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HomeMy WebLinkAboutBuilding Permit #1008-2016 - 607 TURNPIKE STREET 3/28/2014 tAOR BUILDING PERMIT 0 TOWN OF NORTH ANDOVER I APPLICATION FOR PLAN EXAMIN ON Permit NO: Date Received Date Issued: C 40ORTANT:Applicant must complete all items on this page a NO, A TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building E One family -J Addition L Two or more family U Industrial :3 Alteration No. of units: Commercial Repair, replacement E Assessory Bldg El Others: Demolition Other 27 nz& Identification Please Type or Print Clearly) OWNER: Name: t Phone: kd%(90s Address: "Alm WE Rk" 401m M ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$1Z00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 1,q ,500 -OD FEE: $ V-1 L1- Check No.: la? 16 J Receipt No.: `�>a NOTE: Persons contractingwi(b unrAistered contractors do not have ac e 'ic �s, I o the guaranty fund T 9PAR-ew. r BUILDING PERMIT pRTH V% w pF�t�eo t6�+0 TOWN OF NORTH ANDOVER a APPLICATION FOR PLAN EXAMINATION y� T pj h T I,p±�AF 1m Permit No#: Date Received �RoDR47ED gSSACHU`'�4 Date Issued: IMPORTANT Applicant must complete all itemstc on this page tf . ' not PF2.®PERtTY„QINNER � w! fy aa+� f4, t� 4 d2,,1 � 17 * »Sr � F ` t4§ � sG�l .ir#.A x`da +aa+t y -�mT 3-1 `�rW^'�j. y�°4 .''sv tar+.i.y�Prw ! ,;• ,3 h Pr,nt „. fd Structure = "x. ”t'e's t MAPk � '` ` PARCEL' r,'�" `'�`ZONING DISTRICT `� `Historic ®istnct ��, .� ,; �:° Machine,Sbop /illage yes, no . TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ DSe® �}1\le J �trFr ..- PER-4 �'Wefla tls DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: »s tr�'s :+i,�.Sjs»xi r hi' irx j+.r�� 7f""t'^f:i'• Contrra5ctor Name Phone Email1 +yt.unxY"sr,L.+ Vi4+.V r-r+ N s ✓'A'4 M2 K 4'+�'^C1 MV+iK? ' +'dw lr *A+f4r�`1y:3r+3srLn`M+>rt4ire�v¢" � ^�'. '�`•• � �'jT�+�,. r5,-. a r�a� a a-x�.-•..,a. w a- t >3'A rc =vra-.� � c �v, t - ry�ty:+Y � ;� � >i+'�K.'a, rt 3 ... � ��' �`` '�� Yr a .,vYke4wpp�'war r#'., ,e irSk ,y. n 4� Ya �,'sc„•°;. +tAdtlress"'� =1-19 f Y "�ig•�.a ..-E � k h', x .. aY f°"+ *' ...�^ 1-, a .' � ~'C.t�.•C '..,e z:�'t- v 2 . x �.�i•A"�-W ,�� n^ }ty§"' kC ? f t� wh''?kA�i['§.L r '� ' `{ i r a n+•-,•ta r 3. > i r x Supervisorps Construction License��J Exzp Date u2Y.�E M k.Y at s ,r�, � T'a "! " 'k} ,Aa a. r ..S a .� .a.� ` e,. is x� d ''L•"�4S r.�. t t'° a.,, f .. . rHomelmprovement License �.:n .�. x. >.:Exp kQate4 ARCHITECT/ENGINEER Phone: Address: Reg. No. K 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: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted-0- 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 I PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments a Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARWTMEN1T - Temp Dwrnpster on sit yes no "" • < � tR Located at 124 aim Street .:•'` _. " ,� _ " , r _, Fire Department aign Lure/date 11 COMMENTS _: . � �` � �,� r�� � ;,�. :��� ..: ".�-. .,t��. �.��;; "4� • �:� .=r 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 ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 46 Floor Plan Or Proposed Interior Work 4. Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 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 4� Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 4a 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 Location tat r n r1 � �-�'-`-`�.► Y No. Date7. • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ t` Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 4t 0 6 firms` Building Inspector �1pRTH Town of 2Andover 0- �jjjgai�� 0 h ver Mass COCNIC Nl WICM 1. �A�RwTED V�S ,9S U BOARD OF HEALTH PER T LD Food/Kitchen Septic System THIS CERTIFIES THAT ......... � owck BUILDING INSPECTOR ... ........ ....