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HomeMy WebLinkAboutBuilding Permit # 6/11/2015 rosaryBUILDING PERMIT TOWN OF NORTHA DOVER C) APPLICATION FOR PLAN EXAMINATION Permit No#: lo-3 Date Received I QR C US Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION rint PROPERTY OWNER , 10 ------ Print 100 Year Structure yes no MAP PARCEL: M ZONING DISTRICT: Historic District yes 0 Machine Shop Village yes, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building One family El Addition El Two or more family El Industrial )AAlteration No. of units: El Commercial XRepair, replace We El Ass El Others: El Demolition fiher WOTM S DESCRIPTION OF WORK TO BE PERFORMED: ) 0 il&n 300 Identification- Please,T1'eor Print Clearly OWNER: Name Ski 0 i & ZA UA2 ,42f/I Phone: q7Y 0 ovur Address: Contractor Name: Phone: 6 ag 0 V 6.3Z- A/ Address: C a, AU fLIiiY'W�/, fihw4�u'� AJb1 0�?O Supervisor's Construction License: 7 _Exp. date: 0 Z Home Improvement License: 17�?8-7z7l -EX,p. Date: 2(6 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /CI = FEE: V Check No.: � a, Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund inner UU�1 HJU 1,ellf, t4ORTH Town of Andover ® �� 5'' 0 ® �. h ver, Mass, JAI-rif. o�6 rLAKE r COCHIC Ht-[K y A°`"RTe® S � BOARD OF HEALTH Food/Kitchen PEtxMIT T LD Septic System ...... THIS CERTIFIES THAT .............................. BUILDING INSPECTOR .. .. ....... . ct has permission to erect g .................. Foundation .......................... buil in son .. .. .... ...... ....... ..... ;............. . Rough 1%to be occupied as .... .......... ........ ....................... ............... .t`................................ Chimney provided that the person accepting this permit shall in ev ry 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR CONSTRUCTIONUNLESS ST Rough Service ....................... ..... ;' 1t y . .......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. ' I • CONSERVATION DEPARTMENT Community Development Division June 2, 2015 Sylvia Zawadzki 209 Vest Way North Andover,MA 01845 209 Vest Way, North Andover Construction of a deck and stairs on sono-tube supports Conservation Conditions of Approval,NACC #146 Pursuant to section 4.4.2 (A) of the North Andover Wetlands Protection Regulations, Sylvia Zawadzki, owner, filed for a small project for work proposed at 209 Vest Way,North Andover. The p% p c , t „t lud `;%the�constructi of a,1,2'x.,,1.8' deck with a 4'x 38' staircase (^ 288 s.f. total) on sonar tube suppotts`The proposed deck is approximately 65 feet from the edge of Bordering Vegetated Wetland (BVW) as shown on the herein referenced plan. During the May 27, 2015 public meeting, the NACC voted unanimously to approve this project. All work shall conform to the following: RECORD DOCUMENTS: Small Project Filing Including: Application Checklist; Plan Titled: "As-Built" with hand edits Original Date: 11/22/94; Hand Edits Dated: 5/20/15 Filing received: May 18, 2015 The following conditions are hereby mandated: CONDITIONS: 1. Prior to the start of construction the site contractor shall review the small project permit and be aware of the wetland resource area and the limits of the proposed work. 2. Prior to the start of construction a silt sock (or other erosion controls as approved by the Conservation Department) shall be placed along the existing fence between the work area and the wetlands and the Conservation Department shall be contacted for a pre-construction site inspection. 1600 Osgood Street,Building 20,Suite 2-36,North Andover,Massachusetts 01845 Phone 978.688.9530 Fax 978.688.9542 Web ww,%v.http://www.townoftiorthandover.coin/conservel.htm 3. Excess construction material shall be properly disposed of offsite and accepted engineering and construction standards and procedures shall be followed in the completion of the project. 4. Upon completion of the approved project and site stabilization,please contact the Conservation Department for a final inspection. 5. This permit shall expire six months from the date of issuance. Should you have any question or comments regarding the contents of this letter,please do not hesitate to contact the undersigned at 978.688.9530 at your earliest convenience. Thanking you in advance for your anticipated cooperation Nvith this matter. Respectfully, NORTH ANDOVER CONSERVATION DEPARTMENT Heidi Gaffney Conservation Field Inspector 1600 Osgood Street,Building 20,Siete 2-36,North Andover,Massachusetts 01.845 Phone 978.688.9530 Fax 978.688.9542 Web wwxv.http://wunv.townofnorthandover.coin/con-,ervel.htm 010 RT I BUILDI9 (3 PERMIT D� � TOWN OF NORTH ANDOVER APPLICATION FOR PIAN EXAMINATION Permit Nog-:_.... Date Received '��aca�tusr Date Issued: �.---- __ XA t.Applicaiit rnust colzl i1eins oil this pa c _ LOCATION .., �rtilt PROPERTY OWNER t �. rint 100 Year Stricture yep n'v MAP —_PARCEL: ._ZONING DISTRICT:, -.—Historic District yes rto) _ Machine Shop Village yes TYPE OF IMPI-5,OVI-(II1L-Nt C'ROi'0SED USE Residential _. _ _ . Non- Residential New Buildingne family — —) 1 Addition U Two or more family 1) indl_Istrial _ Alteration _ — -_._ _._ No. of units: - =— '] Commercial emoihtlon_ 1 Assessory Bldg_. I I Othel s: - �. e salt i e�lacol• ort_ — �ther D Septic J Water/Sewer Well F:l Flood i t Watershed Iain 1 Wetlands l� DESCRIPTION OF WORK TO BE PERFORMED: m~ Y Iclenra�csafir�ra � I�rt� � >�v� i a int�C Ic.�,>•I � _ OWNER: Name: Phone: Address: t C'antractor Name: Phone �r' Address: l Supeivisor's Construction License: _., :� ~ �d"i Exp. Date: . - Horne ire li Irpl orrclrent License:—, ✓" _ , Exp. Date: ` -7- -' " ( / m77 .� ARCHITECT/ENGINEER Pltone: Add ress: ..__..___._ Reg. No., FEE SCHEDULE:BULDINO PERMIT,$12M PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON S125.00 PER S.F. Total PMjGot.C:ost:: $ ..�.� FEC: $ Check No n Receipt No.: NOTE: j — tr r .. 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"`ifs ✓f7 ;r � + �s��£a���F �L-r.�};.,,�J>�.�#'" �F"�� t{ s • - ��. `,��a-'r`�.k r5'""'" ��, / fts✓r St s .� ,S .� x2�S'�.�'�''`r�x f ?�,,�,-,`r�r I.''�t -„�'y`�`''��`� k. ”. t. ` r:t�;a �z� r,'.' ,lz#x� k:.ti � �' �t �L iii+ � ~" r• h, �3 u"��x++J��a3p'�r" S.: �`��"� ��'�.��'3�r's.�r rG f...ky, � -� rree-F,t,'cr; Syr 3rj�n,'d£i rt. � F L�aa .� r} �,�',�".1����f.�1�>'�Tsa��>{I�',.�fl✓7f�je�� '-� tr � ''�. •,s air .lam � r.: •� �� ,l } r � , ta'r'ps ? �*���r�,l� ,��/,S ��;F�r`� 1�� �2��� "�'" '� ,2~a� �'� > r6//yy))+1�1 � I x al�r�-s FY�f r yr. � rf� 'i, k "' r4s�.� t�,� ✓ '� ,? 'irf '✓4 �YiSG'?-� J �rS�l k Y �r('�'rU��� �",��,..{�,�� k f'`r✓ <�`'qx � r' lT r t�2,. r;^if<vr''�>nf'p � a:�r>) r�U�,af.%fir��"�r`+l,, '�q� rr�� �s^ r� �Sir;av'2'f•�s���1 { .��'�m�� ,^�����i-.of�sff��i'r,•rr /rsr „ �. ��� '�•' k'�"���3� 2 �'�'Y �1`�1SL 5r4 �E�'i�.r'- t ' 'S {E�' J!•i ��� �' � � x:,. �ar fa-.h S.�=�rr�f�,7 f" r, r '�,'�({ n-Sk,r/� f� 5s�'i�2`lam�rs✓„�,� �l�ty�. � �' ',i�6�+�� „sfG�� Y4f dCJ�y%' oF. n t✓ r7 � ',.� n3"'. 6' 6� .;7�` y ,v', l4� P, ��i��r��•t;a� i Z� x ; r,- a5�+.`�-.>:����7.rr"/o # n fit;r r;�h r ����1�i�°�'lsrr•�s �r�+�'� � �Yi�'�i� c�+ r: z _ t �f*,i_ d r� M ✓li,i t " f, f#� bsb �srtyll C 9 To: Maura Deems Page 6 of 13 2015-05-01 18:47:02(GMT) 16032186803 From: Peter Playdon ---- z 02 . ........ . . • • • .. - ....-..- .. .., y . • • 1 I T jj Yl L ECONTRAUr tt r l SERVICES SOLUTIONS INSTALLED SALES CONTRACT J - -------_1(�— -- us lar iLR f REPRE�Er17ATIVE t7U 18ER r AUTHORIZED , rr r STORE NO, TREIT ADDRESS >TRuETADDRESS v -- 4'ITY STATE IF CIi4 STA1C ZIP TELCFtION@ _— -- — ,. TELE,' INL t i r t DATE L04VE'S CO`11RA-TUr,I_If ENSE hJt161BER rkc„ raaur: li.; nru This i;only a quote for the inctrchandiso and services printed balay.Thri beccwes an aquae*meal upon payment.Upon paywent,the"nlne agleement,it CILICI ny fire specifically completed pages of this document,the Tam+.s and Conditlrns included ye h this docurnenf and any other addanda and altarhments hefelo,shall be refarred to hooin as this-Cone act PLEASE READ ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING. IttSTALLATIOt1 STREET ADDRESS CETY STATE ZIP 1 1 f, PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media, worldwide, in perpetuity. Customer authorizes Lowe's to copyright,use and publish the photographs in print and/or electronically,and agrees that — Lowe's may use such photographs for any lawful purpose,including,but not limited to, marketing,advertising,publicity,illustration,training and Web content.By initialing here, Contract Total Customer agrees to the foregoing,g g [customer to initial to the left). *applicable taxes included NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamphlet Renovate Right, By signing this Contract,Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit, NOTE: If rotted wood is discovered during installation additional charges will apply. You will be given a quote and a change order must be completed and signed by the customer for any additional charges:'_ _ Customer must initial, 'Any work or material not specified is not included in this contract.Any changes,or additions will be at an additional charge for the material and labor, WAIVER OF LIEN and ONE YEAR WARRANTY(TO BE SIGNED BY INSTALLER) 1,the undersigned Installer/Independent Contractor,having been ennpioied by the Customer who signed the Certificate of Completion below do hereby certify(flat[tie work for ttiis project trill be or has been completed in a workmanlike manner and to the Customers satisfaction,in consideralion of the receipt of one dollar and other good and valuable considocation,and to the extent permitted by appiicable law,I heroby waive and relinquish all liens and all rights and claims of liens which 1,the undersigned,now have or may hereafter have for labor or materials furnished,and further certify that all work performed and materials furnished,if any,by any other party or parties upon the order of the undersigned,have been fully paid for.Further,I the undersigned,agree to rause the prompt release of any mechanic hen(s)vvhirh tray be fteal a<lainsl th,;Customer's pu hhiaes by any subcol Irac.tbr,laborer,mechanic or material supplier chiming the right to file such a lien through worf;related to the Cuslorner's con!rai1%,erh Lowe's,in addition to any%earraniles provided by lass or specified elsewhere,including the Customer's Contract with Lowe's,the undersigned,further warrants that at ,:.or,,furnished for INS 1 rojo,"I shall nut free from defects ellhel in material or c=.xr,mar�sh p.If any defe,_ts in nhatvial or Workntanship shall be dlc-cmered in the work furnished or material used durinn I'ne,:c,ursN of Erne vrrrk cr Yrilihin cmc year from the dale Of the Certificate of Completion,fie undersigned agrBti.S to replace or coned such detective work or material,free front all expense lo,Lwv'e s and the Customer uh a manner aatisf"(dory to the Customer I fon}her represent that I have given Customer.he option of relaini n I ,cm-e or all of the su.;)'us materials of ha illn 4 s;mco or all of such surplus inwernals removed from file Cu z�tonTer's premises. If applicable to!ties pr;lotto a i,,.of file work required for this pioIcct,i We unite gl,.J iro holreby ,Ally that I have c ornpiied with all r+squucrrenl:>of the Lt,ad Renovation,Repo,r,and Pam!ing Program Rule('t-RRPP Rf l i, +0 C.c.f, ;roc.7 1,e0 rrt ;r t i;r a;;} j1ppi coif=,slaic awls,r p.,grail r.,gl,'al:rlg lead-cased paint safe: ,,;,r.,pra.hues, mduhuSln.{ n}p 1 ar r wtiih all mtonna(Ion distnb tEl Ora lao{Ice rE quer€ , !s a xl ,o L re,sL:,ru}aril in r Mort L,}the w,'k re,iul.,tt hi Ehis,ucivf,t,f e;erfify Istat!have,pro'nded,he doiume "h i n r gulled to h �d u ' „ I f h "'t� nn, ,h h.f main a r icor:; a.tl,wd y hair,ane av,i ll<'a_hed to this d� �,mc,n!crp Cs pf iII:;t y i �f�r oats a(JUif( 7 Su i e t in f r y ltre LRRri ul i,l .�t11 af;r r h ,r Sir e s,,nil s,dkere l th.s , I f To: Maura Deems Page 7 of 13 2015-05-01 18:47:02 (GMT) 16032186803 From: Peter Playdon iTR"cr# 3 k SERVICES�a.R Lhd"�TION INST ti€. L LES,CONTRACT (MIT .1. — — '.6,)r , r • istaritfnr';<Yeti;,cilCJi.isx`!i'nartf!_gti^iid-s:n'i:i:zJtcta =:,:sc�7itis9ilnbfk;eniASu°`.:n. 'f �c;ter:i:i"rt fe R; an..fie l;i 6,y;rcJctic3 blt lhis"dlr Mra lt" axA n Qi�tfr 3r 931t-a and Y 1 . 'l, .C.h:tttt:,"; Pif/1._E F?_nt};,LL.;f..F',b!5/`!idRY:OCai7iriG,1'u ON rtir;RE uE *E u1GE Cal=7hlla P.G,F A,�`t.OL Owl ';PAGE$f EF'!RE _C.cL'v(o. . r?.-t.S7fiitls;I�N[S —�.� - ^-- C.I .-__..e®� 4�, .. � �••..�..;_ �.�:m ._.�.._....�__--•.._.._ �...`__-.._ .. �_T.sem_-..__. _._-__�{ '. k , �y f'KOTQ.R>~ ASE:"Citstvlt erytan.fs:to.LpttiWs intl"Clu e g n�{?!.g}e tend irrdt 1 I contractors tite rigitf tatake pttato"gr."aplmof the Pr n i5eslwher in .,U ttipn Seryjoes.wilt '. ?e-pq fgrfnW znt4 al!W�tr ��EOLttiCtf al ViB i icrii,sEu feiaied it,tliis irf evO,7t)ly r�rar�is to Love s olt nghS t!tl an€1 ft1t E?41 its-and to 4ha photagrapns.far use l to all""markets aad in pP peitrtty,.Ctstenit�r ' ttfRrl::f�o (atVs's Ifa i canl�sint u arul puPPlrsll ttfe pnglagra(ttta lop aftJip electrdnfcaUy Int:t xes that _ i .i cine s rrAayllse sucR phatG lra(ths:;ararty l8K(ul purpctsa tnei!i�'Irlg tJut sol htnlfert to, �^ - rnarkstincd adur rt!sutct;t5u tleily tllts#raticsl;tca!rtulsg and We. t pntert Uv"n(allrtci ii r<: Contra 4. r:fstp rter: err E .1a to Fnraciting, tasl�rrl�r e T�Cdl I�. dp1n11{ailct,ile[�J ", iajallrsa€le saxes 7, 1ClGli"tom i NpTIGi rCSGU$T{3AflEf2; Fedvral Mkt requires t_owe s to.p'nQvidS:you wi.tr the palttphIet Rerfovata Right By S c nine tilifi Caritra.ct" �clstdsYs�"r.� T I j cknov�tf ttges ftauutg racer red'a:co}sy af"this}�TntphfCt.before work::.l.)'L rr a,formic g Customer of ih«t atetttial:rtsk:ot the icaci 3tazard exnti$.t%te" j from"#ertovat[ r�activity to be petfo, ,- din ustlatners d teitirty tiriit, f _tJ( � '.t .faf$eci.: r6¢l,:is:rti cs�ir eerl:clt,aitig i.rts#atl�ttiojt acid.i.tian l:ohit>t"e.s.;vilt apF.Y6 d_Aj—_t : iv.e�t a:: u i€ -unci': q a tsanc�a..nrtA.. rrt�r�t.be trot leEtad.attd stcp-L, by th2 Cttstairtt't far.an�r acltt'tt`. ttrtl charges: Girsfion�ar 11ttlSt rntti{li. l 3tt,i+or} nr maietl t}t oi' pcc ti tx rt t fr rl,,,r t i fl-tai i.�n,rrs.. ,1} c.t;vns =;rr a<,;;irwtts 1y;'i.kic al n!— i4 sic .i t f r<)L ;!l I t batr.na!'aad i,'atxQr_' 1YNV R ar t-li Id a(tt7 CJNI~Y�}(i.Y.,fA[.RMI3;r TO�E�Iu1k�F2 E3 l .unsttoN;Ql,&d lrstal! 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[r'°" _ I .. s Or -%,fS..i;�s= Eir ii:vt)lri=�;iq�rrif'^ ..r G. t" al t�r<1'ti� 51•:," - - - _li.._ ,.}1.,. f: •ilr,.1 t: �1:.. - -..1. - r. _ t"! - .'di.: ' r., re_.1]1}i£. .3!if 'S :,tf4::P- SfC• -Ad iti Lis_"_ _ � - �.1�- - - a €tav=y " ... - ... .. ..:)..=r;t,.Jt::.1":-..,.�'•.tt';'rS . - 4'An^^. - - _ .. - : in ..."3•:= _ _ 1:� .t To: Maura Deems Page 13 of 13 2015-05-01 18:47:02(GMT) 16032186803 From: Peter Playdon _ The:C'onimonwealth.af lVlasscxcbeisetts v, Departinen.t of In.dostritalAccidents 1 Congress StrgO,Naite..1.00 y Boston,_HA 02114-201.7 ww.Iu�nuss.gov/did 1t orkers'Compensation Insurance Affidavit:Builders/Co.ntractors/Electricians/Plumb.el•s. TO BE FILED WITH THE PERMITTING AUTHORITY. Auolicantlnfamation Please Print Lt rib Name (Business/Organization/Individ..al)- 4246.c••' +-cu- •y) UrQd uc j1,nj LL C� Address; 25 4CL �d An& JA4 - City/State/Zip: LqYvA oldQ rr (-,j Phone A: -442-- Are you all employer.?Check the appropriate box: Type of project(required); lam a employer.with employees(full and/or part-time.),* 7.. ❑New constructinn 2.f 1ainasolzproprietororpartnersh;p.and.haveito.employeesWorking forine.ilt $, Rerttodeling any capacity.[No workers`comp,insurance required.] 3.�Iurn a.homeowner.doingall work myself[Ngworkers'`comp:insurance required.) 9• El Demolition 4.®i:am a homeowner-and will be.hiring contractors to conduct all.work:on:my-_property..1 will 10 Q Building.addition ensure that.till eyrIIaetois.either hav6 workers'compensation.iiisurance.or are sole I.1.[]Electrical-repairs"or additions prgprietors.with 110 employees. 12.Q Plumbingxepairs or additions 5:M lam a.gmeral contractor and.1 have hired the sub-contractors listed on the attached.sheet.. Those`sub-contractors 1.lave.employees_and.have.workers'comp,jnswance.T13,f Roof repairs 6.F1 Weare a corporation and its:officers have exercised thcii right.of exemption per MGL c. 14.®Other 152;§1(4),and we.have no employees.[No workers"comp:.insurance required.] 'Any appl[cani'that checks-box.#1.must also fill out the section helowshovving their their policy urrorma-tion,. �,HomeoLviters who submit:this.affidayit indicating they.are doing'all'work and.then hire.outsidc contractors utust submit a new affidavit Indieating such. *Contractors thatclieck.this box must attached an additional sheet-showing theriame of the sub.contractors and state whether or'notthose entities have employees. Ifthe.sub-contractors have employees,they must provide their workers'comp.policy number. I.wit an employer tla.atas.providing workers'conipens.ationinvut:avice for my.einployces. Below is.the policy and job site irrforrrration.. - Insurance Cclmpany Name; '' <.'tx,cid f, O. y• �r (3 _ Policy#orSelf--ins..�Lie,#: ! 1Gt - rt, Expiration Date: "g- i Job Site.Address: U=� ll City%State/Zip; A rll Attach.*a copy of the:workers' compensatii n policy declaration page{shovving.tlt.e..policy number and expiration.date). F,ailUre.to securn coverage as.required under MGL c. 152.;§25A.-is a criminal violation puniahableby.a.fine up.to.:$1,500.00 alidl�?r one-year.imprisontrl.ent,as:well as ci��il.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 Investiga[ions of the DIA for insurance coverage verification. Ido hereby.certify under the ttatr attd petaalties ofpetyury that ljre information provided above is trite and.correcJ Signature: G�.�/+/¢f •-.-..�,,� __Date: '�I�I �� f f _ Phone#: Official ttve-only. -Parrot write in tlais;za:.ea,to..becvmpletetlby-city, or towta.ojJicirtL City or Towns Pe.r'mit/Licemse.# Issuing.Authority(circle one): 1.,Soard.ofHealth 2,:BuildingDepartment 3,City/Town Clerk 4.Electrical Inspector- 5.Plumbing tnspector 6.Other. Contact Person.: Phone#: To: Maura Deems Page 12 of 13 2015-05-01 18:47:02(GMT) 16032186803 From: Peter Playdon ® p DATE(MMIDD(YYYY) CERTIFICATE F LIABILITY l ll. .....- 4/30/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF.INFORMATION ONLY AND CONFERS"NO RIGHTS UPON THE CERTIFICATE:HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY"'OR NEGATIVELYAMEND, 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. 1f SUBROGATION IS WAIVED,-subject to the terms and conditions:af the policy,certain policies may require an`endorsement. A statement on this certificate'does not confer rights to the certificate holder in licu.of s.uch.endorsement(s). PRODUCER AMEE:: a � NCathy Merrifield NAM . Core 'Benefits Group Inc PHONE (603)329-4.933 FAX No):(603)329-9924 E4-MAIL Vi11a e GreetRoad SS:cmerrifield0mYcoreinsurance.com rZluite A-1 INSURERS AFFORDING COVERAGE NAIC 4 Hampstead NH 03841 INSURER A-MerchaI is Mutual Insurance 23329 INSURED INSURER 8: Peter Qlaydon Construction INSURER C: LTIC INSURER D: 25 Nashua Road INSURER E: Londonderry NH 03053-3446 INSURER F: COVERAGES CERTIFICATE NUMBER:CL153900725 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'CQNDITION OF ANY CONTRACTOR OTHER-DOCUMENT WITH RESPECT TQ WHICH THIS CERTIFICATEWAY BE I$SUED: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: -" --------- ADDL SUER POLICY EFF POLICY EXP (NSR TYPE OF INSURANCE POLICY NUMBER MPA/DD/YYY MMIDUYYYY LIMITS LTR GENERAL LIABILITY EACHOCCURRENGE- $ 1,000,000 DAMAGE TO RENTED SOO -DOD X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occunence $ r A CLAIMS-MADE®OCCUR BOP1078503 /1/2015 /1/2016 MFn EXP(Any one person) S 15,000 PERSONAL.,.ADV INJURY $ 'Included GENERAL AGGREGATE S 2,000,00D GEN'LAGGREGATE LIRIT.APPLIESPER: PRODUCTS-COMP/OPAGG_ $ 2,000,000 X POLICY[ l PRO_jEQILUG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident). S ANY AUf O BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 'BODILY INJURY(Per accident) $ 'AUTOS. AUTOS NON-OWNED PeOPE TY DAMAGE $ HIRED AUTOS AUTOS ---- UMBRELLA UAB 1OCCUR ! EACH OCCU.RRENCE $ EXCESS LIAB CLAIMS-MADE AGGRFGATE $ DED I I RETENTIONS S WORKERS COMPENSATION' II IAC',STATti- OTH- AND EMPLOYERS'-LI.ABILITY YIN I T ER ANY.PROPRIETOR/PARTNER/EXECUTIVE(--1 E.L.EACH ACCIDENT _ $ OFFICER/MEMBER t;XCLUDED?. ( I N(A N "— (Mandatory in Hj' E.L.DISEASE-EA EMPLOYE S If yes,describe under _ DESCRIPTION OF OPERATIONS bclow E._.DISEASE-POLICYLIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(AttachACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES EIE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE. .WILL BE DELIVERED IN }?eter. Playdon C.pnstruction./ LLC ACCORDANCE WITH THE POLICY PROVISIONS. ..25 Nashua Road, Unit A4 Londonderry, .NH 03053 AUTHORIZED REPRESENTATIVE C Merrifield/CATHY ACORD25(201.0105) Oc 1988-2010 ACORD CORPORATION, All rights reserved. INS02519ninftm ni r#,- &f'f% n na,nn_­1 I-.-ar®rnnictur®rf marl'.of®rnpn To: Maura Deems Page 11 of 13 2015-05-01 18:47:02(GMT) 16032186803 From: Peter Playdon CERTIFICATE OF LIABILITYINSIl�ANC DATE(Mwul, I'Y)l 04/30/2015 THIS CERTIFICATE IS.,ISSUED AS A MATTER.OF INFORMATION ONLY-AND CONFERS'.NO RfGHTS. UPON THE CERTIFICATE HOLDER, THIS. CERTIFICATE DOES NOT AFFIRMATIVELY'OR NEGATIVELY AMEND, EXTEND ORALTER 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. lf`SUBROGATION IS WAIVED, subject to the terrns 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 PAYCHEX INSURANCE.AGENCY INC PHONE 150 SAWGRASS DR INV No,Ext):(877)362-6785 _ _�(A/C,No), 877677:0441 E-MAIL ROCHESTER,NY'14620 ADDRESS'paychexatrayelers com (877)362-6785 INSURER(S)AFFORDING COVERAGE NAIG# INSURER A!THE PHOENIX INSURANCE COMPANY INSURED PETER PLAYDONCONSTRUCTION LLC INSURER B.: —' 25-NASHUA RD INSURERC: UNIT M INSURER D: LONDONDERRY,NH 03053 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 092402913231021 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 OPANY. CONTRACT OR..OTHER'DO.CUMENT 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 8Y PAIDCLAINS. INSR ADEL SUBR POLICY FF POLICY EXP LTR TYPE OF INSURANCE _MSD VVVD POLICY NUMBER MMIDD/YYYY fIM/DDIYYYY LIMITS COMMERCIAL GENERAL UASILITY EACH OCCURRENCE $ DAMAGE T, REN TEp CLAIMS-MADE OCCUR- PREMIStS Ea occurrence $ MED EXP lAny one ersOi $ PFRSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIESTER: POLICY ❑PRO- ❑LOC GENERAL AGGREGATE $ OTHER_ JECT PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY_ COMBINED.SINGLE LIMIT $ (Ea accident) ANY-AUTO ,BODILY INJURY(Per person) $ ALL OWNED, SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NUN-OWNED AUIOS PROPERTY DAMAGE (Peraccident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE ] ::j 'EXCESS LIAR CLAIMS-MADE $ AGGREGATE UED RETENTION$ $ A WORKERS COMPENSATION N/A UB4068T293-15 0.3/29/2015 03/20/2016X PER OTH- ANO Err.1P.LOYERS'LIABILITY Y/N STATUTE ER ANY PROPRImorRIPARTNERIEXtCUTIVE (� E.L.EACH ACGDEN7 _$100,ODU OFFlCER/yI.NH) EXCLUDEDY (_I Ify ndato.c In NH) E.L.DISEASE-EA EMPLOYEE* S.100, 00. If yes,decaibe-under DESCRIPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORN 101,Additional Remarks Schedule,may be attached if more spaco is required) CERTIFICATE HOLDER _ CANCELLATION PETER PLAYDON CONSTRUCTION.LLC SHOULD ANY OF THE ABOVE DESCRIBED BE,CANCELLED BEFORE 25 NASHUA'ROAD#A i THE EXPIRATION DATE YHEREOF, -NOTICE. WILL, BE _DELIVERED .IN LONDONDERRY,NH 03053' ACCORDANCE WITH THE POLICY PROVISIONS.`....' .:............. `. .:.... ..., AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD.name and logo are registered marks of ACORD To: Maura Deems Page 10 of 13 2015-05-01 18:47:02 (GMT) 16032186803 From: Peter Playdon hx?' Mice of Consumer Affairs and Buqs/i&ne- ss:Regulation IN 10 Park Plaza.- Suite 5170 Boston, Massachusetts 0211.-6 Home Improvement Co-titractor-.Re.g.-i-stiatioiI Reg!Stfati0n: 179874 Type: LLC Expiration: 9/1712016 Tr4 257957 PETER PLAYDQN PETER PLAYDON 0ONSTRU.CTIONILC. --- 25' NASHUA RD UNIT A4 LONDONDERRY, NH-03.053 Update Address and return CArd.1Fhrk reason fpr ebange.. SCA f to Address Renewal T Einployment ;Office otConsuniet*Affairs&BusU),,,,,,It,g t1la tion License..qr registratio dulus only valid for indivi' e 140ME IMPROVEMENT:CONTRACTQR* beforellie.expirationda(e. Iffound.return.ti(n. 479$74 Type: Office OTCOIISPmer Affairs and Business Regulation _:Expiration: . 9/17!2016. LLC 19 Park.Plazg.-Sn4 ' PETER PLAYDON CONSTRUCTION.LLC. BOMD,MA 02116 PETER PLAYDON 4� 25.NASHUA RD UNIT A4 LONDONDERRY,NH 03051 .................. ............. .. ...... ................. ........ without signatures *9' ...... .......... CS�107548 q PETER,PLAYDON 16 WEST STREET Idw riol Londonderry'NO-.0053--- 05/0312017