HomeMy WebLinkAboutBuilding Permit #251-11 - 52 BREWSTER STREET 9/26/2011 tiORT11
BUILDING-PERMIT OFtt�eo
TOWN OF NORTH ANDOVER 0r=
APPLICATION FOR PLAN EXAMINATION
Permit NO: S Date Received Sys R,T.o *aK�y
SACHUSS
• Date Issued: ' •
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IMPORTANT:Applicant must complete all items on this p ge
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building = One family
Addition ' -Two or more•family Industrial
Alteration No. of units: Commercial
P'Repair, replacement Assessory Bldg Others:
Demolition Other
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c DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Prints Clearly) 7J_32
OWNER: Name: ''d Phone: Q G
9 -(7
Address: e_+ vt�5� - - _
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ARCHITECTIENGINEER 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.
�( dJ
Total Project Cost: $ off FEE: $ ��
Check No.: l �� Receipt No.:
NOTE: Persons conte-acting with unregistered contractors do not have access l ty�u�-
:, ,r.4�- _ �;mss:•: _N £- •�..
•.. �.� . . 7�0.. .*sin`
_'=.Sagriaure_<ofgcoTtyraor. � _ ;-
Location "l f _
No. Date
NORr� TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $ _
'E<�'
C MUS Building/Frame Permit Fee $
sA
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
246 i 4 uilding Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE O'P SEWERAGE DISPOSAL-. ..
Public Sewer ❑ Tanning/MassageBodyArt ❑. - . Swirmnmg 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: DATEAPPROVED
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 To-*N;. Engineer: Signature:
Located 384 Osgood Street
FIRE DEP.4RTileT =Temp Rumpster on she yes-. no
Located at 124 Mair Street
Fire Department si'nature/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
❑ Notified for pickup Call Email
Date Time Contact Name
Do.c.Building Permit 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, Siding, Interior Rehabilitation Permits
o Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
a 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
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
o Certified Proposed Plot Plan
Li Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets.of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o Mass check Energy Compliance Report
a 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:Building Permit Revised 2014
NORTfj
® of
ti"r lilt
Y:
No.
o x dover, Mass., •
O
COCHICHEWICK �
S �A0RATED P"'
Cl
'9S Emmlbk BOARD OF HEALTH
PEnMIT T Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT............... ................... rzl%ws. .....................
Foundation
has permission to erect..... ....:.:.......................... buildings on ... !. .....�.r`Mr�. ..... .. a Rough
to be occupied as �! .Q. ®i Chimney
rm
provided that the person accepti this permit shall in every respect co to the terms of the application 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 IN6 S
ELECTRICAL INSPECTOR
UNLESS CONSTRJC., 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 T
No Lathing or Dry Wall 1 o Be Done FIRE-DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SODE Smoke Det.
DAVID CASTRICONE
CASTRICONE ROOFING&SIDING INC.
ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS.
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845
In North Andover 978-683-3420 In Boxford 978-887-6117 In HaverhM 978-374-7314 " -' =i%
I/we the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary
materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and
conditions,on premises below des�fbed:
Owner's Name......(„�:lap... ? (,�.1 ..................... ...Telephone#...Il �
i+fiFiL,�}i7D. � - y
Job Address......./.9...... ..... . r......................................city.., .aP L`1��. ..........................State...!. ..W)
t-ev wY'' ��
Spec 'Aaver
o' ifications:'"E'
.....................................................................................................................................................................................................................
,,Strip existing shingles(f� Ali-oly new drip edge to all edges.
........... ....:......................................................................... ...............................:........................................................................
nllpply _feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane
in valleys and bottom edges of any unheated areas of house.
......... .. .............................................................................................y. ......................................................................................
✓Apply...telt.. paper underlayment Install ridge vent to a
..........
{.� ..... �. .....................
�Reroo[using.... shingles with a year warranty.
......................................................................................................................................................................................................................
—4a6unterflash chimney. -New vent pipe flashing. '-"'legal disposal of all debris.
.......................................................... .................
.... .......
Area(s)to be worked on:
......... r .(:7.C. .. 1t Ttt{L�C?. .. IQ Id �...........................
c�. . :.....�J.F...r........�.� .f.�x..... . . ...... .. ,. ,-
........................................................
Roof board replacement if necessary @ G' /sheet O!!;�Ifoot.
......................................................................................................................................................................................................................
Two Year Workmanship Warranty(Not Transferable) N anufacturer's Warranty as specified by Vnufacturer
The tractor agrees to perform the work and ish the materials specified above for the SUM of S......`.� ..............
r Payable...�/..0...O..........on...5� .......
Payable.............................on............:..................... Balance payable on completion of job
Owner or Owners arc not responsible for Property Damage or Liability wi fob is in operation.
Contractor is not responsible for any damage to the interior of property,including preexisting conditions(i.e.water stains,crumbling plaster,exposed nails)w
conditions resulting from application of materials specified above(i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living
spaces).Items in attic may need to be covered by homeowner.All materials are property of contractor.Any dumpstcr placed by contractor is for his use only.Upon
completion of above work,All undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation as requested by
contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as thea remains unpaid,immediately due and payable. It is
Agreed that,if permitted by law,contractor shall be paid by the owner(s)all reasonable costs,aromey fees and expenses,in addition to the amount due and unpaid,that
shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith.it is further agreed that this contract may be assigned by
contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates of the parties.The undersigned wwant(s)that he is(they are)
the owners(s)of the above mentioned premises and that legal tide thereto stands of record in his(their)names(s).There are no representations,guaranties or
warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the contract dependent upon or subject to any conditions not
herein staled.Any subsequent agreement in refercncc hereto shall be binding only if in writing and signed by all parties.
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration
should be directed to:Director,Home Improvement Contractor Registration, One Ashburton Place, Room 1301,Boston,MA 02108
Tel:617-727-8598
Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction-
related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c.142A.
Approximatestarting date of work................................................ Completion date.........................................................
Receipt of a copy of this contact is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation).
IN WITNESS WHEREOF,the parties have hereunto signed their names this. ..day of. u . .....,20../I*....
Accepted:
Signed.::_....( iJ / ...... ............... Owner
L �]121 Signed.1.. ............................................................I............... Owner
David Castricone,Presiden
i rl a ) >
ACVRCERTIFICATE OF LIABILITY INSURANCE /9/2"°°
9/9/2011
1
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 INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certl8cate holder Is an ADDITIONAL INSURED,the Policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the polity,eertaln PDIICIea may require an endorsement. A statement on this certificate doss not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER QOWACT
Willows Insurance Agcy "*ME 978 475 3414 P --
51 Cochichewik Dr wo
ADDRE":
PRODUCER---'....-- -••••-
North Andover MA 01845 INBw�ERls1 AFFORDING COVERAGE
IIsuR>D INeuRm A jNaidem .9DecialtV Ins Co
DAVID CASTRICONE ROOFING & SIDING INC INSURER 8: - ----- --_ ----
INMMR C
200 Sutton St Suite 226 INCMRD: _
NORTH ANDOVER MA 0184$ INSURERS; _.
INsuRER F;
COVERAGES CERTIFICATE NUMBER CL119906255 REVISION NUMBER,-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOO
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 13 SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MSR _...__..
LTR, bL SUBR TV"OF IN6MKE ' POLICY NUMBER �Ip EiF M�Y E]fP --- LNIRB
GENERAL LIABILITY —AM WVD
EACH OCCURRENCE S 1000000
X COMMERCIAL GENERAL LIABILITY —._..__..._.... ._..—_ ._.
A _ CLAYA3MADE I A I OCCUR 00031600 9/06/2011 /6/2012 PREM�IRF,,SjL�egrinerroe� i S 50000
MEDEXP An see en g 1000
PER.YONAL a ADV_INJURY s 1000000
GENT AGGREGATE LIMIT APPLIES PER GENERALAGGREOATE 3 2000000
PRODUCTS-COMPJOPAGG 3 1000000
POLICY o loc - -.. ... _
AUTOMOBILE uAstlrtr
s
COMBINED SINGLE LIMB 8
ANY AUTO (Fa wcioynl)
ALL OWNED AUTOS BODILY INJURY(Per person) S
SCHEDULED AUTOS BODILY INJURY(Per acdowl) g
HIRED AUTOS PROPERTY DAMAGE :
I_
(Per
Per q=Jder4)
S
UMBRELLA LIAS _... ___ .. ,.. ... b .
=COIC718
�� 11Aa EACIi OCCURRENCE S
E
DEDUCTiRLE AGGREGATE FS RETENTION gWORXERa COMPENSATIONAMDEMPLOYI:R3'LIABILITY WCSTATU- OTHNVYi'ROPRtETORJPARTNERIEXECUi1VE Y!N TQI�YLIMIT LEPOFFICERJMENBER EXCLUDED? N1AE.L EACH ACCE)ENT(Mandatory In NHl deeeriba E.L.DISEASE.EA EMPLOYHDESCRIPTION OF OPERATIONS bdw. .E.L.DISEASE-PpuCY UMrr
i
OEaCWTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 1011,Addeloro Rarnwke Seltaduta,a mac space M Iegmred)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Daviel Castricone Roofing 6 Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS,
Caetricone Roofing
200 Button Street Suite 226 AUTF40RI=RlPRERENTATTVE
N Andover, MA 01845 �7
ACORD 25(2009109) ®4f188�2 CORD CORPORATION. All rights reserved.
INSDZS(zopewl The ACORD name and logo are registered marks of ORD
.11:n�arlwx'tl� Jklia unclli of I'ultlit: JafCC1
f k3ue1'tl ll) Glllltlllt� I\C.111:Itilll0� :111(1 1l allll:ll'11\ ''` -J��c it�o//�//w/�uY:�lllJ. c�//�,•Ih�JJUC/u. !!J
COr1Sif uCt1011 Supervisor Specialty License 01,fice of Cuosumer AtIairs 11lhi less l4gulxtion
:., ,.
License: CS�L 99358 ;,HOME IMPROVEMENT CONTRACTOR �
Registration: 104569 Type:
Restricted w: RF,WS Expiration: 71/4/2012 Private Corporatio`
DAVID CASTRICONE /f`a'). .,'•7C,r DA6 CASTRICONE ROOFING,.SIDING&
31 COURT STREET
NORTH ANDOVER, MA 011345 a;;`r"'i David Castricone
200 SUTTON ST SUITE 226
NORTH ANDOVER,MA 01845 tluJcrsccrctury
`F Explratlun: 1 211 612 01 1
1 �;iuuli"i��u�•r Trx: 99358
A
The Commonwealth of Massachusetts
Department of Industrial Accidents
tt r;lk Office of Investigations
1 Il 1'�•tl t
600 Washington Street
Boston,MA 02111
i www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information x Please Print Legibly
Name(Business/Organization/Individual): ,UAV i I CAA f ifIC oNC POO F t Nlr- i Si p/r-k, tit.
Address: ; () (j Su il-oo Sete+ SU ;T& zZ(1
City/State/Zip: N o. AN aorex_. h/A d 1145 Phone#: 9)% b`c 33'I Z
Are you an employer?Check the appropriate box: Type of project(required):
I.® I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑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. 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.❑ 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 1?-Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A f2TA S
Policy#or Self-ins.Lie.#: C[) dT219 D13 Expiration Date: q
Job Site Address: Sol, CSCity/State/Zip: •linc)o Yn 6 ff j
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,
I do hereby certify under the ains andpe-n�a-1-ties_oflperjury that the information provided above is true and correct.
Si nature: '�-� C�"�"^�
Date:
Phone#: L 7 �}a0
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#:
Town of North Andover
01
�i . ..
Building Department
O .. L
27 Charles Street '' p
North Andover, Massachusetts 01845V.
z n
(978) 688-9545 Fax (978) 688-9542
o4Areo PPw�.�h
-TA HUS
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit# the debris resulting from the work shall be disposed
Of in a properly licensed solid waste disposal facility as defined by MGL c,l 1, s150a.
The debris will be disposed of in/at:
�. Z' l ,
f J
Facility location
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project tluough the Office of the Building Inspector,
Aco P CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYV)
9/23/2011
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(Sy, AUTHORIZED
+rl
IMPORTANT: if 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 CONTACT
NAME:
Eastern Insurance Group LLC - Main PHONE FAX
233 West Central Street MAIL08 - AIC,
C No: -65 3-
Natick MA 01760 ADDRESS:
INSURERS AFFORDING COVERAGE NAIC N
R$LIRERA:CQmTferce Insurance Company 34754
INSURED 31 969 INSURER B:
David Castricone Roofing & Siding Inc INSURERC:
200 Sutton Street #226 INSURER D:
North Andover MA 01695
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2141633407 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.
INSRADDLSUBFI �RMSY FFF PPLAl Y f1XP
lit\ V4Mrl• IIIDC/1 ft ti Ih 11 tl
GENERALLIABWTY EACHOCCURRENCE MT$
COMMERCIAL GENERAL LIABILITY PREMI S a rrenoo $
CLAIMS-MADE 0 OCCUR MED EXP(Anyone person) $
PERSONAL d ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $
POLICY jFcT F7 PRO- LOC $
AUTOMOBILE LIABILITY SCNGCV /1/2D11 /1/2012 BIN 3INGLE LIMIT
E a.klenl 1000000
ANY AUTO BODILY IWURY(Per person) $20000
ALL OS SCHEDULED BODILY INIURY(Per accident) $40000
AUTOS X AUTOS
X HIRED AUTOS X NONOWNED PROPERTY DAMAGE
AUTOS PeraocIlnl is
$
UMBRELLA UAB OCCUR EACHOCCURRENCE $
EXCESS LAB CLAMS-MADE AGGREGATE $
DED I I RETENTIONS $
g WORKERS COMPENSATION C003989723 9/23/2011 9/23/2012 X WCS ATU- OTH-
AND EMPLOYERS'LIABILITYER
ANY PROPRIETOFVPARTNEMXECUTIVE YIN E.L.EACH CMCIDENT $100000
01710ERIM6MBER EXCLUDED? NIA _
(Mandatory In NH)
11yes,describe under E.L.DISEASE-EA EMPLOYE $100000
DESCRIPTION OFOPERATIONS below. E.L.DISEASE-POLICY LIMIT $500000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Castricone Roofing & Siding THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Suite 226 ACCORDANCE WITH THE POLICY PROVISIONS.
200 Sutton Street
North Andover, MA 01845 AUTHORIZED REPRESENTATIVE
0 1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Building Setback(ft.)
Front Yard Side Yard Rear Yard
Required E Provided Required Provides Required Provided
DIM
ENS
ION
Number of Stories: Total square feet of floor area,based on Exterior dimensions.
Total land area,sq.ft.:
NOTES and DATA—(For department use)
Page 3 of 4
Doc:INSPECTIONAL SERVICES DEPARTMENT-BPFORM05
Created JMC.Jan.2006