HomeMy WebLinkAboutBuilding Permit #066-16 - 108 Kingston Street 7/15/2015 NORTH
•� �, J J=�/vaC ��:.. BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: (J lam'' ! Date Received 0RATED Pp`y`y
I� gSSACHUS���
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
1
Print
PROPERTY OWNER C�QV1h �I'1�W'eta)S
Print 100 Year Structure yes no
MAP -23 PARCEL: ONI G DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
❑Addition ❑Two or more family ❑ Industrial
0 Alteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
El Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Ide tification- Please Type or Print Clearly
OWNER: Name: �ULY- -��G�cQ{Rf S Phone: -7- o63
Address: - 108 LidznSf- t 11d�t7 (T ®i
Contractor Name: . 0'5 h 1' �G `� Phone: '-7dQ " 5;53
Email:
Address: 76-7 (A) lax 3 ScI fh(W60 . hA Ol
Supervisor's Construction License: (g ?�{ Exp. Date:
Home Improvement License: -77567 Exp. Date: 1 b /b
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
16
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED C T BASED ON$125.00 PER S.F.
Total Project Cost: 1 50• q�7 FEE:
Check No.: 2 (,5.7 q 6 ? :2 $y 7 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
r
t
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF e U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
'i
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH , Reviewed on Signature
COMMENTS
I
1 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
AP,'anning Board Decision: Comments
Conservation Decision: Comments
Wafter& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
� t -
_ d 384
3 IRE'DEPARRTM¢ENT�'�T�ernp buria�ps e ons%epi �Yesti� ` �� e o�
Located Osgood Street
n
JR6 ted at,1I2„4 Main Street
Fire D partmensnature%dates ''
C®MMEN�TS'
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
4, Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
;ra Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
* Building Permit Application
* Certified Surveyed Plot Plan
:a. Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
;, Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
;6 Copy of Contract
* 2012 I ECC Energy code
* Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2014
NORTH
own of
O ti, _ 0
No.
K Z
oh ver, Mass,
coc MlC NIWKK
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ........1 L1Ix)......1I. BUILDING INSPECTOR
........ Foundation
has permission to erect ...............co. buildings on .1.9�.......���.�:1.>� �!�:S'�1...........
Rough
i. .¢�op�
to be occupied as ......... ....... .... ......................................................................................... 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
• PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO S Rough
Service
..................
...................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to 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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO DOOR
LOWE'S OF SALEM, NH,STORE#2382 STORE PHONE: (603)681-4218
f 541 SOUTH BROADWAY SALESPERSON: ANTHONY CORNACCHIO
SALEM, NH 03079-4499 SALESPERSON ID:631180
Document Print Date *07/11=1-1;
This is only a Quote for the merchandise and services printed below.This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree-
ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, and any
other addenda or attachments hereto,shall be referred to herein as this "Contract."
PLEASE READ THIS ENTIRE DOCUMENT INCLUDING THE "TERMS AND CONDITIONS." BEFORE SIGNING
Lowe's Registration or Contractor License Number/Lowe's Contractor Name
Lowe's Home Centers, LLC's MA HIC NO.: 148688 Lowe's Home Centers, LLC's FEIN: 56-0748358
Customer Name Home Phone
S KEVIN MEDEIROS _ 01
O Customer Address Other Phone
108 KINGSTON ST 774-263-6063
L City State/Province Zip/Postal Co
D NORTH ANDOVER MA
Installation Address
T 108 KINGSTON ST
O Installation City Installation State/Province Installation Zip/Postal Code
NORTH ANDOVER MA 01845
MERCHANDISE AND INSTALLATION SUMMARY
MERCHANDISE SUMMARY
26638 : PRODUCTCODE : SOS : SOS TRISYS 3/4 OVAL FRAME - DF : ARCHITECTURAL DOOR GLASS FRAME (***15% OFF RETAIL ON ALL SPECIAL
