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HomeMy WebLinkAboutBuilding Permit #579-14 - 96 DALE STREET 2/6/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: _ Date Received Date Issued: —`,o ` IMPORTANT: Applicant must complete all items on this page LOCATION L_C4- — ` �' Oco!2 — �+ ,r � Print: PROPERTY OWNER l c�cu.�1.'t-�f Print lIt i 00 ear Old Structure yes UP - MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ' New Building 75-One family ❑Addition ❑Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial ' ❑ Repair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain 0 Wetlands ❑ Watershed District ❑Water/Sewer DESr�RI�OJd OF WORK BE PERFQRMED� ( S Zl Ide tificatif Please Type or Print Clearly) OWNER: Name: hone: 9?46' _ G�� Address: 1'S 6 ori a PA ol� C2'9Z CONTRACTOR Name: 40rllic_� � �7 Phone: Address: 156 A(-/I pi Q__4J " P� � n,-SZ( Supervisor's Construction License: 07116149' Exp. Date. Home Improvement License: f 773 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ V t FEE: $ T�9� 4 160 O G- . Check No.: Receipt No.: NOTE: Persons contracting with q egistered contractors do not have access to th uaran • fund Signature of Agent/Owner Signature of contractor Plans Submitted Plans Waived ❑ Certified Plot Plan Stamped Plans I Location �Iz- No. "' Date { TOWN OF NORTH ANDOVER Certificate of Occupancy $ •00 ' Building/Frame Permit Fee $_ Foundation Permit Fee $ Other Permit Fee $ �.' TOTAL $ Check# 'ILK " 27278 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ElStamped Plans ❑ 'TYPE.OF:SEWERAGEDISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . .Swimming Pools ❑ Well ❑ Tobacco.Sales 0 -Food Packaging/Sales ❑ Private(septic tank, etc.. El- =Permanent I)umpster on Site THE-FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM ._,DATE REJECTED DATE:APPR-OVED PLANNING & DEVELOPMENT ❑ �� COMMENTS W'V/ , I hag be-urn. CONSERVATION Reviewed on -7) Signature COMMENTS i HEALTH Reviewed on C�t Si nature ✓ COI�MENTSA TUW)V\ �)Jzed aA81 (jam k Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection Permit DPW Tow�z Engineer: Signature: Located 384 Osgood Street FIRE DEPARTM.L-A -.tem Dunn star on site :yes no �" p p Located'bt 124 Mair;,Street:-:_ 'Fire'Departine►it signature/date ' ' COMMENTS .-.-Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. 3� .Total land area, sq. ft.: ELECTRICAL: Movement of Meter.location, mast or service drop requires approval of Electrical Inspector Yes No DANGER.Z®NE LITERATURE: Yes No MGL-.Chapter 166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA— For department use i lJ Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department � The foil l wing is=a=list of the required-forms to be filled out for:the.appropriate.permit to`.be obtained. l Roofing, Siding, Interior Rehabilitation Permits I o Building Permit Application 0 Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/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 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 ❑ 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 We decision from the Board of Appeals that the apnaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-tted with the building application Doc: Doc.Buil,iing permit Revised 2012 32 r•.e. •_.'•ape. *o i � �'SACIWSfSg CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 579-14 on 2/6/2014 Date: February 17, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED ON 96 Dale Street—Lot 1 MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE.MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Country Places Development 96 Dale Street North Andover,MA 01845 Bu lding Inspector Fee: PrePaid$100.00 Receipt: 27278 Check : 5137 NORTH '9 A APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION �qs R,TEo�p5 BUILDING PERMIT # �� r SAcf"jus ADDRESS/LOCATION OF PROPERTY: d C�" 6 Map Parcel I Lot Number SUBDIVISION: DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: FIVE_( DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to: (— Address: 66 f�a d`­P_ 14f l j ROUTING - TOWN ENGINEER SITE PL4N—D E-WAY REVIEW 1 CONSERVATION . PLANNING DPW-WATER METER SEWER CONNECTION DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCYANSPECTION REQUEST I DPW , SIGNATURE File:Application for OC form revised Jan 2007/2011 A, ` r 1 - 7 NORTH - . w. .. . � _ i( . ve. . 