HomeMy WebLinkAboutBuilding Permit #328-16 - 41 CEDAR LANE 9/15/2015 p►ORTN
BUILDING PERMIT O�-9iLEo 06�/VO
TOWN OF NORTH ANDOVER �2 ti
i APPLICATION FOR PLAN EXAMINATION
Ado _ m«
Permit No#: r Date Received 74Q0",
US
j Date Issued: �7 I
IMPORTANT: Applicant must complete all items on this page
, LOCATION
Pry
PROPERTY OWNER XA T,," _ I
Pririt 100 Year Str'ucture yes. no,,
I
MAP PARCEL n ZONING DISTRICT: Historic District yes no
Machine'Shop Village yes o
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ane family
❑Addition ❑Two or more family ❑ Industrial
teAlteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well _E1 Floodplain dWetlands, ❑ Watershed District
❑Water/Sewer .
DE ' RIPTION F WORK TO PkPEFORMED:
Wim . _
Idem' ation P ase Type or Print Clearly Q '
OWNER: Name: o.4' Phone:
Address: y C 'CJ�G�
Lcu�
Contractor.Na e: "�._ �� Phone: 0
Email: _ -
Address: --j ; --- k
Supervisor's Construction License: cli SJ Exp. Date:
Home Improvement License: 1 ��� Exp. Date: '
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.,$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Q �
Total Project Cost: $ , n�� FEE: $ a /C�
Check No.: I Receipt No.: Q. ,
NOTE: Persons contracting wit unregistered gered contractors do not have access to the aranty fund
Signature of Agent/Owner Signature of contracto
BUILDING PERMIT O* NORTH ISLE° ,6'91
3r ye �, ", 46
TOWN OF NORTH ANDOVER L
APPLICATION FOR PLAN EXAMINATION
h
Permit No#: Date Received
�gssgc oils���y
Date Issued: �7 I
IMPORTANT: Applicant must complete all items on this page
y�° rt`• R'',t�:-:�z'ri'' ;� —,.,,ra':i+5ot, '�,",..'€ r�.�. - °" Le'. � f- - -.-,-",r .�7r +ir ` ;
l V45-1-�
-- g LOCATION _.
^-e�<,t•.�st...�+, : tf y,�r' "':. .,r �,,,,4�,--_ •nit �•r 4 kG `t S. �" "-�`�'4r ` .7
k M,,;s;'` `t" -.."far • r3 , ' t'�._J. a, Pn !'y',e,-tF� -,.',S`. '.�`+-. .L;„ '-:`-' ��„�' •`r3^`°r k >� +, F :'Y�'`
}PROPERTY°OWNER : � ti �`�
"'r ter' a F7e y —• -
�PnntX 100 YearStrueture Y ;_ rYeS Enor x" '
s MAP �: PARCELi r �ZONING,DISTRICT Historic Distict , ono
0
3.?is.� _+�`
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,gMacnetShop Village � y
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hi
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
DeAlteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
0'Septic''❑:1N 41 i.❑ Flooclplairi` j 'Wetlands ;r ' a: �❑ 1Natershed D'istnct
:.. : Tri. vF >.r ��w 'r' Kr»,t -i r - C 3 T.r 2 ♦: �"1. + 5-4' ryF:
K .Wa c:. '.".r, 'S fi- �' += y^•.!' "_ 't. -a$.& .err - -� , t - - h
,0:. ter/Sewer
DEJERIPTION F WORK TO PkPE FO MED:
Iden ' ation P ase Type or Print Clearly
OWNER: Name: a� Phone: 7�17�.
Address: y- C 'CJ�G�t�
La-x�
taz
x � A�. ef.Yl.,�d r,'��ai"
tCcjritractor�Ny a e uSoN'� '� 1 �Ax : Phone
i i,.�+`ahr'fi+�1 t t '
Email �z
Addcr .� .,,.� � L RJ� � .. r �. h � ��."� .' *"� ;mss- t"�^` x�
ress r r�� =z7�k t �fi ,, E c ,c A. t� � .
x.�,z" •�f�H^�^-. jr'_'x'�r.}sr;tr'�mi�Yrtl:f'�.xid'it"'��;+r�nr it�.r�•. >.'7��-�
7 '�"'Y' A� tic.'' ''i4
Supervisor s Constru8tionLicense ::� 1�0
01
�4t
r � h r3 ra'ax:Y t.r``Y,a. ,,We r 1 - � . a yt•a. `�'�'�;u.pia K,.�s�1.6 X �','w'.��,�" 4�k�...� .+,.,.,.r�,. .�'
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
P �
Total Project Cost: $ �s-0 ; O ®0 FEE: $
Check No.:I_ Receipt No.: ��
NOTE: Persons contracting wit unregistered contractors do not have access to the aranty fund
Signature of Agent/Owner Signatdre of contract
Location
No, 2� "_ � t t�, Date
. - TOWN OF NORTH ANDOVER
• f
Certificate of Occupancy
Building/Frame Permit Fee $ C�
Foundation Permit Fee �$
Other Permit Fee $
TOTAL $
Check# 2— i
2 9 35
4 Building Inspector
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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 ❑ r
Private(septic tank,etc. ❑ Pennanent Dw-npster 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
F',,EALTH Reviewed on_ Si nature
COMMENTS
i
Q
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located
_ _ _
FIRE DEPARTMENT Temp,,Dumpster onsite =yes _�.
384 Osgood Street
____-.. no., 1
' Located;at 124,Main Street - -
Fire Department signature/date
COMMENTS.
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 0
Private(septic tank,etc. ❑ Permanent Dumpster onFSite ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
ti
HEALTH Reviewed on Signature
COMMENTS
u
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
,FIRE- DEPARTMENiT, �TemDum�]stet on site eyesy t
`r,,,,F+.,, # r a7W, sr.E'sr Rdliy'�lp rs.�� ., t# , , '�}`' 4L no:z
Located at12�41MamlStreet�fit- xY" t
{�et Department.g ature/date A d�` ` '��`4' }
A fi +vw 1358ai iwC1�fat5ar ;}
s't �4 +,_; }s � 5 a spx c.�. xw rrsst ` ".ra� eKrarr9 [riis L R yam, µ"
L� I.4.�a+,-. �7F 't- Ps t F .F- -' - . � f Y ,�n+h; f5-,� Ka'"Yq•.`s`, t .'t=
CQMMENT
S°3. ♦ y r .`t , (� i �f "r _ tJ 4f�' 1 kt yia! ia# �,.�
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
i
ELECTRICAL: Movement of Meter location, mast or service droprequires q 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)
i
❑ Notified for pickup Call Email
I
Date Time Contact Name
_..._.........
Doc.Building Permit Revised 2014
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 i
Doc.Building Pennit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: 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
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
❑ 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
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
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
o Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
L3 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
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract - -
o Mass check Energy Compliance Report
o 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
NORTH
Town of �_� ., Andover
O to
No.
ver, Mass,
COC LAKI
NIc"t WIC
P
S V
BOARD OF HEALTH
Food/Kitchen
PERT T Llow L D Septic System
THIS CERTIFIES THAT ..........I........ .� ,,,,,,,,,,,,,, BUILDING INSPECTOR
........ .. .. ....... ..................................L...
.. Foundation
has permission to erect .......................... buildings on ..... . ........Cam ...............................
