Loading...
HomeMy WebLinkAboutBuilding Permit #707-2016 - 9 COBBLESTONE CIRCLE 12/9/2015�C�/�r�•��-D /,) -16 -/,3- Permit No#:_ Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER �J,�IAPPLICATION FOR PLAN EXAMINATION v "1y Date Received IMPORTANT: Applicant must complete all items on this y ttyev �bv •�O\ �of.� LOCATION DI S %aN .12- w N 4 00/6te— / 019 F'rin PROPERTY OWNER ri�T=2/= /P +4 M. , ddAA)A)J,A)�- -� r Ffrint 100 Year Structure yes no MAP PARCEL: t5 ZONING DISTRICT:_ Historic District yes ap Machine Shop Village yes, o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑``Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: a Identification - Please Type or Print Clearly OWNER: Name: NJ&r—F2F_!/ /4AA)MA r Phone: Address: Contractor Name: AAJJ Address: Phone Supervisor's Construction License: Exp. Date:,3/;�' Home Improvement License: r'1/TS4/ Exp. Date:L" ARCHITECT/ENGINEER Phone: - Address: 1 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: $�Dd FEE: $ Check No.: � Receipt No.: NOTE: Persons contractingw re istered c6 tractors do not have access to the of fwd ;� V` !// Sianature of Aaent/Owner4?W/, 4-` "—/_/Ijignature of contractor F Location%��f'`T>1C� No. ` 61-1 () �0 Date 12 05 Check # 2; / 98 TOWN OF NORTH ANDOVER 1 01 Certificate of Occupancy $ Building/Frame Permit Fee $,(, Foundation Permit Fee $ Other Permit Fee $ TOTAL $ I/ wilding Inspector Plans Submitted ❑ Plans Waived. [I Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/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 iti'�.�� Signature_ COMMENTS a CONSERVATION Reviewed on t 2" � — ( , COMMENTS r'4 0A) HEALTH COMMENTS S Reviewed on Signature a 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 DPW Town Engineer: Signa Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on safe yes Located at 1244 Main Street Fire Oepartment signature/date COMMENTS _ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) 12dI ❑ 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 ❑ Bu,ilding 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 ❑ Cert 'ified 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 51i = J O O U O VW W L=I. o O m U Y \ O LL N v+'i N U O N w0CL Z Z m c O "6 O LL i O W C E U LL Z Z d C bA �' 11 a Z V u LY C to U N LnLL C O0 W N Z 0 wLL .L a LU 0 LU �- C m Z H ++ cu Y O E N lw uj lam _ • Q y=r = V •Q• i �• CL as ca 2 o O N V L N d � •CO .0 C tm O _ o 0 L w' N _ d C L = Q1 O N 'O 0 O = t �D Q N .? E "o m OZ CL (A N 'O 0 N = ao1�2 L �Qom.°' msw Q = Z3 H v O = _ � •. 0 N V m LL 'w J R Na P N •O��_ i+ v v LU VN i V Q 0-0 d �, N O = cc o CL L- CL Mh t N N _ tm m L O tmC •O N O t O Z O Q J O F 2 Z O m coZ W w CL W 1_- W a 0 W :a C9 Z . m Q W Z�O V CO O 0 J . M C.l E O -F+ 0 CD Z M O N CD V/ Q .— E CD W W wO �+ W O caV o Q CL CL � Q O �CL O d U)z � O U cnCL CL U) J.K.L. REALTY TRUST CONSTRUCTION AND CUSTOM HOMES 22 Wicker Lane, Wakefield, MA 01880 617.257.4408 This agreement is for the construction of a bulkhead to allow an exit out of the basement. It shall be constructed as shown on the attached plan for the sum of $5,000.00.'- -, 5,000.00.` ,-, I Jim Luciani /1 im -0evivrip,, �,�u r,- . Fcx..,,.� � r�J.✓ .rear.. ria✓ i .��a�. i .% �,J,�'T,=fir. � : v 'r SC/.P ✓.� y, �l -_ //E.PEBY CE.cT/fy TV rye T/TLE /,c/SU,rO.NO rb �� O T PG �� + X11--&-g.V t- rsc9T ry r o., -d-zz r , eoc,47L_ o v ryezar-As ssvrv,avo rsur/r-.oc+-,s ccwFcurf /N !Y/T•S� �'S/E 7Cl-,4/ O/P,td �voOrF� ZQN/NG ,�E6�/LATt2l�s 6.+�CO/.c�G JGi��IC.�S FROM STPE�'7'J l LoT U.vES ' 4 U.e7-v S f!/Ci.S�CX LEt"TiFY 7,Vf7- TNl-f /-f LVOT =OG,*7CO /N 7-�'E FESyry FLoa� .',�9Z•oC0 APE�i, SrJawN Opt/ " O.PAh''/V %�O.P zr, �Y '� n,��:+�OaBGE-STOv6� ,r'• t;,�,y� z5 -009e oaoSB CloSJ l!Ev6LOP.�f✓T CocP JEFFa IS, I?Y3 �ov,�IO,PY L3G"TE.P�tf%.t%4Tlo�t! �o�,vo,vey/,v,L-o,P,yf_ /!fc`.P,P/lyq� �e-�G�EE.P/.{/6 AT/o,!/ T• t'E S/ f.�0il ! EX/SJ t/G .P�LCLC�S. SE.PY/�'ES �o to �-4 �:{� S%��EG�J" �NpOYET; �Y1AS.S,oGvvS�TTS o/Bio �] INorth Andover MIMAP December 4, 2015 C- MVPC Bo Interstates — SR — Roads t Easements ❑ Parcels Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack f 14OR7p Valley Planning Commission (MVPC) using data provided by the Town of O "Uto ,,q . NO North Andover. Additional data provided by the Executive Office of Environmental Affaim/MassGIS. The information depicted on this map is L for planning purposes only. It may not be adequate for legal boundary to definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER • MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING 1 THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY t .M OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT o • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name(Btisiness/Organization/individual):V 1,rL �a&z_i x IKUS/ Address City/State/Zip: fW/i�� �i�' OZ8F1 D Phone #: Are you an employer? Check the appropriate box: 1.❑ I am a employer with employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.0 1 am a general contractor and I have hired the sub-coiitractors listed on the attached sheet. y`� These snb-contractors have employees and have workers' comp. insurance.1 6.F1 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.] Type of project (required): 7. 0 New construction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. n plumbing repairs or additions 13.0 Roof repairs 14. ® OtherJ'c1LK�A 1) *Any applicant that checks box4l must also fill outthe section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing allwork and then hire outside contractors must submit a new affidavit indicating such. tContractors 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-conlractors fiave employees, 'they must provide their workers' comp. policy number. I am an employer tfiat is pi•ovidii2g workers' compensation insurance for my employees.' Below is the policy and f ob site information. Insurance Company Name:. policy # or Self -ins, Lic. Expiration Date: Job Site Address: City/State/Zip:6I�A 7►'ti0JV/f ( Attach a copy of the workers' e'ompepsation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. y `y lr do he: evy cer%I }' //Firs/Zy pa p(s an altierf pe}ju_ry that the information provided ove is true and correct. Official use only. Do not write in this area, to be completed by city or town official. . City or Town: PermitlLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone##: The Commonwealth of Massachusetts Department of Industrial Accidents N 1 Congress Street, Suite 100 ' Boston, MA. 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name(Btisiness/Organization/individual):V 1,rL �a&z_i x IKUS/ Address City/State/Zip: fW/i�� �i�' OZ8F1 D Phone #: Are you an employer? Check the appropriate box: 1.❑ I am a employer with employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.0 1 am a general contractor and I have hired the sub-coiitractors listed on the attached sheet. y`� These snb-contractors have employees and have workers' comp. insurance.1 6.F1 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.] Type of project (required): 7. 0 New construction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. n plumbing repairs or additions 13.0 Roof repairs 14. ® OtherJ'c1LK�A 1) *Any applicant that checks box4l must also fill outthe section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing allwork and then hire outside contractors must submit a new affidavit indicating such. tContractors 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-conlractors fiave employees, 'they must provide their workers' comp. policy number. I am an employer tfiat is pi•ovidii2g workers' compensation insurance for my employees.' Below is the policy and f ob site information. Insurance Company Name:. policy # or Self -ins, Lic. Expiration Date: Job Site Address: City/State/Zip:6I�A 7►'ti0JV/f ( Attach a copy of the workers' e'ompepsation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. y `y lr do he: evy cer%I }' //Firs/Zy pa p(s an altierf pe}ju_ry that the information provided ove is true and correct. Official use only. Do not write in this area, to be completed by city or town official. . City or Town: PermitlLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing 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 lure, 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 oin 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 1he'boxes that apply to your situation and, if necessary, supply sub=contractoi(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 anLLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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-iu'sured 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. ## 617-727-4900 ext. 7406 or 1-877-N SSA.FE Fax #>' 617-727-7749 Revised 02-23-15 www.mass.gov/dia 12/8/2015 8:57 AM FROM: Fax TO: 919786889542 PAGE: 002 OF 002 ACORN CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) TYPE OF INSURANCE 12/8/2015 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(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 Tarpey Insurance Group Water St CONTACT NAME: Lisa Mills PHONE (781)246-2677 FAX (781)224-0973 Ex AIC No IC,442 E MAIL ADDRESS: L1 Sa@ tarpeylnSllranCe . COm PO BOX 567 Wakefield MA 01880-4667 INSURER(S) AFFORDING COVERAGE NAIC & INSURER A Norfolk & Dedham Group INSURED INSURER B : JKL Realty Trust 22 Wicker Lane INSURERC: INSURERD: INSURER E Wakefield MA 01880 INSURERF: uV V en/1V CJ \_rK Ilrll_Li l r Nl1 N1nr K'LV1J-LV10 oc111clr hl nig �nno�o. 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. INSR I LTR TYPE OF INSURANCE ADD U R POLICY NUMBER POLICY EFF MMIDDIYYW POLICY EXP MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X� OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO D 50 000 PREMISES Eaoccurrence $ M ED EXP (Any one person) $ 5,000 NDPO10344 9/29/2015 9/29/2016 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY DPRO TCT F—] LOC GENERAL AGGREGATE $ 2, 000, 000 PRODUCTS-COMP/OPAGG $ 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 Peracddent $ UMBRELLA LIAB' OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PRO PR I ETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F—] NIA PER 70TH - STATUTE I I ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If yes , describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS'f LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) General Contractor. (978)688-9542 Town of North Andover North Andover, MA 01845 l.AIVl.0 LLA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Lisa Mills/LISA © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD I NS025 (201401) J.K.L. REALTY TRUST CONSTRUCTION AND CUSTOM HOMES 22 Wicker Lane, Wakefield, MA 01880 617.257.4408 List of Subcontractor Greenwood and Sons inc. A►�' CERTIFICATE OF LIABILITY INSURANCE >2 �ei2oi5D' 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' FARM FAMILY WESTFORD OFFICE 239 Littleton Rd #5A Westford, MA 01886 CONTACTKIM MURPHY NA PHONE (978)467-1001 855-978-5629 -MAIL .R M.MURPHY FARM-FAMILY.COM INSURERISI AFFORDING COVERAGE NAIL# FARM FAMILY CASUALTY 13803 INSURED GREENWOOD & SONS INC 1 WASHINGTON ST. MELROSE, MA 02176 INSURER B: INSURER D: INSURER F' INSURER F !`lIVCOA!_`CC r`FRTIGIr'ATF A1lIRAP.=- RFVIGICIN MIMRFR• 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. LTR TYPE OF INSURANCE INSD VWD ACCORDANCE WITH THE POLICY PROVISIONS. POLICY Y LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR _E"IrYNUMI3FR 2001L6312 3/1/15 /1/16 EACH OCCURRENCE $ 1.000.000 DAMAG ISES (F EuErrence) $ 100,000 MED EXP (Anyone erson $ S,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: POLICY [:]SET Q LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS qAUTOS I MBI I LEL I $ a i ... BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ $ UMBRELLA LIAR EXCESS LIAB HOCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIIBER EXCLUDE/ XECUTIVE N OFF500,000 (Mandatory In NH) Ifyes, describe under I I NS below NIA 2009W6682 4/8/15 /8/16 X R H - A FR TU E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ IT $ 500,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attachedd more space is required) EXCAVATION & STREET CLEANING �n'rlr'V�AT= Uni nco CAAI(11=1 I ATInKI JKL REALTY TRUST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 22 WICKER IN THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. WAKEFIELD, MA 01880 AUTHORIZED REPRESENTATI _ , f/,��, � 'JIMMYLUCIANI@VERIZON.NET ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD assachusetts - Department of Pusshc SafeT,y . E3oard of Building Regulations and wtanft n Construction Supe�isor. License: CS -051701 Nk .r: r,. FRANKJ LUCIA$JR 22 WICKER LN WAKEFIELD MA Olfto Expiration , Commissioner 09113/201¢- J. Ka La 7 O C-) Q 0 O m Z o 0 co o Q� o o < o m D � C) o a D i CD c7 O c Z3 T V, 0 N O 4' minimum x O A O 7 m O co o o o D � D i ON