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HomeMy WebLinkAboutBuilding Permit #172 - 120 WATER STREET 9/1/2009 NORTH BUILDING PERMIT o` t,�o ,b 6 TOWN OF NORTH ANDOVER cr �°�, APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 9q ��SSACH15 t� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION - ;PR'OP,ERTY OWNER q S � :... . .. - . ` Print _• . gar IVI;4P N0:%+ 1AiC1=LOfii11aIG"DISTRICT: Htsttic#District no 77 .. Machine Shop Village c no ,- TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition - - Two or more family Industrial- Alteration No. of units: Commercial RAssessoBldg Others: Demolition Other septtc Well Floodplain Wetland 1lVaterShed District W. lb iSewer 1- 4 ­ I 0 DESCRIPTIOq OF WORK TO BE PREFORMED: r N, C- k fqt_c— P v t4- Identific tion Please Type or Print Clearly) OWNER: Name _ y� �'J 7 -3�t rJ AdyL- Phone:6)-7-6Z3-" 8 2 fS--" Address: ( I"(1 �_ ✓� ! © �n� t b CsL I ®Z t 4- 3 CONTRAACTTOR Name: Kyw-J 7 W ts- -- Phone Address. IfE`�ttJ � 4 �� (� �4 UN Supervisor's Construction ticerise �, 616 2 -tr °,.'.Exp Date: 74 HornelrnprovernentLicenseExp. ARCH ITECT/ENGINEER_iti M- 14c - Phone:_LL-2--4'23 — ct-L-5;- 1- Address: Address: ucr�S4 19- 9&M,.•, M� 0 LZ(y -Reg. No. 10 Q O FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ U, 0 d 6 FEE: $_ Check No.: IrI S ie-9 Receipt No.: '�?O 3� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature°o Ag ne wnec� ignature of coritractor>'° a. .._ Plans Submitted Plans Waived Certified Plot Plan Stamped Plans . TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site =F I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT 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 Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ,F1RE'DEPA°RTME.NT Temp`Dumpster'kon site. yes no =� 1�cated�t 24 Main Street - „i Fire Depanaen signture/date, �. 'COMMENTS k f i 4 Dimension ! Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: t t ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No �4 DANGER ZONE LITERATURE: Yes No ! MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA- (For department use N I E i E ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 I i 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 NOTE: 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/Crossection/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 ' Revised 2.2008 / y Location *74 FA No. No. � � Date � MORTI, TOWN OF NORTH ANDOVER . F ow x 9 Certificate of Occupancy $ MUS<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # i 22379 Building Inspector NORTH 0 o 0 ." 4 over No. / 7 Z ~ _ - -_ 7 �. zs A E dover, Mass., 0 COCHICMEWICK V ADRATED `s BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THATI _A !,!� �....... ............................................ Foundation has permission to erect....... ............................... buildings on .-.90..........044. ... .... .�..... ............................ Rough q to be occupied as DC.*". ..V......... l D.. �� `� Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 MONTHS UNLESS CONSTRUCTION STAR S . ELECTRICAL INSPECTOR Rough ........... ............'..`:`...-......... Service BUILDING INSPECTOR _ Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. Massachusetts-Department of Public Safet Board of Building Regulations and Standards ,Corsiiuctian Supervisor License ,License: cS 66334 Re'­icted to: 00 - XIERAN T`1NHEIA'N ;31 RICHMOND ST WEYMOUTH; MA``02I}88"� Expiration: 9PZ61Z011 t'ommissiNer' Tr#: 3612 BUS DERS Standard Form of Agreement between Owner and RCG Builders LLC where the basis of payment is the Cost of the Work Plus a Fee without a Guaranteed Maximum Price Date: July 22, 2009 . Owner: I2'CGI�orthAndove�r Mills LLC oRCGLLC �y E 17 luaoo Streef, Suite 1Q0 { Som@roll le, MA 02lo-, a Contractor: IChG'ButldePsLLCZ X17 lua oo Street, Suite31©O h . . � rSomervreVI! r 3 3 Architect: r Burt M1� N Project Name: E3RSM� � n 1a a The Owner and Contractor agree to the terms stated by this contract. This contract supersedes any prior agreements, representations, or negotiations, oral or written. No liquidated damages shall apply to this agreement. This contract consists of the following documents: 1. Obligations