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Home My WebLink AboutMiscellaneous - 30 SARGENT STREET 4/30/2018I Location. 3 0 A 9 6:� No. 6,5 Date 0.1 TOWN OF NORTH ANDOVER Certificate of Occupancy $ C) Building/Frame Permit Fee $ CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 06) Check # C) 17 k 5 1 hvA U,-, Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERNUT NUMBER: DATE ISSUED: SIGNATURE: Building.CommissionELqq�eEtor of Buildings Date SECTION 1- SITE INFORMATION 1. 1 Property Address: :3.0 1.2 Assessors Map and Parcel Number: 16 Map Number Parcel Number 1.3 Zoning Information: Zoning Di��ct Proposed Use 1.4 Property Dimensions: Lot Ar- (sf) Frontage (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide RegWred. Provided iTqTr—ed Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private 0 Zone — Outside Rood Zone 0 1.8 Sewerage Disposal System. Municipal D On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSEEIP/AUTHORIZED AGENT Historic District: Yes —No 2.1 Owner of Record le eAl /j 1�' V4 4:�'RG C --)V 30 -SArc Name (Print) Address for Service A 6;" Signature Telephone 4 2] Owner of Record: flame Print Address for Service: Sinature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable E 'X License Number Expiration Date 3.2 Registered Home Improvement Contractor 11 Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone Ma M X z 0 M 6N, 0 z M go 0 M z 0 SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) I Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ....... 0 No ....... 0 SECTION 5 Description of Proposed Work (check an applicable) New Construction 11 1 Existing Building [I I Repair(s) 0 Alterations(s) [I Addition 0 Accessory Bldg. 0 1 Demolition 11 Other 0 Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION CORT.q I Item Estimated Cost (Dollar) to be Completed by permit applicant QFVIC ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction -3 Plumbing Building Permit fee (a) x (b) 60 1 -4 Mechanical (HVAC) -5 Fire Protection -6 Total (1+2+3+4+5) Check Number aM-11VIN /aVW1'4JPXAU1r1UX1LA11qJA 10BhUUMFLt'J'EJ)WH_EJN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My beha f, in all matters relative to work authorized by this building permit applicat�� 9 P. - - - _';84 - 0 0�' — 'Signafi5e- -of 6w . ner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 of 0,Amer/Agent Date NO. OF STORIES SIZE -BASEMENT OR SLAB -SIZE OF FLOOR TUABERS I ST 2 No 3KD -SPAN -DIMENSIONS OF SILLS DIMENSIONS OF POSTS _13MENSIONS OF GIRDERS -HEIGHT OF FOUNDATION THICKNESS -SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE I -V I t I D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542. Fax Please print. DAtE JOB LOCATIO Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION 3"' -5'h ('� e6 Number Street Address IF" Map / lot "HO MEOWNER LkL)u !Em -4 6&- 0--- �6� . 6z5 3 — --I- Qf 0 7? Name Home Phone Work Phone PRESENT MAILING ADDRESS 3>0 :5/W661A/-r f; T— City Town State Zip Code The current exemption for "home6wners" was extended to include owner-<=upied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5. 1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE Al"P/7� A.Aa��4 APPROVAL OF BUILDING OFFIC North Andover Building Department Tel: 9787688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of IVIGL 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 IVIGL c 11, S 150 A. 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 (A m m x m 4 m X (n m cn EP m CO) CM) CD MZ CA CD 0 '0 CL r_ F" =r CL ca C) C.) CD 0 CD CL cr =r CD =r CD 0 CD CX3 M a. s CD re CD CL C2 CA cm CD -S7 al CO) CD z CD CD w 10"o '"o =r =r., 0 w 0 cr Cc, 9.0 CO3 CL 0 m ca Cl CL C -j CD z =r.0 -4 90 — CD CL 0 =r CL �* m CD =r go -* CD ca CO) CD 0 =r CD C4 i Coon 0 = : OC C2 Z — a LA. a : CD CA g C CL Jc:: dc CD c co CD Im CL jolmows C/) I= CL go 0G; CCD UM 3E 0 Cc, CD w - :: t C2 I = 4 F CA OP CD: co) CD C2: so S c D to C=L C-) cli ch) C,3 W Fg 0 cn 4 to c :v gj III 0 cn (D T A M :3 PO 0 W In n aq CL cn (n cp 0 Ia. P� r) tz 0 rA rA E dp 0 41� CD Location 3o -/� No. .41 Y/ — Date TOWN OF NORTH ANDOVER A Certificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # 17049 Bu-ilding Inspectoo TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERNUT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date -0y SECTION I- SITE INFORMATION _T I 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 06-3 Map Number Parcel Number 1.3 Zoning Information: Zoning Di;V �d Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage (11) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard ReqWred Provide Required ProvicW �ere�d Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 PrhVe 0 Zone Outside Flood Zone 11 1.8 Sewerage Disposal System: Municipal D On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 3,::, 57 C-: All Nene (Print) Address for Service I Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone I I SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 & 2506) 1 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ....... 0 No ....... 0 SECTION 5 Description o Proposed Work (check applicable) New Construction [I Existing Building 0 Repair(s) [I erations(s) 0 Addition 11 Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed bV permit applicant tl� Ust, '7 1. Building (a) Building P�_ite� Multiplier 2 Electrical (b) Estimated Total Cost of Construction -3 Plumbing Building Permit fee (a) x (b) -4 Mechanical (H`VAC) 5 Fire Protection -6 Total (1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLILES FOR BUHDING PERM[IT 1, L_� '=�- P 7-1 AL-:�c U /t/ as Owner/Authorized Agent of subject property Hereby authorize /-t le R-Z"'A /-I /L-, 0 to act on My beh , in all mattersplativg to work authorized by this building permit application. Signatuie-o-TOwner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 Signature of Owne ent Date -NO. OF STORIES SIZE -BASENENT OR SLAB SIZE OF FLOOR TUvIBERS OT 2ND 3RD -SPAN _DMIENSIONS OF SILLS -DINIENSIONS OF POSTS _Dfl�IENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS -SIZE OF FOOTING X -MATERIAL OF CHD4NEY -IS BUILDING ON SOLID OR FILLED LAND -IS BUILDING CONNECTED TO NATURAL GAS LINE 00 0 "o 4ftft 4ft 0 z I 0 1. . E t 0 CO CD C" f 0 cm S 0 N CD z CD 0 r4l F4 r-4 Cf) u Cl) I Q E Q CD CL 0 CO) CD cm C CD MA CD E '= 0 cc CD ca cc 0 CL M. CMCC C:j .0- Cc = .5.0 Q "M 0 CD go CD C.) co m C42 LU uj U) 19 uj w 19 w w ca 0 C/) C�, 0 En 0 or. r. La C2 u —co r. x 0 0 C2 —Cd 0 X. 0 E-4 u u C2 cn _0 .5 W. I W :j C2 —tz .5 r. �4 :� m 6 $. C/) 0 E U) 1. . E t 0 CO CD C" f 0 cm S 0 N CD z CD 0 r4l F4 r-4 Cf) u Cl) I Q E Q CD CL 0 CO) CD cm C CD MA CD E '= 0 cc CD ca cc 0 CL M. CMCC C:j .0- Cc = .5.0 Q "M 0 CD go CD C.) co m C42 LU uj U) 19 uj w 19 w w ca 40 go m CD Q C.) a 16. E Ell w 3: cm C=Q GO CD CLL3 ce CD C:, Ce CS z M C2 CL 'o 0, CD 0 ca CO2 US zz=l C36J = j -.- (a LU C3 . co U 4D Ll CD 0 .0 e COD CL CD — 0:8 (A R m 4- 06* - 0 1. . E t 0 CO CD C" f 0 cm S 0 N CD z CD 0 r4l F4 r-4 Cf) u Cl) I Q E Q CD CL 0 CO) CD cm C CD MA CD E '= 0 cc CD ca cc 0 CL M. CMCC C:j .0- Cc = .5.0 Q "M 0 CD go CD C.) co m C42 LU uj U) 19 uj w 19 w w ca Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542. Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE 2-Z 5zo JOB LOCATION a Number Street Address Map / lot "HOMEOWNER A�pt--,C--7-H T? 8-- ?2!� -!7 9 13 603- �10 L- 2 Y 4) 2 Name Home Phone Work Phone PRESENT MAILING ADDRESS 3,::5j s7 -7- V, /1 ty V>,n L/,-!5::- R /LA A ::f) / '? City Town State Zip Code The current exemption for "homedwners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5. 1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner' certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL 'IVA Date ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... 7, .......... ........... . ............... ........... ......... has pennission to ................ wiringin the buildi!,% of ......... . ....................................................................... .. .. .......... .............. ;,::i ........ r.-,\ .............. . North Andover, Mass. N! -v A�" ..................... Fee.,,-. ........... Lic. No.-'1-0.VZV ELECTRICAL INSPECTOR Check # 5191 X#aW7M5,4.47W 09 70*4 Vomo---r 4 P-0- Sao# BOARD OF FIRE PREVENTION REGULA APPLICATION FOR PERMIT TO P All work to be performed in accordance with the M; (Please Print in ink or type all information) Town of North Andover The undersigned applies for a permit to Location (Street & Number Owner or Tena Owner's Address the electrical work 7 - Official Use Only Permit No. 527 CMR 112:00 Occupancy . & Fee CheckeA� A ELECTRICAL WORK Electrical Code 527 CMR 12:00 Date IS- 19 7- 0 O�L To the inspector of I.Vires: Is this permit in conjunction with a building permit 6s\ V No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service New Service Number of Feeders and Ampacity, 5027 Location Pnd Nature of Pro Electrical Work 174 t 0-7 .9 Overhead 0 Undgmd a No. of Meters Overhead 0 Undgmd 0 No. of Meters -7 Total of Lighting Outlets No. of Hot fuse No. of Transformers - KVA q Above 0 In a No. of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIREALARMS No.ofZone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Torts KW No. of Sounding Devices NoJ of Self Contained o. of Dishwashers S Heating KW DetectionrSounding Devices 9 Municipal 0 Other No. of Dryers Heating Devices. KW Local Connection NO. Of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuarrtto the requiremen6ts of Massachusetts General Lam I have 2 current Liability Insurance Policy including Completed Operations Coverage or its substantial equivallelt YE;V= NO haw-�ub itted valid proof of same to the Office YES = NO - If you have checked YES please indicate the f coverage by checking the appropriate box. '��l SURANCEa BOND - OTHER - (Please Specify) (Expiration Date) Estimated Value of.Electrical Work$_ Work to Start 40, If I spection Date Signed under the Pen v�- FIRM NAME , 4. -/ , &A LIC. lj� LIC. NO. 91p, us. Tel No. Z./ Address 111�0,06S W11, V/00/�, Z4 47v 4�//BrAlt —Tel. No. e OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachuse s General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone -No. PERMIT FEE Name: Location: city Phone 71 am a homeowner performing all work myself. F-1 I am a sole proprietor and have no one working in any capacity F1I am an employer providing, workers' compensation for my employees working on this job. Company name: Address City: Phone #- Insurance Co. Poligy # Company name: Address City: Phone #- Insurance Co. Policy = 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 andfor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DtA for coverage verification. I do herby certify under the pains and penalties of peilury that the irnbrmation provided above is true and coffect Signature Date Print name —Phone # Official use only do not write in this area to be completed by city or town official' E] Building Dept []Check if immediate response is required Building -Dept E] Licensing Board E] Selectman's Office Contact person Phone Health Department Other FORM WORKMAN'S COMPENSATION n Date ...... 478-Z-6 TOWN OF NORTH ANDOVER PERMIT FOR WIRING R -t-4- This certifies that has permission to perform ... T*.zell- wiringin the building of ................. ... ... ...................................................................... at - '5 .......... 3-,,!�9 ....... ...................... North Andover, Mass. JO -10- 'Po Fee._'? - —... Lic. No. 15 ............... ......... .................. Check # 3 I &\ Commonwealth of Massachusetts Official Use Only =95i= Permit No. Department of Fire Services Occupancy and Fee Checd BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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 PRJNT IN INK OR TYPE ALL INFORMA TION) Date: 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) 0 e.4 Owner or Tenant Kc,,,, Telephone No. 6 0 -3 �, 0 1 ztlae Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps Volts New Service Amps Volts Yes El No El (Check Appropriate Box) Utility Authorization No. Overhead [:] UndgrdE:1 Overhead El Undgrd R No. of Meters No. of Meters Number of Feeders and Ampacity Ale Location and Nature of Proposed Electrical Work: % e- e a v, a e t -f_ i-vte- mo /2, I't- goo, e -- Completion of the fiollowing 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 KVA No. of Luminaires Above Swimming Pool El In- d. 0 grnd. grn N—o.of Emergency Lighting Baitery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS JNo. of Zones. No. of Switches 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 Number Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local El Municip? I , F-1 Other Connection No. of Dryers Heating Appliances KW Security Svstems:* No. of evices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring. No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Er BOND [:1 OTHER [-] (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: 'J"C+L_ I -C-5 e--rol. le cj-n-� LIC. NO.: 1412,17 1— Licensee: )-Z- " /Z, Signature LIC. NO.: ff applicable, enter "exein t " in the license number line.) Bus. Tel. No.:229YS-TZJ-rr Address: PC 9,0 9 ST 7 OCA C, L) �- , y4,4- 0 LS Z,6 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires De"partment 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 El owner's t Owner/Agent Signature Telephone No. PERMIT FEE: $ I ACCORV CERTIFICATE OF LIABILITY INSURANCE 16.� DATE (MMIDD"YY) 7/7/2014 TAIS 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 BtLOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RtPRESENTATIVE 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 Eastern Insurance Group LLC 77 Accord Park Drive Unit B1 Norwell MA 02061 CONTACT NAME: Select Department X66807 H lc�%, FAX IPA N Ext), 800-572-4538 (A/C, Nol: 781-586-8244 AE-DMDARLESS: selectwork@easterninsurance. com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:Travelers Inc of America 25666 INSURED R. & L. Berube Electric P 0 Box 537 ,Dracut MA 01826 INSURER B:Travelers Indemnity Cc 25658 INSURERC:Trav Ind of CT 25682 INSURER D: INSURER E : rNSURER F: COVERAGES CERTIFICATE NUMBER:CL147741001 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 ADDLSUBR Wk POLICY NUMBER POLICY EFF (MMIDDNYYY) POLICY EXP (MMIDD[YYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (E. occ ...... e) $ 300,000 A CLAIMS -MADE Fx_1OCCUR 6801233B982 7/31/2014 7/31/2015 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: —1 PRODUCTS - COMP/OP AGG $ 2,000,000 RO MX POLICY I JEC� 7 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BA41A261616 7/31/2014 7/31/2015 BODILY INJURY (Per accident) $ X NON -OWNED PROPERTY DAMAGE $ S HIRED AUTO AUTOS (Per accident) Medical payments $ X UMBRELLA LIAB X N OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 B [hDXE'ED EXCESS LIAB CLAIMS -MADE I X I RETENTION$ 5,000 $ CUP0296YO83 7/31/2014 7/31/2015 C WORKERS COMPENSATION X I TNC ITATI- TH- ORY LIM T, OE R AND EMPLOYERS' LIABILITY YIN E.L. EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/E—W.— I N N/A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) UB41A250767 7/31/2014 7/31/2015 E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) Electrician EvidZnce of insurance for insured while acting in the scope of their normal operations. %,FIX I IF-I%,M I r- nUIL-Ur-IN L;AN1.;tLLA I IL)N Town of North Andover Attn: Wiring Inspector 27 Charles Street North Andover, MA 01845 At,umu zo llzu-iulua) INS025 (201005).01 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 Koegel/KAB1 (0 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a k \/z r Lij L) L LLI LLJ LLJ OC) —J,: zm ui. M, LAJ «e \,) La ca Lf) I= C) 0 -W CL, M 0 C� ON u The Commonwealth ofMassachusetts Department of l'ndlisfrigl Accidents Office of Investigations 6#0 Washington Street Foston, MA 02111 www.mass govIdia Workers' Compensation. bsuran.ce Affidavit: Builders/Contrac RMT IN r Phone # �n, 3 1 Are yoy ant employer? Chtek the appropriate box: with 4. [1 Z am a general contractor and I 1,01am a employer _ employees (fall and/or part time) have nodthe sub -contractors on the attached sheet. � 2111 am a sole proprietor or partner -listed - ship an.d`have no:employees These sub -contractors have . working forme in. any capacity. workers' comp. insurance, 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised.their xequared.] 3. [] 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c.152, §1(4), and we have no insuxancerequixed.] -i [No workers' insurance comp. required.] comp. Type of project (required): 6. ❑ New construction f 7. [( Remodeling 8. [( Demolition 9. ❑ Building addition 10.❑ Electrical, rep airs or additions 11.❑ Plumbing repairs or additions 12.0 Roofrepairs 13.❑ Other xAny applicant that checks box *I must also fill out the section below showing their Workers' compensation policy information. M doing allwont and then hire outside contractors must submit a new affidavit indicating such. Homeowners who submitthis affidavit indicatingihey Untractors that checkthis bol must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that isproviding workers' compensation insurance for my employees Below is the policy andjolr site information. / Insurance Company Name: policy # or Self -ins. X.ic. #: 3117D Expiratlon Date: lob Site Address 3 ' ` City/State/Zip: /V. �'-2 t� Attach, a copy of the workers' compensation -policy declaration page (showing the policy number and expirations date). p'a luxe -to. secure_eovor c as requixedundex Section 25A ofMGL o.152 can lead to the imposition of trammel penalties of a --- -- - -- ime up`to $1;50000 andlar-one�year xmprisonmetit;.as-well, as civ�Enalties in; �.e, fonro. _of ar.STOXWORK ORDBR and a Etna i_= of -up to $250.00 a day against the violator. Be, advised that a copy of this statement may ba forwarded io the Ofhce of Investigations of the DIA. for insurance coverage verification. X do herebycertaTY er the as ripen tees ofperjury Mat the information provided above is true and eorrect. `--T / U. -771- 331/ Ofeial use only. Do not write in giis 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. Plumbing Inspector 6. Other - Phone Information aad Ins%°nciions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to flus statute, an employee is dofmod as "...every person in the service of anotherunder any contract ofhire, express or implied, oral orwxitten." An employe is defined as "an individual, partnership, association, corporation o> other legal entity, or any two ormoxe of the foregoing engaged iu a j oint enterprise, and including the legal representatives of a• deceased employer,. or the redeiv6k or. trustee of an individual, partnership, association or other legal entity, employing employees. However the owner o£ a dwelling house. notmore than three apartments and who resides therein, or the occupant ofihe 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 bean employes." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) andphone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP}with no employees other Than the members ox partners, are not required to carry workers' compensation insurance, if an LLC or LLP does have employees, apolicyisrequired. Be advised thattbisaffidavit maybe submitted tothe Department of Industrial Accidents fob• confirmatton of insurance coverage. Also be sure to sign and date the affidavit. jhe 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' compensationpolicy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. I City or Town Officials Please be sure thatthe affidavit is complete andprinted legibly: The Departmenthas 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 Min the pemrit/license number which will be used as a ref6nce number. In addition, an applicant that must submit multiple pemmit/Iicense applications in any given year, need only submit one affidavit indicating current policy information (ifrieccssaxy) and under "Job Site Address" the applicant should idte "all locaVons in (city or A`copy ofthe affidavit thathas been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid aifidavitis on file for future pe znits or Iicenses..A, new affidavit must be. filled out each — - -year.=W-here-a-home:owner-or -- —0.,o. a dog license orpermitto id persoaz is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: `She CQMMO11weaM OfW-00ac hwe"tlI �eprren`� o�Zndu� .�.ccxc�azits ` , ` • (�f�tce o�Int'�eSli�a-�c�u�. 6bQ WashiV(m Steet B 08U)n, MA 92111 TO, # GMUM900 est 496 or s Revised 5-26-05 Fax # 617-727-7749 EASTERNADJUSTMENT CO. INC. P.O. Boz 445, Topsfield, MA 01983 Tel: 978.887.5858- Fax: 978.887.8081 NOTICE OF CASUAL TY L OSS TOA BUILDING Under Mass. General Laws, Chapter 139, Section 3B TO: BUILDING INSPECTOR OR INSPECTOR OF BUILDINGS TO: BOARD OF HEALTH OR BOARD OF SELECTMEN ---------------------------------------------------------- TOWN/ CITY: Town Hall ADDRESS: No. Andover, MA 01845 Re: Insurer: Commerce Insurance Co. Insured: Kenneth Green and Kathy Romano Property Address: 30 Sargent St., No. Andover, MA 01845 Policy Number: HPM039 Claim or File Number: JTXV73 Eastern Adjust. Co. File: T 12417 Type of Loss: Fire Date of Loss: Jan 12015 As representatives of the above captioned Insurance Company, we hereby notify you, in behalf of said Insurance Company, that claim has been made involving loss, damage or destruction of the above property, which may either exceed $1,000.00 or cause Mass. General Laws, Chapter 143, and Section 6 to be applicable. If any notice under Mass. General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and file or claim number. On this date, I caused copies of this notice to be sent to the persons named above, at the addresses indicated above, by first class mail. czw't�zs-4 ig, 440 Farish B. Hemeon, General Adjuster Date: January 26, 2015 ,. Official Use Only THE COMMONWEALTH OF MASSACHUSETTS Permit No. Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & Fee Checked APPLICATIONFOR' PERMIT TO PERFORIUf ELECTRICAL WORK All, work toibe performed in.accordance ce witty the Massachuasetts Electrical Code 527 CMR -12:00 (Please Print in ink or type all information) Date To the Inspector of Wires: Town of North Andover The undersigned applies for a Location (Street BAumber Owner or Tenant .Jr' Owner's Address 3n to perform the electrical work described below. Is this permit in conjunction with a building permit Purpose of Build Existing Service_for)_ New Service, 2oo--Am Number of Feeders and Location and Nature of F 4�0jf-e�q N6 e r -y A x,a0 v es No • (Check Appropriate Box) Total M11o.,a?ft5, ,.in Armlets. Utility Authorization No. _Voits OverheadlT Undgrnd No. of Meters Voits; Overhead Undgmd No::of.Meters� /1(Ga/ 4- 0M QorK I ew, vP9rloAC OTHER: INSURANCE' COVERAGE. Pursuant to the requiremen6ts,of Massachusetts,General Laws I haveasacarrent Lability insurance Roiicy include Compte2ed mperations Coverage -or its subsiaritiai equity to CF 'NO = have submitted va%proof df same to'the�'>6 _ -,,O = 'nave tiled e3.Y p +fie e:�rre}< k}1e INSURANCE = BOND = OTHER = (Please Specify) /�i/�Q 0 710=7r +n9 aPprarrt ate Done. �i► � _ xoiration Datel Estimated Value bf Work to Start Signed under the P FIRM NAME _ LIC. LicenseeQ / / Signater►e LIG, No liLI _ Q Q legdd5R111 I V Bus. Tel �� AddKess � ICIt TeL Nw: OWNER'S INSURANCE WAIVER: I am aware that the Licenses do s not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $ Total M11o.,a?ft5, ,.in Armlets. 'No.xgf.;Fbctt?fuse 4a.wf.Transformers )CVA Above tm No. of Liohtin =fiixtures Swimnmin rPool �crnd •. camwl tsemerators �MCVA No. of Emergency Lighting No. of Rece tacies Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Di osal No. Pumps Tons KW No. of Sounding Devices Nod of Self Contained No: of Dishwashers SloacelArea.Heating KW Detection/Sounding Devices • Munidpal • Othera No. of D ers Keating Devices W Kw `Locaf Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wirin No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE' COVERAGE. Pursuant to the requiremen6ts,of Massachusetts,General Laws I haveasacarrent Lability insurance Roiicy include Compte2ed mperations Coverage -or its subsiaritiai equity to CF 'NO = have submitted va%proof df same to'the�'>6 _ -,,O = 'nave tiled e3.Y p +fie e:�rre}< k}1e INSURANCE = BOND = OTHER = (Please Specify) /�i/�Q 0 710=7r +n9 aPprarrt ate Done. �i► � _ xoiration Datel Estimated Value bf Work to Start Signed under the P FIRM NAME _ LIC. LicenseeQ / / Signater►e LIG, No liLI _ Q Q legdd5R111 I V Bus. Tel �� AddKess � ICIt TeL Nw: OWNER'S INSURANCE WAIVER: I am aware that the Licenses do s not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $ 4/12/2016 4 1 National Grid Inquiry #NS1155578# Fwd: National Grid Inquiry #NS1155578# SM Shaun Martin To: Estelle Halchak; t? Reply all I v ® Delete Junk I / ••• Action Items Reply all v Mon 5:24 PM We think we've found an action item See below service request # for Sargent Street, it is the #21626004 and needs to be added to the permit for John before submitting it, thanks Ir' Follow up See below service request # for Sargent Street, it is the #21626004 and needs to be added to the permit for John before submitting it, thanks Shaun Martin Operations Manager Voltage Electrical Services 603-475-6648 -------- Original message -------- From: CustomerService@us.ngrid.com Date: 4/11/2016 2:54 PM (GMT -05:00) To: Shaun Martin<sm@voltageelectricalservices.com> Subject: National Grid Inquiry #NS1155578# Your request for a New Electric/Gas service has been processed for 30 Sargent Street N. Andover MA 01845. The ESO/GSO number is 21626004. ----------------------------- Thank you. Your Transaction Number for this request is 'NS1155578'. Q https://outlook.office.com/awalprojecton.aspx 1/2 4/12/2016 Thank you for using our online services! National Grid Inquiry #NS1155578# This e-mail, and any attachments are strictly confidential and intended for the addressee(s) only. The content may also contain legal, professional or other privileged information. If you are not the intended recipient, please notify the sender immediately and then delete the e-mail and any attachments. You should not disclose, copy or take any action in reliance on this transmission. You may report the matter by contacting us via our UK Contacts Page<http:/Iwww2.nationalgrid.com/contact- us > or our US Contacts Page<https://wwwl.nationalaridus.com/ContactUs> (accessed by clicking on the appropriate link) Please ensure you have adequate virus protection before you open or detach any documents from this transmission. National Grid plc and its affiliates do not accept any liability for viruses. An e-mail reply to this address may be subject to monitoring for operational reasons or lawful business practices. For the registered information on the UK operating companies within the National Grid group please use the attached link: http://www.nationalarid.com/corporate/legal/reaisteredoffices.htm ******************************************************************************** This e-mail and any files transmitted with it, are confidential and are intended solely for the use of the individual or entity to whom they are addressed. If you have received this e-mail in error, please reply to this message and let the sender know. https://outlook.office.com/awalprojecbon.aspx 212 d CHARLIE D. BAKER GOVERNOR JOHN:C. CHAPMAN KARYN E. POLITO UNDERSECRETARY, OFFICE OF LIEUTENANT GOVERNOR GONSUitiER AFFAIRS & BUSINESS REGULATION ,JAY ASH (taint ottbied1t4 Of *A51ad)u#Ptt5' CHARLES BORS'TEL SECRETARY OF HOUSING - DIRECTOR M ECONOMIC DEVELOPMENT Division Of Professlanal pIR Licensure' DIVISION IR PROFESSIONAL BOARD OF STAT. E EXAMINERS OF ELECTRICIANS LICENSURE 1000 Washington Street • Boston • Massachusetts • 02118 April l4, 2016 TO Whom. It May Concern: This'letter is to certify that Mr.. Shaun A. Martin(EL-20255-A) has successfully added the company name VOLTAGE ELECTRICAL SERVICES DBA to his license. This change was approved on April 14, 2016. We have recently upgraded to a new system; and unfortunately it is currently not allowing.us to make .any company name changes to licenses. We have been working to resolve this issue and will be sending out alicense card to reflect the company name, Although the company does not have this license card, they are approved'to conduct business in. the state of Massachusetts. If you have any questions or concerns, please contact me at the phone number below. Th , TVIi a Mello Office Support Specialist TELEPHONE: (617) 727-9930 FAX; 1617) 727-9,932: dectricians.board&tate.ma.us http-1/w wJn9ss.gov/dplle 04/12/2016 16:18 FAX 603 898 8269 FOY INSURANCE SALEM Mar O3 16 06:04p Estelle Halchak 6033629715 r Z'he C'oywnonwealili ofMirssach"5' neprrrtment of Industrial.Acctden-ts & 1 Corrglress Street, Suite. 10 a Boston, A" 02,114-2 017 WWW.mass.gol'/dia Wnr'kers' comp eusaiionXusurAlaeeAffidavit: I3rulclers/Conixnctors/]4l@ctricians/Plumbors, TO BE lllfl,13 WXTI(TKM y]&R1Vt[T•1D.NG AUT13O12X7 y. Pease —print Na'nw .AAdress, City/State/? iP:. 001 P. syr.; yon a u crnPloyty? CJlecic the appxopl'jate box. 1•�ItunaemPloYerwith—,�.��P]ayZes full OrFatitimc).y 7. l� Wor&1nS for Inc is lama solo proprietor, or pa�lnlsh inpa dice a cmd c yees aoy ouj a07Ly. [l�� wnrlCOT.,' comp. y L l am, abomc wf=r doing, all WorkmyscLL 100 workers comp.•inslunaeerequ ops d.C�Y a�n n homeowner audwtli be 14,fitg aont'actomto conduct aIla'or& on AW Properly Xwill ensure. tint all contokeorc, eitllar bare worlrera' compensation illeurAnco or ai a sole proPiietor�witttno eanPloyeos- g J arq o. gen�ral contraow and lulvehired tbq dub-,011tnict0rs listed an 1110 uttaolicdaheet. Theec svU coutraewral�sJo cirrployeee an ? hnvo WOrkors' comp- insnmaoe L t;,Q WJ aro a corecrnf?on Pnd itq 4fP4� bavo 0rci01aed thoi-light of8xamption perMC;% c 9nsoreuoo 152 S1(4) Ew�i v✓o bays naP►nglay�4s. �No w°rkets' comp. rcqurred. J ,K ype Qf plroje- (! e4u re 7. Nt'sw conslsuotion 8. Q Resnodel%ig - 9 ❑ Demolition 10 ❑ Building addition 11 Elecizical reptsu-s or additions III 1.2,n71umbingrepaks or additions 13 . [� Roof repairs • 14. �Qtlier .�— +"tiny appllcsntt�atoitcakr B601 must al o fill ou ° 8 loins Ll o k d tTaen hire our t iialidoConlrQcfors m st Si9DmfL' nnoW a£5davreind;catinz Ruah. ncOWnCCD waD s5(irriiE't�ils afftdaviS indicatiu8 Gy ' }C:ontraceprs LHat ehcelcilliI boxluusf,'sttarlied an�rlditional �llcet showinStba nsmD of. the sv6-cotftrdctors and stato lvhetlu>ar oz nDt�tboSC entities avn ees,!li LilusC rovido tieir wodccra' COmD, paUcy number. employees. Jfthcaub-coni +ciarslmvacmDtaY �' p IU e�S Bel01v i� Iltepol ^ altdjub site pay;, an employer that is pi•nvirlitzgworrceas' compensatioYz Qptst[l•ancefop my erne y Inslu'ance CompanyNAxao: poliev # or S e]! nis. Lir,- #: Q FXpiyation.Date: - job Sita Address-^ � satio� declaratiol>_ page, (showing the policy nuubcr and expiration dell). Att2a a Copy of tlLO WOKICCAS Com p y uuisliable by a Ana uP to $1,500.00 Fatllut to secure apvorage asaequire4imdurMGT' °' 152, g25A 's acriminal violatiortp and/or one-yearimpri,solunwt, aswollascivilpence$ be rwatdedtotU the Office invRK ORgado'n of{ &DLA.foriasu-ran;etc clay against the violator..A copy oi.tlns statemen Y coverage veriro " n. -nd a arcs tXp altdes ofper jury ilzat the infoYmutiol°t pz'ovided a ove is truce annnd en . tree Y do ice y t%l1' () /1 / c _ ,�. _ ,.n1 . _.__ �( 1. p r�J iul use only. DU raollvPite iso this arca, to he completed by city or tOlvla o�caat• . )<'aKII1.1.t/License f� —^�— City or Town: Issuing,Authoaity (circle nun): 'pecior 5. P.1umbin9XnsFeu'-Qr 1. Bo:Ird of wealth 2. DnildingDepsu finelxt 3. City/Town Clerk 4. Tleciric�I Ins Phone #• _ C011jacb I?ars On:�_� 04/12/2016 16:18 FAX 603 898 8269 FOY INSURANCE SALEM [a 002 a DATE (MM/DD/YYYY) A� f> CERTIFICATE OF LIABILITY INSURANCE 4/5/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW- THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and Conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsetnent(s). PRODUCER Foy Insurance - Salem 163 Main St - Suite 102 Salem NH 03079 INSURED SMES & DRA VOLTAGE ELECTRICAL SERVICES 61 RROORDALE RD SALEM NH 03079-1903 1 INS 11AVFDA(1_FQ CFR-nFICOTF N11MRFR-CL1632954890 Barbara Harris, AAI (603) 7399-6320 I (N t- (603) 099-8269 .barbara.harris@foyinsurance-court INSURERS AFFORDING COVERAGE NA Allain Street America Assurance 2993' a --National Grange Mutual 14761 C: D: 6- F: 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 AD POLICY NUMBER POrnOnYYY MM/D Y EXP LIMITS A GENErtALLIABIUTY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE t] OCCUR MPT4300Q 1/12/2015 1/12/2016 EACH OCCURRENCE 5 1,000,000 PREMISES Ea oNTED S 500,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: x POLICY RO• PLOC PRODUCTS - COMPIOP AGG $ 2,000,000 $ B AUTOMOBILELIAMLJTY ANY AUTO ALL OWNEDX SCHEDULED AUTOS AUTOS X X NON -OWNED HIRED AUTOS ZT430BQ 1/12/2015 1/12/2016 MBINEEDISINGLE LIMIT 1 000 000 BODILY INJURY (Par pamDn) $ BODILY INJURY (Per accldent) $ PROPERTY DAMAGE5 (Par accident, Uninsured mdltstcombined $ 11000,000 UMBRELLA LIA6 EXCESS LU1B OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE 5 DED I I RETENTION $ i3 WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ EX OFFICERIMEMBERCLUDED? (Mandatory In NH) if yes, doscribe under DESCRIPTION OF OPERATIONS below N/A T9309Q 1/12/2015 1/12/201fi STATU- OTH- r 4 E.LEACH ACCIDENT $ 500 000 C.L. DISEASE - EA EMPLOYEE 5 500,000 E.L DISEASE - POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS r LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more apace is required) Job Site: 30 Sargent St-, North Andover, MA CERTIFICATE HOLDER (978)688-9542 Town of North Andover 1600 Osgood St- Bdg 20 North Andover, MA 01845 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 Michael Foy/9BARBH - rte ACORD 25 (2010/05) m 1958-2010 ACORD CORPORATION. All rights reserved. INS026 (2moos).o1 The ACORD name and logo are registered marks of ACORD