HomeMy WebLinkAboutBuilding Permit #1165-2016 - 981 JOHNSON STREET 5/9/2016 01FJ
BUILDING PERMIT t-qulo
A,/? vA q +b 'TOWN OF NORTH ANDOVER �- *P-0 APPLICATION FOR PLAN EXAMINA IO y �*
Permit NO: `C Date Received
Date Issued: sS^`"use
I PORTANT: Applicant must complete all items on this page
LOCATION ` g,/ JoHNsonf -5-rxeer. &I ,v 418''if5-
Print
PROPERTY OWNER fd4a &94t-&(E JC STA keeLe-p
PT Print
MAP NO: 107.A PARCEL: ZONING DISTRICT: jZ2 Historic District yes no
210/107,6 _�2�_ Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
0 Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic �� Well Floodplain C Wetlands Watershed District
❑ Water/Sewer
Zee! !c�1 of' F X l5TJnlcf DfQ1-' CoM&A(607-s As NktXS54QyT?6
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106 pip C6 kiEm :F1 tg-c-
Identification Please Type or Print Clearly)
OWNER: Name: TT $o RtStA R, Phone: NA-T.
Address: J0qq-TaKf S-K f-t7' N +J Dl� 5! 04 �19b- 49oz
CONTRACTOR Name: Phone:
Sum M. Jn[sEK(
Address: -a-�
31 L-DC-YLWOoy DR%Vb; ST6oV-rA . MA Q2012
Supervisor's Construction License: Exp. Date:
CS — 102 r! 92$l 01 7 �
Home Improvement License: Exp. Date: t.
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: $ FEE: $ 1 �6--
Check No.: _ k! Receipt No.: X4-543
NOTE: Persons contracting with unregistered contractors do not have access to a guaran fund
Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ flans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
i
TYPE OF SEWERAGE DISPOSAL r:
I
Public Sewer ❑ TanmingfMassage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales
❑
Pr'
Private(septic tank,etc. Permanent Dempster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING DEVELOPMENT Reviewed On ? Signatur\
e_
COMMENTS
CONSERVATION Reviewed on 5' / Signature
COMMENTS
l
HEALTH Reviewed A4
Signature
COMMENTS i
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
r
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
]DPW Town Engineer: Signature:
Located 3840
REqol�-aledoj5;$ x240rrlibQ�tr2e�et
PART M-NT Temp Dumpsfie�on sit esca
Osgood Street
.f
FRe [Deppa . menrdate
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51
�'C�IVIMENT�S�,_.
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, rust 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)
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❑ Notified for pickup Call Email
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Date Time Contact Name
Doc.Buildiug Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4. Building Permit Application
4. 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)
4. Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Construction (Single and Two Family)
New C® ( 9
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
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
Location
No. 'rZ " Date
. - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 14q�
Foundation Permit Fee $
Other Permit Fee $ �.
TOTAL $
Check# '�,p
J V J Building Inspector
� NORTF�
own of ? : _ n over
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C% h ver, Mass,
D LAKI
COC MICNew1c« ��•
tl BOARD OF HEALTH
Food/Kitchen
. PERMIT T LD Septic System
THIS CERTIFIES THAT . �. . ' A'&6-I`111 BUILDING INSPECTOR
has permission to erect .... .................. buildings on . . . ....136 ........ .... .. Foundation
........................
Rough
to be occupied as .. ... . .. ....� •4�. . .. ... :.. .... .. ....... Chimney
provided that the person accepting this permit shall every respect coform to the terms 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO TARTS Rough
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.
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WETLANDS DELINEATED BY
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FN LOT 12
4A AREA=45,066 S.F.
3A =1.0345 AC.
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JOHNSON STREET
NOTES PLAN OF LAND
1 . SEE TOWN OF NORTH ANDOVER ASSESSORS MAP
#107 LOT #222 AND DEED BOOK #12138 PAGE IN
#207 E.N.D.R.D. FOR SITE. NORTH ANDOVER, MASSACHUSETTS
t2 DRAWN FOR
2. ZONING DISTRICT IS R2
N MATTHEW BOHENEK
981 JOHNSON STREET
o NORTH ANDOVER, MASSACHUSETTS 01845
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o `� r SCALE: 1�,=40 DATE: DECEMBER 1, 2015
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F. � � 0 20 40 80 120
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TM #78 TL #33 SDL B
MERRIMACK ENGINEERING SERVICES
12/1 /15 68 PARK STREET
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STEP EN E. STAPINSKI, R.L.S. DATE ANDOVER, MASSACHUSETTS 01810
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Jensen Bode and Remodel ESTIMATE
34 Eldenwod Drive,Ctnnagatorn Massachusetts(W—,2 2016-001
P'(781)M-8333 E:.TertsonBrildingtteinodelin�li>9aiaiLe.oin Deck Renovation
March 31, 2016
CUSTOMER NAME/ADDRESS
Matt Bohenek/Krista Keeler
981 Johnson Street
North Andover, MA 01845
PROJECT DESCRIPTION QTY. UNIT COST AMOUNT
Deck Renovation
Base Costs
General Conditions:
Permits ($12/thousand dollars of work) $ 156.00
Equipment Rental -
Concrete Mixer 2 Days 70.00 $ 140.00
Auger 1 Day 80.00 $ 80.00
Travel 8 Days 20.00 $ 160.00
Architectural Drawings - as required for permit $ -
Demolition:
Removal of all necessary components $ 800.00
Debris Removal - dumpster 1 Ea 550.00 $ 550.00
New Construction:
Concrete Piers - replace existing 8"with 10" 18 Ea 90.00 $ 1,620.00
Posts-replace existing 23 Ea 82.00 $ 1,886.00
Stairs (front and rear) - replace framing 15 Treads 31.70 $ 475.50
Trim- replace existing 1x6 w/PVC(white) $ 400.00
TOTAL $ 6,267.50
Decking Option 1 -Pressure Treated
New Construction:
Decking and Stairs - 5/4"x 6" 1000 LF 3.35 $ 3,350.00
TOTAL $ 3,350.00
Railing Option 1 -Pressure Treated
New Construction:
Deck Railing 82 LF 18.00 $ 1,476.00
Gates - 2 single (4'wide) 2 Ea 200.00 $ 400.00
Stair Railing 32 LF 18.00 $ 576.00
TOTAL $ 21452.00
GRAND TOTAL $ 12,069.50
Material Specifications:
All wood framing materials to be pressure treated. All other materials are as noted.
Utility costs (use of electrical,water, etc.)
Any unforeseen conditions
Repair of any existing rot at deck connection to house
Replacement of existing floor joists
Staining or painting of any kind
Estimate is valid for fifteen(15) days from date above.
Any change in work, including unforeseen conditions,will result in the issuance of a change order.
All furniture and personal items must be removed from areas of work by OWNER,prior to start of project.
PAYMENTS: 30%deposit due prior to start of project, 30%due at midpoint,35%due upon project completion.
X K,;t C-
Cu tomer Signature ltl Con ctor Signature hate
Customer Printed Name Contractor Printed Name
(By signing,you are in full agreement with the pricing,terms, and conditions of the proposal)
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North Andover MIMAP April 11, 2016
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MVPC Bo
Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NA083,
—I Meters Data Sources:The data for this map was produced by Merrimack
—SR
NORTIy Valley Planning Commission(MVPC)using data provided by the Town of
Roads OE t�rFn qy North Andover.Additional data provided by the Executive Office of
4,Easements 2 eft r�+s o� Environmental Affairs/MassGIS.The information depicted on this map is
L'Parcels3 _ L for planning purposes only.It may not be adequate for legal boundary
09 definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
16 �- +. THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
• tea' K� E ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
S+,nom THIS INFORMATION
RCMus
1"=93ft 4—
North Andover MIMAP April 11, 2016
927 JOHNSON ST _-
953 JOHNSON ST I 960 JOHNSON ST
107.A-0172 107.A-0007
107.0-0042 107.A-0171
107.A-0098
rn
967 JOHNSON ST 970 JOHNSON ST
i '
107.A-0221
1
107.A-0030
990 JOHNSON ST
981 JOHNSON ST N
R2 107.x-0222 '
1080 TURNPIKE ST '
107.0-0009
�l
CP
If' 1000 JOHNSON S
107.A-0136
991 JOHNSON ST
t- s X 0
; 107.A-0226
07.c-01x ._ ,:_ ,u ev
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107.A-013
107.A-0158
107.0-0108 1001 JOHNSON ST s
1
107.A-0280 107.A-0154 �.
13 MVPC Bo Zoning Overlay Zoning
13 Municipal Boundary 0 Adult Entertainment Distric Busine s t District
Machine Shop Village Ove C Busine s 2 District Horizontal Datum:MA Slateplane Coordinate System,Datum NAD83,
—Rail Line ®Watershed Protection Dist 11 Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack
Interstates 0 Historic Mill Area 13 Busine s 4 District NQRTil Valley Planning Commission(MVPC)using data provided by the Town of
—I 0 Medical Marijuana RGenera Business District QE Yt`EQ ea'14 North Andover.Additional data provided by the Executive Office of
—SR (3 Downtown Overlay District O Planne Commercial Dev a�4 se QQ Environmental Affairs/MassGIS.The information depicted on this map is
0Historic District Conido Development Dist 3 L for planning purposes only.It may not be adequate for legal boundary
Roads U Osgood Smart Growth(40 0 Conido Development Dist Q - A definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
t i Easements r Hydrographic Features 13 Corrido Development Dist 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
Indus:I 1 District 4K �, THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
Parcels Streams Induslri it2 District _
O Induslri 13 District z + OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
Wetlands ✓�us _ `�� i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
fl Indus:I S District ~� THIS INFORMATION
Exempt Lands Reside ce 1 District 'ri4.•b*isEp►e
Reside ce 2 District
R_idei ce 3 District SS4CKt
deice 4 District
1"=93 ftde ce 5 Dist/ct
�a
Ede ce 6 District
a esidential District
The Commonwealth of Massachusetts,
Department oflndustrialAccidents
•� =:F d I Congress Street,Suite 100
u '< Boston,AM 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leaibly
Name (Business/Organizationfludividual): h/ , �-�(���-�,, khtey lwit, fAtlL'*C,I.ou
Address: A ELbEa.�jkm® 17�R
City/State/Zip: 5W 4 OZ pA 2() Phone#: qyl 6 24 2
Are you an employer?Check the appropriate box: Type of project()required):
1.❑I am a employerwith employees(full and/or part-time).* 7. ❑New construction
201 am a sole proprietor or partnership and have no employees working for me in 8./;2 Remodeling
any capacity.[No workers'comp.insurance required.]
3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
4.F1I 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 11. Electrical repairs or additions
proprietors with no employees.
12.[]Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ � 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.❑We are a corporation and ifs of qc rs.have exercised their right of exemption per MGL c.
14.❑Other
152,§1(4),and we have no.employees.Wo workers'comp.insurance requited.]
T;
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who suUmfWs affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
lam'' an employer that is piov1diing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name: IU
Policy#or Self-ins.Lic.#: Expiration Date:
fob Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 verificatio
I do hereby cerilf nder hepai nd penalties of pefjury that the information provided above is true and correct.
