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HomeMy WebLinkAboutBuilding Permit #733-2017 - 4 MILLPOND 1/24/2017Na ,AORTH II- BUILDING PERMIT TOWN OF NORTH ANDOVER o� APPLICATION FOR PLAN EXAMINATIONPermit No#: - �a5 26 Date Received �RAo1. ArED �_f I SSACHUSE Date Issued: IMPORTANT: Applicant must complete all items on this page 1©01ear,S ructu yes {�o) SMA PARCEL: U tw ENING ®IfTR�Hi is ©ism MR ) dye - :=€IVlachi78-0 .og4Vi11age ~`ve tRd TYPE OF IMPROVEMENT PROPOSED USE Resi tial Non- Residential ❑ New Building erone family Supe�"rv,`is i.fts C'®nstrction Lice —se, e�/�"�%.' ❑ Addi ion ❑ Two or more family ❑ Industrial ❑ A ration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 1® Septic Well ®Fho dpnf' ®W,. etlands Watershed ©);istrict 4; Water%Sewer OWNER: Name: A r1 rl roc c • 4 - Please Type or Print Clearly Co tractor Name: �Ph nes l 4w Email dre�ssu Atl-77 Supe�"rv,`is i.fts C'®nstrction Lice —se, e�/�"�%.' - 'Expo,. Date y th Home Imrovement LMice ARCHITECT/ENGINEER Phone: e Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. • $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ib FEE: $ j;;22j Check No.: Receipt No.: -314Cor7 NOTE: Persons contracti g with unregistered contractors do not have access to the guaranty fund _--__._-.__-,-----_---- -.,...-ate' -. .{ -1.--.-�_� _ ,•-•-_,...._-.�...�_.., ,._��.:. -.. 4_.: ��9:.->-�-, 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 J®TE: 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 10TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ . Copy of Contract ❑ Mass check Energy Compliance Report Engineering Affidavits for Engineered products 10TE: 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 Plans Submitted ❑ Plans Waived_❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swnxnnmg Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ 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 Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments o �{ I G!ation Decision: Comments Water & SeWer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Tern ster o �>, Located 384 Osgood Street p p n,�site, r�yes'�,, �� Duem� _ : � no . y X.� pjk , E I.S �aF�'� A.`.w��«'�...`.��+ti.�+.iss_ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.:_ ELECTRICAL: Movement of Meter location, avast or service drop requires approval of Electrical Inspector yes No ®ANGER ZONE LITERATURE: lies MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine 2 Doc.Building Permit Revised 2014 Location 4 - No. Check # f / 31467 � Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ k Z -O Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /"; -1 � 11L - L-" Building Inspector e -r N .O CD 0, Z �D O C- r CL D c� -0 O o v C cr cD o Own iy O y 'a. r_ 0 CSD r* CD 70 N� CD U) v z 0 CCD 9 � C O. — o Q < H O CD y C `° •� NrLD ID cn O DCO S cn So mrn �' :d= cn O 7 O_ O (D �. n O Q \ (� •n m m z a m z -� 0 Cl) O �. o m D0 CD -Oa z C z fA m 0 0 O cn 2) o 0 0 T� N 0- . C Cn �• z O z � Vr c. � Z O z cn -v O O r O z O CD N O cm 0 to s 2. N CD o = O_ Wo y = <, �.a 0 Cn 0. CD C_° CD 0 G7 n o_ n m o =r cn 0) ILI O O •-• a 0 m ft W m .a ai m A. CD 2 a =CD D 0 � c0 CL y M O 0 CD CD 0 -a 0 o OC < co os' N (A oCD =r(D cn Q Dnp �. O. — o Q < H O CD y C `° •� NrLD ID cn O DCO S cn So �� �' :d= O DSC S O 7 O_ O (D �. n O Q \ (� •n m m z a m z -� 0 Cl) O �. D w+ mLA O m D0 CD -Oa @s C z fA m 0 0 O 2) o 0 0 3 _ 0- . 