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HomeMy WebLinkAboutBuilding Permit # 10/13/2016 (2) NaRrH BUILDING PERMIT TOWN OF NORTH ANDOVER a APPLICATION FOR PLAN EXAMINATION Permit No#' Date Received " 2i aaareoR+ww ces A0 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROY OWIEF tut ant '10(31'..lea PERTPr c ure yes F i - MAP, PAf CEL. ZON11410'DISTRICT. _..__H3stbrc D3Stnct 'yds Maph(i i Sh6p Village yes TYPE OF IMPROVEMENT --TPROPOSED USE Residential Non- Residential ❑ New Building 0 One family [.1 Addition 9:]Two or more family 0 Industrial ❑Alteration No. of units: 0 Commercial ❑ Repair, replacement CJ Assessory Bldg C) Others: 11 Demolition Other In Septic 'D Well C7 Floodplain [I Wetlands 0 Watershed District G7 UVat �/ewer' DESCRIPTION OF WORK TO BE F'ERFC)RIUIED:��� ('70 Identification Plear Type or Print Clearly �'. 2 L OWNER: Name: Phone. Address: ,/ '�„ � � wm, a� w, p . Contractor Name- I I° o Phone: 07k S4L2 Email;',� .. Address; _C I L `�k , ' 77 �f ,, f , Siaperuisor's Conistrueti®r3 License: Exp; Date: q I e , IHome f3nprovernent License: Exp. ©ate, ARCH ITECT/ENGINEER w "�� � � � �' Phone: � �`�p � 9, 42 Address: 41V1( M) ✓., .” _ Reg. No. FEE SCHEDUL :BULDt GPERMIT: 1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$725.00 PER S.F. Total Project Cost: $ m � FEE: $ Check No.: Receipt No.: / NC)'I'E: PasvAx.s coaltrc'cti vitXa erre cste�°ecX cvaat.rc�ctvrs donotIi�rrfexcces toae gacrrcrnarnct Signature of Agent/Own Signature of contractor °RTH Town of 2 ? :aT ndover 0 No. # 2 h o -A�E h ver, Mass, 13 zoZ6 I� cocNus4v--'K '' S U BOARD OF HEALTH Food/Kitchen PERMIT T. LD Septic System THIS CERTIFIES THAT ..O. � ,.... .....".c...... � BUILDING INSPECTOR has permission to erect .. buildings on . * ... j .T�. Foundation ................. ..............,,........,... Rough .... ..... ..... ............. ............. ................. to be OCCUpi@d as . .... . � .......... .... .. . . .., ... .. ......, .. Chimney provided that the person accepting this permit shall in every respect 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 Rough VIOLATION of.the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRA;QTION S Rough Service ...... .... Fina] BUILDING PEC R GAS INSPECTOR Occupancy Permit Required to Occupy Buildin 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 Approved by the Building Inspector. Burner Street No. Smoke Det. ........ ......... . -........._......................................... Pians Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ 8wimming 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 PLANNING & DEVELOPMENT Reviewed On Signatures COMMENTS P61 &-UJ cj& �"v1 U( G 0T� cb-VA CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature& Date Driveway Permit DPW Town.Engineer: Signature: Located 384 Osgood Street RE DEPARTMENT Temp Dem FIpster on site yes no 9 � � Loca#ed at 124 Main Street Frre Department signature/date COMMENTS. MERIDIAN ASSOCIN.rES VIA EMAIL: dbeLqV&r(i 110MUT-11"Iff k September 22,2016 Mr. Donald Belanger Inspector of Buildings Town of North Andover 1600 Osgood Street, Building 20,Suite 2035 North Andover, Massachusetts 01845 Re: NEWTS Dear Mr. Belanger: NETTTS(New England Tractor Trailer School)currently operates its business at 1600 Osgood Street. Its current operations include indoor classrooms and office space and field training within the western parking lot. NETTTS is proposing to relocate its current field training operations which consists of two(2) separate training courses. One(1)course is proposed in the north parking lot and one(1)course is proposed within the southern parking lot. Per the Site Plan Approval Dated 9/21/16,all work except the relocation of the mobile classroom trailer will be called Phase 1,consisting of striping,placement of concrete blocks and traffic cones,signage, and catch basin inserts. The future placement of the mobile classroom trailers will be referred to as Phase II, No changes to any interior space is contemplated or requested at this time and no indoor activities are proposed to be moved outdoors.The