HomeMy WebLinkAboutBuilding Permit #921-2016 - Exception 2/29/2016t's N MU � L -F
Perm!tNo#:
Date Issued:
LOCATION
PROPERTY OWNER--q�
MAP 6 9 -PARCEL:J'
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
TANT: A
Date Received
must complet(
,la 76
all items on this
0
�*) �-. - 7 � � I...,-,--.-. . I ly
100 Year Structure yes nc
Pr;;�t�
ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building-
040 e family
0 Addition
7 wo or more family
El Industrial
0 Aoration
No. of units:
El Commercial
�DAepair, replacement
El Assessory Bldg
11 Others:
Demolition
0 Other
-0
0 Septic 0 Well
---
0 Floodplain [I Wetlands
0 Watershed District
0 Water/Sewer
PTION OF WORK TO BE PERFORMED:
entification - Please T p or P
e rint Clearly
OWNER: Name.
.........
Address: , lel,-
�Tl
1-/
Contractor Name)&d.4&,Pt—
Phone:/7j';-- �OV-777V
Email:
Address:
Supervisor's Construction Licer&V-L���4 6 Exp. Date: ZP 7,�— 7
Home Improvement License: 1�17X377 EXD. Date: V- /7
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDiNG PERMIT: 12.00 PER $100 OF THE TOTAL ESTIMATED COST B N 5. 0 PER4 F,
Total Project Cost: FEE: $
Check No.:
Receipt No.:_ !2
NOTE: Persons contracting with unregistered contractors do not have access to thAyarantp
-fund
Location R- CZ /' e-1-
No.9,? /— I a Date ��
Check# \-I 4 7
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
Plans Submitted 11 Plans Waived 11 Certified Plot Plan El Stamped Plans El
TYPE OF SEWERAGE DISPOSAL
Public Sewer El
Tanuing/1\4assage/13ody Art El
Swimming Pools
well El
Tobacco Sales 11
Food Packaging/Sales El
Private (septic tank, etc. El
Pennanent Dunipster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On Signature'
Reviewed on Signature
Reviewed on Signature
Zoning 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 Town Engineer: Signature:
LOcatea 6b4 usgooa btreet
�y
E "r p
-FUR PPUA
d- a Le�d I a t.1,1,2 41 t M i hi�
Fi
GOMM�Nff,8
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.$100-$l 000 fine
NOTES and DATA — (For department use
I U Notified for pickup Call Email I
Date Time Contact Name
Doc.Building Pennit 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
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
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)
,4� Building Permit Application
4. Certified Proposed Plot Plan
• Photo of H.I.C. And C.S.L. Licenses
• Workers Comp Affidavit
4, Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4 Copy of Contract
4 2012 IECC Energy code
4. Engineering Affidavits for Engineered products
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
Doe: Building Permit Revised 2014
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'401ED HIC # 174377
Damphoussen
Roliff
BestOfSurve xotri—" ing LLP
YS trusted name since 1938 011
6 years rut7ning. Roofing - Siding - Windows 10,
87 Belmont Street North Andover, MA 01845
13- 97
8-683-4 88 - F: 978-685-7446
NAME OF OWNER
ADRESS OF JOB
K:54��) DATE:
TEL.
We will remove all roof shingles off total roof area, layer. Replace any boards or sheathing at
additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane
applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing
step flashings to remain. A new base sheet applied. Architectural roof shingle installed with a limited lifetime
warranty. Install new ventpipe boot flashings. Waterproof existing chimney flashin remove debris.
g and
zZShingle Color:
Ridge Vent Upgrade
-51-1
Wood S,heathing Repair $3.50ger ft.
o
4100, 70�
We Propose herby to furnish material and labor - complete in accordance with above specifications of:
dollars
Payment to made as follows ON
Authorized
Signature
NOTE: This proposal may be withdrawn by us if not accepteUith in '-4days
Acceptance of Proposal - The above prices,
specifications and conditions are satisfactory and are herby
accepted. You are authorized to do the work as specified. Payment
will be made as outlined above.
