Loading...
HomeMy WebLinkAboutBuilding Permit #527-2017 - 394 BOSTON STREET 11/16/20161 L NORTI{ BUILDING PERMIT 32 Q6�1�60 6q`OG TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATI N «_> Permit NO: ��—� Date Received t1kco L, 9q< Date Issued: 11Lp l �RSSACHU`� I fie TANT: Applicant must complete all items on this LOCATION &5kbA K 011 1 A,6,eg, MA C)(%4S- f'► \ n Print PROPERTY OWNER_ MAP NO: _PARCEL: Print ZONING DISTRICT: Historic District yesno Machine Shop Village yes Ir no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential LJ New Building C ne family C Addition ❑ Two or more family ❑ Industrial C Alteration No. of units: C Commercial ❑ Repair, replacement ❑ Assessory Bldg C Others: demolition ❑ Other �] Septic ❑ Well ❑ Floodplain 9 Wetlands ❑ Watershed District "I Water/Sewer ��4��'. VP�c,�n 3 T►t.�. �'�L L-% Identification Please Type or Print Clearly) OWNER: Name: (Shrew M- \o -, Address: LA i CONTRACTOR Name: Phone: U -ft) U'�)�r22u2 A OSDTI Phone: Vti- 22 Lite Address: , , Supervisor's Construction License: Exp. Date: C�S-�►7ofp Home Improvement License: 15197-11 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ Ito 3 b;,6b FEE: $ � Check No.: ZO %'( Receipt No.:— ,? NOTE: Persons contracting with unregistered contractors do not have access to the guaranty and Signature of Agent/Owner Signature of contractor Location I2 1 qt� f ��•77 jj No. �') l.-�l Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ a6FouBuilding/Frame Permit Fee $-a6-- Foundation ndation Permit Fee $ Other Permit Fee $ `. TOTAL $ • Check #26 61200 a Building Inspector 0 mo o: r L O Q W U. OC 0 m d u O O LL v N U !]. N {n d Z Z Q m O 'O r_ 7 O LL L to O cr T C E_ t U f0 C LL o W N Z ZV m J d t O K _ N C LL O W EA Z W J W t O d' U N _ m C LL cc O U d CA y Q t K _ C LL z WWc C Q W D W LL m Z `J N N Y N C C .r V O Q d *-fop: • : m Q O 0 N V Q. r CD N .� O � � t E cm AA At _O _ I = � o 0 L V cn :T C CLcn J m d � L O Gs > .--o U) m Q E c V d z Q- c rn O O •n C � 3 tm o0 L Q Q. d d (D :o�� r 140.. CL y V m ujW = 'a O O LL W N C W C L U O. O N U) -0 c O H A- CL O U O CO W Z a w E O O Z N VI c O cc O Q. CL CL �Q O _ (a Cc _v J -0 �r.L O W 0 C) U) cc c CL U) • • • ° Authorization to Perform Services and Direction of Payment Customer Name: Brett Schutzsle Loss Address: 394 Boston Street City: Insurance Company: North Andover Unknown Date of Loss: 11/06/2016 State: MA Zip: Claim Number (if available): 01845 The undersigned Customer, being the building owner, owner's representative, or resident, authorizes the Provider identified below to perform any and all necessary cleaning and/or restoration services on Customer's property located at the property address above, and with respect to items that need to be cleaned at a remote location to remove and clean such items as necessary. Customer authorizes Unknown Insurance Company, herein referred to as "Insurance Company," to pay Provider solely and directly for that portion of the work covered by Customer's insurance policy. If, for any reason, Customer receives a check from Insurance Company made payable to Customer, Customer agrees to pay Provider immediately upon receipt of the check. In order to expedite payment to Provider, Customer hereby appoints Provider as attorney-in-fact, authorizing Provider to endorse Customer's name on Insurance Company checks or drafts, and to deposit Insurance Company checks or drafts for Provider services. Customer agrees to pay Customer's deductible in the amount of $ $0.00 that applies to this claim. If any amounts owing to Provider for Provider services are not covered by insurance, Customer agrees to pay those amounts to Provider within fifteen (15) days of Customer's receipt of invoice. It is fully understood that Customer and its agents, successors, assigns, and heirs are personally responsible for any and all deductibles and any costs not covered by insurance. Interest and finance charges will be charged at the maximum allowable by law, or at 1.5% per month, whichever is less, on accounts over thirty (30) days past due. Time is of the essence. Customer agrees that Provider is working for the Customer and not Customer's insurance company or any agent/adjuster. Property Owned By: Brett Schutzsle Remarks: I HAVE READ THIS AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT, INCLUDING THE TERMS AND CONDITIONS OF SERVICE ON THE NEXT PAGE HEREOF, AND AGREE TO SAME. Customer Reviewed Customer Information Form: O Y ON Provider's Signature: Customer's Signature: �� Franchise Legal Name: Printed Name: Date: Brett Schutzsle d/b/a SERVPRO® of: 11/06/2016 Date: E-mail Address: brettschutzsle@icloud.com Contractor License #: ©SERVPRO® INTELLECTUAL PROPERTY, Inc. ALL RIGHTS RESERVED FE -051707 1.0 Each SERVPROO Franchise is Independently Owned and Operated. KEJO CORP The Andovers 11/06/2016 28000 05/16 Authorization to Perform Services and Direction of Payment Terms and Conditions of Service READ CAREFULLY Note: This Contract includes a limitation of liability and limitation of remedies. 1. SERVPRO® is one of the largest nationwide Cleaning and Restoration Franchise Systems in the United States. The SERVPRO® Franchise owner identified on the front of this Contract (the "Provider") is an independent contractor who agrees to perform the services identified on the front of this Contract (the "Services"). Client agrees to purchase, receive, and pay for the Services pursuant to the terms and conditions of this Contract. Servpro Industries, Inc., the Franchisor, is not a party to any agreement with Client, is not a guarantor of the Provider's Services, and is not subject to liability arising out of such Services. 2. Provider's performance of the Services is limited by, among other things, the pre-existing conditions and characteristics of the premises, material, fabrics, furniture, and/or other items. PROVIDER EXPRESSLY DISCLAIMS ANY RESPONSIBILITY OR LIABILITY FOR ANY PRE-EXISTING CONDITIONS. Client shall retain responsibility and shall be liable for all effects of and costs necessary to correct such conditions, including, by way of example and not limitation, the conditions identified below: (a) Provider may, in its sole discretion, pre-test materials for removability of spots or stains; dye or color fastness; shrinkage; fading; adhesive breakdown; or other problems. It is not always possible to determine these conditions in advance. PROVIDER DOES NOT GUARANTEE SPOT OR STAIN REMOVAL AND COLOR FASTNESS OR PREVENTION OF SHRINKAGE, FADING, OR ADHESIVE BREAKDOWN. (b) Provider DOES NOT GUARANTEE that wall and ceiling cleaning will restore the original color to painted surfaces. (c) Not all fabrics are conducive to cleaning. Provider shall use reasonable efforts to advise Client of any adverse effects which may be reasonably foreseen due to the nature of the fabric or material involved. PROVIDER DOES NOT GUARANTEE THAT SUCH MATERIALS CAN BE CLEANED OR THAT THERE WILL BE NO ADVERSE EFFECTS FROM ANY ATTEMPT TO CLEAN SUCH FABRICS. (d) A variety of materials are used in the manufacturing, upholstery and/or installation process. These materials include backing, lining, tacks, or other unknown substances that may cause discoloration or other adverse effects to the face material. Client acknowledges that it is impossible to determine when such adverse effects may occur and PROVIDER DOES NOT GUARANTEE AGAINST SUCH ADVERSE EFFECTS. (e) Client acknowledges and agrees that mold is commonly found throughout the environment and that it is impossible to eradicate mold. PROVIDER DOES NOT GUARANTEE THE REMOVAL OR ERADICATION OF MOLD. (f) Client acknowledges and agrees that limited photographs or video of the damage and cause may be made solely for work process and insurance claims purposes. 3. PROVIDER SPECIFICALLY DISCLAIMS ANY AND ALL OTHER WARRANTIES AND ALL IMPLIED WARRANTIES (EITHER IN FACT OR BY OPERATION OF LAW) INCLUDING, BUT NOT LIMITED TO, ANY IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE OR ANY IMPLIED WARRANTY ARISING OUT OF A COURSE OF DEALING, CUSTOM OR USAGE OF TRADE. THIS CONTRACT PROVIDES FOR THE PROVISION OF SERVICES AND DOES NOT PROVIDE FOR A SALE OF GOODS. 