proposed mobile trailers in Phase 11 that I discussed with you have been removed from consideration at this time and should not be considered a part of this application. Phase 11 is not part of this application. Phase I is a proposed leased area of approximately I 16,500sf located in the north parking lot adjacent to and west of the existing ball field and 118,400sf located in the south parking areas adjacent to the boiler building.The leased area will be delineated by a combination of rigid barriers and moveable barriers such as traffic cones. The training course within the leased areas will be laid out using traffic cones. No construction activities of any nature are proposed and no structures are proposed for Phase 1. The entire north parking lot contains 1094 parking spaces.The combination of the existing tenanted driving school and the proposed NETTTS north parking lot leased area will make 1054 parking spaces tenanted and unavailable. Forty(40)parking spaces will remain available.The south parking lot contains 497 spaces,all of which will be occupied by the NEWTS leased area. .500 C'ummings Center,Sim 5950 Beverly,Musachusetts 01915 P�(978)299.04,47 F:(978)299-0567 www,i-neridiaf),�5,soc.coni Thank you for our consideration and please feel free to contact me with any questions. Sincerely, &AAA MERIDIAN ASSOCIATES,INC. RICHMARD WA17TDJF;L CIVIL lllell6lle--?!� No.34778 Richard E. Waitt,Jr. AL Principal ►►o" '"+ [l;15723_07z.y-NorthAndovcr1ADMIN\I-ctter.s.Memos\f 5723113etanger(2016-09-2]).doe Enclosures cc: Dan Leary 2 Bk 14831 Pq 130 I-OW-26954 10-12-2014.E & 09 = 37cx NORTHERN ESSEX REGISTRY OF DEEDS ,4 division of the Secretary of the Commonwealth A luau]1=uccillo Register D 0CUM11"iI L COVERSHEET For use with documents that do not meet .Document formatting standards This is the first page of this document—Do not remove PRINT OR TYPE DOCUMENT TYPE, N-UMBER OF PAGES (including cover sheet) ((� TOWN: PROPERTY ADDRESS: I I I INDEXING SMALL BE ABSTRACTED FROM THE DOCUMENT SUBMITTED w ORTH Bk 14831 Pg131 #26954 O� �4eo E�Ati This is to oar . that twenty(20)days y PrP 1 r f_�.r';Y'S r ' Y � i ,r ,• b haus elapsed from deka of doctsian,filed S " H« Without Ming of an appeal. °C Ja `ap11ATEa urs � 2016 SEP 2 1 Afr t59oyoa A. awsc - Town 01ork ► ` ''N ar v�]"i� „ PLANNING DEPARTMENT Community Development Division 1.600 Osgood Street North Andover,Massachusetts,01845 NOTICE OF DECISION-SITE PLAN REVIEW Any appeal shall be filed within(20)days after the date of filing this notice in the office of the Town Clerk. Date: September 20,2016 Searing Dates: September 20,2016 Decision Date: September 20,2016 Petition of: New England Tractor Trailer Training School(NETTTS)of Mass.,Inc. 1570 Osgood Street North Andover,MA 01845 Premises Affected: .1600 Osgood Street and 0 Osgood Street Assessors Map 34 Parcel 17 and 54 The above petition for Site Plan Review is according to the requirements of the North Andover Zoning Bylaw, Sections 8.3, 10.3,and 10.31 and MGL c.40A,Sec.9. This petition is to allow the relocation of the New England Tractor Trailer Training School (NETTTS) driver's training course to approximately 5.4 acres of land adjacent to existing parking areas to the south and north of the main building in the Industrial 2 Zoning District. Amer a.public hearing given on the above date,and upon a motion by L.Rudnicld and 21d by P.Boynton to APPROVE the Site Plan Review-Special Permit as amended and based upon the following conditions.Vote was 5-0 in favor of the application. On be f of the North over Pianning Board John Simons,Chairman Lynne Rudnicki �t�vd�;�ello€ig Lora ii,M Shertj_ Peter Boyntnt) .ATTEST: A True Copy Bk 14831 Pg132 #26954 1600 Osgood Street Map 34,Parcel 17 and 54 NEMS Relocation-Site Plaza Review The Planning Board herein APPROVES the petition to allow the relocation of the New England Tractor Trailer Training School (NETTTS) driver's training course to approximately 5A acres of land adjacent to r existing parking areas to the south and north of the main building in the Industrial 2 Zoning District. The a project is