HomeMy WebLinkAboutBuilding Permit #971-16 - 820 TURNPIKE STREET 3/15/2016BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION-.
Permit No#: Date Received (o
Date Issued:
0
I --I /IMPORTANT: Applicant must complete all ite m�*s 6n this, paRe I I
LOCATION S"A0104 TED") 5_7
If Print
PROPERTY OWNER Cc r'4J -
Print 100 Year Structure yes no
MAPO PARCEL:.t'GbY ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
.n
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residentia-1
El New Building
11 One family
El Addition
0 Two or more family
0 Industrial
Wlteration
No. of units:
XCommercial
0 Repair, replacement
11 Assessory Bldg
El Others:
El Demolition
0 Other
El Septi& EJW-111
Evo E
F, I ood' I'air, owwki�'
U. V p`r$N#'
vat
DESGKIPTION OF WORK TO BE PERFORMED:
. A A�� A 1A C, .4a r7 -e n 41
OWNER: Name:
iLype or rrint
Address: 422 1-114;N '(RJ- I S.L'f� 0 X)4, 0.3079
Contractor Name: Cz;D RC -A LTi4 L L e- Phone:
Email:
Address:
Supervisor's Co nstruction License:- C_S-077o7S,9 Exp. Date:
e:
Home Improvement License:-- )7YZ7q6 Exp. Date: 3/1
ARCH ITECT/ENGI NEER:2�� !�,'D0400QS -Phone: 97S' -/,01/ -
- YOX 1 3A 1
Address: 14, biWQJ<5r- &LAQY_E4Q PJA Reg. No.- 7 97
FEE SCHEDULE. BULDING PERMIT. $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COsrB)tsED ON $125.00 PER S.F.
Total Project Cost: $ ciny FEE: $
Check No.: Receipt,- No.*
NOTE: Persons contracting with unregistered contractors do not:haveaccess to the guarantyfund
IL
I
Plans Submittedk Plans Waived El Certified Plot Plan El Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer 11
Tanning/Massage/Body Art El
Swimming Pools El
well El
Tobacco Sales 11
Food Packaging/Sales 11
Private (septic tank, etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONSFOR OFFICE USE ONLY
� .1 .. '. � I � � I
INTERDEPARTMENTAL SIGN OFF - U FORM
x/PLANNING & DEVELOPMENT Reviewed On �Ii4tbl Signature
COMMENTS 6/1517AIG 7Z-Ah1PW'7- )tglrjakt)4� a)lov 7g1,-jz-.
Ave. exima
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH. Reviewed on
Signature
COMMENTS
Zoning Board of App�als: Variance, Petition No: -Zoning Decision/receipt submitted yes
Planning Board Decision, Comments
Consbrv'ation De'cisloh: Commentg
,:Water & Sewer Connection Pe'rmit
DPW Town Engineer: Signature:
Located 384 Osgood Street
A a4l iT: i r,,W p" -1-5"Ll M p s t g'.1 I dl�' 6
U _iQ' - 0 40
e% gs
1EIR E _ME
0
wreet
A
preiclap
in sig
f j";MV
7MW
_41
INI�
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.$100-$l 000 fine
NOTES and DATA — (For clepartment use
I
Ll Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
_j
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
4, Copy of Contract
4-. Floor Plan Or Proposed Interior Work
a. Engineering Affidavits for Engineered products
10TE: 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
16 Photo Copy of H.I.C. And C.S.L. Licenses
,4. Copy Of Contract
-;6 Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
4. Mass check Energy Compliance Report (if Applicable)
,,. Engineering Affidavits for Engineered products
IOTIE: 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
�6 Certified Proposed Plot Plan
46 Photo of H.I.C. And C.S.L. Licenses
,4, 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
Doe: Building Permit Revised 2014
Location
No. Date 311,-1
Check #
21
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ &,�7 —
— J�7,v C) ()
Building/Frame Permit Fee s/,,...