Si .atur Date:
Phone#:
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): i
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 ofhire,
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 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 tb obtain a W6. rkers'
compensation policy,please call the Department at the number listed below. Self-insured companies shouldenter 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
From:TWINBROOK INSURANCE 781 848 6100 05/09/2016 10:53 #792 P.001/001
DATE-(MM/D�W)
CERTIFICATE OW LIABILITY Y INSURANCE �YY
�- 4�12�161
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 II
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 N :AMMEPaula Neves
Twinbrook Insurance Brokerage PHONE
0
400A Franklin Street E-MAIL (781) 843-700 1 A/c No:
Braintree, MA 02184
ADDRESS_ Pneves@twinbrook.com
— ----
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:Acadla Insurance i
INSURED INSURER B:AEIC
Jensen Building & Remodeling INSURER C:
---- --...-..._...-....... --- -- ------.._....... -......._--------— --- ---
22 Leonard Rd. , #2 INSURERD:
North Weymouth, MA 02191
INSURER E:
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; `ADDLSUBR• POLICY EFF ` POLICY EXP
L`TR` 'TYPEOFINSURANCE IACD IIWDI POLICY NUMBER I MM/DDNYYY MM/DDIYYYY LIMITS
A j GENERAL LIABILITY 7/5/151 7/5/16;_EACH OCCURRENCE $ 1 Q-Q O---.---._---.-.-.-
IBOA5163241 ,000
i s�DAMAGETO RENTED
X: COMMERCIAL GENERAL LIABILITY I j ;_P,gEMI$F�_-jacTc&ulfgrlce/,,,, —O,•00.0 _
CLAIMS-MADE ( :OCCUR i
...-........� X_a ? i-.MED EXP(Any one person) 1...5 ------ 5,000
`PERSONAL BADV INJURY g__._,�-,_QOO,,_O,O.O,..__
_._. I 1
.---- .._.__'----------........----------.-.__....----- ' j GENERAL AG GREGATE is 2 _000 000..-'_
GEN'LAGGREGATELIMITAPPLIESPER i IPRODUCTS-COMP/OPAGG 5 2,000,000
l I ------_................................._......_-- l---" -._..._.....__.._..`----
PRO-
I POLICY r JECT LOC 1 1 s
AUTOMOBILE LIABILITY tCOMBIN�EDSINGLELIMIT
nI
ANY AUTO BODILY INJURY(Per person) ---
I ALL OWNED SCHEDULED
AUTOS AUTOS i BODILY INJIiRY(Per'accident) $
NON-OWNED PROPERTY DAMAGE- _.......__..._..-.__.._
i
HIRED AUTOS AUTOS ; er accident -' $ -
Q' -----�- ----------- -
i
s
UMBRELLA LIAR
OCCUR EACH OCCURRENCE $
EX'ES SLIAB AGGREGATE $
CLAIMS-MADE :
DED RETENTION$
B WORKERS COMPENSATION j WCC-500-5015482-201' 1/25/16; 1/25/17; WC,.TATU- i 0TH-i
AND EMPLOYERS'LIABILITY ! i ;___-.T_,a.LIMITS_
' ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N
OFFICLR/futEMBER EXCLUDED? 1 N/A'! E.L.EACH ACCI DENT _-_; $_ _ 500,000
y I E L A EMPLOYEE!(Mandafary in NH) DISEASE, _ I, 500,000
It es,describe under - —
D SCRIPTIONOFOPERATIONS below , E.L.DISEASE-POLICYLIMIitS '5500,000
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DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is regui red)
Project: 981 Johnson Street, North Andover MA
i
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
1600 Osgood Street
Building 20 AUTHORIZED RE PRESENTATIVE
Suite 2035
IN. Andover—MA 0.1845 _ Joseph P. Riz
1989"1010 ACORD CORPORA All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Phone: Fax: (978) 688-9542 E-Mail:
/c a,u�,zoruaer,ll/a bP ''k, r�rrclrr�etl License or re istration valid for individul use only
Office of Consumer Affairs&Business Regulation g
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
_I egistration: 178614 Type: Office of Consumer Affairs and Business Regulation
- 10 Park Plaza-Suite 5170
xpiration:. .5/5/2016 DBA
Boston,MA 02116
JENSEN BUILDING'&REMODELING
i
SETH JENSEN
34 ELDERWOOD DR _ ��� ?.�
STOUGHTON,MA 02072 Undersecretary Not valid without signature
i
Massachusetts Department of Public Safety
�.' Board of Building Regulations and Standards
License: CS-102888
Construction Supervisor .
SETH M JENSEN r
34 ELDERWOOD DR �.
STOUGHTON MA 02072 f?,
Expiration:
Commissioner 07/09/2017