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HomeMy WebLinkAboutBuilding Permit #483-2017 - 43 HIGH STREET 11/8/2016�t4v BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR. PLAN EXAMINATION Permit No#: 4 8-3 - 9 ® 17 Date Received ;_0 I TYPE OF IMPROVEMENT PROPOSED USE o rA aha 6-dritrad-tof Nafnel, Residential Non- Residential 0 New Building 0 One family 0 Addition 0 Two or more family 0 Industrial Alteration No. of units: —0 Commercial —0 ARepair, replacement 0 Assessory Bldg 0 Others: 0 Demolition 0 Other 7-- �Septic - El Well 0 Floodplain` 0 Wetlahidg ©'Watershed ❑ WA r NA I( -< x(\ \,:-" k- OWNER: Name: -ION OF VVUKK Itit Vtf,(1-UK1V1tL)- 0% ( .1 f m, +q U 1660 � Lc -,c c;,, r COL V\:J Identification - Please Type or Print Clearly JTZ 0_V --e- Phone: Address: T—Vo ti /'J Q o rA aha 6-dritrad-tof Nafnel, 'Address 7,, C, :, � �-_� ­ - ;.;�� ,./ � ��...:.: � F-� a.� 1. � . upet r96nbti6AILie License Exp _ _Home•,mp.go V_emei Exp� DclteF.. ARCHITECT/ENGINES Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $IZOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PE S.F. I.. rotal Project Cost: $ 2,6tS \0.06 FEE: $ q 143 Check No.: 0 YF7 Receipt No. - NOTE: Persons contracting with unregistered contractors do not have: access to the guaranty fund Si ";nature of.AgeeOwne.r '. Signature of con Plans Submitted ❑ Plans Waived Ell Certified Plot Plan ❑ Stamped Plans ❑ TYPF-' F SEWERAGE DISPOSAL Public Sewer ❑ Tannin g/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 FORM PLANNING & DEVELOPMENT Reviewed On Signatu COMMENTS CONSERVATION Reviewed on Signature COMMENTS, HEALTH COMMENTS Reviewed o Sianature 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: FIRE DEPARTMENT' - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS Located Jd4 Usgood Street no limension 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 DANC=ER ZONE LITERATURE: yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine 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. r 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 40TE: 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 Location No. t d' i 016 Date Check # 101U1 7 5149 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 4,-, - 4, /Z - (,B'u'ilding Inspector W, 'V � I? 04'.' nEf * f JO LLI Z LL O p O m � L +U_ Y LL E a0+ ?O N V) a: N z O Z J � m C LL U v C _ LL N ZCL O Z Sm ` J a L cr _ LL O CL N Z a V V W W L to �' N U N _ LL oC O W Z LA a t K LL Z LLI Q n W W 25 U. ` N m z ,�.• Ln .w N Y {n O ea � o CL co _E� <u W 2QC •�• i O� O ANG • o ** v CL E a� dm a c c L 46 _cn k = y+ t t O E C R o 0 rLc14 z a' N C O .y C : C `! O = r ,0c o --- �fts o-_ .a m I- 0 0 c -a Q L a2 o Qy•o N fn N O � m O W_ C 'a w O O ui :E .2 z LL O .O N O � .a O W L V O O F-- • a O (D +L+ Q N�0 Hcu a o v > 2 z co z W CL W H W a 2 v O O o O I O •� N Q O — A AWA0 �+ V` /0 O Q OM r Cc �CL O Cz O V N ca CL U) 23 rlt f j''fl 5 Generations of Boston Roofing,- 11.0 oofing, 11.0 Kinn Ave lu1°ey111outh, TNIA 02.188 781-686-7905 info@portanovaroofng.coni wwtv.portanovaroofng.com Name / Address RCG Eric Giangregorio 17 Tvaloo St. Somefvi Ile Ma 0214; Estimate Date Estimate # 10/19/2016 E456 I Project L�—_ _ Description ( Total Estimate for 43 High St. We will strip rubber of roofeahosing old insulation. Replacing any ,,vet pieces and then installing new rigid .5" insulation over. Roof will have 20 yr manaractwers Nvarrantv Includes all custom copper drip edge Includes all new drains or refurbishing existing whatever is best for the roof 30% of payment due upon agreement of terms fl Remaining 70%ofpayment due upon Complclion of job Total signing this d0(.ntnetlt bccomes a binding contract wider law. Sura-1���2'�z=•--�-.� � - Date:C. ` ;>�3 79,050.00 579:050.00 NORTH Town of North Andover H� A Machine Shop Village Neighborhood Conservation District Commission o,.,,, 1600 Osgood Street North Andover, MA 01840 9SSACHU5E� Application For EXCLUSION From Certificate to Alter For Items 9,10 or 11, provide the following documentation: Photos/drawings of existing doors, windows or siding, as applicable Description/Catalog Cuts of proposed materials to be used for doors, windows or siding Plan and elevation of reconstruction for Item 11 Detetm .ination: This project is determined to be tl exempt ❑ not exempt ,from review by the Machine Shop Village Neighborhood Conservation District Commission. Projects .that are not ea emvt must complete the Application for Certificate to Alter, available from the Building Department and be reviewed by the Commission. Determination made by: Lizetta M Fennessy Signature Neighborhood Conservation District Commission 4 November 2016 Date MSV NCDC• Page 2 Current Chair: Liz Fennessy, 77 Elm Sueet, lizettatennessy@yahoo.com, The Commonwealth of Massachusetts Depaxrtment oflndustrialAccidents M X Congress Street, Suite 100 d Boston, MA 02114-2017 www mass.gov/dia •O'tM 5V'y Ngo kers' Compensation InsurancO.Affidavit:Builders/Con THOs�'- �cians/Plnmbers. TO BE FILED WITH TBE P� 'VI—CA Print C, Name, (BusinesslOzganizaiion/Individual): . Address: ) e ►..