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HomeMy WebLinkAboutBuilding Permit #752-2017 - 56 RUSSELL STREET 2/1/2017Permit NO: ( `Ja Date Issued: 2-11 BUILDING PERMIT TOWN OF NORTH ANDOVER �1 11 APPLICATION FOR PLAN EXAMINATION Date Received IMPORTTANT: Applicant must LOCATIO5 �� all items on this PROPERTY OWNER K\C�cv� i t C', 0 G� Print MAP NO: %PARCEL. ZONING DISTRICT: Historic District Machine Shop Vil yes no ve I no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial Ll Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg k1 Others: G Demolition ❑ Other 71 Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer S OWNER: Name: Identification Please Type or Print Clearly) Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Home Improvement License: 16,0 Exp. Date: 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: $ `� �, (� FEE: $ .116D Check No.: 1 � 15' Receipt No.: 3 i`q I NOTE: Persons contracting with unregistered contractors do not have access to thncnd Signature of Agent/Owner�l Signature —of Q 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_.. Manning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW 'Ibivv: Engineer: Signature: FORE .DEPA;RTMI' NT - Temp Dumpster on site yes Located at '124 Main' Street Fire Departmeht sighatureldate COMMENTS .� Located 384 Osgood Street no " Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions_ Total land area, sq. ft.: ELECTRICAL: Movement of Motor location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A -F and G min.$10041000 fine NOTES and DATA — (For department use B Notified for pickup - Date Doc.Building Permit Revised 2010 `mc Building Department Tree following is a list of the required forms to be filled out for the appropriate permit to be obtained. FZoofing, Siding, Interior Rehabilitation Permits ❑ 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 ❑ Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit a 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 ❑ Engineering Affidavits for Engineered products 10TE: 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 Torun Clerks office must stamp the decision from the Board of Appeals that the apt -,al 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 2012 /17 Location ocation No. 1 Date I coo, Check# . '. ) 1491 TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $ Foundation Permit Fee $� Other Permit Fee $ TOTAL $ Building Inspector v C � U) 0 0 p CD Z N CD �CLO CL c cc N moa, vCD CD O C�= cr CD CD O W w CDa CD CD C O CD Ccn ' C � v O 110 Z CD n 0- O CD 23 O O r O z O_ rr <D N O _ CD CQ W ,0—«• s _ U) 0 in y CD 0 " O CA) 0 v=i =' :5.m CO) r cD m cp•, `�° Q' n o ? =� U) N> rte.► iD-• O O Q O WCD U) o CD O CL O NCD = p C7 �_ rt N O O O " n =CCD r CD 0 =r f:: O O —: h= CO) CD o h a =r CD �O � r�cQ cn 0 CL CD (n = _ O C CDCLW CD y Q) o U) rt � n O O �rt O O (_ y O CD 0 y O -Oi+ � rt D (D <D -0 oSU o CL 3 7C Ln fD O co O T c a z 5.o OZ7 N �' N 70 ? � = o Oq z -� o r- Oq C W z C) a 0 r m s a o2L Oq „ o 3 =3 m;u v, m, �_ N N T o Q s 3 W > v O m D _ c ic O M Z Cl) a 70 Ntz V/ Z m O m �� Z. W r Z Z m 0 O O r O z O_ rr <D N O _ CD CQ W ,0—«• s _ U) 0 in y CD 0 " O CA) 0 v=i =' :5.m CO) r cD m cp•, `�° Q' n o ? =� U) N> rte.► iD-• O O Q O WCD U) o CD O CL O NCD = p C7 �_ rt N O O O " n =CCD r CD 0 =r f:: O O —: h= CO) CD o h a =r CD �O � r�cQ cn 0 CL CD (n = _ O C CDCLW CD y Q) o U) rt � n O O �rt O O (_ y O CD 0 y O -Oi+ � rt D (D <D -0 oSU o CL 3 7C Ln fD O co O T c a z 5.o OZ7 N �' N 70 ? � = o Oq m m '° n V —I 0 „ 3 2L o r- Oq C W z C) a 0 „ n s < s a o2L Oq „ o 3 =3 C o z m 0 v, m, �_ N N T o Q s 3 W > v O m D _ CD v Sweepnman, 108 Main Street Bldg H North Reading, MA 01864 Phone # 978-664-6642 Fax # 978-664-1298 Name / Address Inc. Richard Gacioch 58 Russell St North Andover, MA 01845-2716 E-mail dee.kelly@sweepnman.com Proposal Date Proposal # 12/9/2016 1868 Project Address Richard Gacioch 58 Russell St North Andover, MA 01845-2716 Web Site www.sweepnman.com Customer Phone # 978-265-4899 Description Qty Rate Total Removal & Disposal of the pipe in the chimney on the first floor 1 300.00 300.00 and bricking up the hole. Installation of Oil Flue Liner including all components necessary at l 4,490.00 4,490.00 termination and breaching to connect 4 existing vent connectors. Thermal wall barrier: Installation of a thermal wall barrier between 1 600.00 600.00 the combustible floor joists and the vent