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Home My WebLink AboutMiscellaneous - 30 BEECH STREET 4/30/2018r%) 0 11 b" S b Date IgA�J.ix. ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies ... .............. ................................. ................................... has permission to perform -) F 4P , , C&Q ... .................................................................... plumbing in the buildings of +Vwru-�-3 2 .. ... North Andover, Mass, at .... .... Fee......... 6 ..... ......... Lic. No. ... ................................................................................. PLUMBING INSPECTOR Check # &P k (�00 —�� Cy� 2— �1 �- �)y TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING 6T-H—ER F- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY JA� ;tA'le- :—::= MA DATE __Jj PERMIT # JOBSITE ADDRESSLaj�� Je�e OWNER'S NAME ADDRESS IJ TEL __11FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL NEW: RENOVATION: 0 REPLACEMENT: 0 PLANS SUBMITTED: YES E0 NO Ell FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [j AGENT SIGNATURE OF OWNER OR AGENT CROSS CONNECTION DEVICE and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent pr��on ofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. JiF , PLUMBER'S NAME &—r ` SIGNATURE ,h - :�? LICENSE# F f5o 3 011 DEDICATED SPECIAL WASTE SYSTEM COMPANY NAME 11ADDRESS CITY STATE ZIP 41 TEL ef -AL-1 DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f I DEDICATED WATER RECYCLE SYSTEM I __j --jij —1-1--i ----j -1 ---A DISHWASHER I 1-j ...... I DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR� KITCHEN SINK ---Jl= LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK I TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING 6T-H—ER F- r7l 1,71 JIL .-A-11L. -111- -Ifl- --- --- Ill.- -.. -A Ill 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESR"No IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY D BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [j AGENT SIGNATURE OF OWNER OR AGENT 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 plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent pr��on ofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. JiF , PLUMBER'S NAME &—r ` SIGNATURE ,h - :�? LICENSE# F f5o 3 011 MPO JP CORPORATION [K# PARTNERSHIPP-I# LLC xq COMPANY NAME 11ADDRESS CITY STATE ZIP 41 TEL ef FAX CELL ]EMAIL LL�1� VIM cn LLI 0- lij LU LL. Date ..... 2:J. n . . ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS-IINSTALLATION This certifies that ...... C/V ............................................................ has permission for gas installation .... ................... in the buildings of ...... :7�A .' ............................................................................................ at ........ . .......... ....... Ac . ................... North Andover, Mass. Fee:3qa ...... Lic. No. ...... ..................................................................... GASINSPECTOR Check# \1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA CT_ CITY PATE'� PERMIT # A JOBSITE ADDRESS I 14& OWNER'S NAME G'V OWNER ADDRESS TELF JFAX ME OR PRINT OCCUPANCY TYPE COMMERCIALF-] EDUCATIONAL [3 RESIDENTIALZ� CLEARILY I NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES D NOE] APPLIANCES -1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE J=E�= FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER F__ ROOM / SPACE HEATER ROOF TOP U NIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I.have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES IRg NO Ej I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYF_-] OTHER TYPE INDEMNITY 0 B 0 N D ED] 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 E] AGENT EjI SIGNATURE OF OWNER OR AGENT 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 plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code, and Chapter 142 of the General Laws. zt�_ PLUMBER-GASFITTER NAME -]LICENSE# 41GNATUk�� IMP 0 MGF Ej JP D JGF LPGI CORPORATION CR# �� PARTNERSHIP [j# LLC E3# COMPANY NAME: z ADDRESS CITY ZIP1__0_)_1=S TEL FAX CELL !!EMAIL 0 \1 0 f -j IL :m LLI X I -- Lu U) CL w > w LLI Cl) z 0 C) IL < D) 6i LLI LL. The Commonwealth of Massachusetts Department ofIndustrialAccidents I Congress Street, SUW� 100 Boston, MA 02114-2017 www.mass.gov1dia ictors/Electriciaias/Plwbers. Worker§2 compensation Insurance Affidavit: Bunder5/Contr: RITY. TO BE FILED WITH THE PEP2*RTT�VG AVIt(O AVP Name, (Buiess/Oigai&ationftdividual): Address; City/State/Zip: Ae_16�ZLt /`1 "' Are you an eroP!oye�? Q4eek the appropriate box: oj,�r- -/ 5 ,4', Phone J&]1amaomploy.rwith_1 --oroPl'y"(full andlor part-time)" 2.FJ I am a sole proprietor or partnership and have - employpes working for me in ,No ,,ke any capacity. ,s, comp. insurance required.] 3.[] 1 am I hlmllvler doing all work myselt [No workers' comp. insurance reqaired.] T ar F'tY- I will 4.FJ I am a homeowner and will be hiring contr tors to conduct all work on my prop ensure that all contractors either have workers' compensation insurance or are solo proprietors with no s.F] I am a general contract . pr'and I have hired the sub-contractOrs listed on the attached sheet. These sub-contrad�rAa�� ioYees'and have workers' comp. insurance., 6.FJ We are a corporafloo and its, offic6rs ' have exercised their right of 'exemption per MGL 0. 1,;,) 9 1 (4) and We hate no �m I' ' . [No workers' comP. insurance required.] P OYePs RC 7 -,, ? —,/- —_ U C - 0 6 " ) Type of project ()vequirel)' 7. E] N6*'d6nstr&-HOR 8. 0 Remodeliiip; 9. Demolition 10 Building addition ll.E] Elec#ical rpp.airs or additip-As 1� I pra-mbing repairs or additions 11DK66fre�air§ 14.n Other I I., . I . E. inf atiorr., -k #1 nfdA ki 1 fill Out the section below showing their workers' COMP 'nsat'OnPol'cy orm af ri *Any applicant. that ch ' eck§ 1�b 0 g they — do g all work then hire outside contractors must submit a now davit indicatilg such - and ta e�th i Homo,,.er, who mbjoij,�WsaMdavlt idi6ati. in or or not fliosopnti4es� have tContractors that check jWs �'o'� �nu . st attache(i hn additional sheet showing the name Of the sub -contractors s tp wh Policy R—ber- employees. If the sub -contractors have ,ployes, they must provide tbeir workers' comP loyees. &Zow is thepolicY and)oh sit� I aman employer that is pro viding-workers' compensation insurancefor My eHp information. fmsurance Company Name: Expiration Date'__C__:�,� Policy 4 or Self-inS. LiG. #:- city/state/zip:Az !2� fob Site Address: compensation policy declaration page (Showing the policy number and expiration date) - Attach a copy of the Workers' Failure to secure coverage as required under MGL c- 152, §25A is a criminal violation punishable by a ab up to $1,500.00 penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a ancVor one-year imprisom3aent, as well as civil s th DIA for insurance day against the violator. A copy of this statement may be forwarded to the Office of Investigation Of 0 coverage verification- ofpejury th at th e information provided above is tru e and correct I do hereby certify und5r thepains andpenalties ,'g,, -r,%-4.- __)_ - ,4F I .!=� q --) 2� — t?) 5 - 7 Phone #: ffic,al use only. Do not write in this area, to he completed by city or town OfficiaL ob, City or Town: permit/License Issuing Authority (circle one): i 1. Board of 101ealth 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Phone Contact Person: Information and Instrnctions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their anip�6y'�es. Pursuant to this statute, an employee is defmed as "...every parson in the service of another under any contra'Gt ofw�, express or implied, oral or -written." An employer i!i deffibd as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enf6rprise, and including the legal representatives of a deceased employer, or the receivbt'6r, tnistdd dan individual, partnership, association or other legal entity, employing employapEr. - However the owner of a dwelling house having not more than three apartments and who resides therein, or the occul?6,�i ofthe 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 bd deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall vdthhold the issuance or renewal of a license or permit to opdrate a business or to construct buildings in the commonwealth for any applicalit-who has not. produced -acceptable evidence of compliance with the insurance coverage iequired." Additionally, MGL ch?!Pter 152, §25C(l) states 'Weither the commonwealth nor any of its political subdivisions shall enter intq any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements ofth i I s chapter have been presented to the contracting authority," Applicants Pleasb fill out the workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if nece�sary, supply sub *coutractor(s) name(s), address(es) and phone number(s) along with their certificate�s) Of insurance. Limited -Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If anLLC orLLP d66s have employees, a policy is required. 1�e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city pr town that the application for the permit or license is being requesteq, not the D *artmentof Industrial -Accident' ep s. Should you have any' questions regarding the law or if you. are req*ed to obtain a -�i6rkers' compensatioii policy, please call the Department at the number listed below. Self-insured companies sl�o�ld enter their Self-insuratic'e 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 0 in the permit/license number which will be used as a reference number. In addition, an Applicant thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob Site Address" the applicant should write ffall 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 proofthat a valid affidavit is on file for fbture permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE Fax # 617-727-7749 Revised 02-23-15 www-mass-gov/dia 2 -14Date ..... �:�..-Z ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... V ........... ... 16 ... .......... LLL .................... ---I.k ...... ....... / ... & ... ............................................... has permission to perform ................. LA&Z— wiring in the building of ....... ......... 46 LO ............................................................. at ..... 'L� ... Psvec. .1 ..... C .................. Nq�� Andover, Mass. L" 1, (/t— Fee ... Lic. No. Check # Li -3 . 201'KbA ELECTRICAL INSPECTOR 0; -1 .1 1, � , I Zi .1 ... 0 / 6 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. t �) I 4(lp - t BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PPJNT IN INK OR TYPE ALL MFORMA TION) Date: '&- a- 16 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) *3.0 ece.�k�, Ny_. Owner or Tenant '5-!A Cl-rcow Telephone No. Owner's Address 30 N"C-. Is this permit in conjunction with a building permit? Yes 1;6 No (Check Appropriate Box) L"3_3 -7 Z i Purpose of Building 1; Utility Authorization No. I Existing Service WO Amps \W 2L%jU Volts Overhead � Undgrd No. of Meters New Service kyo Amps \"�u Volts Overhead [9"�' UndgrdE:l No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: <,er V %,cc e too A A" L)o k - Completion of thefollowing table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators K -VA No. of Luminaires Above Ei In- El Swimming Pool grnd. grnd. 0. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches \U No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: JNumb.erJ.Tqns 1 .......... 1 .. K.W ........... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW "Cal E] Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Sig s Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 3 - a - � 6 Inspections to be requested in accordance with MIC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURAN 6tBOND 0 OTHER 0 (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: -,�J f-AeAr",L -r-yNC , LIC. NO.: -ao i Bo A Licensee: a1c, \,Jr\%%ktM — Signature LIC. NO.: (Ifapplicable, enter "exempt" in the licenle number line.) A Bus.Tel.No.-, q7P,-0c((--7BU Address: -�Jk �&NA Nyt. MA'. Alt. Tel. No.: *Per M.G.L c. 147, s. 51-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) F1 owner F1 owner's agent. Owner/Agent Signature Telephone No. PE"IT FEE.- $ N\ �, W6 AA 4 nt rm The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, M4 02114-2017 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ((e�t f- tcfAr,, Address: ALV-- City/State/Zip: � Mt� o�q,,15_ Phone #: q)i3- M(--7 (3o Are you an employer? Check the appropriate box: Type of project (required): 1. El I am a employer with 4. EJ I am a general contractor and 1 6. n New construction employees (full and/or part-time).* have hired the sub -contractors i4emodeling 2 E] 1 am a sole proprietor or partner- listed on the attached sheet. 7. ship and have no employees These sub -contractors have 8. 0 Demolition working for me in any capacity. [No workers' comp. insurance employees and have workers' c9pif'insurance.1 9. E] Buil(�ng addition required.] 5. �e are a corporation and its io.DKectrical repairs or additions 3. El I am a homeowner doing all work officers have exercised their II.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.n Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.n Other employees. [No workers' comi). insurance reauired.1 *Any applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site information. Insurance Company Name: pol-eoNl Policy 9 or Self -ins. Lic. #: we vv�go A — — -- - Expiration Date:_ i I — I 1-11� Job Site Address: *10 Lsz� c,,,e. M6,1we.- AJA oip,,ij City/State/Zip: IVAnl,e�-MA o161 -15 - Attach a copy of 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 form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties of _periury that the information provided ahove is true and correct. Phone 4: 41-1-- Sckk- -1 �,w Official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M I- I ACOPRE!" CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDNYYY) 12/28/2015 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 Phone: 978-688-4474 Fax: 978-327-6558 DEGNAN INSURANCE AGENCY 85 SALEM STREET LAWRENCE MA 01843 CONTACT DEGNAN INSURANCE AGENCY -NAME* =, -): 978-688-4474 No): 978-327-6558 - E-MAIL cdegnan@degnaninsurance.com -ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA NORFOLK AND DEDHAM INSURED VALLEY ELECTRIC INC. INSURER B INSURER C 21 HYATT AVENUE HAVERHILL MA 01835 INSURERD* INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 25829 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 TY PE OF INSURANCE ADULISUBRI INSR WVD POLICY NUMBER POLICY EFF (MMIDPNrm POLICY EXP (MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurence) $ �CLAIMS-MADE 1-1 OCCUR MED. EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ —1 RO $ POLICY 11 JPEC� F—] LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ALL OWNED SCHEDULED AUTOS UTOS 1 BODILY INJURY (Per person) $ BODILY INJURY (Per aGcident) $ HIRED AUTOS ffNON-OWNED UTOS PROPERTY DAMAGE (per accident) $ UMBRELLA LIA13 H OCCUR EACH OCCURRENCE $ EXCES L CLAIMS -MADE AGGREGATE $ DED I IRETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WE132614A 11/13/15 11/13116 A OTH 'T.RYT1I'M1i. ER $ E.L. EACH ACCIDENT $ 500,000 AN PROPRIETORIPARTNEWEXECUTIVE YIN OFFICEFUMEMBER EXCLUDED? I (Mandatory in NH) F NIA E.L. DISEASE -EA EMPLOYEE $ 500,000 if yes' descrbe under DESCRIPTION OF OPERATIONS helo. E.L. DISEASE -POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN N. Andover, MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. Attention: AUTHORIZED REPRESENTATIVE N& gx_ I Carla M. Degnan ACORD 25 (2010/05) (9) 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I— CERTIFICATE OF LIABILITY INSURANCE I DATE I MfDDNYYY) 12/2m,/201, 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 Phone: 978-688-4474 Fax: 978-327-6558 DEGNAN INSURANCE AGENCY 85 SALEM STREET LAWRENCE MA 01843 CONTACT DEGNAN INSURANCE AGENCY -NAME: PHONE FAX . No): (,C,..�Exty 978-688-4474 (AIC 978-327-6558 E-MAILSS: cdegnan@degnaninsurance.com ADDRE INSURER(S) AFFORDING COVERAGE NAIC # INSURER A MOUNT VERNON FIRE INSURANCE COMPANY 26522 CL 2651542A INSURED VALLEY ELECTRIC INC. INSURER 8 INSURER C 21 HYATT AVENUE HAVERHILL MA 01835 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 25830 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 OF INSURANCE ADD'L1 INSR SUBR WVD POLICY NUMBER I ::.Llc.= POLICY EXP (MIMfDDNYYY) LIMITS A GENERAL LIABILITY CL 2651542A 11/14115 11/14/16 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurenoe) $ 100,000 ]CLAIMS -MADE 17OCCUR MED. EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,000 RO- $ C LOC POLICY JE T F-1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO ALL DINED SCHEDULED '—'AUTOS BODILY INJURY (Per accident) $ AUTOS HIRED AUTOS PROPERTY DAMAGE $ UTOS ffON-OWNED (per accident) $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DIED I IRETENTION $ $ WORKERS COMPENSATION OTH ER $ AND EMPLOYERS' LIABILITY AN PROPRIETORIPARTNERIEXECUTFVE YIN E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? F I N/A (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover 120 Main Street N. Andover, MA 01845 Attention: 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 Carla M. Degnan ACORD 25 (2010105) (9 1988-211110 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I m .0 C3 OT, C-1 Oo Ij -3 m I