ORDER ENTRY DOORS***) : DOOR FABRICATION SERVICES INC- QTY 1
326798 : PRODUCTCODE : SOS : SOS RB PNT/PNT DECO SM FG TC DFAB : ENTRY/EXTERIOR SINGLE UNIT, HAMPTON 3/4 OVAL`115% OFF RE-
TAIL ON ALL SPECIAL ORDER ENTRY DOORS FROM 07/01/15 THROUGH 07/14/15*** : DOOR FABRICATION SERVICES INC - QTY 1
111088 : 31570FJPMD : STK : PFJ CASE 315 2-1/2 X 11/16 X T : PFJ CASE 315 2-1/2 X 11/16 X 7' : EMPIRE COMPANY, INC. (THE) -QTY 3
209633 : 02599 : STK : PVC SHINGLE MOULD 8-FT: PVC SHINGLE MOULD 8-FT: EAST COAST MILLWORK DISTRIBUTI - QTY 3
238348 : 2828-8 : STK : 3/4X7.25X8 RF EMBOSD PVC TRM BRD : 3/4X7.25X8 RF EMBOSD PVC TRM BRD : ROYAL MOULDINGS LIMITED - QTY 3
585250 : 20297817 : STK : LARSON QUICKFIT HDL KIT BN : LARSON QUICKFIT HDL KIT BN : LARSON MANUFACTURING COMPANY - QTY 1
Store 2382 Project No. 446903720 for KEVIN MEDEIROS Page 1 of 8
STORE COPY
585279: 14606031 : STK : LARSON TWMV 321N FRAME WHT: LARSON TWMV 321N FRAME WHT : LARSON MANUFACTURING COMPANY - QTY 1
Materials Price $ 1113.9
INSTALLATION DESCRIPTION
Stock or SOS : SOS Door Type : Exterior
Select Location : Back Door Select New Door : Single Pre-hung
Number of Doors to Install : 1 Side Lights or Transoms : No
Hardwood (Mahogany or Oak) Door : No Hidden Damage Description : None
Number of additional holes bored for accessories : None Install Specialized Mortise Hardware : No
Install Storm Door: Install new storm door Select Storm Door : Storm Door
Lead Safe Practices : No Total Linear Feet of Custom Trim to be Installed : 24
Deliver Door: Yes Customer Understands Scope of the Project : Yes
Permit Required : Yes Who Will Obtain Permit : Lowe's
Permit Fee : No Additional Miles Traveled over 20 : 0
Bring Up To Code Description : None Local Disposal Fee : None
Describe Other Work Needed : None Comments : see m20
Labor Charges $ 572.0
Detail Deduction -$ 35.00
Additional Specifications:
Notation: Lowe's will not make structural modifications, paint or stain or remove/reinstall security system equipment. Customer is responsible to advise if prop-
erty is governed by Historic District Regulations.
Additional Specifications:Federal law requires Lowe's to provide you with the pamphlet Renovate Right: Important Lead Hazard Information for Families,
Child Care Providers and Schools. 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.
PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photograghs of the Premises where In-
stallation Services will be performed and all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right, title, 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, publi-
city, illustration, training and Web content. By initialing here, Customer agrees to the foregoing. [Customer to initial to the left].
NOTICE TO CUSTOMER-PRICE CALCULATIONS: In order to properly perform the installation of certain Goods, the Contract Price may include more Goods
Store 2382 Project No. 446903720 for KEVIN MEDEIROS Page 2 of 8
STORE COPY
than actually will be installed based on the measured square footage of the Project Area. As a result, the parties agree that the lump-sum Price stated in this
Contract is calculated upon both the value of the estimated Goods required to fulfill the Contract (including waste), which may exceed the actual square footage
of the Project Area, and the labor which may be estimated based on the amount of Goods required to fulfill the contract (including waste). By signing this Con-
tract below, Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the
Installation Services are performed..
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES where applicable
SUB-TOTAL $ 1650.9
*TAX $ 0.0
DELIVERY $ 0.0
ORDER TOTAL $ 1650.9
BALANCE DUE r. y
7
Work is to commence upon reasonable vaila ontractor which is anticipated to be // [fill in date].
Estimated completion date is [fill in date].
NOTICE TO CUSTOMER
All items liste in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing
on this contr ct form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation
necessitate by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custom-
er.
IF THE NTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full.
C MP ETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00:
[_j stomer to Pay in Full; OR
[_] Customer to use the following payment schedule:
(1) Deposit of$ to be paid upon signing contract. Any deposit collected at the time this Contract is signed will not exceed one-third (1/3)
of the contract price; and
Store 2382 Project No. 446903720 for KEVIN MEDEIROS Page 3 of 8
STORE COPY
(2) Payment of $ to be collected upon or after the commencement of work. I/We authorize Lowe's to do one of the following (check ap-
propriate box below):
[_] Charge my/our credit card for the amount of the payment indicated above upon or after the commencement of work; or
[_] Deposit my/our check for the amount of the payment indicated above anytime upon or after the commencement of work; and
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON-
TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU
HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY
OF THIS CONTRACT AT THE TIME OF SIGNATURE.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c.142A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON-
TRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET-
ARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB-
MIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L. c.142A.
By: Date:
Lowe's Home Centers, LLC
By: Date:
caner
By: Date:
Co-owner or Witness
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION
INITIATED BY LOWE'S PURSUANT TO M.G.L. c.142A. THE OWNER MAY BE PERMITTED TO INITI ALTERNATIVE DISPUTE RESOLUTION
EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE AlhTIES.
WITNESS OUR HAND(S) AND SEAL(S) BELOW THIS DAY OF
Lowe's Home Centers, LLC
By:
Print Name:
(Seal)
Store 2382 Project No. 446903720 for KEVIN MEDEIROS Page 4 of 8
` STORE COPY
Address f ow r
City State/Province Zip/Postal Code / Print Name
Co-Owner or Witness (Seal)
Print Name
Customer acknowledges receipt of a true copy which was completely filled in prior to Customer's execution hereof. You the customer may cancel this transaction
at any time prior to midnight on the third business day after the date of this transaction. See the attached Notice of Right to Cancel for an explanation of
this right.
Store 2382 Project No. 446903720 for KEVIN MEDEIROS Page 5 of 8
The Commonwealth of Massachusetts
Department of Industrial Accidents
t
Office of Investigations
600 Washington Street
Boston, MA 02111
www.niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
'Marne (Business/Organization/Individual): OJC _•_me
T
Address: -747Wo6im .
City/State/Zip: t I M6 012P Phone#: -7 7;1q-6To7 j
Are you an employer?Check the d4propria,le box: Type of project(required):
Y1 am a employer with—�--- 4. [] I am a general contractor andI
eniploveesy (full and/or part=ti��te). have hired the sub-contractors 6. El New construction2.❑ 1 ant a tole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
:hip and have no etnplo_yces These sub contractors have S, E]Demolition
working for me in any capacity. emp'loyecs and have workers'
insurance# 9• E]Building addition
[No workers*comcamp. insurance p.
required] 5. We are a corporation and its 101-1 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions
myself. [No workers` comp, right of exemption per MGL 12❑Raaf repairs
insurance required.]` c. l52 §1(4).and we have no
employees.[No workers' 133. Othcr_Xtol-C4,kur
comp.insurance required]
n\ny applicant that checks box#1 must ritso fill out the section below showing their workers'compensation policy information,
T I tonteowners who submit this affidavit indicating they are doing till work and then hire outside contractors const submit a new affidavit indicating such.
'Contractors that check this lox must attached;m 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.
1 ant an employer that is providing workers'compensation insurance far nky employees. Below is the policy and job site
in/'ortnation. i - ^
Insurance Company Name: .T t1 R t nS. Coftwiles
Policy#or Self-ins.Lie.#: CC 50D �>O N � � ail Expiration Date: 11 /YAS
.lob Site Address: 10S f p�S46p 51 . City/State[Zip: No
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
Cine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in.the fool of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invest:iLations of the DIA for insurance coveraLye verification.
I do hereby certiF uder the pains and penalties of perjury that the information provided above is true and correct.
,-Sionature: Date:
Phone.
Official rise only. Do not write in this area,to be completed by city or tory:official.
City or Town:------- — _ Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other _- ------ -----
Contact Person:----!__-- ---- __-- Phone __—_--
,Ivnn YrnLon IIYJUKHIIUL rax:S1014Oy051 Apr I LU13 YJ:22 P. U2
9MCNA01 OP ID:DP
.4 cam° CERTIFICATE OF LIABILITY INSURANCE OA04/0 /2015
Oarov2ol s
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). AUTHORInD
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 WANED,subject to
the terms and conditions of the policy,Certain policies may require an endorsement A statement on this cortIlleato dohs not confer rights to the
certificate holder in lieu of such endorsements).
PROD
JohnJ ER David C Bruett
Jahn Wa16h Ins Agency,Inc NAME:
P O Box 4407 I=.PHONo EtIj.97$-745-3300 No 978-745.9567
Salem,MA 01970-8407
David C Bruett ADOREas:dbruett@walshinsurence.com
INSURER(S)AFFORbINGd COVERAGE 1 NAIC st
RmsIREH A:Travelers I
INSURED M seaph McNa�ctlon wsuRma:A.1.1U1.Mutual Ins.Companies
767 Woburn Sttrreet INSURERC:
Wilmington,MA 01887 INSURER D:
INSURER E;
INSURER F!
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 15 TO CERTIFY THAT THE POLICIa OF INSURANCE LISTED 8ELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR T'r e POLICY PER'101)
INDICATED. NOr,,MTHSTANDING 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 PALO_CLAIMS.
TF ( TYPE OF INSURANCENRR POLICY NUMHER _.MINOD EFF WYM LIMITS
LIDLA i 0ENERAL WO LIY EACH OCCURRENCE f s 1.000,00
C.r-1.1AERGr,_GENEPAL:IAOLnY 98"621P22A.16.42 0210812015 02108/20181 PaDAMAGE ree , s 300,0
CLAWS4W* [!OCCUR f MEDEXP Atrypiaperm,) 5,00
X Business Owners PEW04AL&ADV INJURY S 1,000;00
GENERALAOOREOATE 3 2,000.0
GEMLAGGREGATE UNITAPPLIESPER: PRODUCTS-COMPIOP,AGO S 2,000,00
POLICY F PRO- LOC ,
Jerr
;S
AUT
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CONiBiNEC S{
ANY NvrO a acede l
ii 8001 LY INJURY(P�r PQMWp
i AUTOS ALL EU {i AUTOS 8o01LY;NJURY(Per e=idt rt) 3
I NCxJ OVYN^D 4DVTO5 , {1kF A � PRO
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AUT
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"�"°, ACCICENT'
i $
UMaREUA LIAe1. OCCUR ; EhCN OCCUnRENCE I S
17 excm LIAR
--r— iL.UIaSNhDE ACGRaoArE
i &
' OED � I RETEkT1OM$
NORKERS COMPENSATION NC STAT"is
N
AND
EMPLOYERS!LIABILITY
8 ANY PROPRIGTORMARTNERIEXECkMVEYIII CC600SO14081-2014A 11/1412014 11/11412015 S.L,EACMACCCENr
OFFICER MEMBER EXGLuoEO7 N I a (5 600,00
If yEs.describe
in NFT) E.L DISEASE-EA EMPL 7 S 500,00
If dux a,dar
i D>sr IPT10N OF OPERATIONS below S.L.OPSEASE-POLICY UMUT $ 500,00
s PROPERTY $4
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Allsch ACORo sat,AedRlonal Rr�Narka Schrdnic,V marc zpacQ Is roQYi►3d)
Lowe's Compantoz, Inc and any and 811 subsidiaries arp additional insured
with ro"*t to commercial gcniotal liabiity. waiver of subrogation applies
At written contract,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES BE CANCE"ED BEFORE
Lowe's Companies Inc THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN
and any and all subsidiaries ACCORDANCE wrm THE POLICY PROMIONS.
Attn:Vendor Insurance
PO Box 1111 AUTHOR=REPRESENTATIVE
N Wilkesboro,NC 28656 David C Bruett
C)1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD
Massach:xsetts-f}sParh»�:nt Of Public Safety.
Baard Of 8taildlr*g Reytr aUOAS alta Standards
glow-
C',enct�Ucl1A4.iYjlaCrrntjt'
License. CS-0B't$74
A'IGNA)RY
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Location
No. Date 1 '
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee LsaZZ
'>t J Foundation Permit Fee $ "
Other Permit Fee $
k•1TED a
TOTAL $ rt
G ,
Check# OS" -id ffYH�
Building inspector� fu6 .5