HomeMy WebLinkAboutBuilding Permit # 1/19/2016 BUILDING IT �. ®� %AORTH
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION t _
Permit No#: 0 le Date ReceivedArED fly
ATR�,��
I �5ACF6US
Date Issued:
ORTAN T:Applicant must complete all items on this page
LOCATION _ � � 2-
Print
PROPERTY OWNER ^� Vtv<e--O-A
" Print 100 Year Structure yes no)
MAP PARCEL.VD04 ZONING DISTRICT: Historic District yes o
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building VOne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
111"1". OWW' dWe
rfe=-a ,�a; { Ml � W�a dp q UUetlas mo
_tar7k ,✓, s. r a- ,. I " t� t,,, z
DESCRIPTION OF WORK TO BE PERFORMED:
, C
Identification- Please'Type or Print Clearly
OWNER: Name: Phone: �tT� Z ~ Ick
Address: cs -
Contractor Name: 6,, a a =eg; LLL- Phone: q _1 -1 '
Email: D Q f R
Address: 9
Supervisor's Construction License:__ t� 114 Exp. Date: i
Home Improvement Licenser` Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
PEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000,00 OF THE TOTAL ESTIMATED COST BASED ON$925,00 PER S.F.
Total Project Cost: $ - FEE: $
.
7-11 cl�.��
Check No.: Re �ce• t No.:
p
NOTE: .Persons contractin with registered contractors do not have access to the gua11 r Tfund
�S a n a wn - _ -- — - -
� NORTly
o � n o � � Andover
O ;' 4 0
® — �' J
04.a- -"h ver, Mass,
CoCMIc"tMCK A.
x.95 RAtE D Cl
lJ BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT .................... BUILDING INSPECTOR
....M.��.Aodo.... !.. ........... ..W1..`.:�!!i!�. ...................... ....
,,.1.,"
has permission to erect .......................... buildings on f.gkxrA.1A... .............Q.9...IY 0ti44b Foundation
Rough
to be occupied as ........ 1 .�
Chimney onprovided that the person accepting this permit shall in eve�respect conto 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
Rough
VIOLATION of the Zoning or Building Regulations voids this Permit.
Final
dgffih� dim PERMIT EXPIRES 16 j4NTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT R Rough
Service
................................................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Reguired to Occupy Buildinz 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.
Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
WILLIAM POGOR as GENERAL CONTRACTOR
Representing Hub City Builders, LLC
NIA CSL
License No.083917
NIA HIC
License No.180234
Inquiries may be made to:
Contractor Registration
One Ashburton Place
Boston,NIA 02108
(617)727-8598
CONTRACT
Customer: Mark Vincent
4 Lacy St
North Andover,Ma 01845
Project Location:
148 Main St,
Stevens 429
N Andover,MA 01845
Nature of Work:
o Design/Layout/Concept Bid Services,Permit Acquisitions
Y General Contracting Services
This Contract relates to the above checked services that William Pogor as General
Contractor through Hub City Builders, LLC shall provide to Customer. The services
being provided are spelled out in the next section. The Customer's Payment Schedule is
provided for in the section following that. This is a written binding contract. Do not sign
if there are any sections or spaces remaining blank. If the contract is not understood,
please have it reviewed by an attorney of your own choice.
Customer Initials Con ctor Initials
1
Hub ity Builders., LLC
10 Lacy Street
North Andover,MA 01845
Services to be performed:
1® General Description of Work
1. PERMIT ACQUISITIONS
1.1. Building Permit.
1.2. Waste Removal Permit. (If required).
1.3. Forms and Filings necessary.
1.4. Meetings On/Off-site as required. (Owners agent)
1.5. Pertaining to permits, any extra permits beyond the scope of this contract,if
required,the financial burden shall be subsequent to this contract and shall be
billed on a time and materials basis and stated in the change of work order.
Note:Design Professionals or other professionals engaged for consultation,
(energy envelope, Structural engineer,ect)if required,the financial burden shall
be subsequent to this contract and shall be billed on a time and materials basis
and stated in the change of work order.
