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HomeMy WebLinkAboutMiscellaneous - 138 Kingston Street /38 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I '1 CITY Ol/P _ MA DATE 11 !GL11 11 PERMIT# JOBSITE ADDRESS ! �� >___ __OWNER'S NAMES/��/r GOWNER ADDRESS e p G fog soC TEO =FAX L— TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:E3. RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES 0 NO F APPLIANCES 7 FLOORS- BSM 1 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATER DRYER T 1 _ _ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE - �1 --- --- -- - -- -E±_ �l -- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ ROOM/SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER _ �— UNVENTED ROOM HEATER _ _ WATER HEATER - OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY —, OTHER TYPE INDEMNITY ® BOND Ej OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Gene I La that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER QI AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi Pert' n oVision of the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP El MGF 0 JP ® JGF LPGI Q( CORPORATION©# PARTNERSHIP #=LLC #� COMPANY NAME: ADDRESS� � CITY OX �`''� STATE ZIP TEL _� FAX CELL _ EMAIL _ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 7 µ The Commonwealth of Massachusetts z . f Department of IndustrialAccidents F d 1 Congress Street,Suite 100 Boston,MA 02114-2017 www rnassgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY.A Applicant Information / Please Print Legib Name(Business/Organization/Individual): �!� Address: 17 S G City/State/Zip: w Phone Are you an employer?Checktlie appiropriate box: Type of project(required): 1.Q I am a employer with employees(full and/or part-time).* 7. F1 New construction 2.F1 I am'a sole proprietor or partnership and have no employees working for me in $, Fj Remodeling any capacity.[No workers'comp.insurance required.] r 9. [�Demolition 3..Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.n Electrical repairs or additions proprietors with no employees. 12:�Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: IS.-n Roof repairs 6.F1We are a corporation and its ofeers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees;[No workers'comp.insurance required.] ri *Any applicant that checks box 41 must also'fill out the section below showing their workers'compensation policy information. I Homeowners who siibmif this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ,:• ,:r . ..,., employees. If the sub-contractors fiave employee's,they must provide their workeis'comp.policy number. Iain an employer thai is pioviding workers'compensation insurance for my employees.'Below is the policy and job site information. �— Insurance Company P Y Name: � � — Policy#or Self-ins.Lie.#: /�/,-- Expiration Date: el"? 'l Job Site Address: l RD f�e; !?/4v � City/StatelWr Attach a copy of the workers' compensation 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 DIA.for insurance coverage verification. I do hereby certify ppder the pains andpeenalties ofperju t the informationprovided above is true and correct. Signature: � 1. l Phone#• 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): 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 152 requires all employers to provide workers'compensation for their employees. x Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, expres's 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 commonvYealth 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 the-boxes 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 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 LLC 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(if necessary)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 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 i YVY•�A�I�Y V1\I ,\V✓V VY1�,At\✓ � �Vl ✓L.,\. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the teens 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 NAME CT Commercial Lines Department Segal Insurance Agency, Inc. PHONE (617)527-4400 1 FAX No):(617)964-9925 424 Langley Road E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# Newton MA 02459 INSURERANational Grange Mutual Ins Cc 42• INSURED INSURERS: Ale ksandr Arenkov, DBA: Alex A Plumbing Inc. INSURERC: 1270 Vermont St INSURER 0: r INSURER E: W=;Roxbury MA 02132 INSURER F• 1,0'- AGES CERTIFICATE NUMBER:CL1622302692 REVISION NUMBER: .WS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD Ii Q CATED. 