HomeMy WebLinkAboutBuilding Permit #831-16 - 60 WINDSOR LANE 1/22/2016BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
PermitNoM Date Received
Date Issued:
IMPOATANT: Applicant must complete all items on this
LOCATION Lr)
/0,
PROPERTY OWNER VCA
Print 100 Year Structure yes
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
[I One family
[PAddition
El Two or more family
11 Industrial
0 Alteration
No. of units:
11 Commercial
0 Repair, replacement
0 Assessory Bldg
11 Others:
0 Demolition
0 Other
0 Septic 0 Well
11 Floodplain El Wetlands
El Watershed District
El Water/Sewer
DESCRIPTION OF WO TO BE PERFORMED'
CZ 5��n r-0,0YVI 7l� C04jal,�4,0ew
luelitill"Utlull ju =4:
OWNER: Name: V C, I 2-C.
Address: 60 IJJ,'4 d5oy bi
Contractor Name: IWO (,00s,
Email: Sr, le 5 eee7 e&i
Address: Po 9,35
or Print Clearly
Phone:
4dvvev- , A
hone: 929- 6.91-9ZO
Supery isor's, Construction License: 6S-07669� -Exp. Date:
Home Improvement License: /0
ARCH ITECT/ENGI NEER
Address:
Date: V/ 0 -
Phone:
Reg. No.
FEE SCHEDULE: BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL EST(MATED COSYbASED ON $125.00 PER S.F.
Total ProjectCost:$ 00 -FEE: $
Check No.: Receipt No.: 5/-7
NOTE: Persons contractihg with unregistered contractors do not have access to' theqlr�Wund
Plans Submitted [I Plans Waived 11 Certified Plot Plan [I Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools 11
well
Tobacco Sales El
Food Packaging/Sales 0
Private (septic tank, etc.
Pennanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
I CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed
Reviewed on /
/11�/'_)_q/j5_S
Signature.
,-V\ � Go,
nature
Zoning Board of Appeals: Variance, Petition No: - --Zoning Decisionfreceipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Con neGtio n/S i_q nature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
RTMENT, )[5qMp -pn te
45C .�tef, psil
t0qj t 12�4,M�,StrMt,
9
FiiO4)epaft'r-hqnt�!%j'! dre/04te',.-
g!7(ot
QOMMLNTS�
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
MGL Chapter 166 Section 21A —F and G min.$100-$l 000 fine
NO UES and DATA — (For devartment use
Ll Notified for pickup Call Email
Date Jime Contact Name
Doc.Building Pennit Revised 2014
1001
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
,;6 Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
4, Copy Of Contract
4. 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
IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
4� Building Permit Application
,4 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
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 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
Doe: Building Permit Revised 2014
Location
Date
No. 31
Check
t7)rf
TOWN OF NORTH ANDOVER
Certificate of Occupancy $wt
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $-
TOTAL $
Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 34,267.00
m
$ -
$
411.20
Plumbing Fee
$
51.40
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
51.40
Total fees collected
$
614.01
60 Windsor Lane
831-2016 on 1/22/2016
16x18 Sunroom
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KeenConstructionCo.com .o
Zablocki, Ed & Valerie
60 Windsor Ln.
N. Andover, MA 01845
Contract # 5562; Appendix A
Create Sunroom:
October 22, 2015
Frame new sunroorn (approx. 18'x 16') where existing sunroom is
Relocate exterior faucet to side of house
Supply & install eleven Andersen A -series double hung windows to match existing (approx. 2'10"
x 4'4") and three Andersen A -series transom windows (approx. 2'10" x 1'4")
Supply & install three Velux FS -001 fixed deck mounted skylights (approx. 21" x 27")
Supply & install swing patio door to match existing
Supply & install PVC exterior trim
Supply & install Hardie siding to match existing
Supply & install roofing to match existing
Install temporary stairs off the back of the deck
Re -configure existing deck to attach to new sunroom
Includes $2000 electrical allowance outlets, lighting and switching
Total Price: $34,267 (thirty four thousand two hundred sixty seven dollars)
Price does not include cost of permits, painting, interior finish or repairs to any unsafe, unusual or non -
code compliant existing conditions not addressed in this quote.
Payment Schedule: $5000 due upon signing contract
$7500 due the first da� of work (plus permit fee)
$7500 due when frame is complete
$7500 due when windows and door are installed
$6767 due at completion of contracted work
. .........
Custom�" Robert A. Keen
OC -7, 7 / 0 /Z-7
Date Date
PO Box 033 Page 1 of 1 P: 978-691-5201
N. Andover, MA 01845 F: _978-662-3231
GSL #07650-91 SalesLWK-eenGonstructionCoxorn HIC, #1083(53
r)
KEEN CONSTRUCTION CO.