�..:...... ..... .............. ................. ..................... .................... has permission to erect ........... b ildings on�o1. %%Af� „_1 I ��C ',,,, Foundation .... .... ...... �... Rough to be occupied as ....... .. .... ' � i ... .. . ........... ... .. ......................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions,of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough Service .... .Grp ? - / .....••....• Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. ° L.)J Est.1984 0 ENGINEERING S CONSTRUCTION MARC®S A. REVERS J., P.E. President/Registered Professional Engineer 16 Woodland Street Tel/Fax:978-685-5691 Lawrence,MA 01841 Cell:978-804-7588 mdjincorporated@comcast.net www.mdjincorporated.com ROOF REPLACEMENT PLAN FOR PATTI MCCRUDDEN 607 TURNPIKE NORTH ANDOVER MA. a. Get roof repair plan all permits for work to be performed. b. Tear off and de-nail existing roof down to sheathing hang heavy duty mesh tarps from eaves of roof to protect house, pard and planting from debris. c: Inspect all wood roof sheathing, re fasten any loose sheathing and replace any damage wood. d. Install GAF stormgard ice and water shield 6' up from eaves of roof and down onto gutter, in all valleys, around all chimneys,skyligths and pipes and against all side and vertical walls. e. Install GAF deckarmor, premium, breathable underlayment to remainder roof. f. Install 8" aluminum drip edges flashing to perimeter of roof. g. Install GAF prostart starter strip shingles to perimeter of roof. h. Install GAF timberline HD, lifetime shingles to roof using six 1 %" round head, galvanized roofing nails per shingle for 130 MPH wind coverage. i. Cover all hips and ridges with matching GAF enhanced hip and ridge cap shingles. j. Replace flashing around all pipes, vents and skylights and at walls of top dormer. k. Replace flashing at all chimneys (aluminum step flashing and lead counter flashing) I. All workmanship guaranteed 10 years. m. Includes GAF systems plus weather stopper warranty (50 year non prorated coverage on entire roof system). `\ NOF" s n. Clean all debris on a daily basis into onsite dumpster to be re Mtce N w � RS .. completion of project. Ale — 44-f � �/7W s nDfr TOTAL COST: $14,500.00 a L S /)a anA. y oFS G� FsS)ONAL�� Contractor: Owner: r The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 MA02114,2017 WWw.massgovIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl T Name (Business/Organization/Individual):—ff .J co rpo rara Address: City/State/Zip: Phone#: q78— Are 70 —Are you an employer?Check the appropriate box: Type of project(required): I.ij I am a employer with_employees(full and/or part-time).' 7. ❑New,construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.O 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 Building addition 4.[]l am a homeowner and will be hiring contractors to conduct all work on my property. twill ensure that all contractors either have workers'compensation insurance or are sole I I.Q Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 Is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 2,06y),01w, 4=41& Policy#or Self-ins.Lic.#: 6-5,51711A-58 7594 Z-0-11137 Expiration Date: �t'�d Job Site Address: rae;,�jv. AL 9nCdOt/Q rCity/State/Zip:N hyi4dkrmA,. Attach a copy of the workers' comP�sation 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 they5piftJ and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Peron: Phone#: From Tonry Mon Mar 28 09:46:16 2016 Page 1 of 2 CERTIFICATE OF LIABILITY INSURANCE 73/29/2016 ATE(MM)DDIYYVY) 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 he 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 Duuud Biyyitls-Atttdri ......................................................................................................................................................................................... Totlry Insurance Group, Inc. PHONE t ,ext}: (617)773-9200 1AIC.No): IclY>YY�-yyzu 300 Congxess Street E-e4AIL .S,Cet.s@t;onxy.com Com ADDRESS: ...........9............................................................................................................................................................................ INSURER(&)AFFORDING COVERAGE NAIL d ..............................:.................................. Quincy MA 02169 INSURER A Endurance American Specialty ; 41718 INSURED INSURERS:L1A .d 8 of London . 15792 r y........................... ..... ........................................................................>........ ...................... MDJ, Incorporated INSURER G: 16 woodland street INSURER O: INSURER E. . ......................................................................................................................................................:.................................. Lawrence tdA 01841 IN$URERF: COVERAGES CERTIFICATE NUMBER-CL1632312820 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. ............................................................................ . .................................................POI ICY FFF.......Pnl ICY FkP.................................................................................................................. IN6R: TYPE DFINS.(BOCCE........................,AISDiCVBA................................ . : LTR POLICY NUMBER MMIOD/YYYV i MMIDOIYYYY I IMITS ){ COMMERCIAL GENERAL LIABILITY FACN Cai:C;IiRRFNOF g .................: I.;E:• ..... 1,000,000 A CLAIM':-MAUI X €UCCUH NAMnr�Ick-rnHu 100,000 CBC10001403eO3 ;12/22/2015 12/22/2016(MFI1Fx1 (nnynnr.hrrnn) s 5,000 ........:............................................................................... i i F'FH:iDNlA K nI:V IN.Il1H'f 1,000,000 7.EIJ'L.AOOREGATE LIMIT ArrLIES PER. € rENERALP.�CRE'ATE 5 2,000,000 XFI:1I<:v IHC)- IID; .hc................................................ I................................................... o-cl ,v•(nut;I1i-COMPIOHAt-Ka 2,000,000 '•OTHER. AFrlmi,iral In urarf HWnsw 5 AU IUMOEl.LE uAtslulYCOMBINED DINGLE LIfv11T y ................................................. E nN�nu 1 U GODLY INJURY(Prl parous) S I tU I OWNI-I1 A1110S AU la; BODILY INJURY(rwao;lism)'S HIHI-u At!108 NON nNNCO ........, E......... AUTOS PROPERTY DAMAGE ; UMBRELLA LIAB :DCCUR FACHcx:G,.;kk�Nf:F ¢ E%GE55 LIAB CLAIMS MADC - :............. .................:_..... .............. . i �.AGC;ZCGATC W i IIFII i kl-I FNllf IN:ri ............................. ............................................ WORKERS COMPENSATION _ .AND EMPLOYERS-LIABILITY i i 6TA Y/N; TIJTC ' i CRH ;ANY PR.'�PRIFT6R:PARTNFRfFXF(;LITIVF :: E.L. i UFHCER;M MBLH tXCLUUhU7 'r.N/A CACI I ACC3DCIJT I .(Mandatory in NII) :........:E ..................... . ... ......... ...... ............................................. If yye..dc.erihe under ; ..................................I................. ............................................. :OCc;CRIPTIi1N or OPCRATIONS LiOW1 DI$FAg - E.L. - E-EA EM%OYE�S E.L. ._E POLICY LIMIT i S B ; DESIGN PROFESSIONAL/ PGIARK0357DO2 2/19/2016 2/10/2017 CACI I CLAIM $1,000,000 VOI�I�II'I'IUN 1,1AHI1.1'I•v nRnTIrTTAT.R! $5,000 A(;C:�tFf;AIF �''I,C106,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule.may be attached PI more space Is required) Project: 607 T.trnpikP StrP..P.t, R011t 114. Operations usual to at residential gelieral contractor. when required by written contract executed prior to loss, the certificate holder and other parties are included as additional insured(s) for work performed by the named insured. CERTIFICATE HOLDER CANCELLATION (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Gerald Brown 120 Main Street AUTHORIZED REPRESENTATIVE _ North Andover, MA 01845 _ L Torry Jr./DONNAFi Q 1989-2014 ACORD CORPORATION_ All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered(narks of ACORD INRn75 r•x:Ian+•. DATE(MM/DD/YYYY) „ ,4co CERTIFICATE OF LIABILITY INSURANCE 3/11/2016 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 ONE CT Donna Higgins-Amari Albert J. Tonry Co., Inc. PHONE (617)773-9200 No):(617)713-9920 300 Congress Street E-MADRess:certs@tonry.com INSURERS AFFORDING COVERAGE NAIC# Quincy MA 02169 INSURER A:Endurance American Specialty 41718 INSURED INSURER B: MDJ, Incorporated INSURER C: 16 Woodland Street INSURER D: INSURER E: Lawrence MA 01841 INSURER F: COVERAGES CERTIFICATE NUMBERCL15122812193 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 TYPE OF INSURANCE ADSL SUBR POLICY NUMBER MM/uDDYIYYYY POLICY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO I A CLAIMS-MADE Fx_1 OCCUR PREMISES (',=n.) EaEoccurrence $ 100,000 CBC10001403803 12/22/2015 12/22/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑ PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: Additional Insured Blanket $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-FA EMPLOYEE $ Nes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: 607 Turnpike Street - North Andover, MA. Operations usual to a residential general contractor. When required by written contract executed prior to loss, the certificate holder and other parties are included as additional insured(s) for work performed by the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE L Tonry Jr./DONNAH ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r?nteni i From Tonry Mon Mar 28 09;46;16 2016 Page 2 of 2 CERTIFICATE OF INABILITY INSURANCE DAfF(MM/DDmm) 03/28/2016 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 llou of such andorsement(s). PRODUCER CONTACT NAME: F2oni'ca Ganzzllas ALBERT J, TONRY& CO,, INC. PHONE.;A/C No Extl- 6,17 77'3.9900 ►Ac No): -MAIL rOnil:dg(gion to ry-. ADDRESS: rn 3OO CONGRESS ST. INSURER(S)AFFORDING COVERAGE NAIC q QUINCY Mfg D2169 INSURERA: CONTINENTAL CASUALTY CO 20443 ............................................................................................................ ENSURER a MDJ INC, INSURERL: INSURER D ................................... 1(3 WOODLAND STRP..FT INevRBRa. ...............................................................................................................................:.................................. LAWRENCE MA 011141 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 40065 REVISION NUMBER: 'I'HI$13 l'O CER11FY THAT THF POI..IriF,1 OF INSURANCE I..I$'I'Ft) BELOW HAVE: BFFN I$8UF'.D'I'O'('HH 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 :AODI.:SUBR.; PC)LII:Y L'►► ! PULIr:Y L]CP LTR; TYPEOF INSURANCE r POLICYNUMBE,R MIUUDtl1WVV MM1DtllYVW LIMIT"S j COMMERCIAL GENERAL LIAOILfrY I............... UI.AIMti-MAI)h. I........�fJL:(UH I EACH GCCUFiIENCE CIJTCtS............ .............................................. "D Tv1A'Gt Tt7 tt • i PR,(-MISE•S IE9 Ul'WIreIV:d) .....� ......... .............................................................................. i ! i P/ILU.._XP(Anx nru:trr::un�.... ........................................... ......... .............................................................................. N/A .................... ..PERSONAL&ADVINJURI'....... ........................................... I OF:N'I.AC,C'+REOA'rt':UMI'1'APPLIF'.'SF'k'R: i '• ,•GFNkRAt.AC)r9Rk'oA'rE. ......b PdLaa, E` LXROCOMPICIPAGG AUTOMOHILL•LIABILll'Y COMBINED SINGLE LIMIT $ (Ca acuidentl ANY AU'I'0 BODILY INJURY(Per person) $ ALL OWNED ' SCHEDULED E ' AUTOSAUTOS i € N/A csonn Y wJtlRv(Por ocx0onl) I N()N-f,)WNFII i ........... ............................................. HINFI')Aul'Lis :......... AUT09 i / t PROPERTY DAMACE . (r`er nccideM` ... UIIIBRELLA I. LIAE1 i..