HomeMy WebLinkAboutBuilding Permit #177-13 - 90 PUTNAM ROAD 8/30/2012 BUILDING PERMIT NORTy Of�,f 0 TOWN OF NORTH ANDOVER o ; APPLICATION FOR PLAN EXAMINATION !y 4 R " Permit N0: Date Received �S0 ATE Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION m ��-1LaJ�'i1�L // pint _. PROPERTY'OWNER r) n Paint 100 YearStructure? y yes oes no MAP 210 PARCEL: ZONING DISTRICT: Historic�District yes no Machine Shop Village TYPE OF IMPROVEMENT PROPOSED USE Resi tial Non- Residential ❑ New Building w6ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well- ❑ Floodplain O Wetlands. ❑ WatershedDistrict ❑Water/Sewer- DESCRIP OF WORK TOB P RMED: ,Of) )to– C� )EA A) Identiticatio eas Type or Clearly) �'���. OWNER: Name: ( Phone: 7 / Address: CONTRACTOR Name AD Phone: Address: Supervisor's Construction License:. lou-7p Exp. Date: C;)-v Home Improvement License:. Ll Exp. Date:-C?-�—001 1 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: $ �r � FEE: $ Check No.: ' Receipt No.: NOTE: Persons contracting with unregistered contractors do not have ac ss to th guar my fund Signature of Agent/Owner Signature of contracto 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 ❑ 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 Signature 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes- no Located at 124,Main Street, Fire:Departinent,signature/date COMMENTS. i 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 i ® Notified for pickup - Date f Doc.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 ❑ Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work a 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 ❑ 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) o Engineering Affidavits for Engineered products .VOTE: 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 o 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) Li Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products IOTE: 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 2008 r Location No. Date • ' TOWN OF NORTH ANDOVER ® AILED D I • • Certificate of Occupancy $ Building/Frame Permit Fee $ OD Foundation Permit Fee $ Other Permit Fee $ ` TOTAL $ !1`l.00 Check#1115'2- 25673 115'Z25673 B�,filding Inspector NORTH Town of 2 _ Andover0 N I No. o C% Mass, ver,h Z o I` coch�c»ew.cK 1' RATES U BOARD OF HEALTH PERMIT T Food/Kitchen L D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ....Aftltj. ......... ... .......... .. .................. ....... .... . . . .A � Foundation has permission to erect .......................... buildings on . .. :`.... .. Rough to be occupied as .......1�1:�. . 11.M..... � Ch .�..4............. .................. Chimney provided that the person accepting this permit shall In eve respect conform to the terms of the application . e p p p g p every p pP � 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 �J PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough .............. Service .... ,t.�................ .................. . 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 0/ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 w Boston, Massachusetts 02116 f�1=ll: Home Improvement Contractor Registration Registration: 149813 r Type: DBA Expiration: 2/9/2014 TO 220986 LANDLINE CONSTRUCTION .,+i TODD LIVINGSTONE t` 73 CROSS STREET =y DUNSTABLE, MA 01827 fi Update Address and return card.Mark reason for change. -- Address E] Renewal F] Employment Q Lost Card DPS-CAI is 50M-04/04-G101216 Office of Con m�a�ir�ines at". License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ,j1L49813 Type: Office of Consumer Affairs and Business Regulation Expiration: :2Ja/2014 DBA 10 Park Plaza-Suite 5170 — _ Boston,MA 02116 - LA INE CONST_UGTJ0,N, TODD LIVINGST©IVE " 73 CROSS STREET DUNSTABLE,MA 01$27, Q` Undersecretary Not valid without signature `r LA r i {. Massachusetts -Department of Public Safety Board of Building Regulations and Standards i Construction Supen-isor Specialt�- License: CSSL-100170 I TODD J LIVINGS"NE 73 CROSS ST Dunstable MA Of-827 954— —Z-1-44(0-- -" Expiration Commissioner` 06/09/2014 L ConS+ruc-hotJ A"I L___ Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Ho wn r Info tion Co tractor Information Company Name q0 -;?,44A le Cl 1 L Acl Street Address(do not use a ost 0ffice Box address) ntractor/Salesperson/O r N e ity S 17 �� Zip Code � ' ess Address(must incl de a street address) , V i �1 aytime Phone Evening Phone rF7,k State Zip Code e3 5— 5-//c)- Mailing Address(It different from above) Business Phone I Federal Employer ID or S.S.Number Home Improvement Contractor Reg.Number Expiration date Low requires that most home improvement contractors h. avalid registration numbcr q The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,u additional sheets if necessary.) ins- �t l a y �t��o � a � .�r�. n �,ta,�tZ LAD ►u7 DS ��� -. c� octible � �e �e-,�tt 1..�F✓IJ HCl =!— r .2ri�Q rfts� il2ir> ✓1 i � � 1�iv►� .60 .3nrn le-��off, Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be y� excluded from the Guaranty Fund provisions of 7-avt'Date when contractor will begin contracted work- MGL orkMGL chapter 142A.) t7 r knA e when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of 91 2,go (*) Payments will be made according to the following schedule: 3j56D upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) _by 9—/-/ if Ror-upon-ciDmpletion-of --- -- - - by�IJDI-Laor upon completion of upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following materiallequipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of arty special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty beine Provided by the contractor? ❑No❑Yes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this aueement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contraeL Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home jWrovt ment Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY B ANK SPACESM Two identical copies of the contract must be completed and signed. One copy should go to the bo owner.The oth py should be kept by the contractor. Homeowner'tlygnature donYrktoPrgign tune za zv/ -aura Date Date 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): ( �' sih,(,A-c Address: r ) C- f c)5 St. City/State/Z�as -{,�&-/�(Q 0 2ne#: �J�5� / Are you an employer?Check the appropriate box: Type of project(required): t_Tv 1. 1 am a employer with j's 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 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. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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' 1311 Other comp,insurance required.] *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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. -:T Insurance Company Name: L4Q Policy#or Self-ins.Lic.#: ExpirationDate: �l��a� fob Site Address: City/State/Zip: /�/ / (� V 1P 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 .me 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 if 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. do hereb erti y der the ins and penalties of perjury that the information provided above is true and correct. ii nature: Date: a-3 '(� 'hone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: .Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE 'evised 5-26-05 Fax#617-727-7749 www.mass.gov/dia 08/30/2012 16: 16 FAX 6174886501 UNDERWRITING /4001/001 oRc� 8130/2012 P .. ATTER OF INFORMATION ONLY A CERTIFICATE IS ISSUED ASA MND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT RAGE AFFORDED BY THE POLICIES BELOW.THIS OF AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVE AUTHORIZED NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), REPRESENTATIVE OR PRODUCER,AND THE CERTIATE KATE HOLDER.CE DOES IMPORTANT: K the cerlflme holder is an ADDITIONAL INSURED,the PO les) u9t be endorsed. ff SUBROGATION IS WAIVED,subject to the terns end conditions of the policy,certain polieles may require an endorsement A Statement on f Is CO iticate does not confer rights to the cernfieate holder In lieu of ouch ondor,GDments(s). CONTACT PRODUCER PHONE FAX (Arc.No.EXII: (781)861-1800 lac Nc.:l Tomy Northwest insurance Agency,Inc. EMAIL 238 Bedford StreetaFRono : Lexington,MA 02420 e'JIST F INSURERS AFFORDING COVERAGE MAIC# INSURER A: Atlantic C:hartcr Insurunce Company VDAC 29211 INSURED INSURER B: Land Linc,Inc. INSURER C: INSURER D: 73 Cross Street INSURER E: Dunstable,MA 01827 INSURER F: COVERAGES: CERTIFICATE NUMBER: REVISION NUMBER: THIS 19 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE 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.uMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TTP!OF INSURANCE FAIDDL :zM POLICYNUMBFJt POLICY EFFECTIVE POLICY EXPIRATION LIMITS LT>a DATE(M WDDIYY) DATE(MMIDDIYY) (In Thousand I PA.WenO uaRENCE 9 GENERAL LIABILITY O RENTED PREMISES 1 COMMERCIAL GENERAL LIABILITY '6n y CLAIMS MADE OCCUR a Any ane pereon)L a ADV INJURY AGGREGATE CM AGGREGATE LIMIT APPLIEa PER s-COMProP AGG POLICY PROJECTLOCAUTOMOBILE LIABILITY D SINGLE uMIY M ANY AUTO BODILY INJURY (Per pmatin) ALL ovmeD Auroe EID BODILY INJURY s SCHEDULED AUTOS (Ea AocldOrQ HIRED AUTOS PROPERTY DAMAGE 3 NON.OWNDED AUTOS (Ea Aodd011Q AIMORCLLA ❑ OCCUR UCH OCCURRENCE S LIABILITY '- EXCESS LIAO❑ CLAIMS MADE AGGREGATE E OEDVOTIBLE ❑❑ S RETENTION 6 ICERSCOMPENSATION AND WCVOI009100 04/05/2012 04/05/2013 1C STATUTORY LIMITS OTHER A EMPLOYERTLIABILITY ANY PROPRIEYORIPARTNER/EXIEWrIVE Y/N ��,t OFFICER/MEMBER EXCLUDED? 'Y N/A ❑ Policy Coveruge State:NIA EACs ACGDENT $ 500,000 Man4my In NN n N yes,daavlbe wider SPECIAL PROVISIONS below DISEASE•POLICY LIMIT S 50(),000 DISEASE.EACH EMPLOYEE s 500,000 OTHER ❑ DESCRIPTION OF OPLIIATIONB&OCATION6NEHICLES(Auaoh ACORD 101,AddW,nal RammUz Scho4mle,O Moro space ie rngVIMd) r: c SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THF ISSUING COMPANY WILL ENDEAVOR TO MAIL North Andover Building Department North Ratcliffe 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Aft:90 Putnam Street BUT FAILURE TO DO SO SHA I POSE NO OBLIGATI OR LIABILITY North Andover,MA 01845 OF ANY KIND UPON THE I ITS AGEWFIX.D01EYRESENTATIVES. AUTHORIZED REPRESENTA ACORD 2e(2008MV) ®1088-2009 ACO DAR PORATIO .AN rlphts resdrvee. Page 1 of 1 CERTIFICATE IIOLDER COPY From Tonry Northwest Thu 30 Aug 2012 04:15:25 PM EDT Page 3 of 3 CERTIFICATE OF LIABILITY INSURANCE ° 8//30/30/'°°201122 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 endomement(a). PRODUCER CCOONNTACT Colleen Mathews Tonry Northwest Insurance Agency, Inc. PHONE (781)861_1800 FAX C o•(781)861-1806 238 Bedford Street I&MAIL ADDRESS:cmathews@tonrynw-cam INSUR AFFORDING COVERAGE NAIC N Lexington NA 02420 IN8URERA:Essex Insurance C 9020 INSURED INSURER B:Commerce Insurance 34754 Land Line, Inc. INSURERc: 73 Cross Street INSURER D: INSURER E Dunstable NA 01837 INSURER F: I ! COVERAGES CERTIFICATE NUMBER:CL121903821 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. LTR TYPE OF INSURANCE POLICY NUMBER POLI EFF POLICY EXP IMWDDnnMn LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY -MWDz9T6W -- PREMISES om $ 50,000 A CLAIMS-MADE 7 OCCUR 3D.T6836 /5/2012 /5/2013 MED EXP(Any one parson) $ 1,000 PERSONAL 6 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OP AGG $ 2,000,000 7X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Eaaccident B ANY AUTO BODILY INJURY(Per Person) $ 100 000 ALL OWNED X SCHEDULED J2022 /1/2012 /1/2013 300 000 AUTOS AUTOS BODRYINJURY(Peracciderd) $ NON OWNED HIRED AUTOSAUTOS Pear . rd) AGE $ 100 000 PIP-Basle $ 8 UMBRELLA LU►B 000 OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION III $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORYLIMITS ANY PROPRIETOR/PARTNER/E)(ECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mendel In NH) E.L.DISEASE-EA EMPLOYE $ If yes descwribe under DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Addidonal Remarks Schedule,It more space Is required) CERTIFICATE HOLDER CANCELLATION (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Attention: Allyn Ratcliffe 90 Putnam Road AUTHORIZED REPRESENTATIVE North Andover, mA 01845 L Tonry Jr./CMATTS :: ,t: •.: ..,:.: : ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved. INS025(2o1om).o1 The ACORD name and logo are registered marks of ACORD From Tonry Northwest Thu 30 Aug 2012 04:15:25 PM EDT Page 2 of 3 �f k MASSACHUSETTS ASSIGNED RISK POOL REQUEST FOR CERTIFICATE OF INSURANCE Use this form to request a Certificate of Insurance from the Assigned Risk Pool Carrier(Atlantic Charter Insurance). Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the Certificate of Insurance should be issued. If this form is fully and accurately completed, the Certificate of Insurance will be issued and distributed by facsimile to each fax number provided below,within two(2) business days of the carriers receipt. This Form may be mailed or faxed to the Assigned Risk Pool Carrier. To obtain each carrier's contact information refer to the Certificates of Insurance section located in the Producer Community section of the Bureau's website www.wcdbma.ora . 1. Name,address, telephone number and facsimile number of the INSURED: Name: Land Line. Inc. dba: Mailing Address: 73 Cross Street Dunstable MA 01827 Physical Address: Phone: (978)835-6063 Fax or email: Fax Number or Email Address 2. Name, address, telephone number and facsimile number of the CERTIFICATE HOLDER: Name: _ Nroth Andover Building Department Atttention:Allyn Ratcliffe Mailing Address: 90 Putnam Street North Andover, MA 01845 Physical Address: Phone: Fax or email: 978-688-9542 8. Name,address, contact person, telephone number and facsimile number of the PRODUCER: Name: Tonry Northwest Insurance Agency. Inc. Mailing Address: 238 Bedford Street Lexington MA 02420 Contact Person: Colleen Mathews Phone: (781)861-1800 Fax or email: (781)861-1804 or certsCaZtonry com A Policy Number,Policy Effective Date and Policy Expiration Date If a Certificate of Insurance is needed for more than one policy term,provide the Policy Number, Effective Data and Expiration Date for each policy term. If the policy has not yet been issued,you must attach a copy of the Notice of Assignment. Policy Number: WCV01009100 Effective Date: 4/5/2012 Expiration Date: 4/5/2013 5. List any special requests for optional coverages/endorsements(see Page 2 for listing of coverages available in the pool and the conditions of availability)or additional information(including changes in exposure not yet reported to the carrier) that will assist the carrier in the issuance of the Certificate of Insurance. NOTE.An additional insured(s)shall not be listed on any Certificate of insurance unless such additional insured(s)is a named insured on the policy. None i I i