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HomeMy WebLinkAboutBuilding Permit #216-2017 - Exception 8/30/2016 BUILDING PERMIT "ORT" q T TOWN OF NORTH ANDOVER �,� h ,,, y,rayb=6 0 APPLICATION FOR PLAN EXAMINATION 7° Permit No#: I11 Date Received 7 SRA rep �SSACHV`'E� Date Issued: [10PORTANT:Applicant must complete all items on this page 1 LOCATION �I Print ® , PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL:0/61;� ZONING DISTRICT: Historic District yes o Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building_ _ - _ . ❑ One family . ❑Addition ❑Two or more family ❑ Industrial ❑Alt tion No. of units: ❑ Commercial epair, replacement ❑Aessory Bldg ❑ Others: ❑ Demolition R-Other ❑ Septic ❑Well ❑Floodplain ❑Wetlands ❑ Watershed District ❑Water/SewerJU� 2ESOIPTION OF WORK TO BE PERFORMED: � I Ident'ficatiion- Please a or Print Clearly } YP Y OWNER: Name: �i� ' 1� ,/� j.�r cJ,�' Phone �- 191-3tl:�:,?7 Address: A/1 Contractor Name: Phone: 7 Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: J��� Receipt No.: 08 ,Z NOTE: Persons contracting with unregistered contractors d Lt;h;ave access to the guaranty fund Location Q Tri d S. No. �� of Date 4 • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $�_ TOTAL $ �r Check# :?C, 7CS J f� Building Inspector / i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swi um"1g Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dwnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature o COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street + FIRE DEPARTiM te ENT Te ® _ �. e e urnpsterr on mp,� .� si = yes��� In +iLocatedjat12.4 MamrStceet t I -Ir04 q'epartment ignature/date:_, 'COMMENTS: Dimension 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 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) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 I 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 4 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 i. Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses 4. 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) . - I � Building Permit Application 4, Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses 4 Workers Comp Affidavit 4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) 4. Copy of Contract -1 2012 IECC Energy code 4 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 I Doe:BuildingPermit Revised 2014 i � NORTH Town ofAndover _ a + 0 ti. ry to ' No. h ver, Mass, 0 2ai C 0CI41C NlWKK Ay1� A0R�TEO �P� y S V BOARD OF HEALTH Food/Kitchen PER, II 1 , LD, Septic System { THIS CERTIFIES THAT ........... !�TT!r ! N .. �w�►.j..�.L,. ..., BUILDING INSPECTOR ...... . ....... ........................ ...... .... Foundation has permission to erect .......................... buildings on .��...���.�... e .. Rough to be occupied as ...... . .. ......tre.mF................................................................ Chimney provided that the person accepting phis 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS CTIOT Rough Service ..... . ........... ....... ...... Final BUILDING SPEC OR GAS INSPECTOR = Occupancy Permit Required to Occupy Building Rough Display in n _ Final p y a Conspicuous cuous Place on the Premises Do Not Remove + 1 No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FIRE DEPARTMENT Street No. Smoke Det. i i Proposal • eBe& HIC#174377 Damphousse - . - com Roofing up years A trusted name since 1938 Roofing - Siding -Windows 87 Belmont Street - North Andover, MA 01845 P: 978-683-4588 - F: 978-685-74411 1 6 I NAME OF OWNER A71 - ADRESS OF JOB TEL. 51 13!7- DATE: d We will remove all roof shingles off total roof area, layer. Replace' any boards or sheathing at additional cost.A new 8"white aluminum drip edge applied on all edges.Approx. Eft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. Architectural roof shingle installed with a 'limited lifetime warranty. Install new ventpipe boot flashings. Waterproof existing chimney flashing and remove debris. Shingle Colo . � Rid a Vent Upgrade Wood Sheathing Repair$3.50 per ft. L I I oe 1000, od� AMD � LC We Propose herby to furnish material and labor-complete in accordance with above specifications,Tfos the sum of: /J ?dollars(s tI 49). Paymenta made as follows I& I {OL 7 ( 677Authorized Signature A019!