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HomeMy WebLinkAboutBuilding Permit #243-2017 - 59 SALEM STREET 9/7/2016 �� + �10RT11 BUILDING PEFa;'aIT °F�tteo �b�ro TOWN OF NORTH ANDOVER o� --- APPLICATION FOR PLAN EXAMINATION _ Permit No#: Date Received Sys R^TEG.P���S I��1 SACHUS Date Issued: I ORTANT: Applicant must complete all items on this page LOCATION S aL f,= m S 1 Print PROPERTY OWNER C—L r i j 4- kA-VVh1 —TOIn'l s� Print 100 Year Structure yes no MAP PARCEL: �® ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building R/One family ❑ Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial s� epair, replacement - ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ `Sept,c� Well',.- -. I F oo�dpl'ain Wetl'a cls Wa shed D stnctE µ a DESCRIPTION OF WORK TO BE PERFORMED: 1 �e� �x►STi ,y L� S Ji^���f'2i -.TSA eS Identification- Please Type or Print Clearly OWNER: Name:, �-�u' Phone: Address: S - Contra ctor Name: Ct2 it Phone: Email Address: liT� �tiN �1 �.3Pi ,rnA . Supervisor's Construction License: Exp. Date:_��� Home Improvement License: 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: $ ®J FEE: $ Check No.: 5 1 5 Receipt No.: 3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund A� e 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 V Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses 1/ Copy of Contract r 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 And With Floor/Cross Section/Elevation Plan Of Proposed Work WI Sprinkler Plan A 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 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 ;rE Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) 46 Copy of Contract 4. 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 e Plans Submitted ❑ Plans Waived D" -Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ El Sf�rim,nin Tanning/Massage/Body Art g pools '❑'r; Well ❑ Tobacco Sales El Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS 1 CONSERVATION Reviewed on Signature I COMMENTS HEALTH Reviewed on_ Signature COMMENTS ZoningBoard of Appeals:ppeals: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 DEP -� ARt MEIVT l`ern Dum ster«onssite. QLro cated at1R24 Main Streeth ,;, j ,:i ! F • , gtFire D"ep A � -. -f^r�...- ,>~ 9nare/dated tsfu .b��•-. �•- &,`. Vii"` -. 4 f s cra. t�. �.- °' t '"A �+�� ' ,.ids 4+ C©MSM E fV Tt Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. I Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No i DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10o-$1000 fine NOTES and DATA— (For department use) I I 4 I' I ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 NORTFj q own of t s ndover �h ver, Mass j! A_ [O[HIC Hl W1CR V 7�A�R�TED �Pa��S S U BOARD OF HEALTH Food/Kitchen PERMIT L D Septic System THIS CERTIFIES THAT ..............� :... ...... ..Sar1 .. BUILDING INSPECTOR . Foundation has permission to erect .......................... buildings on ... ........ ....N..1..... W.Cf............... • Rough to be occupied as ........ ,...... �. .. .�:..... i .. r es.. . ... ... .... Chimney e provided that the personfif� ceng this permit shall in ev respect conorm 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 CONST TIO T Rough Service . .... ......... Final BUILDING I ECTOR 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 repair or replace Contractor: Owner: Job Location Blaine A. Scribner Andrew Parsons Glen Johnson 385 Sutton St. 59 Salem St. North Andover, Ma. 01845 North andover, Ma. 01949 978-265-8188 Contractor agrees to furnish labor, materials, and equipment necessary to complete the following work under industry standards and tolerances, generally described as: Replace the siding on the home including the following: 1 . Remove all siding, trim, soffits and rake boards and dispose of material 2. Install cedar clapboardfs and shingles. P.V.C. trim fascia rakes 3. Replace soffits one piece P.V.0 vented material 4. Provide a dumpster for debris Not included 1 . Painting 2. Cost of electrician if needed 2. Repair of any rotten wood which will be done on a per hour basis Contractor has supplied the owner with a copy of his construction supervisors license, HIC license and liability insurance. Fixed Price: $35,800.00 paid as follows: 1/3 down payment........................