Foundation Permit Fee
Other Permit Fee $
TOTAL $/
Building Inspector
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Pen -nit Number 971-2016 on 3/15/2016 Date: June 1, 2016
THIS CERTIFIES THAT
THE BUILDING LOCATED at 820A Turnpike Street
MAY BE OCCUPIED AS a tenant fit up Laser Center IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to: Peter Shaheen
820A Turnpike Street
North Andover, MA 01845
Buildin Inspe /tor
9 P
Fee: PrePaid $100.00
Receipt: 30121
Check: 7906
0
,,ORYN
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 971-2016 on 3/15/2016 Date: June 1, 2016
THIS CERTIFIES THAT
THE BUILDING LOCATED at 820A Turnpike Street
MAY BE OCCUPIED AS a tenant fit up Laser Center IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to: Peter Shaheen
820A Turnpike Street
North Andover, MA 01845
Buildin lnspe�tory
9
Fee: PrePaid $100.00
Receipt: 30121
Check: 7906
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WILLIAM BALKUS ASSOSCIATES
I
1AACjff1FjM
TEL. 978 887 3351 WBAARCHITECTS.COM
PO BOX 185 TOPSFIELD MA 01983 WBAARCHITECTS41CLOUD.COM
MEMORANDUM
TO: MR. GERALD BROWN
FROM: WILLIAM BALKUS
DATE: MAY 3, 2016
LOCATION: 820 TURNPIKE STREET, NORTH ANDOVER
BUILDING 820
UNIT 101
SUBJECT: TENANT WORK FOR ASTHMA AND ALLERGY AFFILIATES
BUILDING TYPE: IV -B
USE GROUP: B
I have reviewed the completed work done on the above listed unit, and to the best of my
ability, I would say that the work meets the original design concept and the requirements
of the Massachusetts State Building Code.
ReAfec Y, S,
William Balkus
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
S 82,000.00)
m
$
$
984.00
Plumbing Fee
$
123.00
Gas Fee 100 comm.
1100.0,91
Electrical Fee
$
123.00
Total fees collected
$
1,330.00
820 A Turnpike Street
971-2016 on 3/15/2016
Tenant Fit Up for Expansion of Laser Center
FP 006
(Rev. 1.1.2015) PERMIT'
City or Town:,
DIG SAFE NUMBER
Date:
Sfart Date:
Permit Number (if applicable): E
In accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted
to (!::�,7 - `0 /—,>-� ,,/ /- /--,,
krull lmamL or verson, t-irrn or Gorporation)
for Locate dumps'ter for construction/renovation/demolition of
Restrictions:
95ft- from -str
,at
(Street
Fee Paid $ "5-0 —
Signature of Official Granting Permit:
or Describe Location for Adequate
permit will expire on e,/
Title
This permit must be conspicuously posted upon the premises
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Gio Realty LLC
P.O. Box 1016 - Salem, NH 03079
Phone: (603) 231-5009 - Fax: (603) 894-5732
Pr
March 1, 2016
Dr. Azar Korbey
Laser Center
820A Turnpike Street
No. Andover, Ma
RE: Renovation of Space for Laser Center Expansion
Azar
Here is the bid proposal for the Laser Center Expansion fit -up at the above
address. This proposal was developed using a set of plans provided to us by Thomas
Saunders Architect AIA, 16 Brook Street, Andover, Ma dated 2/1/2016 and is attached
here as "Addendum A". The following items represent the scope of work as we
understand it to be.
Included in this bid:
1) Demolition— As defined on page A2 of the attached plans
2) Metal Stud Framing — As defined on page A3, Lines 1-5 of the attached
plans
3) Drywall — as defined on page A3, Line 4 & 5 of the attached plans
4) Acoustic - Ceilings as per the attached ceiling layout, page A4, "Reflected
Ceiling Plan"
5) Finish Trim & Doors — As per page A3, Lines 6,7,8 & 9 of attached plan
6) Treatment Room Cabinets/Counters - We will purchase and install all
cabinets and counters as detailed on page A3, Line I I of the attached plan.
