HomeMy WebLinkAboutBuilding Permit #803-15 - 68 BEAR HILL ROAD 4/14/2015nn BUILDING PERMIT
OWN OF NORTH ANDOVER
l APPLICATION FOR PLAN EXAMINATION
Permit No#: S Date Received
Kz`
�SSACH
Date Issued: ah�-r
IMPORTANT: Applicant must complete all items on this page
LOCATION
// Prit
PROPERTY (OWNER_.
'�i�,c.� Prinf 100 Year Structure yes n
MAP PARCELZONING DISTRICT: _ Historic District yes rf
Machine Shop Village yes n
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
a One family
❑ Addition
❑ Two or more family
❑ Industrial
A Alteration
No. of units:
❑ Commercial
I, Repair, replacement
❑ Assessory Bldg
❑ Others:
[& Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
I Water/Sewer
((��
DESCRIPTION OF WORK TO BE PERFORMED:
�eyYtJe %i t "� /t b.) Co..�o gjkt 1`76J Cann"CSS I /��v�,� mi
W N -CL in K i'chm
e) e.J gas Lt ^ e_ woe. Identificatiopp 291A
ease Type or Print Clearly
OWNER: Name: Pere(- a- Lvv�d�, r -r
Address: iQ g R P"'A RA,
Contractor Name:
Email: mg t z>
Address: 2u
r�N2
97§ ~--337µoa� J
Supervisor's Construction License G5 07a� l_ Exp. Date: -,31 1,Q a
Home Improvement License: Exp. Date: J -0l
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 50) (aaa — FEE: $gym on
Check No.: Receipt No.: Q -k 62 3
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location
No. — Date
Check # an �-
2 �,."') tic,
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ r
Building/Frame Permit Fee $�- i
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Building Inspector
IID
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. ❑
permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS.
Reviewed On
Signature.
Reviewed on Signature
Reviewed on Signature
a
.'Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
k
Planning Board Decision:
Comments
Conservation Decision: Comments
Wafter & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
E
FIRE DPARTMENT Temp urnpster on site yes,, �____� Snot o
oca a od Street
Loated at 124Mam Street
Fire Department signature/date
IMMI
ar-=
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
ivu i to ana WA i H — (i -or 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
rad Building Permit Application
cd Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
ul"Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: 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)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: 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
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: 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
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Estimate # 8
Order #
Date 3/19/15
QUOTE SUBMITTED TO:
ZALANSKAS CONSTRUCTION
34 BIRCH ROAD
ANDOVER MA 01810
978.835-5194
GREG.ZALANSKA$O-)COMCAST NET
WORK TO BE PERFORMED AT
Name
Lynda & Peter Belanger
Name SAME
Address
68 Searhill road
Address
city-state
North Andover MA
Planned Date
Phone
978-337-0291
email
Job Description:
Replace 28 Double hung windows Harvey Classic, pocket replacement, Reframe header in kitchen to accept new Pella awning with bonded grills.
Materials & Windows $8202.00 and labor $3500.00 / Disposal $150.00 / permit $225.00 = $12,077.00 for Harvey windows
Kitchen window, Pella architect series Awning, low -e argon, white clad exterior, painted interior, with bonded grills across the top.
Window cost $1285.00 / labor and materials for new header $1100.00 / Labor and trim to install $575.00 = $2960.00 for The Pella install
Please read the Harvey contract for all the specs on the windows.
Please read Pella Specs for sizing and details.
Harvey classic, low -e argon, tilt in, white, grills between the glass.
An material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and
specifications submitted for above work and completed in a substantial workmanlike manner for the sum of: $15,031.00-1
PLEASE MAKE CHECK OUT TO ZALANSKAS CONSTRUCTION
with payments to be as follows Del2osit 39300.00 received to order windows Submitted by:
Balance due at completion $5737.00 GREGORY ZALANSKAS
Acceptance of Proposal
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized
to do the work specified above. Payments will be made as outlined above.
Accepted by: At/rI/W 4�16'105�4
note: This proposal may be withdrawn by us if not
1C0-V,f
Estimate # 8
Order #
Date 4/12/15
QUOTE SUBMITTED TO:
ZAL NS"S CONSTRUCTION
34 BIRCH ROAD
ANDOVER MA 01810
978-835-5194
GREG.ZALANSKASCa)COMCAST.NET
WORK TO BE PERFORMED AT-
Name
%
Name Lynda & Peter Belanger
Name SAME
Address 68 Bear hill Road
Address
City-state North Andover MA
IPIanned Date Projected start May
Phone Peter 508-284-36851 Lynda 978-337-0291
email Peter, Q.Qe1angerQFMR.co[D
Job Description:
Kitchen , excludes cabinets and countertops; appliances ,alt light fixtures , plumbing fixtures,
Kitchen Demo, remove cabinets and granite countertop (to dispose) remove tile floor $2700.00
change opening to office and install single French door and hardware.$875.00 / install 2nd single French door into 2nd office opening $ 575.00 = $1450.00
Install new kitchen per design $6,500.00 / repair ceiling and walls were needed ,re plaster office wall and laundry wall $900.00
Install ceiling stove exhaust and vent threw ceiling out to back of house. HVAC installer needed. $1100.00
Electric, plugs ,switches, 10 new recessed lights, power for garbage disposal,/ pendent light, power for heater, electric for stove & exhaust fan, $3500
Plumbing , disposal ,sink ,fridge water line, under cabinet heater, gas supply for stove, $2900.00
Laundry Closet, widen opening to accept new double doors, build base and install draws ,shelve, and steel closet pole, plaster repairs, $1650.00
Hall cabinet install into opening , $650.00
Remove file in front hallway , remove tile in hallway and bathroom ,remove toilet (save toilet ?)$1200.00
rile Work , bathroom , hallway and laundry area **Estimate $2350.00 ** includes Dura rock and cement. ***Not included Tile , grout and marble threshold **`
Tile backsplash $1600.00" Estimate* Doesn't include tile or grout.
Hardwood /Kitchen install new 21/4"oak raw ,26' x 14 /install new 2 1/4 in front hall 125 sgft / sand dining room and office to match kitchen
3 coats water, one coat oil, to match new kitchen hardwood. Includes stain if needed. ($700.00 for stain) $ 7920.00
Disposal $700.00 / Permits $465.00 Kitchen Work $34420.00
Hn matenai is guarantees to be as specified, and the above work to be performed in accordance with the drawings and
specifications submitted for above work and completed in a substantial workmanlike manner for the sum of: $35,586.00
PLEASE MAKE CHECK OUT TO ZALANSKAS CONSTRUCTION
IST deposit at signing $12,000.1 2nd at electric rough in $12,000 Submitted by: GREGORY ZALANSKAS
3rd at start of flooring $8,000./ final at completion $3,585.00 OF ZALANSKAS CONSTRUCTION
Acceptance of Proposal
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized
to do the work specified above. Payments will be made as outlined above.
note: This proposal may be withdrawn 16y us if not accepted
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LINE # DESCRIPTION, QTY,
UNPRICE EXTENDED
IT
14000-1 Classic DH, Unit Size 31.75 x 45.5, RO 32 x 46 2
$222.91 $445.82
Full Screen, Fiberglass Mesh, Screen Shipping Separate = No
Window Label = Harvey, Double Locks, Sash Limit Devices = Night
Latch
Double Glazed, Low E, Argon Filled
Energy Star
Unit 1: U-Factor = 0.3, SHGC = 0.28, VT = 0.49, AL -, NFRC CPD
Number = HII M 3101482 00002, Custom / Call Size Option =
Custom Size, Replacement, Fully Welded
Unit 1 Lower Glass, I Upper Glass: NFRC CPD Number = HU M 31
01482 00002
„.n --
Foam Filled, Sill rise extender = No
Base Color = White
Contour In-Glass, Colonial, Match Frame, 4W2H
Foam Fill = Yes
Overall Rough Opening Width = 32, Overall Rough Opening Height
= 46
Head Expander = Yes
Room Location: None Assigned
Paae 5 Of 6
DESCRIPTION QTY UNIT PRICE..EXTENDED
13000-1 Classic DH, Unit Size 31.75 x 59.5, RO 32 x 60 13 $239.49 $3,113.37
Sash Split = Cottage
Full Screen, Full Screen Mullion, Fiberglass Mesh, Screen Shipping
Separate = No
Window Label = Harvey, Double Locks, Sash Limit Devices = Night
Latch „
Double Glazed, Low E, Argon Filled
Energy Star
Unit 1: U -Factor = 0.3, SHGC = 0.28, VT = 0.49, AL -, NFRC CPD
Number = HII M 3101482 00002, Custom / Call Size Option =
Custom Size, Replacement, Fully Welded
Unit 1 Lower Glass, l Upper Glass: NFRC CPD Number = HII M 31
01482 00002
Foam Filled, Sill rise extender = No
Base Color = White
Unit 1 Bottom: Contour In -Glass, Colonial, Match Frame, 4W3H
Unit 1 Top: Contour In -Glass, Colonial, Match Frame, 4W2H
Foam Fill = Yes
Overall Rough Opening Width = 32, Overall Rough Opening Height
= 60
Head Expander = Yes
Room Location: None Assigned
Pace 4 Of 6
iIiVE # DESCRIPTION
DN1T PRICE EXTENDED
12000-1 Classic DH, Unit Size 31.75 x 595, RO 32 x 60, EXTENDED 3 $288.57 $865.71
LEADTIIvIE
Full Screen, Full Screen Mullion, Fiberglass Mesh, Screen Shipping
Separate = No
Window Label = Harvey, Double Locks, Sash Limit Devices = Night
Latch s I
Unit 1 Lower. Double Glazed, Low E, Argon Filled, DSB, Tempered,
Custom Temp IG
Unit I Upper: Double Glazed, Low E, Argon Filled
Unit 1: U-Factor = 0.3, SHGC = 0.28, VT = 0.48, AL -, NFRC CPD
Number = HII M 3101482 00002, Custom / Call Size Option = — D. —
Custom Size, Replacement, Fully Welded
Unit 1 Lower Glass: NFRC CPD Number = HH M 3101533 00002
Unit 1 Upper Glass: NERC CPD Number = HIl M 3101482 00002
Foam Filled, Sill rise extender = No
Base Color = White
Contour In-Glass, Colonial, Match Frame, 4W3H
Foam Fill = Yes
Overall Rough Opening Width = 32, Overall Rough Opening Height
= 60
Head Expander = Yes
Room Location: None Assigned
Pane 3 Of 6
LINE # ::: DESCRIPTION QTY UNIT PRICE EXTENDED
11000-1 Classic DH, Unit Size 31.75 x 59.5, RO 32 x 60 9 $243.07 $2,187.63
Full Screen, Full Screen Mullion, Fiberglass Mesh, Screen Shipping
Separate = No
Window Label = Harvey, Double Locks, Sash Limit Devices = Night
Latch
Double Glazed, Low E, Argon Filled e „
Energy Star
Unit 1: U -Factor = 0.3, SHGC = 0.28, VT = 0.49, AL -, NFRC CPD
Number = HII M 3101482 00002, Custom / Call Size Option =
Custom Size, Replacement, Fully Welded
Unit 1 Lower Glass, I Upper Glass: NFRC CPD Number = HU M 31
01482 00002 ` RO.n
Foam Filled, Sill rise extender = No
Base Color = White
Contour In -Glass, Colonial, Match Frame, 4W3H
Foam Fill = Yes
Overall Rough Opening Width = 32, Overall Rough Opening Height
= 60
Head Expander = Yes
Room Location: None Assigned
Pape 2 Of 6
HARVEY
Aff ME BUILDING PRODUCTS
Harvey Industries, Inc.
1400 Main Street. Waltham, MA 02451-1689
(781) 899-3500 harveybp.com
BILL TO:
ZALANSKAS CONSTRUCTION
34 BIRCH ROAD
ANDOVER, MA 01810-0000
Phone: 978-409-1773 Fax: 9783730736
QUOTE NER CUST NBR
3745740 1036881
ORDERED<BY STATUE
SHIP TO:
ZALANSKAS CONSTRUCTION
34 BIRCH ROAD
ANDOVER, MA 01810-0000
Manufacturing
ACKNOWLEDGEMENT
Dealer Quote Summary
Salem
4B Raymond Road
SALEM, NH 03079-9283
Phone: (603) 893-1611 Fax: (603) 893-8196
111=11pill I
rm 'Up
Phone: 978-409-1773 Fax (978)373-0736
CUSTOMER ENTEREDDATE ORDERED - .ORDER TYPE
3/5/2015 Quote Not Ordered Cash
SHIP TIA DELIVERY AREA
GREG None Whse Pickup
SALEM WAREHOUSE
CLERK JOB NAME;'
COUPON _
ldd - James Dillavou BELANGER 1
EINE # _ . DESG`RIPTION QTY
UNITPRICE E%1TNDED
10000-1 Classic DH, Unit Size 31.75 x 37.75, RO 32 x 38.25 1
$222.91 $222.91
Full Screen, Fiberglass Mesh, Screen Shipping Separate = No
Window Label = Harvey, Double Locks, Sash Limit Devices = Night
Latch
Double Glazed, Low E, Argon Filled
Energy Star
Unit 1: U -Factor = 03, SHGC = 0.28, VT = 0.49, AL -, NFRC CPD
Number = HII M 3101482 00002, Custom / Call Size Option =
Custom Size, Replacement, Fully Welded
Unit 1 Lower Glass, 1 Upper Glass: NFRC CPD Number = HII M 31
01482 00002
Foam Filled, Sill rise extender = No
Base Color = White
Contour In -Glass, Colonial, Match Frame, 4W2H
Foam Fill = Yes
Overall Rough Opening Width = 32, Overall Rough Opening Height
= 38.25
Head Expander = Yes
Room Location: None Assigned
Page 1 Of 6
The Commonwealth of Massachusetts
Department of IndustrialAccidents
=- 1 Congress Street, Suite 100
Boston, MA 02114-2017
Name (Br
Address:
City/Stat
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am.a. employer with employees (full and/or part-time).*
7. ❑ New construction
2.10 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. ❑ 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 E] Building addition
ensure that all contractors either have workers' compensation insurance or are sole
11. N Electrical repairs or additions
proprietors with no employees.
12. ®Plumbing repairs or additions
5. ❑Tam a general contractor and I have hired the sub -contractors listed on the attached sheet.
13. F1 Roof repairs
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.
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.
i 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-corhaciors have e'm'ployees, 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
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address: City/State/Zip:
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 the ains and penalties ofperjury Haat the information provided above is true and correct.
Signature- /Qy1/l� `77 Date:• ql %,�-I nl 5
.- Y C A -
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 Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
"PAe AU&AfAQfnnarrT
ACORD- CERTIFICATE OF LIABILITY INSURANCE
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 1S SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
DATE
01
/2015�rn
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Doherty Insurance Agency, Inc.
P.O. Box 1985
21 Elm Street
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
A
Andover, MA 01810
INSURERS AFFORDING COVERAGE NAIL a
MSUREo
Zalanskas Construction
Gregory Zelanskas (DBA)
34 Birch Road
INSURER A: Arbella Protection Ins Compan
INSURER B:
INSURER C:
INSURER 0:
Andover, MA 01810
INSURER E:
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 1S SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MR
LTRS
01
TYPE OF INSURANCE
POLICY NUMBER
C
POL MMMW N
LIMITS
A
GENERAL LIABILITY
8500022056
06/15/14
06/1 SM S
EACH OCCURRENCE $1000000
NCOM MERCIAL GENERAL LIABILITY
CLAIMS MADE D OCCUR
DAMAGE TO RENTED 8100 000
MED EXP (Any one person) S5,0011)
PERSONAL 6 AOV INJURY S1 000 000
GENERAL AGGREGATE S2 000 000
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS • COMP,OP AGG s2,000,000
rxi POLICY PRO LOC
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT S
IEa acc dens)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Par person) S
HIRED AUTOS
HON-O%VNEO AUTOS
BODILY INJURY $
(Per aoddenR)
PROPERTY DAMAGE $
(Pot attid¢nt)
GARAGE LIABILITY
AUTO ONLY . EA ACCIDENT $
OTHER THAN EA ACC S
ANY AUTO
3
AUTO ONLY. AGG S
EXCESSIUMBRELLALIABILITY
OCCUR D CLAIMS MADE
EACHOCCURRENCE $
AGGREGATE SFI
_
S
S
DEDUCTIBLE
$
RETENTION S
WORKERS COMPENSATION AND
14VC STATU- IEMPLOYERS'
WAVAJTY
E.L. EACH ACCIDENT S
ANY PROPRIETOWPARTNEWEXECUTIVE
E.L. DISEASE - FA EMPLOYEE S
OFFICERIMEMBER EXCLUDED?
o under IAL PROVISIONS
ELDISEASE. POLICY LIMIT I S
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES N EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS
Covering operations usual to Zalanskas Construction...
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
I ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
IEREOF. THE ISSUING #MRER WILL ENDEAVOR TO MAIL In DAYS WRITTEN
TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SMALL
NO OBLIGATION OR LIABILITY OF ANY KIS UPON THE INSURER, ITS AGENTS OR
AUTHORIZED
ACORD 2S (2001/08)1 of 2 #S31825/M30661 / / DML 0 ACOA6 CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the poticy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 2&9120011081 j ..f o AQ41 DOCMI nca-1
.11
Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
V,eg,istration: {;26875Type: Office of Consumer Affairs and Business Regulation
piration: lJ -201fi =; Individual 10 Park Plaza*- Suite 5170
Boston, MA 02116
GREGORY J. ZALANSKAS-i 'li'�, P
GREGORY ZALANSi
34 BIRCH RD
ANDOVER, MA 01810
Undersecretary valid without signature
~Massachusetts _ de
partment of Public Safety
. Board of Building Regulations g ons and Standards
Construction Supervisor
License: CS -072201
`o'k
GREGORY J ZAIANSKgs i
34 BIRCH RD
Andover MA 01830%
IT
f
Expiration
Commissioner
03/18/2016