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HomeMy WebLinkAboutBuilding Permit #226-13 - 86 Second Street 9/20/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:7� I Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION JI GL< l a/bE fZ= 0 QQ SC-6n V*6 51 AC)0 714 AAALL- C . .w-Pfint PROPERTY OWNER bf.! Print 100 Year Old Structure yesnno MAP N04 9 PARCEL�3 ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ['rwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial it Aepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: �a Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: AM b�j +z,,4&J ,i ..- Phone:q ??— g lop — Mz� Address: Supervisor's Construction License:Cs 05�5Exp. Date: Home Improvement License: 402-01 Exp. Date: Lo IZ-o I 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: $ ` �P �� FEE: $ 14o. Check No.: Receipt No.: Z� �-- NOTE: Persons contracting with unregistered contractors do not have access to the u y and s Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stampe ns Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales El Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on — Si nature A A,94 COMMENTS / HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit i DPW Town Engineer: Signature: Located 384 Osciood 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.$10041000 fine NOTES and DATA— (For department use El Notified for pickup - Date Doe.Building Permit Revised 2010 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 o Building Permit Application Li Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) Li 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 a 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) o 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: Doc.Building Permit Revised 2012 Location is rn UI �J No • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ 7 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �' Check#/ 25732 Building Inspector NORTH oven of ndover No. -174j�S -IF i �: oh ver, Mass, . �A COCHICKEWICu`y1 �d 04;?ATEO S 1, v BOARD OF HEALTH PER I' Food/Kitchen .T D Septic System THIS CERTIFIES THAT ......... BUILDING INSPECTOR ..... .L................. . .... ................................................ . Foundation has permission to erect . .......... bui/sh son .. ....... ......... . ...... ..... .. ......:.. �...�,..,........ Rough ...� ..... .... ....... to be occupied as ........... . ., .................. .........:...... .... .......... ........ Chimney provided that the person accepting this permi in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MftTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TA Rough Service ................ ............................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No-Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE North Andover MIMAP 84/86 Second Street September 20, 2012 / d M01 in.Street I N. Awkk Interstates Interstate Major Roads Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack Ci EasementsNORTH Valley Planning Commission(MVPC)using data provided by the Town of pf f Lip , �, North Andover.Additional data provided by the Executive Office of C3 MVPC Boundary ? ��t ���pp Environmental Affairs/MassGIS.The information depicted on this map is L3 Parcels 3 L for planning purposes only.It may not be adequate for legal boundary F p definition or NO WARRANTIES, XPRE THE TOWN LI NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING K # THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION ,SSACHUg� 1"=76ft .�. North Andover Board of Assessors Public Access Page 1 of 2 NpinN North Andover Board of Assessors E MATCHING PARCELS 'sSClick on a column title to sort data by that column Click Seal To o Return 34 items found,displayinigall items.1 Fiscal Year Parcel ID St.No. Street Owner Name 2012 210/030.0-0005-0000.0 0 SECOND STREET NORTH ANDOVER HOUSING AUTHORITY, Search for Parcels 2012 210/030.0-0003-0000.0 11 SECOND STREET FAY,EUGENE, 2012 210/030.0-0007-0000.0 14 SECOND STREET BARTKIEWICZ,CHERYL, Search for Sales 2012 210/030.0-0036-0000.0 19-25 SECOND STREET THORNTON,JUNE G, 2012 210/030.0-0028-000O.A 26 SECOND STREET SLEATOR,SHEERA, 2012 210/030.0-0037-0027.0 27 SECOND STREET LA MOUNTAIN,LISA M., 2012 210/030.0-0028-0000.13 28 SECOND STREET MCCOY,JOANNE&SCOTT, 2012 210/030.0-0037-0029.0 29 SECOND STREET NICOLOSI,RYAN J., 2012 210/030.0-0029-"0.0 32 SECOND STREET MATHESON,HELEN, 2012 210/030.0-0027-0000.0 34-38 SECOND STREET NORTH ANDOVER SECOND STREET LLC, 2012 210/030.0-0026-0000.0 40 SECOND STREET LOOSIGIAN,LISA,AREK KALAYDJIAN 2012 210/030.0-0035-0000.0 41 SECOND STREET EVERHOME MORGAGE COMPANY,C/O GENE ESPINOLA 2012 210/019.0-0003-0000.0 45 SECOND STREET RAADMAE,CATHERINE M, 2012 210/030.0-0025-0000.0 50L-12 SECOND STREET JOYCE REALTY TRUST,JUSTINE M JOYCE TRUSTEE 2012 210/019.0-0004-0000.0 53 SECOND STREET SALINAS,MANUEL,SANDRA SALINAS 2012 210/019.0-0005-0000.0 57 SECOND STREET DUBOIS,PAUL A,ROBIN L DUBOIS 2012 210/019.0-0009-0000.0 64 SECOND STREET STARR,THOMAS M.,STARR, CHRISTOPHER 2012 210/019.0-0006-0000.13 65 SECOND STREET DOHERTY,RHONDA SUE,DOHERTY, PETER M. 2012 210/019.0-0026-0000.0 75 SECOND STREET LICCIARDI,JOHN R,LUCY A LICCIARDI -�� 2012 210/019.0-0038-0000.0 84 SECOND STREET BROOKS,WILLIAM F&REGINA M BROOKS,DANA C HALL&ERIN A HALL 2012 210/019.0-0039-0001.0 88 SECOND STREET GUERTIN,SEAN, 2012 210/019.0-0039-0002.0 90 SECOND STREET MORIARTY,DANIEL A, 2012 210/019.0-0027-0000.0 9193 SECOND STREET RASKOW FAMILY REALTY TRUST, RASKOW,THOMAS TRUSTEE 2012 210/019.0-0028-0000.0 95 SECOND STREET PIACENTINI,EUGENE, 2012 210/019.0-0040-0000.0 96 SECOND STREET DUDNEY,ROLAND A.,DUDNEY, MELISSA A. 2012 210/019.0-0029-0000.0 99 SECOND STREET LAMBERT,RICHARD A,BONNIE L LAMBERT 2012 210/019.0-0032-0000.0 100 SECOND STREET SALIB,ADEL S, 2012 210/019.0-0030-0000.0 103 SECOND STREET HOLLAND,DAVID, 2012 210/019.0-0031-0104.0 104 SECOND STREET CARTER,DANIELLE,NEVIUS,PETER 2012 210/019.0-0031-0106.0 106 SECOND STREET AMOR JR,EDWARD J,CYNTHIA AMOR http://csc-ma.us/PROPAPP/newSearch.do?town=NandoverPubAcc&from=NewSearch 9/20/2012 OW Proposal A.L. CORNELLIER Property Care & Construction Co. 3 Chard Road Tyngsboro, Ma 01879 978-490-7716 AL.Corn@comcast.net Construction Supervisors License#055341 / Home Improvement Contractor Reg#140298 Proposal Submitted To: Date: September 7,2012 Hall Residence Job Name: Porch Renovation 86 Second Street North Andover,Ma ATTN: Erin/Dana Cell 978-239-2665 E-Mail Erindana2l@msn.com As discussed,we hereby propose to do the following installations & renovations to the home at 86 Second Street in North Andover Ma. Project. Demolition/Footings/Framing/Decking Scope: • Remove & dispose of existing screen room & storm door • Erect temporary supports under existing roof • Demo & dispose of existing frame • Jack hammer old footing& remove sections where new footings will be installed • Install four(4) 10 inch footings to 48 inches below grade using high strength concrete • Furnish & install structural post bases • Frame porch deck using 2x8 pressure treated timber 16 oc • Build new stairs • Furnish & install 4 -6x6 posts to support roof structure • Furnish & install Everex Composite Decking (color grey) using colored head coat fasteners Project. Harvey Screen Room Scope: • Furnish & install a Harvey aluminum wall enclosure wall system • Enclosure to be color(white) enamel finish • Screen only(no glass) • Outswing operating door r Project. Trim/Finish Scope: • Furnish & install azek trim boards &white composite lattus over all wood exterior exposed wood framing. We Propose herby to furnish the labor& materials for the above as listed below. Labor 5,699.00 Material 5,487.88 Permit 150.00 Dumpster 300.00 Total Proposal $11,636.88 **Project schedule: - start the week of September]7th /end no later than October24th"'2012 **All construction debris removed from site&project to be kept clean daily **Screen room to be ordered after framing/decking—screen encloser fabrication has a two (2) to three (3) week lead time **Invoices to be submitted at project completion Note: Exclusions/Items not included in this proposal at this time: • Unforeseen condition with regard to rotted wood • Unforeseen conditions with regard to mold & mildew • Interior paint • Electrical/Plumbing / • Any work not specified above • Exterior/Interior Paint "Note,footings/excavation,we have carried up to 8hrs for two men to install four (4) footings,if more time is required due to subsurface obstructions work will continue at an additional cost not to exceed 35.00/man/hr until completion. Note—all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza,Suite 5170 Boston,Ma 02116 Phone(617)973-8700 ONE THIRD(1/3)OF PROJECTS TOTAL IS REQUIRED AT THE START WITH THE SECOND 312D AFTER DECKING INSTALLTION WITH THE BALANCE DUE UPON PROJECT COMPLETION. All material is guaranteed to be as specified for the term of one year. All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviation from the above specifications involving extra cost will be executed only upon written orders to be documented in the contract addendum,and will become an extra charge over and above the estimate at a rate not to exceed$70.00/hr All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary in rice. Authorized Signature: Acceptance of Proposal—the above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified and execute any related permits. Payments will be made as outlined above. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Signature c �. Signature Date of Acceptance 040 The Commonwealth of Massachusetts 1 Department of Industrial Accidents � i Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.g ov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Letribly Name(Business/Organization/Individual): t 4i pQ � CAP—& Address: � )k Lf q _. 7'71 6 1 City/State/Zip: b 01&71Phone #: . i Are you an employer?Check the appropriate box: Type of project(required): 1.QUI am a employer with 5 _ 4, ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on.the attached sheet.t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition. working for me in any capacity, workers' comp. insurance. q. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL i 1.❑ Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t .employees. [No workers' 13.0 Other comp. insurance required.] Any applicant that checks boz It 1 must also filI 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the t 's policy and job site information. Insurance Company Name: j if-4)i C&k r— Policy#or Self-ins. Lsc.#: tJ l{( Expiration Date: ZC`v� :ZE ' Job Site Address: � City/State/Zip:Anj2ii4 &--bow-49 m4 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 e. 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 forth 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 ve 'fication. I do hereby certify under the ins and n toof perjury that the information provided above is true and correct Signature: Date: Phone#: -- ® ,r �Ag Qf)rlcial 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#: Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Super%isor License: CS-055341 "`` ANDREW E CORNELLIER-91 3 CHARD RD = G t; �. TYNGSBORO MA 01879 : ,., FX piraVon y corrumissioner 08/28/2014 r ��ie Vanvrreom�uPa/C�a a�-� 'Qd '�`4e License or registration valid for individul use only Office of Consumer Atfairs&B smess Regulation —=- T CONTRACTOR HOMEIMPROVEMENT before the expiration date. If found return to: Type: Office of Consumer Affairs and Business Regulation `= Registration: 140298 10 Park Plaza-Suite 5170 Expiration: 10%1/2013 DBA Boston,MA 02116 A... CORNELLIER PROPERTY CARE&CO. ANDREW CORNELLIER 54 SAYLES ST. �a</�� ' -- __ ----- –--- LOWELL,MA 01851 Undersecretary of valid out si ature Ro® CERTIFICATE OF LIABILITY INSURANCEa E(MWDD ern 21/20 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 CONTACT Maria Nixon NAME: Strategic Resource Group PHONE (781)246-9002 FAC No):(781)246-9007 27 Water Street, Suite 107 EODRLS:mnixon@strategieresourcegroup.net INSURERS AFFORDING COVERAGE NAIC# Wakefield MA 01880 INSURERA:Travelers INSURED INSURER B: Cornellier, Andrew DBA: A.L. Cornellier INSURERC: Property Care & Construction Co. INSURER D: 3 Chard Road INSURER E: ITyngsboro MA 01879 INSURER F: COVERAGES CERTIFICATE NUMBER:CL11111500237 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lLTR TYPE OF INSURANCE POLICY NUMBER MADDLSUBR M/DD/YYEYYY FF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 )AMAGEX COMMERCIAL GENERAL LIABILITY PREMISESOEa OccurrRENTEence) $ 100,000 A CLAIMS-MADE a OCCUR 6808A712460 0/29/2011 10/29/2012 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY 7 PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident L $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N o Follow Directly from E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) Company E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Dana Hall ACCORDANCE WITH THE POLICY PROVISIONS. 86 Second Street North Andover, MA AUTHORIZED REPRESENTATIVE Jody Crowther/MAN ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25 oninna)ni Thu annp l noma and Inn^nru mniafururl mnrlra of Ar npn Rightfax N1-2 8/23/2012 5:45:47 AM PAGE 2/002 Fax Server v CERTIFICATE OF LIABILITY INSURANCE DATE(MM QF;992-YY) 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 REPRESENI&M OR PRODUCER AND THE CER FICA HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed. K SUBROGATION IS WANED,subject to the terms 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: STRAIEGIC RESOURCE GROUP PHONE FAX 27 WATER ST STE 107 (A/C,No,fid): (A(C,No): E-MAIL WAKEFIELD,MA 01880 ADDRESS: 77YDL INSURER(S)AFFORDING COVERAGE NAI INSURER A: ACE AMERICAN INSURANCE COMPANY INSURED CORNELLIER,ANDY DBA A L CORNELLIER PROPERTY CARE INSURER B: INSURER C: INSURER D: 3 CHARD ROAD INSURER E: TYNC SBORO,MA 01879 INSURER F.- COVERAGES :COVERAGES CERTIFICATE NUMBER: REVISION NUMBEIL I" ISMANCE LISTED HAVEBEEN ISSUED TO THEINSURED KAM ARMEFORTHEPOLICYTED. NOTWRHSTANONG ANY REQUQtEIENT.TERM ORCONDITION OF ANY CONTRACTOR OTHER DOCUMENTWITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAW CLAIMS_ INSRADO SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY XUMBER (MMIDDIYYYY) (RIADDIYYYYI Laos GENERAL LIABILITY ACH OCCURRENCE g r COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED 5 CLAIMS MADE r7 OCCUR. EMISES(Ea occurrence) VOISONAL EXP(Any one person) $ &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. ERAL AGGREGAT E $ POLICY Q PRO,.ECT LOC DUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY OVIRNED SINGLE $ ANY AUTO IMIT(Ea accident) AI L OWNED AUTOS OD LY INJURY $ Per person) SCHEDULE AUTOS HIRED AUTOS Perer aINJURY $ accident) NON-OWNFID AUTOS ROPERTY DAMAGE $ Per accident) UMBRELLA LIAR OCCUR ACH OCCURRENCE $ EXCESS LIAB CLAWS-MADE EGGRECATE $ DEDUCTIBLE $ RETENT ON $ $ A WORKER'S COMPENSATION ANDX WC STATUTORY OTHeR EMPLOYER'S LIABILITY YJN UB-4817P873-12 04!2812012 04/26/2013 LIMITS ANY PROP ER'TORIPARTNER(EXECJTNE YNIA E L EACH ACCIDENT $ 100,003 0 FICERIVEMBER EXC;'UDED? (rdandtlory In NH) E.L.DISEASE-EA ENPLOYEE S 100,000 I!yes,describe urder E.L.DISEASE-POLCY UV.IT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATION (LOCATIONSNEHICLESIRESTRICTIONSISPECIAL ITEMS TMS REPLACES ANY PRIOR CERTIFICATE:SSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORLERS'COMPENSATION POLICY I)OES NOT PROVIDE COVERAGE FOR CORNEI.LIER,ANCY. CERTIFICATE HOLDER CANCELLATION DANA BALL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL 8,9 DEL 86 SECOND ST IN ACCORDANCE WITH THE POLICY PROV AUTHORIZED REPRESENTATIVE NORTH ANDOVER,MA 01845 ,ACORD 2S(2010105) The CORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPO ngh 5 e erved. r A _47! 1 7 -- + - --- I- f - i -- I - I I -t- 7 j --i 41 F- T_ J-1 1 -------------- T__L -L_J ------ .......... L L no -I-- I I + —---I — --- — ----�---� I I I I o I { I � i i i j i I IL_iL -L-1-_L_-j'Ll-------1_4 .L I , t — i I - — i ! 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