-7 City/State/Zip: phone #: Axeyonanemployer?Checktlie .propriatebox: 1. am a employer withemployees (full and/or part time).* 2-Q I am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required-] 3.E] I am ahomeowner doing all work myself [No workers' comp. insurance required.] t <1 I am ahomeowner 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 proprietors with no employees. d ❑ I am a general co {actor an-conh d I have hired the subtraetors "Ste oa te a 5.ttached sheet These sub -contractors have employees and have workers' comp. insurance.,6. Q We are a corporation and its, officers have exercised their right o£ exemption per MGL G. 1 4 and -we have no employees. [No workers' comp. insurance required] Type ofproject (required): '7. E] NdW'd6nsiraction 8. [] R.emodeliiig 9. ❑ Demolition 10 [� Building addition 11.[] Electrical repairs or additions 12. E 'Plumbing repairs or additions 13•. [] Roof repairs 14.07 Other O, . applicant that checks box.4 must also fill out the section below showing their workers' compensation policy information. pp they are doing all work and thenhire outside contractors must submit a new affidavit indicaivag such i Homeowners who submiithis adavit indicating e3' (Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have —11 1nvr.Pa_ Ifthe sub contractors have employees, they must provide their workers' comp. policy number. t am an employer that is providingworkers' compensation insurancefor my employees. Below is tliepoacy andro si e information. T k �� V1 Cc S' --go r insurance Company Name: f tq (,g n S[ 0 "7� L/ 11f- _ Expiration Date: Policy # or Self -ins. Lie. #: � cn City/State/Zip: A6C v qE Job Site Address: Attach a copy of the •ovorkers' cb� pensation policy declaration page (showing the policy num oer and expiration date)- al ViOlatiOUPU Failure to secure coverage as required under penalties?in.the form. of STOP WORK ORDERandfine of up to $250.00 a and/or one-year imprisonment, as vv P day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. es ofperjury that the information provided above is true and correct. X do hereby certify under tliepains andpenalti official use only. Do not write in this area, to he completed by city or town official. Permit/License # City or Tomn- issuing Authoxity (circle one): 1. Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #: Contact Person: 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 of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other Iegal 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 zeceiver'or, trustee 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 b6 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 commonwealth for any applicazutwho has not produced -acceptable evidence of compliance with the insurance coverage r'equir-ed." 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 fil1 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub'contractor(s) name(s), address(os) 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. De advised that this 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 affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Iudustrial•Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensateori 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. 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 "fob 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. 