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Building Permit #318-12 - 45 HIGHLAND VIEW AVENUE 10/13/2011
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: '" Date Received Date ' Issued. IMPORTANT:Applicant must com Tete all items on this age LOCATION _W.9 �-tig��a�� V i a► �. print PROPERTY OWNER Z pSc.e�n Q,rr,nNo Unit# Print MAP NO: 6 _PARCEL: /5 ZONING DISTRICT: Historic District yes n Machine Shop Village ye nom 100 year-old structure ye nom 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 Septic" ®Wellf Flood # ` sc • D Wate � plam ❑ Wetland ® Watershed Dit DESCRIPTION OF WORK TO BE PERFORMED: (Identification Please Type or Print Clearly) &i&-1,v fes-• OWNER: Name: ei9.nlr, K�Q hnzNo Phone cit S•1o.1• b7 $� Address Li �, CONTRACTOR Name: nCXLE" Phone: I ' S'18•gs1• I9 4 Address: Cia C-MI. %.44\e Rhe L Mq Supervisor's Construction License: 0 S 1111 $ Exp. Date: Home Improvement License: talc. I tiA 1 o1 Exp. Date: 3. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ — FEE: $ Check No.: Receipt No.: Cqki NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Cinnnii irW ar'c , X r-,e ° nafiirp n `tray 4 F 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 - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS w HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes � Planning Board Decision: Comments l I Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS - I - `1 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions.__ i I Total land area, sq. ft.: i I ELECTRICAL: Movement of Meter location, mast or service droprequires q approval of Electrical Inspector Yes No I DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine i 1 NOTES and DATA— For department use i I ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 1 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permi Addition or Decks ❑ Building Permit Application u 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 MOTE: 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In all cases if a variance•r 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: Doc.Building Permit Revised 2008mi Location } No. " 12, Date 16 E; ��^TM TOWN OF NORTH ANDOVER Certificate of Occupancy $ �ss,kMUstt�' Building/Frame Permit Fee $ �3 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # A 2701 � Building Inspector L� I NORTH .® . n 0" Of dover . No. 34 V2.0/ap, . 10 dower, Mass., Q LAKE - - COCHICHEWICK AORATE D qS BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..........�T.�� .. ... ..... ..... .. . 1!.. ''...........................................r..................... Foundation has permission to erect........................................ buildings on ......q.7..... . .. 5.�.( c.......l�400............. Rough Chimney L to be occupied as..0 ............... ..:..............�*b.: ............ ►.. .. ... .. •. :.. provided that the person accepting this permit shall in every respect conform to t�e terms of the ap�ilication on file in Final- 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 PENT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS LESS COl V S 1 R V C TARTS Rough ............. .................. .......................... ................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE S U D E Smoke Det. Rackleff Construction Company,, Inc. Builders Carpenters CONSTRUCTION CONTRACT y S" g,r a eA�vb vi ew 4v e, /vow}{ Ao(ojek,M OA�g This contract is made effective as of August 3,2011 by and:between Joe Arrnano("Armano") of 145 Howard Street, Lawrence,Massachusetts 01$41 and Rackieff Construction Company, Inc ("RCC"I of 02 Columbia Park, Haverhill, Massachusetts 01830. Contractor desires to provide construction services to,Owner and owner desires to obtain such services from Contractor. Therefore in consideration of the mutual promises set forth below,the-parties agree as follows: DESCRIPTION S iRV[C Intl:udes labor and materials unless otherwise specified') Permit&Mi;;ellaneous o Apply for and obtain Building.Permit from the Town of North Andover., o 'Pay Building Permit Fee o Provide all floor plans as needed for Town's approval. o Provide all approvals as needed from Town Departments(Assessor,Tax Collector, Fire Department,Board of Health,Water&Sewer Department,etc.) o Provide copy of signedcontract,Home improvement Contractor contract,and work and ipayment schedule to Building Inspector. o Provide for removal of all interior and exterior debris Stone of Work o Re-flash chimney o Repair gutter on rear of house and adjust pitch as needed o Pave 360 square feet of existing dirt driveway o Install 25 replacement windows at current size o Install 2 casement replacements at current size o Install 2 picture window replacements at current size o Remove and replace rotted sills,cover exterior snood with aluminum o Replace pulldown staircase to attic o Replace current existing slider with new o install a new entry door o Install new storm door o Replace existing door between units with a heavy fire:grade door o Remove and replace drywall in kitchen o Remove and close up existing door in kitchen forming a complete and continuous wall o Paint kitchen and bathroom o Touchup paint in bedroorn where water stains are located o Install 370 square feet of new hardwood in bedrooms. o install 250 square feet of Pergo style flooring in bedroom o Install floor in kitchen(Material supplied by owner) o Install floor in bath(Material supplied by owner) o Reconfigure phot water feeds AdmcWedged:Arm _�.kADate cantmet ( Pace [I Rackleff Construction Company, Inc. Builders . Carpenters o install ball valves throughout units o Install new water and waste lines o Install 2 new kitchen sinks and faucets o Install new tub o Install(1)100 amp service o Install(1)200 amp service o Separate electrical service by unit o Provide central air unit(45k RTU)With ducts o Demo 1st floor,cabinets o Move cabinets from knit 2 to unit 1 ,o Install new counter top in unit 2 o fnstall new cabinets and counter in unit 2 o Install bath vanity in unit 2 o Install new appliances COST OF SERVICES The total cost of all services described above will'be$S3,145 ,GUARANTEES Rackleff Construction Company guarantees its work for 1 full year. Materials used in the construction are guaranteed by manufacturers warranty. PAYMENT Payments will be made to Rackleff Construction Company via the HUD 203k Program Draw Request. Cf AMGES ORDER Owner:may snake changes to the scope of the work from time to time during the terra sof this Contract.However,any such change or modification shall only be made by written"Change Order"signed by both parties.Such!Change Orders shall become part of this Contract.owner agrees to pay any increase in the cost of the Construction work as a result of a Change Order.in the event the cost of a Change Order is not known at the time a Change Order is executed,the Contractor shall estimate the cost thereof and Owner shall pay the actual cost whether or not it is in excess of the estimated cast. IM1ISURAN The Contractor shall maintain general liability insurance,,workers compensation insurance and builder's risk insurance for injury to or death of person, injuries or death:suffered in accident and property damage and shall provide owner with proof of such insurance,. CONFIDENTIAUTY Adrnowledged;Armalace Contract Page J2 s Rackleff Construction Company, Inc. Builders w Carpenters RCC,and its employees, agents,or representatives will not at any time or in any manner,either directly or indirectly,use for the,personal benefit of RCC,or divulge, disclo ,or representativesmcate in any manner,any nfcirthAtibn that is proprietary to Armano. RCC and its e�plb`yees,, agents, will protect such information and treat it as,strictly confidential.This provision will continue to be effective after the termination of this Contract,. Upon termination of this Contract,RCC wriil return to Armano iall records,notes,documentation anid ether items that were used,created,or controlled by RCC during the terra of this Contract, INDEl11INlEICATION RCC agrees to indemnify and hold Armano'harm'less from all claims,losses, expenses,fees including attorney fees,costs,and judgments that may be asserted against Armano that result from the acts or omissions of RCC and,/or RCC's employees,a ants or representatives. WARRANT RCC shall provide its services and meet its obligations under this Contract in a timely and workmanlike manner, using knowledge and recommendations for performing the services which meet generally acceptable standards in RCC's community and region,and will provide a standard of care equal to,or superior to,care.used by service providers similar to RCC on similar projects.Contractor shall construct the structure in conformance with the;plans, specifications,and any breakdown and binder receipt signed by Contractor and Owner. DEFAULT The occurrence of any of the following she'll constitute a material default under this j Contract: a.The failure to make a required payment when due. b.The insolvency or bankruptcy of either party.. c.The subjection of any of either party's;property to any levy,seizure,general assignment for the benefit of creditors,application or sale for or by any creditor or government agency. d.The failure to make available or deliver the Services in the time and manner.provided for in this Contract. REM In addition to any and all other rights a party may have avail'ab'le according to law, if a party defaults by failing to substantially perform any provision,term or condition of this Contract(including without limitation the failure to make a monetary payment when due),the other party may terminate the Contract by providing written notice to the defaulting party.This notice shall describe with sufficient detail the nature of the default.The party receiving such notice shall have thirty days from,the effective date of such h6tice to crura the default(s). Unless waived by a party providing notice,the failure to cure the defaults)within such time period shall result in the automatic terrmination of this Contract. FORCE iVlA JEURE AvtmOwledged:Atrmart ytGG +�. ane contratt Rage 13 Reckleff Construction Company, Inc. Builders Carpenters If performance of this Contract or any obligation under this Contract is prevented,restricted,or interfered with by causes beyond either party's reasonable control("Force Majeure"),and if the party unable to carry out its obligations gives the other party prompt written notice of such event,then the obligations of the party invoking. this provision shall be suspended to the extent necessary by such event,The terra Force Majeure shall include, without limitation,acts of God,fire,explosion,vandalism,storm or other similar occurrence,orders or acts of military or civil authority,or by national emergencies,insurrections,riots,or wars,or strikes,lack-outs,work stoppages,or supplier failures.The excused party shall'use reasonable efforts under the circumstances to avoid or remiove such causes of non-performance and shall proceed to perforin with reasonable dispatch whenever such causes are removed or ceased.An act or omission shall be deemed within the reasonable control of a party if committed,omitted,or caused by such party,or its employees,officers,agents,or affiliates. ARBITRATION Any controversies or disputes arising out of or relating to this Contract shall be resolved by binding arbitration in accordance with the then-current Commercial Arbitration Rules of the American.Arbitration Association.The,parties shall select a mutually acceptable arbitrator knowledgeable about issues relating to the subject matter of this Contract.In the event the parties are unable to agree to Such a selection,each party will select an arbitrator and the two arbitrators in turn shall select a third arbitrator,all three of whom shall preside jointly over the matter.The arbitration shall take place at a location that is reasonably centrally located between the parties,or otherwise mutually agreed upon by the parties.All documents,materials,and information in the possession of each party that are in any way relevant to the dispute shall be made available to the other party for review and copyiin,g no later than 30 days after the notice of arbitration is served. The arbitrator(s)shall not have the authority to.modify any provision of this Contract or to award punitive damages.The arbitrator(s)shall have the power to issue mandatory orders and restraint orders in connection with the arbitration.The decision rendered by the arbitrator($)shall be final and binding on the parties,and judgment may be entered inconformity with the decision in.any court having jurisdiction.The contract to arbitration shall be specifically enforceable under the prevailing arbitration law.wring the continuance of any arbitration proceeding,the parties shall continue to perform their respective obligations under this Contract. ENTBRE CONTRACt This Contract contains the entire contract of the artier and there are no other r rni rconditions R , o res o . in any y other contract whether oral or written concerning the subject.matter of this Contract.This Contract supersedes any prior written or oral agreements between the parties.. SEHERABIUT'M :If any provision of this Contract will be held to be invalid or unenforceable for any reason„the remaining provisions will continue to be valid and:enforceable. if a court finds that any provision of this Contract is invalid or unenforceable, but that by lim'it:ing,such provision it would become valid and enforceable,then such provision will be deemed to be written,construed,and enforced as so limited. ,A MY ENDMENT Acknewtedged:Annan cc-�-„ Gaffe! �*5 ^ sl+�1 1 contract Vogt 14 0 a Rackleff Construction Company, Inc. Builders - Carpenters This Contract may be modified or amended in writing,if the writing is signed by the party obligated under the amendment. GOVERNI'hlG'LAiVhI' This Contract shall be construed in accordance with the lags of the State of Massachusetts. NO-TICE Any notice or communication required or permitted under this Contract shall be suffiiclently given if delivered in person or by certified mail,return receipt requested,to the address set forth in the opening paragraph or to such other address as one party may have furnished to the other in writing. Ackr►ovatedged:An-napo /2&-RCCLL&Date5� c_] �ontraet '�a g t I Rackleff Construction Company, Inc. Builders - Carpenters ACCEPTANCE oL CONTRACT Proiect will begin September 1,2011 but not prior to the issuance of a building permit from the Town of North Andover= Completion of the.project is projected for October 31,20111ending any significant weather or inspectional delays. Project updates will be provided.on Friday of every week.tDate of completion for the project will be adjusted per.any adjustment to the obtaining of proper permits. Any additional work required by the building inspector and/or Town of North Andover inspectors to'bring existing conditions to current code that are not included in the outlined contract will be completed via an agreed upon change order by'both parties.Contractor and homeowner agree that existing conditions are to be described as all other areas of home and site that do not encompass construction of the proposed addition and/or remodel.Any additional work. required by North Reading Town inspectors in direct correlation with proposed home addition and/or remodel'Willbe addressed for and paid for by the contractor. All conditions acknowledged in this proposal by both Joe A.rrnano and Rackleff Construction Company have been initialed as satisfactory and hereby accepted, Date: Joe Armano Gary'E. Rackleff(President) 1:45 Howard Street Rackleff Construction Company,Inc. Lawrence,Ih+fA 01841 92 Columbia Park Haverhill,CLIA 01830 Building License#72778 HIC#142107 I I AcknoMedVd:Arrnar` �—'"„c 1�E i'. Date s -S des t contract Page 16 - Office of Consumer Affairs and usiness Regulation _ 10 Park Plaza- Suite 5170 !T( ,. � 1, ; , � ,•t ( 2, 11 6 ,LJ�St lJ i7s 1� tt�Sill,l�i�_)tl J V.._, -. 1_xovement.Cont actorRegistration Registration: 142107 Type: Individual Expiration. 3/15/2012 Tr# 293714 RACKLEFF CONST. CO. CHRISTOPHER RACKLEFF P.O. BOX 567 HAVERHILL, MA 01831 Update Address and return card.Mark reason for change. Address 17 Renewal Employment Lost Card )PS•CA1 0 50M-04104-6101216 �>/ie ..._ License or registration valid for indieidul use only � = before the expiration date. If found return to: T ` HOME IMP JeN_f1 CONTi2 a� ,OR Office of Consumer Affairs and Business Regulation Registration j42107 10 Park Plaza-Suite 5170 g Expiration:.:=311512012 Tr# 293714 Boston,MA0211b Type: ;;;`individual-: RACKLEFF CONST-.