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HomeMy WebLinkAboutBuilding Permit # 3/12/2015 i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:1 Date Received Date Issued: IAA IMPORTANT Applicant must complete all items on this page Y �r t ? yr t 3 � f ` .r � , � �-`�i r ✓i x lilt t� ", ,, f �f� r ` y:.! t t MAP NO � PARCEL ZONLNG DISTRICT f r Historic District r Village MaehmerS r, ,. TYPE OF IMPROVEMENT. PROPOSED USE R%ne e ial Non- Residential ll New Building family ❑AOdition El Two or more family 11 Industrial [?Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other '❑ Septic ❑Well ❑Floodplain ❑Wetlands ❑ Watershed District .,r❑,W.ater/Sewer � , s :., � ."., .,. ,,. ,, ". . , : • . DESCRIPTION OF WORK TO BE PERFORMED: I entification Please Type or Print Clearly) OWNER: Name: P� v- C-ra c Phone- Address: 777 ��CONT,RACTOR Name. one 3'I�ilt►n��t Address f r y Y v l Supervisor's Construction License t Home,Improvement License ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ I ��U FEE: $ - �- Receipt No.: �- - Check No.: � p NOTE: Persons contractin with u regis a contractors do not have access to the guarAve anty fund Siture of'A na gent/Owne ignature of contractor g . Plans Submitted Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ I t%O RTH I own o-1 liduver • _- Z h � � ver, Mass, o �„ 'p, CoCHICHF WICK 1. '7,45 R,rED r4`` `7 U. L DBOARD OF HEALTH P �E IT Food/Kitchen Septic System THIS CERTIFIES THAT ....�... �j ,1�Imot........., .... BUILDING INSPECTOR .............. ................. ... ..... .... .............................. has permission to erect buildings onQ. ��has ® ® Rough to be occupied as ........... �ItJ �N.... .�,oA�. ..... 6. I�e>r 6.!!'1►................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRESI 6 ONT S ELECTRICAL INSPECTOR UNLESS CONSTRUCT ST TS Rough Service .............. ...... ...... ............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay in a Conspicuous Place on the Premises — Do Not Remove, Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 11-28SachnsettS Rome II Tltisform- �`®ve (t'I@ ,�'c`21�7¢>ALe �'®Y& a`�lLe satisfies nth basic requirements of the state's Home Imp rorerrrenE Contractor Lair language to plOfecthomeonn vassachusettsCo e-Seek l nsumerGuidetoHome ��adtiticeifnecessam-AnYperson (141GLchapterl4 ) 6uYdoesnotindude OFrtce of Co°sum1,.AH j,; Improvement"beforeatn<ejn¢to any r Planning home jrproirmentsshould first obtain a eD stand¢rd BtIdBILSinCSSRcpI inn'sCnna,merinfommedonHotrinoat6 urresidence YOU ttrayobtain afrcaw vUPYoF"q Homeowner Information x73 s7a�or 1 seat 2 P. ycalljng the 83 3757 oro¢oursszbsila. Cama Contrat:torInformation Qi 1'�f/' I camMn•�atne Strv.1 Address (donottrseaPOceBOX address) -v Doei� ��a Conttacto/Salespetsaa uner\ a !� Cir ll otsn — s ^ State p ode ;-.. v Eh raft Ti �t �,J,v ` C�j�,� Busi.:e;sAddn;s(mtso11 R. Avenue�f DaywaePhone �� ���/U Evening Phone CinrTonn .Mailing Addy State Zip Code (U ditferrnt from above) llw;nessphooe FedetalEmplover Lu,-S°trsesxte�ua- t—4 r ce IDarSS.Number ira•�RCq,aa,r3neh lra,° ',/ �.=•-ce Le The Contractor °r-'�u rr�„u_,t.o oottrr 1�tJ Q a / rD�criba;ndcta"thenS a�;toccompleted,lowingn•arkFortheHotneotrner. spec.4 ing the tPeY ,bran' � ��//••�� C � v r' 4 aed,, deaf mateiak to be �C._ aseQuseadd / itia zls eetsineeessam.) Required Permits- the faoowiite building andnjl(6esecuredb Penrtitsarerequiretl Pro ytheconmractorasthehomeoxxners,cent:, PosedStartandCompletionScbedule- (flxi nt rwho secure their own a be adhered to unleas circtQnstan the following schedulenitl eveludedfromtheGuarani<1*uadp 8 jpasof cesbeyoadthecontmctofscoatrolarise ib1GL chapter 242A.) Date when co ill'20orxxill beeia contracted ivoe;, --�%D eandPaate sxiren canmactzd utirk njll be cub,,anliallS,compJztzd Total Contract Pric ymwtSchedtile The Contractor amazes to perform the"'Ork,furnish the material PaSments trill be made according to the follawingand laborspecified above for the total sum of schedule: U (,) i S •upansi_ninecan tract(uot to eeceed 18 of the total contract price or the cost ofspecial orderitems w•hjChare[•jS tmaater) — by/ I o ,A—_ ypan completion of ---_�, S�bS 1f�D/or upon completion of upon completion of the contract (Law forbid; _ The fol(oxingmaletid' dem n=felt pa}merfto n[t7 contract is cora 1 ed to both e1NiPmentmttstbesp ;al S / P party'ssatisfacli°n) ,0 meed before the conimeted wart,•beems in order p to meet the comPletion schedule(== i0 b'paid f r MOTES:(_)Including all nuance ch - n be pa!tire,. not exceed the ��(':)!zr°'e4uires thu ane deposit a:done.,. grcaterof(a)onethirdoflhetoulrnnrrac[pricear )theactualGo;raranvs tlitich mast 6e parm=tt required by the con[rector befozsrnrr,be:•itts maty special ardetad in ads uree to meat the completions mule Peeial equipment or custom made material :19—s xL'arrnnh•-ismmer Subcontractors- ''eu tr— •h in rovided hvthee nlrartar? ThecontraI to bz ❑NO(]Yes nit to Pa+m�•Isubconttactoruu7izedb_vtilecon trZctoLT7t-�ontiactorfttrtare. P �0rthennrranrvmust beattnchedinthe... rzsPonsr711e for com letio¢of ole work described re ardless of materials and labor undar this nm'zemenractionsr) COntract Accepinn ce-tI onsi grePs to be solelynzsponshble forxtl the subco any third contract shall no p rating this document becomes a bin din contract underlan:aril Pa7vtents to all subcontractors for trmplS'thatanyljenOrothersecuri(yinteresthasheenplcontaMl actunden Ile sian,T- lesC. sotrthefollotjn carefupy before sieninc this contract essoUrernise noted nitbin this document,the ° Don't be Scautiousandnotices presstuzd into signing the cataract Take time to r ° lvfaAe sure the con tractorhas a solid Home ad and U1 31 subcontractors to be reaisterzd with the Djrceorgf Ment ConnzcmrReuistrane orad it, Ask.q°ems,°„s tfsometitinS js unclear re�strationbyax-ritin totheD' HomeImp rotzmwlContrz The latvrequires mosthome im rvem ° Does the con traclorha to th rrectorat l o Part-P A 02116 or 1,n. I ou mar jn P ent c°nIMCIOM and surance? s azo Raom SLio,$arson,ivi4 03116 or by calljne 617-97 3737 0o S3S contractor see a copy ofa proof of insu 1 the Contraclarforhis ftisurance company information s Guide t ourrieltlsand responsb ities Read tLeImponant lnfma,ation on ate reverse side oftJds ormatand net a 8»737• } can confirm cocz nee;or ask,t0 Gttjde to the Home lmproxement Contractor Lan: You may cancel this amazement ifit has b< - copy of the Consumer ContraI rissda3. at hie e..nsjgnedataplaceo,herlMittheconuaetor'snormalplaceof6usjness, third brtsinesdayioJloni earMaiinjn fo�ranchoffice byordjnars & °went. See the wait posted.6y telegam sent orbs deGvzrtpnot I to t6uanotidnj�lie of the D0 NOT SIGN THIS atteched notice oftxncellation for furan explanation ofthisright Tna;da¢,-.t vya-mert,'reeoar rrtaatt CONTRACT IF THEP.E ANYB E'^UldZo th-homco'=TheI 7PACESItr c. COF: s'+-�.d be l:epl'o�•tl=aetr.;e. Hi 1!'i el: Simatue e '^� 3 Contractor's t �,��- _ Dat-. The Commonwealth of Massachusetts Department of IndustrialAccidents € Office of Investigations 0 1 Congress Street, Suite 100 Boston,M4 02114-2017 sy° www.tnass ggovIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Atlantic Wedthenzatluu. 111-A- 61'R.Jefferson Avenue Address: R-41M ren 01970 City/State/ 'p: Phone#: 7 Are you employer?Check the ppropriate box: Type of project(required): 1, am a employer with 4. I am a general contractor and I b. ❑New construction employees (full and/or part-time),* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet, 7. []Remodeling ship and have no employees These sub-contractors have 8. [] Demolition working for me in any capacity, employees and have workers' 9. n Building addition [No workers' comp, insurance comp.insurance.t required.] 5. We are a corporation and its 10. 1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I LE]Plumbing pails or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Ro epairs insurance required.]t c. 152,§1(4),and we have no 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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 ant an employer that is providing workers'compensation insurance for my empkyees. Below is the policy and job site information. � Insurance Company Name: z UK i Cwt// , Policy#or Self-ins. Lie.#: 617 0 /a, f Expiration Date: 3 ba 01/ Job Site Address: 19,Z 0 SGL -el-, 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 lane 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 cert bl u er the pas att t les of perjury that the Information provided above is true and correct. 0 5imture: Date: a/ / 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 b. Other Contact Person: Phone#: page 3 of 4 AC COR& CERTIFICATE /YYYY) LIABILITY I DATE(MM/DD3/3/2015 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 CONTACT NAME: Construction Eastern Insurance Group LLC PHDNE (800)333-7234 FAx 233 West Central St E-MAIL c °: ADDRESS, NatickINSURE S AFFORDING COVERAGE NAIC# MA 017 60 INSURED INSURER A:Arbella Protection Ins. Co. 1360 Atlantic Weatherization INSURER B.Nautilus Insurance Co 61 Rear Jefferson Avenue INSURER c: INSURER D: SalemMA INSURER E: 01970 INSURERF: COVERAGES CERTIFICATE NUMBERMASTER 2015 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 AND-N 7500042816 LT TYPE OF INSURANCEINSR POLICY NUMBER MM/DDY EFF MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000 000 X COMMERCIAL GENERAL LIABILITY DAMAG TO RE TED A CLAIMS-MADE D OCCUR /20/2015 /20/2016 PREMISES Ea occurrence $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 2, GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 000,000 POLICY X PRO LOC PRODUCTS-COMP/OPAGG $ 2,000,000 AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT ANY AUTO Ea accident $ 1 000 000 A ALL OWNED BODILY INJURY(Per person) $ AUTOS X AUTOSU�D 020015871 /20/2015 /20/2016 X HIRED AUTOS X NON-OWNED BODILY INJURY(Per accident) $ AUTOS PeOaociRdent AMAGE $ X UMBRELLALIAB X PIP-Basic $ EXCESS L OCCUR EACH OCCURRENCE $ 1 000 000 A IAR CLAIMS-MADE 1,000,000 DED RETENTION$ 4600058654 /20/2015 /20/2016 AGGREGATE $ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B POLLUTION LIABILITY 2PL200378613 10/1/2014 0/1/2015 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS f VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE John Koegel/PMA ACORD 26 n1nn51 m(2010105) INS025/9n1 01988-2010 ACORD CORPORATION. All rights reserved. Tho 6Cf1Rll nnmo and Innn aro ronie}opo,{marke of Gr_npn AC IFILI I I Y I /10/D /DD/YYYY) 2014 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 CONTNAMACT COIIBtrIlCtlOn Eastern Insurance Group LLC PHONEFax (AIC,Nm (508)651-7700 luC No: 233 West Central Street E-MAIL _ADDRESS: INSURERS AFFORDING COVERAGENAIC A Natick MA 01760 INSURED INSURER A:Arbella Protection Ins. Co. 41360 INSURER B Arbella Indemnity Ins Co. 10017 Atlantic Weatherization INSURER CNautilus Insurance Co 61 Rear Jefferson Avenue INSURER D: INSURER E: Salem MA 01970 INSURER F COVERAGES CERTIFICATE NUMBER�ftster 2014 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 _WVDR POLICY NUMBER PM/DDY EFF POLIYYYYI ICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) S 50,000 A CLAIMS-MADE OCCUR 500042816 /20/2014 /20/2015 MED EXP Any one person) $ 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S 2,000,000 POLICY $ PRO- LOC $ AUTOMOBILE LIABILITY Ea a� tSINGLE LIMIT S 1,00 000 B HANY AUTO BODILY INJURY(Per person) S AUTOSCHED LL ED X AUTOSUIED 020015871 /20/2014 /20/2015 BODILY INJURY(Peraccidenq S HIRED AUTOS }� NON-OWNED PROPERTY DAMAGE Al/TOS Per. ccident S PIP-Basic S 8,000 XUMBRELLA UAB X{ OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE S 1,000,000 DED I RETENTIONS 4600058654 /20/2014 /20/2015 S WORKERS COMPENSATION VYC STATU- OTH- AND EMPLOYERS'LIABILITY YIN IR ANY OPFIC RIMEMBER�EXC EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE El NIA E.L.EACH ACCIDENT $ (Mandatory In and E.L.DISEASE-EA EMPLOYE S If yes,desgibe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ C POLLUTION LIABILITY PL200378602— 0/1/2013 0/1/2014 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600) OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Ronald Cleaves/SME — ACORD 25(2090/05) ©9988-2010 ACORD CORPORATION. All rights reserved. INS025onrnnsi m Tho Ailnpn name anti Innn arc rcniefcroA marke of Ar.nRn gb-•�jw� •�� /1tS/GV14 'l:54 :'Ll AM PAGE 2/002 Fax Server ,:maxCERTIFICATE OF LIABILITY INSURANCE DA TE(MMJDD/YYYY) TAt IFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON 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 O ODU ER ND THE C TI IC TE HOLD IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(fes)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certfficate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE 233 WEST CENTRAL STREET (AIC,No,Ext): FAX (AIC,No): NATICK,MA 01760 E-MAIL ADDRESS: 22MLW INSURER(S)AFFORDING COVERAGE NAIC(t INSURED INSURERA: AMERICAN ZURICH INSURANCECOMPANY ATLANTIC WEATHERIZATION LLC INSURER B. INSURER C: 61 REAR JEFFERSON AVE INSURER D: SALEM,MA 01970 INSURER-E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TH IS TO C FY THAT THE POLES QF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLOCY PERIOD IIDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERRA OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 HAVEBEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY LTR EFF DATE POLICY EXP DATE - TYPE OF INSURANCE L R POLICY NUMBER (MWDD%YYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ACH OCCURRENCE $ CLAIMS MADE ®OCCUR. DAMAGE TO RENTED $ REMISES(Ea occurrence) ED EXP(Any one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL&ADV INJURY $ POLICY ®PROJECT®LOC ENERAL AGGREGATE $ RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO COMBINEDSINGLE $ ALL OWNED AUTOS LIMIT(Ea accident) BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTYDAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE ^ AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YIN UB-SB270121-14 03/2012014 03/2012015 X WM SAMORY OTHER ANY PROPERITOR/PARTNER/EXECUTIVEN WA OFFICERIMEMBER EXCLUDED? E.L.EACH ACCIDENT $ 500,000 Mandatory In NH) 1I yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 Ind DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CURTIFICATH ISSUED TO THE CBRT(HCATE HOLDER AFFECTING WORKERS COMP COVERAGE CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. N ANDOVER,MA 01845 AUTHORIZED REPR •" A.`VE ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1996=2010 ACORD CORPORATION. Ail rights reserved. Massachusetts-S u hrneni a P::bHc Safety Board OF SU!Idi ng Regal aftns and St,,,mda s license: CS-087977 ERIC W PALMI r r 3 HILTON ST Salem MA 01970= 0 ratio er: cr"ssic:7,� 04123/2016 . . ��✓rc `iro»r»rarrrcK>trlP�ra�P�?.��r�lrtc�arr(P1 Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR eglstration: 142089 TYPQ xpiration: 3/1212016 Ltd Liability Corpo;4 ATLANTIC WEATHERIZATION L.L.C. ERIC PALM 61 R JEFFERSON AVE SALEM,MA 01970. Undersecretary