Signature
Date of Acceptance: Signature
HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS (M.G.L.142A
1. ',v"Z5RK: Provided the Homeowner performs under this agreement, the Contractor shall perform the work on the Property as specified Proposal, attached
incorporated herein. The work does not include extraordinary conditions of which the Contractor could not reasonably be aware. If such conditions are
encountered, this shall be an additional cost to the Homeowner. Materials selected by Homeowner may have to be ordered or custom made, which items are
specified in the Proposal. The Contractor is not obligated to agree to any modifications, extras or change orders unless such items are agreed to in writing by
the Contractor. All extras and changes shall be at an additional cost to the Homeowner. Contractor shall perform the work in a good and workmanlike manner
using materials consistent with this contract. Lawn or Driveway may be damaged by dumpster or equipment. Due to material shortages Contractor may
substitute materials of equivalent grade.
2. PERMITS: If a building permit is required for the work, the Contractor shall obtain same as Homeowner's agent. Contractor is not responsible for any
other permits that may be required for the Work, and Homeowner is responsible to determine whether any zoning, planning or wetland related permits or
approvals are necessary. Homeowners who secure their own permits or deal with unregistered contractors will not have access to the Guaranty Fund.
3. COMMENCEMENT AND COMPLETION: Homeowner acknowledges the commencement date of the work is fluid, and is subject to numerous factors
such as scheduling other contractors, delivery of materials and weather. Contractor and Homeowner shall determine the commencement date of the Work
when a more definite determination can be made and shall execute a written acknowledgment of same. The Work shall be substantially completed within 7
days of commencement, except for longer periods as may apply to particular projects as Contractor shall notify Homeowner in the Proposal, and subject to
delays for circumstances beyond Contractor's control. Notwithstanding, the commencement date and substantial completion date may be extended, and the
Contractor will not be liable for delays caused by, labor or material shortages, delays in delivery of items selected by the Homeowner, governmental action,
and unforeseen events beyond the Contractor's control, including but not limited to weather, strikes, war, the acts of third persons or the acts of the
Homeowner. The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractor's other jobs.
4. PAYMENTS: Contractor agrees to perform the Work and to furnish the materials and labor specified in the Proposal for the amount as stated in the
Proposal. Thirty percent (30%) of the total is to be paid as a deposit with the signing of this contract. Upon cancellation prior to commencement of the
Work, any remaining deposit will be returned less the costs for materials ordered for which Contractor was unable to cancel. Final payment shall be due
upon completion of the Work and Homeowner agrees it may not hold any retainage. Late fees may be applied for late payments. Homeowner shall pay
Contractor's reasonable costs of collection, including attorney's fees and costs. Time is of the essence hereof.
5. WARRANTY: For a period of lyear after substantial completion of the Work the roof will be free of leaks caused by defects in workmanship,
but not those caused by ice backing -up or extraordinary weather events, including blizzards, tornadoes, hurricanes or storms of greater than a twenty-five
year duration or intensity. Contractor gives no warranties with reference to any materials or equipment installed in the Premises, passes any such warranties
directly to Homeowner, and Homeowner agrees to look only to the manufacturer with reference thereto. This limited warranty extends to the Homeowner
only and is not transferable to succeeding Homeowners. This Limited Warranty specifically excludes (i) all consequential and incidental damages; (ii)
damage due to ordinary wear and tear, abusive use, misuse, or lack of proper maintenance; (iii) defects which are the result of characteristics common to
materials used; (iv) defects in items installed or supplied by anyone other than Contractor; (v) work done by anyone other than by Contractor; and (vi) loss
or injury due to the elements. There are no other expressed or implied warranties or representations made or given.
6. ENTIRE AGREEMENT: This contract and all documents referenced herein constitute the complete and final agreement between the parties. In the event
that any of the provisions of this contract shall be held to be invalid, the remainder of the provisions of this contract shall remain in full force and effect. Two
identical copies of this contract have been completed and signed. Homeowner acknowledges receipt of a completed contract signed by the Contractor.
7. HOME IMPROVEMENT REGISTRATION: In accordance with M.G.L.c. 142 A, § 9, Contractor is registered with the Bureau of Building Regulations
and Standards Registration No: 174377. Homeowner may verify by contacting the Director at (617) 727-3200, ext. 25205. A Homeowner's rights under
the Home Improvement Law (M.G.L.c. 142A) and other consumer protection laws may not be waived in any way. Homeowner acknowledges receipt of a
copy of 780 CMR R6 and Massachusetts General Laws chapter 142A, and which are available online at www.mass.gov. Questions may be directed to the
Consumer Information Hotline, (617)727-7780.
8. ARBITRATION: Contractor and the Homeowner hereby mutually agree in advance that in the event 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 Secretary of the Executive Office of Consumer Affairs
and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c. 142A. No lien or security interest is
imposed on the Property as a consequence of this contract, but Contractor has the fight to record this contract or a notice of this contract, or seek a lien ifthe
Homeowner breaches this Contract.
9. HOMEOWNER COVENANTS: The Homeowner agrees, represents and warrants that (a) the Homeowner grants permission to the Contractor to enter the
Property to perform the work as covered by this contract; (b) the Homeowner has funds available to make full payment under this contract to the Contractor
upon completion; (c) the Homeowner understands that construction as contemplated by this agreement creates a dangerous condition, and agrees not to enter
portions of the Property under construction until the Contractor advises the Homeowner that the construction is completed; (d) Contractor may need use
landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and (e) that code requirements may result in
roofing nails penetrating through roof decking and will be visible on the underside of some surfaces. The Homeowner indemnifies, exonerates and holds
harmless the Contractor from any loss, damage, claim, liability or expense (including reasonable attorney's fees, deposition costs and court costs) resulting
from a breach of this provision. Contractor is not responsible for damage to landscaping that will grow back during the next growing season.
10. CANCELLATION: H eobwner I?ly canccl tl�s agreerpent provided Homeowner notifies the Contractor in writing at the address listed in the Proposal not
ii,i� _ da,
later than midnight of the t r y t 101 ing ty signing of this agreement.
— 04 �?
74
HOMEOWNER: DATE:
P
I<
Shingle: ;45' DEPOSIT:
The Commonwealth ofMassachusetts
Department of Industrial A ceidents
Office of Investigations
600 Washington Street
Boston, MA 02111
unow.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
City/State/Z����90�v� Phone#:
Are yo n employer? Check the _Wpropriate box:
4. 1 am a general contractor and I
1. 0 1 am a employer with jV
employees (full and/or pirt-time).
have hired the sub -contractors
2. Fj 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
Iliese sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.t
required.]
5. We are a corporation and its
3. El I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required] t
c. 152, § 1(4), and we have no
employees. [No workers'
cornD. insurance reQuired.1
_J
7 11 -
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10.E] Electrical repairs or additions
I 1.E] PI bing repairs or additions
12.0� 701of repairs
13.n Other
*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 are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContracters that check 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 -contractors have employees, they must proNide their workers' comp. policy number.
I ain an employer that isproviding workers'compensation insurancefor iny eipployee& Beloit, is thepolicy andjob site
information. /n �% __..0
Insurance Company Name: /-7- __L_ 4 4.0e�- 1 , 4
Policy # or Self -ins. I�ic. #: —_7_bAA_77 O'�� rati
!_�3 on Date: 7—
Job Site Address;Z City/State/ZiV"1_ A_�� AIAV I
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
fine up to $1,500.00 andlor 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerlify undeY flzepai�g�penalties ofperjuty that the information provided above is true and con -eel.
�t56 Date:
Official use only. Do not ivrite 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. Plumbing Inspector
6. Other
Contact Person: Phoneg:
7/4/2015 4:45:37 PM
8790 @ 02/02
CERTIFICATE OF LIABILITY INSURANCE
lllia.�
DATE (MM/DDIYYYY)
07101/2015
I
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA71ON 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 SUBROGAnON IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 00474-001
NCRMNTPCT
Doherty insurance Agency Inc
PO Box 1985
Andover, MA 01810
NE AX
(PAHICO Ext): (918)475 [A No.:
No. -0260 F C.
EM�RI�SS:
AD
INSURERIS) AFFORDING COVERAGE NAICA
INSURERA: A,I.M. Mutual Insurance Company 33758
EACH OCCURRENCE $
INSURED
Damphousse Roofing LLP
INSURER 8:
PERSONAL & ADV INJURY S
GENERAL AGGREGATE S
INSURER C,
INSURER 0,
87 Belmont Street
North Andover, MA 01845
AUTOMOBILE
INSURER E:
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. NOTWITHSTAIN DING 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.
IR�
TYPE OF INSURANCE
A
Iffk
�Ull�
h V
POLICY NUMBER
POLICY EFF
(MMIDDIYYYY)
P Y3
yy
(M 5MWIE
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMSWADE [—] OCCUR
EACH OCCURRENCE $
A IG' TO RENTED $
P R MA SES(E..cc.".nc.)
MED EXP (Any one person) $
PERSONAL & ADV INJURY S
GENERAL AGGREGATE S
�ENI_ AGGREGATE LIMIT APPLIES PER-
OUCy [---PRO-
I IJECT F -10C
PRODUCTS - COMPIOP AGG $
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
COMBINED '�INGLE LIMIT $
(Ea acci eU
BODILY INJURY (Per person) S
BODILY INJURY (Per accident) S
PROPERTY DAMAGE
(Pefaccident)
UMBRELLA LIA
EXCESS LIAB
H
OCCUR
CLAIMS MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION
S
A
W
AR,RKERS CO%�,ENSAT]qp
EMPLOYE S'UABIL Y YIN
ANY PROPRIETORIPARTNER[EXECUTIVE
EC
OFFICERIMEMBER EXCLU ED7 MN
(Mandatory In NH)
UkAffft bMERATIONS below
NIA
AWC-400-7028774-2015A
411712015
4/1712016
X I TWINNS I IOJP-
E.L. EACH ACCI DENT $ 500,000.00
E.L_ DISEASE - EA EMPLOYEE $ 500,000.00
E.L_ OISEASE - POLICY LIMIT S 500,000.00
J
J
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mom space is required)
Worker's Compensation Coverage Applies to massachusetts Employees Only.
No partners are covered by the workers compensation policy.
CERTIFICATE HOLDER CANCELLATION
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
7759
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
7759
Client#: 14415
DAMPHOUSSE
ACORD- CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDDMYY)
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
0411712015
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Doherty Insurance Agency, Inc.
P.O. Box 1985
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
21 Elm Street
Y EXPIRATION
VMMMIDDIM.
Andover, MA 01810
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Western World
Damphousse Roofing LLP
87 Belmont St
North Andover, MA 01845
INSURER e:
INSURERC:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REOUIREMENT. 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS=
LTA
NO
TYPE OF INSURANCE
POLICY NUMBER
0 C"VF
Tawwawyn-
Y EXPIRATION
VMMMIDDIM.
LIMITS
A
GENERAL LIASHM
NPP8202847
04/12115
04112116
EACH OCCURRENCE S1.000.000
CO,
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 51 OCCUR
D
P=GE 70 RENTED
$100,000
M E D E X P (Any -0ce 'P'Me rmstwce)l $5�000
PERSONAL & ADV INJURY $1.000.000
GENERAL AGGREGATE s2,000,060
GENt AGGREGATE LIMIT APPLIES PER:
—1
PRODUCTS - cowfop AGG s2,000,000
PRO- F LOC
X POLICY F JECT
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea awdonly
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Perperson)
HIRED AUTOS
N UTOS
BODILY INJURY
(Pet accident) S
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - FA ACCIDENT S
OTHER THAN EA ACC S
ANY AUTO
AUTO ONLY: AGG S
EXCESSZMBRELLA LIABILITY
EACH OCCURRENCE s
AGGREGATE S
<7 R CLAIMS MADE
$
RDEDUCTIBLE
$
ETENTION 3
WORKERS COMPENSATION AND
EMPLOYERS'UABIUTY
E.L. EACH ACCIDENT S
ANY PROPRIETORIPARTNEMEXECUTFVE
E.L. DISEASE - EA EMPLOYEE S
OFFICERIMEMBER EXCLUDED?
It describe under
SMIAL PROVISIONS betow
E.L. DISEASE - POLICY LIMIT S
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Covering operations usual to Damphousse Roofing LLP..
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYSwnnTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO 00 SO $HALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
AUTHORIZED
--066R—PORATION 1988
ACOR025(2001/08)1 of 2 #S31840/MS1835 I( DMC- —0—ACOR
Massachusetts Department of Public Safety
� �V49 Board ofBuilding Regulations and Standards
License: CS -07500
Construction Supervisor
SHAUN MTmwOMsY
61pATmO|TmT
NORTH ANDOVER MA 01946
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\ `~ Expiration:
Commissioner 1012612017
HOME IMPROVEMENT CONTRACTOR
Registration: -174377' Type:
Expiration: '2/4/20117 LLP
SHAUN TWOME
87 BELMONT ST
mANDOVER, m —