0 h Z o : �Ah! h , ver, Mass,I Lt L COCNICMIWICK S'4ATED ►'PP,`�(5 U BOARD OF HEALTH Food/Kitchen PERMIT T L D. S is Sys THIS CERTIFIES THATBUILDING INSPECTOR CJW.. .. NA..... at ... p........-.. ...... .... ........... ..... ...... .................................. oundati has permission to erect.......................... buildings on ...q-J6.......VA.6.......16.....a................. to be occupied as .... ...... ......................�...... ....... .. ..............• ........................... c provided that the person accep g this permit shall in a ery respect conform to the ter of the application :Fin _` on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and !:�4 Construction of Buildings in the Town of North Andover. 'PLUMBINVINSPE&&I VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough � Final /Gs.��- 13 41/Q11/1 � «, G•t� . PERMIT EXPIRES IN 6 MONTHS �L�ECTRALINSPECTOR UNLESS CONSTRS N RTS Rough.. oon mamma Service ............................................................ final BUILDING INSPECTOR -GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final Pis 14-11144p— No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner � Street No. Smoke Det. iZ�/z_� SEE REVERSE SIDE r 1 NORTH : :. . : ver - : No. h , ver, Mass,LAKI t COC MIC"l WIC" A�R4TED 10!�1., �y S U BOARD OF HEALTH Food/Kitchen S is Sys THIS CERTIFIES THAT . BUILDING INSPECTOR PERMIT D .......... r...6...... ...... ...� :its....... ...............p ......................... oundati has permission to erect.......................... buildings on ... .to.......VA.it V,.......16.....a................. iF;wwa • ou '/ tobe occupied as ....S....... .................................. ......... .. .............ier .. ............................. c provided that the person accep g this permit shall in a ery respect conform to the ter of the application F;n 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. 'PLLIMBININSPECTOI ' Rough 0e /d/I r/i VIOLATION of the Zoning or Building Regulations Voids this Permit. Final G n . PERMIT EXPIRES IN 6 MONTHS LALINSPECTOR� ('.. UNLESS CONSTR ION RTS Rough _ ,: r Service %L ........ . .................................... .. ........................ final BUILDING. . INSPECTOR 1, /�"�"l fee GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough /04-x' /1 lIS%t476 Display in a Conspicuous Place on the Premises — Do Not Remove Final P4" 1qj/j No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner � Street No. Smoke Det. 2 SEE REVERSE SIDE LAWRENCE H. OGDEN, P.E. 198 EAST IMAIN STREET GEORGETOWN, MA 01833 978-352-8318 fax 978 352-2858 April 2.1. -70 14 cell: 978-502-5921 Mr.Jeff I-lorne 168 Barehill Road Box.ford . N-1a. 01921 96 RE: Jx,<Dale Street North Andover Dear Mr.1-lorne As you requested I conducted a final site visit 4/14/14 to review the installation of the EnQineered Materials consisting of I,VI-s.beams utilized in the framing,of the above project.. The I-vis are shown on plans prepared Horne Construction Corp.dated 7/1/13�l Nvith the framing plans sheets A- 5.9-10-11.12-13 &14 certified by me 10131'`1 3. at the time ofthis visit the house -tvas framed-the roofing.siding. and garage door trim were in place. Based on the above site visit and based on what I could visibly see. I can certi6, that to The best of my knowledge the LVI-s members and details utilized in the framing raming as shown on the drakvirigs are, installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State, Building- Code for 1&2 Family Residences. provided the following work- is perfori-ned. All other framing requirements of the drawings and code.including but not limited to materials. nailing schedules, blocking connections. manufacturers installation ,requirements and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours tIV. Lal ence H. Qgden P.E. Structural 27765 AAL 0 LOT 1 N O t3? a EXISTING N FOUNDATION ELEV.=186.2' 36�• �,0 5 ao % NOF�yss ag � J. � MICHAEL 9�yG .d 2 RGI 00 No 33191 qFES7SIO��Q 0.01 /'0 E1 V R _ DALE ST. F O U N DAT I N L I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO O O CATION THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. CLIENT. JEFF H O RN E (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT ORDERS OF CONDITIONS,ETC.)THIS DRAWING SHALL NOT BE USED LOCATION: NORTH AN DOVER,MA. BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN &SERGI INC.FURTHERMORE THIS DWING IS THE DATE:1/30/14 SCALE: 1"=100' PROPERTY OF CHRISTIANSEN&ERGi INC.AND ANY COPYRIGHTED UNAUTHORIZED USE IS PROHIBITED.CHRISTIANSEN&SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR-MATION CONTAINED HEREON. PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN & SERGI, INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX. 978-372-3960 DWG.NO.:11032.001.007 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 4081000.,00 m $ - $ 4,896.00 Plumbing Fee $ 612.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 612.00 Total fees collected $ 6,220.00 DALE ST 96 NORTH{ Town of : _ Andover O `�� "' to No. 511— h ver, Mass, t A- c0c.4.2.,cw yq. 7d A�RgTEO r'pa,��� 1S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .0.41^40'�%t4;" BUILDING INSPECTOR ......... ...... ... .... ....... ...... .....P................................. has permission to erect.......................... buildings on ... .......T44. ......16.....a................. Foundation Rough to be occupied as .... ........ ......... �........ ......... .. .............. ... .........®.... Chimney provided that the person accep g this permit shall in eery respect conform to the ter of the application 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final lot) a",0 . PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR ION RTS Rough qf% oon Service ........ . ......:......................................................... 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 NORTF1 Town o ... ndover No. 11- 1 Lt K ver, Mass A COC.41CHI S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System 1111 THIS CERTIFIES THAT .�. /.r....... 3 BUILDING INSPECTOR ...... ....ta... .......... ...... .....per....................... has permission to erect .......................... buildings on ...Q. ....... 4i. ......16.....a................. Foundation Rough tobe occupied as .. ........ .... ...................�........ ......... .. ..............•... .........®.... Chimney provided that the person accep g this permit shall in a ery respect conform to the ter of the application 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final lot) CpsO . PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR woo UNLESS CONSTRS N RTS Rough' q �� Service ..... ............................................................ 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. IL SEE REVERSE SIDE i . TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: — Date Received -� i Date Issued: ` l IMPORTANT: Applicant must complete all items on this age LOCATION-LD4 _t! -- - - - -P _ �� � � dint. PROPERTY OWN ER�r�ac�,l-t/� 02_CG.'S Print 1 Vo r ear Old Structure yes, MAP NQPARCEL:ZONING DISTRICT: Historic District yes. Machine Shop.Village. yes_, .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ' New Building 7.10ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic El Well 0 Floodplain ❑Wetlands ❑ Wate_rshed pistrict o Water/.Sewer _ _ DES IPTIOfN OF WORK TO BE PERFORMED, Con �- z S`�Q c�J erG C;-_ Vice s7 Ide tificat on Please Type or Print Clearly) OWNER: Name: nn hone: Address: 1!3 6 1 c G� �>�C aq CONTRACTOR' Name:. (::",L _ Phone: Address: 156 Supervisor`s Construction 'Li:--11, p. Date: (f l el Ex _. - Horne Improvement Licensee: ���SSZ -- - _ __- Exp. Date ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ loo o L Check No.: Receipt No.: 2--:�aaELI NOTE: Persons contracting with u egist red contractors do not have access to th uaran , fund Signn_ature�offA'gent/Owner ', ;Sigilafure of'contractorr - .�. __ - - Plans Submitted Plans Waived ❑ Certified Plot Plan W Stamped Plans 2/11/2014 14:57 FAX 9787779443 GUARINOINSURANCE 001/001 / 11 /2014 2 : 54 : 17 PM Its 0LV =DA7E(MM/DDNYYY) , CERTIFICATE OF LIABILITY INSURANCE �~ THIS CERTIFICATE DOES NOT AFFIRMATIVELY MATTER OF INFOF NEGATIVELY AMETION ND, EXLY TEND,NORRA TERRTHETS UPON COERAGE THE 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. the fermis an If n certificate holder it ertain polices may require an ethe ndorsement, A statement on this certust be andDirsed. if ificate does not conferDrightsjto the the t®ruts and conditions of the Policy, certificate holder In Ileu of such endorsatnent(s)- CT Daniel Guarino PRODUCER 02956-001 RLI?IWo EYt (978)777-5820 MI (978)777-9443 ; No.: Daniel J Guarino Insurance Agency Inc 199hos! 99 Rosewood Dr Ste 111 Danvers,MA 01823 DING RE A.I.M.Mutual Insurance Company 33756 -Itisu INSURED Home Construction Corp INSURER r. 156 Barohlll Road Boxford,MA 01921 SURE 11,4011 COVERAGES CERTIFICATE NUMBER_ REVISION NUMBER: III THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A1/tBIIOTHERESP FOR THE CT TO LW ICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOPERIOD CUMENT 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 POLICII=S.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS ITYPE OF INSURANCE { POLICY NUMBER M IDO/Y MM EACH OCCURRENCE $ _ GENERAL LIABILITY A • T�� COMMERCIAL GENERAL LIABILITY M FS my ono* rrance MED ElCI?(Any G.ars{+n( CLAIMS•MAOE F7 OCCUR PERSONAL a ADv INJURY $ GENCRALAFGREGATE ti , PRODUCTS-COMPIOP AGO S F-N'L AGGREGATE LIMIT APPLIES PER OLICY RO OC 9FN07�,Kg EUMII $ cc AUTOMOBILE LIABILITY ]BOOILY INJURY(Far ptireonl S ANY AUTO ALL OWNED SCHEDULED BODILY INJ!IRT(per ecoaQn11 $ AUTOS AUTOS { A b y HIRED AUTOS NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE 6 AGGREGATE M:MAO' $ 5%Ce99 LIA® CLAI S DED kETENTION MONWRUTL4P4 Y yN E.L.EACH ACCIDENT $ t,000,000s A gO IPR�P I�TORI XRjf I CECUTIVEr,-7 NIA AWC�00-7028718-2013A 3/29/2013 3/298014 E L DISEA:'•E-EA EMPLOYE' x 1,000,OOO.0 (mandatory In NNI C4 Llr� �d E L DISEASE-POLICY LIMIT E 1,000,000.0 9-9W�p a 5P RA7 ,nein- DEI9CRIPTIDN OF OPERATIONi 1-1 OCATIONS!VEHICLES(Attach ACORD 101,Additional R•maHle Schodula,If mon VPooe le required) CERTIFICATE HOLDER CANCELLATION To"Of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED SEPORE 1600 Osgood Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVI ROD IN North Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS- AUTHORIZED REPRESENTATIVE: ®7 0 CORPMM01N.AlTr1g s reserve ACORD 25(2910!05) The ACORD name and logo are raglstered marks of ACORD 8782 HORNE-1 OP ID:KW '4lcorro° CERTIFICATE OF LIABILITY INSURANCE EDATE 11 1 2 512 01 YY) 11!2512013 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 CONTACT NAME: Daniel J.Guarino Ins.Agency PHONE Ax www.djgins.com Arc No Ext1: a( c,No): 99 Rosewood Drive Suite 111 EMAIL Danvers,MA 01923 ADORESSL. INSURERS)AFFORDING COVERAGE NAM 0 INSURER A:Norfolk&Dedhan Mutual Fire 13706 INSURED Horne Construction Corp INSURER B; 156 Bearhill Rd Boxford,MA 01921 INSURER c: INSURER D INSURER E: IN URER 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 ADDL SUBPOLICY EFF PO Y EXP ' TR TYPE OF INSURANCE INqR WVD POLICY NUMBER M/DDlYYYY M OD/YYYY LIMiT3 GENERAL LIABILITY EACH OCCURRENCE $ 1_,000,00 A COMMERCIAL GENERAL LIABILITY R0640878A 08/29/2013 08/29/2014 PREMISES Eaoccurrence) $ 100,00 CLAIMS-MADE 0 OCCUR MED EXP Any one arson) $ 5,00 X Business Owners PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 POLICY PRO- F I LOC $ AUTOMOBILE LIABILITY O BIINEMSINGLE LIMIT T - -1 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED 1 SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS _ NON-OWNED PROPERTYDAMAGE JI HIRED AUTOS AUTOS PER AC (DENT $ $ J UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE Is OED I I RETENTION$ is WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y 1 N .I ANY PROPRIETOR/PARTNER/EXECUTIVEf� N r A E.L.EACH ACCIDENT is OFFICERIMEMBER EXCLUDED? - u (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE$ n es,desa be under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ PROPERTY 10,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If mora space Is reWlred) Coverage is subject to all terms and conditions of the policy forms. CERTIFICATE HOLDER CANCELLATION TOWNNAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of N.Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept 1600 Osgood St. AUTHORIZED REPRESENTATIVE Bldg.20 Suite 2035 North Andover,MA 01845 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth o fMassachusetts Department of_fndustr afAccidents Office of-Investigations 600 Washington-Street Boston,MM 0.2111 U www massgov/dia 'Workers' Compensation Tnsurgnce Affidavit:Builders/ContractorsfFIectricialns/Plumbers Applicant Yntforlmation 'lease Prmt Lgg bly Name(Businessforganization&dividual): Address: ` City/State/Zip: O / j�— Phone#: j G- [Ere an employer?Check the appropriate box: a employer with 4. T am a general contractor and I Type of project(required): loyees(full and/or part-time).* have hired the sub-contractors 6. New construction a sole proprietor or partner- listed on the attached shget.z 7. ❑Remodeling and have no employees These sub-contractors have S. ❑Demblition ing for me in any capacity. workers'comp,insurance. workers'comp.insurance 5. ❑ We ai•e a corporation and its 9. ❑Building addition red.] 'offcers have exercised their 10.0 Electrical repairs or additionsa homeowner doing all work right of exemption per MCxL11.❑Plumbing repairs or additionslf.[No workers'comp. c.152, §1(4),and we have nonce required.]i em to ees. 12.❑Roofrepairs p y [No workers' comp,insurance required.) I3.❑Other !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submitthis affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors sidcontractors and their workers'comp.policy information. lam information.an employer that is-providing wofkers'compensation inforinsurance for my employees. Below is the policy and job site Insurance Company Name:_ ' Policy#or Self-ius.Lic.# �f �70 7/c�_Z /J/9- 7 _ Expiration Date; J�z`f' .-�`j�• Job Site Address: /4 �� �-� , City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policynumber and expiration date). Uailure to secure coverage as required under Section 25A ofMGL 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 civilpenalties iu the form of a STOP WORK ORDER and a fine )f up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of n.vestigations of the DIA for insur ce coverage verification. do hereby certy under tli airs d enalties o P fperjury tliat the information provided above is true and correct. i nature: Date: 1Z zone#: Official use only. . O not Write in this area,to be completed by city or town official City or Tow: Permit/License# Issuing Authority(circle one): , L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S Plumbing Inspector S Other ry ..OIltact pPrenn• j Massachusetts-Department of Public Safety Board of Building Regulations and Standards F � Construction Supervisor License.. CS-071149 JEFFREY S HORNE 156 BA FJ ILL ItD it BOXFORD MA 61921 ' „ lit Expiration Commissioner 05/2112015 — ` ' --- -- ze Tpananeoazruea o a:sachweM Office of Consumer Affairs&Bus! Css Regulation rOME IMPROVEMENT CONTRACTOR Type. egistration: .;:,173842 pWiration:..;-j1t2QE201.4 Corporation t HORNE CONSTRUCTjO,N JEFFREY HORNE ' T` 156 BARE Hitt RD BOXFORD,MA 01921 Undersecretary