*NOTE: If applicable all working drawings were prepared as an instrument of
services for the two fold purposes of making these designs available scrutiny (client
services, design professionals and contractors) for the securing of construction
material and trade bid costs for the project secured herein. Although they have
fulfilled their purpose when such is accomplished, they are complete set of
documents from which the project may be constructed provided they conform to all
local and state building requirements. Since these drawings are artistic and conceptual
in nature ALL DIMENSIONS SHOULD BE FIELD VERIFIED. At no time should
these drawings be considered or mistaken as Architectural or Structurally Verified
drawings unless the corresponding seals have been placed appropriately upon these
documents by registered licensed professionals.
1. Remove Furniture and all Impediments from Kitchen including Dishes, Silverware,
Cooking utensils to the guest room.
2. Remove all items in the Entry, Hallway,Guest Bath,Living room to the guest room.
Note's Limited liability to use a"best care scenario"is expressed, and is not a
replacement liability when moving Personal Affects or furniture. All personal
affects of any value(jewelry,paintings, sculptures,ect.). No liability is expressed
or implied. It is obligation of the owner to inform the tenant.
3. Demolition
3.1. Remove engineered flooring,Kitchen, entrance hall,Hallway,Bath.
3.2: Remove the Carpet&pad from the living room.
3.3. All Debri is to be removed off site daily.
3.4. Remove and secure bathroom and kitchen plumbing fixtures.
Customer Initials Con ctor Initials
2
Hub ity Builders., LLC
IO Lacy Street
North Andover,MA 01845
3.5. Kitchen cabinets, sink,faucet,dishwasher,stove, microwave and disposal
removed, shall be delivered to 4 lacy st, 01845 and placed under the exterior
deck, tarped on a temporary basis at the customer's request.
3.6. Bathroom Vanity,sink, and faucet, shall be delivered to 4 lacy st, 01845 and
placed under the exterior deck,tarped on a temporary basis at the customer's
request.
4. Tile&Kitchen Cabinets
4.1. Acquire Tile from Lumber Liquidators and Kitchen cabinets from Cabinets to Go
of 1207 Hanover St Manchester,New Hampshire for the client,prepaid by the
client.This line item is to be billed according to time and materials as stated
herein for acquisition and transportation.
4.2. Acquire appropriate amount of"Versa bond Thinset" mortar SKU: YFY1077 or
comparable. This line item is to be billed according to time and materials as
stated herein for materials.
4.3. Prepare and place the with 1/8 "grout lines in the bath, entry,hall, kitchen and
living room. Orientation to be marked on the attached diagrams and initialed by
client,
4.4. Seal file with satin sealer before grouting.
4.5. Grout tile with client's choice, (ref 4.3).
4.6. Kitchen Cabinets to be assembled and installed. As indicated on the attached
drawings. This line item is to be billed according to time and materials as stated
herein.
4.7. Install temporary counter tops(waterproof plywood contractors choice). Two
counters, stove side and sink side.
5. Plumbing Rough
5.1. Guest Bathroom
5.1.1. Re-plumb to accommodate new Vanity sink.
5.1.2. Install new toilet, Accommodations for one two piece toilet(guest bath
only).
5.2. Kitchen
5.2.1. Install Dishwasher provided by client.
5.2.2. Install Refrigerator provided by client.
5.2.3. Install Microwave provided by client.
5.2.4. Install Stove provided by client.
5.2.5. Install Disposal provided by client.
6. Finish Plumbing
6.1. Finish Trims- Install all finish surface trims guest bathroom and kitchen.
7. Electrical-*Note-Code upgrade requirements- AFCI Receptacles the National
Electrical Code has been updated for 2014 and it addresses the use of Outlet Branch
Circuit(OBC) Arc Fault Circuit Interrupter (AFCI)Receptacles as an alternative to
Custo er Initials cont or Initials
3
Hub i Builders, LL
10 Lacy Street
North Andover,MA 01845
breakers when used for modifications/extensions, as replacement receptacles or in
new construction. AFCI Receptacles work to address the dangers associated with
potentially hazardous arcing conditions(parallel arcs and series arcs)by interrupting
power to help prevent dangerous arc-faults that may lead to an electrical fire. AFCI
protection is mandated by the 2014 Code in residential family rooms, dining rooms,
living rooms,kitchens,parlors,libraries,dens,bedrooms, laundry rooms, sunrooms,
recreation rooms, closets,hallways or similar rooms. AFCI receptacles look similar to
GFCI receptacles in that they have a TEST and RESET button on the face of the
device for localized testing. Any upgrade deemed necessary to accommodate building
code,energy envelope requirements,building plans,and as deemed necessary by the
general contractor, structural engineer and or as required by local, state or federal
authorities.If these upgrades are required,the financial burden shall be subsequent to
this contract and shall be billed on a time and materials basis and stated in the change
of work order.
7.1. Accommodations For-
7.1.1. Frigerator
7.1.2. Stove
7.1.3. Microwave
7.1.4. Garbage Disposal
7.1.5. Counter Outlets
Note* (7.1.1:7.1.5)If these electrical upgrades are required,the financial burden shall
be subsequent to this contract and shall be billed on a time and materials basis and
stated in the change of work order.
8. Communications-None
9. Insulation-None
10. Sheetrock-Minor repairs included.
11. Kitchen Counter Tops
11.1. Granite will be acquired,paid for and coordinated by the client separately from
this contract.
11.2. Faucet-will be acquired,paid for and coordinated by the client separately from
this contract.
11.3. Sink will be acquired,paid for and coordinated by the client separately from this
contract.
12. Carpentry
12.1. Install single bowl Vanity guest bath,
12.2. Install Kitchen cabinets following attached elevation diagrams.
12.3. Install Kitchen kick plate finish as provided.
12.4. Install %", '/a round all areas as needed,provided by contractor(PVC type
material).
l
Customer Initials Cojitit Initials
4
Hub it Builders, LLC
10 Lacy Street
North Andover,MA 01845
13. Paint
13.1.No Paint
13.2.No fill or Putty all holes.
14. Substantial Completion- as notified by contractor as defined here in.
15. Clean up- Construction clean,all surfaced wiped clean and vacuumed if required.
16. Return all items moved in Item#1,#2 in a"best case scenario"to the same locations
as pictorially documented.
11. Dates of Performance:
Commencement bate: As Soon as Deposit for services is received and within two
weeks after the rescission date as stated herein.
Substantial Completion ate: A.S.A.P—target date,as indicated herein. (60 Days)
Note: Definitions
1. As defined herein the phrase"owners went"refers to the ability of William Pogor
through Hub City Builders Owner's or Representative designation as used in the
construction industry to describe an individual tasked with controlling the design and
development and process while protecting the best interests of the owner,in the
contracting individuals,local, State and Federal authorities. This Authority is limited
to the project scope contained herein.
2. As defined herein the phrase"substantial completion"refers to 95%point where
work on a specific requirement is complete, as defined by contract herein, and or a
point designated by the contractor.
3. As defined herein the phrase"Preparedness only"refers the state where the next
action can be taken by the owner or a separate/different contractor. But a previous
action/paper work will be filled out and completed.
4. As defined herein the phrase"ongojtig designs"refers the state where daily as build's
drawings are required by either the building dept,design professionals,or building
contractors as the General Contractor(Hub City Builder's or their designated agents)
determines necessary to proceed expediously to a specific tasks conclusion.
5. As defined herein the phrase"inwr ftww allowance"refers the state where a
allowance for a single fixture,materials or services is specified on a line item
contained herein. Example,"max fixture allowance ($40.00)". This means in the
context of this contract that you can spend up to$40.00 per fixture type indicated by
the line item where the amount is listed. If allowance in question does not reach the
example amount,there is no credit implied or realized. If the amount exceeds the per
fixture allowance a change of work order would be required, signed by all parties and
the allowance amounts will be predetermined.
