Loading...
HomeMy WebLinkAboutBuilding Permit # 3/9/2016 OORTH ' BUILDING PERMIT ��®� `ED 3g �oL TOWN F NORTH ANDOVER ® ' -® � APPLICATION FOR PLAN EXAMINATION my lf Permit NO: Date Received 4 •- a ,. X99 a°Rano PPPy•(� Date Issued: 6 SSCHu'S�� IMPORTANT Applicant must complete all items on this page .� ,:� ,%rtr / «<F �'S'`f ,:,s.� Icf, ? r?.:,,r .r.'✓`.f�f,. r'r:. ,. .lf Ce �, ,:.r r./lc>.r r� rs �l ,',,,� �//��„r}' ,tet;,' r / v,,;,,. nrr "ji C,l r ".r ''.�'�f..i,; r,-� 2r �.✓,yFdt a, . . - ' b dkr,-s..,Y�;�2 ���:�. .<s�i,S'�P:s�':�:4, .tSr.,.,. ,,r'sl` '"J'r �/�/�.r ., ,. ,,.,, ,, <f t, r%�`/ ... 'if�� 'f„��.T,F,li'�f<'>�'"� f r�,,r, ✓ �,y +' .3 rJ � � P�'�,���r� "1� .��1Gld Y� ''r 6% Yfi,/`Y�'%1kF r�l�fN i �/ f x !�. ✓�� / ,�� ,r 9 s �'::s,t r v� S � f� 'tf e� � y f'� ,� ; �; ��s,lrr y '�f.� ,;p F 1�� rf��rpt In y'. ,+: ,q fo-' 'si f.. / u/.r r,,..?, f r ,,,,r/. �-�.���1 rY �a r6.� ..�/✓`."0 ,✓ , ,,.(�.t t�r N.� ,,. l'f w� "ter r. .,< ,, m. ,P'r ,<,r a r�� /."r ,;.,r y ':y ?^ ✓/t�Il ✓ :..r'n 6 �, rr�`r.,.r .;/��.. r`� ,.L,. ,.:`/e,rr. utt "f �F,'r,'' -�1i 9`if;:,n3 � r l✓ yDr. z5F<o :f t, 6 fh�'!.l •;,`5. �r,��'r .. I �t,� 1J �����- :,�arlr, r�rs�, �.; .r a'�jt` �,r ty,i�' F aiw�yfr p�:`' <s, 1.�..:,.;.; �.r s ,;?.,;•.F. .',� ,<r rtr," �` �� `^=c�'l�.�f l�w';<�' '�� ��s .a�' tyF,�r J`y;:.. r� ��r.����^�'l,,,. 3,,�'rfs,ra�,� ;� $� r=•�r�rl-'-�:r...�;,;����Pr of r. ? ..jr .� , r .r” „ a' � .;✓'�f��j f 1`s s rr���1x-r:�;� r� �x '� �P R�,,r,<r,,,>r� �':.ryl�i' ' ,;',I�,`,,''.F,;�, ,•r'�t � �� � ��� r� f.'"f� ✓ �'✓r�.,Fa:f��zr�J�f��'�,�,f �' ?<�., ? "'tr?,It .<r r. .,✓.� I ../ r .1,,._ <.. F f / r r ._.,k, c`/, ,:r€...,r'r, ..r,,, ��r/.� �: ,,:�./�"* I ,�,. ,.,.�T f 't i .f„l,,r` r3r „ ,,<.. ,.r.f ._.r. �.✓ .,f,lr:l ,�., _,:�. / N r., r�,/,f v X rr-. ,'U�r :/'..a ry �'°�� .��rt.�� ,,a�rF ,.,�, ,: �r �i', %fr'z frL �"'IT�, ✓.. :,fir r' -..l. r<.,.` r. `� ,;s:.r` L , w"T, .... ->1 5�,r,... ,rpt r.5,,,...,:.,z,„r`-✓3 .F,, ,.,,,,,` i;..,,?�' r, ...>..d'�,r ��.'.,,any. r, r`',,:r::',�'fr� �. r/�rr',;;�,�;N r�/' vr..,.i , ?f r �� .,�<.�,fi,��,rrf"i,tLr<' ;-. ,�,> r -.: �,�r'��;� rvt �,. �1r,.q �. � f`�lrr�, ;.arm , d Y��f,,h:rl' ,✓-..., -../ �a- . ` �f lxl�fr*, :,lr l.,✓,=T.�. F„ �.f .�� � �r: 1 .,<,rf. �A., 1,....r/ Y �.:.:-/F /'w�'.,��r. 9 r/nJ: <,r,si.,{id l?✓r,�`� rr,,. r^, ,� r 1 c` r .r.,. , :r .� t L. ,,,.,;�,1,.sr ,, a„ r „� .,.-..,-r„. .�. ,�., F/'. rn✓'.. r<.. r..,r r, ,,: ,.� <,. „/,s rl.ls'%;1;,r�„ r r''f;�;'. r /� ar✓�' %✓r/I�r/.,.-E* x e Shap . iC n 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 90ther d Septic �7 Well r q Floodplain r6 Wetlands r tal,Watershed District r r t Yf1 :.'4. t/ /r3./'.• ..F-”✓'`f l .'fr ff / f r f Gl / �/Il i l r / 1 !' r:: 1 4/{ ,' Je 1 Identificcation Please Type or Print Clearly)� OWNER: Name: `a c� (-eA <` . k' Phone Address: a> 1&J� ia e .. rf_ A• Iy CONTRACTOR Name w t €� r Phone r r� r Address l e „ Supervisor's Construction License Exp Date' / t r Home Improvement License Exp Date r / ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /61 0 5- FEE: $ Check No.: 3 4)eil Receipt No.: �T—�-p," NOTE: Persons contracting with unregistered contractors do not have access to the gua Fan . and Signature of A-e, _Signature of contractor F t%OR H Town of L ndover s 0 LAKE versI.D9 COCHICKCWICK y1. I � U BOARD OF HEALTH f Food/Kitchen PERMIT I L D Septic System Aft �. THIS CERTIFIES THAT „�,�, � t.... BUILDING INSPECTOR has permission to erect ......................... buildin.II.I n ip;=... YY.. Foundation gs on �1 Rough to a occupied as . .. �. .. ........ .. .. chimney ..... .. ... .. ................................................................ provided that the person accepting this permit shallin every re ct conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 OT ELECTRICAL INSPECTOR ® L TIO R Rough Service ....................... ..... ................... ... .............. Final BUIL®IN INSPECTOR GAS INSPECTOR Occupancy Permit Required t® OccupV Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det, L�trt,j J1 F141 O-RP Ship-To(92) Street IU(rtSP1 V ;j �, 1 Street City N° 'Imo " City e-_— State i"vfi . Zip 01q> l _ \ State ip Contact Name: V I � 1� Contact Name: Telephone#: `�y � f Z Telephone 9: Fax#: Fax#: E-mail Address L -1C- FIkMe [A �, ; �r�, eta-ti E-mail Address Bill To Payer (Customer name where the invoice will be mailed if different from above) (Customer name who will ay the invoice if different from above) Admin Use SAP `SOLD TO' Customer#� SAP `SHIP TO' Customer#' SAP { r t QUOTE #t , ,e}E C { .�,' - - _ :1.5 'Ski :n•C� Y�f.v _ Job Number CM03 I Iq 1 )S Contract Amount NETVBOOKINFO SHEETINF off. {3�wJD Regional Sales Re i ,, .� Billable Rate 61 .9 S National Account RepPercentage �� .S2 Technical Rep Ltl.t� u f�it�d_i Payment Terms y3 q* -30 w44 &'11NMo AutoQuote # t> L Start Date AutoPro osal# I`>)S 1(,b Labors Hours Bid 1035 Tear off or NO Proposal Amount $ /�1 + Total Hours p3� Deck Replacement ' YES OReq Roof System Code —1P rZ� Scan YES or Deck Ty e wlar7� t*�{na r t� ��,; - 'Sy,431a �.�1�1° Warranty # Years Warranty Name 'I.5,V ar Zo Kar2•5 F'tMn�s (�I,,tM1w[, �diPo¢,�',�a 2,q,b ri 1,01y, Insulation Type � J SECTION Sp(! FT SYSTEM WARRANTY -346v a fit. it€ ��b P ' re 8 1� n I l i t alis .t 1 1 1 1 1 iii ti l t 1 1 it t o 1 til u u t tilt DEPARTNIENT FUNCTION REFERRAL '" 0001 Facilities Dept A 01 Site Contact _ CALL Call-In 0002 Purchasing Dept. 02 Purchasing Manager COLD Cold Call 0003 Sales Organization 03 Sales Manager GOOD Goodwill 0004 Maintenance Dept. 04 Personnel Manager HBID Hard Bid 0005 Administration 05 Billings Contact REFL Referral 0006 Roofing Department 06 Payer Contact NATL National Accounts 0007 Quality Department 07 Corp. HDQT Contact SERV Service 0008 Flooring Department 08 Office Contact STOR Stonn Damage 0009 Financial Department 09 Fin.Accounting ContactTELE Telemarketing - tRtgI ,� 0010 Legal Department 10 Marketing Manager TRAD Trade Shows I I Maintenance Person INDUSTP.Y TYPE: 13 Owner CUSTONIERTYPE al Manager (Use the SIC List on the Centranet) 15 plant 14 General N aver NN New National Customer 17 Plant Engineer EN Existina National Customer is Vice president N R New Re,inmil 5-2006 Page 1 of 2 1 a 4 ITIM MW MIN Job Number: Reference Number: MIN Name:Flame Laminating Corporation Name:Flame Laminating Corporation Address: 2350 Turnpike Street Address:2350 Turnpike Street City:North Andover City:North Andover State: Ma. Zip: 01845 State: Ma. Zip:01845 Contact: Eric DiGrazia Phone:(978)725 -9527 Phone: (978)725 -9527 Building(s)/Section(s):Sloped Roof,Lower Roof,Body Shop (approximately 26 572 s ft - I - Per Proposal Dated: CentiMark AP#195966 -Project will be committed NOW and scheduled on or before May V 2016.Emergency Roof Repairs will be performed NOW by CentiMark at NO COST to Owner to help mitigate roof leaks until project commencement in 2016. And/or as follows: On the Body Shop&Lower Roofs,Flame Laminating will be responsible for the Unit Costs of wet roofing/insulation damegd decking up to the first 10% (1,200 sq ft)If MORE than that needs to be replaced it will be done at NO ADDITIONAL COST to Ownership. Purchase Price: $161,125 Warranty to be issued in the name of- Purchase £Purchase PO#: 1.Flame Laminating