1175 TURNPIKE STREET PROPOSAL
NORTH ANDOVER, MA 01845 All home improvement contractors and subcontractors
Tel: (978) 691-6201 engaged in home improvement contracting, unless
Fax: (978) 682-3231 specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered
Submitted fo 2, Icck' with the Commonwealth of Massachusetts. Inquiries
To: E 1-- about registration and status should be made to the
0 Ln Director, Home improvement Contract Registration, 10
Park Plaza, Room 5170, Boston, MA 02116 617-973-
8787 Owners who secure their own construction
related permits or deal with unregistered contractors
will be excluded from the Guaranty Fund Provision
of MG L c. 142A.
PHONE DATE REGISTRATION NO. EIN NO.
(0 MA. H.I.C. 108383 46 —3783401
> C/S = Customer Supplied S + I = Supply + Install See Attached Appendix A
We hereby submit specifications and estimates for work to be performed and materials to be used:
cx-c, A t 0 (,f-,
X
> Construction related permits:
............... ............... ............ . ............................................ ........... ............................................................................................. ............. .. .. . .... . .................
ii&�,K S C -H, - E- 6 U L"E" ............... . .. .. ........ . .......... ....... .. .. ....... *** - - - -- ------ *
Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on or
about (date). Barring delay caused by circumstances beyond Contractors control, the work will be completed by — (date). The Owner hereby
acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violationsof this Agreement.
WARRANTY
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship lot a period of following completion and shall
comply with the,requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is
discovered with n one year after completion of any job, including cleanup, the Contractor shall, at his own exoense, forthwith remedy. repair. correct, replace. or cause to be remedied.
repaired, or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall suivive any inspection performed in connection with the agreed-u,DOn work.
We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of :
A �:J Fc --,,3 �— A-�\ t+y �eveo dollars ($ 34, 7-(,
be made ad follows:
% ($ upon Signing C ntract; ROBERTA.KEEN
Name of Contractor / Designated Registrant
% ($ 1176 TURNPIKE ST.
Street Address
u
% up�nAompietion of N. ANDOVER, MA 01845
city / State
shall be made forthwith upon (978) 691-5201 (978) 682-3231
% ($ completion of work under this contract. :T
Notice: No agreement for home improvement contracting work shall require a k� Fax
>down payment (advance deposit) of more than one-third of the total contract price Name of Sale an
or the total amount of all deposits or payments which the contractor must make, in ature
advance, to order and/or otherwise obtain delivery of special order materials and Authon of Sign'
equipment, whichever amount is greater. Note: This proposal may be withdrawn by us if not accepted within days.
Acceptance of Proposal - I have read both sides of this docu ment and all attached documents and accept the prices, specifications and conditions stated.
I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above,
You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of
this transaction. Cancellation must be done in writing.
DJO 1) , SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signal [).,a 11, Signature
L - �4 Dale
IMPORTANT INFORMATION ON BACK
Windsor Lane
12-22-15
Ney-Bearm NAndoverM.A.
9:35am.
I Of I
CS Beam 4.1120
MawrialsDambaw 1516
MeMber Data
Description: Member Type: Beam
Application: Roof
Top Lateral Bracing: Continuous
Slope: 0.00 112
Bottom Lateral Bracing: Continuous
Standard Load: Moisture Condition: Dry
Building Code: IBC/lRC
Snow Load: 55 PLF Deflection Criteria: U240 live, L/1 80 total
1.000" max. LL
Dead Load: 15 PLF Deck Connection: Nailed
Member Weight: 15.6 PLF
Filename: Beaml
-
Other Loads
Type TrIb. Other
Dead
(Description) Side Begin End Width Start
End Start End
Category
Additional Uniform (PSF) TOP a 0.00" 16 5.5(Y' 9 0.00" 55
15
SnoVV
Point (LBS) Top z 0.00" 597
298
Snow
Point (LBS) TOP 4! 0.00" 597
298
SrKw
Point (LBS) TOP T 0.00" 597
298
Snow
Point (LBS) TOP 9 0.00" 597
298
Snow
Point (LBS) TOP 1z 0.00" 597
298
Snow
Point (LBS) Top 1-V 0.00- 597
298
Snow
—;J7—
t t \to,
Iff
t
0
is 5 8
Bearings and Reactions
Input Min
Gravity Gravity
Location Type Material Length Required
Reaction Uplift
1 a 0.00(r Wall SPF Plate (425psi) 5.5W' 3.75V
8376#
2 16' 5.5W Wall SPF Plate (4255psi) 5.50(r 3.6w
8220#
Maximum Load Case Reactions
Limit for applying point loads (or line loW to carrying "rembec;
Snow Dead
1 6157# 2219#
2 6053# 2167#
Design spans
is
Product: 2.0 Rigidl-arn LVL 1-3/4 x 11-7/8 3 ply
PASSES DESIGN CHECKS
Connect members with 2 rows of 16d common nails at 12.W'oc
NOTE: Nails must be applied from both sides
Design assurnes continuous lateral bracing along the top chord.