3 O (D (D u q (D '"' p C O O O 04 S 3 (D rD O DCO S O (10 S �' _3 7 O DSC S O 7 O_ O (D �. n O Q \ •n m m z a m z -� D w+ mLA O m rm" m n a O A C z fA m 0 0 W C z m m O 3 _ S = W O v O D r- x O v S.Vw -------fQ N -f-- A Service Provrderfor V Customer Info: Job #: N/A (87433495 Passariello Paul) 3487 Passariello, Paul 4 Millpond, North Andover, MA. 01845 (617) 549 -7734 -mobile (978) '738-0986 PIE ESTIMATE] 2/12/21 revised PIF ESTIMATE 12/12/21. revised total: $0.00 CABINET INSTALL yrmits Permits 'alt Cabinets Install Wall Cabinets ase Cabinets Install Base Cabinets Tillers Install wall/base fillers Is Knobs/Pulls .Installation SCRIBE MOLDING KTM Properties, LLC 25 Spaulding Rd Suite 17-2 Fremont, NH 03044 .Phone: (603) 895-0400 .Fax: (603) 253-2600 Company Representative: Mark Minasalli (603)234-9320 Markm@ktniproperties.com ktmproperties.com Job Number: N/A (87433495 Passariello Paul) fication Assembly/Modification & install of loose parts kick Install toe kicks at base cabinet Nims install Shirns as needed le and pennitrations Make penetrations as needed t'UNTER TOP DOES NOT ;INCLUDE COUNTERTOP INSTALLATION ARD DISPOSAL PRICING IN THIS CATERGORYDOES NOT INCLUDE CARDBOARD D ER IS RESPONSIBLE. KTM CAN PROVIDE IT FOR ADDITIONAL FEES ELS (SUPPORTS) Install corbels to support counter tops or decorative vanities Install bath vanities 2 baths UAJINV, YiNSTALL.total: $2,565.00 eceptacle/switch replacement Replace existing receptacle/switch-includes upgrade to GFC1 provides) 'AMPER PROOF washer Wire dishwasher with existing power present add cord and box with outlette rowave - New Circuit Run a new circuit for a dedicated microwave hood (installer provides components) i Fault Breakers Supply .and install arch fault breakers as required by code ,trical Permit Supply electrical permit and inspections STING outlette If there .are existing outlets where new cabinets are going to cover we will cut it into the cabinets leave the outlet or place a blank plate over it inside the cabinet. Removal of the outlet will be additional cost. )E UPGRADES IF ADDITIONAL TASKS ARE NEEDED FOR. CODE UPGRADE THAT ARE NOT ON TH1 MATEADDI.TiONAL FEES FOR THAT SPECIFIC WORD WiLL BE IN ADDITION TO T141S ESTIMATE. total- $2,315.00 PLUMBING Description Connect to undermount Connect to under mount or integral bowl sink w! faucet, disposal if applicable: within 3" of existing location. (Installer provides braided supply lines,; shut off valves, piping and traps as heeded) Cut/Cap Cut & Cap plumbing for new cabinet installation Dishwasher Plumb in dishwasher next to sink Permits Pull permit, rough & final inspections - includes permit cost PLUMBING total. $2,012.0.0 Total. for all sections $6;952.00 Total: $6,952.00 The above signature does not commit either party to the sale of the above listed items 01\i Yif this contract states Preliminary Estimate as one of the first lines. The signature above represents a full understanding of the price :and scope of labor for the categories :listed only. Prices are subject to change based on the final design, layout of the kitchen and unforeseen conditions, We CANNOT start the work at your job until the necessary permits have been procured and a signed "What to F -yea Shed" is on file. Please contact us should you need a copy of this. REMINDERS: this installation quote is based on normal working hours 7am-4pm, unless other arrangements have been made prior with KTM. Plumbing & Electrical work is based on 2 trips - one rough and one finish, finish will occur after countertops. Code or local inspector requirements not mentioned in this estimate will be an additional cost. Cabinets must be delivered in kitchen area or adjacent space on same level, which must have heat. If cabinets have to be moved by KTM, additional fees will be charged. Countertop templates require you to be onsite, no exceptions! If you plan to secure your own trades (plumber, electrician, etc) for your project, and KTM's final inspection is held up because of their inspections, then you will be required to sign a punchlist lien wavier at the end of your job signifying KTM is complete expect for the final building sign oft. By signing this contract, 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. Any alterations or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge over and above the estimate. All agreements contingent on the delays beyond our control. Again if it is NOT mentioned above avid in writing in this contract then it is NOT a part of, or included ir.:. contact. Customer Initials here: Change Orders If there are change orders required on your job, there WiLL be time delays. The time delay depends on the size of the change order. Please consult ether your project coordinator or the office for an estimated time delay on your specific project. By initialing here, you accept that the change orders will result in time delays on your project. Customer Initials Here: P/ -)P— /�j )iC,1 r gompany Authorized Signature Date Customer Signature Date Customer Signature Date This estimate was last edited by Mark Minasalfi ((603) 234-9320, Viarkmktirnpropertes.com) on December 21, 2016. The estimate may be withdrawn if not: accepted within days. Massachusetts - Department of Public Safety Board of Building Regulations and Standards V(i7fStruction ."iiilCi vl rii License: CS -071077 CHARLES J 14iW5 25 Spaulding Rd Sfe 1 P Fremont NH 03044 `V ate' '`-p .�I'14t�� .7,222.-1/r/ Expiration Commissioner 07/25/2017 � Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improven�eneontractor Registration ri THD AT HOME SERVICES, INC. ;; RICHARD FALLONE 2455 PACES FERRY ROAD, HSC ATLANTA, GA 30339 3CA 1 <: 201VI-05 >> _�/w 1Cnrr�rrarat��c%%c`��'G��r,;arccl�c-leff: Mce of Consumer Affairs & Business Regulation R HOME IMPROVEMENT CONTRACTOR _ Type: ' Registrati.09 26893, T Supplement Card Expir�►tiort�8/3f20t13_t . THD AT HOME SERVt�,f-_S704C: `- THE HOME DEP OT`A , EFIVICES RICHARD FALLONE : 2455 PACES FERRY ROADrHSC - - -- AI: ANTA, GA 30339 Undersecretary tr; Registration: 126893 Type: Supplement Card Expiration: 8/3/2018 Update Address and return card. Mark reason for change. Address ❑ Renewal J Employment Lost Card License or registration valid for individual use only before the expiration date. If found return to: office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 - Boston; )VIA 03116 -- of valid with t si ture DATE (MM1DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/1812016 IS THIS CERTIFICATE IS ISSUED AFFAS A IRMATIVELY IRMATIVELYER OF INFORMATION OR NEGATIVELY AMEND, AND EXTEND OR ASNO LTER RIGHTS HE COVERAGE AFFORDEDATE BY THE POLICES CERTIFICATE DOES N AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE i Vt/EEN THE ISSUING INSURER(S), REPRESENTATIVE OR PRODUCER, AND THE CERT(F!CATE HOLDER. N IS (firtPORTANT: if conditions ofate the policy, certain certairlDpoi cDJ I oesAmay require an endorsement.)fn A statement on thiust be endorsed. s certificate does not Wconfer Dightslto the the terms and co certificate