Customer Initials for Initials
5
Hub ity Builders, LL
10 Lacy Street
North Andover,NIA 01845
6. As defined herein the phrase"best case scenario"refers to the state where workers
are doing the best they can overall to perform the task assigned. Through no fault or
malicious behavior a fault occurs, (breakage, scratch, dent,misplacement, ect.)of
objects furniture, appliances, artwork,jewelry,dishes,rugs, walls, doors,rails, floors,
granite, sinks, ect.)
Other Particulariv Agreed Dates
1. 'Target Date 1/25/2016 Commencement,As soon as permitted by the North Andover
Building Department.
1.1. Item 41 Agreed te: 1/25/2016 Commencement
Contractor Int: Date: t 16 , 1
Owner Int: Date: l i�
111.Dates of Performance:
Commencement Date: As Soon as Deposit for services is received and within two
weeks after the rescission date as stated herein building permit application is applied for.
Substantial C
AgWietion Date: A.S.A.P—target date, as indicated herein.
Other Particulariv Agreed Dates
2. 'Target Date
2.1. Item#1 Agreed Date: 1/31/2016
Contractor int: Date: h
Owner Int: Date: I/e- lz
3. No-work on weekends, (unless constrained by completion date), no work
Thanksgiving and Christmas and recognized holidays.
Customer Initials 1njtor Initials
6
Hub City Builders, LLC
10 Lacy Street
North Andover,AM 01845
IV. Work Changes
Any changes to this contract must be mutually agreeable and put in writing under a
Change Order Form. A blank Change Order Form is attached after the signature lines
below and shall be the form used for any changes to this contract. It shall be the
obligation of both parties to adhere to this provision.
Contractor's iti
All dates of performance are subject to reasonable extension(s), at the Contractor's
request, if request is made due to inclement weather, labor disputes, issues involving
acquisition of materials or permits from appropriate authorities, mutual dissolution of
contract by the parties, stop work order(s) by state or local municipalities, or act(s) of
God. Approval of such request(s) shall not be unreasonably withheld. No acceptance of
liability is expressed, assumed or implied due to any of these circumstances. Work may
be stopped, interrupted or ceased at the sole discretion of Contractor if payment(s) under
the terms of this contract, or any written amendment thereto, is not made by Customer as
agreed herein. Work shall be performed in an ordinary standard It is understood that
certain portions of Contractor's consulting and drafting work is deemed artistic and/or
subjective in nature, and therefore, disputes related to subjective portions of Contractor's
work shall never be grounds for non-payment by the Customer.
Permits for Work
The type(s) of permits that will be required for the Contractor's work herein shall
include:
1. North Andover Building Permit.
2. North Andover Electrical Permit if required.
3. North Andover Rubbish Removal (Dumpster Permit)as Needed.
Customer Initials Con for Initials
7
Hub i y Builders, LLC
10 Lacy Street
North Andover,NM 01845
Owners Agent
Customer
Unless otherwise requested by the Customer, the Contractor shall act as the oWNERs
AGENT with regard to Andover Building Department for the sole purpose of obtaining all
necessary permits required to undertake and complete the project. If the Customer
undertakes to obtain their own permit(s)the Customer will be excluded from the guaranty
fund provisions of M.G.L. c. 142A.
Special Conditions of Services:
(If this section is intended to be left blank,state "none"):
1. None
Customer Payment Schedule®
This Contract is:
❑ Agreed Fee
❑ Time and Materials Invoiced
Combination Agreed Fee and Time and Materials Invoiced
Agreed Fee(If applicable):
Contract Base Price Total $14,559.00
Remainder due: *Time and Materials on weekly basis(see below)
1"Payment/Deposit $4,853.00
2nd Payment on completion of item#3.4 as referred to herein $4,853.00
3`d Payment upon substantial completion as defined herein and
notified. $4853.00
Final Payment, due upon submission as invoiced.
