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HomeMy WebLinkAboutBuilding Permit #1154-2016 - 482 MASSACHUSETTS AVENUE 5/4/2016 BUILDING PERMIT �aoRrai p��t�ec ��ti0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 40 y p Permit No#• ` t Date Received �gssgcHus� `�5 Date Issued: I ORTANT: Applicant must complete all items on this page LOCATION, g rin PR.OPE RTY.QWNEfZ.; QV2.��k: !P.nnt x.100 Year Structure, yes Dno MAP _PARCEL: I ZONING DISTRICT: Historic District" x `yes+ Machine.SI op=Village. yes; TYPE OF IMPROVEMENT PROPOSED USE Resi tial Non- Residential ❑ New Building 9110ne family - ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ t p Septic ❑Well4 _ " ❑ oodp`I�iniWetlands, i ❑ti1lVatershedlKD'stnctF I rSCRIPTION�OF WORK TO BE PERFORMED: - ,r`oo5*:tp low �st�1.��-1`— �h, y�o� a �reyfacz Je-Cf S�° (e a 3.9- 5-9-e- GZ v- o sa. - Identification- Please Type or Print Clearly OWNER: Name: M i'ukaC( :bQivea4 Y Phone:4��'60�=0Sfl8 Address: Ll 9fYIASS A-✓-e, A( 'Je� Contractor Name' w?� f Phone: Email Wry Ac7dress: 3 Lc i�, ✓ Mr4 o�B�� 0. Supervisor s Construction License�:C s.. J 0 66 3 'Exp'" Date:c. } { Home Improvement License'. 38 S76.� Exp: Date'. 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 Cosi: $ $®0.0O FEE: $ Check No.: ?nee Receipt No.: �� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund -- Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4, Building Permit Application Workers Comp Affidavit 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 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 j OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) j 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 Dg oe:Buildin Permit Revised 2014 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ r TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Signature COMMENTS I i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection s ignature Date Driveway Permit _ DPW Town Engineer: Signature: Located 384 Osgood Street ' FIRE ll -ENT Temp Dumpster onFORuite 1 Loeated at 124 Main S r e rf. Fire Departmen sig -0 e' . .. s - - - C®N1MENTS _�� t ' I f Dimension Number of Stories:� Total square feet of floor�area, based�on-,- cterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop rec(ires approval of Electrical Inspector Yes No DANGER Z®NE LITERATURE: Yes MGL Chapter 166 section 21A—F and G min.$1oo-$1o00 fine No NOTES and DATA— (For department ease) I h I I I I t Ll Notified for pickup Call Email Date Time Contact Name I Doc.Buildinb Permit Revised 2014 Yr Location ` " t � -tJ Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $y"(n I � I Foundation Permit Fee $ Other Permit Fee $= TOTAL $ w Y Check#7u f r .�! cam 3 0 32 8 Building Inspector NORTH F � � own of �'_ LAndover OT No. 28� - d irMas o h , ver, s , a COCHICKl WICK y1' 'lsi9s RATEO I�P��,(5 V BOARD OF HEALTH Food/Kitchen LD Septic System THIS CERTIFIES THAT PERMIT V eR BUILDING INSPECTOR . . ..... Foundation has permission to erect...... .................. buildings on ..... . ...... ... .. ...... .. ! �:. Rough ���to be occupied as .......... .. ... ......... .... .. ...... .. ...............................................:...................... 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TIO Rough Service .. ..... ...... ......... ..... .... Final BUILDI PEC OR 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. PROPOSAL Construction Supervisor FREE ESTIMATES Lie.#CS102663 FULLY INSURED H.I.C. Reg,# 138569 WRIOHT ROOFING-GUTTERS AND HOME IWROVEMEN'T` All Types of Roofrmg& Gutters 350 BERRY STREET o NORTH ANDOVER, MA 01845 TELEPHONE: 975-687-2247 PHONE DATE PROPOSAL SUBMITTEDTO Y� (-C'ho be-UZOU LOCATION �1,1.2 , )� STREET JOB NAME 1 LOCCATION CITY,STATE ANDZIP CODE JOB START RATE N. Abdo air MA OleY Roof S+rl-p -R-X1`s �'r1 _ a Lae,fs d,h deck , Pq(-ace. a� rQ& v + Pf � 0� s�t of etyt Oed-) Use- � �, 61 1`L� C Wa'4 �r SA d n �!f Uk,S> L t S Q to C>Z r6,VJ W U.+P.-(— W OL l[s o t,\ e�.�F ear -t'��,� t;�(S 3016 4//- Pa p-P-V- f a �—o o cQ e-ck : gi p(a c P ve*,;;f-- b o o f s. Use ��' a L� , - 0 h �'-S r r // f� ® yr 6Li( QAve s t arlA e S, Ye 30 �` 11, ��`►�E ar'•c4i�C c� e,� f h'eafec� r�0'F a�-�S t�, i�•�►, �� �� U� cof 'S � � 1 r; ; ► mss -�[( ��� 0, ciao' ry / F \('C'+e fly iZ Elk tC� We Propose hereby to f 1st„ MM"-M a- lete accordance with abdve specifications,for the sum of:$�� 00, 00 Payment to be made as fo ows: All material is guaranteed to be as specified.A com Tete ab Mia!workmanlike AuthOriZed (, / manner according to specifications submit ,per standard practices.Any alteration or deviation from Signature �J above specifications involving extra costswili be executed only upon written orders,and will become an 9 extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tomado and other necessary insurance.Our workers are fully NOTE:This proposal maybe covered by Workmen's Compensation Insurance.Non payment by agreed party may result In litigation withdrawn by U if not accepted days. with penalties including court cost and compensation both real and punitive. Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted,making this a valid contract. Signature You are authorized to do the rk as^pecified.Payment will be made as outlined. Date of Acceptance: 1(' Signature WRIGHT GUTTERS 350 Berry Street No.Andover, Ma 01345 Homeowner Z n£armation Contractor Information ,'ane Company'\z;,lv StreetAdLess{doratuseaPostOhlceHoxadd;e;s) Ce;�ractor/Safe�;sorJO�Na.;.e s y, rt S a4 ve C•D Cih:To«t State Zip Cede Bu;tressAe die ss(mastircicaaasLe '. et=eress . Anc�OU�� �? 3S0 8Q- 'Cry Da}'itnePhoae —EwingPhonc Cityfra-n Sta�Code At. .Adp��; end O/M- bfalr, Add:essCcdi�Cecat remzbs;e) BusiressPl re T8631 PedttalEm^loyetIDor9.3.Nttctber,2t7 elf' ..reL�•rJrc�tSCu:a:1:r°r;;aa.� S:ae�': Un n,.ires trot mmt kc as ° -;.:crrx,:ttsntncten6:v ,J 3 5(��l 'yfly a0/ :wild nrutn:i:n v.-:a: The Contractor agrees to do the following work for the Homeowner' (Describ•.indetaitthauo;ctocertple:cdspeifyirgi}tety�e,btz�d,e^dE-a'_eof ma!eriEwstobaesed,u�eadditio-a'stiae`s;fr.°_.ossa;,.) ,;p s �{aeti�,P p�v�Pb�p S•��� � �G��• roof rv-2=r o o i`: �i'.e.a s� S t2.Q a P,�v o.l� Required Permits-7Ttofollowingbuildingpennisareregaired Proposed Start and CompletionScbedule-TLefolIoMrigschedalotvill and NYiilbesectttelbyaecontractor asthe Lorleo rer'sagent: be ame:ed totttlessc:rctunstancesbeye 3tl;econtactoisccrtrolr_*ise (Owners who secure their own permits will he excluded from the Guaranty Fund provisions of __�D tovvl.,:i rntrauor Witt begin ccetractedwcr't. MGL chapter 142k) Date s1'In contracted vvor'.<will be substantially completed. TotalContractPrlceandPaymentScbedule �gOQ.00- T jo 00Tile Gontractor agrees to perform the work,fiunish the material and labor specified above forthe total sum of Payments,vill be made according to ilia folio,,ng s hedule; S.3 06Q upon sign 1gce:wac:(noYtoexceeilr3ortieVAr;,tea•tprice•ems'uacost o£speciesorder itexs,w rLeverisgeater) or upon completion of S_by / / oruponcompietiono`f"'"" -, 5_5$®0,,09 jpDacompietionofthe contract. (Law,orb-,dsdemmdingflUpa}Mentnntilcontsactis'�ompletedtobofaparty'satisfaction) T.a a`n s rn M.rial'e -iip^,:_,-,t=;t--be s ::s, I o:de:eibefxaI' ce.;.,caedw kbs; i7,h.--' ter•.eatt�aecxNOTES:(')Llcicdinsallfir,mcecaugea( )Law avdepositcrdoti paymentregciredbyt^sconuacar eti�be� rn.y rofexceedtl,aneaterof(a)onsthirdontractpreao(b)theac:u.lcostoratyspeciategnipmenterc::stemrnara eII cant�ctcrNO❑Yes rna terns of the xarrnnty milsmilst be nttnehed to he contrnct Subcontractors-lite ccntrec'cr agrees to be soIalyrespensiblo fdr eer,,plc*n of 6;e,vork described regardless of d:a actions ofaay tuird n:sty/subco:rtrac:oritedizedbythecen7actor, ell suS;cectractorsRr inateriaisand jabgr.und rthisagreement Co atract Acceptance-Upon signing,Us document becomes a binding contract under IaNv. Unless otL•e,-,visenoted wttlunimscoc:n,ent,c:e contract saallootitnplythat any Ilea crofa-.rsec•rltyinterest has bzcsplaced on:aeresidence. Reviewtuefollut;lag cat:tions and Latices caetitllybefore signing tills contract. • ngilre contract.Ta1;e time to read and fully unde siand it. Ask questions if something is ttncicar. Don c've pressa ed into sgn • ';f..lca�trer:.e-o fracb�ltas vai'dH4,ba:m�rO,�i,,rentContracterlZeeiss�tica. Titelawra1ttiresmosthetxaimprovzmentcoatractorsen4 st,bcontractcrstoberegistered,v:ththeDirectorofHomeimprovementCwtractorRegistration,You may inquire about contractor registration bywsiting to the Director at 10 Park Plaza,Room 5170,Boston,MA,02115 or by calling 617.913-8787 or 868-233-3757. • Does the contractor have insurance?A{tLa Contractor foritis instua ce compaty informetion so t ratyo'rean conErtn Coverage'or as<tc. sea a copy ofz"n:oo£of instuzace'Boca neat. • Kno,v your rig;tts and responsibilities. Read the Important Infernstion cn the reverse side oft:us ferns and get a copy of Lite Cccswuer t'rtude totL•e Y.mneHnpravemeat Coyuac!or law. you may cancel Gus agreement if it has been signed at a place other than rite contractor's normal place of business,provided you notify the contractor in writing nt idadter main office or branch office by ordinary mail posted,by telegram seat or by delivery,not later than midalglrt of tiza third bus mess da follo•,ring the signing ofthis agreement. See the attached notice ofcanceilation form.for as explanatloa ofthis right. DO i OT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!" ®r, Lacc``rz_t�stc.. , :drds'sod.Ocs:crgs,._ds.�toti:etv..__ra.. .:rc:�ys�' jc. `ate-r.c-_:. — igna ra Contractors signature Data Data The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 .� www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Eiectricians/Plnmbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl A licant Information Name(Business/Organizatiouftdividual): r u` R- -S Address: 3 City/State/ZU M A 0 .4S Phone#: q7y' --aa.�f 7 Areyo n employer?Check the appropriate box: F7. E] roject(required);° employees(full and/or part-time).* w'construction1. I ama employer with�_2.Q I am a sole proprietor or partnership and have no employees Working for mem modelingany capacity.[No workers'comp.insurance required.] , emolition 3.Q 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 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 R of repairs These sub-contractors have employees and have workers'comp.insurance.t 14�th r: r re-V- 6.0 We are a corporation and its.officers have exercised their right of exemption per MGL c. 1�t� 152,§1(4),and we have no employees.[No workers'comp,insurance required.] *Any applicant that checks box#f must also fill out the Bare dobelow elaolll showing ok and then hire outside contract rs must submiteir workers'compensation policy affidavit indicating such. t Homeowners who submit this affidavit indicating they g $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. ensation insurance for my employees. Below is the policy and job site X am an employer that is providing workers'comp information. -7-- Insurance Company Name: m U J- h s. Policy#or Self-ins.Lic.#: WC 5- 31 S-387187- 015 _ Expiration Date: d �� Job Site Address:______ y8� MTCI City/State/Zip:n���✓��� $S 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 foie 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 the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify oder the pains and penal' perjury that the information provided above is true and correct y Dater Si ature: Phone#• 7 Off lcial 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#: 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 who resides therein,or the occupant of the dwelling house of another who employs to do maintenance p ys p ersons construction or repair work on such dwelling house � or on the » h 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 Iocal licensing agency shall withhold 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(l)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 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. Please be sure to fill in the permit/license number which will 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 affidavit indicating current policy information(if necessary)and under"lob 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617_ -727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia AcoR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDM/YY) ll`�. 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 T A SULLIVAN INSURANCE AGENCY INC NCNTACT AME: 135 MERRIMACK ST PHONE FAX METHUEN, MA 01844 E-MAIL "'c "°' ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation 33600 INSURED INSURER B: SCOTT WRIGHT DBA WRIGHT GUTTERS INSURER C: 350 BERRY ST INSURER D: NORTH ANDOVER MA 01845INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 26890575 REVISION NUM ER: 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. (NSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYY MMIDDIYYYY COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE s DAMAGE TO RLINTED H CLAIMS-MADE ❑OCCUR ` I PREMISES(Ea ccurrrence) $ _ MED EXP(Any one person) $ PERSONAL&ADV INJURY S I�GEN'L AGGREGATE LIMIT APPLIES PER: i I I GENERAL AGGREGATE $ 1- �! � POLICY D JECPROT I_i LOC }PRODUCTS-COMPIOP AGG $ I OTHER: S AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED I SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED ( PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident HUMBRELLA OCCUR I I EACH OCCURRENCE $ EXCESS S LIAR I CLAIMS-MADE i AGGREGATE $ I I DED RETENTION$ f I s A WORKERS COMPENSATION WC5-31S-387187-015 9/30/2015 9/30/2016 � STATUTE EORH AND EMPLOYERS'LIABILITY ---- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN I E.L.EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? ❑Y NIA i (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. THE WORKER'S COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SCOTT WRIGHT. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. 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. AUTHORIZED REPRESENTATIVE '� n � y� rY LM Insurance Corporation �11 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 26890575 1 1-387187 1 15-16 WC 1 Jagadesh049C.A°®LibertyMutual.com, 1 12:28:10 PM (EDT) I Page 1 of 1 05/04/2016 15:06 9786817775 TASULLIVAN PAGE 02/02 ACQ& CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD""") 05104/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPO il THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVER I,GE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 3SUING 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$I BROGATION IS WAIVED, subject to the terms and conditlons of the Polley,certain policies may require an endorsement. A statement on this ca rtificete doing not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER CONTACT N Thomas Sullivan T.A. SULLIVAN AGENCY INC, PHONE (878)681.8200 a0DRE9S; ann(A�tasulll_!anagen ,Car I 135 MERRIMACK ST, INSURERfS1AFFORDING_:'OVF.RAGE NAIGR _METHUEN MA 01844 INSURERA; LM INS CORP �` 33600 INSURED "_ ---••- ."..._. INSURER B: SCOTT WRIGHT INSURER C: _ Y` DBA WRIGHT GUTTERS INSURERD; - _ 350 BERRY ST INSURER E; — u NORTH ANDOVER MA 01845 I+aURERF; COVERAGES CERTIFICATE NUMBER: 50118 REV,3ION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NF IVIED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOLL IOENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HE'IEIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPEOFINSURANCL1DM POLICY EFF POLIC POLIGY NUMBER DNYYY LIMITS COMMERCIAL GENERAL LIABILITY FACT OCCURRENCE S CLAIMS-MADE �OCCUR -OW �— -- p.5.E51Es occurrenee)�$ .. Mp0�XP trAny one pe�aon) 9 NIA PER:OVAL&ADV INJURY s GEN'L AGGREGATP LIMIT APPLIES PER: GENI iALAWRROATi $ _ POLICY L—'JFCT FI LOC i PR01-UCTS-OOMPIOP ARG S OTHER: Is AU TOM0MILEI.IA131LITYUM�IN$p yINC3LE LIMIT F a i;dqnI1 .."..�.. ANY AUTO BOD[.Y INJURY(Per person) Is ALL OVVNED �'CHEDULED T" AUTOS AUTOS NIA BODi,r INJURY(Parecdd6nti?S HIREDAUTO NON-OWNED AUTOS P�i01`.RdY DAMAGE S arI -o a I —_ UMeREI,L.A LIAR OCCUR EACI OCCURRENCE $ EXCE99 LIAR LCLAIMS-MADE N/A AGOI:EGATE DED RETENTIONS $ ~V WORKERSCOMPF-NGATION !ER OTH- AND EMPLOYERS'LIABILITY YIN X_!TATUTE I ER ANYA OFFCER/MeM�R XC UDED9EcUTIVE NIA NIA N/A WC531S387187015 09!30/2015 08/30/2010 E.L.E 1CHACCIDENT a 100,000 (Mandatory In be" E.L.[ISEASE-QAEMP1,0YtE $ 100,000 It Yes tleeerlDe under .-- DQS IPTtON OF OPERAT ONS below E.L.C ISEASE-POLICY LIMIT S 500,000 r NIA I DESCRIPTION OF OPERATIONS/LOCAr1ON9i VEHICLES(ACORD 101,Addltronjil Remark*Schedule,may bo attochaG It mora apace Is r*qulradl Workers'Compensetlon benefits will be Paid to Maeeechu50tt3 employees only.PurSusnt to Endi)MOmOnt WC 20 03 0613,no authc'izallon Is given to pay claims for benefits to employees in states other than Massachusetts If the Insured hires,or has hired these employees outside of Massachusetts. This ceni<eete of insurance shows the policy In force on the date that this certificate Was Issued(unless the expiration date on the at Ove policy precedes the Issue date of this certificate of Insurance). The status of this coverage can be monitored dally by accessing the Proaf of Coverage-Coverage Verific Idon Search tool at www.mass.govAwdAvorkers-compenaallari/investig-atiorio/. Sole proprietor hes not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCR 3ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERE01', NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PR(iVISIONS, 1500 Osgood St BLDG DEPT Bldg 20 Ste 2035 AUTHORIZED REPRESENTATIVE North Andover MA 01845 Danlef M.Crq�oy,CPCU,Vice Pres dent—Residual Market—WCR16MA ®1988-2014 ACORD I;ORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety pp Board of Building Regulations and Standards License: CS-102663 Construction Supervisor SCOTT W WRIGHT 360 BERRY ST :' NORTH AMDOVI"R NI' 01 .* CA-- Expiration: ' Commissioner 08/12/2017 Unrestricted-Buildings,of any use group which contain less than 35,000 cubic feet (991 M)of enclosed space. Failure to possess a current edition of the Massachusetts _ State Building Code is cause for revocation of this license. For DPS licensing information visit: www.Mass.Gov/DPS .. tia ^�7/r' �r urnri irn•iu�/1 i�"lfrrl;nr�u.,i/� ff—: Office of Consumer Affairs&Business Regulation 7AOME IMPROVEMENT CONTRACTOR - Registration: •138569 Type: - %Expiration: 4/14/2017 DBA WRIGHT GUTTERS SCOTT WRIGHT 350 BERRY ST. NO.ANDOVER,MA 01845 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without Wgnature