Loading...
HomeMy WebLinkAboutBuilding Permit #535-2016 - 91 AUTRAN AVENUE 10/29/2015I- -.. BUILDING PERMIT ,b"tio TOWN OF NORTH ANDOVER 02 APPLICATION FOR PLAN EXAMINATION '" 70 Permit No#: —/ J �^ ��D Date Received ,P- 7 A�RATEO I.PP.�5 ` Date Issued: 1 � 2c(I I5j IMPORTANT: Applicant must complete all items on this page LOCATION' PROPERTY O 'Print 100 Year Structure MAP _© J PARCEL: ZONING DISTRICT: Historic District _ Machme,Shop Vi yes no yes no ves no TYPE OF IMPROVEMENT PROPOSED USE Reside Non- Residential ❑ New Building One family 0 Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑Floodplain ❑Wetlands. ❑ Watershed District ❑ Water/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: 1 Zentircation - Pleas •%Ipe or Print Clearlyi�%a�7 (i OWNER: Name: fi( �i�-70 rl Phone: Address: Contractor- Name: f(, Phone: �� Email: - Address: "e1 Supervisor's Construction License: CS -Q) 9q] ..,Exp. Date: 1A23J Home Improvement License: ��'� �, Exp. Date: ARCH ITECT/ENGINEE Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ key 8 FEE: $ Check No.: q6Oo Receipt No.: NOTE: Persons contracting with unregistered contractors do not have accqssfio the guaranty fund Signature of Agent/Owner Signature of contract r �.� ' Location No. 6u3 -- Check # 4sW 2:599 141-Q- -. Date TOWN OF NORTH ANDOVER ti Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ A Briilding Inspector 1 tl Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swumning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales 0 Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Signature, Reviewed on _ Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes L Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Lacatea 5?54 usgooa Street FIRE;-DEPARTMLNT ,Temp-Dumpster on site ,yes, nog _ z Located.at 124Wbin.Stteet - �- 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.$100-$1000 fine Doc.Building Pennit 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 o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li 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) o Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ 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 ❑ Mass check Energy Compliance Report o 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 3 0 H 'w H Q 2 LL O m O N t u0 +� \ O LL �a) n U O_ VI W (0.2 A z Z 0 J . m O m '6 7 LL t :3 W T ai C EbD U LL O� W H Z Z m J d t K LL 0 W z V J W t O OC u V) Ll O u a Z H L 0 d' IA_ z W °c a W 0 uj5 LL i 07 O z a+ v V) ++ OJ Y O Vl _ O � Cc 0 ci- .Q i O. O O Q — O Q E C i c cc : V y O N J N: r-> Cc ,O 0 O U) — 'a 0 5Do t Q � O = V 4�Z Q N — Z: �yo0 — c �0 L Q. Q 3 'rn _ -a om 0 = _ Q L L LC Q •� ~ m w.2 m ujco W = .0 r O O LL '2 L N = P u) N •� :2,2 aM v v LU v a 0-0 N °'> (n Ov= F— t - CL 0 C.) i Z O co Z Cl) CLx LLIW A C mo O 0 - CL CL a� Q r M J -0 O 'd Z i/Vi Cl) r_ PROPOSAL W.Acc' t• L.E. Morgan Construction Company P 86 Billerica Avenue, Unit #1 WS4 • ' N. Billerica, MA 01862 ----- Office: 978 670-4747 / Fax: 978 670-6477 D ToZ© , PHONE 000ya DAT T JOB NAME V T TE AND CODE JOB LOCATION mlholl> ¢BIER JOB PHONE Strip down to the wood deck, -- layers of shingles dispose of debris to a licensed recycling facility: Install fo ice and water shield at the gutters NIA feet of ice and water shield in valleys. Install synthetic underlayment on the remainder of the wood decking. Install 8" aluminum drip edge on'all perimeters, color choices: 1A White, ❑ Mill, ❑ Brown, ❑ Copper. Install,24 year 3 6 d e ri areh4teettiral asphalt shingles, and hurricane nail. Install ridge vent manufactured by �� b ;- F to all ridges and dormers. Install new skylight flashing kits manufactured by A Flash all cheek walls, pipes, skylights, and penetrations to manufactures specifications. Remove existing lead flashing A14 chimneys and install new lead flashing. WE PROPOSE hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: O p SC -1 �1 ty �..s co r- �tJ i x, t 4c� X.7�� IL W-�Q,, y iso dollars ($ 1 0 All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized Signat e: manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. Our workers are fully covered Note: This proposal may be withdrawn by Workmen's Compensation Insurance and Liability Insurance. by us if not accepted within days. ACCEPTED AS A CONTRACT - The above prices, Date of acceptance: specifications and conditions are satisfactory and are Authorized Signature: ( ' hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Authorized Signature: Additional Remarks: C3s11-.� riTTTAI►TTT V/lTT IMn1D nTTnnCTXTr_ T V A/fnur_AM Vn1%TCT1I?TTVTTnN The Commonwealth of Massachusetts F Department of Industrial Accidents y— d 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 (Businneess/1/1 Address: ® City/State/Zip: Ve U #: fly (f] b 4-7 qr7 *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 state whether or not those entities have employees. If the sub-contraciors have employees, ley must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. A 1 A A �1 A Insurance Company Policy # or Self -ins. Lie. Job Site Address: i I (AAZ] fA4 J Q V Attach a copy of the workers' compensation r7 Expiration Date: V I —( "K' I n &)dAq( City/State/Zip: declaration page (showing the policy number and expirati6n date). Failure to secure coverage as required under MGL c. 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 DIA for insurance coverage vera YoEon. I do herelly•tify under the pains perjury that the in r /��aat`ion provided a110-0 eitstru andcorrect. , Dnfe- / 6, use only. Do not write in this area, to be completed by city or town official 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 Are yon ployer? Check he appropriate box: Type of project (required)• 1. I am a employer with employees (full and/or part-time).* %. New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers' comp. insurance required.] 9. El Demolition 3.FJ 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 10 Building addition ensure that all contractors either have workers' compensation insurance or are sole I L ❑ Electrical repairs or additions proprietors with no employees. 12.E] Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. Thesesub-contractors have employees and have workers' comp. insurance.$6.❑ 13pOth We are a corporation and its officers have exercised their right of exemption per MGL c. 14e — 152, § 1(4), and we have no. employees. [No workers' 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. #Contractors 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-contraciors have employees, ley must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. A 1 A A �1 A Insurance Company Policy # or Self -ins. Lie. Job Site Address: i I (AAZ] fA4 J Q V Attach a copy of the workers' compensation r7 Expiration Date: V I —( "K' I n &)dAq( City/State/Zip: declaration page (showing the policy number and expirati6n date). Failure to secure coverage as required under MGL c. 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 DIA for insurance coverage vera YoEon. I do herelly•tify under the pains perjury that the in r /��aat`ion provided a110-0 eitstru andcorrect. , Dnfe- / 6, use only. Do not write in this area, to be completed by city or town official 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 Yore, 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=contractors) 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 Depattment of Industrial Accidents foi• 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 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE 'DATE 7inw2nir, mmar�n� S,GERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS MFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 5 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX BALDWM',A'ELSH PARKER INS 131 COOLIDGE ST. SUITE #100 (A/C, No, Ext): (AJC, No): E-MAIL HUDSON, MA 01749 ADDRESS: 27KLD INSURER(S) AFFORDING COVERAGE NAIC # INSURED 1 INSURER A: A IERICAN ZURICH INSURANCE COMPANY L E MORGAN CONSTRUCTION INC INSURER B: INSURER C: INSURER D: PO BOX 75 INSURER E. NORTH BILLERICA- MA 01862 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PROJECT [::] LOC GENERAL AGGREGATE Is PRODUCTS -COMP/OPAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT (Ea accident) BODILY INJURY S ALL OWNED AUTOS SCHEDULE AUTOS (Per person) I BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB EACH OCCURRENCE (S EXCESS LIAB []OCCUR CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION S IS A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY Y/N UB-SB738312-14 12/14/2014 12/14/2015 X WC STATUTORY LIMITS OTHER ANY PROPERITOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E. L EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE S 1,000,000 (Mandatory in NH) If yes, describe under D DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ 1,000,000 .DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST, BLDG 20, STE 2035 BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPR TA ` _- _ r ` " "f "`- ACURD 25 (2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. LEMORGA-01 BBOYER '`,� R� CERTIFICATE OF LIABILITY INSURANCE DAT71712IE D/YYYY} 7/7/2015 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 Welsh & Parker Insurance Agency, Inc. / Hudson Office 131 Coolidge Street, Suite 100 Hudson, MA 01749 CONTACT �� No Ext :(978) 562-5652 AIC No (978) 562-7120 E-MAIL INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Western World Insurance Company INSURED INSURER B: Safety INSURER C: Scottsdale Insurance LE Morgan Construction Inc INSURER D: PO Box 75 Billerica, MA 01821 INSURER E: INSURER F : COVERAGES CFRTIFICOTF NI IMRPR- DMIleIAAI MIN=I=10• 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 CONTRACTOR 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 LTR TYPE OF INSURANCE ADDL INSO SUBR WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FRIOCCUIR X Contractual Liabilit NPP8237995 04/1312015 0411312016 EACH OCCURRENCE s 1,000,000 PDAMAGE To REMISES RENTED s 100,000 MED EXP (Any one person) S 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT El LOC GENERAL AGGREGATE S 2,000,000 PRODUCTS -COMP/OPAGG $ 2,000,000 $ OTHER: B AUTOMOBILE LIABILITY ANY AUTO COM6230668 10/1312014 1011312015 COMBINEDBIdSINGLE LIMIT S 1,000,OOQ BODILY INJURY (Per person) 5 ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY Per accident s ( ) X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE s Per accident 5 C X UMBRELLA LIAB EXCESS LIAB X IOCCUR CLAIMS -MADE XLS0096729 04/13/2015 04/13/2016 EACH OCCURRENCE $ 5,000,000 AGGREGATE S 5,000,000' DED I I RETENTIONS s I WORKERS COMPENSATION AND EMPLOYERS LIABILITY Y / N ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ N l A PER OTH- STATUTE ER E.L. EACH ACCIDENT S E.L. DISEASE -EA EMPLOYEE S (Mandatory in NH) If yes. describe under E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Proof of Workers Compensation coverage will be sent directly by the carrier. Town of North Andover 1600 Osgood Street, Bldg 20, Suite 2035 North Andover, MA 01845 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 U 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts - Department of Public Safely ,`Sv^arc of :Cti^iiy ,",.yuiauv„S and 5-5ignuarv5 _ License: CS -079476 `t LAWRENCE E MERG.. Ile_ 86 BILLEERTCA A'NE _ N BH LERICA NFA 0j$ ft j J,•G..� J1/e S ` Expiration Commissioner 06/03/2017 Office oflConsumerilan s &n�inessegufat�ionl%t —r-- y ,cw .-HOME IMPROVEMENT CONTRACTOR - Re istra 9 tion: 137913 Type: -s =-- --,5 Expiration: 1/27/2017 Individual LAV NCE E. MORGAN JR. LAWRENCE MORGAN JR. 86 BILLERICA AVE UNIT 1 N.BILLERICA, MA 01862 Undersecretary occupatraml �'Omi�IeSuYon i 0S Alk This card acknowledges that th& recipient has successfully completed a Department of 30 -hour Ocqupationai Safety and HeafihTraining Course ini occcpationatSafety anG'realth n:: strair;o Construction Safety .and Health LARRY MOR&At-J 1.6mil r Jle by successfully completed a :G-`:c-ur Uccupation_l Safety and.. Health Training Course n Construction Safety & Health i1 (% " c.� i.�3ra 3 LDU� S RoNeJ ®SAU&� (Trainer name - Tintor type) (Course end date) (iraineq - -- - - - irate! I SEAN ANEsTis PRESIDENT & CEO 369 CODMAN H1I L ROAD TEL• 978-263-1899 BoxBoRoUGH, MA FAX. 978-263-1879 EMAIL: ROOFTOPI@VERIZON.NET CELL 508-726-5341