HomeMy WebLinkAboutBuilding Permit # 11/19/2015 �aoaTH
BUILDING ERMIT 0Z.
TOWN OF NORTH ANDOVER ° 5 �
rAPPLICATION FOR PLAN EXAMINATION
�y E A�
Permit NO: Z-- Date Received90
'� °meq<_•• •w•«,.°' �
! SAc HUS���y
Date Issued: G� r
IdIPORTANT: Applicant must complete all items on this page
L 4CAT ION
"
PROPERTY OWNER "
11iIAPNCJ , _P�ARCEt; ZtJING DISTRICT I-lNstorlc District yep
MaFrine Shc► Vlllc, yes: er
TYPE OF IMPROVEMENT PROPOSED USE
Res,identia) Non- Residential
New Building VIOne family
11 Addition ❑ Two or more family 11 Industrial
❑Alteration No. of units: F1 Commercial
" Repair, replacement ❑Assessory Bldg ❑ Others:
Demolition C-1 Other
o Septic ❑Well U Floodplain o Wetlands Q Watershed District
❑'111/ate/Sewer"'
~
Identification Please Type or Print Clearly)
OWNER: Name: Thomas Browne Phone: 978-609-1416
Address: 679 South Bradford Street, North Andover, MA 01845
fl RA' T"OF Flame Jawm /lorlrt I?'Ic er gl
r
Address J,`
80,
GrdJrrrfiwl ,,finny ll 01,E
Q
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i
Superu� o�sConstruofon°LIcense, 'S 0 0`125 xp 1fJ/ / 01
E Cate,
hfc, a lmp rod end license, xp Ca,e,
170510 '
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: 4913.00 FEE: $ 60.00
Check No.: Receipt No.:
NOTE: Persons contracting with,,finrilgister d contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
t%°RTH
Town oft EAndover
0 0
®
C, h ver, Mass, 11
LAKI
COCMIC nlw.CR y1'
A04ATE
S
BOARD OF HEALTH
Food/Kitchen
PERM--IT T LD Septic System
THIS CERTIFIES THAT . .......................... BUILDING INSPECTOR
.... �.
has permission to erect .......................... buildings on ... .......�... . Foundation
to
... ...
Rough
to be occupied as .....C�. .......... �,..�4....................... -- • .�. ............... 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRUCT" RTS 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.
iW
Renewal MA Home Improvement Contractor
1. ® License#170810(Expires 12/23/2015)
E'yACldersen Renewal by Andersen Corporation Federal Tax ID#41.1918413!
30 Forbes Rd. Northborough,MA 01532
(508)351-2200 Fax(508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMEINIT
Buyer(s)Name Date:
THOMAS BROWNE - JOY BROWNE NOVEMBER 4, 2015
Buyer(s)Street Address City State Zi Code
679 S BRADFORD ST NORTH ANDOVER MA 01845
Email Address Home Telephone Number Work/Cell Telephone Number
JOYWALKERB@GMAT L.COM 978-609-1416 978-688-3800
Buyer(s)hereby jointly and severally agrees to purchase the goods and/or services of Renewal by Andersen Corporation("Contractor"),in accordance with
the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s)(collectively,this"Agreement").
Buyers)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement.
Est.Start Date Method of Payment
Total Job Amount S 4,913 Dunt Financed$ 0
Deposit Received 3341 $ 1,637.67 ChecklCash
po ( ) pas,l at=e��,y$ 0.00
10-i2 weeks
Balance Start of Job(335)S 1,637.67 Check
Balance on SubstantialEst. Install Time Credit Card
Al Sub-f dial
Completion of Job(33%)S 1,637.67 $ 0.00
1-2 days If credit card is setected,pleaso
No final pay-1 be demi ded cne;al panfes Ute aatss.,ad see Credit Card Payment form
Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings
changing or modifying any of the terms of this Agreement. No alteration to or deviation from this Agreement will be valid without the signed,written consent
of both Buyer(s)and Contractor. Buyer(s)hereby acknowledges that Buyer(s)1)has read this Agreement,understands the terms of this Agreement,and has
received a completed,signed and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was
'orally informed of Buyer's right to cancel this Agreement DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Renewal by Andersen Corporation Buyer(s) Buyer(s)
By:
Signature of Consultant Sio ature E�—,Signature
X MARC FESTA THOMAS BROWNE JOY BROWNE -
Printed Name of Consultant Printed Name Printed Name
YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION,
SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT
--------------------------------------------------------------------------
I
NOTICE OF CANCELLATION NOTICE OF CANCELLITION
I
Date of Transacdon i I:i/14 You may cancel this I Date of Trasssaed 1 I/ii I .You ntay cancel this
_—actloo aith¢n!an t _.,tater"_¢¢.. ..athin•?�-_e bn=_isse=s da s&-�xex�t•e I transaction,without any Penafty-¢tblh- ¢n,\aitL•in th—bushiessdays rrmm t!•c
above dale.IC you caecal,any ptroperty traded�in,any payments trade by you under I above date.If you cancel,any property traded in,any payments made by you under
the Contract or Sale,and any negotiable instrument executed by you will be I the Contract of Sale,and any negotiable instrument executed by you wiH be
'-turned w=ithin 10 days rollowrng receipt by the Contractor("Seller") of your t retnrssed within 10 days following-celpt by the Com-a.c("Seller") of your
cancellation notice,and any security Interest arising out of the transaction will be i cancellation notice,and any security ince-st arising out of the transaction will be
canceled. tr you cancel,you must snake available to the Seller at your residence,In i canceled. If you cancel,you trust make available to the Seller at your residence,In
'substantially as good condition-when received,any goods delivered to you under I substantially-good conditlon as when-eclved,any goods delivered to you under '.
it this Contract or Sale;or you may,if you wish,comply with the instructions or the I this Contract or Sale;or you may,if you wish,comply with the instructions or the
Seller regarding the return shipment or the goods at the Seller's expense and risk. I Seller regarding the return shipment of the goods at the Seller's expense and risk.
-Itf you do make the goods available to the Seller and the Seller does not pick them up I if)on d¢make the goods available to the Seller and the Seller docs ant pick thein up
iwithin 20 days or the date of your Notice of Cancellation,you may retain or dispose I within 20 days of the date of your Notice or Cancellation,you may retain or dispose
hof the goods without any further obligation. If you fall to make the goods available I of the goods without any further¢btigatio n. If you fall to make the goods available
to the Seller,or if you agree to return the goods to the Seller and fan to do so,then I to the Seller,or it you agree to-[urn the goods to the Seller and faB to d¢so,then
you-main Mable for performance or all obligations under the Contract.To cancel you remain liable for performance of all obligations under the Contract. 'lo cancel
:this transactlor,mail or deliver a signed and dated copy of this cancellation notice I this transaction,mail or deliver a signed..it dated copy of this eauccllatioa entice ,
'or any other written notice,or n send a telegratto Contractor. Renewal by Andersen,I or any other written notice,or send a telegratu to Contractor. Renewal by Andersen,
i30 Foch-Rd. Northhorough,NIA 01532. I 30 Forbes Rd.Northborough,AL]01532.
>I HEREBY C.INCEL THIS TIL],Y&\G KION. I I HEREBY CANCEL THIS TIL\NSACTION.
I
I
I
Renewal L
Renewal by Andersen Corporation MA Home Improvement contractor
�'Y��1C�2t Self \�+ 30 Forbes rd Northborough,MA 01532 License#170810 (Expires 12J23/2015)
WINDOW REPLACEMENT ,,,:N,0:,.< e (508)351.2200 Fax:(508)-986.7072 Federal ID#41.1918413
I
Window Specification Sheet
Buycr(s)i\tune Dine of A-recnlent
THOMAS BROWNE JOY BROWNS WED, Nov 4, 2015
The buyers)fisted above Itelrby jointly and set�eedh agree to purchase the goods and/orsvivices listed below,ill uccordauce with till'prices and Lerma desctibcd
Ion the Specification Sheet and the lomt and the reverse of ill(,accompanying (:US'f0M WINDOW AND DOOR lil:MODE1 l\G AC121 EMEN'l;of which
the Specification Sheet is part.
WINDOW&DOOR DETAILS
Y"Oy,., Gde*ior/Intonor Col I hardware nsnraarn I.rnvEd r Gti!In Gm!� Glass
Room vwich r .l'1 U.t. Window/Door Style Detail Casinqs Ext-Int Color stile Scr ns Sman,_un GriUc. Sa=_h 1/3 S-It2 Lifts Options
Total I BAY BOW&BUILD OUT DETAILS
Apple
Style Detail! width/ Approx. Number Frarro Window End Canter LovrE/ Root/ Hardwaro
Room Count Style Rankers Cash s A Is Lite,. Interior EXiA l Color Grilles sashes sashes SFreens S rortson Soffit Color
SPECIALTY WINDOW DETAILS
Full! Approx. Lauf/ Specialty BAY/BOW ADDITIONAL WORKNOTES
Room Count Style Insert U.I. SmanSun Grilles Grillo Style Eet/int Color
Hall 201 S ria Ilne Full 159 smartsun INTW Colonial WH/CV
ADDITIONAL WORK DETAILS: Monte oumers urr ndtiu>honrL back ort the nuu�lel on nnuar!6fh. The testoid tike file runt irtsentled by that time.
I No Contractor will wrap exterior casings with coil stock color of
Owner is aware that Contractor does not doany painting/staining or rernoval/installation of alarm system or window treatments/hardware.It is the responsibility of
the homeowner to have the alarm system and window treatments/hardware removed prior to installation. We make no guarantee as to whether alarms or window
treatments/hardware will lit atter replacement. Customer is also aware in some cases there will be glass loss. If there is,the amount will be dependent on the type
✓ of existing windows,type of installation and window style.We make no guarantee as to the amount of glass loss.Customer is aware and understands any and all
unseen rot is not Included in this contract.Should any rot be found there will be an additional charge for time and materials unless so stated in this contract.
les Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.Removal and disposal of all job related debris,
windows,doors,storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued.
I Yes Building Permit--Contractor will secure any and all necessary permits. The fee for the pennit(s)Is included in the total contract price.
Yes All discounts have been applied to this agreement.
I; ✓ l'rs No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s).
�It i.u}rrer•d rend untinruntal by and h"I", ,I Ihr pair:(hal IIIir Sprr iflrrmnn 9hrtt,aloof;hill,tin CUS10,NI 1y9NDOW AND DOOR REMODRLING M(Rt.l MEVI; thrrnlin.
[nada•randing heave rn Ihr pauuve,:aid dove sue no v rh:d unJ�•r,mudmg.;r hanl;un;nr nn�rhh int{.:alt of Ihr[rows Thi,.91x,i iralion Sheol m:Lp not r",h:ur,gr 1 or it,,Iron.nlnddird or tarie�l in
'i;,ny oav mole-„sw It I hangr m'ill a ntiug:md ri,qued by bade Ihr IAn rt;and Cnuuarlon 1lucrrf.dl hrrrbl arknoaledgr Ih.0 RuNr.e,;�h.tJ crud dn,Sprrifrt:uiul,Sheri.
(Renewal by Andersen Corporation ]figer:,: Ifuyr r+;ai
Signature of Consultant nature bignature
MARC FESTA THOMAS BROWNE JOY BROWNE
Print Name of Consultant Print Name Print Name
i
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Andersen'NF-RC C atv tided total URR Parf1lraalaallGO (continued)
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Anderson'Product (31-lis Type H•raclor' 31101 V(s Andersen*Product Glassry)m H•Faclorr; SHGV VIa
Loll Sedes
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lip Low E4 with Glides 0.28 0.31 O.54 11P lux-E4 with Elites 0,82 Ola 0.42
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IXarleTap• IIP Low-C-45un 0.27 0.21 0.33 `l -_ lip Low•E4Sun _ U.3. 0.17 0.20 r•`k'
Gru ament WhMow )IP Inw E4 Sun With Gdiles U.29 0.19 G30 -
y.. Casement Window 111,&44 Sun wRft Gdlies 0.32 0.16 0.23 )-
HPlax-EA_S_msasun 0.26 0.23 0,54_ _ __!r lip I m-E4 Smar45un _ 0.31 __0.18_ _0,42
TIP i avt•E4 SmuOun w/(;titles 6.28- 0.21 0A_9 -'^ •1;� �-� TIP tax-N SmartSun w/040as--0.31 0.11 0.38
IIP Lw-E4�0.2.7 03_5_ 0.60_ - __. 1111-- _ _HP Loth-5t0.32_ 028_-GA,- -- �
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IIP Lax E4 SmrtSun w/Grilles 0.28 :::0.21 .....0.49 `'+ HP low E4 SmartSus w/Gnlles 031 0.17 0.38
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IIP low-F4 with Gdllm 028 030 ---0.52.E _- - �- lip Law-E4wldr GrUtcu _0.31 -_0.29 -0.49 -
- ...HP taw•E4 Sun...-0.21 T0.20 0..101 0.31.". - Casament/Awaing '_--.-- _TIP_Lux•E4 Sun---031 - 020T 0_31 r.. .
Flo,iframa•Vfindow - '. etE4S Wi . . - •" - PahnsWindow HPiavwMSarvithGdUes 0.31 ...0.16 020 �fii
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IIP Lor Ct 0.31 033 0.58HP low E4 030 037 0.04 ;
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IIP Lax-F,7 yam Wiles D32 0.30 0.52 TIP Larr-E4 with Grilles 030 03305 r
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HP Low-F4 Sun 0.31 0.20 0.31 ;,3 TIP Low4xT Sun D31 U22 03G I?�
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inec ase LI-Factar radars.See under;-nvrindmrs.cum farspocific performance values.Marvelous reprosanUenrpemd glass.
'Saler Heat Gain Cotffcienl(SIIGC)dofinus die fraction of sular radiation admitted through the gl::ss bath drmcty Vamsminad and absorbed and subseKaenlly released inward.rho fiver the valun,the lees heat is transmitted
through the product.
'VIsIbleTransmittmiee(Vi)measures flow much light comas through a product(glass and frarne).Tha higher the value,Dom 0 to I.the mom dZyfig it the product l:�La in over Ilia product's total unit area.1113ible Transmittance
is measured°ver the 380 to 760 nanomefr.r potion of Ira Snlaf spammm.
NFITC ratings are based an madedrig by a tdni party ag:ncy as validated by an independent lest lab in compliance vrith NrRC pmgr,m and pmcedmai requirements,
•Ihi3 data is accdrte as of Decemher7t1I0.Due to angatng product changes,updated IrSl.memr5 arnew induslrystandams or requbem anis,this note real change AM nim,Ratings are for sizes specified by NFHC for
testing and certification.Ratugs may vary depending an uta of Tampered glass,different grille uptionc,plass for lith c,114-,les,etc.
•Passfve5un"pro ss rotors are available online rot anuar:.anwtndu:is.cnnr
277
Z\ :the Commonwealth of a' dl s ch itis
Deportmeat of Indestrlal'Accidents
Xe of.finVesligail us
600 Washinglon S.reet
Boston,MA 0,2.1.1.1
w .;nr_v .goy%
porkers' -"ontpe siatlon Instamace AftldaYU4.Bud+ders/�Contracto /ElectricYa. s/'tOlua mein
Name(Busitteus/Organization/lndividual): RENEWAL. BY ANDERSEN
Address. 30 FORBES ROAD
Cita/State/Zip: NORTHBORO,MA 01532 - Phone A. 508-3512200
.Are'aou an employer?Check the appropriate boa: 'Type of project(required);
1.' I atix a canployor with 30 4. 1 am a general contractor and I+ h. L New construction
employees(full and/or pail-time).* have hired the qtb-contractors V iF,
2.(� 1 am a sole proprietor or partner- listed on the attached sheet.t 7. °i Remodeling
ship and hove no employees These sub-contractors.have S. 0 )emolition
workingmein capacity. workers'comp insurance.
for L' �• 5. (� We a corporation andits s 9, E]1$oildin�addition
workers'comp,imurance '�' 10.0 Flectriml repairs or additions
required.] officers gave exercised their
3, i am a homeowner doing all work right of w.cemption per M01, l I.Ll Plumbing repairs or additions
myself,(:No workers'camp. c. 152,§1(4),and we have no 12.El Roofrepairs
insurance required.]t employees. [No workers' 13 0 Other
conip.insurance required,] -- -
*Any apple unt that checks box W l must aiso fill out the section nclow showing their workers compensation poiiq information,
t Homeowners who submit this affidavit indiea,ing ihm,are doing all work and then hire outside ccntrautors must submit anew atlitaavit?ndi+rating such
;Contractors that cneA this box must itta,;hed an additional meet'#rowing the name of the sub a outniow-and their workers`comp policy inf nnatioa.
lam are empivver that is provirding workers'eompensradon dnsuran ce for ally employees Below is the policy and job site
information
Insurance Company dame: OLD REPUBLIC INS, CO.
