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HomeMy WebLinkAboutBuilding Permit #812-13 - 76 MOODY STREET 5/26/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Permit NO:J/ Date Receive Date Issued: 1rr /r IMPORTANT: Applicant must complete all items on this page LOCATION MOO c V S+ Print PROPERTY OWNER V\ \ a yj Unit # Print MAP MAP NO: Dd PARCEL:M/ZONING DISTRICT: Historic District yes no Machine Shop Village yes no o / 100 year-old structure yes o TYPE OF IMPROVEMENT PROPOSED•USE Reside al Non- Residential ❑ New Building ❑ Addition ❑ Alteration §dne family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg El Other ❑ Others: �I , 5,,10, r( F! 1-1 W -ll T1 .. I 1 1; Li •Yr tALC1iJ4i VV1.1. DESCRIPTION OF WORK TO BE PERFORMED: 44 4 c- low n CC ( (LL ���-E' 14C — (Identification Please Type or Print Clearly) OWNER: Name: o, • h e. a Phone: Address: �? 60 d �4 S CONTRACTOR Name: fifl¢ W. A* Phone: 1 2 �- ") N- FI Y3 Hi! Street Address: Salem MA 9970 Supervisor's Construction License: ?9-?:) Exp. Date: 2 3 Home Improvement License: /y k 8 5 Exp. Date: h 2 ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE; BULDING PERMIT.• $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. � Total Project Cost: $ 000 - ov FEE: $i — Check No.: 79Z 2_ Receipt No.: a6 �-,�14 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _.......... _ - :Signature of A9ent/OWner , _ __ - _ ...__ Signature -of contactor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ElQwimming Pools El Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Durnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS s' i i d'4=0 1 �r�..yil: {141: 1A lJf� IDAji CALLA COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No:f}r Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comm Comm Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Located 384 Osgood FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS, no Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter location, rust 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 Doc:.Building Permit Revised 2011 June/mi 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perr Addition or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Con'I:rac-(: Cs iOiCl3i'i�.l'it �Vl. (t311/�((.1%c LiCr(1 6''�c11 i '(' m-oposea vvort(c vvi'lf i 6p fl`EKier i-lall Ana Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permi- 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 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 Doc: Doc.Building Permit Revised 2008mi Location No. ��o? .3 Date T 9 17 7 Check # 731 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ,,:� 26444 Building Inspector CO) m m m y m CO) EP U) 0 CD 0 Z C Cr SU � C� >co O oCD p C c CD O �o CDo o S' � c CD O 7 LWT N O U) n' r_ 06)0 (D CD CD cn' cv U) v O 0 CD 70 0 CD ti. c0 IM, m cn 0 m O z cn Z o z fn : m O /; m ♦/m� Vr a� 0 CP O D O z 0i. CD N c0 O W CL co CD co 0 N 0 N CA .O 0 � " 0CA C D Fn 2 c CD, CD � CD 0 rn � o. o � -o N. N N FD T o o CL 0 m W� U)CD o CD �. 0 N 0 0 c0o CL� N 0 \ti ��rtn S 13 nCDU) _o�,=� O. o — ccN <NCL CD 5' o �' < 0 <D ' N W CODU) mol. cm o c� CD %ID U) CDN N D0 @� r � rt a) 0C3 CL In V) W T ;;oT N ;v T PO T (� W T N T 3 Y c O O (D O O' O 7 s O O (D O N j N C N � C N C N C C 'O O 0 (D - Z (D S (DF) S S 7 (D S Q °u n to O < r (D m C N 3 rD T n C W m W v y 0 n z M c) o N m z z z -' �nl m m m O m m D A r- 0 S '� 0 0 O H 0 This form satisfies all basic requirements ofthe state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners 1Seek legaladvice if necessary. Any person planning home improvements should fust obtain a copy of "A Massachusetts Consumer Guide td Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. . Homeowner Information Contractor Information 1� ZZI ale Company Name Street AddrCs (do not use a Past Off ce Box address). Contractor/ Sales on/ Owner Name t `jun' Civrown State Zip Code do 61 Business Address (must include a street address) ,•� � Salem MA 01 970 Daytime PhoQne EvbningPhone ! 1 C. _,31 City/town State Zip Code _ Mailing Address (It different from above) Business Phone Federal Employer ID or S.S. omber require Lmv thnt most home Home lmpmvement Contmetor Aeg. Number Eapintien date C improvement cantmetars I a valid registration numhcr - - - »-•�• »s• �•� •� U" «tom .utwwing worts for the Homeowner: (Des/ncr�be in detail the work to completed, specifying the type, brand, and grade of materials to be used, rise additional sheets if necessa ) L &D'orl ce-NotoS••e_ 'W" 9 is ee- 3 S' Required Permits - The following1b.uilding permits are required Proposed Start and Completion Schedule -The following schedule will and will be secured by the contractor as the homeowner's agnt: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of S1/ //-3 Date when contractor will begin contracted work MGL chapter 142A.) _ 5 4 ff (3 Datc when contracted work will be substantially completed. Total Contract Price and PaymeritiSchedule The Contractor agrees to perform the work, furnish the mater ala t rah e o :asa _ r__. _ ._._, 10 nn 6o LC Payments will be made according to ;the following schedule: a upon signing contract -(not io exceed 1/3 of the total oontrac- price o"r fne cost o-fspeciai order items, wiriahever-is greate7 - -- $ _ _ or upon completion of by /_I or upon completion of —jo I �� $ upon completion bf the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The follbWing material/equipm6t must be special $ to be paid for ordered before the contracted v6k begins in order to meet the completion schedule.