located at 1600 Osgood Street and 0 Osgood Street, North Andover, Massachusetts, 01845, 1 Assessors Map 34,Parcel 17 and 54. The application was filed with the Planning Board on August 22,2016 + The public hearing on the above referenced application was opened on September 20,2016. The Applicant 1 submitted a complete application,which was noticed and reviewed in accordance with Section 8.3, 10.3, and 10.31 of the Town of North Andover Zoning Bylaw and MGL c.40A,Sec.9. The Planning Board makes the following fmdings as required by the North Andover Zoning Bylaws i Section 8.3, 10.3,and 10:31: PERII'IIT DEFINITIONS I) The "Locus" and "Parcel" refers to the 125.69 acre Parcel and 31.34 acre of land with land fronting on Osgood Street as shown on Assessors Map 34, Parcel 17 and 54, and also known r 1600 Osgood Street and 0 Osgood Street,North Andover,Massachusetts. 2) The "Plans" refer to the plans prepared by Meridian Associates, 500 Cummings Center Suite i 5950,Beverly, Massachusetts 01915, entitled"Osgood Landing 1.600 Osgood Street(Route 125) j NETTTS Site Plan located in North Andover, Massachusetts", dated August 19, 2016 and last t revised September 15,2016. 3) The "Project" refers to the relocation of the New England Tractor Trailer Training School l driver's training course to approximately 5.4 acres of land adjacent to existing parking areas to r the south and north of the main building in the Industrial 2 Zoning District. 4) The "Applicant" refers to New England Tractor Trailer Training School (NETTTS) of Mass, Inc., 1570 Osgood Street,North Andover,MA 01845,the Applicant for the Special Permit- Site i Plan Review,its successors and assigns. 5) The"Project Owner" refers to the person or entity holding the fee interest to the title to the Locus t from time to time,which can include but is not limited to the Applicant developer,and owner, FINDINGS OF FACT 6) Because of the unique nature of the Locus the specific Locus is an appropriate location for such a i use, structure, or condition; 7) Because of the unique characteristics of the Locus the use as developed will not adversely affect 1 the neighborhood; 8) There will be,no nuisance or serious hazard to vehicles or pedestrians; 9) Adequate and appropriate facilities will be provided for the proper operation of the proposed use; 10)The use is in harmony with the general purpose of the Zoning Bylaw; 11)The Plans reflects extensive discussions with Peer Review Consultants and Planning Department,I 2 Bk 14831 Pg133 #26954 WX 1600 Osgood Street Map 34,Parcel 17 and 54 NETrrS Relocation-Site Plan Review and Applicant with respect to parking,site design,and stormwater management. 12)The stormwater management plan has been reviewed by the Town's outside stormwater peer review consulting engineer, Eggleston Environmental, The Applicant has altered the original design to provide improvements to the existing stormwater drainage system. These include: adding the installation of Eliminator Catch Basun Oil and Debris Traps to certain catch basins, Flexstorm PC Plus Pure inserts and inlet filters with PC l+lexstorm Filter Bags to certain catch basins, updating the Operations and Maintenance Plan (O&M Plan) to include inspections and maintenance of catch basins, the Eliminator, and catch basin inserts, fueling protocol, spill reaction, vehicle maintenance, and parking lot sweeping. (See email correspondence from L. Eggleston,Eggleston Envirournental,dated September 8,2016 and September 2,2016). 13) The plan reflects discussion with TEC,the Town's civil peer review consultant. All concerns were satisfactory addressed with the exception of items deferred to the Inspector of Buildings regarding ADA access to the adjacent ballfields. (See letter dated.September 15,2016 and email dated September 16,2015 from E.Gerade,P.E.). 14)The Inspector of Buildings,ADA.Representative,has deemed the two new handicap parking spaces,3'wide pedestrian access way and hashed crosswalk to satisfy his ADA review and as safe for pedestrian access to the ballfields;however an appropriate ADA access way across the island connecting the crosswalk to the parking area is required.(See email correspondence from the Inspector of Buildings dated September 8,2016). 15)Moveable,rigid concrete safety blocks will be used to provide a separation from NETTTS active use area from the ballfields and the driving school identified on the Plans.The access way created to the west facing ballfield gate will be strictly for emergency access to the fields,maintenance access to the fields,and ADA access to the fields.This access way is not to be used for other pedestrian access. The ballfield's primary pedestrian access shall be via the south facing gate. 16)The North Andover Fire Department reviewed the Plans and determined there are no concerns over adequate access for firefighting and rescue operations. (See email correspondence from Lieutenant Robert Bonenfmt dated September 15,2016). 17)NETTTS and the North Andover Soccer Association(NASA)have had conversation regarding the hours of use and the possibility of a stray soccer ball entering the NETTTS area.The protocol will be for the ballfield users to implement an"abandoia the ball"policy and forbid any retrieval of a ball within the NETTTS operation area.Signage instructing authorized ballfield players and visitors to avoid retrieving a ball over the fence shall be displayed. 18)The west facing gate located between the NETTTS area from the ballfields will be locked.A designated NASA(or authorized ballfield user representative)member will have the ability to open the gate as necessary for ADA access. 19)The Applicant has submitted parking space data,"Parking Spaces NETTTS Temporary Relocation",that indicates 2,235 parking spaces will be available for use on the Locus. According to current tenant calculations the site requires 1,610 spaces. 20)A portion of the Parcel is subject to a Notice of Activity and Use Limitation(AUL). This portion is show on a plan recorded with the North Essex County Registry of Deeds as Plan No, 15939. The applicant will contract with Golder Associates to oversee construction activities as the Licensed Site Professional(LSP),if applicable. 3 Bk 14831 Pg134 #26954 1600 Osgood Street Map 34,Parcel 17 and 54 NETTTS Relocation-Site Plan Review WAIVERS The installation will be constructed according to the Plans,with the following waivers granted by the Town of North Andover Planning Board,according to the provisions of the Town of North Andover Zoning Bylaw. 21)The Applicant requested a waiver of Section 8.3.5.e.vii-SURVEYOF LOT"/PARCEL.•A boundary survey conforming to the requirements of the Essex County Registry of Deeds Office. The survey shall be dated and include any revision made to the survey or site plan.Any change in the survey shall be recorded before site plan approval may be granted, The Planning Board found that all applicable buildings are shown on the Record Condition flan and granted the waiver. Finally the Planning Board finds that this project generally complies with the Town of North Andover Zoning Bylaw requirements as listed in Section 8.3.5. Upon reaching the above findings, The Planning Board approves this Site Plan Review Special Permit with the following conditions: SPECIAL CONDI'T'IONS 22)Any revisions to the approved Plans shall be submitted to the Planner Director for review.If these revisions are deemW substantial, the Applicant must submit revised plans to the Planning Board for review and decision. 23) Should a relocation of the NETTTS operation be proposed in the future the Applicant shall apply for a Modification to the Site Plan Review-Special Permit through the Planning Department. 24) The protocol shall be,for authorized ballfield users, to implement an"abandon the ball" policy and forbid any retrieval of a ball within the NETTTS operation,area. Signage instructing ballfield users and visitors to avoid retrieving a ball within the NET 7S operation area shall be displayed. 