HomeMy WebLinkAboutBuilding Permit #692-16 - 39 MAIN STREET 12/17/2015NORT#1
BUILDING PERMIT o*�t�eo "ti
TOWN OF NORTH ANDOVER 32 h'.`.- .:= °
APPLICATION FOR PLAN EXAMINATION
0
Permit No#: Date Received
4
�gSSgcHuS���y
Date Issued:
IMPORTANT: Applicant.,must complete all items on this page ,r
LOCATION YKIJ0/,V/
Print 1
PROPERTY OWNER ZT LIf
Print 100 Year Structureyes no
MAP PARCEL: ZONING DISTRICT: Historic District yes o
Machine Shop Village yes n
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Ind stria)
❑ Alteration
No. of units:
ueqxmercial
❑ Repair, replacement
❑ Assessory Bldg
ers* oo
❑ molition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIff ION Of WORK TO BE P RFORMED:
� cr /i✓t� 1/O
2
.aM
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED 025.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: WZ15- Receipt No.: -,g
NOTE: Persons contracting with unregistered contractors do not have access to thy guaranty fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF 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
C.
PLANNING & DEVELOPMENT Reviewed On I3 14 Signature_
COMMENTS &N611- 014D',,- gf-JIVI,)9-MT -4C6 S11)iA16
Le Poe
w'eol loY Plalet/l
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on _ Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition
Planning Board Decision:
Conservation Decision:
Commen
Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIREaDEPARaTMENT TempDumpster,onsi z no i
yte> ,y'esa
E Locatedat 124Ma0tSt�eet
C®MMLNTS,
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.Suilding 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
,4. 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
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
4. 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
TOTE: 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 Aw
No. Date
Check #
1"' (' r r, V
., d r
TOWN OF NORTH ANDOVM
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
Eq
40
I=-
J
W
s
LL
0
DZ
oLLI
m
O
clit
Y
\
O
LL
n
to
U
❑.
Ln
0
d0.
z
Z
ca
C
O
a�
'6
L.L
L
d'
?
N
C
E
U
LL
V
z z
J
d
L
D
d'
LL
0
Ln
cr
U
J
LN
L
K
N
U
iD
Ln
LL
oc
a
Z
t
d'
Ll-
z
W
a
CL
Lu
LL.
m
O
z
a+
v
(%
N
O
Q1
Y
O
Ln
O�
O
�' •Q- L o
CL O
ca =
� ,
O
to
N
O N
150
S . •FCCJ 0
• i
Sa
_
_ N' cN�o �P
U) _
* * 2
H J d
CD
0 m N
L
O �� c ami >
Cl) — o >
Nva c
t t O
�
0 c
O I
CL
=oIm
t > otm
O
.� Q- •�
q � r m
V `� O
cv o y
o c c
F
' i i •O
2 d - Q 4) '� N
H �+ Cc` m
W O
ujcnLL .2to C O
•V F+ O
W .E v ._
• (� N
0-0 N
Cl)U) °'.O4- r p
I— t O. O U >
O
LU
CO
Z
m
2 �
CD Mce�
Z V
W
aci)
X Z
W 0
�w
CL Z
W
O
z
0
W
L
i
W
0
cy
CA
.CL
cn
r_
V
m
CLN
w
c
00
O om
�a
s
Cc
J
O CD
Z
CL
N
Proposal
HIC # assns
TWOMEY & LEGARE
CONTRACTING lNk-.,
"Couldn't your home use a little TLC?"
Specializing in Residential Additions
87 Belmont Street • North Andover, MA 01845
P: 9;89685-7447 • F: 978-685-7446
NAME OF OWNER /39
7 f
ADRESS OF JOB!/S
Ilef/ A,:: r -
TEL. DATE: ��
We hereby submit estimates for. �[ ... /� ✓�..�
C!
We Propose herby to furnish material and labor- complete in accordance with above specifications, fo a sum
dollars (� m
PaWaQW to be made as follows ,
Authorized
Signatu e
NOTE: This pro ay be withdrawn by s if not accepted with in-14ays
Acceptance of Proposal -The above pries,
specifications and conditions are satisfactory and are herby
accepted. You are authorized to do the work as specified. Payment
will be made as outlined above.
j Signature
Date of Acceptance: / �� Signature
HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS .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.
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 7
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 of the
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 furnish the materials and labor specified in the Proposal for the amount as stated in the
Proposal. Thirty percent (301/o) 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
Contractor's reasonable costs of collection, including attorney's fees and costs. Time is of the essence 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
erence to any materials or equipment installed in the Premises, passes any such warranties
year duration or intensity. Contractor gives no warranties with ref
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;tri 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
�� con�tract have been co'mmppleted d signed. Homeowner acknowledges receipt of a completed contract signed by the Contractor.
7. HOME IMPROVEM NT R�EGISSTRA7 i6N'In" ai cordance with M.G.L.c. 142 A, 9 Contractor is
§ � registered with the Bureau of Building Regulations
and Standards Reastration No: ice, 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 maybe 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 if the
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 Contractor 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: Home�.�mer may nce thisgeement provided Homeowner notifies the Contractor in writing at the address listed in the Proposal not
later thanmidnight of the thir busirip y fol win the signing of this agreement.
DATE: �4 lr—
DEPOSIT:
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Are ygrran employer? Check the appropriate box:
1. ETI am a employer with , '3—
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. #
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. �eMolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. ..-I _ — r7
Insurance Company Name .I -f �-IZA7
Policy # or Self -ins. Lie. #/Q�/`� ` Expiration Date:
Job Site Address: A1,4City/State/Z'�p /��i' d,,�,✓✓d%�1 �
Attach 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, as 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.
Ido hereby cert u e Izepain penalties ofperjury that the information provided above is true and correct.
Signature: Date:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License 9 -
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other - - -
Contact Person: Phone
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 employeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association 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 of the
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 required"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work 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 certificate(s) 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 may be 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
Please be sure that -the affidavit is complete and printed legibly. The Department has provided a space at the -bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy
in (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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department ofzndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel, # 617-727-4900 oxt 406 or 1-877:MASSAFF,
Revised 5-26-05 Faze # 617-727-7749
www.Mass,8oV1dia
ax N2-2
1/13/2015 6:42:50 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
T. fi1FICATE 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 BYTHE 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 po(icy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the
terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME:
PHONE
FAX
DOHERTY INS AGENCY INC
PO BOX 1985
(AIC, No, Ext):
(A/C, No):
21 ELM STREET
E-MAIL
ANDOVER, MA 01810
ADDRESS:
22YMX
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED
INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA
TVUOMEY & LEGARE CONTRACTING INC
INSURER B:
INSURER C:
INSURER D:
PO, BOX 366
INSURER E:
NORTH ANDOVER, MA 01845
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 W141CH 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. LRdrTS SHOWN MAY HAVE BEEN REDUCED BY
PAD CLAIMS.
NSR
ADD
SUB
POLICY EFF DATE
POLICY EXP DATE
LTR
TYPE OF INSURANCE
L
R
POLICY NUMBER
(MMIDDIYYYY)
(MRADDIYYYY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE E] OCCUR.
DAMAGE TO RENTED $
PREMISES (Ea occurrence)
ED EXP (Anyone person) $
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY Q PROJECT a LOC
ERSONAL & ADV INJURY $
ENERAL AGGREGATE $
RODUCTS - COMP/OP AGG $
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE $
LIMIT (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULE AUTOS
(Per person)
BODILY INJURY $
HIRED AUTOS
NON -OWN ED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB[]OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE
AGGREGATE $
DEDUCTIBLE
$
$
RETENTION $
A
WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY YIN
UB-029OM994-14
09/IB/2014
09/18/2015
Y WC srantroAY !OTHER
` : LIMITS •
ANY PROPERITOR)PARTNER/E'XECUTIVE
OFFICERIMEMBER EXCLUDED.
N/ A
E. L. EACH ACCIDENT $ 500,000
E.L. DISEASE - EA EMPLOYEE $ 500,000
(Mandatory in NH)
11yes. under
DESCRIPTIRI"ONNOF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCA-(ONSIVEHICLESIRESTRICMONS/SPECIAL ITEMS
TH(S REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTTFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENT/;: VE
ACORD 25 (2010/05) The ACORD name ana logo are reglsterea marKS Ot ACORD 1959-ZUI0 ACORD CORPORATION. All rights reserved.
Client#• 13298
TwnmlzvR
ACORDL CERTIFICATE OF LIABILITY INSURANCE
'015°"'Y""'
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Doherty Insurance Agency, Inc.
P.O. BOX !985
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
21 Elm Street
POLICY EXPIRATION
Andover, MA 01810
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURERA Arbella Protection ins Compan
Twomey & Legere Contracting, Inc.
87 Belmont Street
North Andover, MA 01845
INSURER 6:
INSURER C:
INSURER D:
INSURER E:
CC)VERAGES
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 13E ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSA
AUDI
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
LIMITS
GENERAL LIABILITY
9520040230
OW2115
08/22/16
EACH OCCURRENCE S1,000,000
rA
GENERAL LIABILITY
DAMAGE TO RENTED $100,000
TXCIDIMMERCtAL
CLAIMSMADE a OCCUR
MED EXP are Darien) &S.000
PERSONAL A ADV INJURY 91,000,000
GENERAL AGGREGATE $2.000.000
GEN'LAGGREGATE LIMITAPPLIES PER:
PRODUCTS-COMPIOPAGG $ZOOOGOO
X POLICY JECTPRO MLOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT S
ANY AUTO
(Ea a=WW)
BODILY IWURY
S
ALL OWNED AUTOS
SCHEOULEDAUTOS
(ftparw)
BODILY INJURY S
HIRED AUTOS
NO"WNEDAUTOS
(Perecdclani)
PROPERTY DAMAGE S
(Per »)
OARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC S
ANY AUTO
AUTO ONLY: AGG S
EXCESSIUYBRELLAUA8IUTY
EACH OCCURRENCE S
OCCUR F-1 CLAIMS MADE
AGGREGATE S
S
S
DEDUCTIBLE
S
RETENTION S
WCSTATLF OCH
WORKERS COMPENSATION AND
--
El EACH ACCIDENT S
EMPLOYERS' LIABILITY
ANY PROPMETONPARTNENDtECUT1YE
EJ_ DISEASE - FA EMPLOYEE S
OFFICERIMEMBER EXCLUDED?
E.L. DISEASE - POLICY LIMIT S
11yos. dosalbo under
SPECIAL PROVISIONS below
OTHER
F
I
DESCRtpT10N OF OPEnATmONS l LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
Covering operations usual to Twomey & Legere Contracting, Inc...
CFtmote-ATF i4m nFR CANCELLATION 10 Days for Non•Pavment
ACORO 25 (2001108)1 of 2 #S32193/M32132 V 13ML G,0RD CORPORATION 1988
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. BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATNES.
AUTHORIZED THE
ACORO 25 (2001108)1 of 2 #S32193/M32132 V 13ML G,0RD CORPORATION 1988
Massachusetts Department of Public Safety
® Board of Building Regulations and Standards
License: CS -067560
Construction Supervisor
SHAUN M TWOMEY
61 PATROIT ST
NORTH ANDOVER MA 01845' d:_ :1.es�
�-j ZCK Expiration:
Commissioner
10/25/2017
'. � V 12C �(J607297247tt!/CQL(� O�Vt/(,CIuJnC1tU:1C�J
Office of Consumer Affairs & Business Regulation
ME IMPROVEMENT CONTRACTOR
egistration: 136779 Type:
xpiration: 8/26/2016 Partnership
TWOMEY + LEGARE CONTRACTING INC.
SHAWN TWOMEY
87 BELMONT ST.
N. ANDOVER, MA 01845 Undersecretary