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HomeMy WebLinkAboutBuilding Permit #769-2017 - 428 WINTER STREET 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION / Permit NO:;76 l �9,0 j Date Received ' i�( 26/, Date Issued: IMPORTANT:Applicant must complete all items on this page .c�"4�"'.F''4"'"7fr,_'}�,,„__ f. �:9) .a-•�•..a•.�,y+P...—„�^.p;•a,.".�^^..�^' i. ^^i'” �n .c.. �aM"'G�Kx- �x�^ .+�"*:r{�^ti. i�<. :f"t�1) 'ST"a'Y yx.42y 't•an-::J 4#+('S;.;`s�,,'�tw Az��t„ _. INC NS' h', 'Z8�� :�G'%%%IE' a _ �� a-" a; •� ik Pit n iPROPERTYt&WN.R' C 100 .,ea r OwId Str�u- urea a i JMAPrN0�=1 'PARCEL' ZONING D1STRlCT _._��#Histo is ®istfcti� ' , yes Ma -11 Villa e es4 �,;no.; . .�..g� ]•' `L..a. - - TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building I-One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial V Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition 0 Other Septic ❑Well zx 4 °:.��Floodplain ,.,0,1Netlands ,.. t .❑xWatershed Water/SeweC ` . ;' •, F DESCRIPTION OF WORK TO BE PERFORMED: /z& "I'v/0al ' 4- Identification Please Type or Print Clearly) OWNER: Name: dais ,�°�eaG Phone: 97�'�-��' :?3,P q Address: Y�� t✓ �� s°�' �_ fCONTRACTOR NamePhone97._.. �z'__. a; � .t f � �� `• •tri > l � ,/Address Cx i .ita ♦ ' ti -�.. ,3a.•..+.."r-4L-^'Y`--�Ir �. i,+,x;•t.i*F,.t'-.Wt'L -7 7H . ro ; 'fqn:+�e✓a`',^3�s,n��e x•""' .i..a�.m..�.:. Superiss Constructlori;License o�y6':5`/6 ' "� . 4€--Exp vor' "i �� ;.Y-`,t t;ctr'.. f ,j,1 1�7,, 'Y,t k.'�`t Nei •.'•aka �s. s...`.b::..�,��.T,�•.: i Horne Improvement License �l x'83 `E -7-,X ARCHITECT/ENGINEER Phone: t Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$925.00 PER S.F. Total Project Cost: $ 7�� °° FEE: $ [� Check No.: � Receipt No.: t Sat-. NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _ i nature:of.Agent/.O;iwner a Si -:atd' of contractor �. . Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Building Department `rine foi?ovving 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 DOTE: 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 ❑ Flo or/Crossection/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 DOTE: 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 TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cEisos if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the app,-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must bc- submitted with the building application Doc: Doc.Bui!ding permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-OF'-SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑... Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORINT DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature ay COMMENTS 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 Tows Engineer: Signature: Located 384 Osgood Street FIRE=DEPARTMENT - Temp Dumpster on site yes no Located at'124 Mair.,'Street Fire Departmerit signatutd1date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions_ Total land area, sq. ft.: ELECTRICAL: Movement of!Defer location, mast or service drop requires approval of Electrical Inspector lies No DANGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A-F and G min.$10041000 fine NOTES and DATA-- (For department use U Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department Tine fonowing 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 DOTE: 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/Crossection/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 JOTE: 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 TOTE: 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: apn-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must h� submAted with the building application Doc: Doc.Bui?ding Permit Revised 2012 TOWN OF NORTH ANDOVER T APPLICATION FOR PLAN EXAMINATION Permit NO: ;7 rj ! Date Received ' l�f ?,o/7 Date Issued: EWPORTANT:Applicant must complete all items on this page .70 [PROP,ERTYt NERm!7 _�'Y�r;a� ` s ZZ" � Print 100 YeOId Struct�U urU.. MAP N® � _.' '�€PP,ROE ZONING D STRICHRR__ .. _ Alstorc®istrict .. y Yes a no� ; :�-- - LMach ne shop Village' y-a'sV ,..."iio� ` TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building R-One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial W Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D Septien�❑Wellr .. ,y - ❑ Floodplainu..