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Home My WebLink AboutBuilding Permit #1209-16 - 45 BEECHWOOD DRIVE 5/18/2016 A*[Y =' yORT►y q BUILDING PERMIT t ``o.' TOWN OF NORTH ANDOVER ° ; o O �/6 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received �s A V Date Issued: / �� 4SSgCHUS��9 PORTANT: Applicant must complete all items on this page i LOCATION � PROPERTY OWNER ` LU ` t/ Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Xwo e family F1 Addition or more family u Industrial ❑Alteration No. of units: Lil Commercial U Repair, replacement -J Assessory Bldg U Others: U Demolition _ 1 Other_ L. Septic U Well -j Floodplain U Wetlands U Watershed District Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: ��P �/ /(�Or��Y�� Phone(9a7g) 77 Address: CONTRACTOR Name: Phone: 07f q ,3 42, wrist tint )I t S 0 C-r:n S SLA: &aj Address: Z ,IL04 Af W AQ� h d(/6) ,W4 Supervisor's Construction Licen e: Exp. Date: Home Improvement License: J/ % O Exp. Date: la / a ep ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �3,d00 FEE: $ 300 Check No.: 2 56 Receipt No.: 1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner tature of contractor F i ' i BUILDING PERMIT o`H°RT 6'�ti TOWN OF NORTH ANDOVER 32 y�'.''' "'16 o � s ti APPLICATION FOR PLAN EXAM[NAT IO'R`:::: ~,« . h Permit No##: Date Received: pDRA7ED .F�`y�5 gSSACHUS�t Date Issued: IMPORTANT: Applicant must complete all item'&`an th s page LOCATION Print PROPERTY OWNER Print 100 Year'StrueWre 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 ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El,Septic. ❑ Well ❑ Floodplain Wetlands ❑ Watershgd District Q.Water!Sewer 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: ARCHITECT/ENGINEER Phone: Address: Reg..N.o. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSIE QN4125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt N6-..,'- NOTE: a-.NOTE: Persons contracting witli unregistered contractors do not ham access�to the guaranty fund Location �.�. ` �' r- /j et- No. c No. t �i—.�1. Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ f Check# .l f • Building Inspector i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art El ✓ g 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 . i COMMENTS HEALTH Reviewed on Signature COMMENTS C, Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments �. 'Conservation Decision: Comments Water& Sewer Connectionlsi nafure& IDate Driveway Permit DPW Town Engineer: Signature.. FIREDEP -- Located 384 Osgood Street r ARTMEfVT TempDumpsfer ontslte tyes�. �no� Locatedaf r124tMainxStreet �! `FiiefDepartmentsegnature/date,_ r_ �F z COMMENTS, i Dimension I Number of Stories: Total square feet of floor area, base I.: Bterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Deter location, avast or service drop-Mquires 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 f ' , Date Time Contact Name _ Doc.Building Permit Revised 2014 -, Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 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 i 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 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 Iva Commonwealth of Massachusetts m�cocial use only Department of Fire Services Perlo� _6-W2 � BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 07/13/05 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 45 Beechwood Drive Owner or Tenant. L-Com Telephone No. 800-343-1455 Owner's Address Same Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Manufacturing Utility Authorization No. Existing Service Amps Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o the ollowin table may be waived by the Inspector of Wires. No. of Recessed Fixtures 4 No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets 8 No. of Hot Tubs Generators KVA No. of Lighting Fixtures 2 Swimming Pool Above ❑ n- ❑ o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 2 No.of Gas Burners of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g " No.of Waste Disposers """""" Heat Pump Number Tons KW No.of Self-Contained Totals: ..' """ ""..... .. ' Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other yConnection • No.of Dryers Heating Appliances KW ec Aof Devnces or Equivalent No. o Water o.o o.o Heaters KW Data Wiring: 2 Signs Ballasts No.of Devices or Equivalent J No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 2 No.of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: ASAP Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the infor "on on thi application " tru and complete- FIRM NAME: Hammond Electric,Inc. LIC.NO.: 11011A Licensee: Paul J.Hammond Signature O:: 25730E (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.; 978-373-9979 Address: 60 Railroad Street Haverhill,MA 01835 Alt. Tel.No.: 978-210-1900 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑owner's agent. Owner/Agent PERMIT FEE. $ g0 f 07re13/2005 13: 52 976-521-5127 COSTELLO INS. PAGE 01/01 �r DATE(MWDOIYYYV I A RD,, CERTIFICATE OF LIABILITY INSURANCE OASAMATTEROFtNF R1N31/200 I PRODUCER (978)374-63S2 FAX (97a)521-5127 THIS CERTIFICATE IS ISSN I COSTELi.O INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE i HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2 South Kimball St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW- PO Sox 5248 Bradford, MA 01835 INSURERS AFFORDING COVERAGE NAtC# INSUREDHammond Electric, Inc. INSURERA; Arbella Protection INSURER B; 60 Railroad St. INSURER C; Haverhill , MA 01835 INSURER D; INSURER E: COVFRAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOYt:FOR THE POLICY PERIOD INDICATED.NOTWiTHSTANUING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE IS'S'UED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HER"IN IS SU8JECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUAAIBER POLICYQATF SFFECTI'JE POLICY EXPIRATION LVAITS GENERAL LIABILITY $500014796 10/0$/2004 10/0$/2005 EACI•I C7GCURR(IdCC• S 10p0,000 COMMERCIALGENEI;ALLIABiLIT( DAMAGE TO RENTED w s 50,000 :LAIMS MADE OCCUR MED EXP Any one-,Persor) S 51000 A PERSONAL&ADv wlVRY s 11000,000 GENERAL AGGREGATE S 21000 000 GENT AGGREGATE LIMIT APPLIES PER; PRODUCT:•COMP/OP AGG S 2,000'.9 0 POLICY 4V LOC AUTDrnOaILELIABILITY. 50600400001110/()8/2004 110/08/2005 COM31NEDSiNGLELIMIT � ANY AUTO (Ea occideiit) 500,000 ALL OWNEDAUT05 BODILY INJURY (Perpewon) a0,000 X SCI•{EDULED AUTOS �( HIRED AUTOS 5COILY INJURY X NOW.OtVNEDAUT05 (PerscC*nl) 100,000 PROPERTY DAMAGE S — (Per xmem) t;ARAGE LIA3D.I7Y AUTO ONLY-EA aC ZAAC' S pANY AUTO OTHER THAN �'ACC S� —tl I AUTO ONLY: .AEG S I CXCESVU"RELLA[-LABILITY 4600014797 10/08/2004 10/08/2005 EACH OCCURRENCE s 5,000,0u0 OCCUR CLAIMS MAGE AGGREGATE A - s 5,000,00 DEL)OCTIELC -- RETENTICI; - WORKERS COMPENSATION AND 0044860603 06/04/2005 06/04/2006 WClT,i., DTH• EMPLOYERS'LIABILITY E,'..EACH ACCIOckT 8 500,000 A ANY RROPRIETOR;FARTNERIEXECUTIVE OFFICEPIMEMBLR EAGLUOED? i LL.DISEASE-EA,EMPLCYE 5 500,000 If Yea.de3cribe under SPECIAL PRCOVISION5 bNOly 151.DISEASE-POLICY-LI IT 5 500,000 OTHER E DESCRIPTION 10F OPERATIONS/LOCATIONS 1 VEHICLF9 I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS C TIFICATE.dOLDER CANCELLATION —s SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERrOF,THE ISSUING INSUNFR WILLENDEAVCR TO MAIL 30 DAYS WRITTEN NOTICE 70 THE CERTIFICATE MOLDER NAMED TO THE DEFT. Town of North Andover Att: Electrical Inspector BUT FAILURE TOMAwLSUCH NOTIGESHALLIMPOSE N008LIGAIIONORLIABILITY 27 Charl eS St OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. N. Andover, MA AUTHORLZEDREPRESENTATIVE William Costello ACCIRD 25(2001/08) FAX: (978)521-9972 (DACORD CORPORATION 1988 r 1 NORTH _ A. : ver O 4 �ti• M ry a h ver Mass S /� 6 o Ka _ COCMICM[WICK y1' �i9SORATED ►.P�,�'�� Ll BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..... .-.7.L.I...C... .s....;...........................n..................... EF BUILDING INSPECTOR _- G�a, /..,�U v� Foundation has permission to erect .......................... buildings on .......................... Rough to be occupied as .............S .-. ... . ..l:ao.�................................... Chimney y provided that the person accepting this 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 s VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ?! Service ................. ..... . . .... ... :�..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT } Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. ;Ila / V GEORGOULIS ROOFING & CONSTRUCTION, INC. 96 Arlington Ave. Dracut,MA 01826 AI Greene—Director of Field Operations I-9784534242 Office 1-978-888-1700 Cell georgoulisi4l aol.com CONTRACT Beechwood Properties 05/05/16 Attn:Bud Hart 40-60 Beechwood Dr. N.Andover,MA 1.-978-697-6977 pbhwjh@gmail.com Job Location:40-60 Beechwood Dr.N.Andover,MA Scope of Work: Remove all layers of shingled roofing down to wood deck on entire second building roofs,protecting the grounds, landscaping,and buildings body with heavy duty tarps as stripping is being done.Re-nail plywood decking as needed. Install GAF StormGuard ice/water shield on entire roof deck surfaces,full coverage. Install 8".025 gauge heavy duty aluminum drip edge on entire roof perimeters. Install GAF ProStart starter strips across all eaves and up all takes. Install GAF Timberline HD Lifetime Architectural shingles and Timbertex hip/ridge caps on roof. Install new Coravent V-600 ridge vent on all main ridges. Install new stack pipe boots on existing plumbing pipes. Replace all existing bath box vents with new Broan bathroom box vents. Thoroughly clean and magnet grounds and remove all job related debris from property on a daily basis and at jobs completion. $55.00 Per Sheet Extra Cost to replace any rotted or damaged plywood decking(if needed). Entire job includes GAF Systems Plus Warranty. First 40 yrs.Is non-prorated,full labor and material coverage from CAF,against any material or installation defect cause,and is transferrable one time. WE PROPOSE hereby to furnish material and labor complete in accordance with above specifications, for the sum of. 000.00 Cud{ A2$� ' s�IG�tG Twenty Five Thousand Dollars $25,000.00 PAYMENT TO BE MADE AS F01.I.OWS: $8.000.00 PAID IN ADVANCE TOWARD MATERIAL COSTS $17,000.00 BALANCE PAID IN FULL WHEN JOB IS COMPLETELY FINISHED ACCORDING TO THE ABOVE LISTED PROPOSAL All material is guaranteed to be as specified.All work to be completed in a substantial workman like manner according to specifications submitted per standard practices.Any alteration or deviation from above specifications involving c o extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control.Owner t carryfire tornado and other 6 OLS necessary insurance.Our workers are fully covered by workers compensation insuran . Georgoulis Authorized Signature. This proposal may be withdrawn by us if not accepted with' 0 days. Acceptance of Proposal-The above prices,specifications are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signa � --- Signature Date of acceptanc _13 �1 4 The following is part of this contract: Contractor Registration All home improvement contractors must be registered with the Commonwealth of Massachusetts. Contractor Registration#117870 and Construction Supervisor License#058498.Inquires about registration should be made to: Director,Home Improvement Contractor Registration, One Ashburton Place,Room 1301,Boston,MA 02108(617)727-8598. Better Business Bureau,Inc. Georgoulis Construction,Inc.member IN 35522. Contact the Better Business Bureau (508)652-4888 or at memberservices .bosbbb.org. General All outside work areas will be left rake clean.Roofing may result in dust or debris falling into the attic. This contract does not include clean up or protection of the contents in the attic.In the event a satellite dish should have to be removed to complete project,Georgoulis Construction,Inc.will not be responsible for repositioning after re-installation, should it be necessary.In addition,the Roofing contractor will not be liable for any damage,whether incidental or accidental,that may occur to any A/C, electrical or plumbing equipment that is installed or located in a place that interferes with the roofing or re-roofing process within normal standards&practices of a typical and reasonable roofing or re-roofing installation. Payments The maximum down payment or advanced deposit allowed by Massachusetts law is limited to whichever is larger: (A)One third of the total contract or(B)the entire cost of any special order materials.Final payment is required within 15-days of the invoice date or a late fee charge in the amount of five(5) percent of the said payment shall be assessed for every 30-day period for said payment outstanding. If non-payment becomes a legal matter,the Homeowner will be responsible for all legal fees incurred by both parties.All Credit Card Sales over$1,000.00 are Subject to a 2.0% Convenience Fee. Work Schedule The owner agrees the scheduling date is approximate.The contractor agrees to show good faith in meeting deadlines,but are not responsible for delays caused by weather. Suppliers, subcontractors, building officials.asbestos abatement,hidden damages or conditions, accidents,acts of God or anything beyond our control. Chansze Orders The owner is aware that the work may contain hidden damage, defects,or conditions such as decay,insect damage,or substandard construction practices,that may require additional work not included in this contract.In this case, Georgoulis Construction,Inc. will contact the owner and agree on an additional charge to the original contract price. In the event the owner can not be contacted, and it is crucial that work continue to protect the residence from the elements,(rain,snow,ect.)photographs will be taken to document the necessity of the additional work. The owner understands that any additional work will delay the completion of the project. Warranty The contractor, Georgoulis Construction,Inc. agrees to correct any work that fails to conform to the contract or workmanship that is defective within TEN(10)years from the substantial completion date of the project at NO CHARGE to the homeowner. The homeowner agrees to notify Georgoulis Construction,Inc. specifying the nature of any workmanship defect, immediately.No warranty is provided for ordinary wear and tear,fading, abuse,neglect or casualty, or minor cracking/shrinking of concrete or caulking.No warranty is provided for materials not directly supplied by Georgoulis Construction,Inc. or for used,re-installed materials,(including skylights not installed by Georgoulis Construction Inc)or work done by others.This warranty excluded consequential and incidental damages. Contract Acceptance Upon acceptance of the authorized parties at Georgoulis Construction,Inc.this contract and all work described herein will constitute the entire agreement between Georgoulis Construction,Inc. and the Homeowner. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 t Boston,MA 02114-2017 www.mass.gov/dia «'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization/Individual):Georgoulis Construction, Inc. Address:96 Arlington Av City/State/Zip:Dracut, MA Phone#:9784534242 Are you an employer?Check the appropriate box: Type Of project(required): 1.❑✓ I am a employer with 10 employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in ❑ 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.M I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.F1 Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :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:Admiral Insurance Company Policy#or Self-ins.Lic.#:WC009774283 Expiration Date:9/25/16 Job Site Address:40-60 Beechwood Driv City/State/Zip:N. Andover, MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and the p 'ns ndpenaltie ofperjury that the information provided above is true and correct. I Si nature: 1 Date: Phone#: y 7F `� 39Z2.12 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#: AC40Rn• CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDI Yrri 03/11/2016 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone; (978)263.3500 Fax (978)263-1438TACT Gallant Insurance Agency,Inc. GALLANT INSURANCE AGENCY,INC. P"«'N, (978)263-3500 (978)263-1438 199 GREAT ROAD/P O BOX 975 E-MAIL ACTON MA 01720 ADDRESS: PRODUCER TOM ID 36702 CUS INSURER(S)AFFORDING COVERAGE NAIC If INSURED GEORGOULIS CONSTRUCTION INC. INSURER A : James River Insurance Company C/O SCOTT GEORGOULIS INSURER a : Chartis Insurance Company 96 ARLINGTON AVENUE INSURER DRACUT MA 01826 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 48658 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, ONDITIONS OF St VIITS SHOWN Y HAVE BEEN R LICED BY PAID QLAIMS. INSR TYPE OF INSURANCE ADD'L SUBR POLICY EFF POLICY EXP TR INSR WVD POLICY NUMBER NYYM LIMITS A GENERAL LIABILITY 00070670003105/16 03/05/17 EACH OCCURRENCE $ 1 r000r000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS MADE I�OCCUR .-PREMISES a occurence $ 100,000 MED.EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ i RETENTION $ $ B WORKERS COMPENSATIONWC009774283 09/25/15 08/25N6 X vYCSTATU DTH AND EMPLOYERS' LIABILITY _ YIN I S I ANY PROPRIETORIPARTNER/EXECUTWE E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? N/A If an atony in w Ser - E. L.DISEASE-EA EMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace Ia required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. i AUTHORIZED REPRESENTATIVE Attention: ACORD 25(2009/09) N�arra 198 - A CORPORATION. rightsreserved. The ACORD name and logo are registered marks of ACORD 7Xe, Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 117870 Type: Private Corporation Expiration: 12/12/2016 Tr# 260054 GEORGOULIS CONSTRUCTION, INC. SCOTT GEORGOULIS 96 ARLINGTON AVE DRACUT, MA 01826 Update Address and return card.Mark reason for change. J' [ Address ; Renewal : Employment j Lost Card scAt G 2orn-05111 r'��fr`f Cmn2,n�a!«�irl1�t��'G(17.:su�✓rrl�'rlts fli ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: gistration: 117870 Type: Office of Consumer Affairs and Business Regulation _ piration: 12/12/2016 Private Corporatior. XO Park Plaza-Suite 5170 Boston,MA 12116 GEORGOULIS CONSTRUCTION,INC. 1 SCOTT GEORGOULIS 96 ARLINGTON AVE DRACUT,MA 01826 Undersecretary Not valid without signature Massachusetts Department of Public Safety Board of Building Regulations and Standards I:SE11010-6955849 License:CS-058498 UCSanDiego Extension Agg, Construction Supervisor n INTERNATIONALSAFEN EDUCATION INSITIUM(ISEC � i• *-"' SCOTT C GEORG.OULIS's.. � This card certifies that: i 96 ARLINGTON AVE,t�UE�',� SCOTT GEORGOULIS DRACUT MA 01826 has completed a 10-Hour OSHA Hazard Recognition Training { .` forthe Construction Industry. 08/23/2013 CA-- Expiration: 10/2112017 Director:Scott MacKay Trainer:TaylorSikes Grad.Date: Commissioner