HomeMy WebLinkAboutBuilding Permit #723-2017 - 69 WATER STREET 1/18/2017T
1111 AJ
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: "'* Date Received i 7 ,%
Date Issued:
p tt`.eD �64'NC
e
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IMPORTANT: Applicant must complete all items on this page
LOCATION Z S- 1rJc}-�tr5�
Print
PROPERTY OWNER C hS� r --a YOQI-
Print _100 Year Structure yes no
MAP PARCEL: Mt Y ZONING DISTRICT: Historic District yes no
Machine Shop Village a Y es ' no
TYPE OF IMPROVEMENT
PROPOSED USE
Resi tial
Non- Residential
❑ New Building
One family
❑ Addition
❑ Two or more family
❑ Industrial
Er'AIteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
[I Demolition
Other
Septic E! Well- - .,�
_❑
❑Floodplain 0° Wetlantls µ
❑ V1/atershedi&stnct-,
O WaterlSewer
. - _ I I
OWNER: Name
DESCRIPTION OF WORK TO BE PERFOKMLU:
L�
Identification - Please Type or Print Clearly
S�'
� ' q(
rbo V- Phone: kt 3 o b
Address:
Contractor Name: %G hA J
Email:
Address: P h 1-2 nk 3\4Li 1 it -A\, -J t I
Phone,
6.4VY, a V l • I A�
Supervisor's Construction License: WtS t9 L
.Home Improvement License: l 3 0
ARCH ITECT/ENGINEE
_Exp
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $12' 5.0 PFR S.F.
Total Project Cost: $ 31 . U-0 FEE: $
Check No.: Receipt No.: l `-t" 5h
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swiunming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE US E ONLY
INTERDEPARTMENTAL
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS {-
HEALTH t Reviewed on Siqnature
COMMENTS
a Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
r
Planning Board Decision: Comments v `
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located , 384:Osgood Street
FIRE DEP�R�TMEIU' T - Ternp ®urnpster on sitmeT,i-y s r' "{ no
Located at 124 Main Street ' , .:z -
Fire Department �igna�re/date
s♦�i�thtA:1�A,e ,�'N ,s s .'tiz '�' xi ,.„?a'+} '� k y�?.'" °t"5 i, ». F.t+ t'*n. .s f %i €,�$
y c p E'� e"'��' � } �� �'zc'j ?"� pq� �'t'� ���Cf �i�vY un�+..#d9.... • "�. ,� ,� � �n a� �' tiP� ��i��S<*. � ef"� �.�
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-$1000 fine
NOTES and DATA — (For department use
® Notified for pickup Call Ema
Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
4. Workers Comp Affidavit
4, Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
i� Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2014
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$ 171101
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Frtderal ID 905-040,5629
R1Sr Engineering RI. Contractor Registration No 8186
t'AA Contractor Registration No 120979
RIVE CT Contractor isegistration Nt,
ENGINEERING. Gfi 4haK'hlut Road. Canton. gt:\ CONTRACT (��®® pp�� pp�a
(40 1) 784-3'00 FAX (401) rya 39111 'lrOil TRACT
Page I
PROGRAM _
1. NIA -HES EMKE[N G Apo THE�CU5TOWER FOR woRK AS
DESCRIBED RELow
cusTiY.MR
rNW:E TE CUEnT S WORK OnotR
Christina Poor {603>}965_8766 1PA7:04.2016 4413 27 35M2
sERvccE sTRF.4r
l3M.MM.. STREET
125 Water Street 125 Water Street
SMtVtcE CITY. STATE. LP t k +;y k t 8 �' -�t tf j .`•'�
UJNG CITY. STATE:IIP {t• , '�,,,, 1 -� 'I
North
N:kttdover; MA 0 194 5 :
North Andover, ASA 01$45
rt'
S '
JOU DESCRIPTION F
AIR SFALING: provide labor and mau: ials to seal areast3fyaar home aeaitucw.lstcfuf, v\LYss air leakage. 'Ellis work wt11 fsL
- - '
Performed in mttcert Leith the use of vpc Cia7 tivis and diarnnstic tests to assure that vezur hnmc will he tell with a twiithfed level. lir
air cschangc and indtwr air quality. Materials to he used to seal your home cat, include caul!;,, foams, nd otfttr pn hums. Print, Y
areas for scaling, ine fOdc air ih, l.agi Ill otic,. basements. attached ;aragcs and other wlhcated arias taeindtkars are net s encralit'
addre5x ct.. This hill require (h) working hours.:% reduction in cubic tett per nrinute (efm) nt':sir in(windoutlluallon will occur. but the
actual number ofctm is not guaranteed:
At the completion nfthe wzatltcri'r.,tion evork, anti a, no additional Blest e(r the litsnnowncr. a tinai hlrneL—, dant :uei <,r combustionsaitt� analysis will be ct+nducwd by the sub -contractor to ensure the sat'cty of the ittdut r.tir qualit}.
$5'1I). O
C't.'STC>:LI BAR - CL`5T0N113ARftiER
S9.00AIR SEAUMG provide labor and materials to install Q-1011weatherstripping and u do»rswct:p u) f i) dtttN(s) to restrict air leakage.
75.tt(t
aft AMC TEAT provide labor and matsxiais to install an 8* la) er Of R-25 Class I Cellulose added to (147) square fcet of floored
ic space.
5364 60[JAMMING: Provide labor and materials to install a 12" layer ofR-18 unfaced libcr� las, hate in (Cf$/ squartt tet t tut d�rnrninr
purposes.
$134.34
XMC FLAT: Provide labor and material, to install a 14" Ia}er of R-49 C'lasv i C'ctiulusc added tot 104) square felt of open :otic
space.
5175,.«b
AMC FLAT': Provide labor and materials to install a 9" lkwrt)TR-33 Class t €'cltulou; added to 1200) square tint ofoptat attic
space.
ATTIC FIAT: Rcmove (100) square feet of ban style insulation frunl ux attic 77S?Ra.U(t
SLOPES: Provide labor and rnwri3ts to install a b" lair of R-19 Goss l Cellules added to ( 91) square fean of slope area,
KNEMALLS: Provide tabor and "121=Ws to install R-13 Sated gbergtass to (93),4natc feet of knmvatt. 'then itistalt 2"rigid 5355,26
board insulation. Seal all scams with FSK tape.
$.339.45
itUSly I ng
ineering Federal 10#05-9405629
RI Contractor Registration No a1116
PdA contractor Registration No 120979
CT Contractor Registration No
t hGfNEERIING` ht) ShaWinttt Road, Canton -1f:1
01011784-3'00 F,AX (401) 7"37 10 CONTRACT
cusTOMM
Christina Poor
SZ'M-- STREET
125 Nater Street
SERN{CE CITY, STAMZJP
North Andover. MA 01.845
tetMOVAL: Rcmovc (17) squttrC 1CCt tzf batt style:
K'4LIN ALL I•LWR: Provide labor and materials
open knee wall floor:
to ittstait a 14" (Oyer of R49 Class t ('citulose added to (120) square feel of
Si8-1A 1
r771C
ACCESS., Prtwide lalwr and materials it, insulate 1.1) back of the Weewa(1 hatch with 2 ,rigid board. and seal the edge of
the batch with weatherstripping.
$60.00
A771C ACCESS: Provide labor and materials to insulale the back of the attic door with 2" rigid insulation board and seal the doors
edge with w-eatht:rstrippin_ to restrict air leakage.
S73.91
VENT 11.A'fION: Provide labor and materials to install ( t) 12" diamthcr "maehroom" roof vent(s) to increase: ventilation in attic
amus. 'fire vent can be supplied in (circle color) black. browny gray or mill finish.
4'FtN` nLA1TON: Provide labor and materials it) install ventilation chutes in 199) rafter bays to maintain air (low_ 5114_IO
SI I8.OD
Vtic Orem. Sped y Color labor and materials to install (•l) 4" X l G" tcctangutar aluminum soffit vents it, increase vcmtilatioa in
attic areae. Specify color. litiriic or Crap_
slou.ou
COMMON WALLS: Provide labor and materials to install R-13 unlaced libe:rgiass It, 39 square feet oftxemalwt wall. nnai inttaii
V rigid hoard insulation that meets the sections R-316.5.3 and 316.6 requirements of building code. Seal all scants with FSK tape.
K 138. JO
COMMON W,L1 S: Provide labor and materials to install R-13 unfaccd filurtlass to 17 square feet of cmmiton wall. Then install
V rigid board insulation that meet% the sections R-316.5.4 and 316.6 rcquircn6ts ofbuitding code. Sial all seams with FSK tape.
$62.05
IIASFMI N'f CFILINCG: Provide labor and materials to install (120) linear feet of R-19 unlaced fiberglass insulation to the
Perimeter of the basement ceiling at the house sill,
$210.00
BASEMENT M)R: Provide labor and materials to insulate the back of the basement door leading to the bullhead with 3" rigid
board that meets thr sections R -316.5A and 316.6 requirements of building code. Seal all edges and scants with FSK tape.
$72.22;
Page 2
PROGRAM
C'ti7A-HES
TMS CONTRACT IS ENTERED INTO eTWUN MSE
ENOM1'EERIYD AND TUE ctrsTottER FOR GYORYZ As
DESCRi8E48QOW
GnOr3E
DATE CLIENT6
YORK ORDER
(603)96'-9766
11104,2016 441327
.35002
en1LN6 STREET
... _ .._
`...„�......
125 Water St
87LilNO CITY,flTATE 2IP
E ;. r
i
North Andover, NIA 0.1845
.TOB DESCRIPTION
insulation from the kncewall arta
i
to ittstait a 14" (Oyer of R49 Class t ('citulose added to (120) square feel of
Si8-1A 1
r771C
ACCESS., Prtwide lalwr and materials it, insulate 1.1) back of the Weewa(1 hatch with 2 ,rigid board. and seal the edge of
the batch with weatherstripping.
$60.00
A771C ACCESS: Provide labor and materials to insulale the back of the attic door with 2" rigid insulation board and seal the doors
edge with w-eatht:rstrippin_ to restrict air leakage.
S73.91
VENT 11.A'fION: Provide labor and materials to install ( t) 12" diamthcr "maehroom" roof vent(s) to increase: ventilation in attic
amus. 'fire vent can be supplied in (circle color) black. browny gray or mill finish.
4'FtN` nLA1TON: Provide labor and materials it) install ventilation chutes in 199) rafter bays to maintain air (low_ 5114_IO
SI I8.OD
Vtic Orem. Sped y Color labor and materials to install (•l) 4" X l G" tcctangutar aluminum soffit vents it, increase vcmtilatioa in
attic areae. Specify color. litiriic or Crap_
slou.ou
COMMON WALLS: Provide labor and materials to install R-13 unlaced libe:rgiass It, 39 square feet oftxemalwt wall. nnai inttaii
V rigid hoard insulation that meets the sections R-316.5.3 and 316.6 requirements of building code. Seal all scants with FSK tape.
K 138. JO
COMMON W,L1 S: Provide labor and materials to install R-13 unfaccd filurtlass to 17 square feet of cmmiton wall. Then install
V rigid board insulation that meet% the sections R-316.5.4 and 316.6 rcquircn6ts ofbuitding code. Sial all seams with FSK tape.
$62.05
IIASFMI N'f CFILINCG: Provide labor and materials to install (120) linear feet of R-19 unlaced fiberglass insulation to the
Perimeter of the basement ceiling at the house sill,
$210.00
BASEMENT M)R: Provide labor and materials to insulate the back of the basement door leading to the bullhead with 3" rigid
board that meets thr sections R -316.5A and 316.6 requirements of building code. Seal all edges and scants with FSK tape.
$72.22;
R E '�.
t5ING-,
CUSTOMER
Christina Poor
SERVICE STREET
125 Water Street
RISE Engineering
60 Shavvmut Rand, C'antnn,lla
(401) 784-3700 Fit (401) 784-3710
Federal ID 0 05.0405629
Rt Contractor Registration No 8186
MA Contractor Registration No 120979
CT Contractor Registration No
CONTRACT
Page 3
PROGRAM
TIFM CONTRACT IS ENTERED INTO BETLVEEN RISE
CMA-11FS ENGIS'EENIG AND THE CUStOVFR FOR VMRX AS
DESCIUMSELOW
PHONE
(603)965-8766
SRI= STREET
125 Water Street
DATE CLIENTS INDRNORIM
11/0442016 441327 35002
SERVICE CITY. STATE, ZIP .. .
BILLING CRY. STATE, IIT+
;north Andover, MA 01815 North Andover, MA 01845
JOB DESCRIPTION
Tela!•, Engen mrina will apply all applicable, cligihle incentives to this contract. You will only he billed the Net amount. Currently,
roreligible me;3sures, Columbia Gras offers 75°u incentive, not to exceed $2.000 per caMndar, year, and an incentive of 100so for
the :lir Scaling rumsur s up to the tint 5680 and an additional 5340 irsavings arc justified by the auditor.
for the safety and health of your home's indoor nit Itunlity. we will be conducting a blower door diagnostic of'the available air flour
in your home both hefbre the work is begun, and after the vveatht:rhation work is complete. %.c will also conduct a full assessment
of the combustion safety of your heating systent and water heater. This has a value of $90 and is at no cost to. Total
allowable wcatheri-ration incentive is S3, i l0.
-the Penn it will be secured by the insulation contractor. at no additional cost, it is the homctnvnC s I.esponsibility to Close out this
permit by contacting their municipality at the COmplVion of this work.
590.00
Total: $3,459.60
Program incentive: $2,675.00
Customer Total- $784,60
WE AGREE HEREBY To FURNISH SERVICES - COMPLETE IN ACCORDANCE KITH ABOVE SPECIMATtt & FOR THE SUM OF
'"Seven Hundred Eighty -Four & 60/100 Dollars $784.60
UPQ'r FL9AL LNSPECTrO'd AND APPROVAL BY RISE ENOBIEERING. CUSTOMER AGREES TO REMIT AMOUNT DUCE M FULL UITEREST OF j%tYLLL. SE CNAROEO MONTHLY ONANY
UNPAID BALAtICE AFTER ]b DAYS. SEEREVERStE FOR UAPORTAAiT {NFORMA"M ON GUAR0.NTEES, RIGIrrS OF RECISION, SCNEUULMG. A'tD CDMRACrOR REGISTRATION.
AUTHORIZED SIGNATURE -FUSE Englnmrift CUSTOMERAC CEPTA%CE
NOTE: THIS CONTRACT MAY BE VnTHDRAMI BY US IF NOT EXECUTED Va"M DATE OF ACCEPTANCE
ACCEPTANCE OF CONTRACT-THEASOVE PIU @S. SPECIFICA///TI MS ANDI`P COLNMUNS ARE
DAYS. SATISFACTORY TO US ARD ARE HEREDY ACCEPTED -YOU ARE AUTHORIZED To OO THE WORK
AS SPECIFIED. PAYMENT MrLL BE MAGE AS OUrLRIED A8OVE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
wwwmassgov/dira
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual): �t ids 1 r�i t� �n$U� XNn I \V"L,
Address: `'la- 0 130X -3+N
Ci State/Zip: WLk4$ Lig
Phone #:
Are you an employer. Check the appropriate box:
Type of project (required):
1. Efl am a employer with
4. ® I am a general contractor and I
6. ® New construction
�
employees (full and/or part-time).*
have hired the sub -contractors
listed on the attached sheet.
7. Remodeling
213I am a sole proprietor or partner-
These sub -contractors have
g, ®Demolition
ship and have no employees
working for me in any capacity.
and have workers'
employees9.
® Building addition
[No workers' comp. insurance
comp. insurance$
5. ® We are a corporation and its
10.[3 Electrical repairs or additions
required.]
3. ® 1 am a homeowner doing all work
officers have exercised their
11.® Plumbing repairs or additions
myself. [No workers' comp.
t
right of exemption per MGL
c. 152, §1(4), and we have no
12.® Roof repairs
13.[] Other
insurance required.]
employees. [No workers'
coma. insurance required.3
"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,
compensation insurance for my employees Below is the policy and job site
I am an employer that is providing workers'
information. y�_ nn ,
Insurance Company Name: !'TLt.
Policy # or Self -ins. Lie. #: O o -3 Z� Expiration Date: Lo 1
��
W
Job Site Address:kr� City/State/Zip: Nyr� U -nft oily 4S
�.� �
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or ane 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. Be advised that 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 the pains and penalties 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 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
Phone
Contact Person'. #:
o
ACC>R" CERTIFICATE OF LIABILITY INSURANCE
`..-�
DATE(MM/DD/YYYY)
F 10/18/2016
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(les) 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: Meg Munroe
MARTIN J. CLAYTON INSURANCE AGENCY INC
acDNN Ext: (413) 536-0804 A, No:
E-MAIL
ADDRESS: mmunroe@mjclayton.com
INSURER(S) AFFORDING COVERAGE NAIC#
1649 NORTHAMPTON ST., RTE 5
INSURER A: ACADIA INS CO 31325
HOLYOKE MA 01041
INSURED
INSURER B:
GAUTHIER INSULATION INC
INSURER C:
INSURER D:
INSURER E:
PO BOX 344
INSURER F:
IPSWICH MA 01938
COVERAGES CERTIFICATE NUMBER: 94521 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
ADSL
SUBR
POLICY NUMBER
MM/DDY EFF
MMM/LDI D/ EXP LIMITS
M .L
`niel
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $
CLAIMS -MADE FIOCCUR
_
DAMAGE TO RENTED
NTEDPREMISES Ea occurrence $
-PREMISES
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
N/A
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $
POLICY ] PRO JECT F—]LOC
PRODUCTS - COMP/OP AGG $
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
Ea accident
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
N/A
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Per accident
NON -OWNED
HIRED AUTOS AUTOS
UMBRELLA LIAR
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/MEMBER EXCLUDED? WA
(Mandatory In NH)
N/A
WA
MAARP300327
10/30/2016
10/30!2017
/� SPERTATUTE ERH
E.L. EACH ACCIDENT $ 500,000
E.L. DISEASE - EA EMPLOYEE $ 500,000
If as, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $ 500,000
N/A
DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe 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 CANCELLATION
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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.
1200 OSGOOD STREET
AUTHORIZED REPRESENTATIVE
NORTH ANDOVER MA 01845
M .L
`niel
Daniel M. Crow ey, CPCU, Vice President —Residual Market — WCRIBMA
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
DATE/M"Q)
►co CERTIFICATE OF LIABILITY INSURANCE F1114�2C
TE HOLDER. THIS
THIS
RTIFICATE IS ISSUED IAS A RMAT VELYEOR NEGATIVELY AMENDR OF INFORMATION ONL, EXTEND OR ALTER TAND CONFERS NO IGHTS UPON THE CERTI
HE COVERAGE AFFORDEDFICABY THE POLICIES
CERTIFICATE DOES NOT AFF
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. subject to
ON IS the
IMPORTANT: if the certific the olds certain DpollcOles may NAL sequire�an endors•Yement A statement on(les) must be this his certiffl ate does not conferprights t the
the terms and conditions of policy,
certificate holder in lieu of such endorsement s . T Usher
PRODUCER
Martin J Clayton Insurance Agency,
1649 Northampton Street
P. O. Bos 989
Holyoke MA 01041-0989
INSURED
Gauthier insulation
P.O. Box 344
Inc.
A
D
cy
413)536-0804
(413)534-7874
IPSWICH MA 01938 INSURER r •
COVERAGES CERTIFICATE NUMBER:CL1663001850
REVISION NUMBER:
THIS IS TO CERTIFY HSTANDING ANYt DB ISSI Ir
IREQUIREMENTNTERM OR CONDITION OF ANY CQNTRACTT OR OTHER DOCUMENT WITH RESPECT TOD TO THE INSURED'I�ij`��3; ED ABOVE FOR -11 1E LWHICHRTH S
INDICATED. NHAVE BEEN
OTWI
CERTIFICATE MAY BE ISLIED OF PERTALICIIN,
THE INSURANCE LIMITS SHOWN MAY HAVEEBEEN REDUCED BY PAID CLAIMS. HEREIN IS SUBJECT TO ALL THE TERM
EXCLUSIONS AND CONDITIONSSUCH pDDI SUBR POLICY EFF POLICDY EXP LIMITS
ILTR TYPE OF INSURANCE POLICY NUMBER 1, 000, 000
EACH OCCURRENCE $
X COMMERCIAL GENERAL LIABILITY DAMAGETO EN ED $ 50,000
PREMISES Ea o�utencel 5,000
A CLAIMS -MADE a OCCUR 7 /6/2016 7/6/2017 MED EXP (Any one person) $
g GL43487F 1,000,000
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $ 2,000,0000
GEN'L AGGREGATE LIMIT APPLIES PER: AGG $ 2,000,000
PRODUCTS - CO_MP/�P
R POLICY 0 JECOT [_] LOC G $
C E S LI IT $
OTHER: Ea accident
AUTOMOBILE LIABILITY BODILY INJURY (Perperson) $
en
ANY AUTO BODILY INJURY (Per accidt) $
ALL OWNED SCHEDULED PROPERTY DAMAGE $
AUTOS AUTOS Per accident)
NON -OWNED $
HIRED AUTOS AUTOS
EACH OCCURRENCE $ 1,000,00,
X UMBRELLA UAB OCCUR AGGREGATE $ 1,000,00.
B EXCESS LIAS CLAIMS MADE 10/18/2015 10/18/2016 $
�SE020792125-194985 i
AND EMPLOYERS' LIABILITY
N/A
E.L. DISEASE - EA
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule may be attached If more apace to required}
CLEARP+SULT, RVERSOURCS ATIV 2iATI04iAL GRID ARE LISTED AS ADDITIONAL INSUREDS ON A PRIMARY NON-CONTRIBUTORY
BASIS
CERTIFIGA 1 C r7vw15r.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CLEARESULT p,1,
THE ACCORDANCE EXPIRATION
TH THE POLICY PROVIS ONSE WILL BE DELNERED IN
ATTN.
CONTRACTOR SERVICES DE
50 WASHINGTON STREET AUTHORIZED REPRESENTATIVE
WESTBOROUGH, MA 01581 _ ��y� /i• -
Daniel Sullivan/MEG
®1988.2 014 ACORD CORPORATION. All Nghts reserved.
ACORD 25 (2014!01) The ACORD matt, and logo are registered marks of ACORD
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ENGINEERING
60 Shawmut Road, Unit 2 ( Canton, MA 02023 1339-502-6335
www.RISEengineering.com
OWNER AUTHORIZATION FORM
kc 1 `ilt�`�, �our
(Owner's Name)
owner of the property located at:
(Property Address)
(Property Address)
hereby authorize C ukj K L( ih\S 0- V) i
(Subcontractor)
1 .�L
Oil
. }#
1
�, {{
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's
responsibility to close out this permit by contacting their municipality at the completion of this work.
Owner's Signature
Date
6.2016