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HomeMy WebLinkAboutBuilding Permit # 6/9/2015 �aoaarH BUILDING PERMIT' G` TOWN OF NORTH ANDOVER o� APPLICATION FOR PLAN EXAMINATION '- Permit No#: Date Received oRQM`,m Date Issued: / ��SSACHUs���y IMPORTANT:Applicant must complete all items on thispag e LOCATION TAa Print PROPERTY OW R Print 100 Year Structure yes Do .MAP PARCEL. ZONING DISTRICT: Historic District yesMachine Shop Village yes. TYPE OF IMPROVEMENT PROPOSED USE Resid ial Non- Residential ❑ New Building +6ne family ❑Addifion ❑ Two or more family ❑ Industrial ration No. of units: ❑ Commercial air, replacement ❑Assessory Bldg ❑ Others: Demolition ❑ Other e IT Well � fk.k p ❑ Floodplain ❑.Wetlands N - V4/ater/Sewer�� f�,� ���` `�� �� �� � ��� ✓, ' 0 Watershed,DiStrictf�� � ,� � A 1 DESCRIPTION OF WORK TO BE PERFORMED: ,,V Identification- Please'I' pe or Print Clearly 31 OWNER: Name: Cia ia "a Phone: Address: Contractor Name: ` Jd Phone: - 1 Email: - C I i4 !�,I`. Address: O s Supervisor's Construction License:_ Exp.. Date:_ } °� Home Improvement License: / Exp. Date: ARCHITECT/ENGINEER "a Phone: / Address: , b .`T. l V_ )Je Reg. No. FEE SCHEDULE.BULD/NG PERM/T:$92.00 PER9000 $ .00 OF THE TOTAL EST/MATED COST BASED ON$925.00 PER S.F. Total Project Cost: $_ FEE: $ q n. Check No.: Receipt No.: �{ NOTE: s on ct ng t1i unregistered contractors do not have ace es aranty f nd wy ,- F V%® Tk Town of nuover ® No. /06(0—/57 � = - ' c, 0. . h ver Mass, f20 y S U BOARD OF HEALTH Food/Kitchen PERMIT �Trr Septic System THIS CERTIFIES THAT ...........CA.t'.L U...'...........1: � BUILDING INSPECTOR . .. .. . ...... Uhas permission to erect .......................... buildings on .... .... .fA4........ Foundation.........-................................ to be occupied as .. . . ...... . . . .. ... .. ...... .. ...�. ......... ...... ......... ......... ..t Chimney Rough p provided that the person accepting this permit shall in every resp 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR r LESS CO SR CIO ST TS Rough Service ................. .. ....... .................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy fuildin_- Rough Display 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. Hqrch (k Martin, Inc. Office (978) 532-3224 16 Winter Street 1,,ax (978) 532-3245 Peabody, 4:A 01960 vivvw, Client Proposal May 4,2015 Carlo Allptierto 66 Jay Rd. North Andover,Ma. 978-208-1840 Car1o.a1puerto(& ,gtnail.com HIC Registration number-. 108405 Expiration Date: 08/18/2016 Fed. Employer ID#04-2629083 SCOPE OF WORK Supply and install spray foam insulation to air seal the following: Addition; 1) Spray roof in new BR's with 10"open cell Icynene to R38 $1,260.00 a. With joll R,19 $2,640.00 2) Spray 5.5"closed cell lcynene in old roof on front of house and bath area to R38 $6,696.00 3) Spray walls and gable ends with 5.5"open cell leynene to R20 $1,606.00 a. Spfa"qlls and gable ends.vitt 3"elose4eell $2 �4 00 Total: $9562.00 Notes:*This measure will reduce the probability of ice damming. It is not a guarantee that ice damming will never happen under any conditions in the future *Untrimmed foam will have high and low spots as it does not cure smooth and flat I c' yneyie Inc,NISDS declare job'dies are safe for occupimey 24 hours after instathithm. No enflsdons,deferlable after 30 days. Local building codes may require an ignition harrier paint over foam in attics and crawlspaces or areas not receiving drywall. To have your work scheduled,please select your options and contact the office for a contractor/subcontractor-agreement and scheduling. Please allow approx. three to four weeks scheduling time unless previous arrangements have been made.Thank you! Cleaning: By its nature,insulation can be a dirty endeavor. March&Martin,Inc.will leave the premises"broom swept". A more detailed cleaning is the responsibility of the homeowner/tenant. Scheduling: The above work will be scheduled once a signed contract is returned and the agreed upon deposit is received by this office unless prior arrangements have been made. If all specified work areas are not ready to receive insulation,and another visit will be necessary for completion,an additional fee will be charged for the second site visit. Ventilation:In a tight building,ventilation/air supply should be planned to avoid combustion equipment back drafting and humidity problems. Inadequate ventilation is hazardous. WORK SCHEDULE March&Martin,Inc.strives to accommodate The Owner's schedule and timeline. On rare occasions delays may occur due to unforeseen circumstances.The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. Note:We may withdram,this proposal if not accepted within 30 days. Homeowner's Signature Date: Contractor's Signature Fred Ferris Date: 05/04/15 All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director,Home Improvement Contract Registration,One Ashburton Place,Room 1301,Boston,MA 02108(617)727-3200 x25239. Marc &. Alkirtin, Inc% Office (978) 5'32-.3224 16 Winter Sireet F ax (978) 532-3245 Peabody, MA 0 p 960 Client Proposal May 4, 2015 Carlo Alpitterto 66 Jay Rd. North Andover,Ma. 978-208-1840 Car1o.alpuerto(&,gmail.com HIC Registration number: 108405 Expiration Date: 08/18/2016 Fed. Employer ID#04-2629083 SCOPE OF WORK Supply and install spray foam insulation to air seal the following: Addition; 1) Spray roof in new BR's with 10"open cell leynene to R38 $1,260,00 � , a. SpFay Feef 41 news UR' -with 1(I(, t,-;A +_DAil $2,610.0-0 2) Spray 5.5"closed cell Icynene in old roof on front of house and bath area to R38 $6,696.00 3) Spray walls and gable ends with 5.5"open cell Icynene to R20 $1,606.00 a. Spr-Evy N"Ps and pble-en&With._1­closed G4 leynelle to R.20 $2,524.00 Total-, $9562.00 Notes:*This measure will reduce the probability of ice damning. It is not a guarantee that ice damming will never happen under any conditions in the future *Untrimmed foam will have high and low spots as it does not cure smooth and flat Icynene Ine,NISI)s do"lare job sites are safe for occupa ney 24 hours after oisialhiflon, Calm enfissim"detectable after 30 days. Local building codes may require an ignition barrier paint over foam in attics and crawlspaces or,areas not receiving drywall, To base your work scheduled,please select your options and contact the office for a contractor/subcontractor agreement and scheduling.Please allow approx. three to four w"Its,scheduling time unless previous arrangements have been made.'Thank you! Cleaning: By its nature,insulation can be a dirty endeavor. March&Martin,Inc.will leave the premises"broom swept", A more detailed cleaning is the responsibility of the homeowner/tenant. Scheduling: The above work will be scheduled once a signed contract is returned and the agreed upon deposit is received by this office unless prior arrangements have been made. If all specified work areas are not ready to receive insulation,and another visit will be necessary for completion,an additional fee will be charged for the second site visit. Ventilation:In a tight building,ventilation/air supply should be planned to avoid combustion equipment back drafting and humidity problems. Inadequate ventilation is hazardous. WORK SCHEDULE March&Martin,Inc.strives to accommodate The Owner's schedule and timeline. On rare occasions delays may occur due to unforeseen circumstances.The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that Such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. Note:We may withdraw this proposal if not accepted within 30 days. Ilorneowrier's Signature Date: Conti-actor's Signature Fred Ferris Date: 05/04/15 All home improvement contractors and subcontractors engaged in home improvement contracting,unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director,Home Improvement Contract Registration,One Ashburton Place,Room 1301,Boston,NIA 02108(617)727-3200 x25239. (-)caner O 0 K%tcVlttas-SAths-lZev►wdel iut DWS 781-858-5134 781-858-5134 Homeowner Information Contractor Information Name Company Name Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name �� C> 5 LV City/Town State Zip Code Business Address(must include a street address) VA) -� 1 Daytime Phone Evening Phone City/Town }� / State Zip Code PIO1� Mri DO Mailing Address(It different from above) Business Phone I Federal Employer ID or S.S.Number _ Homc Improvement Contractor Reg.Number Expggg��ation d c Law reqthat most home improvement contractors here A a tatid ,ration number 513 V// The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) V4".if' Cii5t1 1.911 Al" &J&9 � l� � F/oi>Wv L Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adh red to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Z / Date when contractor will begin contracted work. MGL chapter 142A.) V73J Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of 76, (*) Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ ®G by / I or upon completion of St $ by / / or upon completion of Mr.-jet $ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? ❑No❑Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract 6rider law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the co r may submit the dispute to a private arbitration firm which has been approved by the Secr of the f Offs of Consumer Affairs and Business Re lat' the consumer a be required to su it to itra n e assachusetts General L vs,chap r A. Homeowner's Signature Contrac s re NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at littn•//tx,%iAv.mass.pov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at httn•/hvwXv.mass.,-ov/ocabr/ Go online to view tho status of a Homo Improvement Contractor's Registration: httn•//db state ma us/homeimprovement/l ice nseeIist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY,IF YOU WISH,COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE,OR SEND A TELEGRAM TO [Name of Seller],AT[Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: Initial Construction Control Document H To be submitted with the building permit application by a 0 d Registered Design Professional for work per the 8th edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: 66 Jay Road Date: 2015.05.14 Property Address: 66 Jay Road,North Andover,MA Project: Check(x)one or both as applicable: New construction X Existing Construction Project description:Modifications to 2nd floor ceilings& rear roof structure including removal of ceiling& additional new rafters& supporting structure to add volume to the spaces. I, Carmine Guarracino,PE -MA Registration Number: 40104 Expiration date: June 2016, am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning': Architectural X Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge, information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Constructio ontrol Document'. W� OF, Enter in the space to the right a"wet"or electronic signature and seal: c "� cl°`o ` I' .1C RAL N 40104 ,r 4a Phone number: 617.628.1700 Email: uarracino ren com `" g @ g g• �L � Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other' is chosen, provide a description. Version 06 11 2013 The Commonwealth of Massachusetts Department of Industrial Accidents a a 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le0bly Name (Business/Organization/Individual): u�mmr � 7 Address: ®° A)SCJ City/State/Zip: Phone#: '® � ,. Are yoU4n employer?Check the appropriate box: Type of project(required): 1.[?fl am a employer with 1- employees(fill and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs of additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repair's These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] IL *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. $Contractors 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. lam an eznployez•tliat is pz ovidizzg worlcers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: J E Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: A + City/State/Zip: 1 V� v44 Attach a copy of the workers'compelisation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cify and •Xiain nd penal f pezjuz ze information provided a ove ' true and correct. Signature: Date: 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#: Hub International New England To:Dussault Carpentry- C01 For Town of N. Andover (IJ1dbU=)gZ) UZI:94 UU/L:7/IJ UIII-V1 F Client#:256754 DUSSAULTC DATE(MPdIDD/YYYY) ACORD,,, CERTIFICATE OF LIABILITY INSURANCE 1 5)29/2015 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(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 endorsement(s). CONTACT PRODUCER NAME: HUB International New England PAHONrE Ext):978 657-5100 A` No): 978-988-0038 4 West Mill Street E-MAIL ADDRESS: Medfield,MA 02052 INSURER(S)AFFORDING COVERAGE NAIC# 508 359-4151 INSURER A:Safety Insurance Co 39454 INSURED INSURER B:Hartford Insurance Co Daniel Dussault dba Dussault Carpentry INSURER C: 990 Johnson Street INSURER D: North Andover,MA 01845 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 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. ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MfIIDDNYYY MMIDDNYY A GENERAL LIABILITY BMA0012372 9115/2014 09/15/201 EACH OCCURRENCE 5300 000 COMMERCIAL GENERAL LIABILITY PREMISESORENTEDa : , nce $100,000 CLAIMS-MADE E]OCCUR MED EXP(Any one person) $10000 PERSONAL&ADV INJURY $300,000 GENERAL AGGREGATE S600,000 PRODUCTS-COMP/OP AGG $600,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ POLICY jE 0 LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED Per accident HIRED AUTOS AUTOS $ EACH OCCURRENCE $ UMBRELLALIAB OCCUR EXCESS LIAB CLAIMS-MADE AGGREGATE 5 DED I I RETENTION$ WC STATU- OTH- B WORKERS COMPENSATION 08WECEH1833 3126/2015 03/26/201 TORY LIMITS ER AND EMPLOYERS'LIABILITYY/N E.L.EACH ACCIDENT $100000 ANY PROPRIETORIPARTNER/EXECUTNE OFF CER MEMBER EXCLUDED? � N/A E.L.DISEASE-EA EMPLOYEE $100000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) **Workers Comp Information** Proprietors/Partners/Executive Officers/Members Excluded: Daniel Dussault CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved, ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD JC011 #S1390230IM1367154 a/��ccdJC�deeje � _ Office of Consumer Affairs&Business Regulation ! ME IMPROVEMENT CONTRACTOR egistration: T49853 Type: xpiration: -2114/2616:, DBA DUSSAULT CARPENTRY DANIEL DUSSAULT 990 JOHNSON STREET NORTH ANDOVER,MA 01845 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards CuTisti'uC'tIoin Supe;�-;sar License: CS-090846 DANIEL F DUSSibL 990 Johnson Street ' North Andover M-A 0f j o` J I` Expiration Commissioner 12/26/2016