree in advance that in the event the Contractor has a dispute concerning this contract,
the Contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs
and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c. 142A. No lien or security interest is
imposed on the Property as a consequence of this contract, but Contractor has the right to record this contract or a notice of this contract, or seek a lien ifthe
Homeowner breaches this Contract.
9. HOMEOWNER COVENANTS: The Homeowner agrees, represents and warrants that (a) the Homeowner grants permission to the Contractor to enter the
Property to perform the work as covered by this contract; (b) the Homeowner has funds available to make full payment under this contract to the Contractor
upon completion; (c) the Homeowner understands that construction as contemplated by this agreement creates a dangerous condition, and agrees not to enter
portions of the Property under construction until the Contructor advises the Homeowner that the construction is completed; (d) Contractor may need use
landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and (e) that code requirements may result in
roofing nails penetrating through roof decking and will be visible on the underside of some surfaces. The Homeowner indemnifies, exonerates and holds
harmless the Contractor from any loss, damage, claim, liability or expense (including reasonable attorney's fees, deposition costs and court costs) resulting
from a breach of this provision. Contractor is not responsible for damage to landscaping that will grow back during the next growing season.
10. CANCELLATION: Homeowner may cancel this agreement provided Homeowner notifies the Contractor in e address listed in the Proposal not
later than midnight of the thir dPI
the signing of this agreement.
HOMEOWNER: /Ak ---------- DATE:— ty
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Job Description: .1
Or
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employees (fiffl andlar part-timo)
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1. F -I Plimfbtagg repairs, or additions
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-4,ttach. R copy of the wOrken' compensation policy declaraden Daae thepoliqynum�Der.
'shoydng and expiration dateL
Failure - To s --- U T-- c ovem gee as re an ire d u n d -x, S ec�don 2 5, A o -LFM GL c. I s2 c an lea d to th e i= o siti on o -F "mmal p
fint up to S 1,500.00 anWor-. one-yzar imprisonment. as well 2-Q- civil p--naltie, I --n --naltim of a
in the fonm,of a STOP WORK ORDER and a
of up to S250-00 a day a_n=' !h-- violator. Be adviised ffiat
invesn.gations ef the a cOPY 0 this stat-eme-in may be- forward --d to ffi-_, Offi-_t of
DIA. for insurance coverage V--=Ca-aon.
I do hereby C cr 6 --pains andpenaLtLeg oj��ejiny that tL, infO?7nadorz proiided above is true and correxL
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I VV"1W= WO
ACORD. CERTIFICATE OF LIABILITY INSURANCE
DATE JMMIDWYyM
1
WIr
NSA
612MOIS
PRODUCER
Doherty Insurance Agency, Inc.
P.O. Box 1985
21 Elm Street
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.
POLICY-EXPIRAMON
Andover, MA 01810
INSURERS AFFORDING COVERAGE NAIC #
INSURED Twomey & Legare Contracting, Inc.
87 Belmont Street
North Andover, MA 01845
INSURER A- Arbelly Protection Ins Company
IMAERD:
INSURER C,
INSURER 0. -
INSURER I--
,ZORENTED
RMIE 1FA0=1ff@nCQ% S100,000
1ES
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.
INSH
LTR
WIr
NSA
TYPE OF INSURANCE
-- POLICY NUMBER
TrY.E.FFME
Pee
POLICY-EXPIRAMON
LIMITS
A
GENERALLIABILFTY
9520040230
06= S
ofir=6
EACH OCCURRENCE $1,000,000
,ZORENTED
RMIE 1FA0=1ff@nCQ% S100,000
X COMMERCIAL GENERAL LIABILITY
CO"
CLADAS MADE a OCCUR
NED EXP (Aw on par=) $5,000
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $ 000,000
GEN'L AGGREGATE LMT APPLIES PER:'
---
PRODUCTS - compiop AGO s2.000.000
I POLICY f' 1 PRO* F-1 LOC
x JECT
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
We -ddw") S
BODILY WXRY S
(POT perwn)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY IKWRY
INN Goddaffl) S
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE
(Per accident) S
GARAGE UABMJTY
AUTO ONLY - EA ACCIDENT S
OT14FR THAN EAACC 3
ANY AUTO
AUTO ONLY: AGG S
EXCESSIUMBRELLA LIABILITY
OCCUR F-1 CLAIMS MADE
EACH OCCURRENCE $
AGGREGATE $
S
DEDUCTIBLE
$
RETENTION S
WORKERS COMPENSATION AND
WCSTATI 0a
TORYUMFTS
EMPLOVERW LIABUM
ANY PROPRIETORIPARTNER(EXECUTIVE
E.L. EACH ACCIDENT S
F L DISEASE - FA EMPLOYEE
is
OFFICER/MEPABER EXCLUDED?
Ibo�r
UE-CIVAO & 5 bakm
E.L. DISEASE - POLICY LIMIT
OTHER
A
-
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL R3�GONS
Covering operations usual to Twomey & Legare Contracting, Inc..
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, OUT FAILURE TO Do 80 SHALL
IMPOSE NO COUGA710H OR LIABILITY OF ANY KIND UPON THE KWRL% ITS AGENTS an
AUTHORIZED
ACORD 25 (2001108) 1 of 2 #S32196IM32132 DML 9WORD CORPORATION 1988
70
ACC>RV CERTIFICATE OF LIABILITY INSURANCE
111.�
DATE (MWDDIYYYYI
1 03123/2016
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 INSURERIS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SU13ROGATION 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
NAME: Diane LeBlanc
DOHERTY INSURANCE AGENCY INC
(978) 475-0260
E-IIIIAIL
ADDRESS: dleblanc@dohertyinsurance.com
INSURER(S) AFFORDING COVERAGE NAIC 4
P-0 BOX 1985
INSURER A TRAVELERS INDEMNITY CO OF AME
ANDOVER MA 01810
INSURED
INSURER 8
TWOMEY & LEGARE CONTRACTING INC
INSURERC:
INSURER D:
87 BELMONT STREET
INSURER E:
INSURER F;
-NORTHANDOVER MA 01845
COVERAGES CERTIFICATE NUMBER: 39155 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 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.
INSR
I TYPE OF INSURANCE
_J
A
A
UER
POLICY NUMBER
POLICY EFF
IMMIDO)YYYYI
POUCYEXP
(MhUDDrYYYY1
LIMITS
COMMERCIAL GGENERALLIABILITY
EACHOCCURRENCE
S
CLAIMS-MADE D OCCUR
A AGE RENTFff—
PDX M.SF-17EO occurrence)
A --
MED EXP (Any one person)
S
PERSONAL & ADV INJURY
S — ---
N/A
GENI. AGGREGATE LIMIT APPLIES PER:
PRO. F—
POLICY El jECT I LOC
- -- I—
GENERAL AGGREGATE Is
PRODUCTS - COUPICP AGG
Is
OTHER:
AUTOMOBILE
LIABILITY
CON.1811,1EIDSINGLE LIMIT
(E. en
BODILY INJURY (Per person)
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
N/A
BODILY INJURY (Per awdent)
S
N0N*3WNED
HIRED AUTOS AUTOS
PROPER DAMAGE
tPe, .:a,)
$
is
EACH OCCURRENCE
$
UMBRELLAILIAB OCCUR
EXCESS LIAO CLAIMS -MADE
NIA
AGGREGATE
—DED 1 -1 RETENTIONS
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
X-4YPROPRIETOfti-PARTNEftlEXECUTIVE FN--
OFFICERIMEMBER EXCLUDED? A]
WA
NIA
6HUS029OM99415
0911812015
09/1812016
X1 PER OT -
STATUTE ER
+s
E.L EACHACCIDENT
50D,000
E.L. DISEASE - EAEMPLOYEE1
S 500,000
(Mandatory In NH)
S6 dnatbo und r
D RIPTION OF OPERATIONS below
I s 500,000
E -L. DISEASE - POLICY LIMIT
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 11011. Additional Remarks Schedule, may be attached it 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 Massachusetts.
This cerlificate 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 too[ at www.mass.gov/lwd/Workers-compensationrinvestigations/.
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 AUTHORIZED REPRESENTATIVE
North Andover MA 01845
Daniel M. Crow
�y. CPCU, Vice President - Residual Market - WCRIBMA
0 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs & Business Regulation
06ME IMPROVEMENT CONTRACTOR
Begistration: 136779 Type:
xpiration: -- 8/26/201& Partnership
k�w
TWOMEY + LEGARE CONTRACTING INC -
SHAWN TWOMEY
87 BELMONT ST.
N. ANDOVER, MA 01845 Undersecret.—I
20 �'�S�73
Con%truction Supervisor
CS -067560
SRAUN M TWOMEY
61 PATROIT ST :'
N ANDOVER MA 01845
10125/2015
Construction Supervisor
—ce:-Isa: CS -055108
DOUGLAS J LEqARE
79 GARY AVE
HAVERHILL MA 01830
09/0212016