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HomeMy WebLinkAboutBuilding Permit #611-12 - 45 SETTLERS RIDGE ROAD 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT:Applicant must com lete all items on this page LOCATION `�Sf ,�� ��rS Aid M P) Print PROPERTY OWNER lGr An Gross Unit# Print MAP N0: PARCEL: /0 yr ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ❑One family ❑Addition ❑Two or more family ❑ Industrial 5,Alteration No. of units: ❑Commercial ❑ Repair, replacement ❑Assessory Bldg 0 Others: 0 Demolition 0 Other $ ' ❑`dept ®,. ��ll �f ® o h1y �Wetland �� Waernt't ct �t DESCRIPTION OF WORK TO BE PERFORMED: (Identification Please Type or Print Clearly) OWNER: Name: Gros e, Phone: 9> ,62r 2--5-Y.2 3 Address:_ Gls- W4 I?d, CONTRACTOR Name: 'S . or`�v Phone: 6o3 yak 6d-o j Address: r� l �e�ra��e�. cr"J'- 03 ,F-/ / Supervisor's Construction License: C5"057 �`� Exp. Date: Home Improvement License: . /Od-0"7/ Exp. Date: 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: $ __ 3%, 66_3FEE: $_ rj/�0. do _ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignafure of,:Agent%©;wner.<_ - Signature ofcoritactor .j Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/Massage/Body Art ❑ 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 Sianature - COMMENTS • I HEALTH Reviewed on Sianature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes i PI'anning Board Decision: Comments 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 Dimension Number of Stories:___Total square feet of floor area, based on Exterior dimensions.______ Total land area, sq. ft.: LEMovement of Meter location, mast or service drop requires approval of E Electrical Inspector Yes 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 - Date -� Doc:-Building Permit Revised 2011 June/mi 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 o 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/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 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 NOTE: 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: Doc.Building Permit Revised 2008mi Location %� Sr-7��,s R,,j F AV- No. Date • ' TOWN OF NORTH ANDOVER � Fk��11.f.0 IG¢F e • Certificate of Occupancy $ Building/Frame Permit Fee $ �.UD kt3 ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 25039 din Inspector ` 9 FORTH Town of 0 V% No. _++ 0%LAKE dover, Mass., COCMIC EWICK oRATED sll ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........9�'/.G.!!t......�n'?.5S........................................................................................................... Foundation has permission to erect........... buildings on ...A. . . Rough ....................... ............................................. ......... ...................... to be occupied as................ zv ..... ............................................................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough f.. ........................................ Service BUILDING INSPECTOR Final Occupancy Permit Required W Ocatpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do- Not Remove Final No Lathing or Dry Wall To Be Done FIR_E-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - Street No. SEE REVERSE SIDE Smoke Det. 94;" – '18"--7r -33"-- -18" ---48" ---t-24"— --24" 2419 ----66 t —74'+-e' 4" 0" 94-" 30"--�---21"—�---24" 1 v 36" 18" /K. _........._...__....__....__.._.___....__..._. - _.._..._...... 1836E W3336 W1836 W2436 WR82436R 11b,3034 64D2134 24:OISHW 7rr,3 1 D1834 _e rn LO n/6r" I- 50 CD © Q� ch m O N Q N � Q� �; J ni W O W W O d. ca rn rn O � 41 B1D2434' B3b2434 61D2434 wa It 1 1, 75 ii+ v, (A �r o�u all ASO �, c , TIC339024 T013131,19.0242: BD3034" W361924 Q N N? A 1 1S 80 2�� 4 r � � i WW3015 33"— -31 "-- -30"�;, 36" ' 1 4 1B 5 30"— i 36" 4 1374" The Commonwealth o fMassachusetts Department of lnduszr alAccidents 401ce oflnvestigation•s 60013 Washington Sheet Boston,MA 02111 yY Workexs' Compensatio>nilnsur.lnceAffdavit:Builders/Contractors/FIectricians/.Plumbears A. licalat 1[la£oxmation please Print I,e ibl Name(Business/0rganizatiofndividual): �� /t &I C,, . Address: f�sC. .city/state/zip: c� 211 Phone#: l0� .3atiJb.L�� Are Y u an employer?Check the appropriate box: J. L'�z am a employer with 4. El am a general contract 'pe.of project(required): - employees(full and/or part-time). have hired the sub-contra tos s x 6. ❑New construction 2•❑I am a sole proprietor or partner- listed on the attached sheget.1 7• ❑Remo deling ship and have no employees These sub-contractors have Working for mein any capacity, workers'comp.insurance. 