Customer Initials tractor Initials
Hub ity Builders,, LLC
10 Lacy Street
North Andover,NM 01845
*Tinge and Materials/Labor Invoiced as needed (If Applicable):
Contractor shall be paid at a rate of$60.00/per man hour for (Design Bidding services
only). Building contract requires $120.00/per two men per hour. Both rates are subject to
the addition of all materials and out of pocket expenses, including, but not limited to
invoiced subcontractors, consultants and materials suppliers. Contractor shall provide an
itemized entry of his time billed as part of his invoice together with incurred expense
invoices. Invoices shall be issued weekly. Payments due under invoice shall be made
within seven (7) days of receipt of invoice. Receipt shall be upon delivery to Customer's
address, email or in person. Contractor may suspend or cease work under this contract if
payment is more than seven(7)days overdue.
Special materials,or materials of a special order or
custom made nature,shall be separately invoiced and
require advance payment by Customer prior to order.
Description of Combination Agreed Fee and Time and Materials:
1. As specified by any extra work orders
Payment terms may not be altered
Unless expressly agreed by the parties in writing
Deposit Terms
If there is an initial deposit, it shall be refundable only after a full accounting of incurred
cost by the contractor. Incurred costs shall be considered non-refundable inclusive of the
Contractors time. The Customer acknowledges and agrees that the Contractor shall
commence work in good faith upon receipt of said deposit, utilize his time and that of
contractors and/or consultants he may work with, and that the Contractor shall be fairly
compensated for such commencement of work and dedication of time to this Customer
that might otherwise be devoted to other projects. The parties agree there is valid
consideration for the non-refundable deposit.
Customer Initials for Initials
9
Hub City Builders,, LL
0 Lacy Street
North Andover,MA 01 845
DEFAULT OF CUSTOMER
If the Customer defaults for any reason, the Contractor shall be entitled to immediate
payment of all monies owed as of the date the Contractor notifies the Customer in writing
that he deems the Customer to be in default. The Contractor's Notification shall state all
sums deemed to be owed and due from the Customer. Said sums shall be due and
payable within seven (7) days of delivery of said notice. Any sums due after such notice
of default shall be assessed an interest charge of 1 '/2 % per month, or 18%per year until
all sums are paid in full. If the Customer defaults, and does not tender payment of all
sums due within said seven (7) days, the Contractor may record this contract in the
registry of deeds and seek a lien on the property for the enforcement of payment. The
Customer shall be responsible and owe the Contractor all costs and expenses incurred in
the collection of monies owed under this contract, including,but not limited to reasonable
attorney fees.
ALTERNATIVE DISPUTE RESOLUTION
The Customer and the Contractor mutually agree that in the event the Contractor has a
dispute with the Customer, the Contractor may submit such dispute to a private
arbitration service, of the Contractor's sole choosing; provided however, such private
arbitration service shall have been approved by the Secretary of the Executive Office of
Consumer Affairs and Business Regulations and which shall have been in business for
more than five (5) years, and shall be staffed with at least one retired justice of the
Massachusetts Court System. This provision is an election at the sole discretion of the
Contractor. This provision is in addition to any rights afforded the Customer under
M.G.L. c. 142A. The arbitration, if elected by the Contractor, shall follow the rules and
regulations of the American Arbitration Association. Nothing in this provision shall
prohibit the Contractor from mitiat�ng a civil action nor any such defaults. t e
Contractor may have the right to institute a civil action to obtain and enforce any
statutory liens rights the Contractor may have, while contemporaneously seeking
arbitration of the underlying disputed claims, which determination shall be conclusive as
to the amount,if any the Contractor may enforce through such civil action lien.
k)d a
Customer Initials tar Initials
10
Hub its Builders, LL
10 Lacy Street
North Andover, MA 01845
This Contract shall be construed in accordance with the laws of Massachusetts.
This Contract may be executed in duplicate. Customer acknowledges receipt of copy by
signing below.
THIS IS A BINDING LEGAL DOCUMENT. DO NOT SIGN THIS CONTRACT
IF THERE ARE ANY BLANK SPACES OR YOU DO NOT UNDERSTAND
TERMS HEREIN.
Customer Date Email
X 1,�-
. $//A—
Customer Date Email/
x bi�,william o or.com
— 4 Date Email
Hub City Builde OLC
Customer Initials 40—r
Initials
11
Hub ity Builders, LLC
10 Lacy Street
North Andover,AIA 01845
WORK CHANGE ORDER FORM
Owner
Mark Vincent
4 Lacy St
North Andover,Massachusetts
Project Location
148 Main 3t,
Stevens 429
North Andover, MA 01845
Original Contract Date:
Time and Materials Billing:
Description of Changes):
This Work Change Order changes only those items specifically addressed herein.
Nothing in this Change Order shall be construed to change any other term or condition of
the Original Contract.
.kAZL- -a
Customer Initials C n or Initials
12
The Commonwealth of Massmchasetts
Department of IndustrralAceidents
X Congress Street,Suite 100
.Boston,MM 02114-2017
www.mass.gov/dia
Wokkers'Compensation insurance Affidavit:Builders/Contractors/EZectreicians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTIE(ORITY.
A licantlnformation Please Print Ledb
Name(Business/Organization/Individrtal): i Fes'
.A.d&ess:
1 11 City/State/Zip: '
Phone
Are you an employer?CheektTia appiopriate box: Type of project(required):
1.A I am a employer with employees(full and/or part thne).* 7. Q New Construction
2. I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling
any capacity.[No-workers'comp.insurance required.] 9. Demolition
3.Q I am a homeowner doing all work myself[No workers'comp.uiswauce required.]t 10 Building addition
4.❑1 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
11.Q Electrical repairs or additions
proprietors withno employees. 12: Plumbing repair's or additions
5.Q 1 am a general contractor and I have hired tho sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance. 14.M Other
6.Q We area corporation and its of�gers have exercised their right of exemption per MGL c. }
152,§1(4),andwe have nq efnpleyegs.[No workers'comp.insurance required.] ��N
*Any applicant that checks liox#1 must also fill outthe section below showingtheirworkers'compensation policy informatio
T Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such.
(Contractors that cheek 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-c6fi6ntors have employees,they must provide their workeis'comp.policy number.
X am an employer that is providing works rs'compensation insurance for my employees'Below is the policy and job site
information. gk,�t
Insurance Company Name: Am czi
Policy#or Self-ins,Lia#:
z --,)L Expiration Date: /l /
fob Site Address: i!(�f �� i. !L City/State/Zip /44Vy �fp 7
Attach a copy of the workers' compensation policy d aration page(showing the policy).umber and expiration date).
Failure to secure coverage as required under MGL c. 1.52,§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 WORD.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 Iuvestigatlons of the DIA for insurance
coverage verification.
