HomeMy WebLinkAboutBuilding Permit #808-15 - 864 WINTER STREET 4/15/2015u
LF TOWN OF NORTH ANDOVER
`Y APPLICATION FOR PLAN EXAMINATION
Permit NOco�—~ ) r Date Received
Date
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9
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I IMPORTANT: Applicant must complete all items on this Daize I
LOCATION�o � �9 e n�ef' ��
\ Print
PROPERTY OWNER
a I --f% Print
MAP NO.: 1 "—I PARCEL:
TYPE AND USE OF BUILDING
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving relocation
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Identification Please Type or Print Clearly)
OWNER: Name: W.�, Phone: i
CONTRACTOR Name:
Address: P 6 Q)
P
� a
Supervisor's Construction License: �.. �C�d`a.� Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address:
Reg.
FEE SCHEDULE: B ULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST ASED ON $125.00 PER S.F.
Total Project Cost :$ `f< O81) x12.00=FEE:$ `
Check No.: Receipt No.:
Page ] a 4
i
Plans Submitted ❑
1
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TypF., " F SEWERAGE DISPOSAL
P��blic 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 Reviewed On Signature.
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
s _
4 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
4
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
"JDPW Town Engineer: Signature:
rr�rt�1�1Y1C1Y�►1
�124,iMaln:St�ee1„
Located 384 Osgood Street
coni site dyes �� sno
Dimension
Number of Stories: Total square feet of floor area, based on Exteror_:dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop require s:approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Building Permit Revised 2014
t
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
I
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
❑ 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 V o 4_.
fJ
No. 4 Date4fl
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $"�
Foundation Permit Fee $
Other Permit Fee $ _
TOTAL $
Check #2\
2 6 4 `°� Building Inspector
March 4, 2014
Town of North Andover
Town Hall
North Andover, MA 01845
Building Commissioner or
Inspector of Buildings
Policy:
HP0195932
Insured:
Douglas & Teckla Moulton
Loss Locations:
864 Winter Street
Date of Loss:
January 10, 2014
File No.:
C44P-14-6856CM
447 Boston Street, Suite 9
Topsfield, MA 01983
(978)887-8112
FAX (978) 887-8113
Craig McDonald / Owner -Operator
Board of Health
Board of Selectmen
A claim has been made involving loss, damage, or destruction of the above captioned property
which may either exceed $1,000.00 or cause Massachusetts General Laws CH. 143 Sec. 6 to be
applicable. If any notice under Massachusetts General Laws CH. 139, Sec. 3B is appropriate,
please direct it to the attention of the writer and include a reference to the captioned insured,
location, policy number, date of loss, and claim file number.
CAW# JIU)"taW
Claims Representative
On this date, I caused copies of this notice to be sent to the persons named above at the addresses
indicated above by first class mail.
March 4, 2014
Date
Main Office: 447 Boston Street, Suite 9; Topsfield, MA 01983 (978) 887-8112 0 (978) 887-8113 FAX
Boston, MA • Boston / Lynn, MA
Gloucester / Beverly, MA • Framingham, MA • New Bedford / Fall River, MA
Providence, RI • Cranford, NJ • Toms River, NJ • Philadelphia/Bensalem, PA
Shenandoah, PA • State College, PA • Williamsport, PA • Winston-Salem, NC
Date .... z-.
0 TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .............. W ...... 4 A'0'1>F ......................................
h a ipoe 9 &s s i o�t'tlplkfo r m .....
wiring in the building of ......M A Q kJ -P. 'U ..................................................
at .... R6. 4( C'
....................... . .
— 61.Norh Ando
ver, Mass.
Fee.jLic. No.�p7.................. . ....�.
LECTRc�L INSPECTOR
Check #
0664
1'
W
Commonwealth of Massachusetts Official Use
/Only
/
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(E�), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: (l i y l Z -
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant Db U e
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes ❑ No F1 (Check Appropriate Box)
Purpose of Building 6 -mg== Utility Authorization No.
Existing Service Amps , ZO / Volts Overhead g Undgrd ❑
New Service Amps / Volts Overbead ❑ Undgrd ❑
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work:T '
ti
aiYl"f�bL�n`�tl-
Com letion o the ollowin table ma be waived b the Ins ector o Wires
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- El
rnd. rnd.
