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HomeMy WebLinkAboutBuilding Permit #770-2016 - 431 JOHNSON STREET 1/4/2016r O� �10RTF� q BUILDING PERMIT +z TOWN OF NORTH ANDOVER ° 770APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received �9SS ^TED HU`��t�� Date Issued: 1IV MPORTANT: Applicant must com tete all items on this 2age LOCATION✓" 'i" �' PROPERTY OWNER MAP NO: VDI, ARCIIR RIOT; Milc yes nQ Cie V yes nt� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building pNQne family ❑ Addition ❑ Two or more family ❑ Industrial 'Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg WOtherpi ❑ Demolition 11 Other 0, ,e,vgzn� Septic D Well //� 11O }yd /.�it s W district ❑ Water/Sewer Identification Please Type or Print Clearly) Q OWNER: Name: Phone:67 Z11 -N. Address: mL CONTRACTOR Name Address. t`t r% Supervisor's Constructioce ;Expo '' �.. ............ . E/ Home Improvement Lie �� c0 Expo/ ri ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BU((LDD,,ING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $`�( on�- —1 � FEE: $ �A Check No.: 9/l Receipt No.: -A NOTE: Perso�racting with unregistered contractors do not have access to the guaranty fund : . ._._ Signature of Agent/Owner Signature of contractor r 1 BUILDING PERMITo� q� 6�.tLEo � 6t NC -"OWN OF NORTH ANDOVER 02 APPLICATION FOR PLAN EXAMINATION � 2 O Ey Permit No#: Date Received •9 A°Rwreo SSgcHus� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 Addition ❑ Alteration ❑ One family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other ❑ Others: T Septie _ D Well n Water/Sewer7 : ,` ❑ Floodplain n_Wetlands i ❑ Watershed D�stnct. 77, DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. • $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $, FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th,- gau, runty fund 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 4 Building Permit Application Workers Comp Affidavit 4. 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 TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4. 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 . TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application 4 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 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 ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature, COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes t . Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Siqnature & Date Driveway Permit DPW Town Engineer: Signature: LOcateo W4 usgooa Street FIREDEP,AR'TMERITTernppumpster on�site:�.,yes,��_ zrst::inoa .``rl'[1.f.'�� i Located of 124iMaintStreet � � ,� • ,, ! !Fi eJDepar�tn ernt���gnatiire/da�tte "r F*1',.'St .'�i '"i S 5A. °S 1;i+y,� ''f J �'`�{ Fi)•' 4 s`f- ! 'K °.i 1i4s r„� ! a'r't tW r;,..t” - �...-�. .���ti COMMENTS. 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 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 Deter 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.$10041000 fine NOTES and DATA — (For department use ❑ Notified for pickup Call Email Date Time Contact Nam Doc.Building Permit Revised 2014 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 ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On COMMENT'S CONSERVATION COMMENTS HEALTH COMMENTS Signature Reviewed on Sionature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located M4 Usgood Street FIRE DEPAR+T�MENT psfer ontsit&.,, yes s � tr ,�,r�:' Ktno "Tj. m i LocatetlJaf t124MaintStreet• +;^!; t l,'4 `� _, . �� ..� �'� �'`�� r, ..,s�� +'K�, _.�„ e R .t,� ,,.,r�;•�'�. rw'r: qtr - - -__,.._...�.... ..._ -. > COMMENTS', BUILDING PERMIT ""OWN OF NORTH ANDOVER 3� APPLICATION FOR PLAN EXAMINATION ~ ° coc Permit No#: Date Received ��SsgcHus���y Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:_ Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 Addition ❑ Alteration ❑ One family ❑ Two or more family No. of units: ❑Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other ❑ Others: Septics 0 Well - n m 0 Water/Sewer _ _ Flood 1pin. _ ❑Wetlands: ❑ _Watershed Distract _ - DESCRIPTION OF WUKK I U tSt rtKrUrUvitu: Identification - Please Type or Print Clearly OWNER: Name: Phone: FAW6,0 Contractor Name: Phone: Email: Address: Supervisor's Construction License: Home Improvement License: ARCHITECT/ENGINEER Address: Exp. Date: Exp. Date: Phone: Reg. No._ FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ EE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th; �gu0anty fund i- 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 OTEp 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 IOTE: 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 I ECC Energy code Engineering Affidavits for Engineered products TE: 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 t et this recorded at the Registry of Deedshe Town Clerks ofice must stamp the .sion from the Board of Onecopy and proof of recording peals that the appeal period is over. The applicant mu g must be submitted with the building application Doc: Building Permit Revised 2014 Location 451 14. - No. _ 120 r f Check # r n � TOWN OF NORTH ANDOVER Q. Certificate of Occupancy $ tet. Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ ` TOTAL $ Building Inspector Q 2 LL O m -C u O O LL E �; N U L]. N N 0 W tail Z Z = > m c O F "p 7 O LL L 7 O d' T ai C E .0 U LL O W ta/f Z Z > O. O CC C LL O W tai) Z V H v w O D' L. N - iz 0 u w Z Q C7 � w - C LL W a w w m O L m p O 41 N N Y N Q1 vi o cts +=' 0 � o W M D c 0 U s E� z O Z O O Z � "QO O tm � O** 3: N J pz,�• a a d i y N -a �. •� O -0 > Qto � 0 X0 o z Ccm L U) a) o �, a> > o L CD m 0 ea �- •N CD c an 40 = m (D m = o ~ 0 vsCL m N m N t W 0'p O 0 LL •y Qy O O m -� t _ z w E -a O V a) O as Q •> NL- = 0 J f/1m cc .� O = 0 O v :w CLZ z 0 CO) O� Cfl 0 Z V CO a Z w0 U) Li W LLJ -i CL Z 2 E ,o Z O N �O � Q •E m m ams O �+ 0 0 O CL a CL a� Q O _ J �vCL O CD C Z CD O V CL CL _) {� RISE Engineering RISE� A division of Thielach Engineering ENGINEERING 60 Shawmat Unit 82, Canton, MA 02021 339-502-6335 FAX 339-50244 CUSTOM Mary Kilcoyne SERVICE araEET 431 Johnson Street smmcE pTY, STATE, W North Andover, MA 01845 PROGRAM CMA -HES FRONS (978)686-3010 Rn I G STREET 431 Johnson Street Federal ID # 05.8406629 RI Contractor Registratlon No 8186 MA Contractor Regiatroon No 120979 CONTRACT Page 1 THIS CONTRACT IS ENTERED INTO BETWEEN RWE EROS AND TRE CUSTOMER FOR WORK AS DESCRIBED HELOW DATE CUENT / WORK ORDER 11/17/2015 416921 00002 6W [Mr. CnY,BTTAMM North Andover, MA 01845 JOB DESCRIPTION AIR SEALING: Provide labor and materials to seal areas of your home against wasteful, excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a beatthfid level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. Primary areas for searing include air leakage to attics, basements, attached garages and other unheated areas (windows are not generally addressed.) Ibis will require (8) working hours. A reduction in cubic feet per minute (cftn) of air infiltration will occur, but the actual number of oft is not guaranteed. At the completion of the weatherirstion work, and at no additional cost to the homeowner, a final blower door and/or combustion safety analysis will be conducted by the sub -contractor to ensure the safety of the indoor air quality. $680.00 AIR SEALING ADDER (2) working hours. $170.00 DAMMING: Provide labor and materials to install a 12" layer of R-38 unfaced fiberglass batts to (50) square feet for damming purposes- $102.50 ATTIC FLAT: Provide labor and materials to install an 8" layer of R-28 Class 1 Cellulose added to (1216) square feet of open attic space.KEEP DESIGNATED 12X12 FLOORI •-� $1,665.92 ATTIC ACCESS: Provide labor and materials to insulate the back of (1) attic hatch with 2" rigid Themtax board. Weatherstrip the perimeter. $60.00 VENTILATION: Provide labor and materials to install ventilation chutes in (40) rafter bays to maintain air Sow. $80.00 RISE Engineering will apply all applicable, eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures, Columbia Gas offers 75% incentive, not to exceed $2,000 per calendar year, and an incentive of 100% for the Air Sealing measures up to the first $680 and an additional $340 if savings are justified by the auditor. For the safety and health of your home's indoor air quality, we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun, and after the weathnization work is complete. Wt.will, also conduct a full assessment of the combustion safety of your heating system and water heater. This has a value of $90 and is at no cast to you Total allowable weathetization incentive is $3,110. $90.00 2Q15 JOB DESCRIPTION Total: $2,848.42 Program Incentive: $2,371.32 Customer Total: $477.11 WE AGREE HEREBY TO FURNISH 8ERVICES - COMPLETE IN ACCORDANCE WITH ABOVE SPECOMMON& FOR THE SUNT OF ***Four Hundred Seventy -Seven 8111100 Dollars $477.11 ON ANY UNPAID BAtANCEAFTER r8 DAYB. SEE�RE POR 2WORTAHrr MMMT= ON GUARANTr£9, MGOMER AGREES TO MW �= MOF FaMOH, SCIIEMUND, AND CONTRACTOR REOWTRAY TM DO NOT SIGN THE CONTRACT IF THERE ARE ANY BLANK SPACES AUTItORQTcDBt -RiSH ""'� NOTE TIES CONTRACT MAYBE WRF@RAWN BY US IF NOT EXECUTED VA" DATE OF ACCEF[ANCE ACCEPTANCE OF CONTRACT -THE ABOVE MMS,SPECIRCATION8 AND CONDRIONS ARE SATIBPACTORY TO =ARE ARE HER�11 AOLFPIED. YOU ARE AUTHORR�ED TO 00 THE WORN DAYB. ASSPECDTED. PAYMENTVDILBEMADEAS OUTIJNEDABOVE ` W.s RISE Engineering Federal In # 054405828 Rl Contractor Registration No 8186 120878 RISE A division of 1Lielsc6 Engineering NIA Contractor RegtsfraHon No ENGINEERING 60ShawmBtUnit #2,Canton, MA=21 CONTRACT ! 339542.6335 FAX 339-502-634S Page 2 PROGRAM nes COTA3FroOW01:AWS3 gSiGAND DT>3CR18W Ba.OW CUSTOMIX Mary Kilcoyne PHONE (978)686-3010 DATE CUENTO WORKOROER 11/17/2015 416921 00002 SERVICE STREET 02MG STREET 431 Johnson Street 431 Johnson Street ZlPer,dover, �=BTAm MA 01845 North Andover, MA 01845 JOB DESCRIPTION Total: $2,848.42 Program Incentive: $2,371.32 Customer Total: $477.11 WE AGREE HEREBY TO FURNISH 8ERVICES - COMPLETE IN ACCORDANCE WITH ABOVE SPECOMMON& FOR THE SUNT OF ***Four Hundred Seventy -Seven 8111100 Dollars $477.11 ON ANY UNPAID BAtANCEAFTER r8 DAYB. SEE�RE POR 2WORTAHrr MMMT= ON GUARANTr£9, MGOMER AGREES TO MW �= MOF FaMOH, SCIIEMUND, AND CONTRACTOR REOWTRAY TM DO NOT SIGN THE CONTRACT IF THERE ARE ANY BLANK SPACES AUTItORQTcDBt -RiSH ""'� NOTE TIES CONTRACT MAYBE WRF@RAWN BY US IF NOT EXECUTED VA" DATE OF ACCEF[ANCE ACCEPTANCE OF CONTRACT -THE ABOVE MMS,SPECIRCATION8 AND CONDRIONS ARE SATIBPACTORY TO =ARE ARE HER�11 AOLFPIED. YOU ARE AUTHORR�ED TO 00 THE WORN DAYB. ASSPECDTED. PAYMENTVDILBEMADEAS OUTIJNEDABOVE The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 '%w www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Builders Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd Nashua NH 03063 Phone #: 603-578-9275 Are you an employer? Check the appropriate box: ❑ l ✓❑ 1 aa employer with 100 4. I am a general contractor and I . m employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] } have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance., 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ✓❑ Other Insulation *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors 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 -contractors have employees, they must provide their workers' 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: Indemnity Insurance Co of North America Policy # or Self -ins. Lic. #.�,Q0- �-"� ���5�_Z, Expiration Date: 6/30/2014o Job Site Address: H3( tm1 City/State/Zip: &I-0.er �I!$`t� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the gains and penalties of perjury that the information provided above is true and correct nate : Ic27 603-324-1974 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1, Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: �1 ® ACRD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) I 06rz4/2016 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 Aon Risk Services Central, Inc. Southfield MI office CONTACT NAME: PHONE (g66) 283 7122 FAX (800) 363-0105 (A/C.No.Ext): (AIC_ No.): E-MAIL ADDRESS: 3000 Town Center Suite 3000 Southfield MI 48075 USA MWZY3048 4 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A Old Republic Insurance Company 24147 TODBUild COrD. 260 Jimmy Ann Drive Daytona Beach FL 32114 USA INSURER B: ACE American insurance Company 22667 INSURER C: ACE Fire Underwriters Insurance Co. 20702 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570058348882 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. Limits shown are as requested LTR TYPE OF INSURANCE INSD VIVO POLICY NUMBERD/YYYY MNID MMIDO/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY3048 4 EACH OCCURRENCE S2,000,000 CLAIMS -MADE ❑X OCCUR DAMAGETo RENTED $2,000,000 PREMISES Ea occurrence MED EXP (Any one person) $25,000 PERSONAL &ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 X POLICY ❑ PET ❑ LOC PRODUCTS - COMP/OP AGG $4,000,000 OTHER: A AUTOMOBILE LIABILITY MWTB 304835 06/30/2015 06/30/2016 COMBINED SINGLE LIMIT $5,000,000 Ea accident BODILY INJURY ( Per person) X ANY AUTO BODILY INJURY (Per accident) ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE X HIREDAUTOS X Per accident AUTOS F1AUTOS UMBRELLA UABOCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAR CLAIMS -MADE DED RETENTION B WORKERS COMPENSATION AND WL1108151553 06/30/2015 06/30/2016X PER OTH- STATUTE ER EMPLOYERS' LIABILITY YIN All Other States E.L. EACH ACCIDENT $1,000,000 C ANY PROPRIETOR f PARTNER I EXECUTIVE SCFC4815190 06/30/2015 06/30/2016 OFFICER/MEMBEREXCLUDED7 (Mandatory in NH) N/A WI Only E.L. DISEASE -EA EMPLOYEE S1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Coverage CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Builder Services Group, Inc. AUTHORIZED REPRESENTATIVE A TopBuild Company 260 Jimmy Ann Drive Daytona Beach FL 32114 USA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ffi -of Consumer rner Altai s`&d�Business Regulation 10 Park Plaza - Suite 51170 Boston', Massachusetts 02116 Home Improvement Contractor Registration BUILDER SERVICES GROUP, INC. RICHARD SCHWARTZ 110 PERIMETER RD NASHUA, NH 030633 Office of Consumer Affairs & Business Regulation t; i]tdiE IMPROVEMENT CONTRACTOR %'-Registration: 179141 Type Expiration: 61225/20116 Supplement --ard JILDER SERVICES GROUP; !NC. CHAR[) SCH,A'ARTZ 0 jIMIAY ANN DRIVE 1 .YTONA BE CH. F1 X211 Under%tcrzt?ry Registration: 179141 . Type: Supplement Card Expiration 6!2 512 0 16 t',)dat,, Address and return card. Mark reason for change. A dd r tsti Re w-" a I Employ merit Lost Card License or reg'!stration valid for individul use onl% before the expiration date. if found return to: Of%ce of ('onsurner Affairs and Business Regulation ?Gr!' P!nzz- - Suite 51 10 Boston. MA 02 116 Not vafi--��vjjhout si7 gr2ture p •