We will use a thermofoil cabinet and laminate countertop
7) Plumbing: We will purchase and install 15' stainless steel sinks with polished
chrome gooseneck faucets (2 handles) in each exam room. Each sink will
have a pump in the cabinet to force the water to a waste line within the unit.
We will provide a new handicap toilet and sink as per the plan, Page # A3,
Line # 12. The other restroom will remain as is with the current fixtures.
8) HVAC — We will modify the existing diffusers and returns to accommodate
each room. There will be one thermostat and each room will be balanced so as
to provide an even flow of heat and air conditioning.
9) Electrical —We will install all new wiring as per code to include 210 voltage
to each exam room to accommodate the laser units. Exam rooms are required
to have hospital grade wiring and is included in this bid. All other electrical
will be done per code. Included in the bid is Cat6 wiring for any
telephone/data lines for offices and exam rooms.
10) Fire Alarms — There is an existing fire alarm system in the building. We will
install any fire alarm wiring and equipment specific to the unit itself so as to
meet all code. Any upgrades to the building itself will be the responsibility of
others.
11) Paint: All walls and wood trim will be painted two coats of latex as described
on page A3, Line 10
12) Flooring: Flooring will be purchased and installed as described on Page A3
and as per the flooring allowance.
13) Waste Removal and Cleaning: We will provide on-site dumpsters and
maintain a clean and safe site during construction. We will provide a final
cleaning prior to move in.
14) Building Permits: We will pull a building permit and each licensed trade
subcontractor will pull their required permits.
15) Insurance Certificates: We will provide all appropriates insurances and
required the same form all of our subcontractors
Not included in this Bid:
• Any upgrades or improvements to the existing HVAC unit or condenser.
• Any upgraders required for the Fire Alarm System as it pertains to the rest
. of the building.
e If a handicap ramp is required it will be provided by the building owner.
Price Adjustments: We will agree to adjust pricing if there are areas where we can find
a less expensive solution or a better price form a supplier or subcontractor and pass it on
to you dollar for dollar.
ALLOWANCES
Flooring .................................................................. , ....... $8 '0'
Cabinets/Counters ........... o ...................................................... M.75'40
Additional Labor and Material:
Any unexpected work beyond the scope of this contract will require a change order in
writing. Any unexpected or additional work required beyond the scope of this contract as
outlined above will be billed out at $55.00 per man hour. Materials purchased by us will
be billed at cost, plus 20%. Any material purchased by the customer will be the
responsibility of the customer and not warranted by Gio Realty LLC.
Schedule/Pricing:
Occupancy is anticipated to be 90 days from start date.
Our firm fixed price for the above work, and as detailed above is:
Eighty One Thousand Seven Hundred Fifty
If this proposal is acceptable please indicate by signing below and returning to our
office with an initial deposit $15,000 with additional payments as follows:
Invoiced every two weeks as progress payments
As per "Addendum A" Construction Advance Schedule
Thank you for giving us the opportunity to bid this work, and we look forward to
working with you.
T11116
Tom Gioseffi' Date
Gio Realty LLC
" /,' �? z �? 14
Dr- A�ar Korbey Date
All Care Laser
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The Commonwealth ofHassachusetis
0 Department of IndustrialAccidents
EY 1 congress Street, S�ite 100
Boston, HA 02114-2017
wwwmass.gov1dia
vit: BnUders/Contxietors/FIeqtriciansjplWbers-
-Workers, C mpensation Insurance AM&
ITY.
TO BE FILED WITH TM PER?MTTJNG AUTAOR it Le%bl-
lease krii
Name (Busine8s/di'gdi*atiobAndividiW): C-io
Address: vy, /014 1P —on
City/State/Zip:
.Areyouanemp�oyq - q4eckth, appropriate box:
1.[] 1 am a employer vvith__�MP"Y"' (full andlorpart-tilne).*
X1 an a sole proprietor Or Partnership and have no employees Working for me in
anycal)ar
,tj. (No workprs, comp. insurance required.] comp. insurance required.] T
3.olamahomeo-wnerdOingaUworkmysey'lgowo"kers'
4. F1 I am a hoineowper an4 will be hiring contractors to conduct all work on my property. I win
ensure that all contractiSts either have workere compensation insurance or are sole
, "10
proprietors with h0AAPl6YG0s-
rs listed on the attached sheet.
5.F] I am a general contraefor'aid I )iave hiredthe sub-confractcoomp. insuranre.t
These sub -co.". rs-qa I . a
emp oyees and hav workers'
6. n We area corporoq#j�a its of�cdrs have exercised their right of bxemption Per MGL o.
,,,, Rl(,j-, lijV6 �6' niplotyd;e. [No workers' comp. insurance required.]
r_ -j
Type oftprojeci (terioi6d);
7. NdVc6nstr�dfjon
8. Remodel.lhg
9 Demolition
10 E] Building addition
11 -El Electri6a.1 OP Or additi9gs
I " I& airs or dadiRbids
2_ ing rep
11 F] ko6f repairs
14. El Other
3jid§i ;1�6 fill out the section below showing their workers' compensation policy MOrmatIORt'
Mny applicant thatch&. ,, a now affidavit indicating such.
eating the
'y are doing all work pd then hire outside contractors must submit n I ave
I Homeo-wmers who sujmyitjhis; affidavit indi d hn additional sheet showing the name of the sub -contractors and statq whqther qr liot fhosPP titlO
this box must attache
tContract-rs that check provide their workers' comp. policyriumber.
employees. Ifthe sub-con#actqrs have employees, they must
workers' compensation insurancefor MY enplbyees. helow is thepolicy an job Sit�
I am an employer that isproviding
information.
Insurance Company Name;
Expiration Dgte,
Policy # or Self -ins. Lic. #'
!RT - city/state/zip: Ala AW&1/Js0e_
Job Site Address: 2-2 In �sa on policy declaration page (showing the policy number and expir L Wan date).
Attach a copy of the workers' cO . Pei's criminal violation punishable by a f&b up to $1,500-00
Failure to secure coverage as required under MGL o. 152, §25A is a $250.00 a
and/or one-year imprisonment, as well as civil Penalties in the form of a STOPWORKORDERand afine of upto .
be forwarded to the Office of Tuvestigdtions of the DIA for hasurance
day against the violator. A copy ofthis statement may
coverage verification. e information provided above is tru e an d correct
d It' f. ry t7i at th
I do hereby certify "der t1lepains an
--r-44— - A nntw .2 J/ ) ),//.
Phone /P Ok__A�l
n -write in t1lis area, to be com
pleted 7bycity 7=rtowft� Official
t p
official use only. Do no
City or Town: Permit/License
issuing Authority (circle one):
1. Board of Ifealth 2. Building I)epartment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. other
Phone
Contact Person'
Information and Instructions
I
Massachusetts General Laws chapter 152 requires' all emplbyars to provide workers' compensation for their e4fdyq�ul.
11, W4
Pursuant to this statute, an employee is defined as -every person in the service of another under any contract of
express or iniplied, oral or written."
An employer id deffi6d as "an individual, partnership, association, corporation or other legal entity, or any two or more
ofthe foregoing engaged in ajoint enf&prise, and including the legal representatives of a deceased employer, or the
receivU'6j� trujtdd � 'an individual, partnership, association or other legal entity, employing empl6ypp§. - IT9)yev�r the
. - '_ I of
owner of a dwelling house having not more than three apartments and who resides thereh-4 or the occulpf'-&M df`16
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwell�dg house
or on the grounds or building appurtenant thereto shall not be�ause of such . ehiployment b6 deemed to b . a an employe I r."
MGL c , hapter 152, §25C(6) also states that "every state or local licensing agency shall withholdthe issuance o�
renewal of a license or perkifto opdrate a business or to construct buildings in the commonwealth for any
applicant-wh6j hashot produced -acceptable evidence of compliance with1he insurailce, covera I gd i�quiked."
i dl'
Additionally, MGL (�?tptqr i52, §25C(l) states "Neither the commonwealth nor any of its political subdivisio'jas shall
enter intp any con�act for the performance ofpublic work until accep'table evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authority."
Applicants
Pldasb fill out theVorkers, compensation affidavit completely, by checking the boxes that apply to your �ituation and, if
riece�.sary, supply sub-'contractor(s) name(s), address(es) and phone number(s) along with their certificat 6
insurance. Limitiedi-Pability Companies (LLC) or Limited Liability Partnerships (LLP) with no employe6sbiher than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP do 6s have
employees, a policy is required. j3e advised thatthis 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 Affid4vit should
be returned to the city or town that the, application for the permit or license is being requ�steq, not the De0artment of
ludustrial,Accidenis. �hould you have any' questions regarding the law or if you are req*ed to obtain aw—&-kOrS'
compensati&i'policy, please call the Department at the number listed below. Self-insured companies sl��iiid enter their
self-iusurahc'e license number on. the appropriate lind.
City or Town Offalcials
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 ofInvestigations has to contact you regarding the applicant.
Please be sure to Ell in the permit/license number which will be used as a reference number. In addition, an Applicant
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy frif6rinatioii (ifniecessafy) and under "fob Site Address" the applicant shouldwrite ffall locations in � 6 (City or
ioym)." A copy ofthe affidavit that has been officially stamped or marked by th'e cit� or to�m. ihay be �r6ided to the
applicant as proof that a valid affidavit is on Me for future permits or licenses. Anew affidavit mustbe filled out each
year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture,
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
1he Department's address, telephone and fhx number:
T�;e'Commonwoalth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, AM 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE
Fax # 617-727-7749
Revised 02-23-15 wwwmass.gov/dia
GENES4 OP ID: NB
."%4C4r__>NCr
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDYYM
1 0311112016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA71ON 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 CER71FICATE 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]L
PRODUCER
Planright Insurance -Salem
224 Main Street Suite 3C
Salem, NH 03079
James A Santo
CONTACT
NAME: James A Santo
PHONE. -890-6439 (FAAI'C. No): 603-890-6521
WC. No Exti: 603
E-MAIL
ADDRESS: jam ieo_santoinsurance.com
INSURER(S) AFFORDING COVERAGE NAIC I
INSURER A: Tudor Insurance Company
NPP8274856
INSURED Genesis Builders LLC, GIO
INSURER B: Peerless Insurance Company 24198
Realty LLC, GIO MO Properties
40 Lowell Road
INSURER C:
INSURER D:
Salem, NH 03079
.INSURERE:
INSURIER F
E;0VI=HAEilE5 CIERTIFICATIF NUMRFR- Rl:vl-qlnkl KIIIII1111mrow
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 CONDIT`ION 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,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
AULL
5LUSH
POLICY NUMBER
POLICY EFF
(MMIDDNYYY)
POLICY EXP
(MMIDDrYYYY)
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE T OCCUR
NPP8274856
01108/2016
01/08/2017
EACH OCCURRENCE $ 1,000,000.
_15�
PREMISES (Es occurrence) $ 100,000
MED EXP (Any one person) $ 5,00C
PERSONAL & ADV INJURY $ 1,000,00(
GEN'L AGGREGATE LIMIT APPLIES PER:
RO
POLICY0 PJECf LOC
GENERAL AGGREGATE $ 2,000,00(
PRODUCTS - COMP/OP AGG $ 2,000,00(
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident) $
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
—15ROPE—RTY
S NON -OWNED
HIRED AUTO AUTOS
DAMAGE
(Per accident) $
UMBRELLA LIAB
HOCCUR
EACH OCCURRENCE $
EXCESS LIAB
CLAIMS -MADE
AGGREGATE $
DED I I RETENTION$
$
WORKERS COMPENISATI ON
PS7ATUTE
AND EMPLOYERS'LIASILITY YIN
ANY PROPRIETORPARTNERiEXECUTIVE
OFFICERtMEMBER EXCLUDED? El
NIA
I I
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
(Mandatory In NH)
If yes, describe under
I EL_ DISEASE - POLICY LIMIT s
IDESCRIPTION OF OPERATIONS below
I
B
Equipment Floater
BM0566 7579
04/17/2015
U,
ased 11,890
I
Equipment
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks SchedtAs, may be attached If more space Is required)
&99 zF.41 I UR OR -A 1:11111; 101 N 91:1 Z
W I VUV-ZU1 4 ACORD COR PORATION. All rig his reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELWERED IN
Town of North Andover
ACCORDANCE WITH THE POLICY PROVISIONS.
1600 Osgood St
North Andover, MA 01845
AUTHORIZED REPRESENTATIVE
W I VUV-ZU1 4 ACORD COR PORATION. All rig his reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
GENES -4 OP ID: NB
144117CPHLY
l6ft� CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
1 0311012016
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 pollcy(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'
Planright Insurance -Salem
224 Main Street Suite 3C
Salem, NH 03079
James A Santo
CONTACT
NAME: James A Santo
FAX
PH07 (AIC, No): 603-890-6521
(AIC No, Elt): 603-890-6439
-MAIL
E DDREss: jam ie@santoinsurance.com
INSURER(S) AFFORDING COVERAGE NAIC I
INSURERA: Tudor Insurance Company
NPP8274856
INSURED Genesis Builders LLC, GIO
INSURER B: Peerless Insurance Company 24198
Realty LLC, GIO MO Properties
40 Lowell Road
INSURER C:
INSURER D:
Salem, NH 03079
INSURER E:
INSURER F :
COVERAGES CERTIFICATE NUMBER: 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 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
-POLICIES.
TYPE OF INSURANCE
AUL)LISUBR
INSD
WVQ
POLICY NUMBER
PO
(MMILICY EFF
DDIYYYY)
POLICY EXP
(MMIDDIYYYY)
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE FRI OCCUR
NPP8274856
01108/2016
01108/2017
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence) $ 100,000
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY F JPE'CT F—] LOC
GENERAL AGGREGATE $ 2,000,000
ODUCTS- COMPIOP AGG $ 2,000,000
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
(Ea accident�
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE
(Per accident) $
$
UMBRELLA LIAB
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE $
EXCESS LIAB
AGGREGATE $
DED I I RETENTION$
$
WORKERS COMPENSATION
H_
PTATUTE
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNERIEXECUTIVE
OFFICERIME BER EXCLUDED?
NIA
11 EORI
E.L. EACH ACCIDENT $
E.L. DISEASE- EA EMPLOYEE $
(Mandatory IMn NH)
If yes, describe under
E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
B
Equipment Floater
BM056667579
04M7120115
04/17/2016
Leased 11,890
Equipment
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Shaheen, Guerra & O'Leary, LILC & 820A, LILC are included as additional
insured on General Liability when required by written contract.
CERTIFICATE HOLDER CANCELLATION
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Shaheen, Guerrera & O'LearyLLC
ACCORDANCE WITH THE POLICY PROVISIONS.
820 A, LILC
AUTHORIZED REPRESENTATIVE
820 A Turnpike St
North Andover, MA 01845
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
t
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS -077258
Construction Supervisor
THOMAS A GIOSEFFI
P.O. BOX# 1016
SALEM NH 03079
�-Jzz-'Z- &— Expiration:
Commissioner 03/13/2018
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office or consumer Affakirs & Business Regulation
AOME IMPROVEMENT CONTRACTOR
` '',114640 Type:
!-�37k&7.
.–I'V �V�' Individual
THOMAS A.
THOMAS GIOSEM-7�
kA,
L40 LOWELL RD UNIT
S L M 0 9
SALEM, NH 03079
Undersecretary
9
"O'Construction SuPervisor
Restricted to:
Unrestricted - Buildings of any use grouP which contain
less than 35 000 cubic feet (991 cubic meters) of
enclosed sl��ce.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
DIPS Licensing information visit: WWW-MASS.GOV/DPs
License or registration valid for individuluse only
nd returnto*
before the expiration date- If fou Regulation
r Affairs and Business
Office of Consume te 5170
to park Plaza - sui
Boston, MA 02116
Not valid wi Out sitnat re.