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HomeMy WebLinkAboutBuilding Permit #190-2017 - 41 Woodbridge Street 8/24/2016 L oI�D 1"` \ 1 l/V NORTy 1 BUILDING PERMIT oIt%OR quo TOWN OF NORTH ANDOVER 3 APPLICATION FOR PLAN EXAMINATION 0,010p Permit No#: Date Received �'qs RATEO�V' SACHLIS Date Issued: �1C/ I1;W0_ITANT: Applicant must complete all items on this page LOCATION 41 4)e<J �e j Print PROPERTY OWNER CL / �j Print 100 Year Structure yes no MAP U PARCEL: ZONING DISTRICT: Historic District y no Machine Shop Village y no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building &6ne family ❑Addition ❑Two or more family ❑-industrial ❑Alteration No. of units: ❑ Commercial i3IRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain 0 Wetlands El 'Watershed District ❑Water/Sewer - _ - DESCRIPTION OF WORK TO BE PERFORMED: Identifica *on- Please Type or Print Clearly OWNER: Name: VG�1 �ii©�/ Phone: f,d Address: Q a Contractor Name: �/� �g Ceej Phone: ! 7l ���J �� 7 Email: Address: 1 aotGC�f �! 1_c nc1Q4dc '� .Af, Supervisor's Construction License: Exp. Date: Home Improvement License: 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. FEE: $ Total Project Cost: $ d4� T . Check No. Receipt No.: NOTE: Persons contracting with unreg' red contractors do not have access t�t guaranty fund fJ � Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL f Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming 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 II CONSERVATION Reviewed on Signature I ( OMMENTS l I 4 HEALTH Reviewed on Signature COMMENTS t7oning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes °Planning Board Decision: Comments a Conservation Decision: Comments Water& Sewer Connection/signature&Date Driveway Permit DPW Town Engineer: Signature: ; _ r Located Osgood� 11.1 � Street DEPAM - TLm ® s - f=-. -RTIie ,ILRcdea-�12finSt -a_- FUirer(Depar"tr"t�me &x9 ._:� � r .;��..�_. ,.�...a� gnature/date, ��-- �`COMMENtTS 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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1oo-$10o0 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required formsto be filled out for the appropriate permit to be obtained. i Sidin Interior Rehabilitation Permits Roofing, g, 4. 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract ;r< Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) :a Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 1 _ Location No. I 4 Date • - TOWN OF NORTH ANDOVER J Certificate of Occupancy $ -.I�_ Building/Frame Permit Fee $ � '- Foundation Permit Fee $_.. Other Permit Fee $ TOTAL Check# Building Inspector � u % 77 NORTH Town ot 6Andover No. I ( - h ver, Mass , .&,,+1, 7 COCNIc"tICNtWKR � X1,43'R�reo �p���5 V BOARD OF HEALTH Food/Kitchen PER T Septic System 11 L D tile THIS CERTIFIES THAT ....... BUILDING INSPECTOR has permission to erect .. buildings on �1 Foundation ...... ....�...... ...... ....... .................... . ... .�........ Rough tobe occupied as .......... . .. .. i ......A.......lr Of........................................................... chimney provided that the person accepting t is permit shall in every respect conform to the terms of the application 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR.. UNLESS CONST TION Rough Service ... ..... ........ ... Final BUIL NSPEC R GAS INSPECTOR Occupancy Permit Required to Occupy Ruildin 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. Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Namer Compan e nG o'h Street Address(do not use a Post Office Box address) Co /Salespon/Owner Name ties I)e r "Alr Cif City/Town State Z' ode Business Address(must include a s eft address) N: d r MA C /'7a le � Daytime Phone Evening Phone City)I con St e Zip Code �� .a� � vP� o/� 5 7 .37r Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Homr rmpmvement Canuamar Reg.Number Esvhmiandne taw segegist that mort ber � � Improvementul—<antncton hive e valid ngistntlan number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) Re(10 Required Permits-Ile following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty`Fund provisions of 00/6, Date when contractor will begin contracted work. MGL chapter 142A.) S., Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of 5 (+) Payments will be made according to the following schedule: $ C) upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ © by_/_/_ or upon completion of $ O by_/_/_ or upon completion of $�upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(-) $ to be paid for NOTES:(+)Including all finance charges(++)taw requires that any deposit or down-payment required by the contractor before work begins may nut exceed the greater of(a)one-third of the total contract price or(u)the acival cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? ❑No Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this apreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed unit signed. One copy should go to the homeowner.The other copy sho c kept by the contractor. -�ZQ04Za,� &gz' Ho owner's SiContr c is Signature Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration furs which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the con inner shall be required to submit to such arbitration as provided In Massachusetts General Lawk.4pter 142A. a Honleownees Si C actor's Signature NOTICE:The si ures of the parties above apply only to the agreeme of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems hinVberself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at http://www.mass.sov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.asji For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 V—i— 1.11Mm01f) The Commanwealth ofMasso-Ousetts Department of''. idustrialAccideats F 1 Congress street,Suite 100 Boston,MA 02114--2017 www mass:govlclia sY V Workers'Compensation InsuranceAflidavit:Builders/Contractors/Electriciaus/Plu b.ers. TO BE TILED W1rm TSC+pmraTTING AUTSORM Applicant Mormation. Please Print ieaibly Name(Business/Orgmizatiou dividual): 4 Address: ,)7/, r Idd _ City/State%Zip: Lovtd, /U# IS Phone Areyou uaan employer?Chechfe apQxopriatebox-, Type of project(xequired): I SYIam a employarvvitls�employees(fan and/or part time).* 7. Q New eoaistruetion 2..0 1 am a sole propzetor or partnership anal have no employees Working forme in 8. Remo deft any capacity.[No workers'comp_insurance required.] 9, ❑Demolition 3❑I am a homeowner doing all work myself[No workers'comp..insurance required.]i 10 h Ruilqing addition 4.n I am a homeowner and will behiring contractors to conduct all work on my properly. Iwill 11.❑Electrical repairs or.additions ensure that all contractors either have workers'compensation insurance or are sole pr6piietors withno employees. 12:Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13: oof rep airs These sab-contractorsliave employees and have workers'comp.iT��TTance.T • 14.❑Other 6.0 We area corporation and*officers have exercisedther right o£exemption perMGL c. - 152,§1(4),andwehageno.enpl�yees.Mo workers'comp.insmancerequired_] 'Ary applicant that chedcsbox#1 must also"Ell out the seetionbelow shovbgtheirworkers'compensation policy information. i liomeowners who submit!Tans affidawt indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such- xComractors that check"box p:pfiattached an additional sheet showing the name of the sub-contractors and state whether ornotthose entities have employees.•Ifthe sub-coniractors Have employees,iliey must provide their workerscomp.policy number. Iain an employer tTzat isPio vzdirngworkers'compensation insuYaneefor my employees.'Beloit/is thepolicy andjob site ir2fotmation. ��`,J _ Insurance Company Name: Policy#or Self-ins.ZiG-#: �7W 7 7 R Expiration Date: �I� rob Site Address:�7_� 1��1 Woj F ,j^ Q City/State/Zip: . fI � Attach.a copy of the workers' coanpensationpolicy eclarationpage(showing the policynumber and expiration date). Failure to secure coverage as required under MGL o. 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 S'T'OP WORK ORDER.and a flue of-up to$250.00 a day against st the-violator.A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance, coverage verification. Ido hereby c ' rfitder the ui penalties ofr er zry!Iasi the information provided above is /e and correct. Si afore: Date: `�V Phone# Official case only. Do not-write in this arety to be completed by city or town official• City or Town: PertnibUcense# Issuing Authority(circle one): 1.Board oj'Realffa 2.BuildingAeparbneat 3.City/Town Clerk 4.Electrical Inspector 5.Plumblugluspector 6.Other Contact Person: Phone#: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. 1. Pursuantto this statute,an employee is defy ed as"...every person in the service of another under any contract bf hire, express or implied,oral or written." Art employer is deflued as"an individual,partnership,association,corporation or otherlegal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiver or trustee of ati 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 anotherwho employs persons to do maintenance,construction orrepair work on such dwelling house or on the grounds or binding appurtenant thereto shalt not because of such employment bd 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 common7ealth for any applicant who lias not pro duced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any ofits political subdivisions shall" enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements ofthis chapter have been presented to the contracting authority." Applicants Please f lout-the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub contractors)name(s),address(es)and•phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. lie advised that this affidavit maybe submitted to the Depaltment of•Industrial Accidents foi•conliniation ofinsurance 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 thatthe affidavitis 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 areference 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"lob 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit notrelated to any business or commercial venture (i.e.a dog license orpemit toburn loaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fag 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-MA"SSAFE Fax 9 617-727-7749 Revised 02-23-15 www.mass.gov/dia /24/2016 10'44'55 AM ,Degnan Insurance 978-327-6558 1/1 A ® �/ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 08/24/2016 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 pollcy(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 endorsemer l;s). PRODUCER CONTACT Elizabeth Chavez NAME: DEGNAN INSURANCE AGENCY, INC. PMONE(A,c No 978 688-U74 ac No: MAIL ADDRESS: echavez de nanlnsurance.Com 85 SALEM ST. INSURER(S) AFFORDING COVERAGE NAIC* LAWRENCE MA 01843 INBURERA: AIM MUTUAL INS CO 33758 INSURED INSURER 8 JAMES'DEBRECINI INBURII FAMILY ROOFING&PAINTING INBURER0 2 TANAGER WAY INSURER E: LONDONDERRY NH 03053 INSURER F: COVERAGES CERTIFICATE NUMBER: 79579 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. TN_8R TYPE OPINSURANCE ADDL UER POLICY EFF POLIC LTR POLICYNUMBER MMIDD MMlDOY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F1 OCCUR �$ PREMISES Ea nccurzr-nrc MED EXP An see eesen) $ NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F_�JECT PRO- [7LOC PRODUCTS-COMPIOPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acridcnt ANY AUTO BODILY INJURY(Per petsor) $ ALL OWNED SCHEDULED NIA BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUT08 AUTOS (P.r arcid.nt $ UMBRELLALIAB HOCCUR EACHOCCURRENCE $ EXCESS LIAR CLAIMS-MADE NIA AGGREGATE $ DEO I RETENTION S $ WORKEROCOMPENBATION X I STATUTE ETH AND EMPLOYERS'LIABILITY YIN IR ANYF'RONHIh I DH/PAH I NhHftXtCU IVh E.L.EACH ACCIDENT $ 100,000 A OFFICtHlMtMeEHtXCL'I.-9 NIA NIA NIA AWC40070259002016A 05/11/2016 05/11/2017 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 It yes,deecrlbG UnQet DESCRIPTION OF OPERATIONS,Calow E.L.DISEASE-POLICY LIMIT $ 500,000 N/A I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remark:Schad ula,may ba anaahed If more zpaaa Iz raqulrad) Workers'Compeneetion benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay claims for benefits to employees in stales Other than Massachusetts if the insured hires,or has hired thane employees outside of Massachusetts. This certificate of insurance shows the policy in farce on the date that this certificate wan issued(unless the expiration data on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at vvww.maea.govIWdtwarkerscom penas ti onfinvealigati anal. Sole proprietor has not elected coverage, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET BUILDING 20 SUITE 2035 AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel M,Cr y,CPCU,Vice President—Residual Market—WCRIBMA (�5 1968-2014 ACORD CORPORATION. All rights reserved, ACORD 25(2014101) Tha ACORD name and logo are registered marks of ACORD i Massachusetts Department of Public Safety [ Board of Building Regulations and Standards License: CSSL-099685 Construction Supervisor Specialty JAMES J DEBRECENI 2TANAGER WAY LONDONDERRY NH 03053 ,j Expiration: Commissioner 12/06/2017 t� �p C51.Wpanv wnwealM`/b�4Q u`d License or registration valid for individual use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration:�'r2,2385 Type: .. � 10 Park Plaza-Suite 5170 Expiratiort;:- _ 248 DBA Boston,MA 02116 11 FAMILY ROOFING JAMES DEBRECEN�I� "K i;=? 30.RIVER ST. ��•., _a �. .::r �, METHUEN,MA 01844 Undersecretary Not valid without signature •