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HomeMy WebLinkAboutBuilding Permit #555-2017 - 99 WOODCREST DRIVE 11/22/2016� v �ORTy BUILDING PERMIT of ,SLED .b�ti TOWN OF NORTH ANDOVER 02 APPLICATION FOR PLAN EXAMINATION Permit No#: S`��� Date Received �` �-01 " Q�RATED . sgcHus� Date Issued: d--0_' 0 - LYIPORTANT:Applicant must complete all items on this page �..:�� - v, a `Y F-.., W LOCA?;fION �.- 1. Do�Gc?'�'5 �'A. .._.�._ °'���' tC.l '� - °89 . �' X { rint a t r N o .—_®.._ PROPER Y, OWNER R7AY, Pnnt WAj - 1DOYearStructure � yes no - MAPS�4ti+' _ PARCEL Z®NING DISTRICT:),' �° His#oris'®ist�ict yes no Ma}i ne" S p Village es. n`7' ,,. .. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑ eration No. of units: ❑ Commercial EV'Repair, replacement 0 Assessory Bldg 0 Others: ❑ Demolition ❑ Other ` •❑ Septica',#_0 eW II ' � = ❑ Flo do plain " -❑Vlletlands f r gy awr[.b strict'� t�,Di�ate a DESCRIPTION OF WORK TO BE PERFORMED: f Identific tion- Please Type or Print Clearly OWNER: Name: 7 c_. ,(-e Dc.s n C,_s Phone9 N-5d 7`ldG (3 rr Address: &)04bJCre .,gt. w. wi ✓^ u �t$ .• UM lifwl a FContractor Namet_ G' yf1 „ 7P hone � b;5 � .ft. ;'JA � 4� dress'js�'Cl✓6 . .« Su_ervisor's Construcon Licenser ` � �' "� Ll `' p _ �(�d�, Exp. DatePROM” _.� � 7y ML _ c ; Home Icnprovemen ce c .-Exp, Date 2 "��� i ARCHITECT/ENGINEER Phone: i Address: Reg. No. FEE SCHEDULE.BULDING PERMIT. $92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. __ Total Project Cost: $�i� FEE: $ S Check No.: 3�77 Receipt No,." NOTE: Persons contracting with unregistered contractors do not have:access to the g ty and , Signature of Agent/Owher Signature of contractor Plans Submitted ❑ Plans WaivedEl. Certified Plot Plan ❑ Stamped Plans ❑ TYPE"bF 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS e HEALTH ��.� " Reviewed on Signature COMMENTS t Zfoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes "P-Ironing Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located;at 124,-Main Street Fire Department signature/date COMMENTS t; i i ' limension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop.xrequires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email ate Time Contact Name = Doc.Building Permit Revised 2014 _- . Building Department The following is a list of the required forms to be filled out for theappropriate ermit to be obtained. qpermit 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit. Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (if Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses a 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 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 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 j Doc:Building Permit Revised 2014 Location No. ".?6/ — _ Date ° i • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ t Other Permit Fee $ TOTAL $ ' 3v07 L Check# / t 31232 YBW�Iding Inspector •ti NORTH own of EAndover p No. ,, h ver, Mass, x,9COCMIC N�WICw V 5 RATED 1►P��.(5 U BOARD OF HEALTH PERVI . . D Food/Kitchen Septic System THIS CERTIFIES THAT ......�...... . .... ........ ........ ..... ..... . ... . ..�':.c�!'�. BUILDING INSPECTOR . has permission to erect .......... ............... buildings on .....11.... ".*....................... Foundation Rough aryto be occupied as ........... .. . ... ........ ..........................`.................................................. Chimney provided that the person accepting th permit shall in every respect conform 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC STARI 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. Massachusetts Home Improvement Sample 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 Affairs and Business Regulation's Consumer Information Hotline at 617.973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Cc pan ame ei e Street Address(do not use a Post Office Box address) Contrac r/Sal pers n/Owner Name �o b� =itvr!e 6� t Ci i1 T,/�owJn�] y� State Zip Code Business Address(must include a street address) N rl nCj r I�l J� • 143, Sra' Da time Phone Evening Phone Ci /Town State Zip Code ?7*-!;, l Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Horne impruva-m Contractor Reg.Number Expiration date Lw requlra that mors home ,.✓ a valid ement conttacton have y lj jj 3� e valid regatntlon Dumber /(i/},A The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to compl:4ecifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) ✓T�I�$ roe9 Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of J/.U/IA when contractor will begin contracted work. , MGL chapter 142A.) t9n0/b Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule / (*) The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: (� Payments will be made according to the following schedule: $ �+ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $� by _/_/_ or upon completion of by _/_!_ or upon completion of $T upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ V to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work beeins may not exceed the greater of(a)one-third of the total contract price or(o)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty beine provided by the contractor? ❑No ffa Yes fall terms of the warranty must be attached to the contract]' 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. The 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. Review 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 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer i, Guide to the Home Improvement 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 right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner.The other copy shoo a ep a contractor. Homeowners Signature Co tor's Signature /A?/g� Date 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 c er shall be required to sub . to such arbitration as provided In Massachusetts General Law ter 142A. t —— Homeowner's Signature o tractor's Signature NOTICE:The signatures of the parties above apply only to the agree nt 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 iY 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 iy 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 Horne Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ 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 Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at http://www.mass.Pov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.as]2 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 or 413-734-3114 Version 2.1-11/22/2010 The Commonwealth of.Massachusetts _ F Department of 1fidustriaZAceidents 1 Congress Street,Suite 10 0 Boston,HA 02114-2017 y www mass.gov/dia WG kers' Compensation Insurance Affidavit:Builders/ContxactoxsLElectrxczans/ lumTiers. TO BE FILED WITH THE PERMIT TIl�7G AUTHORYI Y Wease Print Legib A '•licant Information --�, Naine(Business/Oiganization/Indi-vidud): cJ� Address: City/State/Zip � � � Phone#: : Are you an employer?Check the pZoy iafe box: Type of project(recluired); . es full and/or part time).. 7. F]NdVw constrdction I. ama employerwith e 2.0IamasoleproprietororparinershipandhavenoemployeesWorkingformein 8. FJ1ZeAlodel ig any capacity.[Noworkers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 10 n Building addition 4.n I am a homeowmer and will be hiring contractors to conduct all work on my property. I will 1LE]Electrical repairs or additions ensurethat all contractors eitherhave workers'compensation insurance or are sole 12 []Plumbiug repairs Or additions Proprietors with 110,6ipwyees. 5.❑I am a general contractor and Ihavehiredthe sub-contractors listed onthe attached sheet. 13.. off repairs These sub-contractors have employees and have workers'comp.insruance.t 14 Other 6,a we are a corporation.and its.o fficers bave exercised their right of exemption per MGL c. 152,§1(4),and We,have no empldydes.[No workers'comp.insurance required-] : . wshowin their workers'compensationpoficymfol ation ' section g *Any applicant that checks box#1 must also fill out sects fi Homeowners who submit•this-fffi. rt mdicatmg they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that checkthis 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. yam an employer that is providing-workers'compensation insuYance for°my employees. Below is the policy andjob site information. Insurance Company Name: )/ /) Expiration Date: Policy#or Self ins. Li..#: ,� 70�6 4C 52 �0� e City/State/Zip: Job Site Address: Attach a copy of thewoxkers' compensation policy declaration page(showing the policy number and expiration date). to S 00.00 Failure to secure coverage as requited under MOL alties m the form of§25A is a criminal S TOP WORK ORDERIand a fine oe by a ffib f up to $250.00 a and/or one-year imprisonment,as well as civil p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. --fdo liereliy under the as penalties ofperfup that the information provided above is true and correct Date: Si atare: Phone#: official use only. Do not-Write in this area,to be completed by city or toren offzciaZ City or Town: PermiMcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk d.Electrical Inspector �.Plumbing Inspector 6.Other Phone#: Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is d'efiited 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 receiviafor 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 ofthe dwelling house of another who employs persons to do maintenance,construction or repair work on such dowelling house or on the grounds or building appurtenant thereto shall not because of such employment b6 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 applica3atwho has not prod-aced-acceptable evidence of compliance with the insurance coverage xeq'aired." 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)nanre(s),address(es)and phone numbers)along with their certificates)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 au LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation ofinsurance 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 Offtce 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:,IV ,.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 to6 may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 fbx 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-MNSSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia i DATE(MM/DD/YYYY) A��o® CERTIFICATE OF LIABILITY INSURANCE 11/22/2016 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 CONTACT NAME: Elizabeth Chavez AX DEGNAN INSURANCE AGENCY, INC. PWC.HONNo,E Ext): (978)688-4474 No: ADDRESS: echavez@degnaninsurance.com 85 SALEM ST. INSURERS AFFORDING COVERAGE NAIC# LAWRENCE MA 01843 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: JAMES DEBRECINI INSURERC: FAMILY ROOFING:(& PAINTING INSURER D: 2 TANAGER WAY INSURER E: LONDONDERRY NH 03053 COVERAGES CERTIFICATE NUMBER: 105376 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 ADDTYPE OF INSURANCE INSD SUER POLICY NUMBER MMI DPOLICY EFF POLICY EXIP LTR /YYYY) (MM DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE 1-1 OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY[::] PRO LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON--OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION XTSTATUTE ETH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 A OFFICERIMEMBEREXCLUDED? N/A N/A NIA AWC40070259002016A 05/11/2016 05/11/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 11$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1 THE EXPIRATION DATE THEREOF, NOTICE .WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET BUILDING 20 SUITE 2035 _ AUTHORIZED REPRESENTATIVE - - NORTH ANDOVER MA 01845 Daniel .0 M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety F Board of Building Regulations and Standards - License: CSSL-099685 Construction Supervisor Specialty J ; JAMES J DEBRECENI tea' 2 TANAGER WAY LONDONDERRY NH 03053 Expiration: Commissioner 12/06/2017 i r, ��� f(arrurr n.irtueu�/h n:^Glrr:i:itcc�cr�e�.l . _Office of Consumer Affairs&Business Regulation . License or registration valid for individual use only 'r /HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: = Office of Consumer Affairs and Business Regulation Registration "122385 Type: 10 Park Plaza-Suite 5170 k = fY Expiration 8/26/2018 DBA Boston,MA 02116 l FAMILY ROOFING&:PAINTING 'i :.ado,•.-Y+.;- � JAMES DEBRECENI,F k., ,� 30 RIVER ST. - - METHUEN,MA 01844 Undersecretary Not valid without signature i i