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HomeMy WebLinkAboutBuilding Permit #744-2017 - 95 SOUTH BRADFORD STREET 1/30/2017NORTFI pf�t�ao ,6'4{.� BUILDING PERMIT 3? g° _ • '�6 �� TOWN OF NORTH ANDOVER ° ( 1 APPLICATION FOR PLAN EXAMINATION Permit NO: �� Date Received'�pAOqTlO �SSACHU Date Issued: 1 IMPORTANT: Applicant must com Tete all items on this page LOCATION n r Print PERTY'OWNER Print ' MAP NO: It PARCEL: ZONING DISTRICT- Historic District yesrcn0o Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Reside ' I Non- Residential ❑ New Building ne family ❑ Addi ' n ❑ Two or more family ❑ Industrial ELAffe0'ration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition[IOther ❑ Septic ❑ Well - _ ❑ Floodplain Q Wetlands ❑ Watershed District El-Water/Sewer OWNER: Name: Address: q5 Identification Please Type or Print Clearly) �_V C, V -o CONTRACTOR Name: perc C l / J I Phone: hone: Address: q O C. tic" (,� t r 4D 5ALr-W(/JH 0 Supervisor's Construction License: O/ "1 Q*5�0 Exp. Date: V i Home Improvement License::Exp, Date: 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: $ 17 0 `S' CYJ FEE: $ Check No.: �1 Receipt No.: i NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund igna#ure of Agent/Owner Signature of contractor , 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 s i Planning Ooard Decision: Comments Conservation Decision: Comments Water & Seger Connection/Signature Date Driveway Permit DPW Town- Engineer: Signature: FIRE =DEPARTI EN*' T - Temp Dumpster on site Located at'124 Mair; Street Fire Departmerit signature/date COMMENTS Located 384 Yes no ood Street QWW --�o Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions _ Total land area, sq. ft.: ELECTRICAL: Movement of Deter 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 El Notified for pickup - Date f E_ Doc.Building Permit Revised 2010 Building Department Tine folrowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofil-,,g, 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 MOTE: 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/Crossection/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 DOTE: 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 ❑ 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 TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cEisCs if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the app, -al period is over. The applicant must then get this recorded at the registry of Deeds. One copy and proof of recording must he- submAted with the building application Doc: Doc.Bul�ingPermitRevised2012 .6 H N W W U N 2 H O R 0 Q..cc Q± W W+ Q O M V Q L y d w ED _O C Cc AJ• O O I- C.) -" 3 m Cc 0.� W , L w m 1. W R i O N > U) - a O O cco :aor O O Z CL x,00 f 0 '> 0 L Q Q. 4) -9: a Q: ) ci .� (.i 0 C i L t6 'a cts y0, N d V m O O d � N C N .Q O V V E Q. O m>;� c O t .. CL 0 G E a� CL U) y O a� a� co W O N O t O Z O Q J O G o LU Z Z �M W V/ 2 z O z CC Z V W C X Z W V F_- U) cnW LLI -j C- Z C-: i .ti w ti '1 O O W Sta/W1 !a/f NV LL z z z a z O z Q W Z V OC m H a- 0 u C7 } m C E J W U. m C d W ..0 Y ate+ TO ,. T O ai p Y N ca C L L U Z O CL 7 hAOA 7 7 hA 7 i r t o — . =) C C L N it Y ILO N LLL W U LL K LL C {n LL K LL m N N H N W W U N 2 H O R 0 Q..cc Q± W W+ Q O M V Q L y d w ED _O C Cc AJ• O O I- C.) -" 3 m Cc 0.� W , L w m 1. W R i O N > U) - a O O cco :aor O O Z CL x,00 f 0 '> 0 L Q Q. 4) -9: a Q: ) ci .� (.i 0 C i L t6 'a cts y0, N d V m O O d � N C N .Q O V V E Q. O m>;� c O t .. CL 0 G E a� CL U) y O a� a� co W O N O t O Z O Q J O G o LU Z Z �M W V/ 2 z O z CC Z V W C X Z W V F_- U) cnW LLI -j C- Z C-: i .ti w ti '1 Massachusetts Home Improvement 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 A1Tairs and Business Regulation's Consumer Information Hotline at 517-973-8787 or 1-888-283-3757. Homeowner Information Name brie w Lisa Kozel. Street Address (do not use a Post Office Box) 05 S 8-radtord Sween North Andover. 141 l 01845 Daytime Phone Evening Phone fi17-2 5 6- 7 5 20 tk, 97118--8 t(6-9172 Mailing Address (it different from above) I Business Phone 603-898-2977 Contractor information Company Name: lrl2(ltqSSl.(yN,il,BUit:tINGSE'RN'tC 4 Contractor/ Salesperson/ Owner Name: PEATA TA CUBA 1.D). Business Address (must include a street address) q ( LP EVt?ODE RD ti,ALF_Ni. Nkl 03079 Federal Employer ID or S.S. Number 45-3129017 La"-ragnires 11181 moll[ home Homc Improvement contractor Improvement contmetors have a valid reg. mnnbcr number 17()870 Expiration Date l!lt)+le The Contractor Agrees to do the following work for the homeowner: (Describe in detail the work to be completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.) l�cfe!'ence Professional .Building Services Estimate 3747 (0C roofing) :attached hereto in Exhibit A Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following and will be secured by the contractor as the homeowner's agent, schedule will be adhered to unless circumstances beyond Owners who secure their own permits will be the contractors control arise (pending weather permitting-). excluded from the Guaranty Fund provisions of Date waren contractor will begin contracted work (*x) ti n si week of MGL chapter 142A.) [Yate when contracted work will be substantially cmnplcied. (**) I,017 Total Contract Price and Payment Schedule The Contractor agrees to perform the work, tarnish the material and labor specified above for the total sum of'SS. } (R) Payments will be made according to the following schedule: K 4)01.67 upon signing contract (not to exceed 113 of the total contract price or the cost of special order items, whichever is greater) S2,Q00.00 upon substantial completion of materials drop on or before the work start date $2.90;'+.33 -+ any agree^€[ overage (in writia ) upon completion of the contract. (Law forbids demanding full payment until contract is completed to'" party's satisfaction) The following material/equipment must be special $_N/A to be paid for NIA Ordered before the contracted work begins in order S NIA to be paid for N/A to meet the completion schedule.('*) NOTES: (*) Including all finance charges of 1-5% per month from due date until amount is paid in full plus $50 processing fee (**) Law requires that any deposit or down- ap yin 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 any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. year v zrant4'rlu all I'M labor. Owens Corning Standar(; per estinlate as tshibit B ti'arraoties shat be timely plrridcil by the Contractor to tner prior ill or gran completinrl of Wit work. E9(; W,rit-rauty to be re; istercd by Contractor for 0V florricoavucr upon _;ob co"1aplction. 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. 'Be contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement- 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. Renew the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement 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 One Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured. • 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. Photography and Testimonials All Photos/testimonials and rights relating to them, including copyrigbt and ownership rights in the media in which the photos are stored, remain the sole and exclusive property of the Contractor. The Contractor has right to reproduce, publically display, and distribute for promotional and advertising. 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 fallowing the signing of this agreement. See the attached notice ofcancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE A.N Y BLAIN K arAILENT I I Two identical copies of the contract must be completed and .signed. One copy should go to the homeowner. The other copy should be kept by the contractor. > s^ Homeowner's Sign; rue I 7-? Date % F/ Contractor's Signatnre Date 1/27/17 Contractor Arbitration The home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. 6� A / a,—ez Homeowner's Signature Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure "their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold .in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law," contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 (617) 973-8787 or 1-(888) 2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Horne Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 Professional Building Services l " 9 Olde Woode Rd Salem. NH 03079 www.professionalbuildingservi ces.com info@professi(malbuilditigservices.com 503-898-2977 / 781-995-2335 . Ndh l Address Eric Kozo] 95 S .Bradford Street North Andover, MA 018115 Estimate . Description +. Qty Rate TOW OWENS CORNING STANDARD WARRANTY - SILVER PLAN i 375.00 375.00 Building Penuit - Administration Fee Home owner can pull building permit themselves. If customer wishes Professional Building Services to pull permit, please. add 5375. ** Customer to reimburse Professional Building Services cost of permit fee paid to Town/City. 0.00 0.00 Building Permit Fee paid to Town/City - TBD This fee to be reimbursed to Professional Building Services or customer can pay directly to municipality Thank You. We look forward to working with you ! Tota Page 1 Professional Building Services r 9 Olde Woode Rd Salem NH 03079 www. profession albu ildingservices.com '.' .., info@professionalbuildingservices.com 603-898-2977 / 781-995-2335 Name:/. Address Eric Kozol 95 S Bradford Street North Andover, MA 01845 Estimate Date Estimate '# 1/24/2017 3747 Exp. Date 1/30/17 Description -QtY Rate: Total 15 440.00 6,600.00 OWENS CORNING STANDARD SYSTEM ROOFING WARRANTY Professional Building Services to register warranty with Owens Coming in homeowner name. Strip and dispose of I layer of existing shingles Cover house with tarps for protection Inspect roof deck. Install Owens Coming Fiberglass reinforced felt iinderlayment Install 6' Tri built ice and water shield in all valleys and edges. Inspect all roof flashings and.re-use if possible Install 5" aluminum drip edge and metal flashing Replace all vent pipe boots. Install Owens Corning Starter Shingles Roll on first course Install Owens Corning TruDefinition Duration Designers architectural shingles. Color - TBD Install TriBuilt Roll Ridge vent on ridges Install Owens Coming Hip & Ridge Shingles on hips & Ridges Thunk You. We look forward to working with you i Total Page 2 Professional Building Services -" 9 Olde Woode Rd Sateen NH 03079 www.professionalbuildingservices.com info crprofessionalhuildingservices.com 603-898-2977 l 781-995-2335 Narne %-Address Eric Kozo] 95 S Bradford Street North Andover_ MA 01845 Description tlty: Rate Total l 575.00 575.00 Chimney Re-leading/flashing. Supply & Install new lead flashing on all chimney penetrations l 275.00 275.00 4' Venture Ridge vent upgrade 11. 80.00 880.00 2nd layer of roofing shingles strip and disposal 0 775.00 0.00 OPTION: Supply & Install Solar powered roof vent ** will not need dumpster if there is enough space in existing 0 495.00 0.00 dumpster** 15 _yard dumpsterwith 2 tons. If additional dumpster needed, customer agrees to pay for additional dumpster or dumping fee of $125 per ton. 0.00 0.00 ROT REPAIR - remove, dispose, purchase and install 4:x8 plywood - $ 100/sheet Structure/frame repair rates: $165/hr for Master Carpenter & Carpenter Apprentice Materials receipt to be provided plus 150,o for administration fee Thank You. We look forward to working with you ! Total Page 3 ;t Professional Building Services 9 Olde Woode Rd Salem NH 03079 w Av.professionalbuildingservices.com infoprofessionalbuildingservices.cum 603-898-29771781-995-2335 Estimate in -;n t ty ` lat total OM 0.00 CONCEALED CONDITIONS: This Agreement is based solely on the observations Contractor was able to make with the structure in its current condition at the time this Aareement was hid. If additional concealed conditions are discovered once work has commenced which were not visible at the time the proposal was bid, Contractor will stop work and point out these unforeseen concealed conditions to Owner so that Owner and Contractor can execute a Change Order for any Additional Work. Thunk You. We Look forward to working with you ! -total $8,705.00 Page 4 The Commonwertlth of Massachusetts Department of Industrial Aecidetrts• Office of Investigations 600 Washington Street Boston, Ii,L4 ()2111 www-nws.got /din Workersr Compensation Insurance Affidavit: Builders/Contractors/Flectricians/Plumbers ADDlicant Information Please Print Leaibdv Name (Business/Organiration/individual): /�,i , Address: City/State/Zip: &1......__lua._._S�,7 2. Phcme ; : iO C) q j� ;lLq-1 -1 Are you an employer? Check the appropriate box: 1.0 1 am a employer with -_ 6 4. 1 ant a general contractor and 1 employees (fall and/or part-time).* 2. ❑ 1 am a sole proprietor have hired the sub -contractors listed t or partner- ship and have no employees on the attached sheet, These sub -contractors have working for mein any eapaciry. workers' comp. insurance. [No workers' comp, insurance 5. We are a corporation and its required.) 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself, fNo workers' comp. c, 152, § 1(4), and we have no I Type of project (required): 6. [ ] New construction 7. Remodeling R, Demolition 9.] Building addition M,;0 Electrical repairs or additions I I . Li Plumbing repairs or additions 12.[� Roof repairs Insurance required.) + employees. [No workers' i3. ,,J Other comp. insurance required.] er_---- _...__._..._ ..._._...._.__..._._.__. "Any applicant that checks box fit mast also till out the section below showing their workers' cnmpensation policy intitrmation--.........._.. Homeowners who submit this affidavit indicating. they are doing all work and then hire outside contractor; must infera new aliiclavit indicating such. 'Contractors that cheek this box must attached an additional sheet showing the name onhe sub -contractor; and thea worker' sump. put icy tntormation. I am an employer shat xs provi&ng workers' compensation insurance for my enrployeec. Below is the policy and job site information. Insurance Company Name:?-{ �J �1 L'T.. +_ j.0 ........ _.... _._..-._._.. Policy # or Self -ins. Lie, ti,- V_ y Qj t - �%' �^ �--=_/-�-_��.�._/_���.____..............�_S._.__.._..........__...... i:xpiration 1�aie.:._........ _,-L Lift .__._....... Job Site Address: ! J /1 (JFGI-I-1 S(, City/State"Zi Attach s 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 MG1.. 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 cerlifv under the pains and penalties of perjury that the information provided above is trite and correct. 11 r. official use only. Do not write in this area, to be completed by city or town of -tial, City or Town: Permit/License # I -Z -�- 261 --- Issuing Authority (circle one): L Board of Hesilth 2. Building Department 3. Cityfrown Clerlt •l. Z;icctt•ic;al Inspcctor 5. Plumbing Ittspectur 6. Other Contact Person: Phone 0 / ACoR" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 1/27/2017 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 Financial Insurance Services Inc PO Box 950 Derry NH 03038 CONTACT Patricia Blais NAME: PHONE (603)432-6414 FAX A/C No:(603)432-3852 -MAIL ADDRESS:p blais@fisins.com INSURERS AFFORDING COVERAGE - NAIC # INSURERAMain Street America Assurance 29939 INSURED Professional Building Services By PMC LLC 9 Olde WOOde Road Salem NH 03079 INSURER B National Grange Insurance Co 14788 INSURER C: INSURER D: INSURER E, INSURER F: COVERAGES CERTIFICATE NUMBER-CL1712606662 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 LTR OF INSURANCE ADDLITYPE IVSD SUER POLICY NUMBER POLICY EFF MM DD POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR MPT1630H 2/5/2017 2/5/2018 EACH OCCURRENCE $ 1,000,000 DAMAGE TO PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: R POLICY JE� F� LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 Employment Practices Liab Ins $ 100,000 B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS R AUTOS - B1T1630H 2/5/2017 2/5/2018 CEa MaOccidentBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ Medical payments $ 5,000 UMBRELLA LIAB HOCCUR EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? ❑N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below PER 12TH - ISTATUTE ER EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CFRTIFICATF HOI nFR CANCELLATION jordan@professionalbuildin SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Eric Kozol & Lisa Kozol THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 95 S Bradford Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE f Sam Fragala/SETH - J ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD I N 3025 r901AM t A66"' CERTIFICATE OF LIABILITY INSURANCE 1227-2016 I 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($), AUTHORED REPRESENTATIVE OR PRODUCER,, AND THE CERTIFICATE HOLDER. IMPORTANT; it 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 eertificate holder in lieu of such endorsement(s). PRODUCER CONTACT HAYS INSURANCE BROKAGE NAVE. PHONE FAR 133 FEDERAL ST WC. N^ ,fl) ac Nol MAIL BOSTON, MA 02127 INSURER(S) AFFORDING COVERAGE NAIL Y.Y INSURER A; THE TRAVELERS INDEMNITY COMPANY OF AMERI INSU� INSURERS SURGE RESOURCES 11 INC 920 CANDIA ROAD INSURER C _... INSURER D MANCHESTER. NH 03109 INSURER E INSURER P LViSITla.f_Tel k11:1ref_ (:*1 U ItT3 II RFVIAIhN NIIOARS`R- 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 L7R TYP90FINSURANCE _ 'A001. INSR SUB 4W0 POLICY NUMRI:7L POLICY I-" POLICY EXP Mt,.U�OlYVYY " _ LIMITS GENERAL°LIASUM EACH OCCURRENCE y COMMERCIAL GENERAL LIABILITYOAMAOP JCZA SS -/,IAD-- 0 OCCUR to RENIED $ .L_.... `JEO EXPAiy ow person) S PM. SCNAL & ADV INJURY _ S GENERAL AGGREGATE S .,,GEN'L, AGGREGATE LIMIT APPLIES PER; POLICY jgp� LOC PRODUCTS - GO`d,PIOP AGG S b BILE LIABILITY# SINGE LIMIT g W-, ANYAUTO ALL OWNED SCNEDULED AUTO$ AIITOS NON-OWNE'O HIRED AUTOS AUTOS I BODILY BODILY INJURY (Per poreott) S LBODILY INJURY (Par accfdotn) S A Q "RTYNii.GE " S. UMBRELLA LIAR OCCUR I EACH OCCURRENCE S EXCESSLIAO CLAIMS -MAGE I AWREGATE 0ED1 1RETEl`,MON$ WORKERSCOMPENSATION,�.—•�.. AND Eh1PLOYERS' LIABILnY Y IN ANY PROP9IETO"ARTNER/EXECUTNr` OrPICER'MEMSER EXCLUDED! N in' If yes,, describe Hunder DESCRIPTION OF OPERATIONS bWw IIIA 6HUS 9F438417 .�......._...._� I 12-31-2016 12-31-2017(Mantletory I X_' WGSTAIU- OTY- , ORY UMI T S R IE.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE w1,000,000 E.L. DISEASE •POLICY it;.fiT g1 ,000,000 DESCRIPTION Or OPERATIONS LOCATIONS VEHICLES (Attach ACORO 101, Add)tlonal Remarks Schedule, If mo ro sone Is reciutmd) "COVERAGE IS RESTRICTED TO THE LEASED EMPLOYESS OF PROFESSIONAL BUILDING SERVICES' ERIC KOZOL & LISA KOZOL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 95 S BRADFORD ST CANCELLED BEFORE THE EXPIRATION DATE THEREOF NORTH ANDOVER,MA 01945 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUT/iWRi,Z,EO REPRESENTATIVE ACORD 25 (2010/05) The ACORD name and logo are i T � C n �6Z3 6 �N U Q^ `4 W O r .20 er •5 ar O y O ^, o C O 16- Vl 7 S 0. O SAO•-ai Co O AGM QOo ' ° c g3z o a ea v y � LU W Q p WJOQ U CL0)0 Im C O � I 6 b y Q r .20 er •5 O y O ^, O 16- Vl 7 S 0. O SAO•-ai i 1 f 4 c im cC O a y u 1 0ii Z W 1 � � U U Z oe w 00 'o w C ,N uWi 1 > O r c U o `. Q o 0 h J W w Q7 O, Z Cl) O w� _� <pz U) U Z W WD J W 4 W Q d CL m (n \ r � Location No. -I q —t— Date Check # �� 6 J' x.33 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 4t-�' — Foundation Permit Fee $ Other Permit Fee $ TOTAL $ f Building IAspector