HomeMy WebLinkAboutBuilding Permit #703-13 - 984 TURNPIKE STREET 4/25/2013Permit NO:
Date Issued:
PRE- R, T V
-0-IN
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
I& Date Received
C- 11-3
[SANT: Applicant must coml
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TYPE OF IMPROVEMENT-
PROPOSED USE
Residential
Non- Residential
D New Building
El One family
El Addition
D Two or more family
El Industrial
El Alteration
No. of units:
[I Commercial
El Repair, replacement
D Assessory Bldg
El Others:
11 Demolition
D Other
i lWek fzi ff d
®Floodplain)
-V da C' ft,
OWNER: Name:
DESUKIF I 1UN VI- VVUMM I U Dr— r'r—F%F—%J IVIL-wo
Type or Print Clearly)
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29)
Address: A/ e -
G OR�IS
Rhone-,�
IRA
C-,GN,T
Supervisor '�c
OM -F!f 7
10 -P
4
P, -IMp
0- `
!�n 11
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED 6-ON$125.00PER S -F-
"-) bt -
Total Project Cost: $ A or(j FEE: $ (2'(0
Check No.: � 10 �5 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of A I cient/oWher Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans D
e
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
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . _
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connectl ,n/Signature & Date Driveway Permit
mW Towp_ Engineer; Signature:— p
Located 384 Osgood Street
FIRE 'DEPARTM�NT - Temp Dumpster on site yes no
Located at'124 Maira`Street
Fire ®epa'tfinert signatiureldate
COMMENTS
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 fro
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
No,
Doc.Building Permit Revised 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate.permit to be obtained.
Roofirig, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
L3 Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
a Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
40TE: 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 app: al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
most be submitted with the building application
Doc: Doc.Bui?ding Permit Revised 2012
Location
No. —
I/
s Check # 11 0 �)
26324
Dat42�/3
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspec r
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Massachusetts Horne 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 catling the Office of Consumer Affairs and Business Regulation's Consumer
Information Hotline at 617-973-8787 or 1 -888 -283 -3757 -
Homeowner Information
Name David Dockham
984 Turnpike St
Street Address (do not use a Post Office Boz address)
North Andover MA 01gys
City/Town State Zi
781-699-27755 —
Daytime Phone TC
Address (It different from
Contractor Information
Company Name
IONAL 11UlLr:)1NG S]iRV1' t3S /Pi'rFR CIARALD1
Salesperson/ Owner Name
!) OLDE 1'i'C ODE RD
Address (must include a street address)
Al,l:hl Nil 03070
State Zip Code
Business Phone I Federal l triployer ID or S.S. Number
_41--
603-898-1977 2Q- 1035)(
Law requires that most home Home improvement Contmelor Expiration Date
lmprovcmentcontreernrshnvcovatid rcgmunbcr
Registration number �'S9�t,�'r 7.14
The Contractor agrees to do the followi g work for the Homeown !r.
(Describe in detail the work to completed, spur hying the type, brand, and gra of materials to be used, u. -,additional sheets
Re€'erence Professional Building Services estimates # 1434
Required Permits - The following buildingpermits are require.
and will be secured by the contractor as the homeowner's agent,
Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of
MGL chanter 141AA
Total Contract Price and Payment
Proposed Start and Completion Schedule - The following
schedule will be adhered to unless circumstances beyond
the contractors control arise
c when contractor will begin contracted work,
when contracted work will be substarmnliy —
The Contractor agrees to perform the work, fumish the material and labor specified above for the total sum of: S f f,000—
Payments will be made according to the following schedule:(#)
s_3,500 upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater)
0,500 when frame is complete
s-4,000 upon°completion of theconlract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
life toinowing matarioltequip'ment must be special $ to. be paid for
WOW before:the Conttv&icd Fvorit begins itt order ���- !o he paid for
it) meet the coenpletionschedule4* j -
NO`I`FS: V) Including all finance charges.(") Law requires that any deposit or down -payment required by the contractor before work begins
may not exceed the greater of(a) onc9third ofthe total Contract price or (b) the actual cost of any special equipment or custom made material
which trust he special orderer) in Advance to tired. rite complclion schedule;
StihcolAraCtors -The contractor agrcrs to be scllcly responsible for contpiction of the work described regardle4s of thio actions of
any third.partytsabeontr»clor tttilind by the contractor. The contractor hu'llierngrecs to be solely respUttsible Etat till payments to
all subcDnti i tors forattatcrials a"'att' la� borunder #his st ctncnt,
Ctrntract Aeccptanec -Upon si€;ning, rhos doctnncni becntttt s a binding c Unl,tct under-la�v..l9ntcss otlYcrwise nr�tc� wiiltin this
docut»ctrl, tltc conttrtc€ shall n+�# imply that
anylion rrr other security intcaest lilts lieutt.placcd ctrl the rGsiticncr Rcviw the
fnllowittg cautions and notices carr'fully (reface si) ninl; this ccs ill liar,
Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear.
TAnkc sort the con"Cir"' Inas b valid Monte lett vutictti Contractor ltcaistratitu�, The lttw :ijuquires trits,t hunie improvelfient
contractors anti subcontractom to be registered -with the Director (A l4rolle lniprovemcnl Cnntraetnr Rc istKation: You may,inquire about
1contractor registration by writ ng to the fiirector at fine Ashburton Place, Room 1301. Boston, MA 02105 or by calling 617-727-1200 or
Does the contractor have insurance? Check to see that your contractor is property 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 House tmprovenienl Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery; not later than midnight of
the third business day following the signing; of this agreement, See the attached notice of cancellation form for an explanation- of this tight,
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two.idtnrti 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.
Homeowner's Signature Contractor's Signature
j 4/23/2013
llate
Date
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.
-4m J 41 � U-0
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 sigI d by the parties.
Homeowner's Rights
A homeowner's tights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer
protection laws (i.e. MGL chapter 93A) naay not be waived in any way, even by agreement. However, homeowners
may tie -excluded frond certain rights if the contractor they choose is not properly.at gistered as prescribed by law..
Horneorvners'whn secure their own building permits are atttonaatically ekcluded fibm all Guartnrty'.- and provisions
of the flume Improvement Contrractof t-aw. The contractor is responsible: for completing the worli {as described, in a
timely and workmanlike manner. Homeowners may be entitled to other specific legal rights:'if the tool-raetor
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 Ott which the homeowner and contractor lawlully agree
maybe added to the terms of the contract as long as they.do not restrict a l omcowncr't, basic zonsurrrer rights. IFyou
have questions about your consumer/homeowner tights, 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
tilled 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 notbegin 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 Home 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
�a4
The Commonwealth of Massachusetts
02 Department ofIndustrial Accidents
Office of Investigations
kvi 600 Washington Street
Boston, MA 02111
www massgov/ilia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address:
City/State/Zip: u'? % Phone
Are you an employer? Check the appropriate box:
1( I am a employer with _?4.
ElI am a general contractor and I
_
employees (full and/or ppart-t e).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. t
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they Lire 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 and their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: U (1 LU(K' L.. ) � Expiration Date:
Job Site Address: 14 / �c/f Al_Ptll City/State/Zip: k,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL 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.
Ido hereby cceefiyr�f/)yr
diear the pains and penalties ofperjury that the information provided above 's true and correct.
Phone #• g;? -2g77
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - -
Contact Person:
Phone #:
Information and Instruction's
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not producedacceptable evidence of compliance with the insurance coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigatitons
6.00 Washington Street
Boston} MA. 02111
Tel, # 617-727-4900 ext 406 or 1-8.77rMASSAFF,
Revised 5-26-05 Fax # 617-727-7749
_.WWW-Mass,govfdia
. ,,�� ✓4-e091'!/I)20'I9.C!/P�yLf��q,�LlldCU6
Win\ Officq of Consumer UVAffairs & B siness Regulation
-HOME IMPROVEMENT CONTRACTOR.
Registration::, 170870 TAIV
Expiration: ¢1%1072014 bBA
PROFESSIONAL BUI fi-&G SERVICES INC.
�k �• 1;`
! PETER.
�k
9 OLDE WOODE RD'
SALEM, •NH 03079
Undersecretary
Licen§e or registration valid for individul �z only .
before the expiration "date. If found return to:
Office of Consumer Affairs and Business Regulation
,10 Park Plaza - Suite 5170'
Boston, MA 02116
� t
�i
Not valid without signature
r*� Massachusetts - Department of Public Safety
Board of Building- Regulations and Standards
?Construction Supervisor License
License: CS 97650
PETER CIARALDI
9 OLDE WOODE RD
SALEM, NH 03079
�'- Expiration: 7/3!.2013
('unuiiissioncr Tr#; 17860
f
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans.
F
WERAGE DISPOSAL Tanning/MassageBody ArtSwimming Pools
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
PLANNING &DEVELOPMENT DATE REJECTED DATE APPROVED
COMMENTS
CONSERVATION
COMMENTS W
HEALTH
COMMENTS
Reviewed on / 9 Si nature
Reviewed on
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comm
Water & Sewer Connection/signature date
Drivewav Permit
DPW Town Engineer: Signature:
FIRE.DEPARTMENT "" d C d Street
Locate 384 s oo S
t -Temp Du�mpster on site yes
Located at,724,Main' Streefizv
}. .0 <.} a4 t—g_..• .r .� a "y i ''` C,.. # 4'r f 'cru-a`'�„3
Fire.Department�sigri`ature/date��rt
S
COMMENT
PR/25/2013/THU 12:09 PM
FAX No.6034323852
P 001/001
corm CEYY
RTIFICATE OF LIABILITY INSURANCE
D/2,/ATE l0rl'3Y)
4/25/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Financial Insurance Services Inc
PO BOX 950
Derry NH 03038
CONTACT Patricia Blais
NAME:
PHC No Ext: (603) 432-6414 FAX
No; (603)932-3852
E-MAIL pblais@fisins.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA:National Grange Insurance CO
INSURED
Professional Building Services, LLC
9 Olde Woode Road
Salem NH 03079
INSURERB:Hartford Insurance Company
INSURERC:
INSURER D :
INSURER E :
INSURER F:
COVERAGES CERTIFICATE NLIMRER,13-14 RFVISION NIIMl
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
TYPE OF INSURANCE
ADDL
UBR
POLICY NUMBER
POLICY EFF
MMIDDIYYYY
POLICY EXP
MMIDDIYYYY
LIMITS
ITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE a OCCUR
MPT1630H
/5/2013
/5/2014
EACH OCCURRENCE $ 1,000,000
DAMAG TO RENTED
PREMISES Ea occurrence $ 300,000
MED EXP Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY � O LOC
PRODUCTS - COMP/OP AGG $ 2,000,000
$
A <-
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED X SCHEDULED
AUTOS I JAUTOS
X HIRED AUTOS X NON -OWNED
AUTOS
1T1630H
/5/2013
/5/2014
EOM�BIINdEDISINGLE LIMIT 1,000,000
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Per accident
Medical payments $ 5,000
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED I I RETENTION $
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PRO PRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED)
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N/A
044JECLB1809
/5/2012
/5/2013
AC STATU- OTH-
TORY LIMITS ER
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEE $ 100,000
E.L. DISEASE - POLICY LIMIT $ _ 500,000
IL
DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
(978)688-9542
Town of North Andover
25 (2010/051
CANCELLATION
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
Fragala/PAT
n 1999_201111 ACORD CORPORATION All rinhtc racarwarf
INS025 (201005).01 The ACORD name and logo are registered marks of ACORD
MAP 107C•.
REFERENCES: LOT 102
1. TITLE REFERENCE:
BOOK 11927 PAGE 297
2. REFERENCE TOWN OF N. ANDOVER
ASSESSORS MAP 107C LOT 6
MAP 107C
LOT 44
TO CHESTNUT
STREET
31.8'
.:5.7'1
148.2
MAP 1070
LOT 6
AREA=52,600 SFt
1.21 ACRES
PROPOSED
•— GARAGE
j V,K
EXIST.
DWELLING
#984 Ci
150.00'
I.1 4 Il lfiiti�
546'31'48"E
TURNPIKE STREET
CERTIFIED PLOT PLAN
984 TURNPIKE STREET
N. ANDOVER, MA
1" = 50' DATE: MAY 30, 2012
MAP 107C
LOT 101
5
MAP 107C
LOT 20
F OFA
JOHN
F.
McOUiLKiN"
No. 36120
t�� Siti�V�b
30.2•
TO JOHNSON
STREET
325 MAIN STREET
984 Turnpike Street
N. Andover, Ma. 01845
JOB NO. 676-486 1 SHEET 1 OF i