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HomeMy WebLinkAboutBuilding Permit #593-2017 - 55 HEATH ROAD 12/2/2016 Y ✓ Np R T{•1 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _y Date Received �'" ' Permit No#: '3_.-00l7 �' ADRATED gSSaC usE� Date Issued: IMPORTANT: Applicant must complete all items on this page r - - T1;Ol�lu P tF PR;®PERTY OWNER' r - — ,nnt4 1 DD Ye�arrstucture' yes, no i PP,-' µEL:_ . _ ZONING_xDISTRI'CT Hi storicbDist��ctr s no =PARC a' MAP�- _ ._ _ .L � _ .- r _ � -- - s " �MachlneShopVillage! _yes,_ no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building $I One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assess!2y Bldg ❑ Others: ❑ Demolition 51 her igZi Sep'fic O11Nellf �'� �;Floodpla n a Wetlands, D Wate`rshedtDistnct n a , DESCRIPTION OF WORK TO BE PERFORMED: Ce�1v10'S kYNSykck'6C>� In KYlee«) ���� Identification- Please Type or Print Clearly . OWNER: Name: Laura C ra%q - Rr(au Phone: q-)�- (-vq Address: a ` { Contractor. Name�.rac�r.�rnocK.-�«��� �hs� ic:�n�;,Agihone _r Addreas,_�, , Ps - ��11VvU.►� _ . � - Supervisor's ConsructioniLicens -05 _. e ' p�SS4 j,•,_ Exp�.. Dateh ZIP _ _ . M -•- t _� b l�_ Ex_- Date: J Horne�lm o�ement.License X50 - ..� _ _ �_ ,� __—�_p= - P •�_J. ARCHITECT/ENGINEER Phone: - Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 3122 C)2 FEE: $ 3 Check No.: 7 9"/ ? Receipt No.: �j f 7 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund .. Si nature of contractor 5J nature of A ent/Ownec _Sianature_ __.-_.__ _ ___ _____ 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 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: FFRD Located 384 Osgood Street EPARRTME Te r. x.- t NT 4 mp�DumpSter on site. ,yeses _ no4-_ _ tlartme p a _ nt,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) ❑ Notified for pickup Call Email Date Time Contact Name Doc.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 ❑ 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 o Workers Comp Affidavit o 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 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 ❑ 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:Building Permit Revised 2014 14 i- Location �►_ �' �� "fi No. SSI _ �O 1 Date f • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 4' Foundation Permit Fee $ k Other Permit Fee $ ` TOTAL $ Check#'�/ 1 � tr . r uilding Inspector I i �' Mai. RT1y Town of � : �' . Andover . �+ 0- * h ver, Mass, ��► '° ,' O GOC LAK NIC Nl WICM �.95 R�rEo �Pp��S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..MAPPASO&A Vmok i..stsvhoi ®. BUILDING INSPECTOR has permission to erect ....... buildings onA Foundation Rough to be occupied as .........00.. ' . ..�. .r..........*_44. .'AO.o..04v.................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TARS Rough ,; 10 111 lllww� Service ......... .... .....A.A.IF..................................... Final BUILDING INSPECTOR 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. , q CRA35-S Federal ID#05-MOS629 RISE Engineering RI Contractor Registration No 6166 `I MAContractor Registration No 120979 ICT Contractor Registration No620120 60 Shawmut Road,Can ton,MA 02021 �OA�.�.�j w^� ENGINEERING 339-502-0335 ! 339-502-0335 'FA-N339-502-6345 Rl1i.r Page 1 PROGRAM Ws CCNrRACTMENEREn MBEIWEEN RUSE ClIML-}IES ENGINEERUNO AND NE CUSIDWR FOR WORK AS DESCRIBED BELOW CUSIONER PHONE DAM CUENTo WM ORDER Laura Craig-Bray (978)689-2887 11/2112016 442824 23903 SERVICE sREET 8111N0 SKEET 55 Heath Road 55 Heath Road f N. SERVICE cnY,SUE.MP sum cny.swE.ap , �.r •- _r�:� North Andover;MA 01845 North Andover.MA 0185 u t JOB DESCRIPTION t Ill PRASE ONE-Proposal for this calendar year. $0.00 HAZARD BARRIER:We have identified that there are recessed lights present in your home.unless the rccessed lights arc scrolled as 1C-rated(Insulation Contact Rated)me trill create a 3'cicmncc space around the fixtu c by using fiberglass blanket insulation as a damming material,no insulation All be installed across the top and closed cavities Khich contain recessed lights will not be insulated. $0.00 AIR SEALING:Provide labor and materials to seal areas of your home against ttasleful,excess air leakage. This twrk Mill be performed in concert with the use ofspecial tools and diagnostic tests to assure that your home trill be left frith 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 scaling include air leakage to attics,basements,attached garages and other unhealed areas(Wridotrs are not generally addressed.) This All require(10)twrking hours.A reduction in cubic feet per minute(cfm)ofair infiltration%%ill occur,but the actual number of cfm isnot guaranteed. At the completion of the twathcrization twrk,and at no additional cost to the homeowner,a final blotter door and/or combustion safety analysis will be conducted by the s6-contractor to ensure the safely of the indoor air quality. $850.00 KNEEWALLS:Provide labor and materials to install R-13 faced fiberglass to(13 5)square feet of kneettall. Then install rigid Ward at R-10 or greater ttith the required fire rating.Seal All scamsttith FSK tape. NOTE:CONTRACTOR DISCREATION.TIGHT SPACE. $492.75 KNEEWALL FLOOR Provide labor and materials to install a 6°layer of R-22 Class l Cellulose added to(86)square feet of open knccwall floor.. NOTE:CONTRACTOR DISCREATION.TIGHT SPACE. $103.20 ATTIC ACCESS:Provide labor and materials to make(3) temporary access to an attic area. The opening trill be closed with materials similar to those existing Finish sanding and painting is not included. $255.00 VENTILATION:Provide labor and materials to install(1)insulated exhaust hose with roof mounted flapper vent to exhaust existing bathroom fan(s).Broan model#636 or equivalent. 6118.75 VENTILATION:Provide labor and materials to install ventilation chutes in(112)rafter bays to maintain air flow. $224.00 Federal ID#06-0405629 RISE Engineering Rt Contractor Registration No 8186 CTContractor Registration No 120929 C7 Contractor Registration No620120 60 Shaw•mut Road,Canton,MA 02021 ENGINEERING 339-502-6335 �Z 339-502-6335 FAX 339-502-6345 L RA Page 2 PROGRAM WS CONWACTIS ENERED INA SEMEEN RISE 014WIES ENOWEERIND AND THE CUSVWR FOR WDRt(AS DESCRIBED 9ELOW CGISTDAER PHONE DAZE CLIENT6 WORK ORDER Laura Craig-Bray (978)(S89-2887 11/21/2016 442824 23903 SERVICE SPEET EILLINO SWEET I! 55 Heath Road 55 Heath Road SERVICE et1Y.SZITE.bP 0111atD.cnT,smm.LP North Andover,MA 01845 North Andover.MA 01845 JOB DESCRIPTION COMMON WALLS Provide labor and materials to.install rigid board at R-10 or greater with the required Pre rating to(86)square feet of common wall area. $301.00 COMMON WALLS Provide labor and materials to install rigid board at R-10 or greater with the required fire rating to(86)square feet of common++all area. $301.00 BASEMENT CEILING:Provide labor and materials to install(180)linear feet of R-19 unlaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. $315.00 BASEMENT DOOR:Provide labor and materials to insulate the back of the basement door leading to the bulkhead with rigid board at R-10 or greater with the required fire rating that meets the sections R-316.5.4 and 316.6 requirements of building code. Seal all edges and scams wit h FSK.tape. 572.22 WINDOWS-OKAY-'WINDOWS $0.00 EX1Sf iNG.DOOR-DOORSOKAY $0.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Sealing measures up to the first 5680 and an additional$340 if savings arc justified by the auditor. For the safety and health or your home's indoor air quality,we will be conducting a blower door diagnostic or the available air flow in your home both before the work is begun,and after the wcat hcrization work is compiete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you Total allowable wcather'vation incentive is$3.110. The Permit will be secured by the insulation contractor,at no additional cost.It is the homeowners responsibility to close out this permit by contacting their municipality at the completion or this work. $90.00 t f Y I Federal ID 9 05-0405629 RISE Engineering RI Contractor Registration No 8186 MAContractor Registration No 120979 CT Contractor Registration No620120 RISE60 Shuwmut Road,Canton,13.4 02023 CONTRACT^� ENGINEERING' V RIy,L 339-502-6335 Et1\334-502-6345 Page 3 PROGRAM "505 C01RACnS ENERED INM SEMEN RISE CMA-HB ERGNEERIRGAND W C SIDWR FOR WORK AS DESCRIBED BELOW CUStONER PHONE OAE CUEM WCRK ORDER Laura Craig-Bray (978)689-2887 11/21/2016 442824 23903 SERVICE SKEET STUM STREET 55 Heath Road 55 Heath Road SERVICE IXSY.SQE,aP SILUNG CnY,5A1E.LP North Andover,MA 01845 North Andover.MA 01845 JOB DESCR MON Total: $3,122.92 Program Incentive: $2,577.19 Customer Total: $545.73 WE AGREE HEREBY TO FURNISH SERVICES-COMMETE Di ACCORDANCE W TTH ABOVE SPECIMA710NS.FOR THESUM OF *'*l=ive Hundred forty-Five&7NI00 Dollars $545.73 UPON RHALINSPEC14N AND APPROVAL BY RISE ENGRNEEROM NSStONER AGREES'O RSUTAMLRaDUE IN FURL RNERESTOFI%WILT.BE CHARGED MONIKLY ON ANY UKPARD BALANCE AFER SO DAYS.SE SE FOR WFORIANJUMXMION ON OUARANEES.RxmOF RECISION,SCHEDULING,AND C=LC!!!REGISIRAIM DON SIGN THIS CONTRACT IF THERE ARE ANYSLANK SP ES AUSNORDED SI E-RS E ft / NUE:IRS CONRACTWY BE WnHDRAWNUS 1: 11CUEDYMM DA80FACCEPZ%NCE ACCEPWNCE OF CONRACr-IRE ABDVE PRICES.SPECMAIG NS AND CUMVI ONS ARE 30 DAYS. SAISFAC'faRY"IDISAND ARE HEREBY ACCEPED.YOU ARE AUIIOR®70 D011E WORK AS SPECMED.YAYMrrWRLRE MWE AS WI RRED ABOVE =� N6`, 2 2 2016 i RISE - 60 Shawmut Road,Unit 2 1 Canton,MA 020211339-502-6335 ENGINEERING www.RISEen ineerin .com 9 9 is flcic icyEne:;i.e OWNER AUTHORIZATION FORM 1, a r- (Owners Name) owner of the property located at: iL (Property Address) �� �; ;y F -"`"' tft 4.3 , (Property Address) Merrimack Valley Insula' 23A Sullivan Rd hereby authorize Billerica,MA 01862 (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. wners Ignatur �T/1k Date 6.2016 The Con:ntonivealth of Massachusetts Deparhnent of Industrial Accidents kq Office of Investigations 600 Washington Street Boston,MA 02111 i<veviv.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Informat7ionII- Please Print Legibly Name(Business/Organization/Individual): V Y12(, J , O3 a o� Address: 3 R clU��lllt ly (i� City/State/Zi tlPhone#: 793 9 Are ou an employer?Check the appropriate box: Type of project(required): 1.91,am a employer with_j� 4. [j I am a general contractor and I employees(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 g• ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. ❑BuiIding 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 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]f c. 152,§1(4),and we have no employees. [No workers' 134 OtherL- fly�f�/U'" 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 lure 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 and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance CompanyName: ��: �3 p I l 1"IW�f i1 (✓'Q 1y l �� QUJSUh�P Policy#or Self ins. Lic.#: V �C ^t�) Expiration Date: Job Site Address:,_ tti�G>✓ �'�— City/State/Zip 4" 4 -0 1 y� 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 certiutde he ins and penalties of perjury that the information provided above is true and correct. Sitmature: V, Date: � �l�' Phone#: �1 7� X09 � `_ Official use only. Do not write In this area,to be completed by city or 1011,18 official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector S.Plumbing Inspector G.Other Contact Person: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant.Information Please Print Legibly Name (Business/Organization/Individual): Merrimack Valley Insulation Corp. Address: 23 A Sullivan Rd. City/State/Zip: Billerica MA 01862 Phone#: 9.78-888-3495 Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 18 4. ❑ I am a general contractor and I employees (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 g. 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 11.❑ Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c_ 152, §1(4),and we have no employees.[No workers' 1351 Other Insulation comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 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: 5Star V3 AAIC American Alternative Insurance Policv#or Self-ins.Lie.#: V9WC749118 Expiration Date: 6/18/2017 Job Site Address: SS ?_6 City/State/Zip:N,flndo�er,MA 0 X645 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 pains and penalties ofperjury that the information provided above is true and correct Signature: Date: )a j o'Z""/J� Phone#: 8-888-349 Official use only. Do not write in this area,to he 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#: -�` MERRVAL-03 WEJE AIC-10IRL- CE-RTIFICATE OF LIABILITY 8 SURANCEDA-E(IANODDNYYY) �--- I 6113120'16 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 NAME: Automatic Data Processing Insurance Agency,Inc PHONE — FAX 1 ADP Boulevard A1C Ne Ext)- I AfC.No): Roseland,NJ 07068 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 9 -INSURER A:5Star V3 AAIC American Alternative InSuran. INSURED Merrimack Valley Insulation Corp INSURERB: 23a Sullivan Rd INSURERC: North Billerica,MA 09862 iNSURERD- — kINS SUREREURER F• { COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I THIS 15 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( ADDL s ( POLICY NUMBER --- I h5 NDDIY w rot°mniP I LTR TYPEOFINSURANCE INSR LIMITS 1 GENERAL LIABILITY i 1 EACH OCCURRENCE 15 7 Ot DAMAGE RENTED � S - C_dhSERCWLGENERAL LL4BILlTY f I � I I PREIAI_SESjEaoeeurrene.j._�—_ —_ .CtAR.1S-MADE u OCCUR. II NiED EXP(Any ane person) 1 S PERSONALSAOVINJURY is GENERAL AGGREGATE IS f GEN'LAGGREGATELIM1IITAPPLIESPER: ;PRODUCTS-CO;,IPIOPAGGS F I PRO- �� t ------ f POLICY I ,JECT 1 1 LOC ( S AUTOA1081LELIABILITY I }ca SINEDSINGLELRAtr accidentl S a ANY AUTO i I BODILY INJURY(Per person)-I8 ALL OWNED SCHEDULED r -- AUTOS AUTOS i i BODILY tNJURY(Per accident) S "RED AUTOS NON-OWNEO ( I I PROPERTY DAMAGE S --- AUTOS —,�UTABRELIAUAB OCCUR ' EACH OCCURRENCE 5 EXCESS WAS CLAWS-1113ADE1 I AGGREGATE S ( DED I I RETENTIONS 1 I —_--- S — WORKERSCOh1PENSATION X WCSTATU- OTH- AND Ef4PLOYERT UABIUTY TORY LIMITS A FNY PROPRIETORWARTNEMEXECUTUCE YJN IV 9WC749118 611812016 6/1812017 E.L.EACH ACCIDENT — 5 _---1,000,000 OFFICERAMEIZEFP.EXCLUDED? NIA — 1 jfAnndatnryin NH) Y ELDISEASE-EAEr.1PUD S "(,000,00 If yes,descn6e.undar - E On OF OPERATIOVS bNan i EL DISEASE-POLICY urza-F, 1,000;00 1 I I DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach-ACORD 101,Additional Remarks Schedule,irrnom space isrequired) I I I CERTIFICATE HOLDER- CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEMBEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover,Massachusetts 120 Main Street North Andover,MA 01845 THORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered:marks of ACORD I ACOO DATE(MMMDNYYY) Q CERTIFICATE OF LIABILITY INSURANCE 11/07/2016 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), AUTHORED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: ff the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. ff SUBROGATION IS WANED,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:CONTACT Carolyn A Coughlin Charles J Coughlin Insurance 14 DinleyStreet PHONE (978)957-3588 FAX AIC No Ext: AIC No P.O.Box 10 EA DRESS: carolyn@coughlinins.com Dracut,MA 01826 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Northland Insurance Company 24015 INSURED Merrimack Valley Insulation Corporation Joseph A.Ryan,Jr. INSURER B: Safety Standard 39454 23A Sullivan Road Torus Specialty Insurance Company INSURER C: p ty nPa y A0159 N. Billerica,MA 01862 INSURER D INSURER E: INSURER 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 CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSO WV0 POLICY NUMBER MM/DD MIDD LIMITS A COMMERCIAL GENERAL LIABILITY WS274182 01/21/2016 1/21/2017 EACH OCCURRENCE $ 1,000.000 CLAIMS-MADE P OCCUR DAMAGE S(RENTED 100,000 PREMISES Ea occrurence $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENL AGGREGATE LIMITAPPLIES PER, GENERAL AGGREGATE $ 2,000,000 J POLICY ❑JECaT 0 LOC PRODUCTS-COMP/OP AGG $ 2,000,0�� OTHER $ B AUTOMOBILE LIABILITY 6205006 11/25/2015 11/25/2016 ccwtI [ED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWOS ONLY J SCHEDULED BODILY INJURY(Per accident) $ AUTOHIRED / NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY �/ AUTOS ONLY Per accident C V UMBRELLALIAB OCCUR 87593L161ALI 01/21/2016 01/21/2017 EACH OCCURRENCE $ 1+000,000 EXCESSLw6 CLAIMS-MADE AGATE $ 1,000,000 DED I I RETENTION $0 $ WORKERS COMPENSATION PEROT l' AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTiVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ i- I I I I I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insulation Installation 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,Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE s @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home lmprovemen:t.G-ntractor Registration w= /��- Type: Corporation Insulation Cor '� Registration: 180506 Merrimack Valley pr; Expiration: 11/23/2018 23 A Sullivan Rd Billerica, MA 01862 -- -i Update Address and return card. Mark reason for change.. SCA t Q 2OM-05111 �L. e,1 clarurrznnlieall�a/011Zas;aclu3ef ,\ Office of Consumer Affairs&Business Regulation ^ rr z NOME IMPROVEMENT CONTRACTOR Registration valid for individual use only 5 Type: Corporation before the expiration date. If found return to: ` J3eaistration Expiration Office of Consumer Affairs and Business Regulation 18D506 11/23/2018 10 Park Plaza-Suite 5170 Boston,MA 02116 Merrimack Valley Insulation Corp Joseph Ryan 23 A Sullivan Rd .� Billerica,MA 01862 Undersecretary y Not v id ithout signature ?ii3SSL li1SC:`;S-uP.�4 "?c6i 'C sai�y: scars lG suiid:r ,.::, ns an.4 star-:�>A _,ze ase:CS-075541 - _ L -100 JOSEPH A RYA'--N= Kiail 200 ng MDr-2,Pt-2I3i ' iynnfieTd M�1 01Y�0 ' -_ 02!0432017 I