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HomeMy WebLinkAboutBuilding Permit #118-2017 - 73 COTUIT STREET 8/5/2016 BUILDING PERMIT NORTH q A1TOWN� I� � � OF NORTH ANDOVER I APPLICATION FOR PLAN EXAMINATION '" _ 70 1° ey Permit No#: Date Received 7QA0RATE° " �5 �SSACHU`�(at Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 3 t.0� S�' Print PROPERTY OWNER WC R S hh Print 100 Year Structure yes no MAP V�PARCEL:�ZONING DISTRICT: Historic District ye no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑ Two or more family ❑ Industrial Wi Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition [] Other _ OtSeptic .Well T ❑Flootldain ❑Wetlands 0 Vllatersh0 Distract. -- - - - — - O Water/Se_we_r C' DESCRIPTION OF WORK TO BE PERFORMED: r s-c l ', r� �ly t ova.► n �t-�L'. ye r\�� Identification- Please Type or Print Clearly OWNER: Name: 6lNt ll. 5 Phone: 01 X688�' • D`-t t6 Address: S�- Contractor Name: ` h cw�'11; r- Phone: 3 S�• �� 3 Email: QJMt Cr ( n tri " &% • 001 Address:-JP 0 Sox 31,49 swr 6 1413(3 Supervisor's Construction License: Z��Z Exp. Date: Home Improvement License: 3 Exp. Date: 1 b 1 ` \,)° 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: $ � � � � • �y FEE: $ b Check No.: 1�1/D Receipt No.: -561 b'FD NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ' - F CLocation No. - �,L�I I Date • - TOWN OF NORTH ANDOVER . Certificate of Occupancy $_ Building/Frame Permit Fee $ Foundation Permit Fee $ s Other Permit Fee $ TOTAL $ Ce , Check# T i J Building Inspector r� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL G Public Sewer ❑ Taming/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 Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/signature gate Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARiTMENT ;T�ernppurimpster onsitec�zxyes,a.� �� Located a-W&� 5ia fSt�eet ,F i ' �: � ��.`� 4 _, * �rpt' rf�� �.�.�.�.r �• �'rrt FireDepartmen � ignaturYe/date, .C�f''''�.. ` ti*� ;w .5.'� + ��. e. � i` •tit�.,.Y�,v�• `.' '*. <,'af Y':r-r.;'t,, i'. r.r (rr .+r, ., - ,ems®... .."�:. .......-. 1 COMMENTS' .�. +. r Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Suilding 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 4. 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 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) 4, 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 NORTFf Town of ? _ 6Andover No. y ,� �h ver, Mass 0 LANE .� 7 C OCNIC.M.C. � �•9 �R^TED J"4g5 S V BOARD OF HEALTH Food/Kitchen PERM LD Septic System ITTHIS CERTIFIES THAT ,.. BUILDING INSPECTOR ....... .. .. . .. .. .. ... . .�. .•: .................... Foundation has permission to erect .......................... buildings on {. .... .... • Rough to be occupied as .. .(..'�4.... .. �!!�......, Chimney provided that the person accepting this p mit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR TION S T.jjW Rough 00440 Service ' Final BUILDING INSP 0 GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Federal IDS0564MM RISE Englntxriag M Corslracter o a Ne 4196 MA0oUftftR IS EA diviatan of TMdmb) wtg O M 1 79 ENGINEERING w shawmuty*A CUI ,KA CONTRACT (491)98437'88 FAR(4OQ 784 3910 9 PROGRAM .. naaoanruerrsusaua�arroeanamrraae 0"-HES araeaareuraar®>gaowrafreervrivrowtae oascaaroemory custom vruerua aserra worpropma Rita wens (978)886-MU 0=2016 429940 00004 ear, arrmrt r aarars arae 73 Comfit Suet 73 Comfit Sheet s errr,m rr►n;m anrmra WIAMMaP Nord1 Andover,MA 01845 North Andover,MA 01845 JOB DESCRWnON MUT-H-&SAFETY*ween wodr carrot proceed ttmillbe>pil�e of oembtustkt gases is nmol Mo ATR SEAL.NCT Provide laborand load mo of your be ee apinstwmbenrl,eraoeas air kdMgD Tbis wodc VA be parkamed in conoat with the ure ofspeeW bola and diegrmstle tests m that your bona;wiH be lath with a 1=Mal]ad of air exab=V and indoor air godhy.WMadable be used to seal your home on Made cemllus,bama ad ofherp odmm Primary arms for sealing i sit lealua8o to attics, ,attached t1 g and other whealed areas(windoaa ata mt gemadiy ad&esm&) This WM require(5)wuximrg bars.A tadmtien in cable t o par miatite(c&)of*faffigado u w0!new,but tlm schw number ofc&is net pwm ft d At the oompter offt wuftteda wod6 amd at no odditiarmt oast fa tbq botnwwm,a Std bbraer door=&or oombusttat sandy analysis wM be eoaducted by the sub-cmaetor to eswrretiu silbty ofdw indoor cele gnality+. $425.00 AIR SEALMO:Provide labor and mataiab b instil!Q4on wedwsMppfag and a doommap to(3)door(s)to reaft air kdmgm $225.00 DAMMNG,Provide labor and materials to isntdl a 12'laysoMM u dked fiberglass battsto(48)sqa n L d ft dance PWS 59&40 ATTIC FLAT:PtovWelabor and materials to irofali an 8°layer of MS ams i Ce dose added to(400)sgeara Leet of open attic spm ' $548.00 AT11C ACCESS:Provide labor and mdaWsfo instill(1)early moved,iosulaft corer for the attic aocem forting at* The cover has uralwedbw-s ippbgtoreMatairkdmp. 5100.00 ATTIC ACCESS:Provide labor ad ma mils to k=bft the bade ofthe attic door whb r rWd Thenow beard and seal fisc door's edge wiW weadast#V*to resertol air le fte. $7391 VEMAT1OR Provide bloc and materials to IwW(1)kwhied chum base wo roof nsoamed Sapper veatim extimst existing bafbsoorn fen(s). $118.75 VFN'M ATEM.Pruxvids labor aril meterids b itsbll vaoh7adon drurtes lar(18)aper bays ro maiabin air ftox. SX00 BMEM O T1'C2?.iUM Pw vlde hhor and morals to had(64)square fhdofR-19wcWsdlzftdftew=iasalatiom to*e basement eclutg.Tbere win be sanecWmd fibagbo fibers whoa the warcasxor wrT bane crit the and ofthe bans daring hutalMon. Yoursigamum on this contntet is your admowledgemeat and apeemea tbat this WaMon is rot W cmc rodded. $126.08 RISE Eagquseerittg wiU apply aU appQt�tle,etigibte itoauives M osis ootdaot. Yoo w01 o*bo bHM ftNd ametttt. Cutmntl}r, fbt eligible measures,Columbia(las offin 75%inoetdive notto cxww 32,080 per calendwyaay and an hweetwe of 10VA hr the Air Sealing rmms ues up to die fast 5680 and an a klfl tal$340 Wswho are josditied by Ste For the safety and health ofyotir home's indoor air quality,vie will be coodi aft a blower door diapostic ofdw available air now in Federal 1D�OSO�IDti62D how"* !it rt�stratlonNoltta� R I j A dlvidu of lUeb&Fzgbmtft CT�CorMnr�orRegletn�idbop fb 1 ENGtNNG 60 ShawmatV&A CaaMa,MA (401) a FAX(401)784.3710 CONTRACT pme 2 PROGRAM ,xes ooarwaerez e�oatro ems, CMA4US a „�aaTar�eeroawowrcas X64 rmw um amms R&Wells (9780864)468 02/291?016 429840 00004 esa"ca sVROW aam ameep 73 Cotuet Street 73 CoW SUM sswsm arr.WATUP muco amr sutr m North Andover,MA 01843 Notch Awk"er,MA 01845 JOB DESCRIPTION your ban both betbm dm wort h bcM and dwtkvmdmdmftwwk is oars Wa wi l alro cooduatfidlaussautaf the combudonsaibty ofyosrbeabgsystm►nd wdwbeatet wo bn avd mofm and isstn000sttoyoo.Totd d mmkk man Wcon w is$3,110. $9000 TOW'. $1,84944 Program hu mmm $1,572.00 Cir Total: $369.14 wta HBUWrnotUaeastta a-COW&iEal ran MDIMaPSWrA= ,PMlMMS=of "-ftft HuRdMd Sb*-Mho 414H00 Dog= $369.14 UPNcase.UNMMaaMNMWALRVF MONO WCUMM marioAMOMOMORKLMIgrAW aR+saeaeeCKA"woom"WOriwr wevucaa�ce�mo�►rs.searoRm+vamiwroeaoe�waiaraa ar�wenees,asonraarasp,saamaaiouwocormeeimeaarton tJallORt3�liTHIBC0'1{iRAC7ffT1�3tEA1tEANY SPAM nurM—�9�p eaten, soca ame / q I�7TE:n.�ooM1e11crruiYea l pMsrungaorEimpI mium a�teoRIM AIp ��T��1,��0 •�V PDOEMMOFCOMOUM-IMpampmom spismip F I'Vm-m BMW °1tY0' a vXnMWWL a m°nemao ramac EN60 Spasm d Road Unit 21 QmtM JAA OMI 1339.0243M EI`l6 !NG7 ++ WW-Rit,LE Efficiency En ized. �M ����� OWNER AUTHORI ATION FORM Rita Wells (Owner's Name) owner of the property located at: 73 Cotuit St (Property Addrm) N. Andover MA 01845 (Properly Addrm) ' hereby atMorize �i ( 1. (Subrwntractor) 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 contact. i- A-, 4jff.— Ownefs Signature Date The Commonwealth of Massachusetts Department of Industrial Accidents t'Jce of Investigations 1 Congress Street,Suite 100 Boston, VA 02114-2017 www.mass.gov1dia Ni'arkers'Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumhers Applicant Information Please Print Legibly Nance iBusinvSsOrpnization Indisidual): �����{-( �y���j����j tr'► �yti�� � �� Address: $0 (sox 3`J4 Citv"Statelzip: viiUft 01936 Phone -: 9 -T9 17'U- 34q3 Are you an employer''Check the appropriate box: Ti pe of project Ircquired,l: am a generacontractor an 1.8 1 am a employer uith� 4. 1 l d I_ © G. ®1cw�construction employers(full and or part-time)." hay c hired the sub-contractors 2. ] i am a sole proprietor or partner- listed on the attached sheet. s. Remodeling ship and have no employees These sub-contractors have S. ®Demolition %vorkim, employees and have workers' for me m an} capacliv. p comp. insurance. 9. ® Building addition ['so workers' comp.insurance r uir•d. �. ® We arc a corporation and its 10.(] Electrical repairs or additions 4 C 3.❑ 1 am a homeowner doing all%ork officer,ha\e exercised their l l,®Plumbing repairs or additions myself ti��workcts' comp, right ofexcmption per MGL I P 11® Roof repair insurance required.) c. 152,0(4),and we have no employees. [`o workers' 13.®Other comp. insurance required.) *An}applicant that check,lox-1 mu-st alw fill mi thr bectian bdvu i&m 1ltg"herr uorf er5'��n,�<an��al p.,hs�tn:.�nnatmn -Homemnm u,ho sutmtt ti=cs alike tti tt t^.duaYl thy"a,'e dolL.Q all xors ae1:then hire mmde contraam must,uhmn a nm af'lid t+it sntticsu ttr stu h. �Cotitractots that check tI 1s box rruo arachcd an addrtt(xu1,heel shov%mv the name of the bub,cm rimers j W btate uhe:t:er or nut those cooties tta-c CtTt�7laya If thr sub-contra.-,ors halt crplanres,they mu t pry-gide ther. wvfkm'.onT.poht)imnbu I am an empto►er that is pror!idin s tcorkers'compensation ins urance for tot•empkrees. Belo ov is the Polity and job site information. Insurance Company Nartx:-U ,t a. luso�ar•,r,Q t (� _ Policy 4 or Self-ins. Lic.�F: ri 1° 11 V.P.3_vo3 2 Expiration Date:�� Job Site Address: 2 3 19,E%� Cite State Zip:N ,An&_AJ r 'rl Attach a copy of the workers'compensation policy declaration page(showing the poiiq number and expiration date). Failure.to secure coverage as required under Section 25a of R1GL c_ 152 can lead to the imposition of criminal penalties of.i fine up to 51,500.00 and.or one-year imprisorin -ni,as well as ci%it penalties in the form of a STOP R`ORK ORDER and a fine of up to$250.00 a day against the Violator. Be advised that a copy of this statement inay be forwarded to the Offlicc of Investigations of the D1A for insurance coy erste yenfication. I do hereby certifi,under the pain,;anyd�penal ies of perjury that the information provided above is true and correct. Signature: Date: 1 1-11v Phone ff:1 105 'SS-U- 34 t 3 Official use only. Do not write in this area,to be completed bY cit} or town official. City or Town: Permit/License# Issuing:Authority(circle one): 1.Board of health 2.Building Npartment 3.City/ToAn Clerk 4.Electrical lttspector S.Plumbing Inspector 6.Other Contact person: Phone#: AC40� CERTIFICATE OF LIABILITY INSURANCE DATE(MlWDDNYYY) F6/30/2016 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 olic les must be endorsed. If SUBROGATION p y( ) B TION iS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME:ONTACT Nancy usher Martin J Clayton insurance Agency, Inc. PHONE (413)536-0804 NM* (413)534-7874 MAIL 1649 Northampton Street E ADDRESS: P. 0. Box 989 INSURERS AFFORDING COVERAGE NAIC S Holyoke MA 01041-0989 INSURERA:Nationwide Mutual.-Harleysville NATIO INSURED INSURER B Allied world Natl Assurance CO Gauthier Insulation INSURER C: P.O. BOX 344 INSURER D: INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBE.R:CL1663001850 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. ILTR TYPE OF INSURANCE A D BR POLICY EFF POLICY NUMBER POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ®OCCUR PREMISE Ea oca-encs $ 50,000 X OL43487P 7/6/2016 7/6/2017 MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO JECT F-]LOC PRODUCTS-COMP/OPAGG I$ 2,000,000 OTHER: Is AUTOMOBILE LIABILITY COMBINED SINGE L IT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident AUTOS AUTOS ) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accl ent $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ B I EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED1 RETENTION$ BE020792125-194985 10/18/2015 10/18/2016 $ WORKERS COMPENSATION 1 STR LTTE ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICERIMEM13EREXCLUDED? ❑IN/A (Mandatory in NH) `Ifl E.L.DISEASE-EA EMPLOYE $ Wes describe under DESCRIPTION OF OPERATIONS below I s E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addltlonal Remarks Schedule,may be etteched It more space Is required) TET, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSURED(S) ON A PRIMARY AND NON-CONTRIBUTORY BASIS TO ANY OTHER INSURANCE CARRIED BY TET, UNDER THE SUBCONTRACTORS GENERAL LIABILITY AND UMBRELLA COVERAGE. 30 DAYS NOTICE OF CANCELLATION CERTIFICATE HOLDER CANCELLATION SMULD ANY OF TKE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THIELSCH ENGINEERING, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 FRANCIS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. CRANSTON, RI 02910 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEGA ©1968-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD PrF'drd§tbd with PdfFactory trial version www.pdffactorv.com A R CERTIFICATE OF LIABILITY DATE(MMAD/YYYY) �.,�.. LITY INSURANCE F05/13/2016 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 NAME: T Kalil n Daysh MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE (413 536-0804 FAA/XC do. ADDRESS: sh wcl AIL CO 1649 NORTHAMPTON ST.,RTE 5 INSURERS AFFORDING COVERAGE NAICA HOLYOKE MA 01041 INSURER A: ACADIA INS CO 31325 INSURED INSURER 8: GAUTHIER INSULATION INC INSURER C: INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER: 52708 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 ADL B POLICY EFF POLICY EXP POLICY NUMBER 1D YYYI (MM/DD/YYYY1 LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 7 OCCUR PREMISES Me occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 7 PRO- GENERAL AGGREGATE $ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLELIMIT $ Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per aoctdent) I HIRED AUTOS AUTOS Per acpden�AMAGE $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S DED RETENTION I $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE ERS ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? WA WA WA MAARP300327 10/30/2015 10/30/2016 Mandatory in NH) if describe undE.L.DISEASE-EA EMPLOYEE $ 500,000 yes, er DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 500,000 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 ca"be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass-gov/lwd/—workers-compen§a ion/invstigations/, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF GLOUCESTER ACCORDANCE WITH THE POLICY PROVISIONS. 3 POND ROAD AUTHORIZED REPRESENTATIVE GLOUCESTER MA 01830 Daniel M.CroW(ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACC RD 25(2014/01) The ACORD name and logo are registered marks of ACORD nC71!lf' (( <11111>�f)17f1.1C'flll/ f�,�'�L�l.}.IfIC'/lll.1!''ififJ �` Office of Consumer Affairs and Business Regulation ` 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173410 Type: Individual Expiration: 10/112016 Tr# 257812 KURT GAUTHIER KURT GAUTHIER P.O. BOX 344 IPSWICH, MA 01938 Update Address and return card.;Mark reason for change. Address Renewal Employment Lost Card SCA t G 2OM-OS I I _:z\ Office of Consumer Affairs&Business Regulation License or registration valid for individut use only `a HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: j� 1 Registration: 173410 Type: Office of Consumer Affairs and Business Regulation �L t y Expiration: 10!1!2016 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER 44 ESSEX RD IPSWICH,MA 01938 Undersecretary of valid wi out signature LiOZ/�Ll� +aunnrss`wura� uolieirdxa (a W610 VW Qal.*rdj 6 ► too*o a Z6SZEfL-�� :aaua�r� %Itrt Ilgj%�...e�.a xlrtti u.tq tni�4rx.'.) epAcpuclS pue suoug fnSag BUIpNng 10 Piece AlOJeS-I!Ignd la 4uaw4jndoo- 240sn4xssv, A ..