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-MASS.AFE Fax # 617.727-7749 Revised 02-23-15 www.mass.gov/dia Oct 2516 02:29p The Insurance Store Inc 6173257892 p.2 CERTIFICATE OF LIABILITY INSURANCE D0.TE (.NM/OO YyYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT -O ALL THE TERMS, 01/19/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER- THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(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 cerllficate does not confer rights to the certificate holder in Reu of such endorsement(s). PRODUCER THE INSURANCE STORE 106 SPRING STREET CONTACI NAME PHONE (AIC, Ne, E.1): (617) 325 - 8952 Iruc, Nel:(617) 325 - 7892 E_MAU. WILL BE ADDRESS: WEST ROXHURY, MA 02132 INSURER(SI AFFORDING COVERAGE NAICa INSURER AWESTERN WORLD INSURANCE COMPANY ' INSURED INSURER a SAFETY INSURANCE PORTANOVA ROOFING INC INSURER C: � I PRE�MISES(Ea oxateroe) s 100,000 50 Elm Street INSURER O: Cohasset MEL 02025 INSURER E: INSURER F: 4,VYGR ljaa VtK I11-ItJA It NUInr3C K: RtVISIUN NUMF7tH: THIS IS TO CERTIFY TEAT THE POLICIES OF INSURANCE LISTED BELOW :-(AVE BEEN ISSUED +0 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 -O ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. L MITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR WVD POUGY NUMBER IMM/DD/YYYYI MMID POLICY EXP (MMATD/Y1^(Y) LIMITS ' GENERAL LWBItirY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN . FACHCCCURRENCE S 1,000,000 a M1RRGAL GENERAL LIAEIDTY CLAIM649ADE OCCUR f1i , NPP8184354 11/04/15 11/04/16 � I PRE�MISES(Ea oxateroe) s 100,000 MED EXP (Any ou Person) S 5,000 PERSONA' S ADV INJURY S 1,000,000 i pis N � ) 46 SJ� GENERAL AGGREGATE S 2,000,000 '_0 I, C 1 - 0 CORD CO R9TION. GEN'L AGGREGATE-IMIT APPLIES PER: PRODUCTS - CJMP'OP AGG $ 2,000,000 The ACORD name and logo are registered marks t ACORD POLICYPET JECT F LOC E AUTOM OBI LE UA BIUTY (Ea am dent) i 1,000,000 BODILY lN.JURY (Per person) S ANY AUTO b AUTCSN�O"AX AUT0SCHE5�� 6238330 05/06/16 05/06/17 BODILY INJURY (Per aaiden:) $ X FIRED AUTOS X NIOWOWNEO AUTOS (Per accidanl) t 100,000 f UMBRELLA LIAR H_ OCCUR EACH OCCJRRENCE $ EXCESS LIAB ClUNLIS-MADE AGGRcGA.TE S DEO RETENTION S 5 WORKERS COMPENSATION I : AND EMPLOYERS LIABIL1rY YIN TORY LIMITS ER EL EACH ACCIDENT 5 ANY PROPRIETORIPARTNERIEXLCUTIVE ❑ OFFICEPoMEMBER EXCLUDED? N IA EL. DISEASE- EA EMPLOYEE $ (Mandatory in NHI Iryes, descdba Lode - E.L. DISEASE -POLICY LNI S DESCRIPTION 0= OPERATIONS balm I I DESCRIPTION OF OPERATIONS I LOCAnONs i VEHICLES (Attach ACORD 101,AdLNonet Remarks Sch pdul0, 8 more SP ece Is r q.ired) ROOFING 6 CARPENTRY: TOWN OF NORTH ANDOVER, BUILDING DEPARTMENT 120 MAIN STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. , AUT IZE REPRESENITATNE i pis N � ) 46 SJ� '_0 I, C 1 - 0 CORD CO R9TION. All rights reserved ACORD 25 (2010/05) The ACORD name and logo are registered marks t ACORD 2516 02:29p --04 The Insurance Store Inc 6173257892 p.1 ACORQ® CERTIFICATE OF LIABILITY INSURANCE DATE MM1DD/YYYY) 10(/25!2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER THE INSURANCE STORE INC. CONTACT NAME' Ann Gallagher N (617)325-8952 FAX No: E-MAIL ADDRESS: ainsur@aol.com _ INSURERS AFFORDING COVERAGE NAIC A 106 SPRING ST. INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 WEST ROXBURY MA 02132 INSURED INSURERS: PORTANOVA ROOFING INC INSURERC: INSURER D: 50 ELM COURT INSURER E: COHASSET MA 02025 INSURER F: COVERAGES CERTIFICATE NUMBER: 9fi994 REVIcrnkI N"UaGo- 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 SUBIR POLICY EFF POLICY NUMBER AMlDDlYYYY POLICY EXP MM/DD,Y,, : i LIMITS COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE $ TO RENTED PREM -SES (Ea occurrencel $ CLAIDAMAGE MS -MADE F7 OCCUR MED EXP (Anyone person) S PERSONAL &ADV INJURY S N/A i GEN'LAGGREG.ATE LIMIT APPLIES PER GENERALAGGREGATE S PRO- POLICY � r ,/ECT LOC HOTHER: PRODUCTS -COR9P/OP AGG 5 5 AUTOMOBILELIABIUTY I COMBINED SINGLE LIMIT S i Ea accident ANYAUTO BODILY INJUR" (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS NIA BODILY INJURY Per accident' ( r,$ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident I S UMBRELLALIAB HOCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE NIA ' AGGREGATE :5 DED I RETENTIONS $ WORKERS COMPENSATION�/ STA AND EMPLOYERS'LIABILITY YIN /� UTE EOR E.L. EACH ACCIDENT $ 500,000 A ECUTIVE O FIArJYCERINIEMBERPEXCLU ED NIA NIA NIA 6HUB8D80784116 10/26/2016 10/26/2017 E.L. DISEASE - EA EMPLOYEE S 500,000 (Mandatory In NH) 11 6 describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 500,000 NIA DESCRIPTION OF OPERATIONS / LOCATIONS! VEMCLES (ACORD 101, Additlonal Remarks Schedule. maybe attachod It more space is required) Workers' Compensation 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 states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate Df insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd;workers-compensation/investigationst. 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. 120 main street AUTHORIZED REPRESENTATIVE f: north andover MA 01845 " t Daniel M. Crowley, CPCU, Vice President— Residual Market—bYCRIBMA iV IV676-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD