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HomeMy WebLinkAboutBuilding Permit #225-2016 - 50 ELMWOOD STREET 8/31/2016 ERMIT NORTy ` t BUILDING P Q��TLED �b.14, TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION ac 1- Permit No#: -�-"J 1 Date Received �14p°17 Rwre° 1 gSSACHU`S'fct Date Issued: l 1 I PORTANT: Applicant must complete all items on this page LOCATION S Print .111; PROPERTY OWNER C�Z— AC�,4 �• '1��'�✓ -4��72 Print 100 Year Structure yes ''no MAP _PARCEL: -5 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ElAddition ElTwo or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial )4iepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well El ❑Floodplain Wetlands 0 Watershedi strict; 0 Waiter/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Z5�p Identification- Please Type or Print Clearly/r, OWNER: Name ��r1? S Phone: Add ress: �?C�Jc Contractor Name:,Cca!�z Phone ! � ��� Email'&Z�&IC�' _�°��''�'..� � Address: Supervisor's Construction License:G Exp. Dater ` ®/y Home Improvement Licenser Exp. Dater ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F. Total Project Cost: $ 2, �� � FEE: $ ,J Check No.: Receipt No.: � Z� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty[And gignature- Location �0 No. !/����r�`C�(p Date I r . • ! TOWN OF NORTH ANDOVEJF.,--,... Certificate of Occupancy $ ` Building/Frame Permit Fee s . 2)6 " Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# �� a - 30,024 ��� � Building Inspectorf Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dwnpster on Site ❑ _ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS 4 4 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes n Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street �FIRE�DEPARTMENT� ,zTerrmIDumpster�on�site yes, ''' w `� `.& x; "`"'"�" .�� 2v; € : foal f�10' Located at 124 Ma'iniStreet :; , ~`,, u�; '.{ • .�p .. „ '"'mow�-�.- .— `. ✓� .'�rx—.� " +.i.,..�t''.e.r'!S-r Fir+e Depart�ment.signaturyldate ' ��� �.A ._,��..1'��` r, !�^'.�-�,pr' �",•"°tr""7�#'v�s-..-,4- �..+—�—fr..—_-m...� I 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.$10o-$1000 fine NOTES and DATA— (For department use) I ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 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) 4, Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: 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 2012 I ECC 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 Doc:Building Permit Revised 2014 NORT1y Town o f aAndover h ver, Mass, COCNIC NlWK.t ��• �7S RATED pP���S U BOARD OF HEALTH Food/Kitchen PE IT T LD 1 Septic System �.... .. THIS CERTIFIES THAT ... .. Lev4 BUILDING INSPECTOR . Foundation has permission to erect .......................... buildi gs on ...... �. lL�. ..@.ted p ..�. .... .. .. ...�. ... ........ Rough t0 be occupied as .... .... •� ►J]... 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 B -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 CONS TION T Rough Service . ... . ......... ........ Fina B I INSPE TOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin-e 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. T J www.RoviseEnergy.com Revise Energy Home Performance Contractor 5 South Summer Street,Bradford,MA 01835 CONTRACT 978-914-2214 FAX(401)784-3710 Page 1 PROGRAM CMA-HPC CUSTOMEk OWNE DATE EN * WORK ORUCR Olivia Lagrassa (978)655-5294 07/27/2016 437952 21203 VICE STREET 91LUNQ STRE T 50 Elmwood Street 50 Elmwood Street SERVICE CITYSTATE,7JP UILUNO MY.STATE North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will.be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) This will require(10)working hours.A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual number of cfm is not guaranteed. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. 5850.00 ATTIC FLAT:Provide labor and materials to install a 6.25"layer of R-19 unlaced fiberglass baits to(1100)square feet of attic space. $1,628.