of the Parties 2. Contract Sum 3. Project Schedule 4. Signatures Exhibits Exhibit A: Estimated Cost of Work Exhibit B: Project Schedule Exhibit C: Drawings Page 1 of 6 BUILDERS 1. Obligations of the Parties Obligations of the Contractor: The Contractor accepts the relationship of trust and confidence established by this Agreement and covenants with the Owner to cooperate with the Architect and exercise the Contractor's skill and judgment in furthering the interests of the Owner; to furnish efficient business administration and supervision; to furnish at all times an adequate supply of workers and materials; and to perform the Work in an expeditious and economical manner consistent with the Owner's interests and in compliance with all applicable governmental codes and regulations. The Contractor shall keep full and detailed accounts and exercise such controls as may be necessary for proper financial management under this Contract. The Contractor shall keep full and detailed records of all books, records, permits, licenses, correspondence, receipts, instructions, data, and drawings associated with the Project including all Subcontractor contracts, invoices, vouchers, insurances, lien waivers, and other correspondence. The Owner and Owner's Accountants shall have access to review, audit, and copy all Contractor documentation. The Contractor shall retain these documents for a period of three years after final payment. The Contractor shall maintain insurance at the following levels with the Owner listed as a co- insured: Type of Insurance Limit of Liability Oomrrercial Gene'r'al,L,iabrli` . ',' $���Q�,OdD n�. .,Yn.�.,.. . ., '..,., .,.) .,,, •'-.. /,8,.,�y ,.>r ...,, ,�., s _�` .c, w�,w`� ruYJ'�.d Eur t: s ? MIS Upon request, and at the cost of the Owner, the Contractor shall obtain a performance bond up to the total Cost of Work. Such costs shall be added to the Construction Volume. The Contractor understands that the Project will be financed by a construction lender and, then, by a permanent lender. The Owner may assign any of its rights under this Contract to the construction lender and the Contractor hereby consents to any such transfer provided no such assignment shall relieve the Owner of any of its obligations under this Contract, unless agreed to in writing by the Contractor. The Contractor shall execute any certificates, lien waivers, releases, receipts, and other documents as may be reasonably required by the construction lender or permanent lender including a subordination of its mechanic's lien rights to the construction lender's and permanent lender's mortgage or deed of trust. The construction lender for the Project will be: M Obligations of the Owner: The Owner agrees to furnish or approve, in a timely manner, information required by the Contractor and to make payments to the Contractor in accordance with the requirements of this Agreement. Dispute Resolution: Claims, disputes or other matters in question between the parties to this Agreement shall be resolved by mediation or by arbitration. Prior to arbitration, the parties shall endeavor to reach settlement by mediation. I Page 2 of 6 BUILDERS 2. Contract Sum Cost of Work: The Contractor shall provide a detailed estimated Cost of Work to the Owner(see Exhibit A). The sum of these costs, including the fee is as shown below: Change Orders: The Contractor does not guarantee the Contract Sum in any form. In the event of changes to the Contract Sum, the Contractor will present written changes to the owner for costs that exceed the Contract Sum in the form of a Change Order. The Contractor will review all Subcontractor Change Orders before submittal to the Owner and Architect and make a recommendation for payment or non-payment. The Contractor's Fee will be calculated including any approved Change Orders. The Owner, Architect and Contractor will negotiate disputed Change Orders in good faith. Contractor's Fee: 15% of total construction volume up to$1 million, and 10% of construction volume over$1 million. This includes pre-construction and project management services, and field personnel and associated management overhead. The fee is based on actual costs incurred, with final true up, and is booked monthly in arrears. Specifically, 1. The cost of pre-construction and construction management services provided by RCG personnel is booked monthly in arrears based on the hours reported by each employee. 