holder in lieu of such endorsement(S). CONTACT NAME AX PRODUCER I PHONE AIC No), MARSH USA, !NC. (A/C. No, E TWO ALLIANCE CENTER E-MAIL 3560 LENOX ROAD, SUITE 2400 ADDRESS: NAIC P.TLANTA, GA. 30326 NSURERIS) APFORDING COVERAGE X26387 INSURER F: COVERAGES CERTIFICATE NUMBER: ATL -00'3746646-14 REVISION NUMBER:a TH! S IS TOCATED.CNOTWITHSTANDING CANYI REQUIREMENTNTERM OR CONDITION OF ANY CONTRACTC OR OTHE DESCRIBED DOCUMENT WITH RESURED NAMED ABOVE SPECT TO WHICH THIS IND RMS. LICIES CERTIFICATE MAYBE ISSUE CONDITIOND OR MAY S OF SUCH POLICIIES. LIMITS SHOWN MAY AVE BEEN REDUCED BY PAID CLAIMS. HEREIN IS SUBJECT TO TO THE TER ADOL SUBRI I POLICY EFF POLICY EXP LIMITS NSR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) IMM/DDlYYYY) 9'000'000 LTR i IGL04887714-06 0310112016 03101(2017 EACH OCCURRENCE b A I X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENT=D I b 1,000,000 F7_1 I ?REMISES Ea occurrence CLAil,AS-MADE OCCUR EXCLUDED LIMITS OF POLICY XS MED EXP (Any one person) S 9.000,000 OF SIR: $1M PER OCC I PERSONAL & ADV INJURY b 9,000.000 GENERAL AGGREGATE S GEN'L.AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 9,000,000 I S 0 O- x PGLiCY ❑ JECT OTHER: 103/01/2016 U31U112017 COMBINED SINGLE LIMIT i b 1 000,000 BAP2938863-113 � fEa accident B AUTOMOBILE LIABILITY BODILY INJURY (Per person) S X ANY AUTO I 1 BODILY INJURY (Per accident) S ALL OWNED SCHEDULED I 'SEL. it`lSURED AU I V PHY DiviG I PROPERTY DAMAGE b I AUTOS AUTOS NON (?er accitleni i �I HIRED AUTOS , AiiT05 b I I I ------------- I EACH i RRENCE !$ HUMBRELLA LIAB OCCUR I I AGGREGATE S EXCESS LIAR HCLAIMS-MADE is DED I P.ETENTION b v3/C11'_016 0310112017 X PER OTH- C I WORKERS COMPENSATION WC015519216 (AO`) STATUTE I I =R 1,000,000 AND EMPLOYERS' LIABILITY Y /N WC015519217 (AK,KY,NH,NJ,VT) 0310112016 03/0112017 E L. EACH ACCIDENT b C ANY PROPRIETOR/PARTNER/EXECUTIVE 03101/2016 0310112017 1'000'000 OFFICER/MEMBER EXCLUDED? a N ! A WC015519216 (FL) E.L. DISEASE - EA EMPLOYE b D (Mandatory in NH! 1,000,000 If yes, describe under Conitnued on Additional Page E.L. DISEASE -POLICY LIMIT I b DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be at' if more space is required) EVIDENCE OF INSURANCE CANCELLATION CERTIFICATE HOLDER i THD AT-HOME SERVICES. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT S, INC.I HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ` ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD ATLANTA, GA 30339 - AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INSURER A : steadfast Insurance Compan/ 16535 100492-HomeD GAW`-16 17 American Insurance Co INSURER B :Zurich 123841 INSURED THD AT-HOME SERVICES, INC. INSURER c New Hampshire Ins Co : 23617 DBA THE HOME DEPOT AT-HOME SERVICES Illinois National Insurance Company 2690 CUMBERLAND PARKWAY, SUITE 300 INSURER D : ATLANTA, GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL -00'3746646-14 REVISION NUMBER:a TH! S IS TOCATED.CNOTWITHSTANDING CANYI REQUIREMENTNTERM OR CONDITION OF ANY CONTRACTC OR OTHE DESCRIBED DOCUMENT WITH RESURED NAMED ABOVE SPECT TO WHICH THIS IND RMS. LICIES CERTIFICATE MAYBE ISSUE CONDITIOND OR MAY S OF SUCH POLICIIES. LIMITS SHOWN MAY AVE BEEN REDUCED BY PAID CLAIMS. HEREIN IS SUBJECT TO TO THE TER ADOL SUBRI I POLICY EFF POLICY EXP LIMITS NSR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) IMM/DDlYYYY) 9'000'000 LTR i IGL04887714-06 0310112016 03101(2017 EACH OCCURRENCE b A I X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENT=D