8' ❑Demblition [No workers'comp.insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] .officers have exercised their 10•❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption perIVIGL 11.❑Plumbingrepairs or additions myself,[No workers'comp, c.152, §1(4),and we have no insurance required.]i employees.[No workers' 12-El Roofrepairs comp,insurancerequired.] 13-ElotherAny applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. -tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,affidavit Poliindicating such. .1'a7n an employer that isproviding workers'com information. pensation insurance,for•yny employees Below is tlaepoliey and fob site Insurance Company Name: C.�0ry--tx t Policy##or Self-ins.Lic.#: Q (,Y C of g- Expiration Date: Sob Site Address: $ Sp for (�i �, jed City/State/Zi r 1 ,r�c� yS- Attach acopy of the workers'compensation policy declaration page(showing the policy number and expiration Failure to secure coverage as required under Section 25A of.MGL c.152 can lead to the imposition ofcriminal penalties of a lne up to$1,500.00 and/or one-year imprisonment,as well as civil If up to$250.00 a day against the viopenalties in the form of a STOP WORK ORDER and a fine lator. Be advised that a copy ofthis statement may be forwarded to the Office of avestigations of the DIES for insurance coverage verification. do hereby certYy under the pains andpenalties ofperjury tliat tine information provided above is true anti correct. ` ature: Date: !one 4: (003 lel•-&X 0 O,jficial use on&. Do not Write in this area,to be completed,by city or town official. City or Town: PermitlLicense# fssuingAuthority(circle one): 1.Board of health 2.Building Department 3.City/Town CIerk' 4.Electrical Inspector 5.PIumbin �.Other g inspector Information an . ci 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 ofHire, express or implied,orA 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 who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shallwithhold 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)andphone numbers)along with their certificate(s)of insurance. Limited Liatility Companies(LLC)or Limited Liability partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. Tf 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.ofinsurance coverage. Also be sure to sign and date the affidavit. The affidavitshould be returned to the city or town that the application for the permit or license is being requested,not the Department of T 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 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.' PIease be sure to fill in the permithicense number which Will be used as a referencd 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(ifnecessary)and under"Job Site Address"the applicant should write"all locations in jcity or town)."A copy of the affidavit that has been officially stamped or marred 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 orpermit notrelated to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOTrequired 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: Ab CoM.�.�uOrme—al'tc,o1 Si1a:ssac ttsetts Do partmeat of hadusWall Accidents MCC Of InVe ftatjons 600 WashhVon Street Bostm M:A,0211 X Tel.#617-727-4900 ext 406 or 1-$77-1ASSAFE Pion 44 1 C7 r70 rr 17B1 A n John Yforan Construction, L.G.C. Bui[ding and remodeling 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 February 7, 2012 Brian&Meg Gross 45 Settlers Ridge Rd. No. Andover, MA 01845 Dear Mr. &Mrs. Gross: Specifications to remodel your kitchen as follows: 1. Removal of existing cabinets no longer included. 2. Removal of existing tile floor and subfloor no longer included. 3. Install a new hardwood floor. Material cost of flooring not included. 4. Install cabinets and soffits per plan. 5. No countertop work included. 6. I will remove corner closet and patch walls and ceiling. 7. Electrical a. Install ten recessed lights. b. Install Progress 7500 series under cabinet low voltage lights on sink wall and cook top wall cabinets. c. Add switches for under cabinet lights and add outlet in island. d. Add a sub panel for new wiring for wall oven. e. Wiring for appliances. 8. Plumbing: Hook up dishwasher, sink and cook top gas connection. 9. Move duct work for toe space under new island cabinets. 10. Install duct work for new cooktop hood. 11. Tile backsplash behind cooktop. Tile and grout provided by owner. 12. Paint ceiling and walls. 13. I will apply for permits. 14. Disposal of debris included. Cost: $14,518.00 Page 1 State of Massachusetts Home Improvement Contractor License#102071 er A State of Massachusetts Construction Supervisor License#47989 NAT-24839-1 John Moran Construction, L.L.C. Building and Remodefing 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 Proposal to change slider to French door as follows: 1. Remove slider and frame a smaller opening. 2. Install a 5'-0"French door unit with single pane glass in a weather stripped jamb with an oak threshold. 3. Trim door unit to match existing. 4. Finish drywall;taped and sanded. 5. Stain and urethane door unit. 6. Paint wall patches. Cost: $2,965.00 Total cost: $17,483.00 Respectfully submitted, John Horan Page 2 State of Massachusetts Home Improvement Contractor License#102071 ( ,*EFA State of Massachusetts Construction Supervisor License#47989 NAT-24839-7 MamaAaset#s Home hnBm ement Sample Contract Tiristam aabasictegonmtems�$xst aHata�uv law(lMdrgtal42A),Letdoes idwkdo and 1aoglvapebp900mi meawaes.Sakfftaecemy Aapm mpba*gb-w-,pro, 1.sbooldfitstobbinacWof•A hffm=&umftCaa+®aGgWtoHomchVwvemwfi,'ate g 'Staaagwad;oaywtc ibmce.Yonm yebtdoafim=9bYeLfttht offfm fCms®aAffimmdBasb=Rexalado*Con acb mEWTmeat617A73S787or1.588-283-3757armoarweI Elemw fwhlrQrum" ContmcowWormwfin Mmey1 bc-�o'n (;ro55 3at,�}loran Gon cvv{i on, L-LC Saes Add>em(doatttseapa�OSeaBarcaddtess) t�aaaemdSao/ovmerTlame HS Se-441vtf5 o«n CIWT— sum Tp Code &sioessMdRa(mastmch,deaAtxtaft=) o0. 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Dodtbepdiato ingtheti=torwdmdfifRy edit.A*gasfimifsooled& istmdes CAxdaoW "ielavvregnaamOsthOaaleimproveexarc snd sabom2ftwimtobc YOaamymgbeaboat reBisleaei bywditto&eDieodwatiOPmkPim%3toomS17kBOOMMA02116orbymllmg619A734Mor888-2833757. DOesftco bavaiasm=wd?AsktbeCoaa rEWUSiasmaaoecoopmy sotbarymancoufamoovaeMormkto seeaaopyma-poofofhmma wedocwnwt xwwI I -hffmmstimonfttewsesi diftli=wd8dacopyafthe GWett►BseHameftpwiuzdcmkadwlm. Ywmaycamddit is ma sifhhnbmskpxdarayincaffim-d &cooanadofs *-ofb-h-%p-nkdyOnno*ft t>o iawNmg#1 >t�Doffroe�b>m�ra�oebym mYmar7Po �tacbl*dd�y>noclatatl=mi&*Moftbe ddb dayihDowiogAesigoisgofffiha�txmmt Saetbet adaoliaeaf ii�foraam mofthBtig�d DO NOT SIGN TM CONTRACT IF THERE ARE ANY BLANK SPACWHI Or�eiO�#@3stL[COe�r,' daragCs.d6COpJ710�tpb�6h=mmmm\'IIs te�1a'�01�'a� S$rg0�[e Daft "�� '�`� Date Coatmetor Aifittratloa ThcHome Improvueoent ContrudwLaw provides homeaW=s with*t tight to initiate an arbihatian action(as an doandive to,court adios)ifthey have a dispute wide a eoutractor:.The smme right is lli aammadcaltp afforded to a contractor,however The contractorwould lave to resolve any dispute helshe has with abomeownerm court unless boor parties agree m the optiond clause providedbelow Thi dense would give the eomhactnrthc same right m arbitradw as is affotdedto the homeownerby the Home hW ovemeat Cantradbur Law the contracx'and the homwwncr hereby mutually agree in advanced intheeventthe orbas adispute this cooback the eomhacbor may submit the dispute W a private arhdlration fimt whic h has been approved by the S=dwy ofthe Exec uwc Office of Coa xw Affadis and Busanessthe shall be mpred t such arbhratiun esprovided In M General Laws, AT - ignatme The sigasirues of the parties above apply only m the agcemment ofthe parties m al6emffiive d resohttior initiated by$re coffirador. The houmeowaermay initiate alieraetive dispurte resolution even where this section is not signed by the parties. Homeowner's W401 s A homwwaces rigbls nndertho Eiome hopmement Conhactor Law(MGL dmpw 142A)and adux consumer p uteedon laws(mi MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners maybe excluded firm certain tights ifft conhadarthey choose is not property regiswa ss prescribed bylaw. Homeowners who sewne titer own bm'ldmg permits ere autooWcally eacdaded from all Guaranty Fund provisions of Ste Hunte hopcovement Contractor Law The contractor is rile for camPletaigibc v m c as dWcrJbed,in a tunclynodwedunimnkenwoer Homeowners maybe enbW to other specific W rights ifthe contractor goafeo. err provides an enspews warranty Ear wodrominshiparmaterighs. m addition m guarantees mrwaaanties provided by the eontracOM all goods sold inMessachusaft cavy an m flied vvanzoly of tty and fitness for a particular pncpose. An enumeration of olher matters an which the homeowner and coatradar lawfatly agree maybe added m the oeuns-of the contractas long as they do not restricta homeow els basic consumer rights. Efyout have questions about your c o zWft the Consumer mon Hotline(fes below). Fzeen—d of Contract The contractmust be moecrsoed in doobmft and should not be sigoedunfi7 a copy of all exhibits sal refa>meed docamneais have been attached.Pmties are also advised not m sign the docurneduntit an blaksections have been filled in ormeftoed asvold,ridded,(W not appliesble. One original sigma copy ofthe contradwith is to beomtDftommmaWftoMaWbyftcanhatw.AW modificafian m the origmet contact must be in writing and agmdtobybo&parfm&Cooftaftdwa&maynotbq#nuofflbolhpwtLeshucrecdvadaftft eked copy of dee eonaad;and do dunce day rescissimn period bas expiied. Accelerated rayments A cenu=*w may not demand payments in advance ofdee dales specified on The paymentschedule in cases where dee homwwnwdmmbuwlmsfftobofmwmmUymsomr- Ebweve4mmstmetswhcmacoubactordmmhmminseff to be financMilyhmcmr,the eooftectormay requueflid the balance of fonds notyat dos be placed in a joint escrow account as a prerequisite to contiouirig the coohacted wodc. Withdrawal off axis from sold account would require the signatures ofbahpasties. Addit."enrd liM&MI tion Ifyoo have general quesboas or need additional infionstim about the Haase lmpsavement Contractor Law or other consm ffdgbts,orifyoawishto obtaur afiveeopyof*Ab&sssKh=MC*osorncrCkMeIn Homehnnovemeor cow CAmsumerhifiamationElotIme Office of Comsomar At3sus and Busies Regrlabon 10 Pa kPhtra,Rom 5170,Basin%MA 02116 617-9734rM,US-283-3757 of visit the OCABRwebsft at htwJM--inass_em/orabd Ifyouwanttoverifytheregiistrationofaeonhactarrsurifyouhavequestionsarneedadditional indformetion specifically about dee comrradorregrshatim eompaamt cf&e lbwovementcantractorJAW,ooutac Director of Home hn;mvement Confract r Registration OfficeefC nsomwAffousanderRegulation 10 PadcPloM Roan 5170,Boston.MA 02116 617-973-8787,888-283-3757 or visit the HEC website at ass-mv/ocand Go online to view ire states of Home Improvement ComtapoWs Regishatice: httnJ/dbsffite ma us/homeimasavemeni/Iiaenseelist_ao For assistance with informal me&sh'om of disputes orm register formal complaints against a business,call: Complaint Sectim Office ofthe Atoomey General 617-7274M AND/OR Better Badness Bum= 508.M 4804 508-755-7548 or 413-734-3114 versionxs-rrmnoro Client#:490547 JOHNHORA ACOR& CERTIFICATE OF LIABILITY INSURANCE F D04(MMIOD 1 NYYY) 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 CONTACT NAME: USI Insurance Svcs of NE,Inc. PHONE FAX PO Box 6360 a ANO Ext): 603 625-1100 (A/C,No): IL S. Manchester,NH 03108.6360 PRODUCER 603 625-1100 CUSTOMER ID M INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A.Maine Mutual Group Insurance Co 15997 John Horan Construction LLC 21 Evergreen Dr. INSURER B:EastGuard Insurance Company 14702 Hampstead,NH 03841 INSURER C: INSURER 0: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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. INR TYPE OF INSURANCE DDL UBR OLICY EFF POLICY EXP LTR N NVO POLICY NUMBER MM/DD MMIDD/YYYY LIMITS A GENERAL LIABILITY SC10955638 /01/2011 04/01/201 EACH OCCURRENCE $1000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $250,000 CLAIMS MADE OCCUR 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 $ A AUTOMOBILE LIABILITY KA10955638 4/01/2011 04/01/2012 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $500,000 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ IX NON-OWNED AUTOS $ A UMBRELLA LIAB X OCCUR KU10955638 4/01/2011 04/01/2012 EACH OCCURRENCE $110001000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION JOWC225195 4/01/2011 04/01/201 X..IIQRY LIMITS WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? �Y NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $100,000 yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500 000 7 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) This Certificate covers all operations usual and customary to the insured's business. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN "For information purposes only" ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S5539928/M5539762 LCACA A ne� 'ntatton IiShaE`ioi] j02011; Exp1Q lion 6/30/2012 JF, V-,H4W'WASTRUCT(bW JohQin . 2�EV(=itfrid D �; gam ` HAMPSTEAD,tdtr.V%4,1` t sec ' .rf: tin +� Massachusetts -Department of Pubic Safety V-- Board of Building Regulations and Standaras icense: CS-047989 JOAN V HORAN 21 EVERGREEN DR Hampstead NHi 03841 E J.�... JJ%�t�►` _ :i E x u r atso.1 Commissioner 03/0212014