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Home My WebLink AboutMiscellaneous - 185 MASSACHUSETTS AVENUE 4/30/2018N � C2 OCf) O D Qcr o = Cil m Sc D O m z C m TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that 1/1 (,P.6 (` has permission to perform ...... t..`....At N.N . -..................................................... . plumbing in the buildingsAV.e f. .......... ... fe- at ..........; . .................._ .............................. North Andover, Mass. Fee - '..`........ Lica No. AAA . .................. ......:........................................................ PLUMBING INSPECTOR Check # i Date.! ............. 11720 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that 1/1 (,P.6 (` has permission to perform ...... t..`....At N.N . -..................................................... . plumbing in the buildingsAV.e f. .......... ... fe- at ..........; . .................._ .............................. North Andover, Mass. Fee - '..`........ Lica No. AAA . .................. ......:........................................................ PLUMBING INSPECTOR Check # i i P TYPE. OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY T i'et'' MA DATE PERMIT # ^- JOBSITEADDRESSSS�tusf%_. OWNER'SNAMErrorl� OWNER ADDRESS. S�G�LuSe TEL FAX OCCUPANCY. TYPE COMMERCIAL ® EDUCATIONAL RESIDENTIAL NEW: 0 RENOVATION: El REPLACEMENT: a FIXTURES 1 FLOOR BSM 1 BATHTUB CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM I� DEDICATED GAS/OIUSAND SYSTEM. DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER 1— FLOOR./ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN. SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK WASHING. MACHIN E CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER 2 1 3 1:4 1 5 PLANS SUBMITTED: YES E] NOB - 6 7 1 8 1 9 10 11 12 1 13 14 I have a current liabilityinsurance 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 SY CHECKING THE APPROPRIATE BOX BELOX. LIABILITY INSURANCE POLICY 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 I hereby certify that all of the details and information I have submitted or entered regarding this applic and that all plumbing work and installations performed under the permit issued for this application will Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN HOGAN LICENSE # CHECK ONE ONLY: OWI_f i [j AGENT accura tope best of my knowl withaiyP61nent provision of the SIGNATURE MPE] JPr� CORPORATION# 3403 PARTNERSHIP Q# LLCEj# COMPANY NAME ATLAS GLEN -MOR ADDRESS 1295 EASTERN AVE CIT YCHELSEA STATE Mq ZIP 102150 TEL800 433 1616 FAX 617 887 7330 CELL EMAIL AGMINSTALLATION@PETROHEAT.COM r rn w F 0 z z 0 N� U a z �l � a d z bt � w � Q O� z O W a � � WLU W � z a 3 w w LLI W z Q O a z � 11' w as a �, J a CL Q V► ' 2 H W LL - w H O z z 0 H U W a z c.7 z a a a x 0 0 a Date.....`fi.}.`.................... r � TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that � ,�.,` 1 i ........................................ i has permission for gas installation ...... , t............................................... inthe buildings of ................... �..................................................................... North Andover, Mass. Fee .. - .......... Lic. No .. e .............. GASINSPECTOR Check # /4 10509 Mid MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM. GAS FITTING WORK CITY f' Ver MA, DATE 3r I PER # JOBSITE ADDRESS 5 SQ OWNER'S NAME l G'r OWNER ADDRESS i 5 �11a ss�.c h use TE14i_ 667`7 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL CLEARLY NEW. RENOVATION: E REPLACEMENT: PLANS SUBMITTED: YESD NO' APPLIANCES -1 FLOORS-- BSM IJ 2 3 4 5 6 7 8 9 1 10 11.11-. 12 13 14 BOILER BOOSTER COOK STOVE DIRECT VENT GRILLE . INFRARED ;HEATER LABORATORY COCKS . MAKEUP AIR UNIT OVEN POOL HEATER ROOM /SPACE HEATER ROOF TOP UNIT UNIT HEATER UNVENTED ROOM HEAT *WATER HEATER IIWViWI\liL �.VYEKAl7t I have a current liability nsurance.policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES :NO I IF YOU CHECKED YES,: PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNIFY BOND [j 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. CHECK ONE ONLY: OWNER , GENT [ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are tru rate to the of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com rice all Perti revision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER'NAME STEPHEN HOGAN LICENSE # 10808 SIGNATURE MPO MGF JP [] JGF D— LPGI Ej CORPORATION Ej#3403 PARTNERSHIP:[]#� LLC L]# COMPANY NAME:j ATLAS GLEN -MOR ADDRESS 295 EASTERN AVE CITY CHELSEA STATE MA ZIP02150 � , ]TEL 800-433-1616 FAX 617-887-7330 CELL EMAIL AGMINSTALLATION@PETROHEAT.COM. *tiny applicant that checks box #I mist also fill out the section below showing their workers' compensation policy information. ., t.Honmwners.who submit this affidavit indicating they are doing all work and thenfiire outside contractors must subinit a new affidavit indicating such. IGontractors the check this box must attadred an additional sheet showing the name of the sub -contractors and state whether or not those entities have :employees: If the sub -contractors have.employees, they.must provide their workers'. comp_ policy number. lam an employer fhat.is providing workers'. compensadon.insurance for M -employees Below is the policy and jab site information Insurance Company Name: New. Hampshire Insurance Company Policy # or Self. -ins. Lic. #: 258=89-049Expiration Date.1.0/1/2!01'6 Job Site Address:1fJ .5. S 5&6 -�e City/StatelZip t ► l d/ i > a 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 Investigattons.of the DIA. or insurance coverage;yenfication 140 h r ':under.the 'sand enalk erjury that the Information provided ab ve: is'frue and correoC Si atur Date. 3.3 1.1 fo_ Phone #: 6.17-887-7395 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 The Commonwealth of Massachusetts Department of IndustrialAccidents. I Congress Street, Suite 100 Boston, MA 02114-2017 www. rnassgov/dia N orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ' Applicant Information Please Print Ujibly Name (Business/Organization/Individual): Atlas Glen -mor. Address: 295 Eastern Ave . City/State/Zip: Chelsea, MA .02150 Phone #:800-433-1616 Arc you.an employer? Check theappropriatc box: Type of project (required): 1.Q 1 am a employer with 120 employee (full and/or pati-time).«7. 'New construction 20 I am a soleproprietor of .partnership arrd imve no et loyees working for me in 8: a Remodeling:. any capacity: [No workers' comp: insurance required.] 9 Demolition 3.Q I am a homeowner doing aq work myself jNo workers' comp. insurance_ required.] # 10E] Building addition 4. fl i am a homeowner and will be hiring contractors to conduct all work on my property. i will ensure that an contractors either have workers' compensation insurance or are sole 11..0 Electrical repairs or additions proprietors with no employees.. . 12.R]Plumbingrepairs.oradditions . 50 I am a:general contractor and I have hired the sub -contractors listedon the attached sheet 13.QRoof repairs These sub -contractors have employees and have workers' comp. insurance.t . 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14:. []Other 152, § 1(4); and we have no employees. lNo workers' comp. insurance required.] *tiny applicant that checks box #I mist also fill out the section below showing their workers' compensation policy information. ., t.Honmwners.who submit this affidavit indicating they are doing all work and thenfiire outside contractors must subinit a new affidavit indicating such. IGontractors the check this box must attadred an additional sheet showing the name of the sub -contractors and state whether or not those entities have :employees: If the sub -contractors have.employees, they.must provide their workers'. comp_ policy number. lam an employer fhat.is providing workers'. compensadon.insurance for M -employees Below is the policy and jab site information Insurance Company Name: New. Hampshire Insurance Company Policy # or Self. -ins. Lic. #: 258=89-049Expiration Date.1.0/1/2!01'6 Job Site Address:1fJ .5. S 5&6 -�e City/StatelZip t ► l d/ i > a 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 Investigattons.of the DIA. or insurance coverage;yenfication 140 h r ':under.the 'sand enalk erjury that the Information provided ab ve: is'frue and correoC Si atur Date. 3.3 1.1 fo_ Phone #: 6.17-887-7395 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 ACORL7® CERTIFICATE OF LIABILITY INSURANCE DATE (M M/DD/YM) 09/29015 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 .REPRESFj4TATIVE 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 enclorsement(s). PRODUCER - - Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 - Attn: NewYork.certs@Marsh.corn CONTACT - - - NAME: AiC, o ExtI: FAX, No E-MAIL :ADDRESS: 360-25-05 - 3602506 (NY) 807464 _ - INSURERS AFFORDING COVERAGE NAIC # INSURER A: Commerce and Industry Insurance Company 19410 073389-PETRO-ACORD-l5-16 INSURED - PETRO HOLDINGS INC INSURER B : New Hampshire Insurance CO 23841 NIA INSURER C :. N/A DBA ATLAS GLEN -MOR 295 EASTERN AVE CHELSEA, MA 02150 INSURER D: NIA N/A INSURER E: NIA ,_.. _ N/A INSURER F: ..: -. AUTOMOBILE X COVERAGES CERTIFICATE NUMBER: NYC -007977061-07 . 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 LTR TYPE OFINSURANCE : ASDL SUERWVD - POLICY NUMBER. - POLICY EFF. MMIDD/YYYY) POLICY- (MM/DDIYEXPYYY) LIMITS - A A A X COMMERCIAL GENERALLIABILITY CLAIMS -MADE OCCUR. X XCU 360-25-05 - 3602506 (NY) 807464 1010112015 90/01/2015 10/012015 _ .. 10/15/2016 10/012016 10/012016 ,.: EACH OCCURRENCE $ 1,000,000 . DAMAGE TO RENTED - - PREMISES Ea occurrence $ 100,000 MED EXP (Arty one person) $ 5,000 X Contractual .- .. PERSONAL— 1,000,000 & ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: POLICY � JET a LOC OTHER:. GENERAL AGGREGATE $ 5,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 SIR $ 1,000,000 A A' A AUTOMOBILE X LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS. HIRED AUTOS, NON -OWNED AUTOS. - - 72046-98 (AOS) - .10101/2015 72046-97(MA) 194-95-31 (VA only) 10/012015 10/0112015 101012016 10/012016 101012016 COMBINED SINGLE LIMIT $ 2,000,000 Ea accident BODILY INJURY (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident _ $ ' UMBRELLA LIAB. EXCESS LIAR 14 OCCUR. CLAIMS -MADE - .. EACH OCCURRENCE $ - AGGREGATE - $ DED RETENTION $ - - - $' B B B . B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY: - ANY PROPRIETOR/PARTNER/EXECUTIVE.. Y/N OFFICER/MEMBER EXCLUDED? -a (Mandatory in NH) If yes, descr be under DESCRIPTION OF OPERATIONS. below NI A 258-89-049 (MA,ND,OH,WA WY) - 012948291(CT,MD,NY,RI,SC) 012948299 (NY,ND,OH,WA,WY) 059901256 (NJ) 10/01/2015 101012015 10/012015 10/012015 10/012016 10/012016 10!01201.16 10/0120.16 X I PTATUER . OTH- STE ER EL. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 - E.L. DISEASE POLICY LIMIT $ 100,000 B Workers Comp Continuted 05990125< (VA) 10/012015 10/012016 SEE ABOVE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is iequi") . %,ANL.tLLA I IUN - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of NORTH ANDOVER THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE - of Marsh USA Inc. David A. Cobleigh U 1988-2014 ACORD CORPORATION.. All rights reserved.. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD • 0 w Of, N It FN Ap, MT..TT-.'E. :S:. PAT ED am n -g 4)"t Rk MB ROM 5 S 'tog, WE ;pq-1, pl� ...... ...... BYxUlb, M M ME Ilomm .0 AR At Ml 3 3D A, APR -MIR El. P"M NZ13:19N., flai-Eg' 4x. Location /gS hiss A U -x No. `-J 33 Date 3 —8 -OA NORTH TOWN OF NORTH ANDOVER F P i Certificate of Occupancy $ samus t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $� Check # I 15359 / Building Inspector SIGNATURE: Building CommissioEE for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.+ Property D onsc Zonin' j)Wd' ProposedUse _ >IA -Area Fronta ft 1.6 BUILDING SETBACKS ft Front Yard _. Side Yard - _ Rear.Yud..- ... Required Provide Provided ReTfired Provided 1.7 water SupplyM.CcLCAO. 34) 1.5.' Flood ZoneInfmm9tion o 18' ..Sew'WWDisposafSYstp= Public 0 Private 0 Zone oatsideFloodZone ❑ Mrwcipal. ❑, oi.t6.ih4 W System 0 SECTION 2 PROPERTY OW.'NERSHIP/AUTHORMI) AGENT 2:3 Owner of Record Name (Print) Address for Service -- SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor Not Applicable 0 Licensed Construction Supervisor. Company Name License Number Expiration Date Not Applicable ❑ Registration Number 01A A5 Expireffin Dat SECTION 4 - WORKERS COMPENSATION (At G.L. C 152 § 25c(6). Workers Compensation Insurance affidavit must lie completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildingpermit. Signed affidavit Attached Yes ......0 No. ....... 0 SECTION 5 Descri tion of Pro osed:Work check -au a ucabte New Construction 0 Existing Building ❑ :Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: A/ / ('\, SECTION 6 - ESTIMATED CONSTRUCTION'COSTS Item Estimated Cost (Dollar) to be Completed by permit,a licant 1. Building (a) Building Permit Fee f, c o Multiplier 2 Electrical.(b) Estimated Total Cost of Construction 3 Plumbing ' . Building Permit fee (a) x (b) 4 Mechanical AC . a; 5 Fire Protection ,6 ,.T_otah,,1+2+3+4+5).,. _ Ch 7-1 SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b O WNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge.' and belief Print Name Sigzature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB i SIZE OF FLOOR TRvIBERS 1 2 3RDl SPAN DIMENSIONS OF SILLS DIMENSiONS OF POSTS Dt1VIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHUvlNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector i r 2 m � � z o� O TT ti D M M00 r coo c > CC r� w m -0 ) zm z Nco m 00 LI) ro �} \ 75,�J L4 C� mZ Z m. 0m � pm C m p m � c Z N ° Z Qo y Z („ p m Co m Z m L7 cn ui cncn 00 ao T P. ' Wr cn M 0o co wo Q- CERTIFICATE OF LIABILITY, INSURANCE OATIDDIM AUG 10 09 01 AUG 1 �' PRODUOCI DEGNAN INSURANCE: AGENGENCYCY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND o 257 ESSEX STREET CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDW THIS CERTIFICATE LAWRENCE MA 01840 DOES NOT AMEND, EMND OR ALTER THF PnVFRAf AFFORDED BY THE PHONE., 978.688.4474 POLICIES BELOW. FAX: 978-687-7718 COMPANIES AFFORDING COVERAGE INSURED COMPANY A: GRANITE STATE INSURANCE DEEIRECINI, JAMES DIB/AJ & D WEATHER SE LL COMPANY S, 1 SEAR MEADOW ROAD COMPANY Q LANDANbE$ZRV NK 09059 COMPANY D; LJABIUIY ANY AU I U ALL OWNED AUTOS SWEDULED AUTOS HIRE� AUTOS NON -.OWNED AUTOS COMPANY E. www • www THIS 18 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEELaN�I ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NCiWITHSTANDING ANY REQUIREMENT, TERM Uk GVNLpIIUN UP ANY VMIKNUI K ` UTHER DOCUMENT WITH RESPECT TO WHICH( THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 8Y THE POLICU DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. TYPE OF 1N6URANCE POLICY NUMBER POWGY!/RiCm POLICY E1IPIIIATIM LIMITS GENERAL LIABILITY _ COMMERCIAL GENERAL LIABILITY fy AIMC MAnP. nrr.iJR GENE AGGREGATE LIMIT APPLIES PER,PROPUGTS�OMPlOP POLICY PROJECT �� FArw n -Cl IRRFNCE S RRE DAMAGE (Any One Fire) $ MEG. LV (Any Orta Porwn) $ PERSONAL 8 ADV INJURY ; GMERAL AGGREGATE i A00. $ AUTOMOBILE LJABIUIY ANY AU I U ALL OWNED AUTOS SWEDULED AUTOS HIRE� AUTOS NON -.OWNED AUTOS COMBINED SINGLE LIMIT $ (Fr w0,wiU BODILY INJURY P"'°O") = BODILY INJURY $ (Per 2wailonp PftOPrrtTr DAMAGE 9 . GARAGE LIA9RfTY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC i AUTO ONLY' AGO $ !�(G<SS L1iLB1LiiY OCCUR D CLAIMS MAGE L1C,I krnpLE RETENTION $ APR 20 01 APR 20 02 EACH OCCURRENCE $ AMARMATF ` vm cs�nr- o„ iFn A WORKERS COMPBNRATION AND EMPLOYEW LIABILITY U I Htlt: WG8349394 r E.L, EACH ACCIDENT $ 1aao0a e.l. U1�1BA•. rkA kW'6UYtt 5 100,000 &L Dig-AN4!'OLICY UMIY i 600,000 DESCRIPTION OF OPERA'IONS/LOCATIONM'UHICLES/SPECIAL ITEMS omF'1CATE HOLDER ' amrtsOlusi. nrsllr:Fn aaatrRee eFrrsrze MERRIMACK VALLEY DEVELOPMENT 28 AEGEAN DRIVE UNIT 11 METHUEN, AAA 01844 Attention: +� ACORD 25-S {71$7) SHOULD ANY OF THE ABOVE DESMHM POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF—RV88UING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN I E CERTIFICATE HOLDER NAMED TO THF LEFT. BUT FAILURE TO TICS B MPOSE NO OBLIGATION OR LIABILITY CeTtifiC8te # 11012 I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02119 Workers' Compensation Insurance Affidavit Please Print Name: Location: Clay Phone am a homeowner performing all work myself. DI am a sole proprietor and have no one working in any capacity f Vl l am an employe providing workers' compensation for my employees working on this job. Company name: Address City Phone # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties.of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a S'T'OP WORK ORDER and a fine of ($100.00) a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the andpenaftles of perjury that the information provided above is true and correct Print Official use only do not write in this area to be completed by city or town official' OCheck if immediate response is required Building Dept Contact person: Phone #. ' R,W WORKMAN'S COMPENSATION Date Rhone #�'� E] Building Dept Licensing Board ❑ Selectman's Office p Health Department Other m M m 0 9 I • y d C � d CO) C7 CD 0 Z CO) O CL y >CO v v cl � Q CD .CD o CL rF Q d CD Er CD o CD C CCD ca _. 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