I do hereby cer fy under r airs andpenaltles ofperjury that the information provided abjove is true and correct
Date:
Sign e:
Phone#:
Official rise onty. Do not write in this area,to be completed by city or town official._
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Realth 2.Building Department 3.City/Town Clerk. 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone M
D
ATE
Y
j! LIABILITY THIS CERTIFICATE IS ISSUED RS A I Y A FERC RIGHTS JP THE CERTIFBY
CERTIFICATE T AFFIRMATIVELY g Y T GE AF
THE POLW.IES
BELOW. TM CERTIFICATE OF MURANCE DOES T C E A COKMCT BETWE04 THE ISSUING IINSU O), AUTHOMM
REPRESENTATIVE OR PRODUCER AND THE CERT*MkTE HOLDM
IMPORTANT: If flm cerffficaft holder is an ADDITKNAL 04SWED,the policyfies).wml be endorsed. If SUBROGATION IS WAIVED, to
the barras.and conditions Of ft Polmy,CeTtifinA stat8mirt Gra this Certificate does riot conler rights to th d
In lieu of such eaddraemerWa5S
CEIrte
N INSURANCE BROKERAGE PHOSE a78)851-3436
I CAM,
P.Q.BOX 121
TEVJKseuRy MA 01876 A: AMWARD INSUi ANGE CO 42390
POG-OR WILLIAM -- —
it#3URERG:
I14SURERD:
10 LADY S T INSUPERE:
NORTH ANDOVER MA 09848 09SURERF:
CERTIFICATE 24142 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES OF INSURAICE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
NDKA' TED NOTMATHSTANDING AA E . e' TEFM OR CONDUMN OF ANY CONTRACT OR OTHER DOUNEXT VWTH RESPECT TO T4 NS
GEMViCATE MAY M ISSUED OR MAY PES TES NWW4CE AFFORDED BY THE POLICES DESCRIBED HERSH is SLIB ECT TO ALL THE s
EXCLUSIONS CO€D n WS OF SUCH POLYCES.LENTS SHOWN We HAVE BEEN REDUCED BY PAID CLAIMS.
LTR;. TYFEOFMURARGE _ PGaSe;Y EPE ,
S
EACH CCCURRft-E S
PREMISES ffA ocmffmTsa '..
j MED EXP(Am—P—) s
_ NIA Y�A.DV I1iL4RY S ._
GFML AGGREGATE LIMIT APPLIES PER:
L f s GEN,_mAGGcREGAiE 5
P U---Y_ t
T £.c:C IPROOMTS-COLIPMOPAGG 1 S
s r � SiPfGtE t.�{T
PAY AdSyC �- i BODILY INJURY(Per person)AR-0-MED —
: .AMT' # t—Aur0s� " i 4 NZA Bt;D{iY INJURY IPS t1,S
L AUTOS � x e RTY'GAi.4aA.GE S
k "S
LA p fSCCUR a EACH OCCURRENCE i S
F.XCM IJA3 Ct 14S-L"•AFJ#: £ I'A'A
t AGGREGATE 9 S
Dw ' iia. -4S t. S
` { i
IARO 3R' Y[{E i t' ,Pki ATE/FE ! EER i
L EACH AC
CADENT S - CADENT s a 100,000
Earn D? �A F Pre t R2tlVG�s49933 E
10/3112015 10/31/2016; -
i 'LDISFASE-Er.r o
'OF
Yt'�S 1ti#7
e
QPa',�' RAsi1:C tim§= ° ;`.E.L_ozEASE-Pm_1cYu r Is 500,1
WA i
may heataadwd i? rare
Wim'C=VWS25M beneft VA be Paid to Wssachusaft WOOYeSS OrdY RffWlark to Emkmw, t VI C 20 03 06 B,no ausn�is given to pay c iamns for beneft to
od�ewr thm WARmacht-metts if the"WMITIKI his,Or Iar,ham.;Fie el`4s',ayees oufsida of Massa"A misef
This cerifflrale of kmuranoa shows the poTrcy in force on Ibe data th-ot this cerii(Icate,was issued(criess 9m expkatim date an the above policy precedes the issue date of this
carffice.eof&4uraawloa� The status of Ilm coverage ern be moruftmed das'y by the Pre Cenaersge-Coverage Verfficabon Search lyot at
r.rnassgona{ tarrdanuests�slfairsl.
Sri PMPfielESS Wt e3
CERTIFICATE HOLDER CANCELLATION
!AT
SHOULD ANY OFF THE ABOVE DESCRIBED POLWAES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF NOTICE V#ML BE DELIVERED IN
Mark Vincent ACCORDANM WITH MIE POUCY MVISJOM.
148 Mast St Sts aem BW9 X423 ATS
No th Andover M.A 4184.5
Dail M Cresue ey,CPGU,lfic —Residual Market—VICA11MM
04 2M4 ACQRD CORPORATION. All rightsresemed.
ACORD 25(201 1) The AGORD mame and logo 2r€:registered marlm of ACORD
WILLI-1 Off'ID:JF
®ATET LIABILITY I 011141201
{wm6
iss
LtC�iFfCATE ISSUED A Y RIG U THE CERTIFICATE HOLDER.
CERTIFICATE E T AFFIRMATIVELY A Y TER GE AFFORDEDTBELOW HE CERTIFICATE OF § a—g C A T INSURER(S),), AA _E
�D
,ETER, 'fATE
f h ) e WAIVED,
of icy, " nt A f on to O
the bwm and candiUmm the
r
ofsuch Em!s
FRODUCM
€€C.Manna
P.O. 1w FROM E 978 658
Nor&Antiwar,KA Oi F —l_[ NG):978557 V30
Lmmme FL ,CIC --
_ . ff-4SURS'48)AFF0R0MG0VfRAGE HMO
&MUFOR:A:Preferved Mubja Insurance CO.MR=pow
Bw
10 C.
Notth Ver,NA 01610 RMFER G
MURRER E: _
F: —
COVERAGES CERTIFICATE ION
THIS IS TO CERTIFY THAT THE POLICES OF WSURANCE LISTED BELOW HkVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERiOO
INDICATED NOTMTHSTANW4G ANY REQMEM NT —40M OR COMTM OF ANY CONTRACT OR OTHER DOGWRAIT VM RESPECT TO WKCH 14S
CERTIFICATE MAY BE tSSUED OR WAY PERTW T NGSURANGE AFFORDEDBY THE IES DESCMED,HER—Emi€S SUBJEcT To ALL THE TE 4S,
B(CLUMNS AND C Y HAVE ED BY PAID C
LTR crF
a
s f S- T4CEBuskkess Owners
S �,
cEa �re5vr�
yona
PERS &ADV NJUTY sGEWL _
r- 7EM.7PP;'11ESP"cP- GEt+€€UIIIACI1ECPRO- AT
jEar
�Ov ( is
.RmYY R.t9M ` S Bom e'KWRY{Per poem} s
ALL OWNEDAb-ms torros
AUTW
CiBE.E�D
{
UTffi5FZ
t� tA« f Cr EACH OC AMUREfCE $
S _
i EKCMLM
DED 5 _S $
RAS YPPZ { ! 1 { TCTYE E2
C F c X L EL EACH ACUDEST 1 S.
EL DWHASE-ER E MLGY€E$
i App#cas 3 18I=1312016IVJLDMM
i,
OEMRPTIM OF OPEPATMS f LOCAMRaf SES(ACOM t'uf,Addffima RWM*S Ste.may Ea aaadmd 6 mom spa�--is g --q.
Carpenter 0: e
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CARCMIM BEFORE
THE EXPRATtON DATE THEREOF, NOTICE MLL BE
Ma*V'mcent ACCORDIL&WE WITH THE POLICY PROVISIONS.
Stevens .rag
148 Maki St Suit--, 429
Narlb g MA 01 US
407
0# ii-d—glgs resemed_
c/Fit oyI v wro"o-we,III tl/
Alice co'CAnstmer AVIAW m Im"J,
phutza S u t,//,,, 7
R*MW V=n 1 W34
Two
VALIUM POGOIF
10 LACY Is
hu i?k 01845
I Pdar AM=*ad nowme INALmmylk v)a w#
4 A dw%A Sa",gpowfumm nh"gmmmew VVW kow"mmOnvuhmA am vuh0h,
dw ,ff Amm"AW9 Iftturn,t/s,/",
016mv,"Fol C, gmd Owmamm UMPAMM
8001,11Z,3144rkdd
%sk AV 'S
,(..........
w, (CPSY-44083,13*00
f1m f/ iIII,
W Of.1 SAIVA 8 PI(IOGNNO 'if,f!ill!
!%A)�ALMIKOVIKA,ILA, 4010 33
....6..4...,