2. Hours are billed at the standard hourly billing rate established from time-to-time for each employee. The hourly billing rates effective 1/1/2007 are shown below. 3. The cost of pre-construction and construction management services provided by independent contractors is booked when invoiced and carried within the fee. 4. RCG Builders personnel functioning as tradesmen outside their management duties will be charged according to their hourly billing rate. 5. If a project is terminated or suspended by the Owner prior to completion, RCG Builders LLC is compensated for the actual cost of services provided prior to receipt of notice of termination or suspension from the Owner. 6. Total Construction Volume includes all construction trades, general requirements, insurance, bonds and miscellaneous costs deemed necessary to perform the construction of the project, but excludes permits and fees. Permits and Fees shall be paid directly by the Owner. 7. Construction management labor, standard tools and equipment, and labor-related overhead are covered "within the fee". Specialty tools or equipment, trade labor supplied by Builders personnel and approved transportation and meals costs shall be charged directly to the Owner without a fee. Employee Rate David Steinber h $125/hr Mike Bernier $125/hr Kieran Whelan $125/hr Jason Downing $50/hr Page 3 of 6 MA BUILDERS Subcontractors: The Contractor plans to hire Subcontractors to perform the majority of construction associated with this project. The Contractor shall provide the Owner and Architect information on all of the bids received by Subcontractors and the names of the Subcontractors selected. Owner shall have the right to reject a proposed Subcontractor; however, in the event that this leads to a higher Cost of Work, the Owner shall pay for the difference. The Contractor reserves the right to reject any Subcontractor, even if it is the lowest bid, and to dismiss Subcontractors from the job that have been previously approved by the Owner. Payments: The Owner shall make progress payments on the Contract Sum according to the Requisition process described below. The Contractor shall, at the conclusion of each calendar month on the project, present to the Owner an application for payment(Requisition)for costs incurred during that month. The Requisition shall include all invoices, vouchers, partial releases of liens, expense reports, and any other evidence to support the validity of the Requisition amount. The Contractor may requisition for completed, but unpaid work based on an expectation of payment upon receipt of funds. The Owner, the Architect, or their representatives shall be afforded five(5) business days to review such application and question the Contractor about its contents. In the event there are no disputes, the Owner shall pay the Contractor within 10 business days of receipt of the Requisition. Payment by the Owner does not represent that the Owner or Architect have made a detailed examination of the documentation, inspection of the work, or verification of the accounting. At the completion of the project, the Owner shall make a final payment to the Contractor based on a final Cost of Work with a truing up of fees. If further corrections to work are required that are not covered under warranties with Subcontractors, or that are not the outcome of negligence or poor workmanship by the Contractor, the Owner shall pay the Contractor for any work associated with performing the corrections based on the hourly rate agreed to in this contract. Retainage: The Owner shall not hold back any fees to the Contractor to ensure completion of the work. The Contractor will be expected to hold back fees from Subcontractors to ensure their performance based on the terms below: 100 df biped costs;'unless otherwise ap rowed b the Owners ' u �,,,._ Termination of Contract: The Owner shall reserve the right to terminate or suspend the Contract at its sole discretion. Within 15 days of