Policy#or Self-ins.:Lic.#; MWQ 305437,Qf1 � �_ _ _ L:xpirationDate: 10-01-16
Job Site Address', 679 South Bradford Street ___ City/St4t0,Zip;Nhr_t)rl Aladov 01845
Attach a ropy of the workers'comprusation policy declaration page(showing the potty number and expiration date)"
Failvre 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 401 penalties in the Marin of a STOP WORK ORDER and a fine
of up to$250"00 a day against the violator. Be advised that a copy ofthis statement may he:orwarded to the Otrice of
Investigations of the DIA for insurance coverage verification,
I do here y c rte ra er the pains and penal des of prerjary that the information provided above is true rand correct,
5.. rixtur
p_ho0(L#: 508-351-2200
Official use only. Do not write in this area,to be conipleted by e!#or town official
City or Town: PeamittLicense#_
Issuing Authoii.y(circle one):
I.hoard of Health 2"Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.06er
Contact Person. Phone#:
ANDECOR-01 YADAVYO
DATE(MMfDDNYYY)
CIERTH19CAINE OF LIABUTY WSURANXE
,01;112015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UP-ON 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).
PRODUCER ONTAC
NAME: Willis Certificate Center
Willis of Minnesota,Inc. PHONE, -7378 FAX -2378
c/o 26 Century Blvd (A/C�No 170):(877)945 (AtC,No). (888)467
P.O.Box 305191 F-MAIL :Certificates
Nashville,TN 37230-6191 ADDRESS owillis.com
INSURER S)AFFORDING COVERAGE NAIC 9
INSURER A.Old Republic Insurance Company 24147
INSURED INSURER B:
Renewal by Andersen LLC INSURER G:
30 Forbes Road INSURER D;
Northborough,MA 01532 INSURERE:
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECYTO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDLSUBR
POLIUY_EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD NYYY) (MM/DDfYYYY) LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g 1,000,000
CLAIMS-MADE P�]OCCUR WWZY 305440 1010112016 1010112016 DWGE ToRETED
PREMISES_(Eaoccurrence) $ 600,000
MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE $ 4,000,000
-
POLICY FIJECPROT F-1 LOG PRODUCTS-COMP/OP AGG $ 4,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT —
AE 6,000,000
A X ANY AUTO MWTB 306438 10/0112015 1010112016 BODILY INJURY(Per person)
ALI.OWNED SCHEDULED
— AUTOS — AUTOS BODILY INJURY(Per accident)
NON-OWNED _P_R_0`P_E_R_TY_D_A_M_AG_9_
— HIRED AUTOS — AUTOS (Peraccident) S
UMBRELLA LfAB OCCUR EACH OCCURRENCE
IEXCESS LIAR HCLAIMS-MADE AGGREGATE— $
DED I I RETENTION$ $
WORKERS COMPENSATION -
AND EMPLOYERS'LIABILITY Y/N A]-; E_U; OTH
_�ER
A ANY PROPRIETOR/PARTNER/EXECUTIVE I_M_I E.L.EACH ACCIDENT MWC30643700 1DIO112015 10101/2016
OFFICERIMEMBER EXCLUDED? rN N/A $ 1,000,000
(Mandatory in NH) E.L.DISEASE- EMPLOYEE S 1,000,000
If yes,describe under __� E
DESCRIPTION OF OPERATIONS bell EL.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached 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
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
lFuirlonrp of Insurance 1W�_
C 1988-2014 ACORD-CoRpOkA'TION
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD . All rights 1711-11med.
9A
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
C'onstructfon Supenisor
License: 126
JABM L MOM
j
LYNN MA 01 r.
s
0214-
"IExpiration
Commissioner 10/0612016
ffcc of Cau nw Affiirs l3usiu O Rejulation
gs 3 _ qqgg Tye
RENEWAL BY AN 1tTION, #
k
JAIME JN I
104 OTIS STREET �. -
NORTHBOROUGH MA 01532 linderber wary
t