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HomeMy WebLinkAboutBuilding Permit #499-15 - 1600 OSGOOD STREET 11/24/2014 °F BUILDING PERMIT NORTH �tLeo j 6 q�•0 TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION / h f app Permit No#: �/S Date Received �yQ-Rw7ED 0 SSAC Hl1`J'fc Date Issued: I PO TANT: Applicant must complete all items on this page LOCATION � d Print - - PROPERTY OWNER . d oaz '57, -O�(ef Print 100 Year Struc ur ye no MAP PARCEL 1� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building ❑ One family lion ❑Two or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial ❑ Repair, replacement 0 Assessory Bldg ❑ Others: 0 Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands q Watershed District ❑Water/Sewer DESCRIPTION (4f WORK TO PERFO MED: Identification- / ae or Print Clearl OWNER: Name: © g4 Address: Contractor Name: Mone: 9f 21 9'/5 �2 Q05 Address: 1 42 Supervisor's Construction License: O r'� 44 c� Exp. Date: a Home Improvement License: -.0 . _ Exp. Date: ARCHITECT/ENGINEER JtZ c�y�� �_ cmc 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: $ FEE: $ � f 0`-' Check No.: 6+� Receipt No.: v,1�Ct is NOTE: Persons contracti wI Lg(�!!��redontractors do not have access to the guaranty fund Signature of Agent/�ner Signature of contractor , r 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 ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 DANGER ZONE LITERATURE: Yes 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 Permit 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 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/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 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:Building Permit Revised 2014 and,�L s w H Location/d C1S vat s'� ST2o L! No. r Date / . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ v e " Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL Check#� U Building Inspector Notary III �SS�CHU°+ES CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 499-15 on 11/24/2014 Date: December 24, 2014 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1600 Osgood Street MAY BE OCCUPIED AS Strolid — Tenant Fit Up IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Ozzy Properties 1600 Osgood Street North Andover, MA 01845 Building Inspector Fee: PrePaid $100.00 Receipt: 28298 Check : 9780 c "NORT#� Town of �. ; _ : Andover No. A499 04. h " T ver, Mass, COC _d_o�f NIC Nl WICK t4 �d ADR�TED r.4��'�5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System • "� THIS CERTIFIES THAT �.,Sr. .Q ....( !.rood .QalaC..l..sT r...... BUILDING INSPECTOR has permission to erect ...... buildings on . ... �.! Ia..Q.��,. ,� r undation .................... ..... Rough to be occupied as .......:i......... A ....... ......�............. c provided that the person accepting this permit shall in every respect conform to the term 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 a PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT! ST S Rough Service /� ............... .. .................................. in 2 1/ BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough 1 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. � t Smoke Det. Final Construction Control Document To be submitted at completion of construction by a 9 a d Registered Design Professional for work per the 8a' edition of the e Massachusetts State Building Code, 780 CMR, Section 107 Project Title: �-� � Date: Permit No. Property Address: + Project: Check one or both as applicable: ❑ New construction CSAxisting Construction Project description: `�6AW 4Q '4,-'z A I MA Registration Number: Expiration date: am a registered d sign professional, and I have prepared or directly supervised thJ preparation of all design laps, computations and specifications concerning: Architectural [ ] Structural [ ] Mechanical ] Fire Protection [ ] Electrical [ ] Other: for the above named project. I,or my designee,have performed the necessary professional services and was present at the construction site on a regular and periodic basis. To the best of my knowledge,information,and belief the work proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building permit and that I or my designee: 1. Have reviewed, for conformance to this code and the design concept, shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Have performed the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work was performed in a manner consistent with the construction documents and this code. Nothing in this document relieves the contractor nsibility regarding the provisions of 780 CMR 107. i Enter in the space to the right a"wet"or RA electronic signature and seal: 1 Phone number: d Email:144( ze kv�a��Al, Building Official Use Only Building Official Name: Permit No.: Date: Version 06 11 2013 i 0 'i7 O'4n°nr�'�19 SSACNUSE CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 499-15 on 11/24/2014 Date: December 24, 2014 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1600 Osgood Street MAY BE OCCUPIED AS Strolid — Tenant Fit Up IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Ozzy Properties 1600 Osgood Street North Andover, MA 01845 Building Inspector Fee: PrePaid $100.00 Receipt: 28298 Check : 9780 r 1NORTFl Town of � �. : : 1� ndover ,. 0 NO. h h ver, Mass, 0 OLA_ A- COCMIC"t WICK y1. REITEC) U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System • THIS CERTIFIES THATQO`!� ..... .. BUILDING INSPECTOR ...... buildings on 42&. ... P.! .,. ,*�., ,� r undation has permission to erect .................... ..... Rough to be occupied as ... ... .0...... w..*�...... ......... r. ...�i�e ............. �Flin�al ',provided that the person accepting this permit shall in every respect conform to the telication 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 MONTHS ELECTRICAL INSPECTOR a UNLESS CONSTRUCT! ST S Rough Service / ............... .. .................................. inal 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. i Enter construction cost for fee cal- North Andover Fee Cakulation Construction Cost 24,500.00 m $ - $ 294.00 Plumbing Fee $ 36.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 36.75 Total fees collected $ 467.50 1600 Osgood Street 499-15 on 12/2/2014 Tenant Fit Up Strolid i � NORTIi Town of A 0 No. y - F h ver, Mass, C OC NIC NlwKK ,- % W4 �� S U BOARD OF HEALTH I Food/Kitchen PERMITIT LD Septic System j THIS CERTIFIES THAT ..�.,�Sr.. Aq,lj......��?.......I. .r .. ').R .!.. ..L 4..... BUILDING INSPECTOR has.permission to erect ...... buildings on . �. ... P' ' a..� r undation Rough. to be occupied as ... ... . ..... , ...... .� ...... ......... R.�ir ....... ....... ................... Chimney provided that the person accepting this permit shall in every respect conform to the term 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ST S Rough Service 00 ............... .. .......... .................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy 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 Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massuch usetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): �b Address: U City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.`�am a employer with�F 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition r comp. insurance. [I�o workers comp. insurance . . 5. We are a corporation 10. Electrical repairs or additions required.] ❑ rpo atlon and its ❑ p 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. o workers' coin right of exemption per MGL y p c. 152; 1(4), and we have no 12.❑ Roof repairs insurance required.]` § 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box 41 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 workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: 67V_,�ecel ���� Policy#or Self-ins.Lic.