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HomeMy WebLinkAboutBuilding Permit #457-16 - 55 PILGRIM STREET 5/1/2018 - V%O R TH BUILDING PERMIT ��SyLED ,b�tio �• y4 TOWN OF NORTH ANDOVER 0 - APPLICATION FOR PLAN EXAMINATION -- _ ry Date Received ADRATED Permit No#: PQa 4`� gSSAC"us�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER VONTaL(41"IAZO ' Print 100 Year Structure jyeso MAP PARCEL: Vc/ ZONING DISTRICT: Historic District no Machine Shop Villageno TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential i ❑ New Building ❑ One family ❑ Addition El Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ FRE Septic _� YNell �: F;Ioodpl'a We�tlan �Y 1/Vatersh- D'strit ill fit eW , DESCRIPTION OF WORK TO BE PERFORMED: �l�IlSfl �/iSFiJ'JElrr .l s"//X<r �t./1�/S�Pcll�l�- �/�+6.•,—�'/,tJJl Hif/�C SVS �i '�J S F�' '- 2 X Z Q�dP C�rr�.�lJ� yrs/y her 7 �d�� �AZW ___Jdentif�ation- Please Type or Print Clearly OWNER: Name: J OffA) � c: c '►'► Phone: 6T79 3l y Address: 5 v 1`t Contractor N me• P �i2 Phone: Email: 0 Address: 410 SIFT('w /,• "�'n� dn UZ�z/ Supervisor's Construction License: 7704-3 Exp. Date: Home Improvement License: /3 Exp. Date:, / ARCHITECT/ENGINEER 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. Total Project Cost: $ ����7 FEE: $ Check No.: ki, Receipt No.: Oci NOTE: Persons contracting with unregistered contractors do not have acce he guaranty fund w z _ r 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) 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 it Construction and Two Family) New Constru (Single � 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 IECC 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 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Sr�yim ing 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature j COMMENTS C HEALTH : Reviewed on Signature COMMENTS a , 1 C Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments Water& Sewer Connection/sigrtafiure� ®ate Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street F11 RR DE 'ARMI9IIE�lY 4-4 'e Dum ster an site yes -,o qtr ��� �- , it ��> u tr v " c,,� � vr. ;f:,'k�'»°. w. Ri = ,•> ..:..At c..it":.+. .t1%{ 13�►' �r1`7,"' �` .,d".1:% :. 6...,:..,' '� i Located at 1:24 Main Streetfi ,� � •�� �. gtf ,�,.,�. --- {".. ! � -�.•. 3 ' .l�ti ��#(� t� 'ti�+l�yly� �� ' �t�rIr�# Fide Departm�n#signature/datert ` s•,...�4=_'. 4Ai ��� .°�'s.'� �ti ttr{'�Y"yr n t ;�+ R #�'���s 1�,,✓;} r� ��-yil4�.��a r �: t�*„r�;.,'t A�" � ;a w,. s ''' �Tt't,r�r, f M; ."M F'a '��,� .+.R r S•'+• 1 S = r " . ♦.A .t ' r �. a„,+ ! d F i}. � 4"x Jr J t4 , COMMENTS�r�;���v�. �?�f;�"�� �� .i.,�.�. ., . ;_ +�. � � �^ rte.-� ,��; '�`��'�! t .�. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICALS Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No j DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1oo-$10o0 fine NOTES and DATA— (For department ease) El Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 t Location No. Date r . - TOWN OF NORTH ANDOVER . Certificate of Occupancy Building/Frame Permit Fee :503 Foundation Permit Fee $ _ Other Permit Fee $ TOTAL $ Check# d 2949 9 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 413957.00 m $ - $ 503.48 Plumbing Fee $ 62.94 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 62.94 Total fees collected $ 729.36 55 Pilgrim Street 457-2016 on 10/9/2015 Finish Basement � �yORT1i al Town of A 0 i1r5l. T Z y o h , ver, Mass, COC NI C.f..,. ,1• S V BOARD OF HEALTH Food/Kitchen PERMIT T LD/ Septic System THIS CERTIFIES THAT ................ ........ .- ,.{ . ., 'e�................................................. BUILDING INSPECTOR -Foundation has permission to erect .....:.................... buildings on .. Vim......... ... ..: .rl ...., ...................... ... ,Q Rough tobe occupied as1 ,�............ ............................ ..... ..' { . ............................................. Chimney provided that the person accepting this permit shall in every rect 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 CONSTRUCTIONS S Rough Service S - ......................... ... ......... .. .......................... 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. CONTRACT TO INSTALL OWENS CORNING BASEMENT WALL FINISHING SYSTEM Owens Corning Basement Finishing Division(the contractor)hereby submits this proposal to sell and install the Owens Corning Basement Wall Finishing System and related items as described herein at the residential premises set forth below.This proposal shall not become a binding commitment unless and until it has been signed by the Contractor and the Customer. Contractor: Owens Corning Basement Finishing Systems a division o/LUX Renovations,LLC. 60 Shawmut Road,Conlon,MA 02021 Telephone#(781)821-0060 Facsimile#(781)821-8552 Federal Tax ID#14-1855297 Mass.Home Improvement Contractor Reg.#137943 - - Date V-Z i Customer: / Customer Name �oh/✓ R/�q/hA/© i Street Address City,State,Zip Telephone( Cl-22 This is a contract between the Contractor and the above named Customer to sell and install the Owens Corning Basement Wall Finishing System and related items specified herein at the Customer's residential premises identified below: Installation Premises: Street Address s!f M P City,State,Zip SAh Scope of Work: Are Sketches and/or speclfjcatlofissheb16jl11�tltached? j ealp oTiVot rY/1 �„ k; t 'All attachments aro incorporated nloang wore a Re sof thl�aonfraGll} 1 ;.--„�` 't¢t& sl rM^: p`t ( - 'kr�11Ai1' 't)t• i r ty("�+.YlcCd�l "�1.iY�xF ,rs,,ilMi arc E7? Jh�#i11'f *xr i , T 2p k 9tY 1 Description of Work/Specfications !S CC Sr (} Kh, -,'a t 1tx31 Duct�lfS }o �r�rm/(�IR�rlr55r����ti�>yn�� �w�4 r,f7.A1+ rrs�"r•RS'u..i'r'�ss'�JZs�- reuJ� ill Pli, sr• ry a� 'h 6l� N r k�- yP I t"1t 1 �� m rrM1 u r kr rS r,'.'!"� T_S rN f i rV� � 7���y /A � /�•Sf T I" Fl�� 7, ,`C✓losr� u N F� ;v ' +�W " �4yl se c� 6 S 4't Y my 47''5 K4 fJ x y i(.. ' ��Ai/c'Ase �at 1��1z�� ��'Com• �}�I+/.�6/ Or Faj `F rr [ d,tnlr.r i T 4 ri ,uf'�y�st w'Slp'gi '� Prv.�rti-ss a.e,L e.2 7—, Work Schedule••: E �`5 �hftRi4 f16r � I � ril €r! i GSaf ' 41•'�S S.}A; Approximate Commencement Date:} re: f(1:2 i t I S<� «4 Approximate Completion Date Ix '11�115'�I. i "The proposed work schedule is approximate and subject to change€ " ` Contract Price: rt 4 tolkrtr>s•«� `tom'" , ' r� "" ""` a -' Total Contract Price: $ Deposit with order: $ Balance Due: Terms: ).O Cash -o Finance: (Cash terms are 10%deposit,50%;on commencement,40%on completion) $ 0�0 I C1 9- Due on Commencement $ 16, 7 9,;2 Due on Completion DO NOT SIGN THIS CONTRACT-UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ AND UNDERSTAND THE ENTIRE CONTRACT,INCLUDING ANY ADDENDUM ATTACHED HERETO,AS WELL AS ANY ATTACHED SKETCHES,MATERIAL LISTS OR THE LIKE,AND THE TERMS AND CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT. YOU ARE ENTITLED TO A COMPLETE,FULLY EXECUTED COPY OF THIS CONTRACT AT THE TIME OF EXECUTION. Witness our hand(s)and seal(s)below on this day of��f LUX Renovations,LL rized Representative: Signal and Title.. Prinf Name - - DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Customer"': Cus me Jjlgnature. - UDh nJ L"A��jif/?f/t/b Print Name Customer Signature - Print Name - Contractor may have certain lien rights in the premises until the price is paid in full.You have the right to cancel this contract;without any penalty or obligation,at any time prior to midnight of the third business day after the date.you signed this contract.See the notice of cancellation below for an explanation of this right. —Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to customer's execution hereof. r Callamaro,John 55 Pilgrim St ��a r CONTRACT Customer Name N Andover,MA 01845 _ Customer Signature SKETCH Contract Date 978-314-8767 _ Sates Representative Signature ATTACHMENT Customer Phone _ Contract Price �e4 9S7 1 2 0 / 5 6 7 e 9 10 ,/ 12 0 14 15 16 -? 10 IB_._20 21 22_.20.._-2 _W-18_.-21--29_- 29_.20-=.21-- 32--90__.Sl- 35 06 37 00 09 00 AI 42 00 N /5 46 47 t8 49 50 51 52 52 64 65 50 57 58 69 60 .. .' t _ I 1 0 }t,. I I .1 �'g .i•.� -i' I I ...:. .. . �_ :.. i i .( i . .,- � � ; I � �•- i � i_.. . . ! i i j. �- } I I 7 '~tir 1 , I 17A�;� I .I .... .i. . I 12 1' �9n "r,i,•:.....,,erl ��-�:Twr '.'«'� � , � I I tr�L�'��I I 'I I I I k \\\ 1 i 14 W , Is 17 i � I I k I j 1 20 22 23 I I I I I it26 , I I u�/• I I i 27 I m 9 ! I 3033 � .I i ; I. � � � I � � � i i i i i � ,. ..; iI � j I � �_. i I � i r ' .' I • 31 , I I I 1 I 34 I I I I j 25 NOTES: t^0 L;G Lf�.At r i Arlo Ax.0 dr%S?gA7 k-le& 10 r A-t-t`DV0 'Each box equals one loot unless otherwise noted.This sketch Is a good faith representation of the work to be done,it is understood that all dimensions t�dd S�et derived from this sketch are approximate,and that all locations of outlets,light (fe'kt v ,� fixtures,plugs,jacks and/or switches are subject to change It necessary. Callamaro,John CONTRACT 55 Pilgrim St Customer Name_ N Andover,MA 01845 _ Customer Signature SKETCH Contract Date_., 978-314-8767 Sales Representative Signature ATTACHMENT Customer Phone _ Contract Price ell, KZ 1 2 0 4 5 6 7 B 0 10 11 12 15 14 i6 19 -17 16 _.10_. 20 21 22_20.. 24 26-.-21- 29 29 -50 ..111--02- _J7....J4. 05 00 07 M 79 40 41 42 49 N 45 46 47 46 49 50 61 52 55 54 55 50 67 56 69 60 i ....1 � ,��• I } .-:~ � i.,,�, 6+.,,,t: 'sc n.f;,.#'r- .,.w x ITeel I I I °fes I I I 1 I I I 9 �'.�•� I I I ' I I i I I I � I, I I , I i � ; i i I i 1 . I ' > t 1 10 14 I � :.. I I I. 1 I/�0�. ., ., .,_.-- I • I i .I i. i I• _.�... I I i. _I......I_.... W , , I 15 I , I 20 21 , i 23 24 ! I i I I I i I " - .�. . ' �."".."i"-.'"�..-..t •..+�.»,,.c I_• ..—o„ �t I. '. I ....1.... 28 I � 27 1 I 26 30 jq 31 1 I 33 ... .I .. ! ( .. I i I I ;.. I — j - •� I i .. i... .i. . I. , i 35 l ! I ! I I NOTES: ono v t t_ta w o cti t u �o c i Ar145 Axw "dry 7o wreck t o C A-1woyo Each box equals one foot unless otherwise noted.This sketch is a good faith representatlon of the work to be done,it Is understood that all dimensions lldd S�e� G;,�Ir & ���axd✓R �s. (, derived from this sketch are approximate,and that all locations of outlets,light �c'�i ` h A2 4.i r r fixtures,plugs,jacks and/or switches are subject to change if necessary. The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Eiectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): L[,(K C✓p��U� Address: 6() ✓ +i _A � City/State/Zip: Wgr0& 42W Phone#: ?V clUl AM0 Are yon n employer?Check the�appropriate box: Type of project(required): J.;;if am.a employer with 4 —✓employees(full and/or part-time).* 7, [:]Ne,, construction 2.Qm I aa sole proprietor or partnership and have no employees working for me in $, emodelirig any capacity.No workers'comp.insurance required.] 9. El Demolition 3-Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 [❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its offigers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'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',us 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 and state whether or not those entities have employees. If the sub-con1racf6rs have employees,ley 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. Y Expiration Date: Job Site Address: �� 1���� � City/State/Zip: / L`<_1'( 6'S Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 violato copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifica' . I do hereby cer vu der ze d penalties ofperjury that the information provided above is true and correct signature: p� Date: 1l/' 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract o�'liire, 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-contractors)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 foi•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 permitllicense 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. Anew 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia A6oa CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) F9/15/2015 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 Y 4 e t on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Andrew G.Gordon, Inc. NAME: 306 Washington Street PHONE—IC-No EA-781-659-2262 1 FAXNoll:781-659-4725 Norwell MA 02061 E-MAIL.ADDRESS.info@agordon.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance 24198 INSURED 4440 INSURERB:Star Insurance Company _18023 _ Lux Renovations, LLC INSURER C:Pil rim Insurance Company 21750 Owens Coming of New England 60 Shawmut Road INSURER D: Canton MA 02021 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 1319789055 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. INSRADIDLisuBR IPCDY EFF MM/DD EXP YYY) 1-1111117'sLTR TYPE OF INSURANCE IVSD WVD PDUCY NUMBER A X COMMERCIAL GENERAL LIABILITY CBP8512851 9/5/2015 9/5/2016 EACH OCCURRENCE $1,000,000 CLAIMS•MADE �OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY❑PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ C AUTOMOBILE LIABILITY PGC10007161409 1/17/2015 1/17/2016 Oa acadentS NG LIMIT $1,000,000 ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $ X AUTOS AUTOS BODILY INJURY(Per accident) $ X HIREDAUTOSX NON-OWNED PROPERTY D AGE AUTOS Per accident $ A X UMBRELLA LIAR X OCCUR CUS11953 9/5/2015 9/5/2016 EACH OCCURRENCE $1,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $1,000,000 DEO I X I RETENTION$ $ B WORKERS COMPENSATION WC0428715 5/24/2015 5/24/2016 AND EMPLOYERS'LIABILITY �,I N X S AT ER ANY PROPRIETOR/EXCLUDED? ❑NIA E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? If(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $1,000,000 Dyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lux Renovations LLC, ACCORDANCE WITH THE POLICY PROVISIONS. 60 Shawmut Rd Canton MA 02021 AUTHORUFn REPRESENTATIVE r� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 4 Office of Consumer Affairs d Business Regulation 10 Park Plaza - Suite 5170 Boston, M achusetts 02116 Home Improvem`' ntractor Registration r Registration: 137943 z �; L�f Type: Supplement Card LUX RENOVATIONS, LLC. C -� Expiration: 1/29/2017 DANIEL WALSH 60 SHAWMUT RD CANTON MA 02021 Update Address and return card.Mark reason for change. scn i G 20M-05/11 [] Address Renewal Employment F] Lost Card �jie Tpom�mwm,�oea.`l/o�C�aclauaeCGs ice of Consumer Affairs&Business Regulation License or registration valid for individul use only E IMPROVEI4f`NT CONTRACTOR before the expiration date. If found return to: _ Office of Consumer Affairs and Business.Regulation egistration-= - Type: � IraU� �__ ��—'- 10 Park Plaza-Suite 5170 p P_n,"M `<' Supplement Card Boston,MA 02116 LUX RENOVATIONStL OWENS CORNING BA INISHING SYSTEMS DANIEL WALSH 60 SHAWMUT RD �� :�•l.' < �, CANTON,MA 02021 Undersecretary. _ Not valid without signature Massachusetts -Departrpent ff Public$pfety A Boor ,of Bui.lding•Regulation'r; and andarcis struction Superviso 1 Lice e: CSZ' 9 wr I DANT EL E j 488]KENDALL R i T'EWSSl URY 111%A 0 f a '11' Expiration. }< o is$roner' a 10/05/2015 •ti I _ r Massachusetts Department of Public Safety i Board of Building Regulations and Standards i License: CS-079893 v Construction Supervisor DANIEL F WALSH`�` 488 KENDALL RU TEWKSBURY MA 01. 76 Expiration: Commissioner 10/05/2017