connector. DISCOUNT TO BE APPLIED 1 -200.00 -200.00 Total $5,190.00 Acceptance Signature This Proposal is Valid for 45 Days 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): C° Address: /1� Are you an employer? Check the appr 1. I am a employer with fj q employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 0, Phone M date box: 4. E] i am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance 1 5. M We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. p Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof rel 13.DJ Other *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. $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 isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. i - 11 Insurance Company Name Policy # or Self -ins. Lic. #:W(�,� _0/J 13 cf --U/0 Expiration Date: Job Site Address: -5 SQ _ City/State/Zip: / rl Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). f 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 cern der the pains andpenaldes ofperjury that the information provided above is true and correct: 0ES_ 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 S. Plumbing Inspector 6. Other Contact Person: Phone #: ACOREP CERTIFICATE OF LIABILITY INSURANCE `6*� DATE(MM/DDNYYY) 1/31/2017 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: Scott Leavitt, r CIC LIA MTMBrainerd IncPHONE lA Andover Road (978)667-9031 FAX C No:(978)667-1018 C No Ext: 'C' E-MAIL ADDRESS: scottl@brainerdinsure.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:James River Insurance Company Billerica MA 01821 INSURED INSURERB:Safety Indemnity Ins Company Sweepnman Inc. INSURER C: 108 Main Street Bldg H INSURER D : INSURER E North Reading MA 01864 INSURER F COVERAGES CERTIFICATE NUMBERIXaster Cert 2015 RFVISION NIIMRFR- 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DDNYYY LIMITS ACLAIMS-MADE X COMMERCIAL GENERAL LIABILITY [A]OCCUR EACH OCCURRENCE $ 1,000,000 ENTED 50,000 DAMAGE TO RENTED-PREMISES PREMISES Ea occurrence $ MED EXP (Any one person) $ 1,000 X Blanket Additional 000691691 11/18/2016 11/18/2017 Insured By Contract PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PRO - ❑LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 Employee Benefits $ OTHER: OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS 6236353 11/18/2016 11/18/2017 BODILY INJURY Per accident) $ X NON -OWNED ED HIRED AUTOS X AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) Ifes, describe under DESCRIPTION OF OPERATIONS below I I I E.L. DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This Certificate of Insurance represents coverage currently in effect and may or may not be in compliance with any written contract. . u kvmv Richard Gacioch 58 Russell Street North Andover, MA 01845 ACORD 25 (2014/01) INS025 Onl4nn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Leavitt, CIC, LIA/S ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/31/2017 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: Scott Leavitt MTM INSURANCE ASSOCIATES LLC alto" o EXt- (978)667-9031 a No: E-MAIL ADDRESS: sGoftl@brainerdinsure.com INSURERS AFFORDING COVERAGE NAIC# 1A ANDOVER RD. INSURER A: LM INS CORP 33600 BILLERICA MA 01821 INSURED INSURER B: SWEEPNMAN INC INSURERC: INSURER D : INSURER E: 108 MAIN STREET BLDG H INSURERF: NORTH READING MA 01864 COVERAGES CERTIFICATE NUMBER: 123319 RFVISION N"MRFR- 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FIOCCUR EACH OCCURRENCE $ AMAGE TO R NTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO- JECT 7 LOC GENERAL AGGREGATE $ PRODUCTS -COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE N/A AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) If yes, describe under NIA NIA WC531S388139016 12/18/2016 12/18/2017 XSTATUTE ERH E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT I $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. .. �..... ....-.. ..v..... �. • VMN V CLLM I Kim SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Richard Gacioch ACCORDANCE WITH THE POLICY PROVISIONS. 58 Russell Street AUTHORIZED REPRESENTATIVE North Andover MA 01845 C Daniel M. Crc�yiey, CPCU, Vice President — Residual Market — WCRIBMA ACORD 25 (2014/01) 91988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ,AcoRON CERTIFICATE OF LIABILITY INSURANCE il`.� DATE(MM/DD/YYYY) 1 1/31/2017 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 Scott Leavitt CIC LIA NAME: r MTMBrainerd Inc lA Andover Road PHONE (978) 667-9031 FAX A/C N Ext : A1C No : (978) 667-1018 E-MAIL ADDRESS: scottl@brainerdinsure.com INSURERS AFFORDING COVERAGE NAIC # Billerica MA 01821 INSURERA:James River Insurance Company INSURED INSURER B:Safety Indemnity Ins Company Sweepnman Inc. INSURER C: 108 Main Street Bldg H INSURER D: INSURER E: North Reading MA 01864 INSURER F: COVERAGES CERTIFICATE NUMBERMaster Cert 2015 RFVISIAN NIIMRFR- 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 LTR TYPE OF INSURANCE ADDL INSID SUBR WVQ POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 1,000 X Blanket Additional 000691691 11/18/2016 11/18/2017 Insured By Contract PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X ❑ PRO - ❑ LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 Employee Benefits $ OTHER: OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 BODILY INJURY (Per person) $ B ANY AUTO ALL OWNEDX SCHEDULED AUTOS AUTOS 6236353 11/18/2016 11/18/2017 BODILY INJURY (Per accident) $ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, descr be under DESCRIPTION OF OPERATIONS below I I I I I E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space is required) This Certificate of Insurance represents coverage currently in effect and may or may not be in compliance with any written contract. Town of North Andover 1600 Osgood Street Ste 2035 North Andover, MA 01845 ACORD 25 (2014/01) INS025 19m4nn %IMMICLLAI IVIY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE S Leavitt, CIC, LIA/S�� U 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORa CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 01/31/2017 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: SCOP Leavitt MTM INSURANCE ASSOCIATES LLC PNC L xt: (978)667-9031 ac No: ADDRESS: scottl@brainerdinsure.com INSURERS AFFORDING COVERAGE NAIC # 1 A ANDOVER RD. INSURER A: LM INS CORP 33600 BILLERICA MA 01821 INSURED INSURER B SWEEPNMAN INC INSURERC: INSURER D : 108 MAIN STREET BLDG H INSURERE: INSURER F: NORTH READING MA 01864 COVERAGES CERTIFICATE NUMBER: 123321 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY) POLICY EXP (MMIDDNYYYJ LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F OCCUR EACH OCCURRENCE $ _ DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO- JECT F—] LOC GENERAL AGGREGATE $ PRODUCTS -COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident)$ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE N/A AGGREGATE OED RETENTION $ _$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? I NIA1 (Mandatory in NH) If yes, describe under NIA N/A WC531S388139016 12/18/2016 12/18/2017 X STATUTE ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT I $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. %1AiYI.CLLA 11UN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Ste 2035 AUTHORIZED REPRESENTATIVE (i North Andover MA 01845 i Daniel M. Cr y, CPCU, Vice President — Residual Market — WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD t Commonwealth of Massachusetts Department of Public Safety License: BU -026558 0 i::77, L'. me !a cEllis C i a n C r-, 01 DAVID A BANCROFT SWEEPMAN INC 108 MAIN ST BUILDING H d J32. NORTH READING MA 01864 r-jzun l— Expiration: Commissioner 03/0912018 Employer: Sweepnman Inc. Oil Burner Technician Certificate DPS Licensing information visit: WWW.MASS.GOV/DPS -�• _Office of Consumer Affairs & Business Regulation Lf7HOME IMPROVEMENT CONTRACTOR�' 1� _Registration: 160389 Type: `\ :7 Expiration: 7/16/2018 Private Corporation :> SWEEPNMAN, INC. l DAVID BANCROFT 108 MAIN STREET BUILDING H :�:c•:--_-- —_ NO. READING, MA 01864 Undersecretary Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-100886 DAVID A BANCROFT SWEEPMAN INC' 108 MAIN ST BUILDING H NORTH READING MA 01864 Commissioner 03/0912018 Construction Supervisor Specialty Restricted to: CSSL-SF - Solid Fuel Burning Device M Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: WWW.MASS.GOVIDPS License or registration valid for individual use only { •beforethe expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, NIA 02116 Not valid without signature Office of Consumer Affairs & Business Regulation (HOME IMPROVEMENT CONTRACTOR �� Registration: 160389 Type: . - Ex iratioric- -7/16/2018 Private p _ Corporation SWEEPNMAN, INC., DAVID BANCROFT 108 MAIN STREET BUILDING H NO. READING, MA 01864 Undersecretary License or registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature _4