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HomeMy WebLinkAboutMiscellaneous - 534 Chickering Road �- V� --F- � � 10538� U dd Date S�!�........ U op".�pT"'tio TOWN OF NORTH ANDOVER * PERMIT FOR PLUMBING r HUS� This certifies than. . . r^1 e ........... .. ............ ...... permission to performoZ41.4....> s ?.......... ....lr- ..... plumbing in the buildings of... .. -+'` .....,. at.•�...' ...... ..�.. ......... orth Andover, Mass. Fev3,7....Lic. No .?�....... ..�;{`:.. ............. ...... .................... 'INSPECTOR Check# �1'!� � � i � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY ISt' _— MA DATE �( PERMIT# JOBSITE ADDRESS 1 OWNER'S NAME POWNER ADDRESS I TEL FAX{ �J TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL Q RESIDENTIAL Lel PRINT CLEARLY NEW: Q RENOVATION:Q REPLACEMENT:Q PLANS SUBMITTED: YES Q NOD, FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 J1314 BATHTUB _( [ ._ _€ 4CROSS CONNECTION DEVICEDEDICATED SPECIAL WASTE SYSTEMDEDICATED GASlOIUSAND SYSTEM ! ( f ( I [ ___. DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER ( I ..—_) .__ -_ I J ) � �! ! ---.-_ .__.. I ! _..__f DRINKING FOUNTAIN I ..-_.-_1 ( ._._._f FOOD DISPOSER _�i ._.--_1 __.__.1 [ ._._ ( I .. _ ! --__—! ( .-. I _..._.) ..__--.! _-_j I FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ti KITCHEN SINK LAVATORY ! _—_f - -j .__.__1 r! —_- --.__..( __._-� -- _€ ..___J .�-- j --_I I _.-__( ROOF DRAIN _( ( . ---[ --( -- __1 — [ - J -- -J---� --- [ - -- - - I SHOWER STALL I � I _^I I _..-__1 __.l __-_) —.ji SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING .OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES RNO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Dd OTHER TYPE OF INDEMNITY Q BOND F11 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 Q 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 pli nce all ent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L_ l U I(3 t L- J I LICENSE# SIGNATOR IMP Q JP 5k CORPORATION 0# PARTNERSHIP 0# LLC f COMPANY NAME ADDRESS CITY STATEE ZIP TEL C�FAX _ y CELL _..___...__...___._._ EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ��S FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth o Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n Please Print Legibly Name(Business/Organization/Individual): ) c `r1/� o f Address: so,;-�N City/State/Zip:A� oJ/t))1 Oay3yPhone#: �3 262�M) Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors 2.LV I am a sole proprietor or partner- listed on the attached sheet.I 7• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition J. working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.E]Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] *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 aie doing all work and then.hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. r Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 c tr under lie ns and p aloes ofperjuty that the information provided above is h a and correct Si ature: Date: ` Phone#: t O 0 ;r Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for they employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, express or implied,oral or written." An employer'is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of r 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 an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. r Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any ciuestions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Gomponwoalth of Massac.-husetfs Department of Industdal Accidents Offloe afInvestigations 600 Washington Street Boston,MA.02111 TeX.#617-727-4900 e)t 406 or 1-877 MASSAFE Revised 5-26-05 Fay#1`617-727-7749 WW_MasS,govaa vt.al."78,C.Al 8-07-' 13 14;57 FROM- Cross Ins Manchester 603-641-5062 T-107 P0001/0001 F-379 1 ® DATE(MWDDIYYVY) CERTIFICATE OF LIABILITY INSURANCE 8/7/2013 RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ICATE 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 t0 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). TACT Sylvia R7]and PRODUCER NAMN: FIAT/Cross Insurance PHONE (603)669-327.8 prC ,, (6031 046-4 3 3b 1100 Elm street Eoi'E :sallard@crossagency.Com INSURERS AFFORDING COVERAGE MAIC N Manchester NH 03101 INSuRERA.Merchants Mutual Ins Co 23329 INSURED INSURER B DAVID gURLETON DBA INSURER C: CARLETON PLUMBING AND HEATING INSURER D: 142 SOUTH MAIN STREET INSURER E: NEWTON NH 03858-3709 INSURER F: COVERAGES CERTIFICATE NUMBER:i3-14 Bop & BA 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 70 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. BR POLICY EFF POLICY EXP IIIN R TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMrnnrYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL CENERAL LIABILITY PREfM�MISES Ea ococSJEa ��-cur�� $ b00,000 A CLAIMS-MADE 7XI OCCUR DOP9097161 /20/2013 /20/2014 MED EXP(Artyone person) $ 15,000 PERSONAL s ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'LACGREGATELIMITAPFL15SPER; PRODUCTS-COMP/OP AGG S 2,000,000 �POLICY PRO- LOC $ COMBINED SIN L 1,000,000 AUTOMOBILE LIABILITY a anrident AMY AUTO BODILY INJURY(Per person) $ A ALL OWNED X SCHEDULED P104I689 /20/2013 /20/2014 BODILY INJURY(Per eccident) $ AUTOS AU OWNED PROPERTY DAMAG $ X HIRED AUTOS X AUTOS Per Mani Uninauredmotorist combined $ 11000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CIAIM3-MADE AGGREGATE $ r DEDRETENTION S $ WORKERS COMPENSATION WC STATU• OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARYNER/EXECUTiVE a E.L.EACH ACCIDENT S _ OFFICER/MEMBER EXCLUDED? NIA (Mandatory fn NH) E.L.DISEASE-EA EMPLOYE $ It yes Geeeriba under E,L.DISEASE-POLICY LIMIT $ DESRIPTIOM OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional RemarKs Schedule,if more spats Is requlred) Refor to policy for exclusionary endorsem®nta and Apacial provisions. CERTIFICATE HOLDER CANCELLATION (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THF POLICY PROVISIONS. Town of Andover, MA Building Inspector, Town Hall AUTHORIZED REPRESENTATIVE 1600 Osgood Street Bldg 20 Andover, MA 01845 ��,t �• C/L+-�—��.. .Till Charnley/JSC ACORD 25(2010/06) m 1988-2010 ACORD CORPORATION. All rights reserved. INS026 poicupi The ACORD name and logo are registered marks of ACORD ti,, J' ,,i `,ii �''� d, ��� 9� i'i i �', i'. i .' �� i �, ��: r ,,t !' I i li�;i ` 0538 4.0p7"'ti TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING r 83AC►nJS�t rr This certifies thatt �etrt e ................ ........................ has permission to performv ...... b.......... .....Lr- ?. ..... plumbing in the buildings of. ...�...�...'}.......:.. North Andover, Mass. Fee3,X ....Lic. �:........ ........................................ j� �j ( ! �LUMBING INSPECTOR Check# _�� v MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK if CITY ISfi aj c- N ; MA DATE ( PERMIT# I � JOBSITE ADDRESS OWNER'S NAME _ POWNER ADDRESS I TEL -- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: � RENOVATION:Q REPLACEMENT:Q PLANS SUBMITTED: YES Q NOD FIXTURES Z FLOOR— B-�Se-M} --__1--__-_- 2 3 4 5 6_ 7 8 9 ._10 1._1 .-1_—.2 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ f _-_-__- .__ (i.kffi�f ( DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ! ( _I l DISHWASHER ( DRINKING FOUNTAIN ' - _ _,. _ FOOD DISPOSER _ __---- FLOOR/AREADRAIN _._-_ _ 0 _ -_1 INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN __ SHOWER STALL SERVICE/MOP SINK TOILET URINAL - WASHING MACHINE CONNECTION f WATER HEATER ALL TYPES WATER PIPING .OTHER _ I i f --__-.! J I i I __-_-f f 771 -1 —_. --s ____I .—_._I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES('NO 011 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 , OTHER TYPE OF INDEMNITY 0f BOND I 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 Q AGENT r SIGNATURE OF OWNER OR AGENT 1 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 pli nce all an vision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEU I Q L= J I LICENSE# { SIGNATURE IMP 0I JP CORPORATION _I#=PARTNERSHIP _a# LLC j COMPANY NAME Jt 0 DRESS 0. p Ir✓ t I CITY IU t _]STATE yv ZIP a ^( TEL 63 j FAX ll CELL EMAIL I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �� FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n .� Please Print Leizibly Name(Business/Organization/Individual): ) e r1 r� 1 )J 1 4 Address: L/� J O,;-�N M AZAJ S City/State/Zip:& _ AD o-j&M CME Ph.#: C,03 26ZXY-: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet.# ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. El Building addition [No workers'comp.insurance 5. F1 We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' comp.insurance required.] 13.[i Other *Any applicant that checks box41 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they ace doing all work and then.hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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. Ido hereby c try under he 'ns and p alties ofperjury that the information provided above is Ir a and correct. Signature: z4 Date: J Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,- express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of ✓ insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials , Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person 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: The Commonwealth of Massarhusotts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Teel,A 617-727-4900 ext 406 or 1-877.7MASSAFE Revised 5-26-05 Fax 0 617-727-7749 www.mass.gov/dia. 08-07-' 13 14;57 FROM- Cross Ins Manchester 603-641 -5062 T-107 P0001/0001 F-379 l 1 ® DATE(MM/DDIYYYY) oRv CERTIFICATE OF LIABILITY INSURANCE 8/7/2013 HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS .:ERTIFICATE 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 policypes)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). TACT Sylvia A]zard PRODUCER NAMN: VIAI/Cross Insurance PHONE (603)669-3218 p!C ,. (603)645-4331 MAIL 1100 Elm Street E.DbR12 _sallard@crossagoncy,com INSURERS AFFORDING COVERAGE MAIC 0 Manchester NH 03101 iNSURBRAMerchants Mutual Ins Co 23329 INSURED INSURER 0: DAVID CARLETON DBA A INSURER C: CARLETON"PLti;NMING AND HEATING INSURER D: 142 SOUTH MAIN STREET INSURER E: NEWTON Na 03858-3709 INSURER IF, COVERAGES CERTIFICATE NUMBER:13-15 BOP & BA 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 13EEN REDUCED BY PAID CLAIMS. BR POLIC EFF POLICY EXP ILTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MMrnn/YYVv LIMITS GENERAL LIABILITY EACH OCCURRENCE $_ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occur anew $ 500,000 ` A CLAIMS-MADE Fx-1 OCCUR OP9097161 /20/2613 /20/2014 MED EXP(Any one Person) $ 15,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OP AGG $ 2,000,000 J4 POLICY PRO LOC $ AUTOMOBILE LIABILITY �LaCO aBrIidentNED31N L 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED }i: SCHEDULED 1041689 /20/2013 /20/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMA S X HIRED AUTOS X AUTOS Per idcnt Unineuredmotorlatcombined $ 1 000,000 5DEDFReTrNTIONS B OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ $ WORKERS COMPENSATION WC STLIM ATU• 0FR AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Ya E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ It yes describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ D8S CRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if move space Is required) ecial r Refer to policy for exclusionary endorsements and a p Povisions. CERTIFICATE HOLDER CANCELLATION (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Town of Andover, MA Building Inspector, Town Hell AUTHORIZEDREPRESENTATIVE 1600 Osgood Street Bldg 20 Andover, MA 01845 ,7111 Charnley/J$C ACORD 25(2010105) m 1988-2010 ACORD CORPORATION. All rights reserved. INS026(201005).01 The ACORD name and logo are registered marks of ACORD