HomeMy WebLinkAboutBuilding Permit #817-15 - 392 MASSACHUSETTS AVENUE 4/16/2015u- BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:S / i/ r Date Received
Date Issued:
ORTANT: Applicantmustcomplete all items on this pag
LOCATION 593
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0• (t LflD 1616
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�RADRATED
PROPERTY OWNER /�W_et4o "A
IF Print 100 NVr Structure yes no
MAP PARCEL: ZONING DISTRICT- Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
11 Addition
❑ Two or more family
❑Industrial
❑ Alteration
No. of units:
❑ Commercial
A Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer_
P 1 1UN UI- VVUK I or- r Kr r[IYICU:
1 I ✓ICD I✓C � IA 0 C2 19-Y 1W'P_, f
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Idgntification - Please Type or Print Clearly
OWNER: Name:
Address:
Contractor Name: 4AtJ V, Phone*
Email: koorA4 a RIPR e C
Address: 12r)
Supervisor's Construction License:y l�01 (OZ Exp. Date: dim 8Z— Zat I
Home Improvement License: Exp. Date. -7 Ac>tS
x
ARCHITECT/ENGINEER Phone:
Address: -,/V �� Reg. No. Al
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 3t d o o FEE: $ i
Check No.: 01 Receipt No.: eT �f
NOTE: Persons contracting with unregistered contractors do not have access
'lo theIFIaty f nd
nature of Agent/Owner Signature of co
Plans Submitted ❑ Plans Waived ❑
Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/1V4assage/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
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On
Signature
Reviewed on Signature
Reviewed on Siqnature
Zonin q Board of Appeals: Variance, Petition N
Pla��ning Board Decision: Comments
Conservation Decision: Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
- 68
- Located 384 Osgood Street
FIRE DEPAR#TNT -Temp Dump -on on sits yes 1 J T - no
Located at 124 Main= -Street
Fire, Department i$jgnature/date
MMENT
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
NU I is and UA I A — (For department use
❑ 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
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o 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
Li Certified Surveyed Plot Plan
o 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
o Workers Comp Affidavit
Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: 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. kf
Date �
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ /
Foundation Permit Fee
Other Permit Fee $—•T
TOTAL $ "
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Express Asset Management
Work Order Information
Client Company: 78569
Customer: 251
Loan #: XXXXXX9032 Loan
Type:
Address: 392 MASSACHUSETTS AVE
NORTH ANDOVER, MA
01845
Lot Size: 145 x145 = 21025
Assignment/Due Dates
,d Date: April 1, 2015
ie Date: April 7, 2015
ned To: Elkin Gomez
PPW #: 4654
Work Type: Bid Approval
Comments
PERMIT MUST BE PULLED- THIS MUST BE STARTED ASAP
Work Order Details Qty Price Total
PHOTO -PHOTOS 0
PHOTOS DOCUMENTING INTERIOR AND EXTERIOR PROPERTY CONDITION, DAMAGES, BIDS,
SUPPORTING BEFORE, DURING (TO SHOW PROGRESS) AND AFTER OF WORK COMPLETED.
PROPERTY CONDITION - COMPLETE A PROPERTY CONDITION REPORT 0
REPORT CURRENT PROPERTY STATUS INCLUDING UTILITY INFORMATION. CONFIRM PRESENCE OF
SUMP PUMP AND VERIFY IF OPERATIONAL. IF NO VISIBLE SUMP PUMP IDENTIFY IF CROCK IS
PRESENT.
COMPLETE A PROPERTY DAMAGE REPORT 0
PROVIDE DETAILED DESCRIPTIONS OF DAMAGES INCLUDING LOCATION, PHOTOS AND BIDS TO
REPAIR. EYEBALL ESTIMATE IS NECESSARY WHEN DAMAGES ARE PRESENT.
PROPERTY CONDITION OTHER n
IF REPORTING A PROPERTY AS OCCUPIED, PLEASE INDICATE REASON FOR REPORTING
OCCUPANCY, NAME, RELATIONSHIP & CONTACT INFORMATION OF PERSON PROVIDING
VERIFICATION, OTHER METHODS USED TO VERIFY OCCUPANCY. PERSONAL PROPERTY IS NOT A
JUSTIFIABLE CAUSE TO REPORT THE PROPERTY OCCUPIED, UNLESS YOU ARE IN A MUST EVICT
PERSONAL PROPERTY STATE. IF THIS IS A MOBILE HOME ADVIS OF MANUFACTURER, MAKE,
MODEL, SERIAL #, VIN # AND HUD TAG VS. ADVISE IF IT IS A SINGLE, DOUBLE WIDE OR TRIPLE WIDE.
ADVISE IF THE AXLES, WHEELS OR TONGUES HAVE BEEN REMOVED. PROVIDE THE LENGTH AND
WIDTH OF THE MOBILE HOME. PLEASE PROVIDE CLEAR PHOTO OF VIN # AND HUD TAGS.
BID APPROVAL - REPAIR / REPLACE ROOF - 0
PLEASE COMPLETE THE FOLLOWING FROM BID#(2599673) ON WORK ORDER#(1046626970).
SECURING - REPLACE- REPLACE ROOF — REMOVE MAIN ROOF - ASPHALT SHINGLE - DOUBLE
LAYER. REPLACE ASPHALT SHINGLE - BASIC 3 TAB (25-40) YEAR.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
n r
i d 1 Congress Street, Suite 100
Boston, ALL 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Bl
Address:
City/State/Zip:_A/. C kY"&fir 1 I f'h t Phone #:
Are you an employer? Check the appropriate box:
1, r� I am a employer with �,5employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.1'1 am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.1
6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. ❑ Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.❑ Electrical repairs or additions
12. ❑ Plumbing repairs or additions
13. Roof repairs
14. ❑ Other
Ttjny appiicam rnat cnecxs oox rti must also till out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site
information.
Insurance Company Name: _ ; - y_ i� /j (< !I I -AW C Q
Policy # or Self -ins. Lic.
Expiration Date:
Job Site Address: �%� rn l�j City/State/Zip:��v2tL
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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 the pains and penalties of perjufy 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 #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
Contact Person:
4. Electrical Inspector 5. Plumbing Inspector
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 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 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=contractor(s) 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 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
DATE(MMIDDrYYYY)
TE OF LIABILITY INSURANCE I 06/11/2014
ACORD� CERT Ir
THIS CECONFERS No RIGHTS UPON TH
RTIFICATE IS ISSUED A5 A MATTER OF INFORMATION ONLYE TEND OR ALTER THE COVERAGE AFFORDEDCBY THE POL C ESATE HOLDER.
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HO11 LD11 ER. Ies must be endorsed. it SUBROGATION 1S WAIVED, subject to
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy{' }
ment
the terns and Conditions of the policy, certain policies may require an endorsement. A stateon this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s). ANDRE SILVA
PRODUCER NAME.
PHONE 508-875-5600 (ac,No):508-875-5885
Rapo & lepsen Financial and In Services Arc No Ext:
1103 Commonwealth Ave ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIG /j
Boston, MA 02215 ARD INSURANCE CO
INSURER A : AMGU
_ _ _– ....nrr►Ir AIJtI CTIITNG TNCI INSURER B -
INSURED
8 BACON SLEEP
APT 1
MILFORD, MA 01757
CERTIFICATE NUMBER:
INSURER C :
INSURER 0:
INSURER E :
INSURER F :
REVISION NUMBER:
GOV kRAldCa
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BE HIS
INDICATED. NOM NT, TERM OR CO
YY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLINDITION OF ANY OS DESC BED HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM LIMITS
POLICY NUMBER (MMM (MMIODNYYY)
ILTR TYPE OF INSURANCE INSR VJUD EACH OCCURRENCE $
GENERAL LIABILITY
PREMISES (Ea ocamerlce) S
I COMMERCIAL GENERAL LIABILITY MED EXP (Any one Pin) $
CLAIMS -MADE 0 OCCUR
I PERSONAL &ADV INJURY $
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETORIPARTNER/EXECUT� NIA
A OFFICEREMBEREXCLUDED? N
/M
(Manantory In NN)
if— describe under
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD -101. Additional Ramada; Schedule, if m m space is required)
E.L. EACH ACCIDENT 5 1,000
E.L. DISEASE - EA EMPLOYEE S 11000
E.L DISEASE - POLICY LIMIT $ 11000
nCor, d%ATG un, nco E_ANr`FI I ATIAN I I A /
SHOULD ANY OF THE ABOVE RIBED CIES ANCEL ORE
THE EXPIRATION SATE TH NOTICE WI E EDi
k�"'
ACCORDANCE WITH THE POUROVISIONS.
RT MANAGEMENT
I ROODY@RTREMODEL.COM
GENERAL AGGREGATE $
Aun,oR�orsEraEserrrATrve
120 MAY ST
NO TN CHELMSFORD, MA 01863
PRODUCTS - COMP/OP AGG $
GEMLAGGREGATE APPLIES PER$
(LIMIT
POLICY JE a LOC
ED SINGLE LIMI
AUTOMOBILE LIABILITY
j
I
BODILY INJURY (Per person) $
ANY AUTO
BODILY INJURY (Per accident) $
ALL OWNED
$
AUTOEI SULED
AUTos NON -OWNED
(Per aoadent)
HIRED AUTOS IAUTOS
$
EACH OCCURRENCE $
UMBRELLA LIAB
OCCUR
AGGREGATE $
EXCESS LIAR
CLAIMS -MADE
S
DED I RETENTION SI
... __'�AUD=NAATION
I
TBA
06106/2014
06/06/2015
X I TORY LIMITS I _ I 1 I
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETORIPARTNER/EXECUT� NIA
A OFFICEREMBEREXCLUDED? N
/M
(Manantory In NN)
if— describe under
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD -101. Additional Ramada; Schedule, if m m space is required)
E.L. EACH ACCIDENT 5 1,000
E.L. DISEASE - EA EMPLOYEE S 11000
E.L DISEASE - POLICY LIMIT $ 11000
nCor, d%ATG un, nco E_ANr`FI I ATIAN I I A /
V 1988-2010 AC tWO CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE RIBED CIES ANCEL ORE
THE EXPIRATION SATE TH NOTICE WI E EDi
k�"'
ACCORDANCE WITH THE POUROVISIONS.
RT MANAGEMENT
I ROODY@RTREMODEL.COM
Aun,oR�orsEraEserrrATrve
120 MAY ST
NO TN CHELMSFORD, MA 01863
V 1988-2010 AC tWO CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
RPMAN-1 OP ID: SW
14on
CERTIFICATE OF LIABILITY INSURANCE
DATE W)�
04115/20/5
THIS CERTIFICATE IS ISSUED AS A CHATTER 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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s)_
PRODUCER Phone: 732,842-2012
CONTACT
NAME:
York -Jersey Underwriters, Inc. Fax: 73230-7080
185 Newman Springs Road
PO Box 810
Red Bank, NJ 07701
PH0 F
AIC No Ext): AIC No
E-MAIL
A°°RESS,
INSURER(S) AFFORDING COVERAGE MAIC 0
Johnnie Rumbaugh
INSURER A: Underwriters at Lloyd's,London
INSURED RP Management
Valias R Herold Jr
120 Main St
INSURER B:
INSURER C
INSURER D:
N Chelmsford, MA 01863
INSURER E
15RAMB0408
INSURER F
02/23/2016
COVERAGES CERTIFICATE NUMBER: REVISION NIJMER-
THIS IS TO CERTIFYTHAT 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS.
NS
IPOLICY
TYPE OF INSURANCE
52 Main Street
POLICY NUMBER
MMIDD EFFMIDDIYYYY
EXP
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A
X COMMERCIAL GENERAL LIABILITY
X I CLAIMS -MADE U OCCUR
15RAMB0408
02/23/2015
02/23/2016
PREMISES Ea occurrence) 5 50,000
MED EXP (Any one person) S 5,000
PERSONAL & ADV 114JURY $ 1,000,000
X $2500 Ded
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS- COMPIOP AGG S 2,000,000
POLICY JECT LOC
S
AUTOMOBILE LIABILITY
Ee egatle tSINGLE LIMIT S
BODILY INJURY (Per person) S
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) S
HIRED AUTOS NON -OWNED
AUTOS
PROPERTY DAMAGE $
Per accident
$
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE 5
EXCESS LAS
CLAIMS -MADE
AGGREGATE S
DED I I RETENTIONS
$
WORKERS COMPENSATIONWC
STATU- OTH-
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIE)ECUMVE ❑
OFFICER/MEMBER EXCLUDED?
NIA
1 d R
E.L. EACH ACCIDENT S
E.L. DISEASE - EA EMPLOYEE $
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
Mortgage Field Services - Errors 6, Omissions $1,000,000 (claims -made) $2500
deductible. Extended Property Damage $50,000 occurrence/$100,000 aggregate
CERTIFICATE HOLDER CANCFI I ATinm
MILFORT
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Milford
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
52 Main Street
Milford, MA 01757
AUTHORIZED REPRESENTATIVE
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
�✓ tte� Jc��si�E'�e•t�•s•��t?Li'�t�r% ��U�ic.i����'�����-{3c
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
w
Registration: 169638
Type: Corporation.
Expiration: 7113/2015
ROODY PROPERTY INC.
VALIAS HEROLD JR.
120 MAIN ST.
CHELMSFORD, MA 01863
Trd 242537
Update Address and return card. Mark reason for change -
SCA 1 Q: 2nM•05/11
E] Address [] Renewal n Employment Lost Card
��1r �r-u[[i[n[[[rrul/� [•% " %in.L,'ncfuJr(!' . _ ..—._— —^ --- -- -- --- -- — _ . _ -- -
` Office of Consumer Affairs & Business Regulation License or registration valid for individul use only .
SOME IMPROVEMENT CONTRACTOR before the expiration date -If found return to:
kk
egisir'don: 169638 Type Offiof Affairs and Business Regulation
SRO,Consumerce
iExpiration:. 7113I2015 Corporation 10 Park Plaza - Suite 5170
.Boston, MA 02116
ROODY PROPERTY INC.
VALIAS HEROLD JR. /
120 MAIN ST.
CHELMSFORD, MA 01863 Undersecretary Notvalid WVqht
signature
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Board of Building i>euulatic:-,s and Stan dardc
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_,cense: CS -106968
VALIAS R HEROID JR
120 MAIN STREET
North Chelmsford:KA 01863
E x o + r -,i t: a
Commissioner 01/02/2017