I b 1,000,000 F7_1 I ?REMISES Ea occurrence CLAil,AS-MADE OCCUR EXCLUDED LIMITS OF POLICY XS MED EXP (Any one person) S 9.000,000 OF SIR: $1M PER OCC I PERSONAL & ADV INJURY b 9,000.000 GENERAL AGGREGATE S GEN'L.AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 9,000,000 I S 0 O- x PGLiCY ❑ JECT OTHER: 103/01/2016 U31U112017 COMBINED SINGLE LIMIT i b 1 000,000 BAP2938863-113 � fEa accident B AUTOMOBILE LIABILITY BODILY INJURY (Per person) S X ANY AUTO I 1 BODILY INJURY (Per accident) S ALL OWNED SCHEDULED I 'SEL. it`lSURED AU I V PHY DiviG I PROPERTY DAMAGE b I AUTOS AUTOS NON (?er accitleni i �I HIRED AUTOS , AiiT05 b I I I ------------- I EACH i RRENCE !$ HUMBRELLA LIAB OCCUR I I AGGREGATE S EXCESS LIAR HCLAIMS-MADE is DED I P.ETENTION b v3/C11'_016 0310112017 X PER OTH- C I WORKERS COMPENSATION WC015519216 (AO`) STATUTE I I =R 1,000,000 AND EMPLOYERS' LIABILITY Y /N WC015519217 (AK,KY,NH,NJ,VT) 0310112016 03/0112017 E L. EACH ACCIDENT b C ANY PROPRIETOR/PARTNER/EXECUTIVE 03101/2016 0310112017 1'000'000 OFFICER/MEMBER EXCLUDED? a N ! A WC015519216 (FL) E.L. DISEASE - EA EMPLOYE b D (Mandatory in NH! 1,000,000 If yes, describe under Conitnued on Additional Page E.L. DISEASE -POLICY LIMIT I b DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be at' if more space is required) EVIDENCE OF INSURANCE CANCELLATION CERTIFICATE HOLDER i THD AT-HOME SERVICES. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT S, INC.I HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ` ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD ATLANTA, GA 30339 - AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD p-1-�0 CERTIFICATE OF LIABILITY INSURANCE DATEf(YYYLIABILITY 0212a/2016rzo,s 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 MARSH USA, INC. TWO ALLIANCE CENTER CONTACT NAME: PHONE FAX IAIC. No Ext • A1C No): E-MAIL ADDRESS: 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 INSURER(S) AFFORDING COVERAGE NAICT INSURER A: Steadfast Insurance Company 26387 100492-HomeD-GAW'-16-,7 INSURED THE HOME DEPOT, INC. HOME DEPOT U.S.A., INC. INSURER B - Zurich American Insurance Co 16535 INSURER C: Nav Hampshire Ins Co 23841 INSURER 0: Illinois National Insurance Company 23817 2455 PACES FERRY ROAD, NW BUILDING C-20 ATLANTA, GA 30339 INSURER E: A 1AGE TO REE PREM I.E. Ea occur ence S 1,000,000 INSURER F: CnVFRA(_.FS CERTIFICATE NUMBER: ATL -003741310-01]1 REVISION NUMBER:O 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 SUBR POLICYNUMBER POLICY EFF MMIDD POLICY EXP (MMIDDM'YY LIMITS A X COMMERCIAL GENERAL LIABILITY GL048877%06 0310112016 03101/2017 EACH OCCURRENCE 5 9,000,000 7 CLAIMS -MADE a OCCUR A 1AGE TO REE PREM I.E. Ea occur ence S 1,000,000 MED EXP (Anyone person) $ EXCLUDED LIMITS OF POLICY XS OF SIR: SIM PER OCC PERSONAL &ADV INJURY s 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 9,000,000 X POLICY F-1JEa LOG PRODUCTS -COMPIOP AGG S 9,000,000 s OTHER: B AUTOMOBILE LIABILITY BAP 293886313 03/01/2016 03101/2017 COMBINED SINGLE LIMIT Eaaccident 5 1,000,000 BODILY INJURY (Per person) S X ANY AUTO BODILY INJURY (Per accident) S ALL OWNED SCHEDULED AUTOS AUTOS SELF INSURED AUTO PHY DMG PROPERTY DAMAGE s Pzr accident NON-01AINED HIRED AUTOS AUTOS 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE S AGGREGATE ' s EXCESS LIAB CLAIIdS-MADE DED RETENTIONS 5 C C D WORKERS COMPENSATION EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? N (Mandatory In NH) NIA WG015519215 (AOS) _ WC015519217 (AK,KY,tdH,NJ,VT) WC015519216 (FL) 03/01/2016 03/01/2016 03/01/2016 03/01/2017 03101/2017 03101/2017 X I PER —TR STATUTE ER E.L. EACH ACCIDEtJT S 1,000,000 E.L. DISEASE -EA EMPLOYEE S 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below Continued on Addlional Pae 9 E.L. DISEASE- POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) I t MULUtK TOWN OF NORTH ANDOVER 1600 OSGOOD ST. NORTH ANDOVER, MA 01345 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 of Marsh USA Inc. ManashiMukherjee _3VL100.-1V,;0"1Z ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014!01) The ACORD name and logo are registered marks of ACORD The C'ominonN,ealth of +ltassac�usetts Department of IndustrialAccidents Office of .investigations o� 1 Con,,ress Street, Suite 100 B.Oston, I LA 112114-2017 www.mass.gov/dia rs N or%ers' Compensation Iasai'aace davit: Builders/Conirat tors,�EleP� ase Print LLe eb] -pplicant Laormation c IV Arad (BusinesslOro,,anizati()o Individual): Address: I U Ci Are you an employer? Check the agp>'op ate box: a cofactor and 1 ag 1. ❑ I am a employer with ve heneral haam ired the sub -contractors employees (full and/or part-time).* listed on the attached sheet_ 2_ ❑ I am a sole proprietor or partner- These sub -contractors have ship and have no employeesemployees and have worker' working for me in any capacity. comp. ii surance.t [oto wor!cers' comp. insurance 5 We are a corporation and its required-] oiitcers have exercised their 3, ElI am a homeowner doing all wor'c right of exemption per ;VIGL myself. [1\10 workers' comp. c. 152, 91(4), and we have no insurance required-] t employees. Do workers' comp. insurance required] Type of project (required): 6. ❑N constriction 7. (Remodeling S. E] Demolition 9. E] Building addition 10. E] Electrical repairs or additions 1 l.❑ Pllmmbing repairs or additions 12. [] Ro z13.Cier t i �Iy applicant ha[ checks nox? must also fill oLrt he section below shovnng Their workers' compensation policy ormauon. t Homeowner. who submit this affidavit indicating they are doing all work and then erre outside contractors and submit er or nonm ott ihose�ntiticshave `-Contactors that check this box must attached an additional shet showing the name nl the sub -contractors and s employees, if the sub -contractors have employees, they must provide their workers' comp. policy number,. I am an employer Heat is providing workers' compensation insurance for my employees. Below is the policy and job site information. 1- l (_o - _- Lusurance Company Name: a / 9 i A/ /� 1 _Expiration Date: J Policy # or Self -ins. Lic. #: y v L City/State/Zip: �j\ Airl Job Site Address: LJ_ Attach a copy of the workers' compe cation policy declaration page (showing the policy number and expirationriminal Isof a Faire to secure coverage as required under Secof N sonm,tson t, 2 well asate lcivil penaltieOL C. 152 casin the formad to e of a STOP Wosition of ORK ORDER and a -az fine up to $1,500.00 and/or one-year imp ri 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 vestignations of the DLA, for insurance coverage verification. Ido hereby c fy �nde�the pains and penalties of perjury that the information provided above is true and correct. l_ Official use only. Do not write in this area, to be completed by city or town official Permit/License # City or Town: Issuing Authority (circle one): 1. Board of Health I. Building Department 3. CityTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #: Contact Person: