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Home My WebLink AboutBuilding Permit #038-13 - 47 BAY STATE ROAD 7/18/2010 pf ��Eo t• qti BUILDING PERMIT ? 6tTT q6*6 Op TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ff c� Permit NO: - Date Received 9SSACHUSEt Date Issued: IMPORTANT Applicant must complete all items on this page k rZy J L- tti`f-[I its T,; r7� 5 f 'kt F4� PROFEF '�O1JIINER1 >; y , t `- fkl y} h Y t ra 7„ nr i ° r Pt 4 iT s_ w , - {r r C• v x,. }r{`-`cf MAI?t;NO�� fP,�4F�CEls ,ZONING b,ISTRIC��.��istor�c Dist�act Y Er ��`Ye5,� �..„.�!ai :;rx ?b 'cs ar a , t teShop lfllage no - TYPE OF IMPROVEMENT PROPOSED USE Residenti Non-Residential ❑New Building ne family ❑Additio ❑Two or more family . ❑ Industrial UAfferation No. of units: Q Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ; Sepflc We ' prFl�oiplainh s> Ill/etfal�ds r S1fl, atershedLDisfrict r. D SCRIPTION OF WORK TO BE PREFORMED: e- add Identification Please Type or Print Clearly) OWNER: Name: Lz% /CoGw'c/ Phone: Address CONTRACTOR Name �� `� � �r� Phoney �" '�". r - } �r i � � � � r r I r� � z) Address t t{ ,, '`' 4 r 5 k k r r Supervisor's Constrpction El- ev. Ot 3 ; ARCHITECT/ENGINEER Phone: yr Address: Reg. No. FEE SCHEDULE.BULDING IRMT.$92.00 PER X 000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ X00, (� _FEE: $ i Check No.: `V I Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r _ tr - nature �f Agentf,Qwner _ :..' : ::. .. :, .Signature o#conractor '`= Sig . - Location 41 ' -` '{' QJ No. C, ` Date I I • • TOWN OF NORTH ANDOVER r�46 e s Certificate of Occupancy $ Building/Frame Permit Fee $ 3 Foundation Permit Fee $ Other Permit Fee $ AV tvw TOTAL $ Check 25515 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Seng Pools j ❑ 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Con nection/signature&Date Driveway Permit Located at 384 Osgood Street FIRE DEPAfiTMENT Temp;Durnpsfer on site �eS Located at'124dVIam:Stree# _ - _ Fxre�Department sic�natureldate :: f .--. -= �OMNfENTS= - _ 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 - Date _ _ l Doc.Building Permit Revised 2007 Building Department The following is a list bf 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 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 ConstructionSin le and Two Family) ( g ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 NORTH oven of 2 � E ., Andover No. 3 C, h ver, Mass, stJ1.I 12. o COCHIC Hl WICK y�• A�R�1TED - S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .... ... .... ....... BUILDING INSPECTOR ....�,. . .. . ...sem,......... ............. .... ....... ... .. . .. ... .. .. ... . has permission to erect .. ... buildings on „' Foundation Rough tobe occupied as .. f............................................................................................ Chimney 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTH ELECTRICAL INSPECTOR UNLESS CONSTRU S 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. SEE REVERSE SIDE MASSACHUSETTS HOME IMPROVEMENT CONTRACT This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),lout does not bielude statrdlard language to rotecthomeowners. Seek le advice if nee ''` �S g P Em easarS• f+nY person planning home irtaprovements should fii"st obtain a copy of"a Massachusettstconsumer.guide to home improvement"before special;to any work on yourresidence.You may obtain-a free copy bycalling the Office of Consumer.Affairs;and Business.ReguladOWs Consumer Information Hotline at6'17-973?8787 or d>88&283-375.70 Homeowner Information Contractor Information Name . PmY arae' ... 44 aG T,TGfJ LS71. N Sans Street Address(do not use.a Post"Of6 ei.arm-v-i tractor/Berl esiperson/ownerName CStyfroan State Zip Cone lusiness Address(mast include a street address) . Daytime Phone Evenin Phone +. 97�� ityRown State Zip Cade /yo w"/oovdif Mailing Address(It different from above) lusiness Phone Vedaw Titaplbyar ID or S.S.Number 4v merlin Wrmon borne rail am"e ICmaneor:-b]_,e,sdmdcaaaa reaimatl®®ba The Contractor agrees to do the following work for the HO meoi nor: Required Permits-The following building permits are required Proposed Start and Completion Schedule•The fdlloviing schedule will and will besectred.bythe c6htractor4s;the'homeowncr s agent; be adhered witi less circumstances beyond:the contractofsL control arise (Owners who'secure their own permits will be ezclnded from he Guaranty Flied'provisions of stat whtoi conaactarwill begin contracted work. . „ MGL chapter 142A.) awe when contracted .work willbe substantially completed. Total Contract Price and Payment Schedule The Conbactonagrees to perform the work,furnish'the material and labor specified above for the total sum of (s) Payments will be made according to thefollowing schedule: S upon.signing contract'(nottb ecce d U3 of the mtai.contMet price.qr the cost:of apebial order items,whicbcver is:greatcr) by_�l or upon completion of �l S by ,or upon completion of upon completion of the contract (Law forbids demanding full payment until.contract is completed to both party's satisfaction) 7be following material/equipment must be special S la*paid for ordered before the'connected workbegios in order S to be paid for tomeet the..wmpittion schedule.