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Home My WebLink AboutMiscellaneous - 155 GREAT POND ROAD 4/30/2018 (2) 155 GREAT POND ROAD 210/037.C-0022-0000.0 Locationl No. Date (0 [IV t f • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ • Building/Frame Permit Fee $ �" Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# J Building Inspector Commonwealth of Massachusetts Com � 1 r 0,IJ Sheet Metal Permit 2,7 � Date : `r �D '° Permit#_ Estimated Job Cost: 00 r Permit Fee: Plans Submitted: YES NO r/ Plans Reviewed: YES NO Business License:# 77b Applicant License# Business Information: Property Owner/Job Location Information: Name:��-E' 'llsl� d'L S �3 Name: Street: Giv!� ' WJ Street: /5"5 City/Town:f r�J l (;/,?32 City/Town: po tL t 0 d9��v�',� VM Telephone: 9 7 Y' 4- Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES P"' NO Building Type: &es=identiah 1-2 family Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. f over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC Metal Roofing Kitchen-Exhaust System ✓ Chimney/Vents Provide brief description of work to be done: 3;rde'D Ale s J-4m T/4 Jac �r1�a C 1I jef-1A.—ely 1 7 � RJttt t rro U vim . r � INSURANCE COVERAGE: r` 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes EloNo❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy D Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box0,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Pro;;ress Inspections Date Comments Final Inspection Date Comments Type of License: By Master Title . ❑ Master-Restricted Cityn ❑Journeyperson Permit Signature of Licensee # ❑Journeyperson-Restricted -- Fee$ License Number: 72d s Check at www.mass.gov/dpi Inspector Signature of Permit Approval ` The Commonwealth of Massachusetts . ' .Department of IndustrialAccidents ;,.�: _• F d I Congress Street,Suite 100 Boston,MA.02114-2017 `.. .. : ,�t www mass.gov/dia yY� Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Lep-ibI NaMe(Business/Organization/fmdividual): �'` J o j e?it✓��i Address: 6- C&S u S>` �- City/State/Zip: rA-eOL14Je P /V -0/7(V9, Phone#: Areyou an employer?Checkthe appropriate box: Type of project(required): 1.Wf am a employer with - ! employees(full and/or part-time).* 7. Q New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. [ emodeling any capacity.[No workers'comp.insurance required.] ❑Demolition 1 Q I am a homeowner doing all work myself[No workers'comp..insurance required.]t 10 n Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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]rave employees and have workers'comp.insurance.1 14. Other 6.Q We are a corporation and its of�cers have exercised their right of exemption per MGL c. Q 152,§1(4),and we have nqQ employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who sulirizit this affadavit indicating they are doing all work and then hire outside contractors must submit anew 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-coritracfors have employees,tliey must provide their workers'comp.policy number. I am an employer drat is pi ovidingworkers'compensation insurance for•my employees.'Beloit/is thepolicy acid job site information. Insurance Company Name: 1^1 if S If 1 A/S s;I "Z/q9�-/ — Policy#or Self-ins.Lie.#: W AJ Z 3/ Expiration Date: 3_ �^ Zd` 7 fob Site Address: )re-vi 9cl ijQ duju City/State/Zip:1.&'i �4a��"'� ✓� 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify m0er thepainsand en ' s ofperjury that the informationprovided above is true and correct Signature: Date: -7 Phone# 7 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: r Information. and Instructions Massachusetts General Laws chapter 1.52 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of Le, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver-or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonv.�ealt$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'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 cavy 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 fok cor6amation 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 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 e F, ' Sheet Metal Commercial Guidelines/Life Safety/Critical System_s Inspection Checklist Yes No N/A/ Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with properjourn.eyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation r/ Smoke and combination fire/smoke dampens with access doors properly installed- actuator checked for proper operation(May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke/atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) / Stair pressurization systems installed(where required) and operation verified(May also be verified by fire department during fire alarm testing) —ZGrease/kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper cle `ances,fire rated enclosures and pressure testing required. , f: •. . _,tiE>4::aiL ke��;:uint3 insraltu xrlic r uire'd'on'eq lii.ment and d�=.;t1 q. P t _ _ Duct penetrations in fire'ratQ%vall=3 and floors sealed•• / Metal roofing systems installed watertight using proper materials and fasteners / Flexible duct runs installed 6'-0"maximum length i/ Ductwork installed using proper hanger spacing,hanger stock,threaded rod and angle / iron J Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean-properly sized filters installed(final inspection) Testing nd Balancing report plete(final sign-ofd Sheet Metal Residential Guidelines/Inspection Checklist Yes No N/A. Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumWerson-to- apprentice ratios Equipment sized per heating/cooling load calculations Duct work sized per manual "D"calculations Bath/shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0"maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean-properly sized filter installed(final inspection) Testing and Balancing report complete(final sign-off) GOMMONWEaLTH OF MASAHUSETC SHEETIVIE"fiALNG R SSE AS A ':ISSUES THE FOLLOWI Mf$1 ER UNRESTRICTED FREDERICK R SKAFE' 29 Ei3LUNG MEADOWS LN W HAVERH�� -s 01832 8815 : �x-f 1 l 05 0712 812018.: 77 07-25-'l 6 14:07 FROM- 9785572130 T-015 P0001/0001 F-999 V,ElrRS,ZTFICATE CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/25/2016 TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TME CERTIFICATE HOLDER. THIS 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(ias) 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 CeKifiCate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Michaud,Rowe And Ruscak Ins- NAME, Lawrence R-Michaud,CIC P.O.Box 188 PMONE .978 688 8829 (A/C.No:978 557 2130 North Andover,MA 01845 ADo�ss:Imichaud mrrinsurance_com Lawrence R.Michaud,CIC INSURE%S AFFORDING COVERAGE NAIC# INSURER A:SafetyInsurance Company 12808 INSURED Skaff Refrigeration Sery Inc INSURER B:Wesco Insurance CompanyI 55 Chase Street Methuen, MA 01844 INSURER C: INSURER D: 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 I TYPE OF INSURANCE POLICY EFF POLIC LTR p POLICY NUMBER MM/D MM/D LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMSJNADE OCCUR BMAD005633 05/08/2016 05/0812016 PREMISES fga occurron $ 100,00 X Business Owners BMA0005633 05/08/2016 05/08/2017 MED EXP(Anyone ereon S 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT,AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY PEC ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: I $ AUTOMOBILE LIABILITYEd dBINED SINGLE LIMIT $ 1,000,00 A ANY AUTO 2100163 02/1312016 02/13/2017 BODILY INJURY(Per person) $ ALL OWNED XSCHEDULED BODILY INJURY(Per accident $ AUTOS AUTOS ) NIREO AUTOS X NON-OWNED PROPERTY DAMAGE $ X AUTOS Par acc dan[ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,00 A X EXCESS LIAB CLAIMS-MADE CM00001654 04110/2016 04110/2017 AGGREGATE $ 5,000,00 DED 1 X RETENTION$ 10000 2 WORKERS COMPENSATION P R OTH- AND EMPLOYERS'LIABILITY STAME ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y� WWC3189244 03108/2016 03/08/2017 E.L OFFICER/MEMBER EXCLUDED? N/A EACH ACCIDENT $ 1,000,00 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 1,000,000 If Yds,desoribs under DESCRIPTION OF OPERATIONS below E. .DI _ 1,000,000 L SEASE POLICY LIM i DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,mAy be.gtedched if more space is required) Refrigeration Contractor CERTIFICATE HOLDER CANCELLATION NORTH 13 SHOULD ANY OF THE ABOVE DESCRISED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept. 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover,MA 01845 ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD 11.�..s�v ,ph¢MI/mi U�endove�mi.vlewpohtdoW.comisJrerurA c'Y:�7? j�- sf ,[7'PMn61n9 PcmR B20973-Y...k� - ____-. - �y Town of North Andover,MA 4 Search. - ^ 20973 'Plumbing Permit-In Conjunction with a Building Permit(Commercial or Residential) TIMELINE Submission received Your request is in progress ).125,2016 at 11:39— We'll let you know of any updates via email.Feel free to check the '...... —`------- ---- status at anytime by coming back to this page. ® Plumbing Permit Review In Prog— 0 Permit ree CteaiPO`�Hr4 s4p:, G13a`, Per VIA Issuance fx:c.,ne�� 't Rd Gteat Pond Rd 0 GI' - F.PPlicar.. locaxicn fred Webster 155 GREAT POND ROAD,NORTH ANDOVER,MA CONWAY TRS,ANDREW F&JANICE L A Attachments gA�E81AIMQt'?lti 7(ZSJ2U16Q. 132-% - 1 -2 7, L? Monday,Jul 25,2016 11:39 AM �. � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY — e4'-.... MA DATE ..`G..015 .. . ... PERMIT# JOBSITE ADDRESS k� S , -(�� OWNER'S NAME _ vat h t OWNER ADDRESS TEL tom ipp-75 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1-71 RESIDENTIAL PRINT CLEARLY NEW:EJ RENOVATION: REPLACEMENT:El PLANS SUBMITTED: YESE] NO FIXTURES 7 FLOOR–+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER : FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ............. KITCHEN SINK LAVATORY _ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET _. URINAL WASHING MACHINF CONNECTION WATER HEATER ALL TYPES ..... ........ WATER PIPING _ ( .. INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY f—%A OTHER TYPE OF INDEMNITY _ BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to - best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 9 PLUMBER'S NAME ( (�11e (( LICENSE# p t provision of the SIGNATURE MP� JP[ CORPORATIONPARTNERSHIP[ #r COMPANY NAME E=LLC[ #E :: ADDRESS BE CITY Unto. .6 ;STATE... MA ZIP FAX _ TEL US3 _S _ `I �' CELL EMAIL �Q The Commonwealth of Massach usetts _.__. ... =� ti i.Eiui r�r�l'I(I Vf /!tl JlJl/JIJJ 1 Congress Street, Suite 100 Boston,MA 02114-2017 wWW.ntass.govIf la \Yorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO 13E FILED WITH THE i'ERMITfING AUTHORiTY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): il i_-T�:f:si ��,1;♦„1�41;,� a "�.� 1h}( (�� City/State/Zip: l�` 1 1`� l f2-I� rl `P�.C'i` Phone M :�vys Are you an employer?Check the appropriate box: ",' Type of project(required): L[2'1 am a employer with employees(full and/or part-time).* 7. New construction 2.[:]1 am a sole proprietor or partnership and have no employees working for me in aci 8. Remodeling an,capacity.ry.[No workers'comp.insurance required.] 3.®1 am a homeowner doing all work myself.[No workers'comp.insurance required.) 9• ❑Demolition 4.1-1 1 am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10 E] Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 i.[]Electrical repairs oradditions proprietors with no employees. 5.F11 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.Q Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.' 13.F]Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.EJ Other 152,$1(4),and we have no employees.[No workers'comp.insurance required.] Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating 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 employees,they must provide their workers'comp.policy number. I am an employer that is providilig workers'compensation inst[rance for nil)employees. Below is the policy and job site information. Insurance Company Namejeci—_-A2 , Mu ,O Policy#or Self-ins. Lic.#: Q. i-{' 1 Expiration Date: _ o Job Site Address:_ City/State/Zip:n An&cf-,l UA MI .-, 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 tip 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 verification. I do hereby certif it der Ih pains and penalties of perjitry that the information provider'above is trite and correct, Si nature: Date: r7 �� ( , Phone#: [F0fJftc1ia1ii,s1,eon1y. Do not write in this area,to be completed by city or tmv/i official. r Town: Permit/License# g Athority(circle one)':`'? L6. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing inspector Otherontact Person: Phone#: i ACORO® CERTIFICATE OF LIABILITY INSURANCE DAT 04/28/D/YYYY) � oa/28rzo1s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONT CT FEDERATED MUTUAL INSURANCE COMPANY N.MEACLIENT CONTACT CENTER HOME OFFICE: P.O. BOX 328 A CNNo Ext):888-333-4949 A/c No):507-446-4664 OWATONNA, MN 55060 AIL ADDRESS:CLIENTCONTACTCENTER FEDINS.COM INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 247-960-8 INSURER B: MILLTOWN PLUMBING &HEATING INC INSURER C: 131 STEDMAN ST UNIT 6 CHELMSFORD, MA 01824-1868 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 119 REVISION NUMBER:0 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 TYPE OF INSURANCE DL SUER POLICY NUMBER POLICY EFF POLICY EXP LTR INSR WVD MMIDDIYYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE ❑X OCCUR DAMAGE I RENTED $100,000 PREMISES Ea occurrence X BUSINESS OWNER'S LIABILITY MED EXP(Any one person) A N N 9064734 06/15/2016 06/15/2017 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 ❑ ❑ POLICY PRO LOC X JECT NPRODUCTS-COMPIOP AGG $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED Ea IT accident)SINGLE LIMIT $1,000,000 X ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) A AUTOS AUTOS N N 9064735 06/15/2016 06/15/2017 BODILY INJURY(Per accident) HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE Per acciden X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $1,000,000 A EXCESS LIAR CLAIMS-MADE N N 9064736 06/15/2016 06/15/2017 AGGREGATE $1,000,000 DED I I RETENTION WORKERS COMPENSATION OTH_ AND EMPLOYERS'LIABILITY Y/N X PER STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $500,000 A OFFICERIMEMBER EXCLUDED? NIA N 9354812 06/15/2016 06/15/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below - E.L DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION 247-960-8 1190 TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER, MA 01845-2420 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ® 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD