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Building Permit #533-2017 - 638 CHICKERING ROAD 11/17/2016
i BUILDING PERMIT of "O RT b�ti L)'��1��� TOWN OF NORTH ANDOVER a :.._ APPLICATION FOR PLAN EXAMINATION Permit No#: 3 - 17 Date Received 17 `IL �sgSsgcHus���5 Date Issued: f f '-� IMPORTANT: Applicant must complete all items on this page LOCATION Ch--ICKen n� P -a Jr �e� ��ci PROPERTY OWNER _.- ._-_ a __ _ Print 90.O'YearStructure yes nno MAP ____ _ PARCEL: __ ZONING DISTRICT: Historic District yes Machine,Shoo, Village ves TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 'Q One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ElWell ❑ Floodplain. El Wetlands Qs Watershed'District 0 Water/Sewer QUI WOOT11:41 ■ Now" ..L!. Identification - Please I OWNER: Name: Addressf y,59 Ch1 C =--mirAFORMS-11AW, L Oei It eor Print Clearly t FO-rf Y Phoneq `tQ hone:C 13�✓ t ' Ex p. ateSupervisor's ConstructionLicense: -012 Home Improvement License: 1_5t'Iu7 _.Exp. Date:,Ij�l��7 J 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: $ L1q 31. FEE: $ �q - Check No.: (� �J Receipt No.: 2, 1 �� NOTE: Persons contracting with unregistered contractors do not have access he ara u d ,Sig nature_ of Agent/Owne Signature of con-tract- IF Location 1', -�-6 C 'A' L No. ,-*4-4' rl o 17 Check # / 7 31 Date t I— / 7 -.4vf TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 07 /* f --� .� L�Suilding Inspector Plans Submitted ❑ Plans Waived.[] Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature, COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition Planning Board Decision: Comments Conservation Decision: Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FI0 ,bEPARTMENT Temp, Dumpster on, site yes no,, .Located at 124 Main Street Fire,Department signature/date, COMMENTS _ 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 NO I Lb and ®A FA — (For department use ❑ Notified for pickup Call Ema Date Time Contact Name - Doc.Building Pennit 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 ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products ,4OTE: 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) o Engineering Affidavits for Engineered products VOTE: 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products VOTE: 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 t'n O _ O ~ U cc WCC J O W WLLJ O G N Z Z acr L6 ? C7 J Z W D Z Z V N 0 Q 0 m F- Q w L6 _ � U iy m E co J J y Q)m d W O N Y t C L _ U -C a) C N O \ U bbf E f0 7 � i C 0 i 7 y E 0 CL =3LL w In LL m VI N n G W, WN 1� W F- W CL C) V W a z l Mz 0 J on E O 2 _ O V Q� ca �o �. E Q. L r: C CD 4) O 0 �+ C L O _ vm L CA J �m CD � > _ ccL O W > O �: 'a ED� 0 j = o o �� �, z IA: c xeo G W, WN 1� W F- W CL C) V W a z l Mz 0 J on E S A L E S O R D E R THE STOVE SHOPPE 25 INDIAN ROCK ROAD, ROUTE 11 WINDHAM, NH 03087 Phone #: (603)537-0555 Fax #: (603)537-0556 Picked Up By: PHONE #: (978)390-9242 CELL #: ALT. #: P.O.#: TERMS: Cash SALES TYPE: Sales Order CP: Sue E SALES REP: Sue E DATE: 10/21/2016 ORDER #: 33104 CUSTOMER #: 137054 LOCATION: 1 STATUS: Active PAGE: 2 TAX: $0.00 ORDER TOTAL: $4,932.73 10/21/2016 PMT VISA: 07060D $2,000.00 10/27/2016 PMT VISA: 07731D $2,932.73 BALANCE REMAINING: $0.00 DEga� llc A: Fireplace is: Rectangular_ J Arched __ A= Fireplace Width: Bottom Top t-, B= Fireplace Height: Left_ Right - +' Height to Top ofArch ifApplics B 1=Height to Lintel Bar See lDra`vi11g B C= Fireplace Depth__L�-I D= VVIdth at BackZ,L4 E=Distance to Mantel Shelf (From Hearth or 1=loor)__Ne . F= Hearth Depth_ I f, _ G= Hearth Height tt.k-Ir H= Distance to Combustible Trim/ L,eos__Pe 1= Distance to Combustible Wall N A J= Height to Damper Rod K= Height to Breastplate of Mantel L= Thickness of Breastplate ��A M=Depth of Mantel N� A- _ DRAWING C_ Ii\1STAI LATICiI,iINTO A FIREPLACE Customer Q`iL.4,. '1.__ -- . — -- ---- -- . —Salesperson I Address n LA_ ;� l C'..Cl-� G2t1�C'ity '`� LlJState _'` zip - 1, The Fire place is a: A'lasonry I/ Metal (ZC)_ _ Preformed Metal/Brick_ - - 2 Facin; material: Brick ✓ Tile_ Fieldstone_ Other 3. Is the Facing \'laterial... Flat ProtUuding/rcou;h _ -t. S. Chimne\'all_ Inside \'all y: Outside Clav liner In Chimney: Yom[ N Siz of Tile (If not sure ppros ;1gC of hoUSe___) 0. Chimney Height(From floor of where unit to be installed to Very top of the chimney)- �5 7. Type of Appliance: Free Standing Insert_ :lass Door _ 8. Is There a Chimnev Cap: Y'_ N 1f Yes. Type Pellet Other 9. rope of Fuel: LP Nat v�'ood �. 10. Stove Brand and Nlodel being installed: Arco fK'$ L ; 11. 12. Liner: Full x Partial Type of House: Ranch Colonial Split Split_ Gambrel_ Con temporary_ Slate _Other 13. Type of Roof: Shingle Rubber 'file Wood Shingle_ Nletal Other There is an additional fee of, 14. imleaned at time of install? Y N_ 1Yould you like the chney c DRAWING A: Mantel Side View Drawing B FT 17 p E: 7 1 R H —.. 131 ,: DEga� llc A: Fireplace is: Rectangular_ J Arched __ A= Fireplace Width: Bottom Top t-, B= Fireplace Height: Left_ Right - +' Height to Top ofArch ifApplics B 1=Height to Lintel Bar See lDra`vi11g B C= Fireplace Depth__L�-I D= VVIdth at BackZ,L4 E=Distance to Mantel Shelf (From Hearth or 1=loor)__Ne . F= Hearth Depth_ I f, _ G= Hearth Height tt.k-Ir H= Distance to Combustible Trim/ L,eos__Pe 1= Distance to Combustible Wall N A J= Height to Damper Rod K= Height to Breastplate of Mantel L= Thickness of Breastplate ��A M=Depth of Mantel N� A- _ DRAWING C_ 0.. - - I_P _ r' Drawing C: N=Height to Taper O=Lintel Depth�— R—Depth of Fireplace at Height of Unit These measurements are a guide to help us formulate an estimate for materials to be used in the installation. You will be billed only for labor and materials used. Please see your salesperson for a written quote which will provide you with the estimated costs of the installation. Signature Date S A L E S O R D E R THE STOVE SHOPPE 25 INDIAN ROCK ROAD, ROUTE 11 WINDHAM, NH 03087 Phone #: (603)537-0555 Fax #: (603)537-0556 BILL TO 137054 Harry Irawan 61 638 Chickering Rd N Andover, MA 01845 USA ' {,.. t MFR PRODUCT NUMBER HAR 1-90-574240-1 **** LAB22 LAB note DESCRIPTION Accentta 52i Insert - 24" - Black S/N: 008268087 Install of Pellet Insert w/Full 4" Liner .k PHONE #: (978)390-9242 DATE: 10/21/2016 CELL #: ORDER #: 33104 ALT. #: CUSTOMER #: 137054 P.O.#: LOCATION: 1 TERMS: Cash STATUS: Active SALES TYPE: Sales Order CP: Sue E SALES REP: Sue E SHIP TO Harry Irawan 638 Chickering Rd N Andover, MA 01845 USA PAGE: 1 ORD SOLD B/O PRICE NET TOTAL 1 0 $4,199.00 $4,199.00 $4,199.00 1 0 $0.00 $0.00 1 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $535.00 $0.00 $423.00 $44.95 $14.00 $95.00 $21.78 ($100.00) ($300.00) $0.00 SUBTOTAL: $4,932.73 ********NOTE********** LAB NOTE 1 These parts represent a 1 0 $0.00 $0.00 typical install LAB NOTE 2 However other parts may be 1 0 $0.00 $0.00 require. LAB LABOR COST 3 Labor Cost For Install 1 0 $535.00 $535.00 LAB 22Note Install of Pellet insert w/ fui 4" 1 0 $0.00 $0.00 liner NEC L4251K-R6 4" X 25' Liner Insert Kit 316 1 0 $423.00 $423.00 SS, - w/ A Type Connecter ROC 4DP Damper Plate 4" 1 0 $44.95 $44.95 RUT 76C Silicone CLEAR High 1 0 $14.00 $14.00 Heat10.3oz Cartridge * PER Permit Permit & Processing Fee 1 0 $125.00 $95.00 SIM PVP-4AD 4" PV Pro - Appliance 1 0 $21.78 $21.78 Adapter * **** COUPON COUPONgrv61x18327g 1 0 $0.00 ($100.00) MID SALE Tent SALE 1 0 $0.00 ($300.00) cm 36 x 28.75 x22.25 took unit only 10 27 16 tf **** CUSTOMER PICK-UP CUSTOMER PICK-UP 1 0 $0.00 $0.00 ****NO SALES TAX**** customer has unit Thank you for your business! All material must be paid in full at time of pick up or delivery Please note that if you are using our installation services all materials and labor must be paid in full at time of installation. If the installation takes more than 1 visit $250 may be withheld until the job is complete. $0.00 $0.00 $0.00 $0.00 $535.00 $0.00 $423.00 $44.95 $14.00 $95.00 $21.78 ($100.00) ($300.00) $0.00 SUBTOTAL: $4,932.73 s s pa a AM s :1��� � ■ '�: € E S wa�m� a�Edgab 5gg �.a �g8 x• = E 6 S � E i g maw€ sE�a.QS"`4 �$ __°PDLL a,m; O��Ezrc aV �WYIIe+'agS m m6O * 5 �o �EB ��� m � � f� 9� �6■$ 5 PE y FomEF JiE " e 5§£NYJ $ R E cm'2 €'� @ a ''4 C E 17- N d O. E - U c > m o E N N C m E O L W c iS ~ m > Z c .N m > L `o U m LL � m j c °, m � os H U — C O R y m a« �N m C O A E'er c u d > o c d v ° cO •OA N N N C d u � ID u 9 0 > L `d � N c o a w o d c O N V m O 5E c 02 > 01 � U j N O C C y d j a,N ao >-c m =r UN m .6.oc d g 7 E m p m% L o U O W e d d � w d �R 1pO Eo m C m m V c •� E m s� E N - cC N d X10 LL IL N N d � d Q W 0p C W J LL 0 2 F W LL F U F �_ Ru Q N Z W ¢ W R Z O �W W g LL O> NLu K LL w w LL ¢ Z p O_ f W z ? 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N 0 C d .N_. O C d _0 m a- O S O L d O rn r rn m e D a o m o >O m' 7 a m> °0 o o cc a N c E o L " °� m �' m ao E x o c ,.7. m �'Q m w a m a c«-'� coo x c 3 mmrnm15 m.tEtcw E ao 2xo mOa o�mcco cE morn Ec c mo_ 7 °0 °� 0 OErn cw m alb a a c L ympym aNm G c W a�E °cLpo c d2 turn a'vJaE 'xaom`� EaON O`0 'c aciu.57 m�7tn00`om ;nxE mac nm m °1o�m Qct yc ° I°�Em ins ml. � CL (j mm o >. m a >. w E `m w a LLL T m o 7 c oy N O ow 3�dc o p 7 c N c a T o3 mddm OE :E Tl a N d m ., m m w a Y 21 m rn °mc E o c 5 E'_` $ao 0 o f m d�0 wD uiL rno d o J LL T a U d 0 y E N `� O la C (a L a) 0 E N L o H d o a E as n N C p L° a 3 E rn o L mwo o E 0 E E S o m c° a LL`dqj° cNym�ie7(JpiL5oa�7 xruN°Namii!rNidT� v`o' aNEa`N(p• Ldy C�Om ani d-� m•jU-arn_ V'c�O caMKCOye`°N7 °EmUp�EE y .0 C °NS m 0 m p U L ° U w N>c�73VNCl waa7Zc7I '' DaY0 aNpNmTNN Ol0oOCTrna) EaL$ •�`cL rLp..oaac E 2 Epo 2m'o0 °0k` E . C,C O L3 Nm C N � mn 0N mN y E>LLLN mLOU dr En pa N GOOf >mC NfNO � ° «yjCL N LEo m 0 NjL OL m pE cN`i>ios.. oEc x m vmX10o�mCUomm_ 7 Eo maoDd m=c -'7 W.y O A.- -0 mdCl ID oC 0Et2O'D E � a Ow76 -am _oN.m-i°2Y`SwiUic0 ,a aaNNTi mm 3 0 0 E ) LL a E x« .... - .0 IoQ mc z rr 2) \\\ �) §(§ 2& kK {§« § )2 a ® I §) e[� % 2E )k)@ ] ;ffƒ \k §(k) k X #r§t \ k § ! � k ) k b ! *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. 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 am an employer that is providing workers' compensation insurance for any employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: W L o j aa` V Ljoo o 3 Z Expiration Date: Job Site Address:� ( rZ�f���-l' Y ➢ City/State/Zip: Nhu6g /_ f} u$YJ 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 $20.00 a day against the violator, A copy 0,�Iis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vera l non. 4,1 I do hereby 1p*/nAPtfiPafis amen es of perjury 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 of City or "Town: Permit/License # Issuing Authority (circle one): I. Board of health 2. Building Department 3. City/'Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: The Commonwealth of Massachusetts IJepartfnent of IndustrialAccidents - 1 Congress Street, Suite 100 Boston, MA 02114-2017 o^ Syev'„a www.mass.go li a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricims/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legiblyi Name(Business/O[rrganization/Individual): 446&c- b , es Address: aL J :4v4t%6 . �C M City/State/ZipUA0 Phone #: 603 S37 —QS'- Are you an employer? Check thee"" appropriate box- l am a employer with _14 _employees (full andlorpart-time).* 'Type Of project (required): 7. []New construction . 2.7 I am a sole proprietor or partnership and have no employees working for me in 8.g Remodelin ❑. o any capacity. [No workers' comp. insurance required.] 9. ❑Demolition 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 10 ❑Building addition ensure that all contractors either have workers' compensation insurance or are sole I I. ❑ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5.0 I 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. 6. ❑ W e are a corporation and its officers have exercised their right of exemption per LvIGL c. �j/C 1 4. P.Other ^ r/ �'•1"" 1521 §1(4), and we have no employees. [No workers" comp. insurance required]( � r— 6� *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. 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 am an employer that is providing workers' compensation insurance for any employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: W L o j aa` V Ljoo o 3 Z Expiration Date: Job Site Address:� ( rZ�f���-l' Y ➢ City/State/Zip: Nhu6g /_ f} u$YJ 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 $20.00 a day against the violator, A copy 0,�Iis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vera l non. 4,1 I do hereby 1p*/nAPtfiPafis amen es of perjury 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 of City or "Town: Permit/License # Issuing Authority (circle one): I. Board of health 2. Building Department 3. City/'Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: A� oe CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/27/2016 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. I&ORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to rms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the CMcate holder in lieu of such endorsement(s). PRODUCER FIAI/Cross Insurance 1100 Elm Street Manchester NH 03101 CONTACT Judith George CIC, CPIA, CPIW PHONE (603) 669-3218 (FAX No: (603)645-4331 E-MAIL jg g g �eor a@crosses en com ADDRESS:' INSURERS AFFORDING COVERAGE NAIC # INSURERA:Continental Western Iris Cc INSURED Mis-Bec of NH, Inc. dba The Stove Shoppe The Commons at Windham 25 Indian Rock Road, Suite 19 Windham NH 03087 INSURER B :Union Ins Co dba Berkley Property & INSURERC:Safety National Casualty Co INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:16-17 All w/MA & CT WC 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 MMIDDY POLICY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADEFZ OCCUR DAMAGE TRENTED PREMISES Ea occurrence $ 250,000 MED EXP (Any one person) $ 5,000 CPA0311123-15 1/1/2016 1/1/2017 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JE� FX� LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS CAA0311124-16 1/1/2016 1/1/2017 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident Uninsured motorist property $ 25,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 A EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ CUA0311125-16 1/1/2016 1/1/2017 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE FPP40504571 (3a.) MA & CT PER STATUTE ER E.L. EACH ACCIDENT $ C OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA To be issued directly 1/1/2016 1/1/2017 E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below I 1by carrier DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Town of North Andover, MA is included as additional insured with respects to the CGL as per written contract. PFRTIFlrOTF NAI nF:R CANCELLATION ACORD 26 (2014/01) INS025 ON 4m t ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover, MA 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. •N. Andover, MA 01845 AUTHORIZED REPRESENTATIVE J George CIC, CPIA, CPI ACORD 26 (2014/01) INS025 ON 4m t ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety 1®i Board of Building Regulations and Standards License: CS -096606 Construction Supervisor KEN T SZYMANSKY 27 TICKLEFANCY LANE SALEM NH 03079 P�-Jzu� D'— Expiration: Commissioner 02/26/2018 -- �lze toammzaizurea� a�./�%acu,/e.,raetfa _ Office of Consumer Affairs & Business Regulation - = HOME IMPROVEMENT CONTRACTOR Type: '_- Registration: ''154473 Expiration: 3tT?4117 Private Corporation MIS -BEC OF N.H :4NC. KEN SZYMANSKY,, 25 INDIAN ROCK RL?,. SUITE 19Z--- WINDHAM, NH 03087 `' - Undersecretary