(-) $ to be paid f NOTES: (•) Including all finance chaiges (••) Law requires that any deposit or down -payment required by the contractor before work begins may not atceed the greater of! (a) one-third ofthe total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. LixT)res Warranty -Is an exnrrce.,,a;•ra"t,, h,.;.....,_,,..:a _ n -- n -_ --- ----- - --••• •�.• .-.. v um eu nr:mior: u NO u Yes all terms fthe warra nty mut be a a hed to the contract Subcontractors -The contractor agrees to be solely responsible for completion ofthe work described regardless ofthe actions of any third party/subcontractor utilized by thebdntractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for is an mater ams and labor under three'nient Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lienor other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contrad6 • Don't be pressured into signing the contract Take time to read and fully understand it. Ask questions if something is unclear. • Makes re the contractor has a'valid Home Improvement' Contractor Re stration. The law requires most home improvement contractors and subcontractors to be registered' -with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy ofthe Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if contractor in writing at his/her me third business day following the s DO NOT SI Two identical copies ofthe been signed at a place other than the contractor's normal place of business, provided you notify the ice or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the of this agreement. See the attached notice of cancellation form for an explanation of this right THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! t must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. Pte, Homeowmr s mgnature 1 Date Contractors signature Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an i arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a cgptraetor, however. The contractor would have to resolve any dispute he/she has with a homeowner in couri unless both parties agree to the optional clause provided below. This clause would give the contrialctor the same rigat to arbitxa3iQn as is afforded to the homeowner by the Home Improvement Contractor Law. Ti o..coiVactor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute ,onccm pg this contract, the contractor may submit the dispute to a private arbitration firm) which has been wpproved by the'Sedfetary of the Executive Office of Consumer Affairs and Business Regulation and thelconsumer shall be recuired to Submit to-spelliirbifratioil as provided In Massachusetts General Laws, chapter 142A. ' ,p ,,_,; - me vner's Signature Contractor's 1gna e NOT CE: The signatures of the parties above apply only to the agreement of the parties to; alternative dispute rwoiuflon initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this sectiop is not separately signed by the parties. Hameowner's Rights A honteowner's rights under the Home Improvement Contractor Law (MGL chapter 142A). and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homepwners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund pro-,isions of the home Improvement Contractor Law. The contractor is responsible for completing the iv�ork as described, in a tilaely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the cpntractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a,: oticular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may oe adO*d to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If yo,.i have quer* Qas about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The coitract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been .#filed in or marked as void, deleted, or not applicable. One original signed copy of the coritiact with attachments is to by@iven to the owner and the other kept by the contractor. Any modification to the original contract mush b6n.writing___ -and_ agreed -to by-both-parties.iontracted wo3Kmay il-oTtiegin until 6offi p—arties have receiuied a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems hiln/herself to be financially insecure, the contractor may require that the balance of funds not yet duel be placed in a j oint escrow aceount as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the sigtratures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Impro-rement" contact:: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, coptact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 I 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Ga online to view the status of a Home Improvement Contractor's Registration: h_ptt ://db.state.ma.us/homeimprovementilicenseelist.asl2 For assistance with informal mediation of disputes or to register formal complaints against] a business, call: iiConsumer Complaint Section Office of the Attorney General i if 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 ' I Version 2.1-11/22/2010 ACORO`oCERTIFICATE OF LIABILITY INSURANCE `.•� DATE (MM/DD,Y 4/26/20133 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and Conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Eastern Insurance Group LLC 233 West Central Street Natick MA 01760 COMM ACT NAE : COIIStTL1Ct] OA PHDNE(508) 651-7700 Fax C o: EA-DRLF INSURERS AFFORDING COVERAGE NAIC # INSURERAArbella Protection Ins. Co. 41360 INSURED Atlantic Weatherization 61 Rear Jefferson Avenue Salem MA 01970 INSURER B Arbella Indemnity Ins Co. 10017 INSURERCNautilus Insurance Co INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:HASTER 2013 RFVISInN NIIMRFR- 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. ILSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MM/DD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_] OCCUR 8500042816 /20/2013 /20/2014 PREMISES Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY Ee 13INEDaccidentSINGLE LIMIT 1,000,000 BODILY INJURY (Per person) $ BI AUTO ALL OWNED X SCHEDULED AUTOS AUTOS 020015871 /20/2013 /20/2014 BODILY INJURY (Per accident) $ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Peraccident $ PIP -Basic $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1, 000, 000 AGGREGATE $ 1,000,000 A EXCESS LIAB CLAIMS -MADE DEO I I RETENTION$ $ 1 4600047820 /20/2013 /20/2014 WORKERS COMPENSATIONS DTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNER/EXECUTIVE ❑N OFFICER/MEMBER EXCLUDED? / A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ C POLLUTION LIABILITY CPL2003786001 0/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010105) INSn25 t9n1nnsi nt ©1988-2010 ACORD CORPORATION. All rights reserved. The Ar npn nnrna 2nri Innn 2m mniatamel mnrira of AnnR11 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. 1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 Rosemary Fulham/PIS ACORD 25 (2010105) INSn25 t9n1nnsi nt ©1988-2010 ACORD CORPORATION. All rights reserved. The Ar npn nnrna 2nri Innn 2m mniatamel mnrira of AnnR11 Rightfax N2-1 3/11/2013 %-55:57 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) IFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE OLDS TH T IS 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 thet{ .-5 and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). . PRODUCER CONTACT NAME: PHONE FAX EASTERN INS GROUP LLC 233 WEST CENTRAL ST (A/C, No, Ext): (AIC, No): E-MAIL NATICK, MA 01760 ADDRESS: 22MLW INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: INSURER D: 61 REAR JEFFERSON AVE INSURER E: SALEM, MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS O CERTIFY THAT THE POLICIESOF INSURANCE LISTEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERMOR 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 POLIOS. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER UVMDD%YYYY) (MMADDIYYYY) LIMITS GENERAL LIABILITY ZACH OCCURRENCE g COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR. DAMAGE TO RENTED $ EMISES (Ea occurrence) ED EXP (Arty one person) $ RSONAL & ADV INJURY $ GEM_ AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY [:] PROJECT Q LOC ODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT (Ea accident) _ BODILY INJURY $ ALL OWNED AUTOS SCHEDULE AUTOS (Per person) BODILY INJURY id $ (Per accent) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIABOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB 11 CLAIMS -MADE DEDUCTIBLE $ $ RETENTION $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YM UB -5B270121-13 031202013 03202014 XWC STATUTORY LIMITS OTHER E. L. EACH ACCIDENT $ 500,000 ANY PROPER ITOR/PARTNERIEXECUTIVENIA /M OFFICEREMBER EXCLUDED? (Mandatory In NH) E -L. DISEASE - EA EMPLOYEE $ 500,000 r yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. R' CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE -POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REP ,. • y. ACORD 25 (2010!05) The ACOKU name and logo are registered marKs 01 ACVKU 19UU-ZU1U AGVKIJ GVKPUKA IIVN, All rights reserved. Unrestricted -Buildings of MY use group which contain less dm 35,000 cubic feet (991m3) Of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. for DPS Licensing information visit www.Man.GovjDPS License or registration valid for individul use only before the expiration date. If found FMM to: Office of Consumer Affairs and Business Regulation 10 park Pim - Suite 5170 Boston, KA 02116 M Not valid Wiffi signature Pal a— C CS -087977 ERIC WPAL04 3 HILTON Sr - SALEM MA—_01970 n 04232014 a WO -A Office rs F----.-4@HOME IMPROVEMENT CONTRACTOR -Re9l'.tratiType- on,. 1420B9 A5 Expiration: 3!1?J2014 Ltd Liability &jrpor i C WEATHER17A'nOW-*L-LC- ERIC PALM 61R JEFFERSON AVE SALEM, MA 01970 Undersecretary