- ,1Netlands „», , �. .❑ 1Natershed s - ; 0 Water/Sewer: 1a < DESCRIPTION OF WORK TO BE PERFORMED: P P. cam,neo 4L � to�9 �iP s.We o S �0/Q l/Gr �//'/►�oCY� ('�c� �4'/C�/e /�<i/1/t .fi�`��yf g w Identification Please Type or Print Clearly) OWNER: Name: �� F°�� Phone: ?7�����' :?3,o Address: -s7' .CONTRACTOR Name / _� _.e��o � � 1?hone= �7.. -�z'__. _t_� x M r r. .,,.a.. ,�. ..H,�x s 3'Y`;;:- ..�t `:r.4. a �_y.»,<.. -•1 S��—x _ r -�i ._}_-pty v=yrwa .r - ... ♦. .�.. r:�., _yr. �...�...— S Y -a.�:^ a "`,�: yam.'e"r i`."•�eT.. Supervisor's Constructlon'Llcense v� /6 ' gyp` � r� x ,� � Ex Date c= r�., •. tN. ri.{ y ,z aKt i�: L.1 1 f Horne Imp ovement License 'll�x , t E p Date Y =7 �., 7 ARCHITECT/ENGINEER Phone: P Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COSTBASED ON$925.00 PER S.F. Total Project Cost: $ 742 °° FEE: $ Check No.: 2 h7 7 Receipt No.: , NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund g _ :' Sig�atu:re:;of:.contractor ignatiare..of.A:ent/Owrer >::- _:... Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location q23, w i ei4 -eA No. Date o t 7 • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# -7 2 9'—? , L � // Building Ins6eSurr----- OORTH q Town of s ndover 0 I(A-0 2017 Z ,� oh ver, Mass, ty AV/ 7 1. �/- cocAcMewIcK � 7,4 A0RATEO S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ......:. ..9.........Trity....W...�......�........sowl... ..................... BUILDING INSPECTOR y .4..'...� Foundation has permission to erect .. .... .. ......... buil ings on ..... ..�... ......W.1 44.eft ..... � Rough to be occupied as ..... .C. .I.&.ItrC.. ............ .....Im.lo .b..1I.W 5................................... Chimney provided that the person accepting this per it 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 CONSTRUCTI S ART Rough 6Service ......... .. ...... ......,... .. .... ... ........................ 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. -tech i 1is Inc. SIDING 20 Aegean Drive Unit 4 ; !i/IA Pig. # 118836 � �018,14 MA Lic # GS 106508 5-800-851-0900 f '(h Date: ._/_ J�" VRIV+N,Ih°itechcorp.blz Consultant: vA� Job Name: d eiephon-: 7f? 3� Job Address: �r own: f Contractor agrees to start described work on or about weeks after final fittings,and complete described work in about working �S plants.Contractor shall not be liable for any damage to paining days.Contractor shall not be held liable for delays due to cause beyond our control.Hi-Tech shall not be held liable for any damage to lawns or -or stain during installation of windows or doors.Hi-Tech does not do any paint- Ing or staining. in the event that a punch list should accrue at the end of the job,a maximum of 2%is the allowable amount to be held back. The following work includes all labor and materials needed to comp :des lete your job in a workmanlike manner. 61 f~F - -vo� TrMt � # cj Combination Job-Siding with Other V✓or!��,�p7 Buy.hg ❑ P.V.C.Coated Alum Aluminum Bng and Elec.Permit I Fascia Trim - I F--scia Treatment movaSohn L,Sidi Rel i� _ � ❑ '.Trim j Fascia Color A C�rep -,on Package window&Door Trim rryo ❑ Full Custom ❑ None +r sso .ackage Shutters CD Location ❑Un*.rlayment Insulation" Guttefs S!dinSoffit rec'tent ant _ g ❑Dgwnspouts k C emove Debris ❑Lock.Elec.?aeler j soffit Color Center Vent IVon-Venled F f eP a_Vc n Iricd�dec { ❑ Fully(/anted ❑ t LI Replace Visible Rot Location ®„+ ❑Vented as Needed �! ❑Energy Savings/Bug Guard Starter i �r ic3C4t=!And Door Casing 1 reat £r?t lg Window And Door Casing Color w �y l A.ccessot ar CrrCaEj£Includes ❑ Full Custom Formed J-Less ❑ ull Custom Formed .� i Color: t e I ❑ Blind Sbp Capping ❑ None iii , ❑ ®b 1j Locationrnyl Light Blocks M vinyl Dryer Blocks t M •i E, 1 ❑Vinyl Electric Oullet Blocks ❑vinyl Exhaust Vents Gutter C& O1Vnspouts ❑Vinyl Faucets Blocks Gutter Color Downspouts Color ❑ rayl Gable Vents t kLocation t;t?derlayrnee:t insulation Toe user f Special .totes ��( .m r; Yi ❑Hi-Tech 318 -- — Other / _jP1 i Location A-irea To Be Sided 5 ❑Complete House Garage Got / � �"�Yy � � �l� 14 -S 1/d4�f�1 (� •` ( -Sto,ng To e used ---- m t k LA cglor Payment Policy BranoProfile y Bank Financing ❑Owner To Arrange ❑ Hi-Tech To Arrange _ F"u.►^ _ s // ❑Cash Or Check ❑ Master Card Corn Post To 3,e4 t:3t CornerPoslCo!or: _ZL 0 � ( total l✓ ❑wide Insulated ❑('Vide Non-Insulated 113 Deposit 3 ❑Regular Insulated i Regular Non-Insulated 1 113 Payment t 1i3 8aiance of Day Substantia(Completion a�77� M 'tou may cancel this agreement.if it has been signed byla party thereto at a place other than the address of the seller,which may be his main office or branch;hereto,provided you notify the seller in dYrritin o or branch by by telegram sent,or try delivery,not later than midnight of tate third business day following he signing of l sragrepentdinary !posted, the attached notice of cancellation form for an explanation of this right. An interest charge of 1.5%per month(18%per year)will be � � I added to any amount unpaid after 30 days from invoice date- Date Of/aCCe tame J !r the evert of default of payment of this aider ar am part thereof and the account is referred to as a,:crney for colfeciion,:he chaser I p ob i all aeon 'ry per its. . Ignaic 1 1!4Ve give Hi-TeElf pednis 't t ob t ail eves ry permits. ptomeovmar Signature >t Signature .A � z. Massachusetts Department of Public Safety, j Board of Building Regulations.and Standards y License: CS-096516 Construction Supervisor TIMOTHY W WICI(e 3 ELLIS ST 4 =! V METHUEN MA 01844 r Ij If Expiration: Commissioner 09/09/2018 til� 1fze�ori�imrmcoea�f ae� addpcltfldeCld`- W�ce of Consumer Affairs&Business Regulation ' C IMPROVEMENT CONTRACTOR - eistration:: ``118836 Txpiration! ' Type: 4 6/2017, Supplement Ce HI TECH WINDOW&"SIDING INSTALL INC ' TIM WICKS <t 29 ARROWWOOD ST METHUEN, MA 01844 Undersecretary . The Commonwealth of Massachusetts Deparfnwnt of-[ndus&ialAccidents F 1 Congress Street,Nlte 100 " - d Boston,MA.02114-2017 WWYV•Xm ass govtdza 'Wiavkers' Compensationaned Affid WITH P B 0°d O AU2HOItTTY•�iczabsl'Immbers. • TOB Please Print L I A licant Information Name(Businessf6igatizalionllndiviclna�: T G !,/.R�rst� '� frit/` �I1f�//i✓f�aw! Address: Ile telt /ylcf�dGn Phone#: 9 ?9" City/Sts / p= Areyou an employer?Cjle*flie approprlatebox: Type off project(xec,['*BcI�'_ 1 er.9fh�—�ploye�(�and/or part time 7. ❑I�T6Vdo`nstt-itction I.��a�Po3' g, []Remodeling 2.[]I am a sole proprietor or partnership and hate no employees Vaorkmg for me in any capacity.[No work"''comp.insmanee required.] 9. ❑DeMOM-flu e oworkers'comp.i'll ncerequired.]f IQ❑Building addition 3.Q I am ahomeowner doing allworkmys 1£[N ro IwiI1 4.j]IamahomeownerandwhlbehiringcontractorstoconductaIlworkonmyP P 1] ❑Electricalrepaixsor?d��o?� ensnre•that all contracto=s eitherhave workers'compensation insurance or are sole ' g repairs or additions proprietors vAfino employees. rtto-a ttached sheet 13•.[]Roof 5.QIamageneralgaeB'#-Joyees andhaveworkerscomp-insm�a Thesesub-contractors re�pairs IQ..W Other r 6.F1 vire are a corporation and fts offices have exercisedtheir right of exemption per MGL e. 152,§1(4),and$ve hoes no emmployees.jNo workers'comp.insurance required] Itcantthat cherdLs bbx#1 must also fill outihe sectionbele�v showingtheirworkers'eompensationpolioyinfounation �AuYaPP mdicafingthey are doing altwork and•thenhire outside contractors must submit anew affidavitindica5ng saeh. t Homeowners who submrttb�s affidavit the name of fhesub-contractors and state whether or notfihose entd?es have Contractors that checkthis'6foxmusf attacliedan additional sheetshowing oIic nrnnbet .._-.. . - �npl�yees. Ifthe sub-contractors have employees,they nmst provide thein workers'comp.p y •. , em to er that is p�'ovidingwo�keNs'corrcpensation irzsiir�ice for°my employees. Below is fire policy arzd j-ob site x arra an p y information. �.' aA� rc Insurance CompanyName; �R Policy#ox Self ins.Lzc.#:. e✓GS' _V 6 6 0 o o l 6 Expiration Date fl 9 17 • City/State/Zip: ,/� �'a�li'�'01, lob Site Address: yam ' .ST ofthe�vorkers coin ensall on policy declarationpage(shownrg epopcpn berandexp atzortdate). A.ttaeh a copy p to $QQ.00 Failure to secure coverage as required under MGL c.es2x,§tb e f is ofcr�TOl�Olat! R� land aline ofup to $250.00 a and/or one-year imprisonment;as well as civil penaltt day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. cern under the-Palls arxd enalties ofpe jury that the informeoi2proYided aiRave is t�u_e cid correct ido Hereby fY Date: �^� Z Si ature: Phone Official use only. Do notWrzte in this area,to be corfapleted by city or toren official. • Pexmit/License# City or Town= fssuingAurthority(circle once): ' Clerk 4.Elecectox 5.Plumbing inspector I.Board of health 2.PuRding7Departmen:t 3.C�itylTown. txicalbsp G.Other Phone#: Contact Person: Informadon and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hite, express or implied,oral or written:' An employer is defined as"an iadMdual;partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver"or t ustde 6 'an individual,partnership,association or other legal entity,employing employees:.However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the' dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to op orate a business or to construct buildings in the commonwealth for any applicazttwho has not produced-acceptable evidence of compliance with the insurance coverage xe4&ed." Additionally,MGL chapter 152,§25C(�)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=-b--'contractor(s)name(s),address(es)andphone numb er(s)along-with their catificate(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 d6e's have employees,a policy is required. Be advised Iatthis affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The afff-Aavit should b e returned to the city or town that the application for the p ermit or license is b eing requested,not the D epartment of Iudusfrial:Accidenis. Should you have any questions regarding the law or if you are required to obtain a vaoxkers' compensation policy,please call.the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate lute. 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 Inveftijatioris has to contact you regarding the applicant. Please be sure to fill la the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pamm Vlicense applications in any given year,need only submit one affidavit indicating current PORGY information.(ifnecessary)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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A neva affidavit must be$fled 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 burnt leaves etc.)said person is NOT required to complete this afftdavit. 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-MASSAI'E Fax# 617.727-7749 Revised 02-23-15 wwwmms.gov/dia DATE A� (MMDD/YYY1� V CERTIFICATE OF LIABILITY INSURANCE 2(14/2017 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 have ADDITIONAL INSURED provisions or 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 BARRY J KITTREDGE INSURANCE NAME:CONTACT 81 S MAIN ST PHONE FAX BRADFORD, MA 01835 / (AIC,No): E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC fl INSURER A: LM Insurance Corporation 33600 INSURED INSURER B: HI TECH WINDOW&SIDING INSTALLATIONS INC 20 AEGEAN DR STE 4 INSURERC: METHUEN MA 01844 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 34225723 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. (NSR ADDTYPE OF INSURANCE IVSD WVDSUBR POLICY NUMBER POLICY EXP LTR MM DDPOLICY EFF (MM/DD1YYYY1 LIMITS COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ r_1 OCCUR DAMAGE S(RENTED CLAIMS-MADE PREMISES Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY E1PECTRO [7] LOC PRODUCTS-COMP/OP AGG $ J OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PRO PERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per=DAMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-383602-016 11/29/2016 11/29/2017 SPERTATUTE EOR Y/N H AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500000 OFFICER/MEMBEREXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS.NOTICETHE EXPIRATION DATE THEREOF, WILL BE DELIVERED IN NO. ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 34225723 1 1-383602 1 16-17 WC 1 n0270256 1 2/14/2017 9:54:35 AN (PDT) I Page 1 of 1