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Home My WebLink AboutBuilding Permit #082-2017 - 50 HIGH STREET 7/24/2014 BUILDING PERMIT NoRT{1 V � � � � �� • � O�'• LED 6 q�O TOWN OF NORTH ANDOVER 1 �? - -� IN APPLICATION FOR PLAN EXAMINATION- yc * 1 .0 � '" 1 Date Received O Permit No#: � QDgRTEO�PPy�S 1 CHusEc Date Issued: �SSA IMPORTANT: Applicant must complete all items on this page LOCATION i &H V Y`i—c Y'4K4n- Print � PROPERTY OWNER rL d-- �,�c5 It Ll LL_ �— Print 100 Year Structure yes no MAP �PARCEL: ZONING DISTRICT: Historic District no Machine Shop Village a no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family 0 Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg 0 Others: ❑ Demolition ❑ Other 0 Septic 0 Well ❑ Floodplain. 0 Wetlands 0 Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: IdentificaYon- Please Type or Print Clearly f OWNER: Name: Ca° . I,I-- Phone: 11-G ZS Address: s c.Jt�'rL j c1 rt,vrw1��6 Contractor Name'? K Will4oaL7 7h & Phone: Email: 4M- K eA r-T-r4 cfft IL-%C.o M Address: Supervisor's Construction License: Exp. Date: /2-6/1 -Home Improvement License: Exp. Date: ARCHITECT/ENGINEER 3 r-S R 1 i►16 f=-4 Phone: cl-7 Vicr z Address:Z,b OH6rMIAAc-25� 045WVVyL&fifWReg. No. FEE SCHEDULE.BULDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST�BASED`ON$125.00 PER S.F. �/ Total Project Cost.- $ 4-L -3 -3 6 170 FEE: $ �O `T 1()o = (-0 Check No.: e!-61 `j Receipt No.: �XIp -3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Siana_t��rP o Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL j Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On 7�(of�tlo Signature_ COMMENTS — i 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 1, Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE4DEP„ARTMENT -.Tempi®umpster.Bgnsite eyes.— retD_epartment signature/date o - - _ - COMMENTS. 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.$100-$1000 fine NOTES and DATA— (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, 9 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) 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 4 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 INIOTE: 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 �3:-,,• _ ,..a+'K-: -ryn,ss',-Ai:`:r.+t .3.C`.:sw.�.::sc=f+.�w.:s,;.,:.sa:.-..............-r,w;,,,*5�.._--� r� .,.� ...y-is.,i,...�... .... Location /- - P7 712- No. tr��- Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $/4 7 Building/Frame Permit Fee $ � Foundation Permit Fee $�"* Other Permit Fee $ TOTAL $ {P Check# � i f of j 30663 Buildir j Inspector ♦ iSL. CERTIFICATE OF USE & OCCUPANCY TOWN ®IF NORTH ANDOVER Building Permit Number 082-2017 on 7/26/2016. Date: September 7, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 50 High Street— Suite.12 MAY BE OCCUPIED AS a tenant fit up - Maker Mill IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG, West Mill LLC 50 High Street North Andover,MA 01845 *Building41nspector Fee: PrePaid $100.00 Receipt: 30663 Check : 2515 NORTfi ' - w. .. . . . . �. .c . . ve,. o9 C, LAKI ver, Mass CoCMICM.WICM y1. �,9s RATED V BOARD OF HEALTH Food/Kitchen PERMIT .TI. I LD Septic System THIS CERTIFIES THAT k BUILDING INSPECTOR Foundation has permission to erect buildings on 5%jill. ... .- R ...�.�... Rough Og to be occupied as .............. .. ... . ....... .................. Chimney . ......................................................... provided that the person accepting this per t all in a ry 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONST IO Rough Service / ... .. . . ....... ...... ........ ........ Fina B I INSP TOR 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. CERTIFICATE OF USE & OCCUPANCY TOWN ®IF N(CDR7IHI ANDOVER Building Permit Number 082-2017 on 7/26/2016. Date: September 7, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 50 High Street— Suite. 12 MAY BE OCCUPIED AS a tenant fit up - Maker Mill IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG,West Mill LLC 50 High Street North Andover,MA 01845 Building Inspector Fee: PrePaid$100.00 Receipt: 30663 Check : 2515 r 1 NORTH�\ ' ve". 'o No. ver, Mass , T1zjJ4 lc�O COC"IC"EWKM �1- �.9s RATED U BOARD OF HEALTH Food/Kitchen PERMIT .Ti .' LD Septic System THIS CERTIFIES THAT e k BUILDING INSPECTOR . uea.... A. .. . .%.. .. . .. .. ..... .. . Foundation has permission to erect buildings on .�� ..., .- ,R ...�. .. Rough Og/o-/,�22qL tobe occupied as .......... ... .. ....... ........................................................................... Chimney provided that the person accepting this per t all in el y 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 a Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final All (- PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST IO 7-A Service ... .. ....... ...... ........ A (1� // ....P ........ Fina y —/ b B I INSTOR - 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 d Street No. Smoke Det. Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 42A7.00 m $ - $ 508.04 Plumbing Fee $ 63.51 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 63.51 Total fees collected $ 735.06 50 High Street Suite 12 - Maker Mill 082-2017 on 7/26/2016 Tenant Fit Up 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 PLANNING & DEVELOPMENT Reviewed On ?i(at W Signature_ 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 KI-KEt-80—RTMENT, -�;TempjtDumpster mon,site; ,yes.,. . .._ .: �tnoL rLro�ated�at�124iIVla nfSt�eet :-� �..'-1 --- FiretDepart mentisignat%ire/ddte .a�'! .� _. / 14 _ _ _ 7_ _ ► z COMMENTS. ' f r 1 NORTH . w: .. . . _ 1 . ve. . h ver, Mass 0 COC NICHt WI[M �.'►' s 4ATED fJ BOARD OF HEALTH Food/Kitchen PERMIT T D�I Septic System THIS CERTIFIES THAT ........ t �I ` BUILDING INSPECTOR .... ...:� .......wes ....r..�: ...... ...L`....... ...... ..................HAW Foundation has permission to erect.......................... buildings on .6;1j..... . .. . ... .-...��. A,R ...�. ....... � ' Rough tobe occupied as .......... ... .. ....... ........................................................................... Chimney provided that the person accepting this per t all in eJ�ry 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 LMZ MONTHS ELECTRICAL INSPECTOR UNLESS CONST Rough Service Colo—__ ..... ....... Final BSP TOR 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. JK Contracting LLC Proposal 31 Richmond Street Weymouth, MA 02188 617-592-6775 (Kieran) 781-254-2862 (Judy) Proposal Date: 6/13/2016 Proposal#: 203-21 Project: Bill To: David Streinbergh, Suite 12, Maker Mill, 50 High St N.Andover, Mass 01845 I Description Est. Hours/Qty. Rate Total General Conditions 2,000.00 2,000.00 "Permit andC of 0:. 920.00 920.00 Demo, Wails, remove doors. 3,000.00 3,000.00 Wall Frame ,Includes materials. 3,500.00 3,500.00 7 Doors&Trim 2,500.002,500.00 .Electrical&Lighting[Estimate] 8,000.00 8 000.00 Tel/Data(estimate} 3,500.00 3,500.00 Heating &Cooling, [Estimate without plan] 6,000.0-0- 5,000.00 Insulation 1,500.00 1,500.00 :Interior Walls, l3oard. 2,400 00 +42,400.00 Millwork&Trim, oak cap 450.00 450.00 'Cabinets&Vanities_ _ _. _ _ OeoO 0-00 Painting 5,000.00 5,000.00 & iCleanup Restoration _ 300.00 _ 300:00 Sprinkler Work 900.00 900.00 _. - . Supervision . _ ._ . : 3,897 00 :_3,897.00 Insurance 389.70 389.70 -----CHANGE ORDER -- --- July 14, 2016 > Removed 1 24 Paint. (-$10,500.00) > Removed 1 29 Supervision. (-$4,447.00) > Removed 1 30 - Insurance. (-$444.70) >Added 1 24 Paint. (+$5,000.00) > Added 1 29 Supervision. (+$3,897.00) >Added 1 30 - Insurance. (+$389.70) Total change to estimate-$6,105.00 ------------------------- Total $43,256.70 JK Contracting LLC Proposal 31 Richmond Street Weymouth, MA 02188 617-592-6775 (Kieran) 781-254-2862 (Judy) Proposal Date: 6/13/2016 Proposal#: 203-21 Project: Bill To: David Streinbergh, Suite 12, Maker Mill, 50 High St N.Andover, Mass 01845 Description Est. Hours/Qty. Rate Total General Conditions 2,000.00 2,000.00 Permit and C of O 920.00 920.00 Demo, Walls, remove doors. 3,000.00 3,000.00 Wall Frame ,Includes materials. 3,500.00 3,500.00 Doors &Trim 2,500.00 2,500.00 Electrical & Lighting[Estimate] 8,000.00 8,000.00 Tel/Data[estimate} 3,500.00 3,500.00 Heating & Cooling, [Estimate without plan] 5,000.00 5,000.00 Insulation 1,500.00 1,500.00 Interior.Walls, Board. 2,400.00 2,400.Q0 Millwork &Trim, oak cap 450.00 450.00 Cabinets &Vanities 0.00 0.00 Painting 5,000.00 5,000.00 Cleanup & Restoration 300.00 300.00 Sprinkler Work 900.00 900.00 Supervision 3,897.00 3,897.00 Insurance 389.70 389.70 ----- CHANGE ORDER ----- July 14, 2016 > Removed 1 24 Paint. (-$10,500.00) > Removed 1 29 Supervision. (-$4,447.00) > Removed 1 30- Insurance. (-$444.70) >Added 1 24 Paint. (+$5,000.00) >Added 1 29 Supervision. (+$3,897.00) >Added 1 30 - Insurance. (+$389.70) Total change to estimate-$6,105.00 ------------------------- Total $43,256.70 OFFICE OF BUILDING INSPECTOR ►� d4 TOWN OF NORTH ANDOVER ,r A Gym' CONSTRUCTION CONTROL No.95 PROJECT NUMBER: 15-0718 i o SCITU Qj o �r PROJECT TITLE: West Mill - Maker Miff Suite 12 PROJECT LOCATION: 50 High Street, N. Andover, MA NAME OF BUILDING: fest Mill NATURE OF PROJECT: Tenant demising and tenant tit out. IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, REGISTRATION NO. BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, i COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ' ARCHITECTURAL STRUCTURAL ® MECHANICAL ' FIRE PROTECTION ' ELECTRICAL ® OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become, generally familiar with6the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY , A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. l H SIGNATURE SUBSCRIBED AND SWORM TO BEFORE ME THIS� DAY OF CHERYL' URKIN SHAY - Notary:Public NOTAR L1LIC MY COMMISSION EXPI Commonwealth',of Massachus y ommfssion Expires March 7, 2019 The Commonwealth of Massachusetts - Depar tment of lndush*1 Accidents Office oflnvestrgations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Conti•actors/Electricians/Plumbers Annlicant Information Please Print Legibly Name(Business/Organb2 ion&dividual): Cotj7 ogL1 (1V 4, Address: S, fid 10 go ou Vq i City/State/Zip: N - A rs 0 ov sem' b9 a I 1 SrlPhone#: b 14—E i Are you an employer?Check the appropriate box: Type project(required): 1.® I am a with er em to 4. ❑ I am a general contractor and I employer � 6. E)New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. J&Pemodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. El lladdition rNo workers'comp.insurance 5. ❑ We are a corporation and its 9,10.[]BBuilding gl repairs or additions required.] officers have exercised their 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' 13.0 Other comp.insurance required.] `Any applicant that checks box#I must also fill out the section below showingtheirworkers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a newaffidavit indicating such. #Contractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:.C5 %p14 L`1 a NQ U K1DN Lv` 19 C _v-^j o C_ Policy#or Self-ins.Lic.#: e' 0 -7 Lt— Z_ Expiration Date: Z I —7 r Job Site Address: y47 City/State/Zip: 61 C4 J Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or on-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup 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. ~.1 do hereby cerfiry under thepains andpenalties ofperjury that the information provided above is trued correct Signature: Date: 4" Phone#• 6 1 1 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.PIumbing Inspector 6.Other - - Contact Person: Phone#: JKCON-1 OP ID:HS ACORO' DATE(MMIDo1YYYn CERTIFICATE OF LIABILITY INSURANCE 0211712016 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: ff the certificate holder is an ADDITIONAL INSURED,the policy(les)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 NAME: DeSanctis Insurance Agcy,Inc. PHONE iuc No 100 Unicom Park Drive L Woburn,MA 01801 INSURER(S) AFFORDING COVERAGE LANCE INSURER A:Star Insurance Company 012245 INSURED JK Contracting,LLC. INSURER B:Selective Insurance Company 18259 4 High Street Suite 108 INSURERC: North Andover,MA 01845 INSURER D: INSURER E: Q1eURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ISMS. OR TYPE OF INSURANCE POLICY NUMBER LTR 1,000,0001 B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 02/1012016 02/1012017 MAG�TO $ 100,00 CLAIMS-MADE Fx—IS2205113 OCCUR MED DP one mon) $ 10,00 PERSONAL a ADV INJURY S 1,000,0001 GENERAL AGGREGATES 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: 3,000,00 PRODUCTS-COMP/OP AGG S X POLICY�JECTT ❑LOC $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ ANY AUTO ALL pyyNEp SCHEDULED BODILY INJURY(Par eeddent) S AUTOS AUTOSMINON-OWNED d AGE $ HIRED AUTOS p AUTOS $ UNBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ $ DED I I RETENTIONS WORKERS COMPENSATION X ATU ER AND EMPLOYERS'LIABILITY YIN C08S3742 02/17/2016 02/1712017 E.L EACH ACCIDENT S 100,00 A ANY pROPRIETOR/PARTNER/E)�CUTNE N/A 100,00 EXCLUDED? MA E.L.DISEASE-EA EMPLOYEE S Ii yes dIn NK) escribe under E.L DISEASE-POLICY I WIT S 500,00 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VErBCI"(ACORD 101,Additional Rsnwks SdwduK msy be gUsaW N more sp�is mqulnd) Evidence of coverage. CERTIFICATE CANCELLATION TO WHOM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TO WHOM IT MAY CONCERN ACCORDANCE VKM THE POLICY PROVISIONS. AUTHOR9MD REPRESENTATIVE ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo aro registered marks of ACORD Massachuse Board of Building Rpartment of P License: egulations and St Safety Const.u�t oCSi 66334 Standards 3 MND STR MOUTH MA 021 p Commissioner Expiration: 09/28/2017 i I