Rough
to be occupied as ..............5... ........ ..or � � ... .11 ha... .... ............ Chimney
provided that the person accepting is permit shall in every ect conform to terms of thall cation Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the Town of North Andover. ^d PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO TA S Rough
Service
............... .. ..................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing.or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Capital Capital Contracting Inc. Estimate
C� PO Box 3189
Conhacting lnc
Wakefield, MA 01880 Date Estimate#
www.capital-contracting.net 6/13/2015 437
Name/Address
Ken Tarbell
41 Cedar Lane
N.Andover MA 01845
Description Total
Customer to cover and/or remove any items in the attic to protect them from dust/dirt that may fall. 10,200.00
1. Tarp off house and yard as needed to protect against falling debris.
2. Strip existing shingles from all roofs on house.
3. Remove all of the sheathing from both sides of the roof.
4. Remove the existing roof rafters from both sides of the roof,and replace with new roof rafters.
5. Install new roof sheathing over the new roof rafters, .
6. Remove and replace the wall studs and the sheathing from both gable ends.
7. Install new,eight-inch,aluminum drip edge on all edges.
8. Install six(6)feet of new ice&water shield on all lower edges,and three(3)feet in valleys and around dormers.
9. Install new premium synthetic roofing underlayment over all remaining exposed roof boards.
10. Install new,limited lifetime laminated roofing shingles on all roofs being re-roofed.(Customer to choose color)
11. Cut peak of main roof, if needed.
12. Install new Cobra ridge vent where roof peak was cut.
13. Install new ridging over new ridge vent.(Color to coordinate with new shingles.)
14. Seal all flashings with Karnak fibered roof cement and/or Geocel tripolymer sealant.
15. Remove debris from any gutters where new roofing was installed.
16. Remove all other job related debris and dispose of properly.
***Payment terms: 1/2 down when job starts,the balance when the job is complete.
***All debris will be removed daily by truck.No dumpster is to remain on site.
Tot
Phone#
Signature
781-587-0066
Page 1
Capita/ Capital Contracting Inc. Estimate
C� PO Box 3189
Contractin Inc'
Wakefield,MA 01880 Date Estimate#
www.capital-contracting.net 6/13/2015 437
Name/Address
Ken Tarbell
41 Cedar Lane
N.Andover MA 01845
Description Total
1--Set up necessary staging to complete job in a timely manner, 9,800.00
2--Remove all of the windows from the entire house.
3--Fur out and install new windows in the existing openings.The new windows will be new construction,and will be sealed to
the house.
4--Cut a new hole in the kitchen and frame for a new window.There will be no interior finish done for the new window.
5--Install new 1"insulation over the entire siding area of the house.
6--Install a new vinyl siding system over the new house wrap.The new system will include standard double 4inch siding,
standard corner posts, window and door areas will either have a built in J-channel or will have one added to it.Vinyl soffit
panels and aluminum coverage on all soffits,fascias and rakes.
7--Install new seamless aluminum gutters and downspouts on the house where currently existing.
8--Install any new lights,numbers,doorbells and mailboxes if provided by the homeowner.
9--Seal any areas on the aluminum coverage that may require it.
10--Remove all job related debris and dispose of properly.
WINDOWS
To remove and replace the existing windows in the house,the labor cost is$125.00 per window for the double hung windows,
$250.00 for the picture window,and$500.00 for the new window that will be cut into the existing wall. Total labor for
windows$2,250.00
**Homeowner will make arrangements to remove all of the existing siding on the house.Homeowner will supply all materials
needed to complete job.This above price is for labor only.Homeowner will supply all materials.
All materials are guaranteed by the manufacturer. All work is to be completed in a professional manner according to standard
practices. Any alteration or deviation from above specifications involving extra costs will be executed upon written orders,and
will become an extra charge over and above the original contracted price. All agreements are contingent upon weather and/or
delays beyond the control of Capital Contracting Inc.
Total $20,000.00
Phone# Signature
781-587-0066
Page 2
The Commonwealth of Massachusetts
F Department of IndlustrialAccidents
+F ,. :.F d X Congress Street,Suite 100
Boston,MA.02114-2017
sy;Y`�t www mass.gov/dia
Workers'Compensation.Insurance Affidavit:Builders/Contractors/Electricians/Plumbers-
TO BE FILED WITH TIM PERT&TTING AUTHORITY.
A licant Information Please Print Le 'bl
Name(Business/Organizationftdividual): JW �L
Address:
City/State/Zip: w Phone
Are you an employer?C&c'kthe appropriate box: Type of project )Vequired):
I4?41 am a employer with_1 - employees(full and/orpart time).* 7. E]New construction
2.Q I ama sole proprietor or partnership and have no employees Working for me in $. [1 Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3_FJI am a homeowner doing all work myself[No workers'comp.insurance required.]t
-
10 E]$uilding addition
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 11.❑Electrical repairs or additions
proprietors with no employees. 12.[1 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.gRoof repairs
These sub-contractors have employees and have workers'comp.insruance.t
• 14.�Other S(�
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§i(4),and we have nQ employees.(No workers'comp.insurance required.]
*Any applicant that checks Box 41 must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
rContractors 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-conlracfors fiave employees,they must provide their workeis'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:
dl7 Expiration
Policy# Self-ins,
'c or Lic.#:
Job Site Address: 1 \ C 1� City/State/Zip:
Attach a copy of the workers'compensation-polley declaration page(showing the policy number and expiration elate).
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 Investigatlons of the DIA for insurance
coverageyerification.4
I do hereby certYYdder the pains andpenalties ofperjury that the information provided above is true and correct.
Date:
Si ature: 1
Phone
q �
Official use only. Do not write in this area,to he completed by city or•town official..
City or Town: Permit/License#
Issuing Authority(circle one):
3.Ci /Town Clerk 4.Electrical
1.Board of Health 2.Building Departmentty Inspector 5.Plumbing 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 bfhire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,of 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 trustde 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."
i
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 cant'workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial
Accidents fbi 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 ifyou'axe 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. Ia 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 proofthat 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(MUIDDIYYYY)
,�C R®® CERTIFICATE OF LIABILITY INSURANCE 12/24/2014
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. U SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsemeaL A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
CONTACT
PaooucER Tarpey Insurance Group PHONE FAX
PO Box 567 "AIL arc"
Wakefield, MA 01880 -
BNSURER AFFORDING COVERAGE NAIC tl
1NSURERA: Liberty Mutual Insurance 23036
INSURED Capital Contracting Inc INSURERS:
73 Renwick Rd INSURER C`
Wakefield, MA 01880 INSURERE:
INSURER E
INSURERF.
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 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 TYPE OF INSURANCE OL SUER � �� POLICY EFF POLICY ERP LIMITS
LTRCOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
CLAIMS MADE ME TO RENTED
OCCUR PREMISES1Fa rtence S
MED EXP Any one person) S
PERSONAL&ADV INJURY S
GEWL AGGREGATE UMIT APPUES PER: GENERAL AGGREGATE $
POLICY Q EC r—]LOC PRODUCTS-COMROPAGG S
OTHER: $
ILITY
AUTOMOBILE LIABcideM NG MI $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS NON-OWNED PROPERTY $
HIRED AUTOS AUTOS (per
$
UMBRELLA LUIS OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS-MAGE AGGREGATE S
DED I I RETENTIONS S
WORKERS COMPENSATIONPER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
ANY EMPLOYERS'PA BILITYEXECUTIVE YIN E.L.EACH ACCIDENT $ 100 000
Edi M'EM'9 EXC'LUD'ED? NIA WC2-31S-600141-014 11/26/14 11/26/15
MenNIQ
EL DISEASE-EA EMPLOY s 100,000
DESCRId POTION OFFOOPERATIONS betaw EL DISEASE-POLICY LIMrr S 500,000
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DESCRIPTION OF OPERATIONS 1 LOCA71M I VEHICLES(ACORD 101,Addittanat Remartcs Schedtft may be aUtaehed R more space Is mquked)
CERTIFICATE HOLDER CANCELLATION
SNOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE. EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOAM!D REPRESENNT�TIME Nt y�t
®19W2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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- ---------- --- ---- - - --_-___• 03/30/2017