Design assumes continuous lateral bracing along the bottom chord.
I
I
Allowable Stress Design
Actual Allowable capacity Location Loading
Positive Moment 33229.# 38173.# 87%
8.23! Total Load D+S
Shear 76684 138611 550%
O.N Total Load D+S
Max. Reaction 8376A 122724 68%
a Total Load D+S
TL Deflection 1.OD45" 1.045T U187
8.23! Total Load D+S
LL Deflection 0.7376" 0.78W U255
8.23' Total Load S
Control: TL Deflection
-�kA 0 F 10,q
DOLS: Uve--10D% Snow=M% Roof=1251/6 Wind --1601/6
Design Increase in bencling 4 %
assumes a repetitive member use stress:
ROBERT Al -Mi.
MASYS
All PMOUct names ata Uada-adm of Moir mPowive
�'�'SS/C)NA
Copydgld (C) 2013 by Simpson Stamp -Tie Company Inc. ALL RIGHTS RESERVED.
delined as,0len the=oar joist, beam or glide; almm on We dialwAng meets applicable design ctiWat fo, I oade Loading Corlditiom and Spans listed on Me almml. The
be reviewed by a q Inner or desion em!Oonal as imlaid for approval. This desIg2 assmnes;ET941 installation accordi!M to Ite manufacturses!Mifications.
Windsor Lane
12-22-15
N[AndoverNLA.
9:42am
I Of I
CS Rearni][120
JmiBeamFjV*4.l1M1
1516
Member Data
Description: Member Type: Beam
Application: Floor
Window Header Top Lateral Bracing: Continuous
Bottom Lateral Bracing: Continuous
Standard Load: Moisture Condition: Dry
Building Code: IBC/IRC
Live Load: 40 PLF Deflection Criteria: U360 live, U240 total
1.000" max. LL
Dead Load: 10 PLF Deck Connection: Nailed
Member Weight: 12.5PLF
Filenarne: Beam2
Other Loads
Type Trib. Other
Dead
(Description) Side Begin End Width start
End start End
Category
Additional Tapered (PLF) TOP 9 0.00" 19 0.00" 0
80 so 0
Live
Point (LBS) Top 6 0,00" 6118
2219
Snow
10 0 0
10 0 0
Bearings and Reactions
Input Min
Gravity Gravity
Location Type Material Length Required
Reaction Uplift
1 a 0.000" Wall SPF Plate (425psi) NfA 2.047
4557#
2 1U 0.000" wail SPF Plate (425psi) N(A 1.979'
4414#
Maximum Load Case Reactions
Used for applying point loads (or line loads) to canying memlows
Live Snow Dead
1 334# 3059# 1498#
2 477# 31O&W I
Design spans
110' 1.7W*
Product: 2.0 RigidLam LVL 1-3/4 x 9-1/2 3 ply
PASSES DESIGN CHECKS
Connect members with 2 rows of 16d common nails at 12.0!'oc
NOTE: Nails must be applied from both sides
Minimum P-04!'beaiing required at bearing# I
Minimum l.W'beadng required at bearing# 2
Design assumes continuous lateral bracing along the top chord.
Design assurnes continuous lateral bracing along the bottom chord.
Allowable Stress Design
Actual Allowable capacity Location Loading
Positive Moment: 219511 251224 870/6
6 Total Load D+S
Shear 44764 110891 40%
-0.06 Tolal Load D+S
TL Deflection 0.4375" 0.5073" 1-1278
4.9EY Total Load D+S
LL Deflection 0.3065" 0.3310 L/397
5 Toted Load S
Control: LL Deflection
DOLS: Uve=1000/6 Srxm=1150/. Roof=125% Wind=1605%
Design asstnes a repetitive member use increase in berdrig stress: 4 %
0
ROBERT LAN.
0 MASIA
P
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Cn
No. 29174
T -
All piodmt�amtmdemarksoldwArmqmcti"o—z
Copydght(Q2013by Simpson Stiong-TieCompany lnr.ALLRtGHTS RESERVED.
ng ,defined as when the me=oorjoL% beam orginjec sown on posdrawing meetsappucme oftgn omedmov Loaft Loac%nq CiondiUanz, ad Spanstisked an lhissk�t M*
dP'V m.. be miewed by a quali or design em!zwonat as mquited for leMal. Thisclesion assumes ptoduct installation accomfina to the mant0acturees qMilications.
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The Commonwealth ofMassachusetts
Department ofIndustrial Accidents
ongress Street, Suite 100
3 1 C
Boston, AM 02114-2017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Narne (Business/Organization/Individual):
Address: M�:) V-) 0 A Z.-
Citv/State/Zh):
Are you an employer? Check the appropriate box:
9?3- 57
#: al I _.
1. M I am a employer with 2-�- employees (full and/or part-time).*
2.R I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.n I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.n 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
proprietors with no employees.
5.FJ 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. insuranceJ
6.FJ 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):
7. E] New construction
8. E] Remodeling
9. F1 Demolition
10 rVI Building addition
11. Electrical repairs or additions
12.M Plumbing repairs or additions
13.E] Roof repairs
14. E] 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.
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-conlractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name:_—rf—c, \,e- ler5 bi_5
Policy # or Self -ins. Lic. 14 L) rj� - 9 5� 5) 1 N5S - 2- — \_VD Expiration Date: I Q '97 Z 1
Job Site Address: �n WikV1J5&— Ln City/State/Zip:A I J Aldmojr 0/
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 violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification. =:::i!:::
Idoherebyceti 5 paqls andpenalties ofperjury that the information provided above is true and correct
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#:
DATE(MM1DD/Y yy)
ACC)RV CERTIFICATE OF LIABILITY INSURANCE I Y
is—� 10/23/2015
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 on this certificate does not confer rights to the
certificate holder In lieu of such endorsemengs).
PRODUCER
Gilbert Insurance Agency, Inc.
137 Main Street
Reading MA 01867-3922
CONTACT Barbara onough
NAME:
HONE -2225 FAX -2226
IA/C. No. Exth (781) 942 [�,C. 0,. (781) 942
E,IVIAIL
ADDRESS: bmedonough@ gi lbertinsurance. com
INSURER(S) AFFORDING COVERAGE NAIC 0
INSURERANorfolk & Dedham Insurance 23965
INSURED
Keen Construction Company
483 Chickering Road
North Andover MA 01845
INSURERB:Safety Insurance Company 39454
(NSURERC.�Travelers Ins. Co. 0031
INSURERD:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER-CLI552101779 RFVI.qlnh PJIIMRFR-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTVATHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH 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
I TYPE OF: INSURANCE
ADOLSUSR
iNsn
Town of North Andover
POLICY NUMBER
POLICY EFF
IMWDDrYYYY)
POLICY EXP
(MMfDDrlrYYY)
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE Fx-1OCCUR
IM Gilbert, CIC/BARBAR
ND -P-010078/000
3/13/2015
3/13/2016
EACH OCCURRENCE $ 1,000,000
DAMAGe TO HE NTE15—
PREMISES (Es occurrimm) $ 100,000
MED EXP'(Any we Person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENI AGGREGATE LIMIT APPLIES PER:
POLICY PRO, F
JECT LOC
OTHER:
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMP/OP AGG 1; 2,000,000
$
IS
AUTOMOBILE UA131UTY
ANY AUTO
ALL OWNED (---I SCHEDULED
AUTOS UTOS � AUTOS
HIRED A NON -OWNED
X AUTOS
6228807 COM 01
5/23/2015
5/23/2016
COMS(NEDSINGIM'DWIr— $ 1,000,000
"'ML
:�=Y I.`JURY (Per Person) $
BODILY INJURY (Per amident) $
a0PERTY DAMAGE $
r
U,dad...red mot.,W S 100,000
EUXMCBEMSS"LIAUSA13
HCCLAIMS-MADE
CUR
EACH OCCURRENCE $
AGGREGATE $
DED I I RETENTIONS
$
C
1If
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNERIEKEOUTIVE
OFFICERtMEM BER EXCLUDED?
(Mandatory In NH)
es,dewdbe under
DACRIPTION OF OPERATIONS b.1o.
NIA
6HUB-9991MSB-2-15
10/8/2015
10/8/2016
PER
STATUTE OERTH
E.L. EACH ACCIDENT $ 100,000
DISEASE - EA EMPLOYEE $ 100,000
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addhional Remarks Schedute, my be attached If more space Is required)
Llwmiwi[;Ai� Him 11�ff �AIU�Cl 1 -.1
(978)623-8320
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
IM Gilbert, CIC/BARBAR
W 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
INS025 (2014011
Massachusetts - Department of P.,ublic Safety
Board of Building Regulations and Standards
License: CS -076691
1"S
ROBERT A KEErj�
12 E WATER ST
North Andover A�k 01V
Expiration
Commissioner 08/16/2017
Office of Consumer Affairs & Business Regulation
ME IMPROVEMENT CONTRACTOR
V.,epistration: jb8383 Type:
ration: --8/4812046- DBA
!, , , �� -i.,
� ga ��
KEEN CONSTRUCY1bN---.-QQ,.'
Kenneth Keen
1175 TURNPIKE ST
NO. ANDOVER, MA 0
Undersecretary