HomeMy WebLinkAboutBuilding Permit #61-16 - 71 Winter Street 7/14/2015TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued: -7 d
IMPORTANT:
Date Received
must complete all items on this
LOCATION lam ->I j'�i�.f- �`"7��Q•Yt UT N yam' C tt�y _ l�-�v_
_. - ._ Print
PROPERTY OWNER
- _ Print 900 Year Old Structure yes no
MAP NOIPARCEL ZONING DISTRICT .Historic District yes no
Machine Shop Village yes. no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
One family
❑ Addition
❑ Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
D Septic D Well
❑ Floodplain D Wetlands
Q Watershed District
El Water/Sewer
DESCRIPTION OF WORK TO BE PtKI-OKmtu:
Please Type or Print Clearly)
OWNER: Name:
Address:
LT4'®S
CONTRACTOR Name: Lamraef 0 Q,� Phone. _.. ` _ .
Address:Qtbs.SIDIA-yo -
Supervisor's Construction License: _Exp. Date:
Home Improvement: License: Date:
A
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
�1 L f
Total Project Cost: $ (d 4� FEE: $
Check No.: °Z1- Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have acc t gu and
Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑
Stamped Plans ❑
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 - U FORM
DATE REJECTED DATE.APPROVED
PLANNING & DEVELOPMENT-
COMMENTS
EVELOPMENT
COMMENTS
.CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
?oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow;! Engineer: Signature:
FIRE QEPARTwIVT -Temp Dumpster on site yes_
Located'at 124 Mair, Street
-Fire Departrrierit signatu"re/date"
COMMENTS
Located 384 Osgood Street
no
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
NL) i t5 and UA I H — (yor department; use
® Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The fol:owing 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/Crossection/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 apt), -al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submated with the building application
Doc: Doc.Building Permit Revised 2012
Location
No. 6 b 6v Date
Chec k
29057
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
F -T -T
Foundation Permit Fee $
Other Permit Fee $-T
TOTAL. . $
Y,
�—guilding Inspector
NQ FD 10598
Date ...,.-.7
TOWN OF NORTH ANDOVER
RECEIPT
This certifies that .............................................. �?,f .... e ...................
haspaid ..... ....................................................................
for . .......
...............................
Receivedby ... . ........ . . ....... ... . . ....... .......................
..............................................................
Department .....................
WHITE: Applicant CANARY: Department PINK Treasurer
f -)N
r
The,Cdmmonwealth of -Massa.Ghusetts
De.partm*eht- of Fire Se"Wi.Ges'
Off -ice of the State Fire Marshal
P. 0. Bo -x 1025 State'Road,.Stow', Na 0177J
PERMIT'
Dated -) —IT - -/
North Andover Termit No
.(C4ofTown) (IfApplicabic) 'Di.9
Th accordarici.with the ons of M- G -L
provisi -.14 8 C-halfttrr 10 aspruyide� in section–i2l—EXR. 3 4
This P61mit is granted to
Full namp of person, FfisWr Corporation
Permissionto locate d ump.st;er-for cOnstrl"c t I'a n /renovation/ demolition of building
Comments:* dump�ter. must be. 25' from structure if unable to -place wi�h reQuire . d
�"�'60":clear�nce dumps -ter must be covered with plywo*od or tarp end of 'work -day
at —7— lflli 7—ir,.y C, Air, cf.-7
Gi-VC [ocation by strcea,�d no., or desc i?b(:,,, h maaiaqr as to pro-vicd adequate idcnEEcation.of Ibcatica
FccPaids 50.00 Fire Chief
TEs Permit will expire" S ignatura of ofE a] Offical granting permit Title)
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EIN # 51-050-3313
MA Reg. HIC # 149221
-10- MA Lic. UCS # 78130
ME Single -Ply License# 1711
*Licensed
r;A
35
265 Winter Street
Haverhill MA 01830
*Insured Factory Trained *Factory Certified
Billing Address: rt t i f i ezr_ ! CUh r. City:
Job Address: City:
V IC 77i-1k:1-�)7
Haverhill MA 978.374.9224
Lawrence MA 978.687.7339
Hampton NH 603.929.9224
Hampstead NH 603.329.8200
Toll Free 1.888.SOS.R`OOF
Scope of Work tg Strip and Re -roof ❑ Re -roof Approximate Roof Area:
❑ Prepare for re -roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected.