Corporation Centimark Sales Rep:David Pineo 2. Office Location:#1800 Warranty Length/Yrs: 20 Years Total System Warranty Phone: (978)513 -3300 Payment Terms: 1/3 down-balance net 30 upon completion Purchaser to initial acknowledgement of Payment Te s: I Bank Name: Account#: Address: Contact: Phone: City: Trade References: 1.Trade Reference: Phone: Address: City: State: Zip 2.Trade Reference: Phone: Address: City: State: Zip 3.Trade Reference: Phone: Address: City: State: Zip Page 2 of 2 By my signature below,I certify that I have authority to bind the purchaser and have had the opportunity to review the terms of this Agreement, including those set forth on the second page. On behalf of the Purchaser, I understand and accept said terms and agree to be bound thereby; and acknowledge that a sample copy of the warranty has been provided for my review. I also authori the release of credit information to Centimark Corporation. Eric DiGrazia -Owner Approved and ac ' ped y PurcAa'ser Printed Name and Title Date SUBJECT TO THE FOLLOWING TERMS AND CONDITIONS ON SECOND PAGE INITIAL PAGE 1 05-2006 Page 2 of 2 This Sales Agreement confirms the purchase of the services and work described in the CentiMark Corporation Proposal to the Purchaser and the Sales Agreement. The Scope of Work is limited to what is stated in the Proposal and Sales Agreement. Unless specifically stated otherwise, the Purchase Price does not include the cost of performing the Work with union labor or at prevailing wage rates; nor does it include removal or abatement of any hazardous materials, including but not limited to asbestos. Purchaser acknowledges that it is responsible for obtaining any structural, engineering or other architectural analysis of the building(s) on which the Work is to be performed. Unless otherwise stipulated on the face herein, the Payment Terms covering this Sales Agreement are: One third (1/3) down payment with balance due net 10 days from invoice. In the event Purchaser fails to pay any balance when due; then the entire balance shall immediately be due and payable. A Service Charge of one percent (1%) per month will be added to all Balances past due thirty days. This sale is subject to credit approval by CentiMark and Purchaser hereby gives CentiMark express authority to check the credit references of the Purchaser. Any disputes or actions relating to or arising out of the Work to be perfonned pursuant to this Sales Agreement shall be exclusively governed by the laws of the Commonwealth of Pennsylvania. Jurisdiction and venue of any action or proceeding arising out of or relating to the Sales Agreement shall be vested in the state or federal courts in Washington County, Pennsylvania. Purchaser irrevocably waives any objections it now has or may hereafter have to the convenience or propriety of this venue. The performance of the Work contemplated by this Sales Agreement shall be governed solely by the Tenns and Conditions stated herein, and no other tenns and conditions, order acknowledgement or purchase order or any other documentation furnished by the customer shall be construed as an acceptance of any terms or conditions contained in such document which are inconsistent with the Terms and Conditions stated herein, unless accepted in writing by a Corporate Officer of CentiMark. The only warranty to be provided by CentiMark to Purchaser will be the CentiMark Corporation Non-Prorated Limited Warranty for the length of time stated on the face of this Sales Agreement, which terns and conditions shall govern all warranty matters between CentiMark and the Purchaser herein. To be valid, any changes to the Warranty must be specifically approved in writing by a Corporate Officer of CentiMark Corporation. NOTICE Purchaser acknowledges and agrees that Moisture may have entered into the building prior to CentiMark's roof installation and/or repair of the roofing system, which may have resulted in Mold Growth. CentiMark disclaims any and all responsibility for damage to persons or property arising from or related to the presence of Mold in the building. By executing the contract to which this Notice is affixed, Purchaser agrees to the following: 1) releases CentiMark from any and all Claims Purchaser and Purchaser's insurer, employees, tenants and/or any other building occupant or invitee may have as a result of such Mold growth; and 2) agrees to defend, indemnify, and hold harmless CentiMark from any and all penalties, actions, liabilities, costs, expenses and damages arising from or relating directly or indirectly to the presence of Mold on or in Purchaser's Building. INITIAL PAGE 2 05-2006 i �i kk tr� fi I .i i iii lukh v7 s:,a .�' J+'{i Vry41''� Vxi FI�tI n,I yr.. � ..i ll� I f l f} I it Ira 1 1 I r r l y i I z ham+` i �' �l; 0 ` a{�:}I I , I��� � 9�' ✓ �K4 � ^t��� � �ry{�II ,, I I�l��^'�� uy �ir�TA' M.M 4u' W1, l �'7� �jp M i � �Iru rl IitY/1d1? w{III M����+T{+4I��a+ � � {�` ��7 •r.l �,�'� r dk , CK WA� 1 .�� 16tky a Yk ,4E$ y�yyr�l � ,9tdr A v b�,N1pPr + om 6,4�VYY�`t4I�l y i..}�ggiC�,�t�Y� Ft rlh'ya�fdd� `�11 I�s� �^SrTq��igq+ n��. Construction i i o Flame Laminating Corp. 2350 Turnpike St North Andover, MA 01845 Speci 'cations For CeiitiMark RoofBond System V Sections included: Body Shop, Lower Roof,Pitched Roof Project Preparation: Perform a pre job meeting to determine jobsite logistics and safety requirements. Furnish and install temporary rooftop chute assembly for debris removal. Furnish and install proper safety equipment in accordance with Centimark's written safety program. Safety Related Furnish and install warning lines to identified areas associated with ground related roofing activities. Store roofing materials in accordance with good roofing practices. Material placement will be to distribute weight loads throughout the entire roof area. The power lines along the Body Shop must be blanketed prior to the start of roofing work. The blanketing of the power lines will be coordinated between the property owner and their service provider. Surface Preparation: Remove and dispose of EPDM roof systems down to the original B.U.R. The primary layer of roof will be spot cored for deteriorated/wet insulation. If any is found, it will be removed and replaced at a unit price of$1.25 per square foot per inch of thickness. Areas of removal will be approved by an Owner's representative. (Body Shop, Lower Roof Only.) Remove and dispose of the existing membrane. (Pitched Roof Only.) Removal of existing roof will be limited to an amount that can be replaced the same day. Inspect existing structural deck for deterioration. Identify and remove structural deck not capable of providing an acceptable substrate for the installation of the new roof. Furnish and install new deck at a unit cost of$8.75 per square foot. Areas of removal will be approved by an Owner's representative. The raised steel equipment supports will be cut up and removed from the roof. (Body Shop Roof Only.) Remove and dispose of all skylights, the openings will be decked in with two (2) layers of 1/2" plywood and the voids will be filled with rigid insulation boards. Remove existing perimeter drip edging and dispose of debris. (Pitched Roof,Body Shop Only.) Remove existing sheet metal copings and dispose of debris. (Body Shop, Lower Roof Only.) Remove existing wall flashings to a workable surface and dispose of debris. (Body Shop,Lower Roof Only.) CentiMark Confidential view instructional video Insolation Attachment: Furnish and install a layer of V polyisocyanurate insulation, (R-Value = 5.6), This layer of insulation will be mechanically attached to the prepared substrate utilizing FM Global(FM)approved 3" plates and fasteners. Along the transition between the pitched roof and the body shop roof, a layer of 2" ISO insulation and a layer of tapered insulation will be installed. The added insulation will allow water to drain more easily off the pitched roof. Furnish and install tapered insulation at the roof drains creating a sump. (Body Shop, Lower Roof Only.) System Application: Furnish and install CentiMark 60 mil reinforced,TPO roof membrane. Position the TPO membrane over the prepared substrate and allow the membrane sufficient time to "relax" prior to installation. Install the new TPO membrane over the prepared surface by utilizing mechanical fasteners on 10 foot centers. (Body Shop,Lower Roof Only.) C) Mechanical attachment of the membrane shall be done utilizing a V wide polymer batten bar or 2 3/8" round seam plates and FM Global (FM) approved fasteners. Maximum spacing 6" on center. (Body Shop, Lower Roof Only.) Install the new TPO membrane over the prepared surface. Secure the membrane in place by welding it to the plates utilizing induction methodology on 5' centers every 1 foot. The plates will be fastened to the roof purlins. This will create a roof assembly whereby no penetrations shall be made to the membrane! (Pitched Roof Only.) The thermoplastic membrane seams will be overlapped a minimum of 5", then hot air welded together. Weld width shall be a minimum of 1.5" in width for automatic machine welding. Weld width shall be 2" in width for hand welding. Upon completion of welding, each seam shall be probed to ensure proper securement. HVAC. Curbed Penetrations and Other Air Handling Unit Details (Body Shop, Lower Roof Only.) Furnish and install at the base of the unit 2 3/8"round seam plates to the field membrane. Adhere a second piece of thermoplastic membrane to the curb with bonding adhesive and install prefabricated universal corners for reinforcement. (Body Shop, Lower Roof Only.) Pipes Less Than 6" In Diameter (Pitched Roof Only.) Furnish and install new prefabricated thermoplastic pipe boot secured at the top with a stainless steel screw type clamp fully adhered to the field sheet. (Pitched Roof Only.) Stacks Greater Than 6" In Diameter (Pitched Roof Only.) Furnish and install a 60 mil, non-reinforced thermoplastic flashing,where applicable. (Pitched Roof Only.) Miscellaneous Projections Furnish and install thermoplastic flashings to the roof projections. Upon completion of welding, each seam shall be probed to ensure proper securement. (Pitched Roof Only.) Furnish and install thermoplastic flashings to the roof projections. Upon completion of welding, each seam shall be probed to ensure proper securement. (Pitched Roof Only.) Furnish and install at the base of the unit round plates to be mechanically attached to the deck and the around the perimeter of the projection. The membrane will then be attached to the plates via the induction welding process. Install prefabricated universal corners for reinforcement. (Pitched Roof Only.) Pipes Less Than 6" In Diameter (Body Shop, Lower Roof Only.) CentiMark Confidential `_:view instructional video Furnish and install new prefabricated thermoplastic pipe boot secured at the top with a