o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiatin Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat PumpNumber
Totals:
Tons
- •........... "
KW
......"•
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters'
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such co'erage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.:
Licensee: �odt"r�l� ay+tiaCbAg Signature LIC. NO.: Z F
(Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: gni % %moi
Address: I
Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
_ EI,ECTRTCAL PERMT NO. INSPECTxONREPORT:
_ ELECTMAL IN•SPEC'z'Op, s _
Passed--:[_ I Failed - [ j Re -inspection requiurecY ($50.00) •- [ j
Xnspectors' comments:
(Xusp ectors' Signature •- no inztxals) Date
2. FINAL INSPECTION!
Passed — Failed—[ ] . Reinspection required ($50.00) •- [ r
Inspectors' c mmenfs:
`"tel vi
e ectors afore •- no inftiaTs) Date
3. UNDER G OUND INSPECTION:
Passed— [ ] Faifed— [) Re -inspection required ($50.00) •• [
Inspectors' c mments:
(Inspectors' Signature- no Htfafs) Date
D ® OR TAGS .ARE TO BE FILLED OUT AND LEFT ON SHE 7F THE AREA. TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE INSPECTION OF L50A0 IS TOM CHARGED. -
The Commonwealth of Massachusetts - -
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): b\,l, ,11 i a. A %I C` -c a."1 -6—
Address: ',3 7 J`% a C) b C,; 'D �5 `--
City/State/Zip: L , �, <c r rN e, t A) IL Phone #: � 7 9--- 3 7 S 7 � lZ
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
_/employees (full and/or part-time).*
have hired the sub -contractors
2. I am a sole proprietor or partner-
listed on the attached sheet. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. [f 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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:, T,4 5yTY- hG-e—
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
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 the pains aJyd penalties of perjury that the information provided above is true and correct.
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 #:
l�
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
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 61.7-727-7749
www.mass.gov/dia
TYPE OF SEWERAGE DISPOSAL
Tanning/Massage/Body Art F]Public
Swimming Pools 11❑
Sewer
Well F1Tobacco
Sales ❑
Food Packaging/Sales 11
F1
Permanent
Permanent Dumpster on Site ElPrivate
(septic tank, etc.
Meter location to
project
NOTE: Persons contracting wi h unregiSterd contractors do not have access to the guaranty fund
Signature of Agent/Owner ;/,QSignature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION11
COMMENTS
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
❑ Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE REJECTED
DATE REJECTED
11
Comments
Comments
71
DATE APPROVED
DATE APPROVED
Water & Sewer connection/Signature & Date Driveway Permit
Temp Dumpster on site yes—no— Fire Department signature/date
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VI
Perry Brothers Construction Contract
www.perrybrothersconstruction.com
Fully License and Insured Date
SER4r1 r- r
ry
LIC.# 022831 HIC.# 108292 04/10/15
Estimate No.
17
P.O. BOX 646
Newburyport MA 01951
T: 781-233-7511
F: 978-465-0929
E:perrybrothersconstruction@gmail.com
Description
* Described work: Bedroom 13'x13'
* Gut exterior wall down to studs
* Gut ceiling down to studs
* Remove existing insulation
* Spray walls and ceiling with shockwave mold disinfectant
* Change electrical outlets damaged by water
* Re -insulate walls and ceiling
* Blue board and skim coat with plaster
* Install new window and base trim
All permits and inspections performed by contractor
- Certificate of insurance to be issued to owner
- One year gaurantee on workmanship
- Warranties on products to be provided by contractor
- Remove all debris
Name/Address
Adam Clark
864 Winter St
North Andover 01845
T: 978-685-0350
E: aclark@aceticket.com
Total
TOTAL STOCK AND LABOR - $2,300.00
ELECTRIC - $600.00
CARPENTRY - $500.00
10% OVERHEAD - $ 340.00
10% PROFIT - $340.00
TOTAL - $4080.00
We propose hereby to furnish materials and labor - complete in accordance with
above specifications,
for the sum of: Four Thousand Eighty 0/100 Dollars
Payment to be made as fol,6ws: $2,220.00 $1,860.00
Rightfax N3-1 4/8/2015 7:31:51 AM PAGE 2/002 Fax Server
"�"�"M CERTIFICATE OF LIABILITY INSURANCE DATE (LINDD/YYYY)
�'
T , TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPONTHE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE
ORP OD C R AND E CE F C E OLDER -
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polley(les) must be endorsed, if SUBROGATION IS WAIVED, subject to the
erms 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 endorseme s .
PRODUCER
CONTACT
NAME:
PRESS BATEMAN & TURNER I
460 TOTTEN POND RD STE 630
PHONE
(AfF Nc, Ext):
pAX
WALTHAM, NIA 02451
E-MAIL
ADDRESS:
22W3L
INSURERS) AFFORDING COVERAGE NAIC #
INSURED
PERRY BROTHERS CONSTRUCTION INC
INSURER A:'1RAVELBRSPROPMnyCASUALTYCOMPANY, 0FAMERtCA
INSURER B:
INSURER C:
PO BOx 646
INSURER D:
NEWBUR YPORT, MA 01950
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. NOTWlTHSTANDNG
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OA OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE NSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS
INSR
LTR TYPE OF INSURANCE
ADD
L
SUB
R
POUCYNUMBM
POUCYEFFDATE
(MMIDDIYYYY)
POUCYEXPOATE
(k4diDD%YYYY)
LIMITS
GENERAL UABIUTY
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $
DAMAGE TO RENTED $
PREMISES (Ea Occurrence)
CLAIMS MADE OCCUR.
H�
ED EXP (Anyone person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
ENERALAGGREGATE $
POLICY PROJECT ❑ LOC
PRODUCTS-COMP/OPAGG $
AUTOMOBILE
LIABiLrN
ANY AUTO
ALL OWNED AUTOS
SCHEDULE AUTOS
MMSINED$INGLE $
LIMIT (Ea accident)
BODILY INJURY $
(Per person}
HIRED AUTOS
BODILY INJURY $
NON -OWNED AUTOS
(Per accident)
PROPERTYDAMAGE $
(Per accident)
UMBRELLA UAB
EXCESS LIAR
OCCUR
CLAINSNADE
EACH OCCURRENCE S
AGGREGATE $
DEDUCTIBLE
$
RETENTION S
$
A WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY YIN
ANY PROPEWTORIPARTNEWEXECUTIVE
OFFICEWMEMBER EXCLUDED?
(Mandatory In NN)
if yes, descry under
NIA
US-024OMS85-14
09114MO14
09/14/2015
X WC STATUTORY OTHER
LIMITS
E. L EACH ACCIDENT $ 300,000
E.L. DISEASE -EA EMPLOYEE $ 600,000
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICYLIMfr S 600,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTMCTIONS/SPECIAL ITEMS
THIS RHPLACES ANY PRIOR 01RTIRCATE LTSUBD TO THP CER7MCATE NOLDPR AFFECTING WORKERS COMP COVBRAGE.
CERTIFICATE HOLDER CANCELLATION " r
TOWN OF IPSWICH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
25 GREEN STREET BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
IPSWICHMA 01938 AUTHORIZEDREPRESENSf,�VE
�` �`•�x,
•
ACORD 25 /2nin/n51 Tha dflSRr1 h ,e �. , r - - -- -^^ ^ --^ n
-•- »oo-cVruiawnuuvnrvxRUUN. All rlghtsreserved.
ACORD,. CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDIYYYY)
TYPE OF INSURANCE
04/08/2015
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(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
Press, Bateman & Turner
460 Totten Pond Rd, suite 630
Waltham, MA 02451-1965
NAME:
PHONE (781)890-0050
AIC, No Ext): qIC, No 4(781)890-11
ADDRESS,
INSURER(S) AFFORDING COVERAGE NAIL 0
Ip with, NA 01938
INSURERA; Western World
INSURED Perry Brothers Construction, Inc.
P 0 Box 646
Newburyport, MA 01950
INSURER B: Safety
INSURER C :
INSURER D:
A
INSURER E.
INSURER F:
• —1-11 11 V IYI W Cr%.
THIS 1S TO CERTIFY THAT THE POLICIES OF IN SURANCE 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.
LTR
TYPE OF INSURANCE
INSR
I WVD
I POLICY NUMBER
MM/DD
MMIDD
LIMITS
25 Green Street
GENERAL LIABILITY
Ip with, NA 01938
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE -MADE I OCCUR
NPP 8201246
09110/2014
09/1012015
EACH OCCURRENCE $ 1,000,000
ISES
PREMocaurence) $
MED EXP (Anyone Parson) $ 5,000
PERSONAL BADV INJURY $ 1,000,000
GENERAL AGGREGATE s 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POUCYF—j jEI7 LOC
PRODUCTS -COMPIOPAGG $ 1,000,000
$
B
AUTOMOBILE
LIABILITY
ANYAUTO
ALL OWNED X SCHEDULED
AUTOS AUTOS
3003590
05/12/2014
06/12/2015UMB't``lFA
$ 1,000,000
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
X
HIRED AUTOS X NON-0WNED
AUTOS
Per accident)$
$
UMBRELLA UAB
EXCESS LIA6
HOCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED I I RETENTION $
WORKERS COMPFNSATtON
AND EMPLOYERS' LIABILITY \, /N
ANY PROPR]ErORfPARTNERIEXEcvnvoE.L.EACH
OFFICERIMEMBER EXCLUDED?
$
A
TORY LM I I ER
NIA
ACCIDENT $
(Mandatory In NH)
tFyyeess,, describe under
E.E.L.DISEASE - EA EMPLOYE $
E.L. DISEASE- POLICY LIMIT S
OESCRIPTiONOFOPERATIONS below
DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
r•corinrwrr unl nr� _ _ _ _ ___ _
W Tvaa-X.ully ALrUKt7 L:;WKPORATION. All rights reserved.
ACORD 25 (2010/05) 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 WILLBE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town Of Ipswich
AUTHORIZED RERES NTATIVE
25 Green Street
Ip with, NA 01938
W Tvaa-X.ully ALrUKt7 L:;WKPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD