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HomeMy WebLinkAboutBuilding Permit #763-2017 - 33 Regency Place Lot 5A 2/7/2017�eavr--v-J ButDING PERMIT OWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATfON Date Received Q l0 c J TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building /One family 0 Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District krWater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Tofc"i ., quay �rG� Q- 5;10i Identific tion - Please Type or Print Clearly OWNER: Name: No✓ f' �4in10Ue-v� _ kcs, I H, 6 W-� . Phone: VA 7� ;�77k Address: 10 Lin /-}it 1 Mvu- Contractor Name:JtAt5 veto It Phone: �� �l J �� a770, (31 6 Address: , t�l.j�A civ,� t�i,Sciv,V.AAo12'_v'^ MA Dl �LI S7 t= Supervisor's Construction License: CS Exp. Date: Home Improvement License:_ `t Tate: ARCHITECT/ENGINEER L---,gL-t, Le . ogfNA Phone: Address: Rect-Ra -I Z7 FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED �ON $125.00 PER S.F. Total Project Cost: $ 000 FEE:-_ % 0� • �� Check No.: Receipt Nd'--::..-., NOTE: Persons contracting with unregistered contracto do not h�vve%niacc s�itjo/1�t�hfe guaranty fund Signature of Agent/Owner Sign u of contractor: ± Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans V F!'EF SEWERAGE DISPOS 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 - U FORM 2 PLANNING & DEVELOPMENT Reviewed On Signature V -4,— I I &Lt6 H) 14 5 - , AQ COMMENTS VC,( �VC� incl �l;r�►�sxn �. a.kn .b' &o I o' )a CONSERVATION Reviewed on Signature!j_� LA4 Voi COMMENTS kA1 i -v"- I oo` HEALTH Reviewed on Signature COMMENTS r A Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes a Planning Board Decision: Comments Conservation Decision: Comments t2—`�--(� Water & Sewer Con nection/Sin nature & Date % Driveway Permit ---7/7 _ DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site no Located at 124 Main Street Fire Department signature/date COMMENTS��� 15 Dimension r Number of Stories: _2 Total square feet of floor area, based on Exterior dimensions. 5 o Total land area, sq. ft.: rel 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 Emai 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 ❑ 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 ❑ Engineering Affidavits for Engineered products NOTE: 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 ❑ 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 NOTE: 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) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 3 ;!{ tr�ryc t Inc r_ S� Location 3 / No. 7r- 3. ce" 0 ! 7 Check # Co 4. (- Date P- i•;"17 TOWN OF NORTH ANDOVER Certificate of Occupancy $ IUo e Building/Frame Permit Fee $ 'r I Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Q I �.` Building Inspector i LAWRENCE H. OGDEN, P.E. 198 EAST MAIN STREET GEORGETOWN, MA 41833 978-352-8318 fax 978 —352-2858 cell: 978-502-5921 August 16, 2017 Mr. James Carroll North Andover realty Trust 21 Johnson Street North Andover, Ma. 01845 RE: Lot 5 Regency Way North Andover Dear Mr. Carroll As you requested I conducted a site visit 8/15/17 to review the installation of the Engineered. Materials consisting of LVLs, beams and Engineered Joist utilized in the framing of the above project. These are shown on plans prepared Martha Macinnis dated 8-8-16 with the framing plans sheets 6&8 and D-1 and D-2 certified by me 5-11-16 with SK. -I dated 9/1/16, SK -3 dated 4/21/17 and SK -4 dated 5/9/17/16. I can certify that to the best of my knowledge the LVLs members and Engineered Joist and associated details utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1&2 Family Residences. This certification is based on what I could visibly see at the time of this visit when the framing was complete and the siding was in place. The purpose of this site visit was to form an opinion and comfort level that the construction appears to be constructed in compliance with the drawings. This certification should not be construed as a thorough detailed inspection of the construction and framing. Nothing in this certification relieves the Licensed Construction Supervisor and or the permit holder of the responsibility for construction of this project per Section 110.85.2, and sub section 110.R5.2.15 or of the Massachusetts Residential Code 780 CMR 51, or the proper execution of the details and framing requirements of the drawings, including but not limited to materials, blocking, manufacturers installation requirements and nailing schedules or other requirements of the code. Should you have any questions please do not hesitate to call. Yours truly, L ZoKH07gden P.E. Structural 27765 3 3 P-QG-e-''c-y Tp -w (—( d "763-x'7 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 6513000.00 m $ - $ 7,812.00 Plumbing Fee $ 976.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 976.50 Total fees collected $ 9,865.00 33 Regency Place Lot 5A 763-2017 on 2/7/2017 Single family home a a Q 2 LL O � a m cu t Y \ O LL aa+ T n V Q to CC O W tail Z Z o J m C m 'O 7 LL L 7 OC N C E U U- O W ttA z ap J a L ti' LL 0 W LA z Q t_l U W J LU t 7 d' N V i V) LL O t~j Wa Z t/1 a to 7 LL' m I.l W oC Qa W 0 W tl i co Z w (% 41 O Ln —,% -,% cl 'o # p O .`° c r S E Q L N i Y �• d N .t .1 Y = t v W gypC+ O V G t V � L = r Q4 h qb �.. cuJ i . d Lm y.. U)0 43�~ •� O 'a 0 S: N (1)Q C �O O cn — N G p O '> O = �• �•' v = o F :c CL m 'R 'N 0 0 o = c = = O= m o m N o m �m mm oo w c ON = o LLJL w m E 0�_0 O LU L v m._ � H v a 0-0 a �7 N ch -0 .p '~ _ 0_ IL-1 1— t CL 0 0 > lw S.: O .r V N N 2286 APPLICATION FOR SEWER SERVICE CONNECTION North Andover, Mass. Application by the undersigned is hereby made to connect with the town sewer main in subject to the rules and regulations of the Division of Public Works. The premises are known as No. 5.5 'e, bd' ' ' I t 61 or su rvision o no. j Owner Address Contractor Addres j , ' NL -21 � Applicant's Signature PERMIT TO CONNECT WITH SEWER MAIN The Division of Public Works hereby grants permission to A, ?A /" ,q! -01 C to make a connection with the sewer main at subject to the rules and regulations of the Division of Public Inspected by Date Ce Street, Street Street Divisiorl of Public Works (3y See back for rules and regulations APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. � 17 20 Application by the undersigned is hereby made to connect with the town water main in /c/ O"Street, subject to the rules and regulations of the Division of Public Works, The premises are known as No. .53 !/ ` ��pw C'� /0/ Street or subdivision lot no. ffA Pce-Z7 Owner Contractor Address Addres ,,#pplic nt's Signature PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to Af, to make a connection with the water main at subject to the rules and regulations of the Division of Public Works. Inspected by Date r Street Board of Public Works By See back for rules and regulations n F- � z g F-- w v w Z vii w z w h L �— w z h W Q ce i Li Q W Z H h Q O y h 0 N Z � W � Q = 0 A � M 1 i pq LLJ `^ g N Z O h z O h Q ce i Q W H h O y h 0 N Lo C o 0 0 0 0 0 0 0 LO M O m O V 4 U 'I M C L p d a +'o �n 00 0 o v U) O Ln O O) LO O EA �j U Z� cm O) d C c W R ! = 0 N M N N O 1L> 7 m M N N (O O v UO N CO CO p O w d R E cn w y U) W c y rn R U c0 Q t O c c w O R O t O Z 0 O O 0) t N p S U 2 J d U) F- V d cr d w n 2 .+ I-1 O m W L T �FCD m C O c U W N JR 7 LL a <)<L M Na Ltd _ O .a d N m m r NNm I.f. v O .0 E a� y T c L m c W E C U) N 2 w O J � O U) o LO r c6 1- 65 6 U.) co N 7 a (0 m o U) m � O O U) 0_ O i N O Cl) cn o M O N N d o N N c9 O LO (n N N N � N N C C N Cl) N a o M N O c o v .0.. O M O O M LO x m a S co w W x c a� aLi E U cyA � R N Q T (D E .0 w O O U C C U) U W LL LL Q N O O O ui LO 0) 0� LL W W N Wr- vi y U) (L cp O O R >- Z Z C 3 O U O O 3 ' N O s U N W Z 00 LO W a R O O W O .c } - LL a N m CO � 7 C U C @ R L Q U CO LLu = U) N N w O) 0) O) U E 16 Q = O LL c0 O c6 .0• U) O y m> -0 0 = U= O E p c a O E o c)« .o c m r w a) o M m Ec o �+ m`-° ) LL L O a N x c m a c U 0 Q m> E ai U J R •c U @ _ 7cm c V LO = Q_ m r O O c0 C7 Q = O U) O O M N C) Cl? O U 0 00 U O 7 M N c O R �? O M i p Z = m O O LL R LLL lL W R N O O N0 N C O) r- R cw _O LL R p U O) IX U c U O O O 0 0 0 0 O O) c0 O (O N Q- Z Z U- L.L .. .. .. .. U Q) N 12 w O) O -a0 c 0 N V > LL p O O rn N R U-0 N c O v Q) �0 N w U U) w m R C7 Lmc=o a)a c c w w p O LL Q U Q c a a R t J M � N rn T � i N d L 0 R N O O U N � 6 � O N C C O " o R oU T � O c a) R co O y 3m° T c 7 O Z cm N L c co d 0 O C N C W c 'a y o = E O w C_ R N L F- W w AIR LEAKAGE REPORT Date: December 07, 2016 Rating No.: Projected Rating 9/12/2016 Building Name: NAND RegencyPl L -5a Rating Org.: The Energy Hound Owner's Name: 2225 Phone No.: 781-369-5921 Property: L-5 egency Place Rater's Name: Ian Rex Address: North Andover, MA 01845 Rater's No.: 1454792 Builder's Name: Weather Site: File Name: North Andover, MA NAND RegencyPl L-5a.blg Rating Type: Rating Date: Projected Rating 9/12/2016 0.18 ACH @ 50 Pascals: CFM @ 25 Pascals: 3.00 1418 3.00 1418 Whole House Infiltration Duct Leakage Ventilation Leakage to Outside Units Blower door test Heating Cooling NaturalACH: 0.22 0.18 ACH @ 50 Pascals: CFM @ 25 Pascals: 3.00 1418 3.00 1418 CFM @ 50 Pascals: 2225 2225 Eff. Leakage Area: [sq.in] 122.2 122.2 Specific Leakage Area: 0.00017 0.00017 ELA/100 sf shell: [sq.in] 1.38 1.38 Leakage to Outside Units Throughout CFM @ 25 Pascals: 160 CFM25 / CFMfan: 0.1600 CFM25 / CFA: 0.0317 CFM per Std 152: CFM per Std 152 / CFA_: CFM @ 50 Pascals: N/A N/A 251 Eff. Leakage Area: [sq.in] Thermal Efficiency: 13.78 N/A Total Duct Leakage Units Total Duct Leakage: CFM25/CFA 0.0317 Mechanical: Exhaust Only ASHRAE Sensible Recovery Eff. (%): 0.0 62.2-2010 _ Total Recovery Eff. (%): 0.0 Rate (cfm): - 88 88 _ Hours/Day: 24.0 24 Fan Watts: 6.0 Cooling Ventilation: Natural Ventilation Regarding ASHRAE 62.2 Ventilation Compliance The ASHRAE 62.2 flow rates shown above are the CONTINUOUS mechanical fresh air ventilation which will meet the 'whole -building' requirement under that version of the standard. Both values incorporate any appropriate 'infiltration credit. Intermittent mechanical ventilation may be used if the flow rate is adjusted accordingly. For example, the runtime can be reduced to 12 hours per day using a doubled flow rate, as long as the system provides ventilation at least once every 3 hours. For more detail, refer to the appropriate standard. REM/Rate - Residential Energy Analysis and Rating Software v14.6.3.1 This information does not constitute any warranty of energy cost or savings. @ 1985-2016 Noresco, Boulder, Colorado. 1 W M ~ h, ct �: JA ia; d H r � lijc): B v o 0; o m a zCE/�W'en X FL]waN �W3l 0 a — CN W to U J U iv, 4.1 J O 2 3 rp O O 4-/ cz Q w n CL 4 «3 y L7 j4 dM w icz?U o ID d Q Qozzw z zw .9 r 'gig` Irv: z � 0 U- � U3 if 75a °�Op >zo� oL #4d _ c' L •L i' to O cf7 w cv to U co r W w W 0 1 h, ct �: JA ia; 4: 1 to U J U iv, 4.1 J O 2 3 rp O O 4-/ cz Q w n CL 4 «3 y L7 j4 dM w icz?U o ID d Q Qozzw z zw .9 r 'gig` Irv: z � 0 U- � U3 if 75a °�Op >zo� oL #4d _ c' L •L i' to O cf7 w cv to U co r W w W 0 1 I I N T, lu LD �R u lu Z L\l 00 �4 ItL 73 Non Ow U , c0 X C\j 0O Ei z V-- :3w Lt 0 U-1 . f) OL U-1 m OZU-i :z tu 0 U- Z Zlu 0 u tu 'CL) tu x tu LL. azlu 0 V, � �� � � �: nlllllllllll Mai=i Eli MEMEME M —■ mnnlnlll ■EE ■ ■■ ■■■.. ■■M! Elm ME ■■ C ■■ 0 Ken NEESE ■ MEN©EM O■■■■■■■ ■■■■■ i of ��■�` IN Elm ■■ ■■ ■■ ■■ �,��I lid.=mllllllllll HOME INS ii ii =iii s� I --mmm 0 C1116:� ii ,��Innlllnllllllllllllllnl IIS Inlllnlnllnllllll„ • O� 1 �Illlllnlnnl � WA � ��►��:' �.� =_ IIIIIIIIIIIII MEN ME No • e1. II� �� o 0 ' • • �� 1 j =iii �— _ ■ ii�4i ■ iii©ii • s ....... ■■■■■ Ennnn1111 MNAME 11 - 1111111111111 ii ii iii, �� :� Illllllnlll ■■�■ M■ ii ii ii ii :� �:� � nlllnlllll OO I� O � n � II( , , • The Commonwealth ofMassaschasetts Department of ndustrraiAecidents h X Congress Street, Smite 100 — ! Boston, .NIA 02114-2017 :~ t- ww.mass gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Elec#lclans Tlumbers. TO RE ME)) WITH THE PEPMJ[TTING .A.TJTRORITX. Please Print Legibly Applicant Information NaMo(BLIsiness/Organization/individual): .Address: City/State/Zip: Phone #: Axe you an employer? Check the appropriate box: I.❑ I am a employer with employees (full and/or part tune) 4' 2.Q I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] IE] I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub-contractorAade employees and have workers' comp. insurance -t 6.0 We= a corporation and its of6gers have exercised their right o£ exemption per MGL c, 152, §1(4), andwe have nq en4pl1 yees. [No workers' comp. insurance required.] Type of project (required): 7. d Now construction 8. i] Remodelbig 9. ❑ Demolition 10 ❑ Building addition 11.[( Electrical repairs or additions 13. [] Roof repairs 14. [] Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. Homeowners who subriiit I. affidavit indicating they are doing allwork andthen hire outside contractors must submit anew affidavit indicating such. tContraotors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities ha_ ve employees. if the sub-cbnlrac6s have employees, they must provide their workers' comp. policy number. .I' am an employer that is pr'ovidirzg works rs' compensation insurance for my employees' Below is the policy and joie site information.'—' ��,�� Insurance Company Name: A 5o c i c o %M Ci ,7" ' 10-� Usti V � Policy # or Self -ins, Lic. #: ( C S 0 10 7 5 4() I —2016° Expiration Date: t 6 Job Site Address: -' P (a tee, City/State/Zip: Ar Attach a copy of the workers' ca pensati u policy declaration page (showing the policy number and expiration date). failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be, forwarded to the Office of Investigations of the DTA for insurance coverage verification. .t do raereby certify under the pains andpenalties ofpea jury treat the information provided above is true and correct. Signature: Date: Official use only..Do not -write in this area, to be completed by city or town official. City or Town: PermitUcense Issuing Authority (circle one): i 1. Board of Health. 2. Building Department 3. City/Town Clerk 4. ]Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone ##: Information and. Instructions Massachusetts General Laws chapter 1.52 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract oi?liire, expres's or implied, oral or written.." An, employer is defined as "an individual, partnership, association, corporation or other legal entity, of any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives o£ a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. Ho*ever the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance -with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill -out the workers' compensation affidavit completely, by checking theboxes that apply to your situation and, if necessary, supply sub=contractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of -ins uran c.e limited -Lability -Companies-- U--C)-or-LimiterLL�abxliiyPart�rsln�(LDP�ith no emp oyees o er an e members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of industrial Accidents for confaulation ofinsurance coverage. Also be sure to sign and date the affidavit. The'afCdavit'should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidenis. Should you have any questions regarding the law or if you'are required to obtain a workers' compensatioil policy, please call the Department at the number listed below. Self izi'sured companies should'entertheir self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit1cense numb er which will be used as areference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia oR CERTIFICATE OF LIABILITY INSURANCE DATE(MM9/2i/) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsem6nt. A statement on this certificate does not confer rights to the PRODUCER M.P. Roberts Insurance Agency 1060 Osgood Street North Andover, MA 01845 INSURED NORTH ANDOVER REALTY CORP C/O CHARLIE CARROLL 12 MARTINGALE LANE ANDOVER, MA 01810 (A/C�Na Ext) (978) 683-8073 (A'ic No): (978) 683-3147 E-MAIL ADDRESS: Sandi.@mprobertsinsurance. com —_..-__......_..__.._._.__INSURE_(R S)AFFORDING COVERAGE NAIC Y INSURER A: Specialty Iris Co ' ... .... _ _. ) ._..,.. __. INSURER _B_:_Merchants _Mutual. Insurance Co _--_-._...-...-.___.... INSURER C: Associated_ Employers Insurance COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR LTR TYPE OF INSURANCE I ADDL R SUER' - - - - WVD I POLICY NUMBER - POLICY EFF -I MM/DD/YYYY POLICY EXP ( MMIDD/YYYY LIMITS A I GENERAL LIABILITY JAGL0038376-00 6/13/16) 6/13/17 EACH OCCURRENCE I $ 1 OOQ, 000 X COMMERCIAL GENERAL LIABILITY _. I ( )CLAIMS -MADE I7X]OCCUR I $ 100,000 $ 10,000_. DAMAGE TO RENTED P_f3EMISES (Fa occutreltce) ME D EXP (Anyone person) .......... PERSONAL8ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2. 000 , 000 i I { j GENLAGGREGATE LIMIT APPLIES PER X I POLICY l PRO- JECT LOC I I S 2,000,-0Q0 $ PRODUCTS COMP/OPAGG B AUTOMOBILE LIABILITY . I iMCA7015484 ( 6/13/16 6/13/17 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANYAUTO i I ( 80DILY INJURY (Per person) $ ALLOWPED SCHEDULED AUTOS X AUTOS NON -OWNED HIRED AUTOS X AUTOS i I I j ---� $ $ _--- -- -- I BODILY INJURY (Per accident) I PROPERTY DAMAGE fPer.acctdent) $ ' UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE ( EACH OCCURRENCE l AGG RE GATE I's $ _ DED RETENTION $ ( ) is � WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY FIR OPRIETOR/PARTNERIE XECUTNE �! OFFICE MEMBER EXCLUDED? it (Mandatory in NH) If yes, describe under ( DESCRIPTION OF OPERATIONS below N / A �WCC501073401-2016A t I 3/13/16 3/13/17X WCSTATU IOTH __ _TORY LIMITS ER EL.EACHACGDENi �$ ....... _ 500,000,_.1 $ 500,000 000 I _ _.. $ 500,000 DISEASE _-EA EMPLOYEE _ - E.L. DISEASE -POLICY LIMIT I I i ' I I )ESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is regui red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. v' BUILDING DEPT / 1600 OSGOOD STREET AUTHORIZED RE yNT/A�VE NORTH ANDOVER, MA 01845 {((j/t(� 2, i © 1988-2010 ACORD CORPORATION. All rights reserved. aCORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD hone: Fax: E -Mail: Office of Consumer Affairs & Business Regulation ,14F HOME IMPROVEMENT CONTRACTOR Type: � Registration: 171245l Expiration: 3/1/2018 Individual CARROLL V. JAMES CARROLL JAMES 21 JOHNSON CIRCLE - NO. ANDOVER, MA 01845 Undersecretary Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -063503 Construction Supervisor JAMES V CARROLL 21 JOHNSON CIRCLE NORTH ANDOVER MA 01845 (-JZC. Expiration: Commissioner 07/19/2017 License or registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Construction Supervisor Restricted to: which contain Unrestricted - Buildings of any use group less than 35,000 cubic feet (991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: WWVII.MASS.GOV/DPS