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unlaced fiberglass batts to(12)square feet for damming purposes. $24.60 ATTIC ACCESS:Provide labor and materials to insulate the back of([)attic hatch with 2"rigid Thennax board.Weatherstrip the perimeter. 560.00 VENTILATION:Provide labor and materials to install(1)insulated exhaust hose to existing bathroom fan(s). 550.00 VENTILATION:Provide labor and materials to install ventilation chutes in(66)rafter bays to maintain air flow. S132.00 r www.RoviseEnergy.com Revise Energy Home Performance Contractor 5 South Summer Street,Bradford,MA 01835 CONTRACT 978-914-2214 FAX(401)784-3710 Page 2 PROGRAM CMA-HPC -. CUSTOMER - PHONE - SITE NT WORK ORDER Olivia Lagrassa (978)655-5294 07/27/2016 437952 21203 SERV ST 9 50 Elmwood Street 50 Elmwood Street OWE.Zip B NI ATE:sp - North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $2,744.60 Program Incentive: $2,270.95 Customer Total: $473.65 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF **`Four Hundred Seventy-Three&65/100 Dollars $473.65 � F NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE 7149 nzL DAYS. Planview Diagram 3V41 Le . r Customer ri t 1 Advisor Name: ' r ( r Address �J r ((`t trcN d Advisor Phone #: ' Town �� �n v'� Any limitations to access y truck? Site ID 7 7 S NOTES Any work scoped outside of Best Practices? r ` Approved by: (lie e- �(1) ) kJ I, (JIS S fy" U I UIA 8/26/2016 50 Elmwood Street North Andover MA 01845-Salesforce-Professional Edition • Close Window S �"'�� . Print This Page Expand All Collapse All 50 Elmwood Street North Andover MA 01845 Account Name 50 Elmwood Street North Andover MA 01845 Contact Name Ken Campisi Parent Account Rise Engineering Phone 978-852-7942 Account Owner Dana Hills Phone Type Home Preferred Time to Call Email campisik@verizon.net Address Information Billing Address 50 Elmwood Street Shipping Address North Andover,MA 1845 Building Information Living Space Sq Ft 1,400 Type of Home Ranch Number of Units 1 Year Built Condo Association No Years in Home 1988 Owner/Landlord/Renter Owner Number of Occupants Utility Information Primary Heating Fuel Natural Gas Gas Account# Primary DHW Fuel Electric Account# Gas Utility Columbia Gas Last Name on Utility Bill Lagrass Electric Utility National Grid First Name on Utility Bill Olivia Fuel Assistance No EBR/EFR/EAC -Advisor Heating System Eligibility Customer EAC Rebate Form Customer Has EBR/EFR Cooling System Type Rebate Form Heating System Type Cooling System Year https:Hna30.salesforce.com/0013600000SFA61/p?retURL=/0013600000SFA61 1/6 8/26/2016 50 Elmwood Street North Andover MA 01845—Salesforce-Professional Edition Heating System Year EBR/EFR/EAC Notes Heating System Manufacturer EBR/EFR I EAC Submitted to Clearesult Heating System Model Number Heating Serial Name Photos Submitted System Information Created By Dana Hills,7/11/2016 12:34 PM Last Modified By Sam Webb, 8/26/2016 10:02 AM Custom Links Google Maps Google News Google Search Opportunities 50 Elmwood Street North Andover MA 01845--Rise HEA Opportunity Record Type HEA Stage Closed Won Amount $585.56 Close Date 8/9/2016 Probability(%) 100 Lead Source DiPietro Referral Owner Full Name Tara Carroll Won Fiscal Period Q3-2016 Next Step Type Last Modified Date 8/16/2016 Description 50 Elmwood Street North Andover MA 01845 -Weatherization Opportunity Record Type Weatherization Stage Opportunity Identified Amount Close Date 8/9/2016 Probability(%) 5 Lead Source DiPietro Referral Owner Full Name Dana Hills https://na30.salesforce.com/0013600000SFA61/p?retU RL=/0013600000SFA61 2/6 8/26/2016 50 Elmwood Street North Andover MA 01845—Salesforce-Professional Edition Won Fiscal Period Q3-2016 Next Step Type Last Modified Date 8/22/2016 Description Contacts Ken Campisi Landlord/Owner/Renter Owner Email campisik@verizon.net Phone 978-852-7942 Phone Type Home Fax Mobile Open Activities WX Install -Revise Energy Truck 1 Name Ken Campisi Task Due Date 9/2/2016 8:00 AM Status Assigned To Revise Energy Truck Location Related To 50 Elmwood Street North Andover MA 01845 Comments the homes for 9/1 and 9/2 are right next to each other and owned by same homeowner so if needed can work on both on both days if one is faster than the other Activity History Rise HEA-Do Not Move Name Task Due Date 7/27/2016 12:00 PM Location Assigned To Kyle Meredith Related To 50 Elmwood Street North Andover MA 01845--Rise HEA Comments Please call&email to confirm the day prior Email: Pre Visit Email 7/27/2016 12noon Name Kyle Meredith https:Hna30.salesforce.com/0013600000SFA61/p?retU RL=/0013600000SFA6[ 3/6 8/26/2016 50 Elmwood Street North Andover MA 01845—Salesforce-Professional Edition Task f' Due Date 7/26/2016 Location Assigned To Dana Hills Related To 50 Elmwood Street North Andover MA 01845--Rise HEA To: kyle.meredith@reviseenergy.com CC: BCC: dana.hills@reviseenergy.com Attachment: --none-- Subject: Pre Visit Email 7/27/2016 12noon Body: EM Status: Not Submitted SitelD: Name: Ken Campisi Landlord/Owner/Renter: Owner Email: campisik@verizon.net Phone: 978-852-7942 Address: 50 Elmwood Street Comments North Andover,MA 1845 Primary Heating Fuel: Natural Gas Gas Utility: Columbia Gas Gas Account#: Electric Utility: National Grid Electric Account#: On Fuel Assistance: No Last Name on Utility Bills: Lagrass First Name on Utility Bills: Olivia Living Space Scl Ft: 1,400 Year Built: Number of Units: 1 Condo Association: No How did they hear about us?DiPietro Referral Notes to Home Energy Manager:Weatherization.Referral from Donnie Briggs,DHC Install Mgr Email: Revise Energy: Scheduled Appointment Name Ken Campisi Task ✓ Due Date 7/18/2016 Location Assigned To Tara Carroll Related To 50 Elmwood Street North Andover MA 01845--Rise HEA To: campisik@verizon.net CC: harry.black@reviseenergy.com BCC:tara.carroll@reviseenergy.com; dana.hills@reviseenergy.com Attachment: --none-- hUps:Hna30.salesforce.com/0013600000SFA61/p?retURL=/0013600000SFA61 4/6 8/26/2016 50 Elmwood Street North Andover MA 01845—Salesforce-Professional Edition Subject: Revise Energy: Scheduled Appointment Body: Hi Ken, Thank you for scheduling a home energy assessment with Revise Energy.You are confirmed for the following date and time.Please do not hesitate to contact me with any questions. Comments Date:Wednesday,July 27th 2016 Time: Noon Energy Manager: Harry Black Address: 50 Elmwood Street North Andover MA 01845 North Andover,MA 1845 Thank you, Tara Carroll Revise Energy tara.carroll@reviseenergy.com Call -Outbound 1 Name Ken Campisi Task v/ Due Date 7/18/2016 Location Assigned To Tara Carroll Related To 50 Elmwood Street North Andover MA 01845--Rise HEA Comments Columbia Gas Customer-Called to reschedule HEA Files 0079 001 Ken campisi elmwood Program Disclosure Last Modified 8/23/201611:39 AM Last Modified 8/9/2016 4:36 PM Created By Dana Hills Created By Dana Hills Ken campisi elmwood Material Install Summary Ken campisi elmwood CST Last Modified 8/9/2016 4:36 PM Last Modified 8/9/2016 4:36 PM Created By Dana Hills Created By Dana Hills Ken campisi elmwood Last Modified 8/9/2016 1:12 PM Created By Kyle Meredith Copyright©2000-2016 salesforce.com,inc.All rights reserved. https:Hna30.salesforce.com/0013600000SFA61/p?retU RL=/0013600000SFA61 5/6 101REVISEENERGY A DIPIETRO COMPANY As an employee of Revise Energy (DiPietro Home Energy) holding an Unrestricted Construction Supervisor License (CS-056846), I hereby grant permission for either Dan Carroll, Matt Hammer or George Desroches of Revise Energy to apply for and or pull a permit in my name and under my license for Weatherization work. Weatherization work may include, air sealing, blown cellulose insulation, Installation of weather stripping, door sweeps, thermax, etc. approve this permit to be filed under my name by either gentlemen listed above in the town of: AloA;� Sincerely, John Cullen License # CS-056846 Cell: 781-526-5581 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 Commonwealth of Massachusetts .Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia 7/26/2016 IM G_0605.J PG IpMMMachuSetts - Department at pubolle Safra. Board of Build,- Regulations and St*ndtir .�MCr"11GR"' 4"V+I ST ob 4" OEM Expiration j contri, ftt n" 0003017 Y� 1 https://mrail.google.com/mail/Mnbox/156288b66940610d?projector=1 1/1 Unrestricted-Buildings of any use group which Massachusetts Department of'?U a,VQ;eJ Contain less than 3 s Board o. ..iid;�~y omega;at;c^s a 5,000 cubic feet�991nt of �onst�acs;c,r,super�i or enclosed space. License: CS-056846 JQli[N D CULLEN 46 VALLEY S7[ �. Wakefield MA Of880 •fY ` Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. 04103/20' For DPS licensing information visit: www.Mass.Gov/DPS Commissioner Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 185083 Type: Corporation Expiration: 4/25/2018 Tr# 288111 DIPIETRO HOME ENERGY JOSEPH DIPIETRO 5 SOUTH SUMMER ST. HAVERHILL, MA 01830 Update Address and return card.Mark reason for change. SCA 1 20M-05111 Address E] Renewal Employment ❑ Lost Car (✓�e T�o�nawarr•cuea��a,�����usaa�ase(�3 Office of Consumer Affairs&Business Regulation WOM'E IMpROV•EME1 CONT CTType: Registration: ``1850$3 oration lA ,8 Co rp Expiratioia�<- DIPIETRO HOME EN i SOLUTIONS,INC. JOSEPH DIPIETRO .y VNO _L 5 SOUTH SUMMER Sl-, — U d ecreta►7 HAVERHILL,MA 01830 {� 1he Commonwealth ofMassachusetts �� `ratarorm- j ,r5 Department of Industrial Accidents Office of Investigations - 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ' 1 Name (BusinesslOrganization/Individual): Address: City/State/Zip: Phone # � ` W on an employer? heck the appropriate box. Type of project(required): 1 am a employer with 4. ❑ I am a eneral contractor and I mployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. � required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I .❑ Plumbing repairs or additions myself. [No workers' comp. ri ht of exemption per MGL 12.0 Roof repairs insurance required.] t . 152, §1(4), and we have no employees. [No workers' 13.[:] Other� i4 _"A/ comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#:_0 I y io h1` 06!�_ (oS Expiration Date: D 4 1 Lo ( 2 O 1 Job Site Address: 3 � City/State/Zip:A/,a, Attach a copy of the workers' compensa on 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. I do hereby cerWfy u der the paim and zwnallies o er u that the in ormation provided above is true and correct~ Si nature: --- [Phone Official 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#• ACORU® DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 8/30/2016 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 EmilyCostello NAME: Costello Insurance Agency, Inc. PHONE : (978)374-6352 FAA/CNo:(978)521-5127 2 S. Kimball St. E-MAIL ADDRESecostello@costelloinsurance.com S: PO BOX 5248 INSURERS AFFORDING COVERAGE MAIC# Bradford MA 01835 INSURERAColony Insurance Company INSURED INSURER B:Commerce Insurance Co. 34754 Dipietro Home Energy Solutions, Inc. INSURERC:Star Insurance Company DBA: Revise Energy INSURERD: 5 South Summer St INSURERE: Bradford MA 01835 1 INSURER F COVERAGES CERTIFICATE NUMBER CL1642500527 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM DIDY EFF MM/DD� LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS MADE ❑X OCCUR PREM SES Ea occuDAMAGE TO ence$ 50,000 PACEP305047 4/25/2016 4/25/2017 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO F71 Loc PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COEa accident MBINED SINGLE LIMIT $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED HS6325 4/18/2016 4/18/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS Ix NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I X I RETENTION$ 10,000 EXC305048 4/25/2016 4/25/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA (Mandatory in NH E.L.EACH ACCIDENT $ 1,000,000 C MFEXCLUDED? WC 0856525 00 4/20/2016 4/20/2017 E.L.DISEASE-EA EMPLOYE $ 1,000,000 ( rY� ) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION (978)688-9542 dbelanger@northandoverma.g SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Inspector of Buildings Dori Belanger ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St, Suite 2035 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Emily Costello/HOYECI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025t9m4m1