25) The Applicant shall install additional rigid barriers on the easterly side of the north parking lot, abutting the fence,to the north of the temporary shelter to provide a barrier between the playing fields and active truck maneuvering area. 26)Upon installation of perimeter barriers on the northern training area the hire Department shall conduct a site visit to ensure adequate ballfield accessibility for firefighting and rescue operations.if necessary,barriers shall be shifted to ensure proper access. 27)Per the Inspector of Buildings email reference in Finding of Fact#14 an appropriate ADA access way across the island connecting the crosswalk to the parking area is required. 28)One of the recently striped accessible parking spaces shall be re-striped to provide a van accessible space. 29) Signage for accessible parking spaces(R7-8,R7-8A)and the crosswalks(WI 1-2,W 16-7pL)shall be installed. 30)All signage requirements referenced in TEC letter dated September 15, 2016, with Applicant responses included,shall be approved by the Planning Department prior to installation. 4 Bk 14831 Pg135 #26954 1600 Osgood Street Map 34,Parcel 17 and 54 NEWTS Relocation-Site plan Review 31).All stormwater management best practices shall be maintained as specified in the final NETTTS Stormwater Operations and Maintenance Program for Existing Stormwater Management System located at 1600 Osgood Street, North Andover, Massachusetts dated September 15,2016. 32)The use of coal tar based pavement sealants is prohibited with respect to the Project due to the high levels of polycyclic aromatic hydrocarbons(PAHs)associated with these products. PRIOR TO THE ISSUANCE OF A BUILDING PERMIT 33)A detailed plan concerning the relocation schedule shall be submitted to the Planning Department staff for the purposes of tracking major milestones and project completion. 34)The Notice of Decision and Plans must be recorded by the Applicant at the Essex North Registry of Deeds. 35)Two (2) copies of the signed, recorded Decision and Plans must be delivered to the Planning Department. 36)A bond in the amount of five thousand dollars($5,000)shall be posted for the purpose of insuring that the Project is constructed in accordance with the approved Plans and that a final as- built plan is provided,showing the location of all applicable Project structures. This bond shall be in the form of a check made out to the Town of North Andover. This check will then be deposited into an interest bearing bond account. 37)If applicable, the Applicant shall provide the Planning Board with copies of permits, plans and decisions received from all North Andover Boards. PRIOR TO THE ISSUANCE OF A CERTIFICATE OF OCCUPANCY 38) The Applicant must submit a letter from the project engineer stating that the site layout substantially complies with the Special Conditions stated in this Notice of Decision and the Plans referenced at the end of this decision as endorsed by the Planning Board. PRIOR TO THE FINAL RELEASE OF ALL SECURITY AND ESCROWED FUNDS 39)The Applicant must submit a letter from the engineer of the project stating that the Project construction and layout substantially comply with the Plans referenced at the end of this Decision and any and all amended,approved Plans as endorsed by the Planning Board. 40)The Applicant must submit a letter from the engineer certifying that the lighting provided properly illuminates NETTTS on both the northern and southern operation areas as well as the western perimeter roadway and that the lighting meets minimum Illuminating Engineering Society (IES) standards for the Project area. 41)A final as built plan showing the location of all Project utilities, structures, parking spaces and drainage facilities, including invert elevations of all stormwater structures, within the Project areas of work must be submitted to the Planning Department. The as-built must be provided in paper form as well as in SDF(Standard Digital File)format. 5 Bk 14831 Pg136 #26954 1600 Osgood Street Map 34,Panel 17 and 54 NETTTS Relocation-Site Plan Review 42) The Planning Board must by a majority vote make a finding that the Project is in conformance with the approved plan. GENERAL CONDITIONS 43) The contractor shall contact Dig Safe at least 72 hours prior to commencing any excavation. 44)No open burning shall be done except as is permitted during burning season under the Fire Department regulations. 45)If a dumpster is required once the construction is complete,the owner shall apply to the Board of Health for the appropriate permit. 46)The provisions of this conditional approval shall apply to and be binding upon the Applicant, its employees and all successors and assigns in interest or control. 47)Any action by a Town Board, Commission, or Department, which requires changes in the Plans or design of the Project, as presented to the Planning Board, shall be subject to review by the Planning Board. 48)This Site Plan Review-Special Permit approval shall be deemed to have lapsed after September 20, 2018 (two years from the date permit granted), exclusive of the time required to pursue or await determination of any appeals, unless substantial use or construction has commenced within said two-year period or for good cause. For purposes of this development,the developer shall be deemed to have undertaken substantial use or construction if any trailer and/or truck equipment is relocated from its existing area. 49)The following information (as may be amended as conditions of this Decision dictate) shall be deemed part of the decision: Plan titled: "Osgood Landing 1600 Osgood Street(Route 125)NETTTS Site flan located in Forth Andover,Massachusetts" Prepared for: New England Tractor Trailer Training School(NETTTS)of Mass.,Inc. 1570 Osgood Street North Andover,MA 01845 Prepared by: Meridian Associates 500 Cummings Center,Suite 5950 Beverly,MA.01915 Scale: 1"=40' Date: Dated August 19,2016,last revised on September 15,2016 Sheets: 1-2 Report: NETTTS Operations & 11 Wntenance Program for Existing Stormwater Management Systema located at 1606 Osgood Street, North Andover, Massachusetts Date: August 19,2016,Revised to September 15,2016 cc: Town Departments Applicant Abutters 6 F"LEXSTORN P/Ns 62mDFx 6 62MHDPxP �e.vee,rrro sa v¢mccr�r m Tm tm..strr carat s 7 $Wn r_x ;; THF 4 CATCH RASPY r'. 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" 4 - ar,,,wc�i�uc .Y..W ar.r arsmr ' .,_ ;. ..�t -r f• a an aw ........,.....�x.rrcHv.vrnr / / � —�MMawKC.Rf YLp�rrsEl AG a[Ra.� • ' - - ,,iy y4 1<, / - ¢ vn7rrrur ro-rw.r r _ w« -r/, pC � 423` �Y.i 4 - �"�'`�0 ' 4 ` 1 _ •3 - �f—Kw C� r<wwawu rav:ams •� ` 1�� \ /, .mow' - _ 2 3`4 f:3 _yrc O o•.mr,Mw�ur .a cm vu.u.r mcc r r ;� ��'S -4}�;._: � _ 1 / ` \ -. v�ic•T- '`r�srs+ rs n.rc..mw wr r ✓r / / ! //� %, 1, S...1 - �, - '^moi CRAPM'C SCALE start:Y-rm' Ip PHASE.A AWN PANAW COT FEET am W KE7FRS a a�e a b rx NOW?TO OPERAAON ANF MAMENANCE PUN 17A7ED SLP7EMHCR 2 2076 OSGOOD LANDING" 1600 OSGOOD STREET (ROUTE IRN to t r•rc a..wra a7w rrwra�..o aau ra.- NETTTT�BmP�PLW {4 �l" rtcasarcn<rn.arzrrs.a.ura�rnww+crrosrawnan. NORTR ANDOVER MAS'.`s'/tiCHVSE,T 2 o c ro-oe ppv.e er a a.rrw yo raa J (ESSEX L1atlNm A� FRL(rAR£D IVR 3 rn+tcnar..auwm+.wnvdmraws ncmmnrsrr 4 Ir NETTTS woo xm000:m7rr rcc 'REWS0�'"�' sera-.r'..W' 04MsP.pTexe2R a tore Tt � xOaM aWHMr,✓r.1�YYA'Iq O:r4 MEIDiAN N ASSOCIATES � ow:.r.en�vtnx.ptirryas.sr,o-rmspv. 517 Na. l 0211 1 PROJECT Nv. 5723 j Ln byte commonwealth of Massachusetts Department of IndustrialAccidents M . =: u Y Congress Street, Suite 100 tl Boston,MA.02114-2017 qr Www.mass.gov/dia d^ si -Workers' Compensation Insurance Aff1davit:Builders/ContaactarslElectriciauslPXWors. TO BY,FIGUDW1kTHTM�Tr" WTTINaAUTHORITX B. -Please Print Legibly A licantlnfor•:mation Nam(,,(Business/Orgmzationl.Individual): Address: S Phaae#: City/state/Zip: _,a.; . pP g Type of project(required): Are you an emgloyex?Check trio a z o xiate box: em to ees full andlor art time)-- 7. ❑N&O'donstruction 1�I am a employer with__......-_ p ( P 2.0 I an a sole proprietor or partilorshig and have no empleyces Working for mo in S• ❑Rernadelh�g any capacity.[Noworkers'comp.insurance required.] 9. Demolitio. 3.0 I am ahorneowner doing all workmyseli~[No workers'comp,insurance required.)' 10❑Building addition 4.[:]I am a homeowner and will.be hiring contractors to conduct all work on my property. I will I1 E]ectrical repairs or additiorrs ensure that all,contractors either have warkers'compensation insurance or are sole re ajrg or additions proprietors with no employees. Plum. g P 5.0 I am a general contractor and I have hkedthe sub-contractors listed on the attached sheet. I3. Rbofrep al is These sub-contractors have employees and have workers'comp.insurance. i4�Othcr�G.�A'�`���'`�' 6.❑We are a corporation and it,offiicer.s have exercised their right o£exemption perMeL c. bb�� employees.[No workers'comp.insurance required.] 152,§1(4),andvle have no *Any applicantthat checks bbt#1 must also fill out the section below showingtheirworkers'compensation policy ir,fermation. Iioineowners who su6mit•this affidavit indicating they arc doing all work and than hire outside contractors must submit anew affidavit indicating such I oluactors that check flus tso must attached an additional sheet showing the name of the sub contractors and state whether or}lot those;entities have employees. Ifhe sub contzactozs have erriployees,they must provide their workers'comp.policy number. x ane an employer that is providing warkers'compensation insurance for°my employees. Below is the policy arzd}ob site information. fusuranee Company Name: ExpixationD06,: }� 7 Policy#or Self-ins.Lic. — !� ,L City/State/zip: } Tab Site Address: l hp Job Site a copy of the worlters' compensation polley declaration page(showirtg tlae policy number arzd expir tion date). Att nal olation Failure to seeuxe coverage as requrz well as penalties in the farm of a Sx P1�10��ORDERiand a finef p to $250.00 a and/or one-yeax hnprlsonment as w dagainst the violator.A copy of this statement tray be forwarded to the Oflc0 of Investigations of the DTA for insurance ay coverage verification, I da herelty c tify nd t1 az ndpenalties ofperjury that the information provided alcove is trre and correct Date: j Si lature: Phone#: Official use only. Do not-w"te ire tl:is area,to be completed by city or town official Permit/License 10 City or Town: Issuing A utho?•ity(circle one): i 1,guard of Health. 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbinglnspector 6.Other Phone#- Contact Person: i ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDfYYYY) `.� 6/1/2016 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(les) 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 Mi NAME: chael Laorenza MTM Insurance Associates PHNE"19. E (978)681-5700 arc No: (978)681-5777 1320 Osgood Street MAIL certificates@mtminsure.com A❑DRE$$; INSURER(S)AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURER A:Nautilus Insurance Cpm an INSURED INSURER B Martford Accident & Indemnity 22357 PowerOwners, LLC, DBA: Attn: Dan Leary INSURER C: 857 Turnpike Street INSURER D: Suite 233 INSURER E North Andover MA 01845 INSURERF; COVERAGES CERTIFICATE NUMBER:15-16 & 16--17 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD'SUER POLICY EFF POLICY EXP LTR ❑ POLICY NUMBER MMIDDNYYY MMIDDfYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR H RENTED 100,000 PREMISES fEa occurrence $ BN961699 1/14/2016 1/14/2017 MED EXP(Anyone person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY J PRO- LQC PRODUCTS-COMPIOP AGG $ 2,000.000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ AL OWNED SCHEDULED BODILY INJURY Per eccitlent AUTOS AUTOS ( ) $ HIRED AUTOS NON-OWNED PROPERTYDAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MAGE AGGREGATE $ OED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ 100,()00 S OFFICERIMEMBER EXCLUDED? {Mandatory In NH) D$WECCL7124 1/10/2016 1/10/2017 E.L.DISEASE-EA EMPLOYEE $ 100,000 ifyas,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ozzy Properties THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1.600 Osgood St ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE M Laorenza/LAURIN f ©1986-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 f2014D11 nt Of public \ m Pa \Massachusetts \ EAaaA\ /s as ¥emmi� §"! ~ License: CS-093806 e ,(,)nstfucjj,)n s,peMsW \ JIAI kL III Erm P L ARY \±�: VFR S_ H ",)v M \ _ Ey,pirati0K 11121r#mg Com, Is&9 r