(**) NOTES:(s)including all finance charges(ss)Law requires that any deposit or down-payment required by the contractor before work begins may noteuoeed the greats of(9)one-third of the total contract price or(b)the actual cost of airy special.equipment or custom made material whi'cb must be special ordered in advance to meet the completion schedules EzorwWarrantv-IsanezoressmsrrantvbeinQ+.rovldedbvthesontnctorT No faliewa aofvmmtbe r++bed to theconha� ctl bdroSubcontractors Ther contractorag*as tube solely responsible for mplenonYaeworkedrmesoegardlwsoftheactionsofanyfuid Party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all Payments to all subcontractors foi materials and labor under this aereemcot Contract Acceptance-Upon signing,this document becomes a binding.contract underlaw. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest)sas been placed on the residence. Review,the following cautions and notices carefully before signing this contract • Dont be pressured into signing the contract Take time to read and fully understand it Ask questions ifsoinetithij is unclear. • Make sure the contractor her a valid Home Immovemmt ontractoRe 'strut Ther hiiv requires most home improvement contractors and. subcontractors to be registered with the Director of Home Improvement Contractai Registration. You may inquire about contractor registration by writing to the Director it One Ashburton Place,Room 13Q1,.BosmA MA 02108 orby:calling 617-727.3200 of 1-800.223-0933. Does the contractor have insurance? Check to see that your contractor is properly insured. " Know your rights and responsibilities. Read the Important Information on the reverse side of fids form and get a copy of the Consiimor Guide to the Home lniprovemcot Contractor Law: 7t1hilidbusinews ancel this agreement if it has boon signed at a place other than the eontract0s normal place of business,provided you notify the n writing at his/her main office or branch office by ordinary rail posted,by telegram sent or by delivery,not lata then midnight of the. day following the signing of this agreement.Seethe attached notice of cancellation form for an explanation of.this right DO NOT SIGN THIS C CT IF THERE ARE ANy BLANK SPACES!! Tv ! oidm� ameo'mal cepi !' mmaeraautbe daipmt OoemDYahould coo io thehwaer. eo �Db ThdwcDWWmWbe t the .. ' y��,/c/aJooa�anm. o e er' igna _ 4 VV'Y^e % Conftcter,s Signature Dau Date Contractor Arbitration The Home.Improvement Contractor Law provides-homeowners with thenglivto-initiate an arbitration action(as an altemati e'to court action)if they have a,ispute with a contractor. The same tight_is nbj automatically afforded tok. contractor,.however. •The conuaetumpuld have_to resolve any dispute helshe.ltas with a homeowner in court unless both parties agree to,the optiongl "clause.provided below..This clause would give the.contractor.the same.right to arbitration as is afforded to the homeowner.by the Rome Improvement Contractor Law.. ' The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been.approved by the secretary of the Executive Office Consumer Affairs and Business Regulation an. the consumer shallbe required to submi tion as pro v' In.Massachusetts General Laws,chs 142A. Homeo et's r Contractor's Signature NOTICE Th of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.The homcowncr:may initiate altemativeAWute resolution even where this section;is not separately Sn..�si edr ]thegrti es:: Homeowner's Rights A homeowner's tights und'erthe Iome'Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(Le.MGL chapter 93A)may not be waived in any way,even by agreementt.However,homeowner$ may be excluded from certain rights if the contractor they choose is not property registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor lAw. The contractor is responsible for completing the work as described,in a timely and rworkmanlike manner. Homeowners-may be entitled to.other specific legs}rights if the contractor guarantees. or provides an.express warranty for workmanship oi•materials. In addition to.guarantees,or warFanties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and Atness.for:a particular purpose. An enumeration of other matters on which,the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicete and should not be signed until a copy of all'exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by.the contractor. Any modification to the griginal coniract must be in writing and agreed to by both parties.Contracted work may not begin until both parties havereceived a fully executed copy of the contract,and the three day recission period has expired Accelerated Payments A contractor mpy not demand payments inadvance.of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a.contractor deems him/herself to be financially insecure,the contractor may require that the.balance of funds not yet due be placed in a joint.escrow account as a prerequisite to.continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need:additional information about the Home Improvement Contractor Law or other consumer rights,_9* if yoti wish to obtain a tiee;copyof"A Consumer Guide to the Home.Improvement Contractor Law,"contact. . Cgnsumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 1-(888)28.33757 If you want to verify the registration of a contractor or if you have questions or need additional information spect8cally about the contractor registration component of the Home Improvement ContractorLaw,contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 (617)727-3200 ort-800-223.0933 For assistance with informal ihediairoinof d spittes or to register formal complaints against abusinfts,call : CoiYstiime cointplaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 i Propont Page# of pages CS # 022680 978-688-67T7' HIC# 103358 A. J. Walsh 8t: Sons or 55 Pleasant Street 1-866-AJWALSH North Andover, MA 01845 Proposal Submitted To: ,/��j' Job Name Job# Address4 ` 7 � Job Lora'on /r � �S u,—. Date / Date of Plans ICZ/� Phone# Fax# Architect r1Weereby submit specifications and estim tes for. AOL We pr77", ereby to furnish material and labor—cornpiete in accordance with the`above specifications for tFie sura of: Dollars I, with payments to be made as follows: fir Any alteration ordeviationfrom above specifications involving extra costs will be Respectfully /L�%�/ ' /(1T/G "1 ( ✓ executed onlyupon written order,and will become an extra charga over and submitted / above the estimate.All agreements contingent upon strikes,accidents,or delays / beyond our oohtrol. Note—this proposal may be withdrawn by us if not accepted within days. acceptance of Vropof; The above prices,specifications and conditions are satisfactory and are k gignature - f hereby accepted.You are authorized to do the work as specified. / Payments will be made as outlined above. Date of Acceptance Signature Massachusetts - Department of Public Safety Board of Building Regulations and Standards (_11nctructia11 Supers icor License: CS-022680 ARTHUR J WALSi�JR .:.� 159A WAVERLY:RD< I (l N ANDOVER MA 01845 dp+ 1,, Uxp�ratior cornmissier,er 06/09/2014 .\ Office of Consumer Affairs&Busihess Regulation(ll. �,HOME IMPROVEMENT CONTRACTOR 1 Aegistration:� 103358 Type: Expiration: 7/7/2014 ., Private Corporatio A.J.WALSH&SONS,INC. Arthur Walsh,Jr. 55 Pleasant St N Andover,MA 01845 Undersecretary 1 The Commonwealth ofHassachusetts . - Depadm nt oflndustriglAccidents Office of Investigations 600 Washington Street LWOBoston,MA 021I1 IF U. www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/ElectriciansfPlumbers Applicant Information ` (' Please Print L,eell �ibly Name(Business/Organization/Individual): �7//`TA/— v BCI`1r� Address: �i'S' ��k_Wil' owT T7 City/State/Zip:_ Alt tq)AX j P)&A,'' dy ne#: 97f-- --/'kJ- -6 23 7 Are yo employer?Check the appropriate box: Type ofproj ect(required): I. I am a employer with 4. F1 I am a general contractor and I 6. []New cbnstrmotion employees(fall andtorpart-time)* have liked the sub-contractors 7. Remo doling 2.El am a sole proprietor orpartner- listed on the attached sheet. These sub-contractors have 8. Demolition ship and'haveno employees ❑_ working for me in any capacity. workers'comp.insurance. g, El Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑I am a homeowner doing all work right of exemption per MGL l LE]rT!9j9ng repairs or additions myself.[No workers'comp, o.152,§1(4),and wehave no 12• oofrepairs insurance required]t employees.[No workers' .13.❑Other comp.insurance required] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensationpolicyinformation. t Homeowners who submitthis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is thepolicy and job site information. f Insurance CompanyName% / / `k-W qiql, l i s G iJ Policy#or Self-ins.LIG.#: 701 V�(Id d/Z U/O Expiration Date: Job Site Address: Ll S r/�"T Ro—I City/State/Zip: ,1,?A'Yod 11 tfe)- /117 Attach a copy of the workers'compensationpolicy$eclaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.0 0 a day against the violator. B e advised that a copy of fhis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby cerci rider he pains and penalties o perjury tliaf the in provided above is true and correct. Si ature: 4.�Lr�� / Date: 7 Phone#: Official use only. Do not write in this area,to be completer)by city or town official. City or Town:. Permit/License# Issuing Authority(circle one): 1.Board of Health 2.PuildingDepartment 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: 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 defmcd 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,cr any two or more ofthe 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 andwho resides therein,or the occupant oftho 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.deemedto be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the Issuance or renewal of a If cense orpermit 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 ofits political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants ` 1' Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Comp anies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequiredto carry workers'compensation insurance. 7f an LLC or LLP does have employees,a policy is required. 13 o advised that this affidavit maybe submitted to the Department of Industrial Accidents fox 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 In 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 tho bottom Of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number whichwill be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one of fidavit indicating current Policy information(ifnecessary)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. Anew affidavit must be filled out each year.Where ahomeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is N'OTxequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, P lease do not hesitate to give us a call. The Department's address,telephone and fax number; Tho Gommonwealt�of mfassaohwotts Dap-Ulment of Industdal Accxda is Office ofW08tigatiom.. 600 WasWjooa Streot Boston,MA 021.11 nil#617-72,7-4900 ext 406 or 1-87MASS.AF`B Revised 5-26-05 Fax 4 6M727-7749 txtcrjsrr mnnn n•,�tify... - i CERTIFICATE OF LIABILITY INSURANCE 712/12/2011 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 Durso & Jankowski Insurance 'FAME: }• PH HE FAX Agency Ina (A/C. No. Ext); E-HAIL 198 Mass Ave Suite 1011 ADDRESS: North Andover, MA 01845 PROTOMER CUSTOMER IDB. INSURED INSUREDS) AFFORDING COVERAGE NAIC 8 Arthur Walsh INSURER A: A.I.M. Mutual Insurance Co 33758 dba A J Walsh & Sons INSURER B: INSURER C: 55 Pleasant Street INSURER D: North Andover, MA 01845 INSURER E: INSVRER 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 DE 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. L"r TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MI/DD/YYYY) IHV/0D/Y4YT) GENERAL LIABILITY EACH OCCVRANCE $ []COMMERCIALGEIJERAL LIABILITY DAMAGE TO RENTED ❑CLAIMS MADE OCCUR PAEMISES(Ea.aecvzzence) $ ❑ MED EXP (Any one P..... $ ❑ PERSONAL b ADV INJURY $ GEW L AGGREGATE LIMIT APPLIES ER: GENERAL AGGREGATE $ [] POLICY ❑PROSE..❑LOG PRODUCTS-COMP/OP AGO $ AUTOMOBILE LIABILITY CO!lHINPD SINGLE LIMIT FIANY AUTO (ea accident) $ FALL DINNED AUTOS BODILY INJURY (per pezeon) $ SCHEDULED AUTOS BODILY INJURY(per...ideet) $ ❑HIRED AUT05 PROPERTY DAMAGE (per accident) $ ❑NON-OkRIED AUTOS $ 9 ❑UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ �EXCEGG LIAR ❑CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION He sCTH- AND EMPLOYEES LIABILITY ® my AND LIMITS ER THE PROPRIETOR/PARTNERS/ EXECUTIVE OFFICERS ARE E.L. EACH ACCxDENT $ 100,000 ❑ 1IICl ® exci 7014648012011 E.L. DISEASE-POLICY LIMIT $ 5500,000 11/14/2011 1.1/_14_/2012 E.L. DISEASE-EA EMPLOYEE $ 100,000 COMMMNTS/DESCRIPTION OF OPERATIONS OR LOCATIONS: ARTHUR WALSH IS NOT COVERED BY THE WORKERSICOMPENSATION POLICY. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1 600 OSGOOD STREET EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. y///� NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVEG