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HomeMy WebLinkAboutBuilding Permit #506 - 550 TURNPIKE STREET 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received �O Permit NO. J Date Issued: IMPORTANT:Applicant must com lete all items on this age - LOCATION �� e z '�� Am PROPERTY OWNER Print MAP NOOjS�(_)PARCEL:UDU ZONING DISTRICT: Historic District yes nn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family p(Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other � . .�- �-- [ eptc �:lWell} ®IF41:oodplaui �❑ VJr:etlands;, T DESC14PTIONN OF WORK TO BE PERFORMED: entification Please Type or Print Clearly) OWNER: Name: Phone: . Address: 06. .� CONTRACTOR Name: L Phone: L1'P o� Address: Supervisor's Construction License: 7e'Cl�d6 Exp. Date: Home Improvement License: 444C,S'3 _Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:M00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: Check No.: 1,617X Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th guaranty d Si'Y natureofA ent/Ovvnerx,' :.. Signatureofcontracf" _�—_ ..9 _ ._ __.. 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 ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/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 Yin all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals Chat 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: Doc.Building permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SE77EJ Public Seweranning/Massage/Body Art ❑ Swimming Pools ❑Wellobacco Sales ❑ Food Packaging/Sales ❑Private(septirmanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Si nature COMMENTS N HEALTH Reviewed on Signature-'. COMMENTS I 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 FIRE DEPARTMENT - Temp Dumpster on site yes ° no Located at 124 Main Street Fire Department 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 I i i ® Notified for pickup - Date i Doc:.Building Permit Revised 2008 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 ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/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 Tin all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals Chat 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: Doc.Building Permit Revised 2008mi TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0. L :i4_/ Date Received �u Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATIONie�S�1_ /� ,, rmt r PROPERTY OWNER __,-4 o Print 62 MAP NOr9)S.U PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family p(Addition 11 Two or more family 11 Industrial El Alteration No. of units: Commercial El Repair, replacement 11Assessory Bldg El Others: ❑ Demolition ❑ Other � a �1Flood lysin E etlandsr i 4® WatershedlDistrict� Septic ®.Wella R W . DESC14PTIONN OF WORK TO BE PERFORMED: entification Please Type or Print Clearly) OWNER: Name: /n LLQ Phone: Address: 4 v erg' �ir CONTRACTOR Name: Phone: Address: .� �7� 3� �!3c t�,.•► d� S F a �� a3a 5 Supervisor's Construction License: !j'rl�d 6 Exp. Date: Home Improvement License: / Z3 Exp. Date: 2md Z 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 Coat: $ FEE: Check No.: /,6/74 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th guaranty d Signature of AgentLOwne"r _' .: _ . d; Signature of confract ` � i i Location No. rU Date NORTH TOWN OF NORTH ANDOVER F � 9 Certificate of Occupancy $ cMus`� Building/Frame Permit Fee $ 1 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 7� � 2382' " 8 2'0 B ildi9 Inspector TOWN OF NORTH ANDOVER F o 1• +[O[r wwKw`y SIGN PERMIT ��SSACHUSE��� DATE: February 17, 2011 PERMIT: S028-2011 THIS CERTIFIES THAT Tripoli's Pizza Bakery Matt and Rosario Zappala #978-682-7754 Has permission to erect a Wall sign 46" x 147" x 1" on 544 Turnpike Street, North Andover MA 01845 provide that the person accepting this Permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Sign Regulations in the Town of North Andover. Violation of the Zoning of Sign Regulations, Section #6, Voids this Permit. INTERNALLY ILLUMINATED SIGNS ARE PROHIBITED Receipt 23894 Inspector of Buildings Paid: 30.00 • SIGN PERMIT APPLICATION 1600 Osgood Street Building 20, Suite 2-36 Alf �oSfl,2 , o TOWN OF NORTH ANDOVER m Z,4PPy4A 11 LL / � 0 'T r7, G1� s P�Z z�- t3�k�� ��S' ��.i 764 Site Owner 0rT' t.�a5Sr0 S �►u� C Applicant-P_ Sny\ C2w� Tel 923'372-372A Site Address - Size of Proposed Sign L((, X 1 LI7 May Parcel Illumination: 4boet= �ilminHow attached: a)Against the wall L'' ally illuminated b)Roof c)Externally illuminated c) Ground d) Other Materials: ALU4%14 N Proposed Colors: Background ye.Q0W Lettering 5\ Border "630 Cost of Sign` Required Attachments: Note: No permanent/temporary sign shall be erected,or enlarged until an Photographs of building application on the appropriate form furnished by the Sign Office has been filed Material sample with the Sign Officer containing such information including photographs,pians Color sample - and scale drawings,as he may require, and a permit for such erection, alteration, Site or Plot Plan(Required for.all free-standing signs) or enlargement has been issued by him. Such permit shall be issued only of the Drawings of proposed sign Sign Officer determines that the sign complies or will comply with all Other, specify applicable provisions of the By-Law. Will sign overhang any public road or walkway Yes O No If Yes,Name of Agency who will provide liability insurance: AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED DATE FILED: Receipt# Check# Revised 10.31:2006Form Sign Permit Application SIGNATURE OF APPLICANT APPROVED BY P:\REST—AkJRANTS\Tripoli Bakery 544 Turnpike N Andover.plt 2/9/2011 11:35:28 AM Scale: 1:83.31 Height: 634.154 Length: 717.245 in Y i m _ ' w J w > ( E PIz7� rBAKI�Iff! � A! - .. �€'"e .a wiF .1ct-cra'_....vi+>._,.. '�ti.�yd- .: �.... .V^Y-�µ>rE�Y•'M�.• •'4r&—^:.rY+»�6-+1t. _ '` ro,..,, ,mom �...,.. �• Tripoli date 1-31-11 � GN ®Zoo designed by N Earle a„ ", `NU, 544 Turnpike Street, N Andover,MA file name Tripoli Bakery 544 Turnpike N Andover.plt HAVERHILL MA 978-372-3721 Sales Associate Matt Rothwell details 46"A47" HP vinyl graphics -Location �� �/(��'' ► �1S / �ZZs�.-- No. Date NORTiy : TOWN OF NORTH ANDOVER Otaao ;•'��.0 O L F R �. ; + Certificate of Occupancy $ ITS ACNUS I� Building/Frame Permit Fee .$ Foundation Permit Fee $ Other Permit Fee j7N $ TOTAL $ Check # 23894 Building Inspector CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit IVi ii lies 506-2011 Date: Mardi 29, 2011 THIS CERTIFIES THAT THE BUILDING LOCATED ON 550 Turnpike Street, North Andover, MA 018#5 Tripoli Picea MAY BE 4CCUPIEDAS PiZZA.S1161) retrofit IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER RECULAT1ONSAS MAY APPLY. Certificate Issued to: North Andover Crossroads,Limited Partnership 550 Turnpike Street North Andover,MA 01845 ll Building Inspector Fee: 100.00 Receipt, 23997 F ORT ToVM of Andover _ LAKElover, Mass., �-'�o COCMICME WICK �psO ATED pS 11 BOAR F HEALTH PERMIT T U Food/Kitche U Septic System BUILDINP INSPECTOR THIS CERTIFIES THAT......lfkle'1­4....../);��1611,16C OA-00 S el �a 5.............................�......./............................... Foundation L f� has permission to erect........................................ buildings on .....5.3 '........... .. ........................ Rough to be occu ied as c e .............................................................................................................. provided that the person accepting this permit shall in every respect conform 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. BING INS ECT VIOLATION of the Zoning or Building Regulations`Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS ELECTRICAL IN;FLCTbR UNLESS CONSTRUCTIONS ARTSL ...................... ...... . . .... .����.... ,r,,. ,,.................. Service ... . ... .... . UILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a n _ Rough p y Conspicuous Place on the Premises Do Not Remove No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. _, F QRT►y ToVVn of Andover LAKE over, Mass., I� COCHIC_JE WICK 7�ADRATED ��C� SS lillpsh BOAR F HEALTH PERMIT T U Food/Kitche Septic System e ........... ..................................................................,. . ......................... u/nBUILDIN INSPECTOR THIS CERTIFIES THAT...... �7, G, /�C Oee SS FtoI ` ...... • ln 1` has permission to erect......................................... buildings on .....�4�...... ......................... Rough to be as occupied "�� ©�,`"� 4 �6� C * e p' / ....... ............................................................................................................. .... ...... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final -N 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. BING INS ECT VIOLATION of the Zoning or Building Regulations'Voids this Permit. Rough � . L PERMIT EXPIRES IN 6 MONTHS `V ELECTRICAL INCTOR UNLESS CONSTRUCTION S ARTS O '4—%- ......................... .......... ................... Service �----- IALDING -e INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPECTOR — Rough J f"CV Displayin a Conspicuous Place on the Premises Do Not Remove J Y 4 P No Lathing or Dry Wall To Be Done Until Inspected and Approved, -by the Building Inspector. BurnerFlRE DEPARTMENT' �.. Street No. , SEE REVERSE SIDESmoke Det. _lj Construction Control/final Report North Andover, lassachusetts PROJECT TITLE: TRIPOLLI PIZZA&BAKERY—PIZZA SHOP RETRO-FIT PROJECT LOCATION9U-RNPIKE STREET NAME OF BUILDING: ROSS ROADS SHOPPING CENTER NATURE OF PROJECT: Approx 2,000 sf Interior Retro-fit of existing retail space to Take Out Restaurant, use group "B". IN ACCORDANCE WITH SECTION 116 OF THE MASSACHUSETTS STATE BUILDING CODE, 780 CMR I, JOHN T.BRENNAN, REGISTRATION #AR-4808 BEING A MASSACHUSETTS REGISTERED PROFESSIONAL ARCHITECT DO HEREBY CERTIFY THAT THE INTERIOR RETRO-FIT OF EXISTING RETAIL SPACE TO TAKE-OUT RESTRAUNT SPACE, USE GROUP "B" , HAS BEEN COMPLETED IN ACCORDANCE WITH THE PLANS AND SPECIFICATIONS PREPARED BY MY OFFICE AND, TO THE BEST OF -MY KNOWLEDGE, DOES CONFORM TO ALL APPLICABLE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND ALL APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY AND THEREFORE IS APPROPRIATE FOR OCCUPANCY AT THIS TIME. SIGNATURE: V( F Na. 4808z 1 ACTON, DATE: -7 ORTH F 0VM of O LAKE O over, Mass., COCHICHEWICK �oRATED 7 v S ` BOARD OF HEALTH Food/Kitchen .PEKM IT T Septic System ,,�/ l BUILDING INSPECTOR THIS CERTIFIES THAT......i110/2� /7 0Vee. O,eO 19 �%qW �I'M fk-� ......... ................................................................................................................ Foundation F has permission to erect........................................ buildings on .....5, �...... �'' ' ..�.. �..... ............ Rough to be occupied as � Chimney p° ................. .�........�............................................................................................................. ............... provided that the person accepting this permit shall in every respect conform 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 INSPECTOI VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTO UNLESS CONSTRUCTIONS ARTS Rough ....................... Service BUILDING INSPECTOR Final Occupancy Permit Required to OcLupy Building GAS INSPECTOR Display in a Conspicuous Place on the Rough 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. SEE REVERSE SIDE ' Smoke Det. I I_I ! i ! i i I ! I_ ! I i I I_ ! I ! i I �1! 4 ! � I I I I ! I I I I I !Cgnck to FqU4 had. I i 38Ali , � � I Ir t I I I 1 -1 at FT I 6„ a ` I 'e. i It 0 I j. A16T 13 s A rlot lzwfu , lL -- -77 c. 1 I ' 1.• �T- i + _ I. ._:i! - - I I T- i 1 _ 1 I r- i ii I ► 1�—�i ! � li i o ! ! I � ! ! III I 777 � 1 Concrete Foundations, Inc. An Authorized Dealer of Rockford Steel Building Systems General Contracting Proposal December 27,2010 TO:Ram 4 LLC Job:Tripoli Pizza&Bakery 106 Common St Crossroads Plaza Lawrence,MA 544 Turnpike st N.Andover,Ma We hereby submit a proposal for: 1. Footing& foundation poured in place per plan 2. Excavate for footing 3. Supply & place rebar grade 60 4. Concrete 3000 psi 5. Drill & dowel into existing foundation 6. Supply & place rigid insulation 7. Back fill& compact 8. Pour concrete slab Total Material&Labor: $6,150.00 All material is guaranteed to be a specified. All work to be completed in a work like manner according to standard practices.Any alterations or deviation from above specifications involving extra costs will be excluded only upon written orders,and will become extra charge over and above estimate. Our workers are fully covered by Workmen's Compensation Insurance. Payment terms: Payment due upon receipt of invoice, unless pre- arranged payment net 30 days.A finance charge of 2%per month (24%per annum) charged on all past due accounts.Notice:Pur7t t A 447:6 Authorized Signature Date Joseph D.P'et Acceptance of Pr posal: The above prices, specifications and conditions are hereby accepted. You are authorized to do the work as specifi d. Signature: Date of Acceptance:/1) P.O. Box 622 Office: 603-898-2057 38 Golden Oaks Drive Fax: 603-894-4599 Salem, NH 03079 www.p-gincorporated.com 3 - Estimate efrienation DATE Estimate# Est.1945 12/6/2010 17463 55 CHASE STREET METHUEN, MA.01844 Phone: (978)-683-5821 Fax:(978)-327-6277 TRIPOLI BAKERY 106 COMMON STREET LAWRENCE MA 01841 TERMS PROJECT valid 30 days DESCRIPTION AMOUNT Estimate for walk-in freezer. Supply and install IOxI6x10 walk-in freezer on pad behind building. Install rain cap. Flash to building. Install trim on two sides outside. Pipe to remote unit on top of 1 Ox 16 walk-in freezer. Supply and install outdoor remote condensing unit. Install indoor electric defrost evaporator. Supply all tubing, drains,thermostats, defrost timer and gas. Five year warranty on compressor. One year parts and labor. 1-Harford duracool RDC IOx16x10 walk-in freezer for stand alone outdoor use. With floor and rain roof. 36" door. Flash to building at roof and sides of box. (Cut out for walk-in door by others) 1- CHRCZT04566CF Outdoor condensing unit. Low temp. R404A. 208/230. 3 Phase. 1- CHRE 1 C 160BEK Indoor electric defrost evaporator. 208. Single phase. 1- Paragon 8145-20 defrost timer. 1- Ranco 1408 thermostat. 1- Sporlan expansion valve. 1- Sporlan Solenoid and coil. 208 volt. 20' 1 1/8. 1- 1/8 Soft. 20' 1/2. 20' 7/8x3/4 Wall armoflex. 1- Drain heater. 208 volt. 12'. 1- 4x6x8 PT. 1-Roof penetration. lx5 Pine x12'. 6- 1 1/8 elbows In Misc. 2- 1 1/8 coupling. Solder torch. 4-can foam. R404A refrigerant. PARTS & LABOR. Tax included 17730.73 Total $17,730.73 Pappy's Electric Inc. Estimate 387 Lowell Street DATE ESTIMATE# Methuen, MA 01844 12/24/jOl 106 NAME / ADDRESS Tripoli Bakery 106 Common Street Lawrence,Ma.01840 PROJECT DESCRIPTION QTY RATE TOTAL Estimate for wiring outdoor freezer according plans & specification . Labor & Materials $ 1200.00 1,200.00 1,200.00 TOTAL $15200.00 f1e Cogn3no9ar.ea c�- rruscdc fuse! i Office of Gonsumer.Affuirs&Bi+gness Regu#ation HOME#MpROVEMENT C.01. G TOR + ':Registration 1 W .66653 TYPe' ' Expiration 6/2112012 Corpora#ion GOiCRETE FOUNDAT#ON INC, T.NOMAS CONNELL-; 38 GOLDEN OAK QRiVE l " SALEM,NN 03079. Undersecretary *- i1rl, a.ttitirsitt; 1J par€r#crrt of Ptri�lii �.ittr Board.of Buildirr; RcI!41ul4tiu11N 3" tat [ uc#s on Supervisor Lir emae: License: CS 99806 Restricted-tip: 00_ THOMAS CONNELL 60 WHEELER AVENUE SALEM, N 03070 H ;,.:.. . Expiration: 1 1 11 41201 1 Trn -99806 i ACORD,,, CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 09/10/2010 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:ONE Lakeside Insurance Agency, Inc. HICK Ext: 603.432.3666 a No:603.432.6076 Three Wall Street E-MAIL ADDRESS: Windham, NH 03087 PRODUCER CUSTOMER ID#: INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Merchants Insurance Group P & G Concrete Foundations, Inc. INSURER B: Guard Insurance Company 38 Golden Oaks Dr INSURER C: Salem, NH 03079 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 09-10 & 10-11 Master 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS __CERTIFACATE MAYBE-ISSUFD-OR MAY_P.ERTAM_THE.INS.URANC€AFFORDED_B_Y_THEPOLICIES_DESCRIBED.HEREIN IS SUBJECT TO-ALL THE TERMS,. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDLITYPE OF INSURANCE INSR SUER POLICY NUMBER MM DD//YYYY MM1DD/YYYY POLICY EFF POLICY EXP LIMITS LTR GENERAL LIABILITY NSR VWD CCP913758 10/10/2009 10/10/2010 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence S 100,00C CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,OOC A PERSONAL&ADV INJURY $ 1,000,00C GENERAL AGGREGATE $ 2,000,OOC GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,OOC POLICY JEC- LOC S AUTOMOBILE LIABILITY CAPI04866 05/2912010 05/29/2011 COMBINED SINGLE LIMIT (Ea accident) S. 1,000,00C ANY AUTO BODILY INJURY(Per person) 'S ALL OW NED AUTOS BODILY INJURY(Per accident) $ A X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS S S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS MADE AGGREGATE $ DEDUCTIBLE S RETENTION S $ WSTATUTH- WORKERS COMPENSATION PGWC01654 10/10/2009 10/10/2010 X ORY LIMITS OER AND EMPLOYERS'LIABILITY v/N .F—I ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACviDENT I` 100,O{1{ B OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE 5 100,00(i If yes,describe under E.L.DISEASE-POLICY LIMIT S 500,00( DESCRIPTION OF OPERATIONS below DESCRIP.TION OF OPERATIQNS/LOCA ON /VE"CLES (A ch CORP 101,A ditional rparks Schedule,if more spa a is required) Covering operations of the insure dAuring the policy period. Workers Compensation coverage is statutory for NH. Denis Pinet is excluded from WC coverage. OB: Tripoli Pizza CERTIFICATE HOLDER CANCELLATION FAX: : '894.4599 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Town of North Andover AUTHORIZED REPRESENTATIVE �. 384 Osgood Street N. Andover, MA 01845-2909 Edwin Duvall/PAULI ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD