HomeMy WebLinkAboutBuilding Permit #871-16 - 61 COACHMANS LANE 2/8/20161
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
TANT: Applicant must comblete all items on this
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
Y`One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Meration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
ht4k
hew act ICQor 4,il e,
Identification Please Type or Print Clearly)
X
OWNER: Name: O wYle) d4 &wWM PPhone:
Address: COa-Ama of Law /t/, hAver
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT.- $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ G I, 4Q. O -O FEE: $
Check No.: Receipt No.: 4f'
NOTE: Persons con r t' th unreg#tgred contractors do not have acc to h ranty fund
"i;
A
BUILDING PERMIT o"O oT "�tia
TOWN OF NORTH ANDOVER a 5.. '` 6
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received �4A�R17ED yea'` c5
9SSAC14V`'��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
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
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
�: Septic; ❑ 1Nellb s
�'Floodplai:n O Wetlan�ds
i D, �UVatershey � 4®��tnc�§
Q VVateTlSewe�
'
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name:
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License:
Home Improvement License:
ARCHITECT/ENGINEER
Address:
Phone:
Exp. Date:
Exp. Date:
Phone:
Reg. No._
F
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
e
A
f
Locatio)4 64-" 4
No. Date
Checko/_5�*
29992
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee . $13_1:�
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
r
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
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Signature
COMMENTS
HALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comm
Conservation Decision: Comments
I Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
�ocatea 364 usgooa Streett ►�*as�s sts t� s ist: +
SIRE DEPARTMENT Temp ; u p j njs�� yeses Q.'
iLo ated at 124 Main Street ''�e •�A ''
,� - .�, ` r�.`v[r9.� i
Fire Department signature/date
�•�X
-�"�}}�t�Ti'�ss3`,`x^*r�i�t`+s y
i 4i t?§ ��+ FTd x*f�y s a�,-; +�t4 i,#"! S3`' s # ' m.4 .c$
X . `� '}'�+� 'f.'�, "-tf °"� #`"f.ift+j„�..Gi.^5ffi .UT�'}54
gCOMMENTS f i
r.M.,,�.a-+a . ...w:wa:.s1+....i..Y,....,�..�.aaa�,i'«,Y.tS�,�i:R�3..�.w.�:.,�tx'r..�a.s:�i..t>�.u.rL'�uta ' r+`+.►tai. r= r�rL� o r. ;.., , f
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)
❑ 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
a, Building Permit Application
4, 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
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
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
4� Engineering Affidavits for Engineered products
TOTE: 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
Enter construction cost for fee cal -
North Andover Fee Cakulaf/on
Construction Cost
$ 61,432.00
m
$ -
$
737.18
Plumbing Fee
$
92.15
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
92.15
Total fees collected
$
1,021.48
61 Coachmans Lane
871-2016 on 2/8/2016
Bathroom (2) remodel
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Ratte' Construction Co., Inc.
33 Walker Road
North Andover, MA 01845
Tel. 978-682-4982
February 5, 2016
Charles and Susan Papalia
61 Coachman's Lane
North Andover, MA 01845
The following are specifications to remodel your master bath and main bath.
Permit -
Obtain necessary Town of North Andover building permit.
Demo -
Remove and dispose of existing vanity/top, shower, tub, tile floor, hamper and linen
closet. Remove drop down ceilings above shower and tub.
Framing -
Frame for shower and close in (2) bifolds to single doors. Blocking for future grab bars.
Plastering -
Install blue board and skim coat plaster on new walls and ceiling finished smooth.
Wedi shower system -
Supply and install a Wedi shower system for shower floor, walls and ceiling.
Electric floor heat -
Supply and install Schluter Ditra floor heat all floor except closet.
Plumbing -
An allowance of $3,500.00 to disconnect and cap existing tub and shower and vanity.
Relocate drains as necessary. Supply and install new shower valve with personal shower.
Supply and install new tub valve. Pull and reset existing toilet. Replace shut offs for
vanity.
Plumbing fixtures -
An allowance of $3,000.00 to supply a 5-6 Maxx acrylic soaking tub, (2) undermounted
sinks, (2) lavatory faucets, shower trim and tub faucet.
PLEASE il`lli AL
Electrical -
An allowance of $2,500.00 to rewire master bath to include (4) recessed lights, Panasonic
fan, night light, updated vanity lighting and switching as necessary.
Interior trim -
Supply and install (2) 2-6 x 6-7 %2" custom door units for entry to bath and closet. Swap
toilet room door to match existing. Install crown moulding in vanity area. Patch base as
necessary.
Floor tile -
Supply and install tile floor TBD.
Shower tile -
Supply and install tile on shower walls and ceiling TBD.
Tub tile -
Supply and install tile on tub walls and area between shower and tub to ceiling. Tile TBD.
Cabinetry -
Supply and install a Wellborn vanity with pencil drawer in Glacier paint. Supply and
install a tower in Glacier paint.
Vanity top -
Supply and install a custom Quartz top TBD with (2) undermounted sinks and 4" back
and side splashes.
Shower door jamb, seat and niches -
Supply and install Quartz parts as follow.
(1) Shower corner seat with round front.
(1) Jamb and threshold set for shower door opening.
Niche parts as necessary.
Painting -
Paint bathroom walls, ceiling and trim complete. Touch up wall and baseboard in master
bedroom after wall patching.
Mirrors -
TBD
Hardware -
Install owner supplied towel bars, robe hook and toilet paper dispenser.
Lighting -
PLEASE INITU
Install (3) owner supplied vanity lights, cabinet knobs and (1) owner supplied ceiling
fixture.
Main bath -
Demo by others. Supply and install Wellborn vanity in Glacier paint. Supply and install a
custom quartz double bowl vanity top. Supply and install a new tile floor over new
underlayment TBD. Remove and reset toilet. Remove and reinstall existing lavatory
faucets.
All work is covered under our workman's compensation liability and contractor's public
liability insurance policies.
PLEASE U111 i B *'
MR
goods carry an implied warranty of merchantability and fitness for a particular
purpose.
XII. COMPLETENESS OF AGREEMENT FOR EXECUTION
The owner is hereby advised that he should not sign this Agreement unless and
until all blank sections have been filled in or marked as void, deleted or not
applicable, and until all exhibits or referenced documents that are incorporated
herein are attached hereto.
XIII. COPY OF AGREEMENT TO BE GIVEN TO OWNER
This Agreement is governed by the Laws of Massachusetts. It must be executed
in duplicate, and an original signed copy hereof given to the Owner at the time of
execution. No work under the Agreement shall begin prior to the signing of the
Agreement and transmittal.
RIGHTS TO CANCEL
The Owner may cancel this agreement if it has been signed by the Owner at a
place other than an address of the Contractor which may be his main office
or branch thereof, provided that the Owner notifies the Contractor in
writing at his main office or branch by ordinary mail posted, by telegram
sent or by delivery, not later than midnight of the third business day
following the signing of this Agreement. See attached Notice of Cancellation.
Note: This proposal may be withdrawn by us if not accepted within 30 days.
HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY
BLANK SPACES.
SIGN RUM! Owner's Signature Date Signed_3
SIGN RECEOwner's Signature Date Signed
Contractor's Signature Date Signed �1
IX. CONSTRUCTION -RELATED PERMITS
The following construction -related permits will be necessary in order to complete
the scope of work included in this Agreement:
Town of North Andover building permit.
The Contractor under provisions of Chapter 142A of the General Laws is required
to apply for and obtain all construction -related permits. The Contractor shall not
be deemed responsible for delays in the work described in this Agreement caused
by regulatory, permit granting or inspectional agencies, authorities or individuals.
Notice: If the homeowner obtains his own construction -related permits for
the work described under this Agreement, the homeowner is hereby advised
that in the event of a dispute, judgment and nonpayment of the contractor,
the homeowner will not be entitled to make a claim to or collect from the
guaranty fund established by Chapter 142A, M.G.L.
X. MODIFICATION
This Agreement, including the provisions relating to Price (Section III) and
Payment Schedule (Section IV), cannot be changed except by written
statement signed by both Contractor and Owner. However, cancellation by
Owner is allowed in accordance with the Notice of Cancellation (annexed).
XI. WARRANTIES
The Contractor warrants that the work furnished hereunder shall be free from
defects in materials and workmanship for a period of 1 Year 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 within one year
after completion of any job, including cleanup, the Contractor shall, at his own
expense, 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 survive any inspection performed in connection
with the agreed-upon work.
All warranties for equipment supplied by the Contractor under this Agreement
shall be those given by the manufacturers of such equipment, which shall be and
are hereby passed through directly to the Owner. Under such manufacturers'
warranties, the Owner may be required to register or mail in a warranty card or
other evidence of ownership and use of such equipment in order to activate such
warranties. The Owner's failure to mail in or register such documentation, which
failure voids the manufacturer's warranty, shall not create any responsibility for
the Contractor to warranty such equipment.
This warranty gives the owner specific legal rights, and owner may also have
other rights which vary from state to state under Massachusetts law, sales of
PLEASE INITIAL
Ratte' Construction Co., Inc.
33 Walker Road
North Andover, MA 01845
Tel. 978-682-4982
RESIDENTIAL CONTRACT AGREEMENT
Read this Agreement and make sure you understand it before signing it.
This Agreement has legal force and effect and binds those who sign it.
Note: All home improvement contractors and subcontractors engaged in
home improvement contracting, unless specifically exempt from
registration provisions of Chapter 142a of the General Laws, must be
registered with The Commonwealth of Massachusetts. Inquires about
registration and status should be made to the Director, Home
Improvement Contract Registration, One Ashburton Place, Room
1301, Boston, MA 02108.
This Agreement is made on 2/5/16 between Ratte' Construction Co., Inc. of 33
Walker Road, North Andover, MA 01845 (978) 682-4982, hereinafter called
"Contractor" and Charles and Susan Papalia, 61 Coachman's Lane, North
Andover, MA 01845 (978) 685-0916, hereinafter called "Owner".
I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED
Contractor agrees to perform in a good and workmanlike manner all work
detailed below. Such work consists of the following:
See attached specifications.
II. DETAILED DESCRIPTION OF MATERIALS TO BE USED
Materials to be used in performing the above described work consist of the
following:
See attached specifications.
III. PRICE
Contractor agrees to do all work described on a cost-plus basis.
Materials at contractor's cost. Subcontractor's at contractor's cost.
Carpenter's labor at $54.00/hr. Total of all above plus 21% overhead and
fee. Projected cost approximately $61,432.00.
HIDDEN CONDITIONS AND NECESSARY ADDITIONAL WORK
Hidden conditions may require adjustments to the contract price. In such a
case the contractor will inform the homeowner of such condition forthwith
PLEASE INITIAL
Ir
St,
and where necessary a written amendment of this contract will be negotiated
and executed by the parties.
IV. PAYMENT
Payment will be made as follows:
$15,000.00 deposit upon signing contract;
Deposit will be credited as job nears completion.
Job to be billed weekly with copies of all backup invoices and an updated job
cost report.
Notice: No agreement for home improvement contracting work shall require
a down payment (advance deposit) of more than one-third total contract
price or the total amount of all deposits or payments which the contractor
must make, in advance, to order and/or otherwise obtain delivery of special
delivery materials, and equipment, whichever amount is greater.
V. COMMENCEMENT AND COMPLETION OF WORK
Contractor will not being the work or order the materials used before the third day
following the signing of the Agreement, unless specified here in writing.
Contractor will begin work on or about February 8, 2016. Barring delay caused
by circumstances beyond Contractor's control, the work will be completed by
March 25, 2016. 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 violations of this Agreement.
VI. NO ACCELERATION OF PAYMENTS BY ESCROWING ALLOWED
The Contractor may not require payments to be made in advance of times
specified in Section IV (Payment) above for reason that he deems himself or the
payments to be insecure. If however, he deems himself to be insecure, he may
require as a prerequisite to continuing the work described herein, that the balance
of the payments under this Contract that are in the control of the Owner, shall be
placed in a joint escrow account that requires the signature of both the Contractor
and the Owner for withdrawal.
VII. INSURANCE
Contractor will be responsible to Owner or any third parry for any property
damage or bodily injury caused by himself, his employees or his subcontractors in
the performance of, or as a result of, the work under this Agreement. Contractor
agrees to carry insurance to cover such damage or injury.
VIII. SUBCONTRACTING
Contractor agrees that, notwithstanding any agreement for materials and/or labor
between Contractor and a third party, Contractor is responsible to Owner for
completion of all work described in a timely and workmanlike manner.
PLEASE INITIAL
vqyz
5t
Ratti Construction, Inc.
2/5/2016
mat'I & unit cost mark up
0
tax on materials
subcont. mark up
21%
contingency
E6.25%
5%
PLEASE I-1ITIAI
MSR: 2/5/2016 Page 1
Papalia master bath
Ratte Construction Co. Inc.
33 Walker Rd
North Andover, MA 01845
JOB faek
SHEET NO. I OF-
CALCULATED
F CALCULATED BY DATE
CHECKED BY
DATE
FORM 204 Available from �wC. TOwmend, Mass 01469
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
t
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organizadon/Individual): GaNSirzcc�fir�GV
Address: 3 3 M6441(' aod�
City/State/Zip: /V, JJtyw' r Na$ Phone #:A
Are you an employer? Check the appropriate box:
1.i th
am a employer with _ 1 employees (full and/or part-time).*
2.L] I am a sole proprietor or partnership 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
4.❑ 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. ❑ 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.,
6. ❑ 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. ❑ New construction
8. [I/Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.0 Electrical repairs or additions
12. E] Plumbing repairs or additions
13. [] Roof repairs
14.0 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 -contractors have employees, they must provide their workers' comp. policy number.
I atn alt employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A ► r l
Policy # or Self -ins. Lic. M V W ' 110 —6W I s._(i - ?M 4_ Expiration Date: I l% 1& (04
Job Site Address: Ut ( (0a4wU0 1�dw City/State/Zip: N.' Tdow ) 1' a Li
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.
Ido hereby certify tinder the paiinr�k
sndpenaId of petjuty that the information provided above is tate and correct.
SiLmature: nJA Date: _ 2I Sb1/1
Official use only. Do not ivrite 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 #:
16.. > ® CERTIFICATE OF LIABILITY INSURANCE
��
DAT2/05/2016
02/05/2016
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
NAME: Charles Kurkjlan
MTM INSURANCE ASSOCIATES LLC
AJC"N Ext; (978)681-5700 FAA/c No:
ADDRESS: charliek@mtminsure.com
INSURER(S)AFFORDING COVERAGE NAIC #
1320 OSGOOD ST
INSURER A: AIM MUTUAL INS CO 33758
NORTH ANDOVER MA 01845
INSURED
INSURERS:
INSURERC:
RATTE CONSTRUCTION CO
INSURERD:
RATTE CONSTRUCTION CO INC
INSURER E :
33 WALKER ROAD UNIT 2E
INSURER F:
NORTH ANDOVER MA 01845
COVERAGES CERTIFICATE NUMBER: 29313 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
SUER
POLICY NUMBER
EFF
MMI D/YYYY
MMLICY EXP
LDDY
/YYYY
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $
CLAIMS -MADE 1-1OCCUR
PREMISES (Ea occurrence $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
N/A
GENT AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $
POLICY 1 PRO JECT ❑ LOC
PRODUCTS - COMP/OP AGG $
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
Ea accident
BODILY INJURY (Per person) $
ANY AUTO
BODILY INJURY (Per accident) $
ALL OWNED SCHEDULED
AUTOS AUTOS
N/A
PROPERTY DAMAGE $
Per accident
NON -OWNED
HIRED AUTOS AUTOS
$
UMBRELLALIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
N/A
DED I I RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N
OFFICER/MEMBEREXCLUDED? N/A
(Mandatoryin NH)
N/A
N/A
VWC10060045502015A
10/06/2015
10/06/2016
X STATUTE ORH
E.L. EACH ACCIDENT $ 500,000
E.L. DISEASE - EA EMPLOYEE $ 500,000
E.L. DISEASE - POLICY LIMIT I $ 500,000
If yes, describe under
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/.
CERTIFICATE HOLDER
Town of North Andover
1600 Osgood St Building 20 Suite 2035
North Andover
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
MA 01845
Daniel M. C*6y, 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
~�,JIM&Massachusetts - Department and Standards I
f Public SafetY
Board of Building Regulations
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License: CS -04381.650
MARK S RAVE
20 CHATHAM ROAM
APIDOVER MA 8181
Expiration
05/08/2017
Commissioner
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. Office of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
�. egistration:
117532 Type:
s Expiration:, 1011612016
Private Corporatii.
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MARK RATTE
33 WALKER. RD
NORTH ANDOVER, MA
Undersecretary