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HomeMy WebLinkAboutBuilding Permit #489-15 - 8 UNION STREET 11/19/2014BUILDING PERMIT TOWN OF NORTH ANDOVER 4,�ljj I� APPLICATION FOR PLAN EXAMINATION Permit NO: ',` / Date Received Date Issued: ! 1q I IM ORTANT: Applicant must complete all items on this nage LOCATION 1-10 Uw:o. S+. Print PROPERTY OWNER 8'to t9A:oh 54. C,&,Ado Tao.%i Darcy AArcy ,.••— Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yesCn Machine Shop Villaae ves TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition O'Two or more family ❑ Industrial ❑ Alteration No. of units: 1 ❑ Commercial C►VRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition_ ❑ Other L Septic _ Well _ !J Floodplain 1 � Wetlands Watershed District C Water/Sewer J 4�la IdentPlease Type or Print Clearly)OWNER: Name: ��Uz ��/�r (Z 7)W Phone: /7r� Address: 6r • CONTRACTOR Name: 4 Phone: 7 5222-11 Address: Supervisor's Construction Licens : C�• U�y9� Exp. Date: Home Improvement License: , / Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ /,z FEE: $ 142 Check No.: 221 Receipt No.: NOTE: Persons contracting with unreg!*pe4wdleontractors do not have access to the uara ty and ;Signature of Agent/Owner _ ignature of contractor i he or NOKTH BUILDING PERMIT °��<,Eo "tio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION °t ,f �o,P Permit No#: Date Received 7,y�°�gA7eo Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family 0 Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic []Well ❑ Floodplain 0 Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: ArIrIrPG-,- Phone: Contractor Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 24 Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swumning 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 Reviewed On Signature_ Reviewed on Sianature HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: Comments Comments ing Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Os ood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate COMMENTS Dimension Number of Stories Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 NU i t5 and uA I A — (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. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o 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 o 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) Li 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location 8 , 0 �k No. `'7` O — ) 6— Check Check # 12cW1 U Date TOWN OF NORTH ANDOVER , Certificate of Occupancy $ Building/Frame Permit Fee $ r�► �� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector GEORGOULIS ROOFING & CONSTRUCTION, INC. 96 Arlington Ave. Dracut, MA 41826 Al Greene - Estimator 1-978-453-4242 Office 1-978-888-1700 Cell georgoulisl4lCct� ol.com CONTRACT 8-10 Union St. Condo Trust Attn: Marcy Aubrey 10/29/14 10 Union St. N. Andover, MA 1-978-387-8777 mlacaa@gmail.com Job Location: 10 Union St. N. Andover, MA Scope of Work: Remove all layers of shingled roofing down to wood deck on entire house, bay window, and front porch roofs, protecting the grounds and house with heavy duty tarps as stripping is being done. Install 6' GAF Weatherwatch ice/water shield across all eaves, around all protrusions, in all valleys, and Yup rakes at all roof to wall locations. On upper flat roof, Install new 1/2" structo board and new .060 Black EPDM fully adhered rubber membrane roof. Install GAF Shinglemate felt paper underlayment on remaining exposed roof deck surfaces. Install 8" .025 gauge heavy duty aluminum drip edge on all roof perimeters. Install GAF ProStart starter strips across all eaves and up all rakes. Install GAF Timberline ID Lifetime Architectural shingles with Timbertex hip/ridge caps on roof. Install new Coravent V-400 ridge vent on all main ridges. Install new stack pipe boots on existing plumbing pipes. Install new lead flashing on existing brick chimneys. Thoroughly clean and magnet grounds and remove all job related debris from property on a daily basis and at jobs completion. $2.50 Per Lineal Foot Extra Cost to replace any rotted or damaged plank board decking (if needed) Entire job includes GAF Systems Plus Warranty. First 50 yrs. Is non -prorated, full labor and material coverage from GAF, against any material defect cause, and is transferrable one time. WE PROPOSE hereby to furnish material and labor complete in accordance with above specifications, for the sum of. D<? - Pai x 3830.60 CK 4 541 Eleven Thousand Eight Hundred Thirty Dollars $11,830,00 1t�a� 14 PAYMENT TO BE MADR, AS FOLLOWS: All material is guaranteed to be as specified. All work to be completed in a substantial workman like manner according to specifications submitted per standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Iger to carry fire, tornado and other necessary insurance. Our workers are fully covered by workers compensation ins ce w Georgoulis Authorized Signature This proposal may be withdrawn by us if not accepted withi 30 s. Acceptance of Proposal- The above prices, specifications are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature ature Date of acceptance 11 to of The, following is part of this contract: Contractor Registration All home improvement contractors must be registered with the Commonwealth of Massachusetts. Contractor Registration #117870 and Construction Supervisor License #058498. Inquires about registration should be made to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-8598. Better Business Bureau, Inc. Georgoulis Construction, Inc. member ID# 35522. Contact the Better Business Bureau (508) 652-4888 or at memberservices@bosbbb.org. General All outside work areas will be left rake clean. Roofing may result in dust or debris falling into the attic. This contract does not include clean up or protection of the contents in the attic. In the event a satellite dish should have to be removed to complete project, Georgoulis Construction, Inc. will not be responsible for repositioning after re -installation, should it be necessary. In addition, the Roofing contractor will not be liable for any damage, whether incidental or accidental, that may occur to any A/C, electrical or plumbing equipment that is installed or located in a place that interferes with the roofing or re -roofing process within normal standards & practices of a typical and reasonable roofmg or re -roofing installation. Pam The maximum down payment or advanced deposit allowed by Massachusetts law is limited to whichever is larger: (A) One third of the total contract or (B) the entire cost of any special order materials. Final payment is required within 15 -days of the invoice date or a late fee charge in the amount of five (5) percent of the said payment shall be assessed for every 30 -day period for said payment outstanding. If non-payment becomes a legal matter, the Homeowner will be responsible for all legal fees incurred by both parties. All Credit Card Sales over $1,000.00 are Subject to a 2.0% Convenience Fee. Work Schedule The owner agrees the scheduling date is approximate. The contractor agrees to show good faith in meeting deadlines, but are not responsible for delays caused by weather. Suppliers, subcontractors, building officials. asbestos abatement, hidden damages or conditions, accidents, acts of God or anything beyond our control. Change Orders The owner is aware that the work may contain hidden damage, defects, or conditions such as decay, insect damage, or substandard construction practices, that may require additional work not included in this contract. In this case, Georgoulis Construction, Inc. will contact the owner and agree on an additional charge to the original contract price. In the event the owner can not be contacted, and it is crucial that work continue to protect the residence from the elements, (rain, snow, ect.) photographs will be taken to document the necessity of the additional work. The owner understands that any additional work will delay the completion of the project. Warranty The contractor, Georgoulis Construction, Inc. agrees to correct any work that fails to conform to the contract or workmanship that is defective within TEN (10) years from the substantial completion date of the project at NO CHARGE to the homeowner. The homeowner agrees to notify Georgoulis Construction, Inc. specifying the nature of any workmanship defect, immediately. No warranty is provided for ordinary wear and tear, fading, abuse, neglect or casualty, or minor cracking/shrinking of concrete or caulking. No warranty is provided for materials not directly supplied by Georgoulis Construction, Inc. or for used, re -installed materials, (including skylights not installed by Georgoulis Construction Inc) or work done by others. This warranty excluded consequential and incidental damages. Contract Acce Lance Upon acceptance of the authorized parties at Georgoulis Construction, Inc. this contract and all work described herein will constitute the entire agreement between Georgoulis Construction, Inc. and the Homeowner. ums 1�O ti C C Q cc Cc O co 4 Q EQ LN a) C O d ' E Ol C C 40 RD i V tn N ' M Cc J • > L O O o -a cm t C..) Q . y E '�O 00 O Z �..=oo ' L Q Q. a) Q `12 cc Q, ai � Nd 2 m W O -aO O LL 'U) d N C Q t O wc3 L U Q O 'a m ,_, co a) '> ;� c N -0 O 1— t 0 � Q 0 C.i r 0 W CL Z CDZ 5 Ca i Z G Z W fin x O W V H Cl) GW.. z 1 E�l Cc 0 J O O oC Z uQ, a a a � Z Z z a oFc Z Z O Z V 7W 0 J m Q W (� mC J W N. L aoj 0+ m C: d W ++ N Y T N O Y co v O Z UJ \ Ucu O N -',4_ O UJ O O t C O C O 0 L v O LL to LL CC U LL LL to U- OC LL m N N C C Q cc Cc O co 4 Q EQ LN a) C O d ' E Ol C C 40 RD i V tn N ' M Cc J • > L O O o -a cm t C..) Q . y E '�O 00 O Z �..=oo ' L Q Q. a) Q `12 cc Q, ai � Nd 2 m W O -aO O LL 'U) d N C Q t O wc3 L U Q O 'a m ,_, co a) '> ;� c N -0 O 1— t 0 � Q 0 C.i r 0 W CL Z CDZ 5 Ca i Z G Z W fin x O W V H Cl) GW.. z 1 E�l Cc 0 The Commonwealth of Massachusetts Department of Industrial Accidents w Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibly Name (Business/Organization/individual): Georgoulis Construction, Inc. Address: 96 Arlington Ave Citv/State/ZiD: Dracut, MA 01826 Phone #: 9784534242 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 10 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 6. El New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.1 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *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. I am an employer that is providing workers' compensation insurance for my employees. Below is lite policy and job site information. Insurance Company Name: Seneca Insurance Policy # or Self -ins. Lic. #: WC009774283 .lob Site Address: 8-10 Union Street Expiration Date: 9/25/15 City/State/Zip: N. Andover, MA 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 under tie pai a penalties perjury that the information provided above is true and correct. Signature: , Date: Phone #: � / KY Y Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax # 617-727-7749 www.mass.gov/dia Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 117870 Type: Private Corporation Expiration: 12/12/2014 Tr# 234343 GEORGOULIS CONSTRUCTION, INC. SCOTT GEORGOULIS 96 ARLINGTON AVE DRACUT, MA 01826 --- - -- SCA 1 0 20M•0511I Update Address and return card. Mark reason for change. Address [] Renewal [ I Employment -I Lost Card w. Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Super -*Nor License: CS -058498 I{I� SCOTT C GEORGOULIS ' 96 ARLINGTON ANW �• _ DRACUT MA 0826 " ,� ash �• Expiration Commissioner 10/21/2015 ISEI I OI O-6955849 UCSanDiego Extension A erica INTERNATIONAL SAFETY EDUCATION INSTITUTE (ISEII S - C ound This card certifies that: SCOTT GEORGOULIS has completed a 10 -Hour OSHA Hazard Recognition Training I for the Construction Industry. 08/23/2013 ' Director: Scott MacKay Trainer: Taylor Sikes Grad. Date: ACORLY CERTIFICATE OF LIABILITY INSURANCE/18/2014 (MM/DDIYYYY) [71E, 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(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 Phone: (978) 263-3500 Fax: (978) 263-1438 GALLANT INSURANCE AGENCY, INC. 199 GREAT ROAD / P 0 BOX 975 ACTON MA 01720 CONTACT Gallant Insurance Agency, Inc. A/CO"Na Ext: 978 263-3500 ac No: (978) 263-1438 E-MAIL DDRES PRODUCER COSTO RID: 36702 INSURER(S) AFFORDING COVERAGE NAIC # PRODUCTS - COMP/OP AGG $ 2,000,000 INSURED GEORGOULIS CONSTRUCTION INC. C/O SCOTT GEORGOULIS INsuRERA :Seneca SpecialtyIns Co INSURER B : Chartis Insurance Company INSURERC 96 ARLINGTON AVENUE INSURER D: DRACUT MA 01826 INSURER E INSURER F BODILY INJURY (Per person) $ COVERAGES CERTIFICATE NUMBER: 42377 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, INSR I TYPE OF INSURANCE ADD'L SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DDIYYYY) flMMIDDrYYYY1 LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X I OCCUR BAG -1019845 03/05/14 03/05/15 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Eeoccuren e $ 100,000 MED. EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB HOCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE DEDUCTIBLE RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS bebw NIA WC009774283 09/25/14 09/25/15 XWC STATU- OTH TORY LIMITS E.L. EACH ACCIDENT$ 100,000 E.L. DISEASE -EA EMPLOYEE 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CERTIFICATE HOLDER CANCELLATION 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. 120 Main Street N. Andover, MA 01845 AUTHORIZED REPRESENTATIVE Attention: �^� �'— Ray Gallant, President ORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights re The ACORD name and loco are registered marks of ACORD