stainless steel screw type clamp fully adhered to the field sheet. Stacks Greater Than 6" In Diameter (Body Shop, Lower Roof Only.) Furnish and install a 60 mil, non-reinforced thermoplastic flashing,where applicable. Miscellaneous Projections (Body Shop,Lower Roof Only.) Furnish and install thermoplastic flashings to the roof projections. Upon completion of welding, each seam shall be probed to ensure proper securement. Sheet llletal Accessories: Furnish and install new retrofit drain inserts into existing drains. (Body Shop, Lower Roof Only.) Furnish and install new 24 gauge white thermoplastic coated metal gravel stop/drip edge with continuous cleat. Standard Operating Procedures: Employee Professionalism All work shall be performed in a safe,professional manner in compliance with Centimark policy. Permits CentiMark will supply the necessary permits for the project. During permitting,the Town of North Andover may require the services of a certified professional.Any fees related to obtaining permit approval are not included in CentiMark's proposal. If the permit is purchased separately from the roof contract, CentiMark can submit all required documentation to secure the permit on the owner's behalf. Nightly Tie-In's Depending on new roof system being installed, temporary water cut-offs are to be constructed at the end of each working day to protect the newly installed roof system and building interior. Clean Un All work premises will be cleaned daily during the construction process and at the completion of the project. Job Acceptance and Punch List Conduct a post job walk through for final sign-off of our job completion form. Warranty Upon purchase of the roofing system, you become entitled to receive the benefits of single source responsibility through CentiMark's comprehensive written warranty. This warranty protects your roof against defects in materials or workmanship. If your roof leaks at any time during the warranty period, we will provide complete warranty service. Quote Name Section Name Length All Quotes. All Sections. 20 CentiMark Confidential (7) : view instructional video The Commonwealth of Massachusetts . ' F Department oflndustrialAecidents 1 Congress Street,Suite 100 - - d021142017 - Boston,MA o�t www mass.gow/dia Workers!'Compensation Insurance Aflxdaviit:Builders/Contractors/Electricians/1'lumbexs. TO BE FILED WITH THE PEPJ MTTINC AUTHORI�S. Blease Print Le 'bl A ••licant Information o Name (Business/Oxganization&dividual): Address: City/State/Zip: _r AAA Phone#: 11Y-L 7 � ' ...•;3 , Type of project()required): Are you an employer?Check the appropriatebox: with eal toes fll and/or parttime).' 7. []NdVdonstructlon 1. maemployer 2.E]I atn a sole proprietor or partnership and have no employees working forme in 8. Remo deliiig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[]1 am a homeowner doing all work myself[No workers'comp.insurance required]t 10 []Building addition 4,❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 11.E]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole PXumbing repairs or additions proprietors with no employees. 5.Q 1 am a general contractor and.have hired the sub-contractors listed ur the attached sheet. 13 0Roofrepairs These sub-contractors have employees and have workers'comp.insurance.t 14." Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),andwo have no employd9s.[No workers'comp.insurance required.] "Any applicant that check bokf1 irinst also fill out the sectionbelow showing theirworkers'compensation policy information: avit suolL i Homeowners who c b s r at attached an additional shee�showing the all-work name o£tl een hire usub-c sub-contractors and state whether or retside contractors must submit a now pot Phos indicating tContractors that the k employees. If the sub-contractors have employees,they must provide their workerscomp.policy number. rovidingworkers'compensation insurance for my employees. Below is thePO X am an employer that is pWY ala jo i site information. n f Insurance Company Name: 1 c�9 0 e Expiration Date: Policy#or Self-ins. elf ins.Lie.#:__l_.—_ ` ,�n Ll �Ogi.- J�(�� City/State/Zip: f V A t '6 Job Site Address: ' compensation policy declaration page(showing the policy number and expiration.date). Attach a copy of the workers'rkexs' by a flAb Up to Failure to secure coverage as required under MGL c.152,§25A is a cximiTOP violation ORDER punishaband a fine of up to $250.00 a and/or one-year imprisonment,as well as civil penalties in.the form of a S� day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. lties ofpeijury that the information provided above is true and correct X do hereby certify under t •epains andpen . - r Date: 3 3 J,04, Signafore: Phone#: 3 f official use only. Do not write in this area,to he completed by city or town official Permit/License## City or Town' Issuing Anthoxity(circle one): 1.Board of Health. 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person• CENTCOR-01 MUDALIARTA CERTIFICATE OF LIABILITY INSURANCE DATE(tdrA/DD/YYYY) 4/29/2015 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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: certificates@willis.com NAME: Willis of Pennsylvania,Inc. PHONENo (877) 945-7378 �c Ne: (888)467-2378 ry c/o 26 CentuBlvd AIC Ext: P.O. Box 305191 E-MAIL Nashville,TN 37230-5191 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Arch Insurance Company 11150 INSURED INSURERB:Zurich American Insurance Company 16535 CentiMark Corporation INSURERC: 12 Grandview Circle INSURERD: Canonsburg, PA 15317 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: .REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES.OF INSURANCE LISTED BEL— HAVE BEEN_ISSUED TO THE INSURED NAMEDABOVEFOR THE-P_OLICY.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. INSR TYPE OF INSURANCE DL S BR POLICY NUMBER POLICY EFF POLICY EXP LTR MM/DDIYYYY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g 2,000,000 CLAIMS-MADEF3qOCCUR 11PKG8900709 05/01/2015 05/01/2016 PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 5,000 PERSONAL BADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY a JECT a LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 2,000,000 A X ANY AUTO 11PKG8900709 05/01/2015 05/01/2016 BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS $ Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 B EXCESS LIAR CLAIMS-MADE AUC930387913 05/01/2015 05/01/2016 AGGREGATE $ 10,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER _ AND EMPLOYERS'LIABILITY YIN X I STATUTE I TI QERH A AN PROPRIETEREARTNERE ECUTIVE N/A 11WC18900609 05/01/2015 05/01/2016 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation Policy#11 WC18900609(AOS=All Other States except OH,WA, ND,WY which are insured through state funds), CERTIFICAT CANCELLATION 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 idence of Insurance 0 ©1988-2014 ACORD CORPORATION. All rights reserved. LORD 25(2014101) Tha A( C)Rn namp and Innn aro ronictora i m Lr -f Ar'rnDn PA assachusetts - Department of Public Safety Board of Building Rcgulaaons and Standards • t.Ci inti ii C'Ll i�ii Su7ci�liGi - License: CS-102083 DAVID M YOUNG` 15 GREAT HILLDRIVE r WEYMOUTH MA 02191, , ox Expiratio Commissioner 10/211201F: I