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' TYPE OF INSURANCE ADD SUER POLICY EFF POLICY EXP LTR POLICY NUMBER IMMIDDIYYYYI (MMIDD/YYYY1LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 r A: CLAIMS-MADE FIOCCUR DAMAGE TO RENTED 500,000 PREMISES Ea occurrence $ MP182419 12/18/2015 12/18/2016 MED EXP(Any one person) $ 10,000 f>. PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 B POLICY El JECCT- D LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Is AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident i. - AUTOS AUTOS ) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ er accident UMBRELLA UAB OCCUR EACH OCCURRENCE $ }) ...'s EXCESS UAB" CLAIMS MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN S TUTE ER ANY PROPRIEfOR/PARTNERIEXECUTIVEWCI82419 7/30/2015 7/30/2016 E L EACH ACCIDENT }" OFFICER/MEMBER EXCLUDED? N/A $ Ax((Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ --_. If-yes.describe under 'DESCRIPTION OF OPERATIONS below E-L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) The certificate is issued in the interest of the named insured and certificate holder kER_-T�1FICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE J' THE EXPIRATION DATE THE OF, NOTICE WILL BE DELIVERED IN ^ . ACCORDANCE WITH THE POLICrROVIS)ONS. a r AUTHOPR ENTA 7 L _ c O 1981-2/M4 ACORD CORPORATION. All rights reserved. ''ACORD 25(2014/01) The ACORD name and logo o o are registered marks f ACORD 9 e9 INS025(201401) 3/8/2016 Town of North Andover Mail-RUSH Request for Open/Expired Permits&Outstanding Code Violations:138 KINGSTON ST,NORTH ANDOVER MA :x No AN OVER Maura Deems <mdeems@northandoverma.gov> MaSWChu RUSH Request for Open/Expired Permits & Outstanding Code Violations: 138 KINGSTON ST, NORTH ANDOVER MA I, Lisa McClure <Imcclure@atr.guru> Tue, Mar 8, 2016 at 4:21 PM To: "mdeems@northandoverma.gov" <mdeems@northandoverma.gov> Hello, Please provide any open/expired permits to include but not limited to Building/Zoning, Electrical and Plumbing/Gas as well as any outstanding code violations for the following property location: Parcel#: 210/023.0-0006-0138.X 138 KINGSTON STREET NORTH ANDOVER, MA 01845 Owner: BARBARA WALSH We do NOT need a full history of inspections/permits/violations if items have been resolved. Only if OPEN/EXPIRED permits or outstanding code violations are currently present on the referenced property, please provide the type of permit/violation, permit/levy date and instructions on how to correct these items to include any/all applicable fees with remittance details. Thank you for your time and assistance regarding this matter and if you need any additional information or have questions, please do not hesitate to contact me directly at the number below. Regards, Lisa McClure, Senior Tax Analyst American Tax Reporting, Inc. 2727 LBJ Freeway,Suite 420,Dallas,TX 75234-7409 Toll Free: (877)923-4829,ext 254 Direct: (214)731-7686 1 Fax: (888)688-8803 lmcclure@americantaxreporting.com I www.americantaxreporting.com https://m ai l.google.com/mai l/ca/u/0/?ui=2&ik=aeO2b3b5c4&view=pt&search=i nbox&msg=153581 b1e106fcc9&si m 1=153581 b1 e106fcc9 1/2 Date..... .1k. ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING sSgCHU Ml�,0,4Q This certifies that has permission to perform*'*'****'*1� .*'.*..*.'.A"*"4 �......................................... .................................................. wiring in the building of...............6I.V-7k).............................................................................. ............... at ...... 'J............................................North Andover,Mass. Fee�.().............Lic. No-'-20zc1Z.............................I................................................... ELECTRICAL INSPECTOR Check# C111rnoru.*eJM of�1&1.1.,zc4u '�j _j er Official Use Only Permit No. -L Occupancy and Fee Cric-clKM BOARD OF FIRE PREVENTION REGULATIONS [R11. 1/07) L (leave blank) APPUCAT[ION FOR PERN,71T TO, PERFORM ELECTMCAL � All Nvork to be performed in accordance with &JODRK E1tC'F:cR!C00- M-EC), 527 CMR 12.00 (PLEASE PRINT IN JIVK OR TYPE ALL r IFORMA 770j\) Cif y or Town of: TO "he By this application the Undersigned gives notice of his or her intention to p"t-forli-, `-t Location (Street& Number) �ri:described belo,,�'. Owner or Tenant wo Is this Permit In conjunct!Joiri -ivitli a building permit? ! NO (Check Appropriate So.�,) Purpose of Building I — Ufflit-N Authorization Na. Existina service WeL Amps 0 1 t s Overhead UndgM F- No. of Meters New:Service -Loz,_ .-krrips Und"Ird _i�u�,2Y__ovoits Overhead .7j Q�_ Pj Nj 0. o f Meters 9- Number of Feeder's arid Ampacity Location and Nature of Proposed Electrical Work, GYi-e �C_�OLC aF I f��Akl t U_U W,-t-A, cor-mi;!.iotl iaL,;ic h,.?waived by!k;e 3 Wires. No. of Recessed Liurriiiaireb- N.0. INO. of ceil.-Susp. (Pad I-Ins No, of Luminaire Outlets INo. of Hot Tubs (Generators No. of Luminaires6 1�e ------ n�- __:Fj N'o. o �merv��n2 : ,ijjr r Swimming Pool IS L7rnd. ornd. 'nits No. of Receptacle Outlets No. Of Oil Burners :FIRE ALA.RMS No. of Zones ml No. of SwitchesINTC). of Gas Buxners V�� 0 f Defection 0 11 and Tnit-iatiric, Devices INo, of RangesTotalNo. of Air-Cond. ::.N`O. c-1 Alerting Devices Tons IIIE:-t Pump NUmber ITon c. Of Waste Disposers f ---- Na. n Contained Jii e .............. ...................... d ali: -II.Alerfing Devi,es I To� CO ,No. of Dishwashers space"A.1-r-a HeatingK-W u ni ection 'No. of Dryers Heating m%ppliancesn., r �J. L- ).zvic�s or. Er i.No. OTW­atel —0f 0. H-_a t er K VY 2 Signs a I I F.s s D vires o r P21 e n t No. Hydromassage Bathtubs -No- of Motors Tota! HP No. No c1l Devices or- E QUiValent OTHER: E� _ C Es,,irnated Value of'Ejectrical ;j 0",OS ­�ou-�:Tcd by r" -.icip'-d policy.) nul Vo.1- to Start: 17�77, or .- . L :�Sz-d i'l -7,cordance with 1viEc Rulc 10, '1.7-d 1:[).01 -101 111 p com INSURA.NCE COS' .�n RAGE: Ur­_.If�ss w-_,�vt .'Ittion. 7 _1 _c^ ca v,or-k c- �,t c T LfOr the peifo;-rnaji(;.- fciz C, D_100fofhal ility ir'sul-ar1cf! Y issue uz r".-Ption"cove!-- ap or its slibsiPriti-al equ: P"alcni. t s ],.at such cove-rawe nni L _Z7 ­_ ZR77 L) �21 C -r-CKONE: INSUR-kNCE B 0 1,1 D and ri-najl' .16S 011 jet U FIRM NANIE: L' Fs A', .5 Ue C.112, n.g V_t' LIC. "NO.r e : 9 J. in he licenFe LIC.NO.:X� 00�c�,2 ex Address: B ir s. Tel. No. 9 1/100 `Per Iv' s. �7 -C - -61, security we-,; Alt. Tel. JNO,..'1_)9�7W ;,It oft�ub5ic�Saff 1--, MVNERS INSU S C c. N r). R-k NC E, WAIVER.- 1 Licensee docs not ------ recluired by By try SjE_-_ture -equireme.n.t. I air, below, Owner Tent Downe.. j I,, Signature' e .The Comtnonwealtla ofMassachttsetts ' Department oflndttstrialAceidents 1 Congress Street, Suite 100 Foston, .1VIA 02-714--20.77 www.mass•.gov/dig Workers, Compensation insurance.A.ffdavit: Builders/ContractorslElectricians/Phuubers. A> plicant Information To 13E FILED WITH TIM PERMITTING AUTHORI' .Y. Name (Business/Orgaiiizatioillindividual): __ - ----^ Please Print. Address:_ ---- -'� C)( City/State/Zi�• � ^ ��, � � ~--------_— ---- ----- � ' Are yqp an cmployrr?Check the apprnpriatc boa: — --- ---------------- —__ --------------�-- i.�I am a employer with �( , emTYpe of project(required): _ — ployees(full and/orpart-time).* am a sole proprietor or partnership and have no employees working .fbi rile in y CJ New constriction 3.L any capacity.[No workers'comp.insurance required.] g. (-] Remodeling II am a homeowner doing all work myself [No workers'comp.insurairce required.]t .9. FJ Demolition 4f]I am a homeowner and will be,biting contractors to conduct all work.on my property. I will 10 L]Bililding addition ensure that all contractors either have workers'coo insurance or arc sole f proprietors with no employees. 11•[Yj F.,lectrical repairs or additions 5.Fj 1 am a general contractor and I have hired the sub-contractors listed on the attached.sheet. 12. Plumbing repairs or additions Thcse sub-contractors have employees and have workers'comp.ursurance.t 13•�Roof repairs 6 Cl We are a corporation and its officers have exercised their right of exemption per MGI,c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required] ------- -- *Any applicant that check box#1 most also fill out the section below showing their workers'carnpensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating Contractors that check tris box must attached an additional sheet showing tilt,name of the sub-contractors and state whether or not those entities hz;e employees. If the sub-contractors have employees,they must provide their workers'comp.policy nrunber. Taln an employee that isprnvidinn wor information. kers'compensation insurance for illy employees. Below is thepolicS and job site Insurance Company Name: f ;; { t�t✓ -- 1 ------------------ Policy#or Self-ills.Lic.#: Expiration Date: Job Site Address:_ -� '�� � ti -- _ City/State/Zip: Attach a copy of the worket��OlnellsatiOtl cpolicy declaration page(showing page the policy number and expiration date). Failure to secure coverage as required under]�IC;I,Cl. 152, §25A is a criminal violation punishable by a fine up to.S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER.and a fent; day against the violator.A copy of this statement may be forwarded to the Office of Investi�, °f tip to 5250.00 a coverage verification. ations of the DIA for insurance I do hereby certify under t1le pain a d penalties of peijucy that the iilfor•matiorl provided above isIr .and correct. Signature: c , , Q c --- � S Phone#_-- I - Official use only. Do not write in this area,to be completed by city or town official -- City or Town:_ ----- Perrrlit/License# _ Issuing Authority(circle one): — ------- 1.Board of Health 2.Building Departulent 3. City/'Town Clerk 4. Electrical lnspectur. �. Plumbing Inspector 6.Miter Contact Person: _ ---- . --- --- Phone#: ''7/01/2015 09;21Neil & Neil Insurance Agency (FAX)14137316629 P.001/001 . r ACM CERTIFICATE OF LIABILITY INSURANCE °A07101/2o 5 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 AFFORD90 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 pollcy(les)must be endorsed. If SUBROGATION IB 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 e. CONTACT PRODUCER NAME, David Jarry Neill&Neill Insurance Agency Inc PHONa (413)732-4137 1 FAX (413)731-8829 662 Riverdale Street Weal Springfield,MA 01089 AAN&6 5 °1 IN R,.. AFFORDING COV91RAOL4 NAIL N a E State Auto Insurance Company STA INSURED Michael Farelll Electrical a Acadia Insurance Co; 31326 9 Applewood lane Methuen,MA 01844 N INSURER F t 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 INDICATEO. 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.Avw� INSR npH OF INSURANCE POLICY NUMORK M I M LJMITe A GENERAL LIABILITY SOP2745517 0611012016 08/10/7016 EACH OCCURRENCE s ,000,000 COMMERCIALGENERALLIABILITY $ 80,000 CLAIMS-MADE �OCCUR MLO EXP An one croon b 5,000 PERSONAL BAOVINJURY $ 1,000,000 OENERALAOOREOATE $ 2.000,000 GEN�t.AGOREOATELIMIT APPLIES PER: PRODUCTS-COMa_OP_40t3 S 2,000,ODO POLICY P LOC i AUTOMOUILa LIABILITY ANY AUTO BODILY INJURY(PV Verson) S ALL OWNED SCHEOULID BODILY INJURY(Per eWdent) b_ AUTOS OS NON-OWNED S HIRFDAUTOSAUTOS UMBRELLA UAB HOCCUR EACH OCCURRENCE b } ax°esSLIAN CLAIMS-MADE A-00FROAT9 S � OEb RETENTION! S B -WORKERS COMPENSATION WC-20-20.OD1481.08 03120/2018 0312012D16 A U- I IOTH- AND aMPLOYKRS'LIAaILTY YIN ANY PAOPR1ETORIPARTNSR/1rX!CUYIVE NAA 9.L.EACH ACCIDENT t 100,000 OFFICYR/MSMBSR EXCLUDGDi 100,000 t(MandatcryIn NH) E.L.DISEASE-EA EMPLOYEE S (( w dascrlboundar 500,000 Q09E.L.DISCASE•POLICY LIMIT b DISCRIP71ON OF OPERATIONS I LOCATIONS I VKHICLES (Attach AOORD 101,Additional Remarks Schedule,H mora space la requlted) Faxed to., 978-682-1480 CERTIFICATE HOLDER ! CANCELLATION SHOULD ANY OF TH8 ABOVE D68CRiB60 POLICIES HE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street,Building 20 ACCORDANCE WI E POLICY PROVISIONS, Suite 2035 . North Andover,MA 01845 AUTHORIZED REPRES TA 5 r r , Q 1988.2010 ACORD OCKPORATIONN4A rights reserved. ACORD 25(2010106) The ACORD name and logo are registered marks pf ACORID I ilii da Ril♦ 1 Ba-EMD 9N NyMBE .:. 2-.Q 2013 N6NE ns,` e 9/1PRL� ��A SNE G - �ETWQ FiA a�$aa•»o�, Cx OD,NOddaIJR e'07 fiJaa9 mill "ta y, 26Z'©z:rr r • L 1 . tti c 54N VOW ' tel�►Y�C. h �`}`f ���l���w� '"I�1 Ty��j•2�4S�S�A��((Y�� �1r JW}��u����.���� Si ''` t: , iV�x�)`�h*3���.�5����`ili 1.1�U111���7 �N,l.� $•3fla 7J " t , J