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Home My WebLink AboutBuilding Permit #313-2016 - 1-High street 3/13/2014 s �6p 9 z sNORTH ofTfpwS NoC BUILDING PERMIT , o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �o Permit No#: Date Received gSSACHl1`+�� Date Issued: MPO TANT:Applicant must complete all items on this page LOCATION G'f'� �� v �'� w �� y Print PROPERTY OWNER CS VL C_ " r� '�� Print 100 Year Structure yes no MAP PARCEL: _ZONING DISTRICT: Historic District s no Machine Shop Villagees no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition ❑Two or more family ❑ Industrial IK,Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ _ Ei _tip [ Well ❑ Floodplain ❑Wetlands ❑ Watershed District __p VVateewer DESCRIPTION OF WORK TO BE PERFORMED: car C-3 `t - Identification- Please Type or Print Clearly OWNER: Name: w�� S"►'�S w�?�- c� Phone: Address: V'A 7o \ � Contractor Name: �� W Ate--- Phone: Email: ti3 C, . �o Address: S .r t—z&_ `3 Of Supervisor's Construction License: �_'Z X33 l "" _Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER OrLl- '�_ WR 1'T'6kl— Phone: -L Address: 3"w B�✓� y �o r-G 0 /a J�L7 Reg. No. Q 3 FEE SCHEDULE.BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASEIP ON PER S.F. X h •� Total Project Cost: $ 4-J J — FEE: $� �/ � z1 7 Check No.: � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes I Planning Board Decision: Comments i Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street �FIREIE)F— sTMENTk-;Tern Dum'Qster�gn�site yes i p� i? , t,Locatedlat 1241.MaintStreet n �`_ � `"" -C®MMENTaS. nRTH 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 DAGGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Penuit 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) i6 Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 d is over. The applicant must then et this recorded at the Registry of Deeds. One copy and proof of recording that thea appeal period g PP P PP must be submitted with the building application Doc:Building Permit Revised 2014 ALocation Date j�.. 313 . - TOWN OF NORTH ANDOVER d Certificate of Occupancy r Building/Frame Permit Fee $ Foundation Permit Fee •�* ``` Other Permit Fee $ TOTAL $ Check# (> �. Building Inspector 04 NORTH,h 3?i<�a t.'•�t �SSACHOSf� CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 313-2016 on 9/10/2015 Date: October 20, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at I High Street MAY BE OCCUPIED AS tenant fit up— office space & redesign lobby IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG LLC NA Mills LLC 1 High Street North Andover, MA 01845 Building Inspector Fee: PrePaid$100.00 Receipt: 29335 Check : 2278 OO R Tht Town of �� ndover o - �+ h ver, Mass o coc 1C«ewrcw 1_ "S RATED r.P�`�.(5 U BOARD OF HEALTH Food/Kitchen PERM Septic System THIS CERTIFIES THAT . BUILDING INSPECTOR �......... .... -...............�A �'"r r� ��.....S�c l,�. ............ ... ................ has permission to erect uildings on Foundation Rough RW to be occupied as ......... ... .... Pesand . .......... ................................................... Chimney .�..... f.... L provided that the person accepti g this permit shatry respect conform to the terms of the application final on file in this office, and to the provisions of the Co 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rou C;4� �z S ................................ Service ............. �...n'r. BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. it Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 453595.00 m $ - $ 547.14 Plumbing Fee $ 68.39 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 68.39 Total fees collected $ 783.93 1 High Street - Entrance and Lobby 313-2016 on 9/10/15 Creat Office space and redesign lobby NORT11 own of ? . � E ndover h ver, Mass O COC KIc„l WICK y1• AP (5 s u BOARD OF HEALTH Food/Kitchen PERMT jirpC Septic System &o&.v D THIS CERTIFIES THAT �� BUILDING INSPECTOR ............�.�....... ... ........ ........!. ....�'�...�.... ................ .. .... Foundation has permission to erect .......................... uildings on ...�........ .. .... .. . �l► ...A....... Rough to be occupied as ...I......Min. . .*k&Aoe.... Pesand . .......... ................................................... Chimney provided that the person acce tl this permit shal respect conform to the terms of the application p p p g p rY p pp � Final on file in this office, and to the provisions of the Co 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 44'',� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ............. ' q ................................ Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Ruildinz 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. JK Contracting LLC Proposal 31 Richmond Street Weymouth, MA 02188 Proposal Date: 8/19/2015 Proposal#: 167 Project: Bill To: David Steinbergh, Sales Lobby,West Mill N.Andover, MA 01845 Description Est. Hours/Qty. Rate Total Plans and Permits 850.00 850.00 Demo, including gym seats, dumpster cost„ removal 5,200.00 5,200.00 and replacement of glass window,Temporary weather protection during demo. Wall Framing, Including soffits and blocking at 8ft 3,200.00 3,200.00 where glass panels will be installed,M&L Windows&Trim, Glass removal and reinstall, Glass 5,000.00 5,000.00 door install, Using all existing doors and glass from Basement space[Estimate] Electrical &Lighting, Demo of existing fixtures ,wiring, 5,000.00 5,000.00 etc[Estimate] Tel-data.{Estimate] 2,000.00 2,000.00 Heating &Cooling 0.00 0.00 Insulation 200.00 200.00 Interior Walls, Board and Tape,walls, soffits. 5,000.00 5,000.00 .Carpet install in lobby, Sand and refinish Pine floors 7,500.00 7,500.00 Painting, Including ductwork 5,000.00 5,000.00 Cabinets &Vanities 0.00 0.00 2,500.00 2,500.00 Supervision 4,145.00 4,145.00 Thank you for the opportunity to bid this work. Total $45,595.00 OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL PROJECT NUMBER: 14-0682 A PROJECT TITLE: West Mill Leasing and Sales Center PROJECT LOCATION: 1 High Street, N. Andover, MA NAME OF BUILDING: West Mill NATURE OF PROJECT: Lobby improvement/fit out IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, I, 'Dd.�pq-.r-> wk• WAd_—Ct REGISTRATION NO. Q'55( BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ' ARCHITECTURAL STRUCTURAL * MECHANICAL FIRE PROTECTION ' ELECTRICAL ' OTHER (SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become, generally fami" A with6the progress and quality of the work and to determine, in general, if the work is be' G�g,ERED R performed in a manner consistent with the construction documents. �'�� PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY , A PROGRESS RE No.95 TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDINGS EC a O ti UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE�Z�F SPGr`�+f� SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPAN� OF MA J $IGNATURE SUBSCRIBED AND SWORM TO BEFORE ME THIS DAY OF 66Z=20 CHERYL L. BURKINSHAW � Notary Public NOTAR UBLIC MY COMMISSION ESommonwealth of Massachusetts MY Commission E pires March 7, 2019 : The Commonwealth of Massa.chusetts Department of IndustrialAceidents I Congress Street, Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information - Please Print Legibly Name(Business/Organization/Individual): \ , �� _ �va�'4A e rll 0 C �-- Address: U 0S_ t 2- 1 �t l (rn �, 9• dk+ City/State/Zip: N- A o ��— I t tq Phone#: U t z "J—f L — S Are you an employer?Check the appropriate box: Type of project(required): 1.11 am a employer with _employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. XLRemodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition I Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q We are a corporation and its officers 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.] *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. #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 employees. If the sub-contractors have employees,'they must provide their workeis'comp.policy number. -tam an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: [ rn^_� J 1 1 U'�14, I — Policy#or Self-ins,Lie.#: W �-Z- _3 3 o Expiration Date: t 7 Job Site Address:_ M i&-M gC - w� VL- — City/State/Zip: DJ (t-- A 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 cer y under the pains and penalties of peiyury that the information provided ove 's true and correct. Si ature: Date: J l G Phone#• � l S q Z — 6 ^ Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.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. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an 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' compensatioii'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 pen-nit/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 A&V a CERTIFICATE OF LIABILITY INSURANCE 7 3215 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: It the certificate holder Is an ADDITIONAL INSURED,the policAlss)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 endorsame PRODUCE RVTMaria Dupont Insurance Agency, Inc. P E 18 Copeland Street 617 376-0795 ; (617) 479-9121 Quincy, NA 02169 me@dupontinsuranceaaancy.com INSURERISI AFFORDING COVERAGE NAIL• INSURBRA:Main Street America INSURED INSURERS: JK Contracting, LLC INSUREI1C: 31 Richmond Street INSURER D: Weymouth, NA 02188 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER- S 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 CLAMS. / LTR TYPEOFINSURANCE POLICY NUMBER MMIDD/YYYY LIMITS A GENERALLIABSITY MPT7794H 2/10/15 2/10/16 EACH OCCURRENCE $ 1.000.000 X CCMMERCLALGENERALLIABIUTY DAMV+GE RENTED $ 500,000 CLAIMS-MADE 7 OCCUR MED E)P ryone perwn) $ 10,000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE S 2,000,000 GEN'LAGGREGATELIMITAPPUESPER PRODUCES-COMP/OPAGG I$ 2,000.000 POLICY I P LOC $ AUTOMOBRE LIABILITY a acddent i ANYAUM BODILY INJURY(Per person) S AUTO PED AUTOSEOS BODILY INJURY(Pwaccident) $ NON-OWNED PROPERrY DAMAGE $ HIREDAUTOS _AUTOS eracdderd ' S UMBRELLA WIB OCCUR EACH OCCURRENCE $ EXCESSUA13 CLAIMS-MADE AGGREGATE S DEO RETENTION WORKERS COMPENSATION WC STATU CrrH- AND EMPLOYERV LIABILITY Y/N ANY PROPRIEIORIPARTNERIEXECUTIVENiA E.L.EACH ACO DE NE OFFICERMEMBER S CLUDED7 INardabry In NH) E.L.DI -EA ENFLOYEE Kye8 describe under DESdRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT S OCscmp-nONOFOPERATIONSILOCATIONS IVEHICLES(MachACORD101,Additional RenodraSallie".Kmore space Isrequired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUINORMD REPRESENTATIVE Bridget McGowan ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: apedranti@crowninshield.com ',?/3/2015 7:22:03 AM PST (GMT-8) FROM: 100005-TO: 2'6174799121 Page: 2 of Z _ co CERTIFICATE OF LIADILITY INSURANCE DATE pEEIDODfNYYYY) 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: K the cut" ads holder is an ADDITIONAL INSURED,the policy(Ise)must be endorsed. H SUBROGATION tii WAIVED,auk to the tem4s and conditions of the policy,cartain policies may require an endorsement. A statement on thin 4 ertlificaft does not confer rights to the certificate holder in lieu of such andome a s. PRODUCER DUPONT INSURANCE AGENCY INC an 18 COPELAND ST PHONE QUINCY,MA 02168 ONURNM AFFORDING COVE MAIC N A• Libeft Mutual Fire Insurance 23035 JK CONTRACTING LLC 31 RICHMOND STREET WEYMOUTH MA 02188 D MURER E: COVERAGE$ CERTIFICATE NUMBER: 23MM 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. e0R AM OUSK LTK TYPE OF WOKUMNCE E {JOE COMLlERpAL.GENERAL LMeLI Y EACH OCCURRENCEDAMAGE TO PEWTW- S CLAa484iADE ❑OCCUR wealS MED EXP WW one s PERSONAL&ADVINJURY 6 GENLAGGREGATE LIMIT APPLIES PER: GENERALAflGVMTE $ POLICY❑•RO1:1 LOC PRODUCTS-COMP/OP AGG OTHER: $ ALIT0100=E LMaLrIY S ANY AUTO 9=ILYINJURY Mw F I $ OWNEDALL SCHEDULED SODILY IMAM(Per eeddetqAUTOS AUTOS s HIRED AUTOS AAUUTOS : s uLa>tRL3LA LMA OCCUR EACH OC 0LNMNCE S EXCM L 4e cLAoYre LLAOE AGGIREGATE A Y - S4016g8-015 2M 712015 712016 ANY PROPRETORIPARTNERIEX:CUTNE Y!N Et.EACH ACCIDENT S 100000 OFFICER/MMINIMEXCLUD®7 a NIA mandaeory In MN) E.L.DISEASE-EA EMPLOY $ 100000 Mdaaaunder BLit ObeN OPERATIONS b a b w E.L.DISEASE•POLICY UMR I S 500000 DESCHN'TION OF OPEtA71M I LOCATIONS I VENICI MS(ACORD 191,Add ll"I RamarMa ae,.d,%rwy M.mEnd ed It more epeoe Is re*dred) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This ceniflcam cancels;and supersedes all previously Issued caffloates,only ae they relate to workem compenselion coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOAIE DESCRIBED POLICIES BE CANCELLED BEFORE THE DIPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN !MINNACCORDANCE WITH THE POLICY PROVISIONS. ::ar- ;1y,•",4 .. 1Nr1}I011®11l�IMaFMAT1YE Liberty Mutual Fire Insurance 018884014 ACORD CORPORATION. All rights reserved. ACORD 25(201401) The ACORD name and logo aro mgh>:t and merles of ACORD CERT NO.: 23677622 CLIENT CODS: 1644469 Lucy Oasfi.*ld 3/3/2015 10:19:07 AN (SST) saga 1 of L Massactlusetts -Department cf aublr:Safety egulations and Standards Board of Building R ('un,tructit)n Super-i%or icensc CS-0 3 r RANT WHEN M s 31 RICHMOND ST WEyMOM MA ;Expiration 12 091261212015 Commissioner