❑ Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from theob site.
❑ Inspect wood deck, if we discover any rotted wood, replacement will will performed at *$ ,3 . PS per LF for roof deck boards. If
substantial deck rot is discovered, re -sheathing of roof deck can be performed at *$ / Zv per SR If individual sheets are found to be
rotted/or de -laminated, removal, disposal and replacement will be performed at *$ per sheet. If any trim boards are rotted,
replacement will be performed at *$ per LF for new pre -primed pine. Inspect siding at roof Une and all flashing behind siding, if
we discover any damaged flashing or siding at the roof line, replacement will be performed at *$ If wood deck, siding, and
flashing is sound, we will re -nail any loose wood to rafters, sweep deck, and prepare for roofing.
❑ Install 8" drip edge to all rakes and eaves. Color Whiz �
❑ Apply ice & water shield (UNDERLAYMENT) as per manufacturers' specifications and/or
❑ Apply premium (UNDERLAYMENT) to the balance of the exposed wood deck.
❑ Re -flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensure water tightness.
❑ If upon inspection, we discover chimney lead to be worn or deteriorated, replacement will be performed at *$.
❑ Install a new: _ Year ❑ Traditional P(Architectural ❑ Designer Color
❑ Furnish and Install a new shingle over style ridge vent system ❑ Soffit vent system *$
❑ All debris generated by Lambert Roofing Co., Inc. will be cleaned up and disposed of from the job site in a legal fashion. Under no
circumstances will the watertight inte pity of the buildi'} g be compromised. �J 1
Special Notes `�' �f-� ad tsfl �� ji���Z19"YF in�y d�
V V 11 -
UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF
YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND )�q YEARS HONORED AND ISSUED BY THE
SHINGLE MANUFACTURER. ❑ MANUFACTURER UPGRADE *$ Lt
*Denotes potential additional costs above the total estimated price. �✓) L ,
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE 0 •
The Contractor agrees to perform the work, furnish the materials and labor specified above for the total sum of: $
Payment will be made according to the following work schedule:
$ deposit upon signing contract j
$ by _/_/_ or upon completion ofi /W
$ upon completion of contract.
(Law forbids demanding full payment until contract is completed to both party's satisfaction)
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail -posted, by telegram or by delivery, not later than midnight of the
third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right.
ADO/NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES
.Acceptance of the Contract Proposal
Home Owner(s) Signatures :
Contractor's Signature:
ertroofing.com
Date:
Date: 7,,711,5' /,7/1,5'
(Please see reverse side)
Company Insurances
TGLRC Inc. DBA Lambert Roofing Company will provide certification of insurances, demonstrating that we are fully insured for worker's compensations,
general liability, automobile liability and an umbrella policy. This documentation will be sent through the US mail to the above named party if not already
provided.
TGLRC Inc. dba Lambert Roofing Company agrees to:
• Commence the described work on or about
• Complete the described work in approximately days.
• Not be held liable for delays due to circumstances beyond our control.
• Not be held liable for any damages to landscape and or fixtures due to circumstances beyond our control.
• Not be held liable and not covered under the workmanship warranty, for pre-existing conditions including but not limited to:
• Mold and or wood rot, defective, faulty, rotted or worn building counterparts such as, but no limited to: siding, roofing, masonry,
plumbing and windows, all of which may jeopardize the watertight integrity of the structure.
• Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the
residence.