termination or suspension, the Contractor shall present an accounting of all its costs incurred for reimbursement by the Owner. If the Owner elects to proceed with the project without the Contractor, the Owner shall have the right to assume the Subcontracts and agreements related to the Project. Working Capital: RCG Builders shall not bear the costs of Working Capital for the project. If the Owner would like the Contractor to gain beneficial pricing on its behalf by paying subcontractors ahead of the Requisition schedule, the Owner shall either(1) put on deposit with the Contractor a sufficient amount of Working Capital for the Contractor to pay these Subcontractors, or(2) make immediate payment upon request from the Contractor outside of the normal Requisition process. Provision of Working Capital shall entitle the provider to all discounts and savings associated with that capital. Page 4 of 6 UP—LDERK 3. Project Schedule Date of Commencement: The Contract Time shall be measured from the date of commencement. The date of commencement of the Work shall be the date of this Agreement, unless a different date is stated below or provision is made for the date to be fixed in a notice to proceed issued by the Owner. „A�u vst 28,2009,�or such'trme that Notifcation�to Pro�ceed�s g�ve�rt�by;Qwr�Er' '�"�`�� ,�r ?� ' Contract Time: The Contractor shall provide to the Owner a Project Schedule (see Exhibit B). This Schedule is based on assumptions reached prior to the signing of this contract, which assumptions the Contractor shall attempt to clarify in the Schedule. However, the Schedule always assumes the Owner and the Architect respond promptly to requests for information and do not request any significant changes to the construction program. In the event that the Owner or Architect find any discrepancies with the Schedule or its Assumptions, they will promptly notify the Contractor, who shall make adjustments to the Schedule as necessary. According to the attached Schedule, the Contractor shall achieve Substantial Completion of the entire Work as follows: DateF,of Swl� is antial Com„letiort,to,bei o laterthan'Decern er,,l,u2009 The Contractor does not guarantee the date of completion. However, the Contractor shall not be entitled to additional fees based on delays in the project unless those delays can be shown to incur extra costs for the Contractor and were caused by the actions or requests of the Owner or Architect. The Contractor shall present an updated Project Schedule to the Owner and Architect on a weekly basis for their review. Page 5 of 6 BUILDERS 4. Signatures The Owner's representative is: David SteirabeN_ ,,Principal SKx k ,�. , RCG LLC '171rraioo Street;Surte°1;©0 Somerville, MA302143 § 14.4 The Contractor's representative is: Kieran Wf�ela RCG BW1dd(s`LLC '17�Eualoo�Street` Su�te 1e00. SoriierviE)e, MA 92443 This agreement is entered into as of the day and year first written above and is executed in at least thre original copies, one for the Owner, one for the Contractor, and one for the Architect. Owner Contractor Signat4fre Signature Printed Name and TiA Printed Name and Title Page 6 of 6 f ERS Schedule of Values 8/27/2009 Demolition $10,500.00 Frame walls and workstations $10,000.00 Drywall &tape $12,000.00 Prime and Paint $12,000.00 Doors &Windows $53,000.00 Carpet(8,000 SF) $18,000.00 VCT (1,000 SF) $3,500.00 Vinyl base $2,000.00 Cabinetry& Countertops $10,000.00 Bookshelves &Trim $10,000.00 Plumbing $2,500.00 Sprinkler Work $2,000.00 Electrical $20,000.00 HVAC $36,000.00 Cleaning &dumpsters $6,000.00 Su b-total $207,500.00 RCG Builders fee $31,125.00 Insurance $2,386.25 Total $241,011.25 Building Permit $2,904.00 Total Construction $243,915.25 1 e Lom►nanwea&k ofMassachusetts Q Departmc�e-nt of industrial Accidents �l L ce Of IftreStle crofts »� 600 If,=linglnn Street BO"0m, MA 62111 r7 Workers' Compensation Insitranee w>w� rf zas�gov/dia Affid$vit~ Euilders/Caatracfors/Eieatriciaras/PiQmbsrs A •cant Infornaatif>fn. -_ Please Print LeQibf Name (B� ge n,-Wonimdiunnedividual); Address: ! Citylsta&ziOZ �� r-tcs->w p: (4—3 f�t� Phone 4- Are : A�re,y�ou an employer?Cheek.the appropriate•bo= I.� I lima employer with 4. Type of Project❑ I am a gemeral contractor and I p ! � ° 2•❑ employees(full and/or part time).* have Hired the sub- 6. E]Now construction . I am zaole proprietor.oz Pffi m - list md on the attached sheet 3 7. ❑:Remodeling ship andhaveno employees Thome s workingfor me in ub-contractors have ffiry capacity. workeers comp.insurance. g' ❑Demolition - 3 workers' comp.iasfrarsce . S. ❑ We arc a corporation and its 9• ❑Budding addition required.] Offi 3•�] I ain a homeowner doing all wontOffic= havc excreised their l0•❑Electrical repairs or additions myscl£[No•w.ork='conte.-. of axciftption per MOL I I.E] junibing insurance. ?+ §I(41, nd•we have no repairs or aclort�ans required.]t .•emPlayews:[No worl�' 12Z Roof repairs Camp. insurance required.] `I3.(❑.0fcT '�9 epPi n=ti�at dKcks boz (nm also fill out the section below also 1 fiomeowttera who submit this a'a'idavh indicating they srs&oin aII �*!tng their.workerc'botttpenset policy infomtatioa tCaatnmmrs that cheek this box must g wank and fim hue outside conmmtora mast submit a new afndavit tndi as additioasl sheet siww*M the name orthe sub- cah,such' I conoaotoa twi timir worimm, irtiestmtion. inti as etrt.roper fnr a � trtg:wQr&�R' cszs � irrsrcr rmatio._ anrefor fry. proves fiel1ow.h•*,14-c pabL;Andick site Insmartce Company Name: (IzS Z)Ct `� �/ t1 Y tf1.•-f 6 /.. f U Policy#or Sat=ins.Lic. #: L G-,S v 0 Expiration Job Site Address; 12 .ij ` r �J�-�� CttylStatelZ' . �v Attach a copy of the workers' cam tP I WD V Vv� 0 pefzsation policy aecFaration page(sbowiug the policy numbier and e Failure to secure eove;agc as required under Section 25A of MOL C. 152 can lead to the i APisatioa aia�e� . fine up to S1,5DU D and/or one-year itnprisonm mposition of aminal Of up to$250.00 a �as well MS civil penalties in the form of a STop WORK ORDER p 'cs of a- day against the violator. Be advised that a copy of this statement Wray be forwarded.to the and a fine Investigations of the DIA for insurance coverage verification: Office of ------------ 'Ida hereby cerci under the aims andpenaltesc of p PrJ+vy x5fiat tl:c information PrOvided above is trice co Si rred Date: CJ Phone#: 1-2 4f facia7A:Zhorjjy(cirrJe t write in this Qrea,to be c»mpietedby� or town offtd4( City or Pertnit/License# Issuing one): 1. Boariltling Department 3.City/Tovvn Cietk q Eieetrical Inspector 5. Pluarbiuo litsa.Otbepector Contact Phone*: Infarmtiond In§tructions Massachusetts General Laws,chapter 1 S2 requires all emp Ioyers to provide workers' compensation for tineir employees. Pursuant to this statute,an employee is defined as"..:every person in the service of another under any contract of hire, f^ . express or implied,oral or wrist m" An empfayer is defined as"an individual parncership,as im iation,corporation or other It* entity,or arty two ormore of the forgoing engaged in a joint enterprise,and includi"g the legal ris�es of a 666__sad employer,orthe receiver ortrustrx'of an individual,partnership,associatiozn or other legal entity,tasrpioying employees. "Howe=the owner.of a dwelling house having not morn than three apaa-tnents and who resides therein,or the occupant of the dwelling house of another who employs persans to do ma.Lmt mance,construction or repair work on such dwellinghouse or on the grounds or building appurtenant thereto shall not b-.. win of such irapioyment be d--med to be an eraploy=." MGL chapter 152,525C(6)also states that"every state a;-;Deal licensing agency shall withhold the ismanceor renewal of a license or permit to operate a business or to construct building in the commonwealth for any applicant who has not produced acceptable mideuce.of eompiisnee with the.insurauce coverage required." Additionally, MOL chapter I SZ PC(7)stator"Neither the co, unwealth nor any of its politicgl subdivisions shall enter kft any an act for the pufnrmance of publiz wade until•sacepfsiile evidence of complia=with the ins== requirements.of this chapter have bean presented to.the cmrttr•acii ng m6ority." App>ticania •• Please fill out tic workers'compensation,affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-cotrhactor(s)rmme(A addresses)aand phon e numbers)along with their certificate(s)of insurance. Limilmd'Liabiiity Companies (LLC)or Limited Liability Pw ns=hips(LLP)with no empioyees othergum the members or partners,arc not requhrd,to carry workers'c>rnperrsa#ion irsosance. Van LLC or-LLP doeshave empioyees,a policy is required. Be advised tient this of d.--x*it nnay be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also.boe sure to sign and date the affidavit The affidavit should btu returned to the city or town that the application for the persnft or license is being-requested,notthe Department of Industrial Acoideata Should you have airy questionsre g the tawor if you are required to obtain a workers' compensation poky,please-cail the Dolma meat attic number listed below. Self-insured oompanies should trum their self-insurancie1icansc mince on iic'uppropi•iate tin:. Gly or Towns Of icWk Please be sure that the afvdevit is complete and printed Ee:gibly. The Dle artmier t hes provided a space at the bots m of the affidavit for you to fill out in the event the.Office of Investigations has to contact you regarding the app3ic cit. Please be scat to fill in the permit/licanse number which v+ m be cased as a reference number. In addition,an applicant that must submitImultipie permit/iic W=applications in any given yrat,need only submit one.affidavit indicatingeurrent policy information(if necessary)and under"Job Site Adds-ass"tine appiicant should write"all iocations in (city or tx)%M).'A copy of-fat affidavit that has been.officiaily stzmped or marked by the city or town may be provided to the supplicant as proof that a valid affidavit is on file for futnaz p=mits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen k obtaining a Ticensc or permit not related to any business or commercial veature (i.e. a dog license or permit to burn leaves etc.)said person is NOT.requised to complete this affidaviL The:Office of Investim6ons would like to drank you in advance far your cooperadcm and,should you have any questions, please do not.hesitate to give us a call The Department's address,telephone.antt fax nwnber. The CommonweatIth of Manac husetts Deparlmznt of hndsssiaai A=dimts OfficeoEf Lnvesti-.2ions 600 Washirr,-grton Stre:rt Bacton, MA 02111 TeL #617-7274900 i=406 or 1477-MASSAFE Fax#61 7-727-7741 Revised 5-26-05wvv�v.�1 . ,CZ a v{d2a Clien!#:35588 RCGBU 09 ACORD- CERTIFICATE OF LIABILITY INSURANCE o,5 0, °^'" PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE MARKETING AGENCIES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 306 MAIN STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR WORCESTER,MA 01608 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 508 753-7233 INSURERS AFFORDING COVERAGE NAIL# INSURED RCG Builders LLC INSURER A. Associated Employers Insurance 21865 do RCG-LLC INSURER B. 17 Maloo Street,Suite 100 INSURERCM D' INSURER D: Somerville,MA 02143 INSURER E COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MaR TYPE OF INSURANCE POLICY NUMBER POLK Y EFFECTIVE POLICY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL.GENERAL LIABILITYRENTED DAMAGE fFST Ea 00cumancal $ . CLAIMS MADE F]OCCUR MED EXP(Any are Person) $ PERSONAL.S ADV INJURY $ GENERALAGGREG ATE $ GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-OOMPIOP.AGG $ POLICY PRO LOC AUTOMOBILE LIABILITY ANY AUTO (COMBNGLE LIMIT $ Ea ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE _ (Per accident) 1 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO / OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESSAIMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F-1 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND WCC5005531012009 05/10/09 05x10/10X We sTATu- GTH- EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $500.000 OFFFIsCERIMEMBER EXCLUDED? EL DISEASE-E11 EMPLOYEE SSOO OOO SPECPROVISIONSdescribe below EL DISEASE-POLICY LIMIT SM,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION For Informational Purposes DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAB Ilk DAYS YISBnTEH NOTICE TO THE CERTIFICATE HOLDER NAMED 707M LEFT,BUY FAILURE TODD SO SHALL IMPOSE NOOBU6ATION OR LIABILITY OF ANY KIND UPON THE INSIAtM ITS AG8IT8 OR REPRIMENICAVIIIES. AUAIORIM REPRESENrATIVE ACORD 25(2001108)1 of 2 #S158999/M158998 GCE 0 ACORD CORPORATION 1988