-� �46Z�� > ( — Vn )1114 NOTE:This proposal may be withdrawn b s if not accepted with i ays Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are herby accepted.You are authorized to do the work as specked.Payment will be made as outlined above. Signature Citi' Date of Acceptance: / Signature HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS(MGL 142A1 1.WORK:Provided the Homeowner performs under this agreement,the Contractor shall perform the work on1 the Property as specified Proposal,attached incorporated herein.The work does not include extraordinary conditions of which the Contractor could not reasonably be aware_If such conditions are encountered,this shall be an additional cost to the Homeowner.Materials selected by Homeowner may have to be ordered or custom made,which items are specified in the Proposal.The Contractor is not obligated to agree to any modifications,extras or change orders unless such items are agreed to in writing by the Contractor.All extras and changes shall be at an additional cost to the Homeowner.Contractor shall perform the work in a good and workmanlike manner using materials consistent with this contract.Lawn or Driveway may be damaged by dumpster or equipment.Due to material shortages Contractor may substitute materials of equivalent grade. 2. PERMITS:If a building permit is required for the work,the Contractor shall obtain same as Homeowner's agent.Contractor is not responsible for any other permits that may be required for the Work,and Homeowner is responsible to determine whether any zoning,planning or wetland related permits or approvals are necessary.Homeowners who secure their own permits or deal with unregistered contractors will;not have access to the Guaranty Fund. 3. COMMENCEMENT AND COMPLETION:Homeowner acknowledges the commencement date of the work is fluid,and is subject to numerous factors such as scheduling other contractors,delivery of materials and weather.Contractor and Homeowner shall determine the commencement date of the Work when a more definite determination can be made and shall execute a written acknowledgment of same.The Work shall be substantially completed within 7 days of commencement,except for longer periods as may apply to particular projects as Contractor shall notif} Homeowner in the'Proposal,and subject to delays for circumstances beyond Contractor's control.Notwithstanding,the commencement date and substantial completion date may be extended,and the Contractor will not be liable for delays caused by,labor or material shortages,delays in delivery of items selected by the Homeowner,governmental action, and unforeseen events beyond the Contractor's control,including but not limited to weather,strikes,war,the acts of third persons or the acts of the Homeowner.The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractor's other jobs. 4. PAYMENTS:Contractor agrees to perform the Work and to furnish the materials and labor specified in the Proposal for the amount as stated in the Proposal.Thirty percent(30%)of the total is to be paid as a deposit with the signing of this contract.Upon cancellation prior to commencement of the Work,any remaining deposit will be returned less the costs for materials ordered for which Contractor was unable to cancel.Final payment shall be due upon completion of the Work and Homeowner agrees it may not hold any retainage.Late fees may be applied for late payments.Homeowner shall pay Contractor's reasonable costs of collection,including attorney's fees and costs.Time is of the essence hereof. , 5. WARRANTY:For a period of 2 years after substantial completion of the Work the roof will be free of leaks caused by defects in workmanship, but not those caused by ice backing-up or extraordinary weather events,including blizzards,tornadoes,huiicanes or storms of greater than a twenty-five year duration or intensity.Contractor gives no warranties with reference to any materials or equipment nistalled in the Premises,passes any such warranties directly to Homeowner,and Homeowner agrees to look only to the manufacturer with reference thereto.This limited warranty extends to the Homeowner only and is not transferable to succeeding Homeowners.This Limited Warranty specifically excludes(i)all consequential and incidental damages;(ii) damage due to ordinary wear and tear,abusive use,misuse,or lack of proper maintenance;(iii)defects which are the result of characteristics common to materials used;(iv)defects in items installed or supplied by anyone other than Contractor;(v)work done by anyone other than by Contractor;and(vi)loss or injury due to the elements.There are no other expressed or implied warranties or representations made or given. 1 6. ENTIRE AGREEMENT:This contract and all documents referenced herein constitute the complete and final agreement between the parties.In the event that any of the provisions of this contract shall be held to be invalid,the remainder of the provisions of this contract shall remain in full force and effect.Two identical copies of this contract have been completed and signed.Homeowner acknowledges receipt of a completed contract signed by the Contractor. 7, HOME IMPROVEMENT REGISTRATION:In accordance with M.G.L.c. 142 A,§9,Contractor is registered with the Bureau of Building Regulations and Standards Registration No: 174377.Homeowner may verify by contacting the Director at(617)727-3200,ext.25205.A Homeowner's rights under the Home Improvement Law(M.G.L.c. 142A)and other consumer protection laws may not be waived inany Y.Homeowner acknowledges receipt of a copy of 780 CMR R6 and Massachusetts General Laws chapter 142A,and which are available online at www.�riass.gov.Questions may be directed to the Consumer Information Hotline,(617)727-7780. i 8. ARBITRATION: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 such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G"Ke. 142A.No lien or security interest is imposed on the Property as a consequence of this contract,but Contractor has the right to record this contract or a notice of this contract,or seek a lien if the Homeowner breaches this Contract. I 9. HOMEOWNER COVENANTS:The Homeowner agrees,represents and warrants that(a)the Homeowner giants permission to the Contractor to enter the Property to perform the work as covered by this contract;(b)the Homeowner has funds available to make full payment under this contract to the Contractor upon completion;(c)the Homeowner understands that construction as contemplated by this agreement creates!a dangerous condition,and agrees not to enter portions of the Property under construction until the Contractor advises the Homeowner that the construction is completed;(d)Contractor may need use landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and(e)that code requirements may result in roofing nails penetrating through roof decking and will be visible on the underside of some surfaces.The Homeowner indemnifies,exonerates and holds harmless the Contractor from any loss,damage,claim,liability or expense(including reasonable attorney's fees,deposition costs and court costs)resulting from a breach of this provision.Contractor is not responsible for damage to landscaping that will grow back during the next growing season. 10.CANCELLATION:Homeowner may cancel this agreement provided Homeowner notifies the Contractor in writing at the address listed in the Proposal not later than midnight of the third business day following the signing of this agreement. HOMEOWNER- �i DATE: Shingle: i^ j DEPOS �� The Co1rirttomflealth of 1Mlassachnsets ' Department of Industrial Accidents Office of Im estigations t 600 Washington Street Boston .SIA 02111 lflliil•it.ltlaSS.gOVldia Workersl Compensation Insurance Affida-vit: Builders/Contractors/Electricians/Plumbers AlRulicant Information Please Print Legibly tl Name (Busine /Organizationllndividual): t� /'��/� �e! [�- 1 s Address: v City/State/Zip 1' Phone#r: c-✓ Are y an em lover?Check the appropriate box: Type of project(required): 1. am a employer with 4 ❑ I am a general contractor and I 6 F1 New construction employees(full and/or part time)." have hired the sub-contractors 2.❑ I am a sol4roprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g_ n Demolition employees and have workers' 9 Building working fbr me in any capacity. (� Q addition (No workes' comp.insurance comp.insurance. aired.] 5. ❑ We are a corporation and its 10.❑Electrical re'airs or additions req officers have their 11. Ph ina re.airs or additions 3.r7 am a homeowner doing all work cers ave exercised ❑ b - right of exemption per MGL myself.[N`�workers'comp. p 12. oofrepairs i c x152, §1(4),and we have no insurance equired.] 13.❑Other employees. [No workers' comp.insurance required.] tA.ny apP licant that c eels box r1 must also fill out the section below showine their workers'compensation policy information. Homeowners who sdbmit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit ndicatin_ such. `Contractors 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 employes,they must provide their workers'comp,policy number. I aur an employerl that is providing workers'compensation insurance for my employees. Below is the police and job site in arniation. Insurance C.:paj f - Ile ��i�! z rry Name: /4, . Policr or Self-*s.Lic.rr, dill c 7L ��/V Expiration Date: Job Site Address: .�/�t�� 1� - City/State/Zi . '1e Attach a cagy o the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 fornl of a STOP WORK QRDER and a fine of up to$250.00 a day against the Aolator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of Ithe DIA for insurance coverage verification. Ido hereby cerci in r the pains and penalties of perjury that the information provided abode is true anh correct. o. Sintuature: l ..1.�� Date: Phone r: Official use o;11y. Do not write in this area,to be completed bj,city or tou'll official City or'I'oWn: Permit/License m 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: r I Client#: 14415 DAMPHOUSSE ACORD- CERTIFICATE OF LIABILITY INSURANCE 04/18/0o6nYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O.Bax 1985 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 21 Elm Street Andover,MA 01810 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A Western world Damphousse Roofing LLP INSURER B: 87 Belmont St INSURER C: North Andover, MA 01845 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTA D'L EXPIRATION NSR TYPEOFINSURANCE POLICY NUMBER D DCLIC OMITS A GENERAL LIABILITY NPP8202847 04/12/16 04/12/17 EACH OCCURRENCE S111000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S11001000 CLAIMS MADE a OCCUR MED EXP(Any one person) s5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 X POLICY0 PRO• LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO (Ea acc eenll ALL OWNED AUTOS BODILY INJURY � SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE S (Peraccident) GARAGE LIABILITY AUTO ONLY.EA ACCIDENT S ANY AUTO EA ACC S OTHER THAN AUTO ONLY: AGG S EXCESS/UMBRELLA LIASIUTY EACH OCCURRENCE $ OCCUR D CLAIMS MADE AGGREGATE S 5 DEDUCTIBLE S RETENTION S $ WORKERS COMPENSATION AND WC STATU- 0TH, Y LIMITS ER EMPLOYERS'LIABILITY ANY PROPRIETORMARTNEWEXECUTIVE E.L.EACH ACCIDENT S OFFICERrMEMBER EXCLUDED? El DISEASE•EA EMPLOYEE S It yes.describe undor SPECIAL PROVISIONS bale. E.L.DISEASE-POLICY LIMIT I S OTHER DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS Covering operations usual to Damphousse Roofing LLP... CERTIFICATE HOLDER CANCELLATION 1O De S for Non-Pa ment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TOMAIL 11)_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRE NTAT ACORD 26(2001108)1 of 2 #S33484/M33480 ML O ORD CORPORATION 1988 i A , CERTIFICATE OF LIABILITY INSURANCE DATE(M 04118/2016 THIS CERTIFICATE IS IS UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NO AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICTE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRIODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions bf the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu a>jsuch endorsement(s). PRODUCER GO NAME:CT Diane LeBlanc DOHERTY (NSURANs E AGENCY INC PHONE (978)475-0260 ac Ne AORDess: dieblanc@dohertyinsuranre.com P.OBOX it365 1NSURERSAFFORDING COVERAGE NAIC9 ANDOVER MA 01810 INSURER A: AIM MUTUAL INS CO it 33758 INSURED INSURER 13: DAMPHOUSSE ROOF NG LLP INSURER C: INSURER D: 87 BELMONT STREET INSURERE: NORTH ANDOVER MA 01845 1 INSURER F COVERAGES CERTIFICATE NUMBER: 45466 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. NOTWITHSTANEIING 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 CONOITld�S OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR NSR TYPEOFINSURA� E A L R POLICY EFF POLICYEXP POLICYNUMBER JMMIDDIYYYYI (MMfl3DNYYYILIMITS COMMERCIAL GENERAL IABILITY EACH OCCURRENCE 5 CLAIMS-MADE OCCUR PREMISES DAMAGE 1`0 R occurrence) _ 5 IIENT MED EXP(Any one person) S II N/A ���� PERSONAL 8 ADV INJURY S GEML AGGREGATE LIMIT APPLIES PER: PRO- i GENERAL AGGREGATE I$ R POLICY I I --- El JECT n LOC PRODUCTS-COMP/OP AGG 5 OTHER: ' S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I S tE aceicentl �^ANY AUTO BODILY INJURY(Per person) ,5 ALL OWNED S I EDULED AUTOS A&OS NIA BODILY INJURY(Per NUN-OWNED OS accident) S HIRED AUTOS AT PROPERTY DAMAGE GE Per 2ccidon1 S 'i �s - UMBRELLA IJAS 11 OCCUR EACH OCCURRENCE I s EXCESS LIAR ILII CLAIMS-MADE N/A AGGREGATE S DED RETENTtONA 1�— WORKERS COMPENSATION I! X I g AND EMPLOYERS'UABILnT YIN STATUTE ?RT" ANYPROPRIETORIPARTNEPJEX -UTIVc A OFFICERIMEMBEREXCLUDEO? NIA NIA NIA AWC40070287742016A 104 EL.EACH ACCIDENT j S 500,000 (Mandatory In NH) /1712016 04/1712017 [(gas.describe under E.L.DISEASE-EA EMPLOYEE S 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT g 5()0,000 TNfA i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additianol Remarks Schedule,may be attached If more space Is required) Workers Compensation benef its 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 employes in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance s i ows 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.golwd/workers-compensationfinvestigations/. I� CERTIFICATE HOLDER I 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 AndoverL` I MA 01810 Daniel M.Cr CP CU.CU.Vice President—Residual Market—WCRIBMA l ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) II The ACORD name and logo are registered marks of ACORD iI Massachusetts Department of Public Safety y Board of Building Regulations and Standards License: CS-067560 Construction Supervisor SHAUN M TWOMEY :. 61 PATROIT ST NORTH ANDOVER MA 01845 (�_�lZ':K vim-- Expiration: Commissioner 10/26/2017 i ✓� V64TUiJZO?lll1CQf,LlL 6,�✓��Q!AL[[G2�6 Office of Consumer Affairs&Silsmess Regulation HOME IMPROVEMENT CONTRACTOR Registration: 174377 Type: I Expiration: .2/4/2017 LLP DAIMPHOUSSE ROOFING LLP`; SHAUN TWOMEY 87 BELMONT ST _ N.ANDOVER,MA 01845 g � � Undersecretary I I I I I i i