• This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inc. DBA Lambert Roofing
Company and the Homeowner/Business Owner or Agent.
Permits
A building permit may be required to remove and replace your roof. It is our obligation to secure these permits if required as the home owner's agent. Note:
Homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c. 142A.
Accelerated Payment
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be
financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds
not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the
signatures of both parties.
Payment Terms
A finance charge of 1.5% a month (18% per year) will be added to all invoices on the 31' day. All legal and or collection fees will be paid by the binding holder
of this contract.
The law requires that any deposit or down payment required by TGLRC Inc. dba Lambert Roofing Company before work begins may not exceed
the greater of -
0 1/3 of the total contract price or:
0 The actual cost of Special or Custom made materials which must be special ordered in advance to meet the completion schedule.
Arbitration
The contractor and the .homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this
contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs
and Business Regulatio d the consumer shaU be required to submit to such arbitration as provided in MGL c 142A.
Contractor:
Date:
Date:
Contractor Registration t✓ C, y
All home improvement contractors and subcontractors must be registered, any inquiries about a contractor or subcontractor relating to a registration should
be directed to:
Contractor Registration:
Home Improvement Contractor Law:
Director of Home Improvement Contractor Registration
Board of Building Regulations and Standards
One Ashburton Place, Rm. 1301
Boston, MA 02108
(617) 727-3200
Consumer Information Hotline
Commonwealth of Massachusetts
Office of Consumer Affairs and Business Regulations
10 Park Plaza, Rm. 5170
Boston, MA 02116
(617)973-8787
For assistance with informal mediation of disputes or to register formai complaints against a business, call:
Consumer Complaint Section
Office of the Attorney General
(617)727-8400
AND/OR
Better Business Bureau
(508)652-4800
(508) 755-2548
(413)734-311.4
Cancellation
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be in the main office or branch
thereof, provided you notify the seller in writing at the main office by ordinary mail posted, by telegram sent or by delivery, no later than that midnight of the
third business day following°the signing of the agreement. �`�•
' INITIALS
The Commonwealth of Massachusetts -
Department ofIndustrialAccWd is
Ofj ice of Investigations
600 Washington Street
Boston, MA. 02111
www.mass govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibiy
Name (Business/Organizationffndividual):
Address: CE, xp, nl- c�
City/State/Zip: AaVQ -"0\ Phone #: q1 B 4 90;3 q
Are you an employer? Check e appropriate box:
Type of project (required):
LQ I am a employer with (y
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (fall and/or part-time).*
have hired the sub -contractors
t
7• ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
9. ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.E1 Electrical repairs or additions
required.]
3. ❑ 1 am a homeowner. doing all work
officers have exercised their
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, §1(4), and we have no
12.❑ Roofrepairs
insurance � ired. re q ui
employees. [No workers'
13.0 other
comp. insurance required.]
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company
Policy # or S elf -ins. Lie. #: ,00 UI?) -^off - , q &J S ' �o ; I y _ Expiration Date: 3 -95 -)Lo-
. (.
Job Site Address:)A o4-e—r
C�6 R.P-n pr City/State/Zip: Ain d (S-rer MC&.
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
'Investigations of the DIA for insurance coverage verification.
I do hereby cert underfperjury that the information provided above is true anti correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other - -
Vnnfarf PP.YCnn: Phone #:
Information and Instruction -S
Massachusetts General Laws chapter 152 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 of hire,
express or implied, oral or. written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However 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 ofpublic 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 the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LT C or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
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 permit/license number which will be used as a reference 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 (ifnecessary) and under "Job 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Gomzx�onweaXt ofassar?zusPtts
Department of fadustrial Accidents
Office of Intvestigatiolis
600 Wuhington Street
B oston� MA, Q.2 X X 1
TO, # 617-72.7,4900 ext 406 or 1-877MASSAFE
Revised 5-26-05 Fax # 617-727-7749
ti r GATE JMMIODIYYYY)
�o CERTEFICA 'E OF L8AMLILY INSURANCE 04/07/2015
TWS CERTIFICATE 18 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 DOZES 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 poticy(ies) 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
--tat—t- hnlelur in IiAu of such endorSement(s).
'RODUCER
r+,I,LAtiT INSM"CE AGCY 1180.
53 1/2 Jefferson Avenue_ 2nd Floor
P.O. BOX 511
SALSK NA 01970-0511
INSURED
TGLRC
dbai Lambert Roofing Co.
265 winter Street
Haverhill - mA 01830 -
Jerrold_ ICameras
(978) 745-5905
.cam
745-5483
COVERAGES CERTIFICATE NUMBER: •.�..- -- �-
BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE
OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS
INDICATED NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
THE TERMS.
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED
AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
265 Winter Street
EXCLUSIONS POLICY EFF POLICY EXP LIMITS
161
AUMP#6REAESENTATM
1NSR LTR TYPE OF INSURANCE PO CY NUMB M
11000,00
GENERAL LIABILITY EACHOCCURRENCE $
Haverhill MA 01830-
t
/ ! / - S
50.000
=Tre
X COMMERCIAL GENERAL LIABILITY PREMISES rn
1112/201411/12/2015 MED EXP (An OnePOrsOM S
11000
AI CLANG MADE aOCCUR hES1029029
! / !
11 000, 000
PERSONAL A ADV INJURY S
X Per Project Agg
GENERAL AGGREGATE 15
2,000,000
UCTS-cCAW400PAGG s
2,000,000
AGGREGATE LIMIT APPLIES PER
rPROEoEN'L
POLICY X PRO• LOC
I I !!COMBINED s LIMIT
1,00(),_000
AUTOMOBILE LIABILITY i
BODILY INJURY tPcr pemM) S
ANY AUTO
B ALLOVMED 1 ACBEOULED 6203819 OOOtLY INJURY (Ps" axideml)3
X NON-OVJNEU 7/16/2025 07/16f2025 PROPERTYDAIAAGE $
x HIRED AUTOS AUTOS
X
UMBRELLA LIAR
X
OCCUR
18430331
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EACH OCCURRENCE S
5,000,000
AGGREGATE 5
5,000,000
1/12/2014
11/12/2015
C
EXCESS LIAO
CLAMIS-MAOL
s
OLD] I RETENTIONS
X YVC SLIMIT OT
WORKERS COMPENSATION
E L EACH ACCIDENT S
1 000 000
AND EMPLOYERS' LABILITYYINJ
I
J I
ANY PROPRIETORIPARTNERIEXECUTtVE
OFFICERIMEMBEREXCLUDI:D^ }U
NIA
S62UB-2E09875-2-1e Kh
3/25/2015
3/25/2016
EL DISEASE -EAEMPLOYEE 8
1 000 000
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(Simdatarq In NH)
IE yyos_ deer under
DE3CRIPIION OF OPCRATIONs te1.-w
Worker's Compenstaion NH
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(S62UB-SD81311-6-14 Na
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2/22/2014
J J
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2/22/2015
F. L DISEASE . POLICY LW S
saniekram
11000,000
1,000,000
W
1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Attach ACORD Jul, AMIlanal Remarks Schedule, V mora spaeO Is requtrodl
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIED POLICIES BE CANCELLED BEFORE
TGLRC dba Lambert Roofing
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
265 Winter Street
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Office. Of Cunsumer Affairs and Business Regulation
10 Park Plaza e Suite 5170
Boston, Massachusetts 02116
Home improvement Contractor Registration
Registratian: 149224
T"m: Pmrate Corwfation
T.G.L.R.0 dba Lambert Rooung wmpany Expiratton: 1219t2a16 Trot 246813
RICHARD LAMBERT
265 WINTER STREET
HAVERHILL, MA 01630
update Addras9 aad rntara card. Nes* ria for changes
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