$12,000.00 1/3 upon delivery of material........$12,000.00 Balance upon completion.............$11 ,800.00 a Work will commence within one week upon signing of the contract and will take no longer than three weeks to complete, weather permitting. Date_ kZ ,1-7�ZL _ Signature of contractor Signature of Owner/ Rep You may cancel this transaction at any time prior to mid night of the third business day. Acceptance: I/we agree to these terms, acknowledge receipt of a signed copy of the contract and confirm work has not started before signing, and authorize the contractor to proceede. Date: v ignature of Owner The Commonwealth of Mass�chusetis 49 Department of Industrial Accidents 1 Congress,Street,,Suite.100 ' d Boston,MA 02114-2017 w7ww mass.gov/dia Workers,CompensationlusuranceAffidavit:Builders/Contractors/Electxacians/Plumbers. TO BE)[TEED WITH THE PER MTING AUTHORITY. APlease Print Le-blY Applicant Information Name(Business/Organization/Iudividual): L M P SC'rt b n-Pi Address: s•,�s_-'r- t—J '�— City/State/Zip: Phone#: Areyou an employer?eheektlie appropriate box: Type of project )Vequired); 1.❑I am a employervwith employees(full and/or part-time).* �,• New construction 2. • lam a sole proprietor or padnership and have no employees working for me in 8. 0 Remo delilig any capacity.(No worke s'com .insmnance required-] r p q ] x 9. ❑Demolition 3- lam aomeo hwner doing all work myself[No workers'compAnsurance required] ❑ 10 [1 Building addition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will ❑ 1. Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 1 ❑ p pr etors withno 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_'❑Roof repairs These sub-contractorsliade employees and have workerscomp.insurance. Other 6.❑We are a corporation and iN of�cers have exercised their right of exemption per MGL c. 152,§1(4),and we have-4o. es.[No workers'comp.insurance required.] `Any applicautthat checks box 41 must also'M out the section below showing theirworkers'compensation policy information. i Homeowners who suliriu t'z affidavit indicating they are doing all work and then hire outside contractors must submit anew 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."Ifthe sub-contractors have employees,they must providetheir workers'comp.policy number." lam an employer that is pi-ovadiingworkers'compensation insurance for my employees.'Beloit/is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ExpirationDate: Xob Site Address: --> City/State/Zip: Q v Zd Attach a copy of theworBeers' 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 violator.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 time pains and penalties ofpeijziry tlaat the information provided above is true and correct Signature �� Date /7 Phone Official use only. Do not write in this area,to be completed by city or town official• City or Town: Perxnit/License# Issuing Authority(circle one): i 1.Board of Healtlh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbingfuspector 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 ally contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,asso ciation,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiver-or trustee of-aa 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 anotherwho 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 bd 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 common-Tealth fox•any applicant-vvholias 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 fdi•out-the workers'compensation affidavit completely,by checking1he'boxes that apply to your situation and,if necessary,supply sub'contractox(s)name(s),address(es)and-phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or p artners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. B e advised that this affidavit may be submitted to the Department of•In.dustrial 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 requjred 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 hag 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 permit/license number which will be used as areference 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"rob 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. A new 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 bum 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 I ACOO�® CERTIFICATE OF LIABILITY INSURANCE DATE` 8i;i'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(tes)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). PRooucFR CONTACT Kristin Linnane M.P. Roberts Insurance Agency PHONE r FAX -8073 1060 Osgood Street �na1 • (978 683 N (978) 683-3147 ADDRESS: kristin@mprobertsinsurance.com North Andover, MA 01845 INSURER(S) AFFORDING COVERAGE NAIC# INSURERA:American European Insurance Co INSURED INSURER B:Merchants Mutual Insurance Co BAILEY CUSTOM HOMES INSURER C:Associated EmploVers Insurance BLAINE SCRIBNER INSURER D: 385 SUTTON STREET INSURER E: NORTH ANDOVER, MA 01845 IINSUIRERF: 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 AWL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MIDDY MM/DD/YYYY LIMBS A GENERAL LIABILITY CPP120069010 1/27/16 1/27/17 EACH OCCURRENCE $ 1,000,000 $ COMM ERCIAL GENERAL LIABILITY DAMAGE TO RENTED occurrenW $ 100 000 CLAIMS-MADE ®OOCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PRO- LOC $ B AUTOMOBILE LIABILITY 10/27/15 10/27/16 COMBINED SINGLE LIMB MCA7015253 aaccdalt $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ ALLOWN-eD SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS _AUTOS eraccident $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION C WORKERS COMPENSATIONWCC-500-5013965-201 10/17/15 10/17/16 WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/NIMIT_ FR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACHACODENT $ 500,000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 500,000 If yyes,describe under DESCRIPTIONOFOPERATIONS below E.L.DISEASE-POLICY LIMIT t 5100,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Rernarlrs Schedule,N 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 M TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET SUITE 2043 NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE MICHAEL P ROBERTS ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: OP 10:JO PAYE(MWDQ-M) CERTIFICATE OF LIABILITY INSURANCE Of3l1 712016 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(31 AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require:an endorsement. A statement on this certificate doers not Confer rights to the certificate holder in lieu of such endorsemen s. PRODUCER N E: _ Segrave&Hall InsurAssoc.lnc P Pio ac,NoI: 305 North Main 3t. — Andover,MA 01810 ADDRESS: „, Lawrence J.Hall PARS-01 roatEri ID a� INSUitERES)At'F"QADINCCOVERAOF I—gyp INSURED Andrew S,Parsons tNSUK9IkA:ArbeIIa Protection Ins.CO. 141360 OSA Parsons Construction INBURER8 A.I.M.Mutual(ns.Co. _ 33758 334 Ferry Road INSURER C: -- Ward Hill,MA 01835 IN UR@R D INWFMR E INSURER F COVERAGES CERTIFICATE NUMBER: RirVISION 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 8E ISSUED OR MAY PERTAIN. THE INSURANCE AFPORDcD BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIL)CLAIMS. 777A I POUCT RP TYPE OF INSURANCE ?O ICY H MM MNUDDYMONYVYW UNITS OENERALLIABUjTY EACHOCCLStRENCE a 1,000,001 A X COMMERCIAL GENERAL LIABILITY I pR�ye1� owyffenesiS 100,001 CLAIMS-MADG i X OCCUR MED EXP(Any One Parson) S 6,00, 8620046376 12/011ZD15 12JDi12016 PERSONAL BAEW INJURY 13 GENERAL AGGREGATE $ 2,000,00' GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-CCMFJOP AGG S 2,000.00 POLICY PRO- LOC ._ �...�.--.- $ AUYOMOBILE LABILITY COMBINED SINGLE LIMIT S 1 (Ea acddarrt) 10200014125 '02116!2016 1 0211 61201 7 A ANY AUTO i 506ILY INJURY IF Panar,l S ALL OWNED AUTOS BODILY INJURY War accidmi) S X SCHEDULED AUTOS I PROPERTY DAMAGE S �. X HIRED AUTOS 1 (PERACGIDENT) ^- I � X NON-OWNEOAUT08 UMBRELLA L1Aa OGCUR EACH OCCURRENCE $ EXCE99LIA9 OIAIIASN.40Ej AGGREGATE s DEDUCTIBLE — RETENTION Ti WORKERS COMPENSATION � X i AND EMPLOYERS'UARIL17Y I ! 05!10!2019 D$/1012017 r , B ANY FftDARIETJRlPARTN6R/'cXECUTNE YIN fWC6006754 E.L.EACH ACCIDENT S 100 0CI CFFIOERtMIEMBEREKLUDEDf O N/A� I E.L.OISFASE-EAEMPLOYE� 10�A,®� (MandwWrII In UN) n 98 daeaibo urWer E.L.DI A8E-PDUCY LIMIT S 50o,0( DE R PTI N OP as .+_ "— BEPCRIPTION OF OF MT10NS/LDCP,TU4 f VEHICLES(Attach AC'ORD 161,Ad Ztfonai R"ar;e 8critd le,If morn op;w.Is mcI%Ired) Sole Proprietor has not elected coverage under Workers Camp. CERTIF GATE FlOLDE.RCA CELLAT ION — NORTNAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCRLLED BEF4RE THE EXPIRATION DATE THEREOF, NOTIC9 WILL Be DELIVERED IN. Town of North Andover ACCORDANCE WITH THE POLICY PROVISICN8. Main Street North Andover,MA 01945 AUTHORIZED REPRESENTATIVE 01888-2009 ACORD CORPORATION. All rights reserved. red logo are registered marks of ACORP 2 9109 The ACORD Warne a q ACORD 25{ 00 ) OP ID:J ,41614C" "®' CERTIFI Ar,TE OF LIABILITY INSURANCE DATEJUMJ!rnYyY, 0812212016 THIS CERTIFICATE 15 ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER.($), 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 an tttis certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Se revs 6 Hall Insur.Assoc.lnc VnsaE: ONE 305 North Main St. R1 C.PJ Andover,MIA 01810 S-4°AIL Michael L.Sagme ADDRESS TONER ID w:PAR8•01 _ INSIiRER(6)AFFORDING CDVeRAGE NA INS10aEo Andrew S, lvsons INSURERA!Arbelle Protection Ins.Co. 141360 DBA Parsons Construction MSURERa:A.I,1111.Mutual Ina"Co. 13375$ 334 Ferry Road Milord Full,MA 01635 INSURERC:_�,�` 1RaURRR D NSURER F: � COVERAGES CERTIFICATE NUMBER: R;EV i N Nl M THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 13ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOC INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CGNT'RA,,T OR OTHER DOCUMENT WITH RESPECT TO""CH 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 NW(HAVE BEEN REDUCED BY PAID CLAI41S. INSIR A.001.WON POUoY EFF 1 PC5 t'1`'9, E LTR TYPE OF INSURANCE _— POLICY NUMBER Mk11L19r/YYY RiFODlYYYY, _ _ LIMBS GENERAk.L"ILITY ;EACH OCCURRENCE $ 1,000,00 . A X 00MWIRCIALGENERALLIABIL11'Y ES occursnoa $ 100,00 CLJUMS-MADS I T",OCCUR I MED EXP(Any ane Person) $ 5100 9520040376 121011301511PJ01/Z01B;PERSONAL&ADV INJURY $ 1,000,00 GENERALAGGREGATE 1 2,000,00 GEN1 AGGREGATE LIMIT APPI-IE$PER: PRODUCTS-COMP(OP AGG 3 2,000,00 POLICY 'PRO LXiC B AUTOMOBILE LIAmiw I COMBINED SINGLE LIMIT A ANY AUTO 10200014125 02/15/2016 02/1&2017 {Ea ax dant) ALL GINNED AUTOS ' I BODILY INJURY;Per pereoln) 11 J BODILY INJURY(P®;—;!dnni) 6 X SCHEDULEDAUrp8 PRQPERIYDAMACE M—�� X HIRED AUTOS ! (PER ACCIDENT) S I i � X NON-OWNED AUTOS i I 3 UAtaRELIA LIAe OCCUR 1 EACH OCCURRENCE S _ ExC68s UAe CLAIFAg-MADE AGCIREOATE $ _ DEDUCTIBLE $ — TENTiOH WORKER6 COMPENSATION X I WC 9TAM�T- OTRH- AND EMPLOYIERS'UASILITY YIN ' 13 ANY PRGPRIETOR>PARTNFQxx6CVTly6 X6005754 05/10/2010'05/1012017 E,t.EACH 4UCIDENI' $ 100.001 OFF'ICER&EMSER EXCLUDED? !; NIA — --- (M®tS=00 In NN) j E.L DISEASE-EA VIPLOYEE $ 100,001 If ,dsscribq Vnosr RPT P -I E.LDISEASE-POLICY LIMIT $ 500,01)1 I I 066CRIPTION OF OPERATIONS I LOCKRON6l VEMOLES Attach ADORE 101,Addigmal RaMeA6 Sehedule,if me—space Is-q.1-d) ' Sole Proprietor has not elected coverage under Workers Comp. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE 0"CRI9ED POLICIES BE CANCBLLFP BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Glenn$Kathy Johnson ACCORDANCE WITH THE:POLICY PROVISIONS. 60 Salem Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE �r Q 1888-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009108) The ACORD name and logo are registered marks of ACORD i i Ll0Z/8l/ZI. Iauo;ss:_:-- :uoliel;dr_ 508L0 VW 2I3AOONV NIHON 1S NO11f1S 48£ '83NOINOS V 3NIV-18 £4 S£WSO :asuaal-1 spiepuelS pue suollelnBaa Bulppriq go pjeoe IQaIeS oilgnd to luawliedao sllasnyoesseW SN Office of Consumer Affairs&Business Regulation License or registration valid for individul use only a -I OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 174751 Type: Office of Consumer Affairs and Business Regulation Expiration: 3/15/2017 Individual 10 Park Plaza-Suite 5170 - - ; - Boston,MA 02116 BLAINE A.SCRIBNER ri BLAINE SCRIBNER 385 SUTTON ST NO.ANDOVER,MA 01845+ Undersecretary Not valid without signature I