4. Limitation of Liability: IN NO EVENT SHALL PROVIDER, ITS OWNERS, ANY OFFICERS, DIRECTORS, EMPLOYEES, OR AGENTS, FRANCHISOR, OR AFFILIATES BE RESPONSIBLE FOR INDIRECT, SPECIAL, NOMINAL, INCIDENTAL, PUNITIVE OR CONSEQUENTIAL LOSSES OR DAMAGES, OR FOR ANY PENALTIES, REGARDLESS OF THE LEGAL OR EQUITABLE THEORY ASSERTED, INCLUDING CONTRACT, NEGLIGENCE, WARRANTY, STRICT LIABILITY, STATUTE OR OTHERWISE, EVEN IF IT HAD BEEN AWARE OF THE POSSIBILITY OF SUCH DAMAGES OR THEY ARE FORESEEABLE; OR FOR CLAIMS BY A THIRD PARTY. THE MAXIMUM AGGREGATE LIABILITY SHALL NOT EXCEED THREE TIMES THE AMOUNT PAID BY CUSTOMER FOR THE SERVICES OR ACTUAL PROVEN DAMAGES, WHICHEVER IS LESS. IT IS EXPRESSLY AGREED THAT CUSTOMER'S REMEDY EXPRESSED HEREIN IS CUSTOMER'S EXCLUSIVE REMEDY. THE LIMITATIONS SET FORTH HEREIN SHALL APPLY EVEN IF ANY OTHER REMEDIES FAIL OF THEIR ESSENTIAL PURPOSE. Some states/countries do not allow the exclusion or limitation of incidental or consequential damages, so the above may not apply to you. 5. Should Provider bring legal action to collect monies due under the Contract or should the matter be turned over for collection, Provider shall be entitled, to the fullest extent permitted under law, to reasonable legal fees and costs of any such collection attempt, in addition to any other amounts owed by Client. This attorney fee provision shall not be effective or enforceable in jurisdictions where attorney fee provisions are made reciprocal or invalid by operation of law. Consent is hereby given for filing of mechanic's liens by Provider for the work described in this contract on the property on which the work is performed if Provider is not paid. 6. Any labor, materials or other work beyond that identified in this Contract shall require a written amendment to this Contract and will result in additional charges. 7. Any claim by Client for faulty performance, for nonperformance or breach under this Contract for damages shall be made in writing to Provider within sixty (60) days after completion of services. Failure to make such a written claim for any matter which could have been corrected by Provider shall be deemed a waiver by Client. NO ACTION, REGARDLESS OF FORM, RELATING TO THE SUBJECT MATTER OF THIS CONTRACT MAY BE BROUGHT MORE THAN ONE (1) YEAR AFTER THE CLAIMING PARTY KNEW OR SHOULD HAVE KNOWN OF THE CAUSE OF ACTION. 8. A failure of either party to exercise any right provided for herein shall not be deemed to be a waiver of any right hereunder. 9. CLIENT AND PROVIDER EACH WAIVE THEIR RESPECTIVE RIGHTS TO A TRIAL BY JURY WITH RESPECT TO ANY AND ALL CLAIMS OR CAUSES OF ACTION (INCLUDING COUNTERCLAIMS) RELATED TO OR ARISING OUT OF OR IN ANY WAY CONNECTED TO THIS CONTRACT AND AGREE THAT ANY CLAIM OR CAUSE OF ACTION WILL BE TRIED BY A COURT TRIAL WITHOUT A JURY. 10. If any provision of this Contract is found to be ineffective, unenforceable or illegal for any reason under present or future laws, such provision shall be fully severable, and this Contract shall be construed and enforced as if such provision never comprised a part of this Contract. The remaining provisions of this Contract shall remain in full force and effect and shall not be affected by the ineffective, unenforceable or illegal provision or by its severance from this Contract. 11. No modification, termination, or attempted waiver of this Contract shall be valid unless in writing and signed by the party against whom the same is sought to be enforced. SERVPRO® Franchisees are always looking for motivated employees. SERVPRO's individually owned and operated franchises offer a variety of positions including crew chief, production technician, marketing representative, administrative assistant, and many more. 28000 05/16 Each SERVPRO� Franchise is Independently Owned and Operated. Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Client: Schetzsle, Brett (Permit) Property: 394 Boston St. North Andover, MA 01845 Operator: STEVEN Estimator: Steven Fumero Company: SERVPRO Of Lawrence - SERVPRO Of The Andovers - SERVPRO Of Salem/Plaistow Business: 8 Blakelin St. Lawrence, MA 01840 Type of Estimate: Water Damage Date Entered: 11/8/2016 Date Assigned: Price List: MAEM8X SEP16 Labor Efficiency: Restoration/Service/Remodel Estimate: 2016-11-08-1513-1 Home: (978) 810-0976 Business: (978) 688-2242 E-mail: steven @ servprooflawrence. com Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Kitchen 31' 7" -� T T r^7 , a n T t2�� i 72'2" 2'D'=-13'8" ^ r 9' 2" ti _14'- --27'T' 14'--� I --27. T' -� Missing Wall - Goes to Floor Missing Wall - Goes to Floor DESCRIPTION 2016-11-08-1513-1 Main Level 749.78 SF Walls 1105.33 SF Walls & Ceiling 30.85 SY Flooring 97.33 LF Ceil. Perimeter 2'2"X6'8" 2'2"X6'8" Height: 8' 355.55 SF Ceiling 277.61 SF Floor 93.00 LF Floor Perimeter Opens into Exterior Opens into Exterior QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 1. Tear out wet drywall, cleanup, bag for disposal 120.00 SF 0.81 1.43 98.63 (0.00) 98.63 Totals: Kitchen 1.43 98.63 0.00 98.63 Total: Main Level 1.43 98.63 0.00 98.63 o -5'7°-i i 4' 11 " 1 r- Tathroon I 1" a rCTm 2,2.. x., 6„ Bathroom Level 2 200.00 SF Walls 234.81 SF Walls & Ceiling 3.87 SY Flooring 25.00 LF Ceil. Perimeter Height: 8' 34.81 SF Ceiling 34.81 SF Floor 25.00 LF Floor Perimeter DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 2. Cabinet - vanity unit - Detach 3.50 LF 12.94 0.00 45.29 (0.00) 45.29 3. Sink - single bowl - Detach 1.00 EA 22.56 0.00 22.56 (0.00) 22.56 4. Countertop - solid surface/granite - Detach 3.50 SF 6.51 0.00 22.79 (0.00) 22.79 5. Tear out non -salvageable tile floor & bag for disposal 34.81 SF 2.88 0.52 100.77 (0.00) 100.77 6. Tear out non -salt' underlayment & bag for disposal 34.81 SF 1.24 0.20 43.36 (0.00) 43.36 Totals: Bathroom 0.72 234.77 0.00 234.77 2016-11-08-1513-1 11/11/2016 Page:2 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Total: Level -38,8, -38' B -n -t IFI lF 1 0.72 234.77 0.00 234.77 Basement T Basement Height: 8' 1092.00 SF Walls 2073.17 SF Walls & Ceiling 109.02 SY Flooring 136.50 LF Ceil. Perimeter 981.17 SF Ceiling 981.17 SF Floor 136.50 LF Floor Perimeter DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 7. Tear out wet drywall, cleanup, bag for disposal 24.00 SF 0.81 0.29 19.73 (0.00) 19.73 8. Tear out and bag wet insulation 24.00 SF 0.64 0.11 15.47 (0.00) 15.47 Totals: Basement 0.40 35.20 0.00 35.20 Total: Basement 0.40 35.20 0.00 35.20 Job DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 9. Equip. setup, take down & monitoring - after hrs 1.00 HR 69.28 0.00 69.28 (0.00) 69.28 10. Emergency service call - after business hours 1.00 EA 192.80 0.00 192.80 (0.00) 192.80 11. Equipment setup, take down, and monitoring (hourly 4.00 HR 46.14 0.00 184.56 (0.00) 184.56 charge) 12. Asbestos test fee - full service survey - base fee 1.00 EA 380.00 0.00 380.00 (0.00) 380.00 13. Asbestos test fee - full service survey - per sample 5.00 EA 50.00 0.00 250.00 (0.00) 250.00 14. Add for HEPA filter (for negative air exhaust fan) 0.20 EA 184.46 2.19 39.08 (0.00) 39.08 15. Negative air fan/Air scrubber (24 hr period) - No 2.00 DA 72.99 0.00 145.98 (0.00) 145.98 monit. Used during demo to minimize dust particles in the home. Totals: Job 2.19 1,261.70 0.00 1,261.70 Line Item Totals: 2016-11-08-1513-1 4.74 1,630.30 0.00 1,630.30 2016-11-08-1513-1 11/11/2016 Page:3 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Grand Total Areas: 2,108.89 SF Walls 1,297.97 SF Floor 0.00 SF Long Wall 1,297.97 Floor Area 2,418.83 Exterior Wall Area 0.00 Surface Area 0.00 Total Ridge Length 2016-11-08-1513-1 1,375.92 SF Ceiling 144.22 SY Flooring 0.00 SF Short Wall 1,465.90 Total Area 271.97 Exterior Perimeter of Walls 0.00 Number of Squares 0.00 Total Hip Length 3,484.81 SF Walls and Ceiling 262.89 LF Floor Perimeter 267.22 LF Ceil. Perimeter 2,108.89 Interior Wall Area 0.00 Total Perimeter Length 11/11/2016 Page:4 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Summary for Dwelling Line Item Total Material Sales Tax Replacement Cost Value Net Claim Steven Fumero 2016-11-08-1513-1 1,625.56 4.74 $1,630.30 $1,630.30 11/11/2016 Page:5 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Recap of Taxes Material Sales Tax (6.25%) Clothing Sales Tax (6.25%) Storage Tax (6.25%) Line Items 4.74 0.00 0.00 Total 4.74 0.00 0.00 2016-1.1-08-1513-1 11/11/2016 Page:6 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Recap by Room Estimate: 2016-11-08-1513-1 Area: Main Level Kitchen 97.20 5.98% Area Subtotal: Main Level 97.20 5.98% Area: Level 2 Bathroom 234.05 14.40% Area Subtotal: Level 2 234.05 14.40% Area: Basement Basement 34.80 2.14% Area Subtotal: Basement 34.80 2.14% Job 1,259.51 77.48 Subtotal of Areas 1,625.56 100.00% Total 1,625.56 100.00% 2016-11-08-1513-1 11/11/2016 Page:7 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence, MA 01842 Tax ID# 02-0353691 Recap by Category Items Total % GENERAL DEMOLITION 275.41 16.89% PERMITS AND FEES 630.00 38.64% WATER EXTRACTION & REMEDIATION 720.15 44.17% Subtotal 1,625.56 99.71% Material Sales Tax 4.74 0.29% Total 1,630.30 100.00% 2016-11-08-1513-1 11/11/2016 Page:8 ..6.0 i I� r -N Opo a C cz 00 M i A lz w Z ,LZ .V .9Z C cz cC 00 M "IT IOi M ..tl 101 1 ,L A t JI as cu as crn ., 0 N • The Commonwealth of Massachusetts 0._ F Department offfidustrialAccidents M X Congress Street, Shite 100 02114 20X7 _ - Boston, HA ^Y wwly mass gov/dia • ' dM sv+Y9 Warkers' Compensation bsurance Affidavit,B �dldexs/Contxacioxs/E1.lectricians/Plumbers. TO BEFMEDWITH THE 'EM4[TT'NGAUTHORITY' Name (Bus gaftization/Individuat): J e& p2o Address: City/State/Zip:_ Axe you an employer? the appropriate box: Phone #: (11%) (� Z'�- - 22u Z 1./V T am a employer with A . employees (full and/or part-time)-* 2.❑ l an a sole proprietor or partnership and have no employees working for me in anycapacity. [No workers' comp. insurance required.] 3.❑ l am a homeowner doing all work myself: [No workers' comp. insurance required.] t <1 l am a homeowner and will be hiring contractors to conduct all work on my property. l will ens urc that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑lama general contractor and l have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. ins uranca.t 6. ❑We are a corporation and its, officershave exercised their right of exemption per MGL c. 152 § l tx, and yve have no employees. [No workers' comp. insurance required ] Type of project (vequired); 7. ❑ New'constriidiion 8. 0 R.emodeBg 9. UWDemolition 10 ❑ Building addition I1.[] Elecixical repairs or additions ja,g:Plumbing repairs or additions 13•. [] Roof repairs 14.Other *Any applicant that checks bb -k,#1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submitthis affidavit indicating they are doing all work and then hire outside contractors must submit a new affipot those, indicating such a;; (Contractors that check this box must attaclied'an additional sheet showing the name of the sub -contractors and sfate whether or not (hose entitres, have employees. if the sub -contractors have employees, they must provide then workers' comp. policy number. rovidingivorkers' compensation insurancefor my employees. Below is tliepolley aizdjob site X am an employer that is information. f Insurance Company Name: K ExpirationDate_ Policy # or Self -ins. Lie. #:.- lob Site Address: n�4 City/State/Zip: M C-) (i Attach a copy of -the woxkers' compensation policy declaration page (showing the policy number and expira 'on date . al Failure to secure coverage as required a Well asc ivil penalties ?in the form of aaSSTOP violation punishable ORDER and a fine of p to $250.00 a and/or one-year imp risonmen , of this statement may be forwarded to the Office of ynvestigations of the DIA for insurance day against the violator. A copy coverage verification. X do lierehy cerd under tliepains andpenalties ofperjury that the information provided lhave is/true and correct / / l --T T)afF-.- Vl -2 2 Official use only. Do not write in this area, to he corrapleted by city or town official. City or Town: permit/License # issuing Authority (circle one): i 1. Board of Health. 