#: j2 10 Expiration Date: —o. Job Site Address: t' e2 02 p City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date l> ,g-f Phone+: If:) ® 7 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials li Please be sure that the affidavit is complete and printed legibly. The Department.has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions; please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Revised 4-24-07 Fax#1 617-727-7749 www.mass.gov/dia 10/31/2014 12:10 9786833147 PAGE 01/01 DATE(MWDTNYY'lY) �► '+Q`! CERTIFICATE OF LIABILITY INSURANCE F10/31/2014 THIS CERTIFICATE 19 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT$UPON THE CERTIFICATE HOUR, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTAR THE COVERAGE AFFORDED BY THE POLICIES BELOW. THI$ CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN DIE ISSUING INSUM:RS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CER719FiCATI:HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policWes)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditkms of the policy,Cettatin poildes may require an endorsement. A statement on this certificate does not Colmer rights to Me cWhIkate holder In Rim or such endorserrrent(s> PRODUCER NAME:t. _ M P ROBERTS INS AGCY INC ��I o Erdt: (978) 683-8073 tA!C,No:t176)693-3247 i 060 Osgood Street A danielle@mprobertsfnsurance.com North Andowir, MA 01845 etsuMM A.ormaa 001IEuME I>acr INSURER A:MERCHANTS SCE INSURED DOWGIERT CONSTRUCTTON COMPANY INC. INSURER 13:GUAM INSI,TTRMCE T 175 BRADY AVE INSURER C: SALEM, NR 03079 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUM4ER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE:POLICY PERIOD INDICATED. NOTWIT-(STANDING 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 POUCIE$ DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND COIVDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY)DAVE SEEN REDUCED BY PAID CLAW. LLTTRR TYPE OF'NSURANCE wwo POLICY NUMB MM DDIyy EM96 LIMTIB X cowllERCIAL MI_RAL LMLI1`r EACH OCCURRENCE Snnn CLAIMS MADE (OCCUR PREMISES Ea mcwnenFp) 5 MED FXP(Any one perxan) IC (3 A _�yY.,.T_ 709151506 43/23!14 03!23!15 PERSONAL&ADV INJURY F 1,000,000 GEWL AGGREGATE IW7 APPLIES PER: GENERAL AGGREGATE s 2 000 0OO Pmr-YDJIO- Pigo- Loc PRODUCTS-coNlpioPAw s 2,000,000 ROTHER: 5 nurpMOBaE uAB1lITraccident`s $ 1D_ 00,000 _ ANYAUTO BODILY INJURY(Per person) 5 AUTOS NFD SCHEDULED CAPI054694 03/31/14 3/31/15 BODILYTNMYper adcden� S A HIRED AUTOS AUTOSAUTOS NONOWNED ererclde MMPIN"TDAMA S s uMBRFI,IUAE. O=R03!23/14 03/Z3/1S FA 1]CCURRENCE 5 1,000,000 A DCCESs LIAR CLAIMSwos CUP9142034 AGGREGA78 3 DED RETENTION 5 S WORKERS COMPENSATION ARJTE FR AND EMPLDYERS'LIABILITY ^- nrry PRoFArvvRtPAAR1ER*,vACUnvE v© DOW125571 77 10/26/14 10/26/7.5 E.L.EACH ACCIDENT s 1,000,000 $ OFFICER1MEMeER exCLUDC MIA (Madermy in RHI E,L,DISEASE-FA EMPLOYet 1 1,000,000 Ndescribe under DESCRIPTION OF OPE=RATIONS bnlwv E.L.DISEASE-POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VENULES(ACORD 101,Addltbnel Remarks ScI dvlc,may IM attached IT rngmr.paml in rcquilL•d) THE CERTIFICA179 HOLmIRR IS NAND AS ADDITIONAL INSVM AS PER THE =20 OF THE WRXTTEN CONTRACT ANn AS PER THEIR TEST IN THE INSURED'S OPERATX099 ON A PRIMARY AM VON—CONTRIBLtri4)RY R&SIS CERTIFICATE HOLDER CANCELLATION OZZY PROPERTIES INC 1600 OSGOOD SHOULD ANY OF THE:ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BT IJrC DUNDEE OFFICE BARK LLC THE EXPIRATION DATE TKREOP', NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS_ EIMMI.E STATION LLC DUNDEE REDSI?RING LLC HERITAGE PLACE LLC AU`n-I Ri7F,D RE.PRESENTA 21 HOWE ST LP ZORCON LP C/O OZZY PROB9ERTIBS 1600 OSGOOD ST NO.ANDO 019M.2014 ACORD CORPORATION, All rights reserved. ACORD25(2014101) The ACORD name and logo are registered males of ACORD Initial Construction Control Document z To be submitted with the building permit application by a d Registered Design Professional A �< for work per the 8a'edition of the °4t Massachusetts State Building Code, 780 C SYe MR, Section 107 Project Title: AM&C, Date: (/ Property