`.'CO. RISTOPHER RACKLEFF 45 LOCUST STREET HAVERHILL,MA 01830 Undersecretary Not valid without signature i i I ' i I I t }tans chusettN' Department of Public$afcv- i Bo tr d of Building Regulations and Standards E >orrls ructiorcane -visor License License: CS 72778 ' Restricted to: 00 CHRISTOPHER G RACKLEFFA, ff J, t 45 LOCUST ST#717 f HAVERHILL, MA 01830 { 's Expiration: 319/2012 ('.nnmi>xionrr Tr.`:. 20734 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leg><bly Name(Business/Organization/Individual): Address_9 Cc�,W,M b'A �at2,1 City/State/Zip: N A LQ10; M A 6191,1a Phone#: Q"1 '$5w.\ 11 q y FP an employer?Check the appropriate box: _ Type of project(required): m a employer with 4, 4. ❑ I am a general contractor and I ployees(full and/or part-time). have hired the sub-contractors 6, ❑New construction a sole proprietor or partner- listed on the attached shget. # T ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp,insurance. [No workers' comp.insurance 5. ❑ We are a corporation and its 9• ❑Building addition required.] .officers have exercised their 10.El Electrical repairs or additions 3.E] I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no required.]fi 12.❑Roofrepairs insurance re ] employees.ployees. [No workers' comp.insurance required.] 13.0 Other *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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: LLTtt,p Mures L Z ��e Policy#or Self-ins.Lic.#: 4'3S a4 V , - Expiration Date:J Job Site Address:_4 5 14 ,mll V 1LU2 City/State/Zip_Wgg�Aq ,& M A d I g y S Attach a copy of the workers' compensation policy declarationa e p g (showingthe Policy p cy 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Si nature: Date: 10. p Phone#: I Official only. 1)o not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one):ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: 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 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 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 wfi 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 s7tate`6r local licensing agency shall4ithhold`the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." 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 fill out the workers',compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be 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 Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy;please call the Department at the number listed below. Self-insured companies should enter their .self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided,"space'at the bottom of the affidavit for you to fill out" 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 app ,, licant thatmust submit=multiple permitnicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)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 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 burnleaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Gol�-norowealtl-I of Massachusetts Department of Industrial Accidents Office Of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia ACORDDATE(MMIDDIYYYY)Thl CERTIFICATE OF LIABILITY INSURANCE 09/19/2011 THIS CERTIFI TE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE OES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS ERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTA E OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: I the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and� onditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate hol r in lieu of such endorsement(s). PRODUCER CONTACT NAME: COSTELLO IN URANCE AGENCY uvc. . 978.374.6352 acNq 979.S21.S127 2 South Ki all St. ADDRESS: PO Box 5248 INSURERS)AFFORDING COVERAGE MAIC# Bradford, Kk 01835 MSURERA: National Grange Mutual Ins. Co 14788 INSURED Rackleff Construction Company INSURER B: Utica National Insurance Group PO Box 567 INSURER C: Haverhill, MA 01831 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:Master 2011 REVISION NUMBER: THIS IS TO CER IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO ITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE Y BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS D CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSIR AVULbUOK POLICY EFF POLICY EXP LTR E OF INSURANCE INSR WVD POLICY NUMBER wDD/YYYY MMIDDIYYYY LIMITS GENERAL LIAN MPFS398 12/3012010 12/30/2011 EACH OCCURRENCE $ 1,000,0001 X COMMERC IAL GENERAL LIABILITY PREMISES Ea occurrence $ S00,000 CLAIMS-MADE FX]OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2'.000,00 GEN'L AGGREG kTE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY dECT LOC $ AUTOMOBILE L ABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS N D AUTOSULLD BODILY INJURY(Per accident) $ HIREDA OS AUTOSPar NON-OWN FRUaccidentDAMAGF $ UMBRELL LIAB OCCUR EACH OCCURRENCE $ EXCESS B CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS CON PENSATION 438246 12/12/2090 12/12!2011 X AND EMPLOYE LIABILITY y/N TORY LIMITS ER ANY PROPRIE7 )RIPARTNER/EXECUTIVErE.L.EACH ACCIDENT $ ]00 000 B OFFICERIMEM ER EXCLUDED? N/A (Mandatory In N ) E.L.DISEASE-EA EMPLOYEE $ 100,000 Ryes,describe nder E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION F OPERATIONS below I DESCRIPTION OF OPE RATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN NORTH ANDOVER AUTHORIZED REPRESENTATIVE 1600 D STREET NOATH DOVER, MA 01845 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(201 /05) The ACORD name and logo are registered marks of ACORD