-. OUCUR I EACI I OCCURRENCE. $ EXCCSS LIAe CLAIMS PAADti N/A �.................. AC GIiEGATE Dr:D RETENTION I WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y I N I. € X ANYPHOPHII::I OHIPAN I N1041:XIr.DII IIVI:: i E ........l:.l_0.11)IF............i............. ....r.................................... E.L.EACH ACCIDENT ►R $ 100,000 A ;OFFICERIMCMDEREXCLUDED; WA'NIA NIA 6S59UB5B75967015 1-1120/2015 i 1112012016 t............................................................................................................ (Mandatory in NH) '; L If yyos,downbo undor E....DI8FA3r t A kMP.OYE.k 1 500,000 ❑E9CRIPTION OF OPERATIONS Lwluw P.I.DI,-.EA,-,G•POLICY LIMIT $ 500,000 N/A _..................................................... .......................... ...... ....._....._......_.:...._......_......_......_......_......_......_......_......_...-----...._......_......_......L......_......_......_.....:_......_..................................... ................... ........................ ..._... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE6(AGORD 101,AQtllNonal Remarks Schodule,may be attacnBd rf more Space is requirod) Worker,;'C:ompensaton benelits will be paid to Massacl)usells employees only.Pursuant to Lndorsenlenl WC 20 03 06 B.no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hiree,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 issut�dile of thiti r,Frtiricale of insuranre). ThP stsltu5 of Ihig rnvt�rRde<:an be rnnnil:nrr:d doily by f�ct:f?s5inrl the Proof of Cnverar)P-t:nvF�r»rte VerifcAtinn Search tool at WWW.inass.gov/lwd/workors-compoi)sationfli)vostigations/- CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main SlreP,t AUTHORIZED REPRESENTATIVE North Andover MA 01845 L7y(zafil.6A,K;tt3Wy,CPCU,Vice President Residual Market WCRIBMA PJ 1988-2011 ACORD CORPORATION. All rights reserved, ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD DATE(MMIDDIYYYY► ,�coRo CERTIFICATE OF LIABILITY INSURANCE 03/11/2016 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 NAME: r Roni'Ce Ganzzllas ALBERT J. TONRY&CO., INC. PHONE , (617 773-9200 --T—FAX Na: E-MAIL ADDRESS: ronicag@tonry.com 300 CONGRESS ST. INSURERS AFFORDING COVERAGE NAIC# QUINCY MA 02169 INSURERA: CONTINENTAL CASUALTY CO 20443 INSURED INSURER 8: MDJ INC INSURER C: INSURER D: 16 WOODLAND STREET INSURER E: LAWRENCE MA 01841 INSURER F: COVERAGES CERTIFICATE NUMBER: 36544 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 TYPE OF INSURANCE ADDL SUER POLICim_Ma POLICY NUMBER MIDDY EFF PM DEXP D1 LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO CLAIMS-MADE F OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- JECT F__]LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _{Es accident) ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Par 7 dent $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X I STATUTE ETH AND EMPLOYERS'LIABILITY A OF CANYPRERIMEM ERREXCLUDED?ECUTIVE NIA NIA NIA 6S59UB5B75967015 11/20/2015 11/20/2016 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached K 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-compensationAnvesbgations/. CERTIFICATE HOLDER CANCELLATION 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 Oscgood Street STE 2035 AUTHORIZED REPRESENTATIVE -p North Andover MA 01845l" Daniel M.Crey,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 I .... '`�/!t•�fINN«:dfllOX/ffll r- -/p�(✓g�lairgri!liC�� skifte COKrRACTOR w 1t10<�8 Type: Erq�lntlon: .7124t20/a Pfiiate COMOffift MDJ INC. Mare pavers 61 WOOD LAND STREET Q -�a LAWRENCE,MA 01841 iio6erxerrmry Massachusetts Department of Public Safety Board of Building Regulations and Standards License: x$47 Construction Supervisor MARCORS A DEVERS I$ WOODLAND STV LAWRENCE MA 01 CA, Expiration: Commissioner IW2612017 Project Address: The above license are authorized for the Project address stated above only. DO NOT REPLICATE. Authorizing Signature or Initials MDJ Engineering&Construction Nlarcos A Devens J.,P.E. 16 Woodland Street Lawrence,MA 01841 (978)804-7588