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HomeMy WebLinkAboutBuilding Permit #43-12 - 49 UPLAND STREET 7/19/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permi t NO: Date Received Date Issued: I� r� IMPORTANT:Applicant must complete all items on this page LOCATION :7 Print _PROPERTY OWNER v Iry \ CnEWe—_ Unit# Print MAP NO: ;10 a?PARCEL:,00 ZONING DISTRICT: Historic District yes Machine Shop Village yes 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family dAddition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ So El El Floodplain ❑ Wetland's; [] WatersliedDi"strict ;­.FSI Water/Sewer s . _ DESCRIPTION OF WORK TO BE PERFORMED: 4:ze.46 we r X ti 3�Go✓� l Q e ,nOO N, eAl tre;S (Identification Please Type or Print Clearly) i OWNER: Name: �70.5�l ,i C�W- Phone �I (� Q04 9. 11id Address: CONTRACTOR Name: e,5,,- '..,t 4y,,! ✓ot"e� �� c�Jr'ZD Phone: See-s"2 3 - 7ZSS . i Address: jT_�i�t�,,, �o i1.voor✓e^� il, d!a yrs 3 Supervisor's Construction License: Exp. Date: 3. Home Improvement License: 5'3 l0 9 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �, dao. FEE: $_ _ Check No.: Receipt No.: NOTE: Persons contracting with ' tered contractors do not have access to the guarantyAnd �_g ure?ofAgent/_Owner{_ Signaturejof;contractor 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 HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dum ster 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.: 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 I ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi i 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 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 d New Construction (Single and Two Family) 4 ❑ 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��'_� 2�-, � No. 114— Date 1007M TOWN OF NORTH ANDOVER Mw A + » Certificate of Occupancy $ 4�s'•^"E<�' Building/Frame Permit Fee $ '` f sit Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # / L • r 24v# 0 Building Inspector IE i, ��lam-� � L, -:`r � iJ -�.,�:... F. .- � � ���� �l � :: �� -�✓ - _� _ , V � � '�� Y _ ./'_ r j � - i a � - � i � �r use✓ a ' y .�� ` i _____-- — r� .. � .r.....w.�s .. �.�� r w�� i NORTfy TONM of Andover .. 043 o , '� dover, Mass., T Q C LAKE COC MIC ME WICK � X1,9 AORgreo P11P S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR tom► ou THIS CERTIFIES THAT,.......... . .II..... \\ . .......... Foundation. . ` s has permission to erect........................................ buildings on ......... .�...... ..��.... .............. Rough to be occupied asi���..... .. .... ...... �I�.�......�ir.. .��.......f.... ....... � Chimney Ch' e provided that the person accepting ti.%i'6V)6mft shall in every respect conform to the terms of the applica ion 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 S ELECTRICAL INSPECTOR UNLESS CONSTRUCTI T 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 SIDE Smoke Det. rauuteuwuer anaurmnuon Contractor Information ameotnEany ame Street Address(do not use a Post Office Box address) Contractorl Salesperson/Owner Name Li lid Cityfrown State Zip Code usiness Address(must include a street address) t W Jd�✓t'.•�- iMA 0? S e A✓oatl 4-z" s99 Daytime Phone Evening Phone ilyffown State Zip Code 01—))r Q,U� �l d -' 72ri �SYy Y Mailing Address(It different from above) Business Phone gederal Employer M or S.S.Number Law rAuires nut most home im- Ham AqnVCM,,t contnow Reg.Almnher Expcatioo dse povau mt coubacton have a L *eitistnOan maoher %3l 9 The Contractor agrees to do the following work for the Homeo nee t: Lil me worK to completed; g tp,origin,ano gr m—ebT-flMyEfiVS=o LaNJT�a f 0 Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of _ Ali I Date when contractor will begin contracted wont MGL chapter 142A.) 1�Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,fumish the material and labor specified above for the total sum o£ 1:t V`d40 M Payments will be made according to the following schedule: $ eorq, 'r, upon signing contract(riot to exceed 1/3 of the'total contracf price or the cost of special order items,whichever is greater) by ��/_ or upon completion ofy7c� $ f OQ,a, by /_I� or upon completion of ,!�DDi�i a.� Z,v��,i,'e 1�f✓q $ 4 10, do upon completion of the contract (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special S to be paid for ordered before the contracted work begins in order $ to be paid for to meet the completion schedule.(**) NOTES:(•)Including all finance charges(••)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special orderedin advance to meet the completion schedule. Express Warranty Is an express warranty being Provided by the contractor? No Yes (all terms Qf the warranty must be attached to the contract) Subcontractors-The-contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 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 this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. E ay cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the tor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the usiness day following.the signing of this agreement See the attached notice of cancellation form foran explanation of this right NOT SIGN THIS CONTRACT IF THERE ARE ANY BLA K SPACES!!! de 'cal copies of the wontmot must be completed end signed. One copy should go to the homeowner. The other * should be kept by the contractor. Hom is Signature ontractor's Sign tore Contractor Arbitration The Home Improvement Contractor Law provides homeowners with fine right to initiate an arbitration action(as an . alternative to court action)if they have a dispute with a contractor.„The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home 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 o I xecutive Office of Consumer Affairs and Business Regulation and the co umer shall be required to submit t c arbitration as provided In Massachusetts General Laws,chapter 142A. Hol ner's Signature Contractor's Si afore NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties._ Homeoivner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly 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 workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the term's 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 duplicate 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 original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day recission period has expired. Accelerated Payments - — - - A contractor may not demand payments in advance 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,or tf you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law,"contact: Consumer Information Hotline' Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 1- 8 - ( 88)2833757 , If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,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 AN-15-2004 09;52 FROM-MICHAEL T. STELLA SR,P.C. +9786835396 T-712 P-002/002 F-644 EX SQRVEY INC . ' O HAVERHILL,VA PhcMgT8.689.19 6•Fax 998.469-'046 MORTGAGOR r►1w1&."e DA941 YE: DEED REF. 9261 PG•j r AOORE88 OF PI INCIPLE BUILDING PLAN REF. I Z3 3 o i,o/.ein V17, _ OATS OF INSPECTIONr.�L B�_2�,c 3 u Ary OaYfa�j �cA SCALE:1'z Go t — � 4.49p Ler!"S 28 '28 11L g Z j RUD-�L 1e �p CERTIFICATION T0:{� ul1 i INVEO/��- Na 36032 . T{1©IN�4t8nnhe principle sVucture/s Th6 MoRgage Piot Plw was prepared specJltcalry tar tQ' a� vrththo tical zaning bylawr�In effect wnen canatrvcied monytfge purposes ons;and It is not 1rdonded a repraeanted �f�si RlCI ST( •� and/k a enonl pt from violation wnenrnrvrt to be a prolM line or lend w".This pian is oat to be used �Al uK: action Is w Maas from B.LTale Vii,Chao. no Sec.1. w astabr5h any or the property Bnea ror Any purpose.No responaibilty13 maen ledtoww land atwneror oecupmrl. I"SubJer_t building not in a Flood HazardAnw. U6 ?ars aenmcadon b tt Dabed on ve toeatbn Of survey marxet#r ©SubJtw n8 is In a Food Hazard Argo. of othorn. Flood Hazard determined from the FIRM maw OaRed J08 _ t .d OOZE .v.3rN3SW*1 dY WUSO_:OT EOD'c -•G AOW The Commonwealth of Massachusetts Department of IndustrialAccidems Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Plcase Print Le�>bly Name(Business/Organization/Individual): �rs,y 0-0 Co f ✓c fi o-.,, Address:l9 City/State/Zip:, Phone #:_!Z 7 A 7 p Are you an employer?Check the appropriate box: _ 1.❑ I am a employer with—�— 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6 El construction 2.❑ I am a sole proprietor or partner- listed on the attached sheget. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers'comp.insurance. 9. Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 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 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. L. i 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ /Ve d-t ,cy�fv/1 c %yfvc C, Policy#or Self-ins.Lic.#: AA1 C`7,s r q X�A Expiration Date: Job Site Address-.t/-Z City/State/Zip.. Attach a copy of the workers' compensation policy declaration page(showing the policy 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. Ido hereby certify under the s and penalties ofperjury that the information provided above is true and correct. Signature: Date: // Phone#: �S'tJ�� r2 EEfD only. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one):Health 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 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 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(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-contractor(s)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"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 burn leaves 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 Col-nrnowealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727,7749 www.mass.gov/dia ACCOREP® CERTIFICATE OF LIABILITY INSURANCEF7/8/2011 ") 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 Sullivan Insurance NAME: Sullivan Insurance & Financial, Inc. PHOAIC.NE (978)372_2790 FAX 487 Groveland Street EMAIL S:ksullivan@sullivanlF.com INSURERS AFFORDING COVERAGE NAIC# Haverhill MA 01830 INSURERA:COmmerce Insurance 34754 INSURED INSURERB:Citatlon Insurance 40274 Desmond Construction, Inc. Matthew Desmond INSURERcAIM Mutual Insurance Company 3758 19 Upland Street INSURER D: INSURER E: North Andover MA 01845 INSURER F: f COVERAGES CERTIFICATE NUMBER:CL117801341 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. INSRADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000 DAMAGE TO COMMERCIAL GENERAL LIABILITY R TED PREMISES Ea occurrence $ 50,000 A CLAIMS-MADE OCCUR ZS1282 /7/2011 /7/2012 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 500,000 GENERAL AGGREGATE $ 500,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 500,000 X POLICY PRO JFCT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 100,000 B ANY AUTO BODILY INJURY(Per person) $ 300,000 ALL AUTOS OWNED X SCHEDULED CNZGY 9/12/2010 9/12/2011 BODILY INJURY UTOS (Per accident) $ 100,000 NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION I WC STATU- I 0TH- AND EMPLOYERS'LIABILITY Y/N TORY I IMITq ER ANY PROPRIETOR/PARTNER/EXECUTIVE D E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) WC7019598 /23/2010 /23/2011 E.L.DISEASE-EA EMPLOYEd$ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Construction Operations CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Diane Fraioli/DNF - ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD Nlassachusett<- T1cli:t4rtmm�t(}t Pulflic Satct% BO:trtl of Bulldin'.1 Rel�wtil:ititins and Stantl:it•ds `J Construction Supervisor license License: CS 7248-1 MATTHEW F DESMOND u 19 UPLAND S? ` N ANDOVER, MA 01845. Expiration: 3122/2012" Tr#: 29377 ('n�nmi��irncr /die Office of Consumer Affairs�Business Regulation License or registration valid for individui use only before the expiration date. if found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: 143109 Type: Expiration: 6/18/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 DES,OND CONST,INC. MATTHEW DESMOND:C, 19 UPLAND ST N.ANDOVER,MA 01845 Undersecretary Not v id withou signature