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HomeMy WebLinkAboutBuilding Permit #857-15 - 79 GRAY STREET 4/27/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: i Date Received Date Issued: it LITI� Ir -IMPORTANT: Applicant must complete all items on this page 0� �tLE° 16'6NO\ Ic LOCATION r i`,- •-r i Print PROPERTY OWNER P4C �C�y� ) b0, ' Print 100 Year Structure yes t1no MAP T; PARCEL: 15 ZONING DISTRICT: Historic District yes o Machine Shop Village yes rr TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial A.Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORIf TO BE P RFORME : a �.P ti's D � rr 0 rf ci r-- - r-rm .4- de4 OWNER: Name: K `mak Ab Kms' Address: 9 G <'c -t -I '5�- - Please Type or Print Clearly A r - Y -(496-r72-&, kc �7 L g 1-S { Contractor Name: Phone: Address: 15 y f ME— I1T �1 !It Supervisor's Construction License: C; -()-7 Exp. Date: �I //!5 Home Improvement License: __+.y(F 3S-5 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASEDON $125.00 PER S.F. Total Project Cost: $ � \ �, IT q(0 i d0 FEE: $ hLI S do-- Check No.: .1 `t 0 () Receipt No.: 40 NOTE: Persons contracting with unregistered contractors do not have access to A Location No. Date Check # I �0 C) TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL $ j2C) Building Inspector ..,r; Plans Submitted ❑ Plans Waived El 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 Siqnature Zoning Board of Appeals: Variance, Petition No: Olanning Board Decision: 6 Conservation Decision: Comments Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Siqnature & Date Driveway Permit DPW Town Engineer: Signature: LOcatea 564 us ooa Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email 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. r 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 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 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 ❑ 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 Doc: Building Permit Revised 2014 CA CD 0Z CD O CLr CL —• >(� O 00C Q C rF CTD O CDW O' O CO CD 57 U) CD 0 z m cn cn O cn n Z ►a m x 55 Z m 29 Z 2 < C - O --I CD CDN MU —1 O• m O CD n • O rt a' n Z (• o. o, O a. :3 m N � C° '0 cn _ as CD CD @ D �. c 0 ' U', o U) memo 00 CD CD S. CD CL s M 00 c� 0 0 c :,y :1 n CD � a. U O < Q• O CO)= Q G. CD 0 N N m CD CD ry CD** N rt C .a� O7Nt rt �� _ y sa � O c� R O O CD CD C') �+ O -Ow C o �+ C1 O v (n CD (D (n fD �'+ Z O W N m V m z T p1 ;a O C S y H O w (n n .Z O C S r m n > m T w = O C S 'O C m T p� n 7 N .7 O C S T O C D_ N O 0 O C z M z m 0 N N U n N O T O O \ � n S O W O 2 D = s 55.rd(, 00 KEEN CONSTRUCTION CO. e PROPOSAL 1175 TURNPIKE STREET NORTH ANDOVER, MA 01845 All home improvement contractors and subcontractors Tel: (978) 691-5201 engaged in home improvement contracting, unless Fax: (978) 682-3231 specifically exempt from registration by Provisions of n / Chapter 142A of the general laws, must be registered ' Submitted �C `G �j (J �t + y ' f q J��tL h with the Commonwealth of Massachusetts. Inquiries �\ ��` To: 1r fff v about registration and status should be made to the 9G Director, Home Improvement Contract Registration, 10 Park Plaza, Room 5170, Boston, MA 02116 617-973- 8787 Owners who secure their own construction .G r - related permits or deal with unregistered contractors yl will be excluded from the Guaranty Fund Provision of MGL c. 142A. PHONE DATE/ REGISTRATION NO. EIN NO. - y (1 5 /2 G 1`7 MA. H.I.C. 108383 46 —3783401 > C/S = Customer Supplied S + I = Supply + Install See Attached Appendix A We hereby submit specifications and estimates for work to be performed and materials to be used: ! +�. G Int a Pa (` --- S -e e > Construction related permits: __ .......... ,.._......... ._ ................. ._........ _... ........... .____..................................................................................._..._..........._............._:................._......_......_._...._.._._....._.._............_..... _. _ _.___.._.....__... .. _...._. WORK SKS H Contra not the work or order the materials before the third day following the signing of this Agreement, unless specified here'nf'ting. tractor will begin the work on or � about b (date). Barring delay caused by circumstances beyond Contractors control, the work will be completed by (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contra tor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor - complete in with specifications, for the sum of accordance 'above \1h1VC--A Vt�'�l �� 1 x --dollarsI$ g%,GU ). Payment to be made as follows: ($ ) upon signing Contract; ROBERT A. KEEN Name of Contractor / Designated Registrant ($ )upon coraio�n o 1175 TURNPIKE ST. Street Address ($)� n -completion of N. ANDOVER, MA 018.45. " _ City I State ^ ° shall be made forthwith upon (978) 691-6201 (978) 682-3231 completion of work under this contract. PhFax Notice:: No agreement for home improvement contracting work shall require a pe,,, > down payment (advance deposit) of more than one-third of the total contract price Name nI Said an or the total amount of all deposits or payments which the contractor must make, in ; �----- advance, to order and/or otherwise obtain delivery of special order materials and Authori ed Signature ' equipment, whichever amount is greater. Note: This proposal may be withdrawn by us If not accepted within days. Acceptance Of Proposal - I have read both sides of this document and all attached documents and accept the prices, specifications and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Cancellation must be done in writing. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. I fjpY�'' , . �..1 ' - ` \ - J��' /`e`� Date 11 �C' � �\ Data signature Signature IMPOHTAN I INI-UHMA I IUN UN IJAUK fffl>r ,r _, Cans�lr�uc�ion Co;. REMC�UELIPI C: SPECl/a61STS 978-69'�-5207 s,,KeenCons tructionCo.com..0 Halbach, Rick & Kathy 79 Gray St. N. Andover, MA 01845 Contract #5530; Appendix A April 15, 2015 Repair office walls and ceiling: $2000 • Remove and dispose of ceiling and damaged part of wall • Remove and dispose of existing insulation • Supply & install insulation in ceiling • Supply & install wallboard and skimcoat plaster to walls to smooth finish and ceiling to textured finish • Paint walls Soffits & gable vents: $1394 • Remove existing soffits on front and rear of house and rear of office • Supply & install Musket Brown fully vented vinyl soffits to match existing trim color • Supply & install gable vents on each side of office Living room, stairway and hall: $2892 • Remove existing crown molding • Apply stain blocker and paint walls and ceiling • Supply & install new crown molding and stain & seal to match existing • Remove and replace approx. 20 sq. ft. of flooring to match existing (2 %"Bruce Fulton strip "Seashell") Front door: $3110 • Remove front storm and entry door • Supply & install new Masonite 6 -panel door with camber top Element glass at the top, with an Oak texture (BLT -137-328-4) • Stain & seal door with Masonite Early American stain kit • Supply & install new exterior trim (PVC) and interior to match • Stain & seal interior trim to match • Supply & install new Emtek door knob (brass interior, nickel exterior) • Supply & install Andersen Contemporary Deluxe full -lite storm door in Bronze with nickel hardware 1175 Turnpike St. Page 1 of 3 P: 978-691-5201 N. Andover, MA 01845 F:, 978-682-3231 CSL #076691 Sales@KeenConstructionCo.com HIC #108383 �t°; G`'OY3Jtf^uC�lOi'l CO, REMC�DEI_IMC: SPEGI/aWSTS 9';rAE% .,_ Keen ConstructionCo_com Main Bathroom: $1550 • Remove wallboard on outside wall • Supply & install blueboard and skimcoat plaster to smooth finish • Install customer supplied 110cfm bath vent and pipe to soffit vent • Paint walls and ceiling Front corner bedroom: $640 • Stain block as needed • Paint walls and ceiling Window sills: $300 • Supply & install new stainable window sills on 16 windows • Repair exterior sill of vinyl window in mid front bedroom Kitchen window: N/C • Re -secure top casing All prices include disposal of all construction related debris, but do not include cost of permits or repairs to any unusual, unsafe or non -code compliant existing conditions that have not been addressed in this contract. Total Price: $11,886.00 (eleven thousand eight hundred eighty six dollars) 1175 Turnpike St. N. Andover, MA 01845 CSL #076691 Page 2 of 3 Sales@KeenConstructionCo.com P: 978-691-5201 F: 978-682-3231 HIC #108383 i ° :; CDY3J tf"GfC�1DY);: CO. REIA"DFLINiG SPECIALISTS 978-69'7-5207 KeenConstructionCo.com i Payment Schedule: $1000.00 due upon signing contract $3000.00 due the first day of work (plus permit fees), $2000.00 due when front door is installed $1500.00 due when soffit and gable vents are installed $2000.00 due when plaster is complete $2386.00 due at completion of contracted work Customer Date 1175 Turnpike St. N. Andover, MA 01845 CSL #076691 Robert A. Keen Date Page 3 of 3 Sales@KeenConstructionCo.com P: 978-691-5201 F: 978-682-3231 HIC #108383 The Commonwealth of Massachusetts x W Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:Q��� Address: (% �j �U f- n Qt k �^ City/State/Zip: Are you an employer? Check the appropriate box: 114 I am a employer with 3 employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req] #: 97 y—( 91- J zlo *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # 1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ra 'fir' P1 5 Insurer's Address: © Q O)C 3 155 City/State/Zip: 0 A- dy , F L— -?- 2,7d z- / / Policy # or Self -ins. Lic. #0 G --9991 K 5'ZZ — I LJ Expiration Date: 10 / � ( I 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 one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, uqor the of perjury that the information provided above is true and correct Sipmatur_ : `/`— / �-"Date: "// 2- -7 t `_7 Phone #: 9 7 1 — C,,g / -- VS 2-0 / Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia 03/23/2015 08:56 FAX 781 942 2226 GILBERT 0001/001 '�� CERTIFICATE OF LIABILITY' INSURANCE DATE'11WDDIYYYY) 4/15/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER$ NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDEDIBY THE POLICIES 9ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURED($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. I IMPORTANT: IF the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and Conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements .__ paocuGER Gilbert Insurance Agency, Inc. 137 Main Street Reading MA 01867-3922 �nME: cT Sa.rbara McDonough PHONE . (781) 942-2225 (10i)94x-2226 E-MOAL egg, bmodonough@gilbertinsurance.coi INOV, 111 1116) AFF RDINO C LRA E NAIL e INSU ERA:NORB'OLK F DEDH M INSURANCE INSURED Keen Const %lction Company 1175 Turnpike Street North Andover MA 01848 _23965 INSURER B :$afet: Tna rant INsuRERC:Travelers Insurance 0022 INSURER D: INSURE E : INSURER F: COVERAGES CERTIFICATE NUMBER:CL1441500922 RFVISlnfd NII IMRFR, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORHE 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 PAD CLAIMS, ILTR TYPE OF INSURANCE A DDL SU OR POLIC NUMBER PMIDOY YY MMLDO EXP LIMITS A GENERALLIASIUTY X GOMMERCIAL GENERAL LIABILITY CLAIMS -MADE ©OCCUR -P-010079/000 /13/2015 /13/2016 EACH OCCURRENCE 1 S 1,000,000 DAMA E REN TED a na I s 100,000 ME EXP An one arson , S 5,000 PERSONAL & ADV INJURY I $ 1,000,000 GENERA. AGGREGATE 1 9 2700,000 GEML AGGREGATE LIMIT APPLIES PER; x POLICY PRO, 7 0 PRODUCTS. COMPIOP AGG S 2,000,000 s 13 AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED X SCHEOULEO AUTOS AUTOS HIRED AUTOS NN -Ox AUT 9�ED 6226907 5/23/2014 5/23/2015 1f.u01 ED IRGLE LIMIT0 0 400 BODILY INJURY (Per person) ffi 80DILY INJURY Per;Mdant 3 I ) _ P fpftf$ER Y *AMATO- I underinsured ItA9Wsl I S 100,000 UMBRELLA LIAR EXCESS LIA9 OCCUR CLAIMS MADE EACH OCCURRENCE S AGGREGATE 6 DED RETENTION 3 I g C WORKERS COMPENSATION AND EMPLOYERS' UABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFIOERIMEMBER EXCLUDED? a (Mandatory Id NH) Ir yas, desonbe under DESCRIPTION OF OPERATIONS balow NIA TO Be Provided directly in the CAYtilr• 0/8/2014 0/9/2015 M ST 7 -OTH- E.L EACH ACCIDENTS 100,000 G.L.DISEASE - EA EMPLOYE S 100,000 23L DISEASE - POLICY LIMIT 3 500 00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addllom) Raw*$ Sehadulo, If mora 041" to ►aqulr114) Evidence of Coverage (978)682-3231 Evidence of coverage 25 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE "NCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ailbartr CIC/DARRAR ®1988.2010 ACORD CORPORATION. I All rights reserved. INS02512otoos).o1 The ACORD name and logo are registered marks of ACORD Rightfax 142-1 3/26/2015 2:29:24 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) T. ' IFICATE 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 2MODUCER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the arms 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 Ileu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX GILBERT INS AGCY INC 137 MAIN STREET (AIC, No, Ext): (A1C, No)- o):E-MAIL E-MAIL ADDRESS: READING, MA 01867 246WY INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA KEEN CONSTRUCTION CO INSURER B: INSURER C: INSURER D: 1175 TURNPIKE STREET INSURER E: NORTH ANDOVER, MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 6 TO FY 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 ADD L SUB R POLICY NUMBER POLICY EFF DATE (MM\DD\YYYY) POLICY EXP DATE (MMMD\YYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY — CLAIMS MADE r OCCUR. AMAGETO RENTED REMISES (Ea occurrence) $ ED EXP (Any one person) $ ERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC ENERAL AGGREGATE $ RODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR EACH OCCURRENCE $ EXCESS LIAB []OCCUR CLAIMS -MADE AGGREGATE $ !� DEDUCTIBLE $ $ RETENTION $ A WORKER'S COMPENSATION ANDWC EMPLOYER'S LIABILITY Y/N UB-9991MS82-14 10/08/2014 10/08/2015 STATUTORY OTHER X LIMITS I ANY PROPERITORIPARTNER/EXECUrIVE N OFFICERIMEMBER EXCLUDED? NIA E. L. EACH ACCIDENT $ • 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 (Mandatory In HH) It 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. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD STREET BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. At REPRESENT YE � NORTH ANDOVER, MA 01845 ACQHD ZS (ZU10/U5) The ACURD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. Massachusetts - Department of Pub4ic Safety Board of Building Regulations and Standards Construction Supervisor $ ' License: CS -076691 ROBERT A KEEN-` 12 E WATER ST North Andover NFA 01845 I Expiration Commissioner 08/16/20,15 �� �parrurnoauueal,(� a��aczc>livaeC� Office of Consumer Affairs & Business Regulation rxME IMPROVEMENT CONTRACTOR eigistration: ;ID183 Type: piration:-.8L18120.16 DBA KEEN CONSTRUCTIO�I..CQ.'a Kenneth Keen 1175 TURNPIKE ST' NO. ANDOVER, MA 01845y Undersecretary