Address: — Project: Check one or both as ap icable: ❑New construction xisting Construction `' Project description: ` � Y'(^/1�(}G /� Ib"ffM V'II,G�/`WI OJ`Ci MA Registration Number: Expiration date: G am a register d design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Architectural [ ] Structural [ ] Mechanical ] Fire Protection [ ] Electrical [ ] Other for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work,I shall submit to g `Final Construction Control Document'. Enter in the space to the right a"wet"or ca. Pte. electronic signature and seal: w Phone number:-Almail: J V1 Buil ' g ffici se Only Building Official Name: Permit No.: Date: Version 06 11 2013 .0 , Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen isor License: CS-048040 TADEUSZ DOWGfER 175 BRADY AVEC ° SALEM NH 030 921 Expiration Commissioner 10/29/2015 10/31/2014 12:10 9786833147 PAGE 01/01 DATE(MMIDDM�YY} CERTIFICATE 4F LIABILITY INSURANCE 110/31/20 MIS CERTIFICATE IS 19SUED AS A MATTER OF WORMAMON OKY AND CONFERS NO RIGHTS UPON THE QERTIF(CATE HOLMI.THIS cERTIF(CATE was moT AFRIRMiTIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE covie AGE AFFORDED BY THE POLIt.YES s6Lt)W. THT9 r;ER'tIF cm OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE JSSUNG INSURER(91, AUTHOR)21M REPRESENTATIVE OF PRODUCER,AND THE tER1IFMATE"MAW RN pmTANT: tr tBe cigM me holder Is an ADDITIONAL 1NSURbo,Ow paucy(les)must be endmaed. N SUBRCOATION IS WAtM,subject to the kens and conditRM of the potley,certain Wdes may require an endotsemeent. A statement on this RerifRCate dM not Confer"gI is to Hie cera cdo holder In linin of suO wWwwmffA(s). PRODUCER M P ROBERTS INS AGCY INC FBI 683-13073 178)693-3147 1060 Osgood Street 1C 'eII�@mprca}�ertsftzsurance.ataart North Andover, MA 01845 mmonO oavmmim VA" INSURER k-NERC $ CE INSURED DWGIERT CONSTRUCTION COMPANY INC- INSURER 9:GUARD INSMWCE _ 175 RPMY AVE INSURER C 'SALEM, N8 03079 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT Tile PoUelea OF INSURANCE LISTFD BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTwmiSTANom ANY REQUMWNT,TERM OR CONDITION OF ANY CON'tT7At71'OR OTHER DOC MNT WITH RESPECT TO WHICH THIS QERnmi:ATE MAY BEE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED INY THE POUCIE$ DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITION$OF SUCH POLICIES.UMTS SHOWN MAY HAVE TIEE°'N REDUCED BY PAID CIAM- LTR TYPE OF*SURANCE Nib POLICY N MBER M umn X COIRIERCIAL 901RAL UMMf EACH OCCURRENCE S 011INAGE 10 N ;w CLAIMS-flr1A13S F&I OCCUR PRI Is (E�°°&MtRcp S100,000 MED EXP(Any one permit) S CMF9151506 3/23/14 03/23/15 PERSONAL&MN INJURY R 000,00 OWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2 00Q 000 PpI,IGY jt El LOC PRODUCTS.cONr+roPAoO s ,2,000,000 s EU,%NGLE Lima 1 000 004 AUTOMOF)RE LIABIL"Y aCeRtlLmt r A�NYALITO BODILY INJURY(Per perxm) S AUr�OWNED SCHEDULED CAP1054894 03/31/14 3/3I,/1S 130MLYINJURY(Parsowder,4 S AUTOS A NON QWNEOIMPIRM S HIRED AUTOS 2S arm s UMBRrI.I A LIRE. 0=11 EACH OCCURRENCE S 1,004 100 CVP9142034 3/23/14 03/23/15 AGGREGATE S EXCESS LIAR CLANS.MADS -- DED RETITITION 5 S WO! KERS COMPENSATION ATUTE E<it AND EMPLAYE3i5 uABILtrY WN ANY PROP N!A DCS SI 10/26/14 10/26/3.5 E.L.EACH ACCIDENT S 1,0 7 i 777 ormc h�7AeER EXCill My CEL,DISEASE•FJI EMPLOYES 1,000 000 W40yy erverortneuRda< S below L E. DISEASE-PC 1 400 404 DE6CRIPTiDN OF OPE' N DE=RIPnON GF OPERATKNdS I LOCATIONS!VEHICLES(AGGRO 101•A6dRIMeI Rema Sdredule may bb albxhad U ngtB spare LS,equiN!d) THE CERTIFICATK HOLDER IS NR=) AS ADDITIONAL INSUMSAS PER THE TMM O1: THE NUTTEN CONTRACT AVb AS PER THEIR INTEREST IN THE INSUMM'S C'itPERA'IXCM Mq A PRIISARY AMD NON-•C01MIBf3TORY SIS CER IFl CATE HOLEER CANCELLATION OZZY PROPERTIES INC 1600 OSGOOD SHOULD ANY OF THE AGM DESCRIBED POLICIES BE CANCELLED BEFORE ST NX DT7NI3EE C3FE'ICE BARK LLC THE EXPIRATION DATE "MWF. NOTICE Wn.L ESE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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