2. Building Department 3. CitylTown Clerk 4. Electrical inspector 5. Plumbing inspector 6. Other Phone #: Contact Person• ACORl�►0. CERTIFICATE OF LIABILITY INSURANCE ATE (MMIDD/YYYY) r11/11/2016 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 Dabney Collier C/o Collier Insurance 606 S. Mendenhall; Suite 200 CONTACT NAME: PHONE FAX A/C No): (901) 529-2916 AIC No Ext), (901) 529-2900 (A/C, E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # Memphis, TN 38117 INSURER A: American Zurich Insurance Company 40142 INSURED Adams Keegan, Inc. INSURER B: EACH OCCURRENCE $ 6750 Poplar Ave Ste 400 INSURER C INSURER D Memphis, TN 38138 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 15TNO09858085 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL R ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY Lj PRO- JECT LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ ( ) NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATIONPER_ AND EMPLOYERS' LIABILITY YIN ANY OFFICER/MEMBER/ EXCLUDED? F-1 F-1 N/A - WC56-11-865-0212/01/2015 12/01/2016 X STATUTE EERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below Location Coverage Period: 12/01/2015 12/01/2016 Client# 2410 -MA DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage is provided for KEJO Corporation dba: SERVPRO of Lawrence Bi only those co -employees Weekly of, but not subcontractors 8 BLAKELIN ST to: Lawrence, MA 01842 Town of North Andover Building Department 120 Main St. North Andover, MA 01845 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 REPRESENTATIVE ©1988-2014 ACORD CORPORATION- All rights rPSPrvPrl ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD WHITKE1 OP ID: PI •%�1"11c"_CERTIFICATE OF LIABILITY INSURANCE FDATE TO WHICH.THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 11/11120Y6 11/11/2016 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)i AUTHORIZED REPRESENTATIVEOR 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 Stanley McDonald Agency 1101 Main Street Onalaska, WI 54650 James R. McDonald NAME CT James R. Mc Donald MUNE xt • 608-788-6160 ac No : 608-788-7012 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSUREDdba Corporation N Lawrence See NoteSeryFor See Note For Named Insured . INSURERA;Rockhill Insurance Company 28053 wsURERB:The Federal Insurance Co. 20281 INSURER C ACE Pro e & Casualty20699 INSURER D: PO BOX 328 Lawrence, MA 01842 INSURER E : INSURER F: IVVIVI6CR: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH.THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE WWL INSD B WVD POLICY NUMBER POLICY EFF MM/DDNYYY) POLICY EXP (MM/DDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ENVP016006-00 EACH OCCURRENCE $ 2,000,000 13AEMISEs Ea occurrenceR NTE $ 50,000 OCCUR 03/01/2016 03/01/2017 MED EXP. (Any one person) $ 5,000 PERSONAL BADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ PRO F]JECT GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG $ 3,000,000 POLICY LOC OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO _ BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ oraccident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS -MADE M00798617 01/14/2016 01/14/2017 AGGREGATE $ 1,000,000 DED I X I RETENTION $ 10000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N ST TUTE E _ E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L. DISEASE - EA EMPLOYEE $ If yes tory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below D Property Section 7 03/01/2016 03/01/2017 B Crime =670-66-147 03/01/2016 03101/2017 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder Is Additional Insured Per Attached CG 2037 (07/04) And CG2010 (07/04) A.T.I.M.A. Policy#ENVP016006-00 lit:R I iFiL;A I t HUL.L1tl< CANCGI l ATInki TOWNNO3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD i �J Office of Consumer Affairs & Business Regulation '-HOME IMPROVEMENT CONTRACTORI } A ;Registration:158271 Type: Expiration: 12/31/2017 Private Corporation KEJO CORPORATION SERVPRO OF LAWRENCE; ET ALS. GREGG WHITE 8 BLAKELIN STREET LAWRENCE, MA 01841 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 of valid without ,sIgmtt`iare ® Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -067690 Construction Supervisor GREGG M WHITE 4 CHATBURN RD WINDHAM NH 03087 -"-� �`--=zptranon. C0rnm;sssoner 02/20/2018