HomeMy WebLinkAboutBuilding Permit #378-2016 - 21 HIGH STREET 9/23/2015 NORTH BUILDING PERMIT o��t�eD 'bq�o TOWN OF NORTH ANDOVER �2 5 '`- ,..,, •6 APPLICATION FOR PLAN EXAMINATION 7D �no uy " Permit No#: 71 �Ao Date Received '!sR°R�reD QPy(y �SSgcHus�c Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION tGM Qi . 5�vl-r62.01— PROPERTY OWNER e i 1iP1 t LL Print 100 Year Structure yes no MAP _PARCEL:�_ZONING DISTRICT: Historic District a no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition _ _ ❑ Other g Septic D 1Nell ; D Flootlplain. Wetl_antls: w _ V1latershedlKDstnct ❑WaterlSewer 1 DESCRIPTION OF WORK TO BE PERFORMED: g �\ �� d �C� SIP ►q Cv� VL S N aS�'� �i `t'P is 0 Identification- Please Type or Print Clearly .--- OWNER: Name:r3�14v oo S.' tra gML-xl+t Phone: -6ZJ_ 4 3 l Address: , tris 101� ;a91O0 -�G' �drtvr- (LV1 G- I tl8 C� L-L4-3 Contractor Name: Phone: Email: uS i-.W,tet tti3 e- t' CLI . C rn Address: 2 I tcxrWN,0 �C'� L5- VnGUG-K ol- 02 -1 eZ Supervisor's Construction License: 0 6 633 Exp. Date: f 2-t 2c� ►� Home Improvement License: Exp. Date: ARCHITECT/ENGINEER` Phone: ?-7 Address: 2,\o\) 1��1�-vc��ws C- �Ci' 501kir`'yP��-G^Reg. No. �^ b FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE-TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 1 ( � S-o FEE: $ 9 c Check No.: - I Receipt No.: U� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _, Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/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 Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS ,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 =FIFZEDEP/ R�TMENT �TernDumpstero'nsite,==yes ,y �5' �,'.�° ' nog° i;Locat'ed at412�4MainiSt�eet _ t,FirDepartment�s gr�atu�e/datei�#_. " 'a i I 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 i DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) I �I I I ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 J 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 4. Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 4� 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 4. 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) 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 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 Location 1 ""� I `���. <�Y + c Z.07— No. ���© "' G �}o Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ 160 Building/Frame Permit Fee $ C/4-9 Foundation Permit Fee $ Other Permit Fee $ ' 4TEly ' TOTAL $ Check# c Z- s [r Q j Building Inspector NORTH Town o . t E ndover O -P W, - � Sl %I.- 2,biZ h ver, Mass 2,S- Z �` oLAKI coc MIc"two'" y1' AQRATEo PPp��S S tl - BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System Pr 1ATHIS CERTIFIES THAT ......... .� ��� BUILDING INSPECTOR has permission to erect .......................... buildings on 1. �... . .. .., `&A Foundation O 411111111h, .Rough to be occupied as ....... , ' ..... .......... ............... ..o.. .®..14.0.................... Chimney provided that the person accepting this permit shall in every 1'espect conform to the terms of the application in O on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and /sea; Construction of Buildings in the Town of North Andover. PLUM G INSPECTOR Roug VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTSRough �0 ..............� ••• ��... ....... Service ............ • BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired 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. 3 Smoke Det. }} pHpRTH,ry t o a 4 i ; •y,SS^00 C"U's 9 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 378-2016 on 9/23/2015 Date: November 12, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 21 High Street— Suite 202 MAY BE OCCUPIED AS a tenant fit up — Corporate Benefit Audits IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG N.A. Mills LLC 21 High Street North Andover, MA 01845 BuiYding Ins�ector Fee: Prepaid $100.00 Receipt: 29405 Check : 2291 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 80,118.00 m $ - $ 961.42 Plumbing Fee $ 120.18 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 120.18 Total fees collected $ 1,301.77 21 High Street Suite 202- Corporate Benefit Audits 378-2016 on 9/23/2015 TENANT Fit up NORTH Town of . � E ndover 0 � - No. _ * _ 2,b z ti oLAKO h ver, Mass, X11. � O C0CNIC"2W1CN 1. qs U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS.CERTIFIES THAT .� ..., � LL� BUILDING INSPECTOR ......... ....... .... ............................................ .. 11 has permission to erect .......................... buildings on 2.111.. . . ..,.5\. ��'.L�,,,,ZOZ Foundation Rough tobe occupied as ....... ........................... W.................................................................. Chimney provided that the person accepting this permit shall in every 1'espect conform to the terms of thea application pp 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 CONSTRUCTION STARTS Rough Service BUILDING INSPECTOR Final 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. d OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER � CONSTRUCTION'�;yn•m.�.� n�wr CONTROL FS4rHy..}'1 I I PROJECT NUMBER: 14-0683 D PROJECT TITLE: Corporate BenititS Audit - Tenant Fit Out PROJECT LOCATION: 21 High Street; N. Andover, MA NAME OF BUILDING: East Mlii NATURE OF PROJECT: Tenant Flt Out IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, I, ])ONAL-D W AL-- e-,R—. PZIEGISTRATION NO. 9.53(0 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 I 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. &AA PPP G�gT E R D,y 2. Review and approval of the quality control procedures for all code-required controlle 3. Be present-at intervals appropriate to the stage of construction to become, general � Cc) iliarNo with6the progress and quality of the work and to determine, in general, if the work ii g Stir ?6 7D * g performed in a manner consistent with the construction documents. e PURSUANT TO SECTION 116.2 .2 I SHALL SUBMIT WEEKLY , A PROGRESS REP ��T of sP��J�A � TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING IN wvv' � UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. 5� SIGNATURE SUBSCRIBED AND SWORM TO BEFORE ME THIS a i - DAY OF 5E Ca F 20 1S CHERYL L. SURKINSHAW t Notary Public NOTA PUBLIC MY COMMISSION EXPIRE Commonwealth of Massachusetl My Commission Expires March 7, 2019 i Standard Form of Agreement between owner and RCG LLC where the basis of payment is the Cost of the work Plus a Fee without a Guaranteed Maximum Price Date: September 18, 20IS �r Owner: µRCG "A'ndMilts SLC Clo RSG L.LC i 7 lvaloo.Street;,Sii te'I do aY Somerv1Ite MA Q21 3 y Contractor: ! & K.Contracting LLC r �o Architect: Dore &Whittier:r Project Name: "Corporate Bereft Audits 21 High Street S061102— The ite 2021The 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 j 2. Contract Sum 3. Project Schedule 4. Signatures Exhibits Exhibit A: Estimated Cost of Work Exhibit B: Project Schedule Exhibit C: Drawings I Page l of 6 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 Liabilit Gomrrmerctal:General;'Liabil'r $1 10'00000:00' 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: 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 shalt be resolved by mediation or by arbitration. Prior to arbitration, the parties shall endeavor to reach settlement by mediation. Pagge2off6 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 casts, including the fee is as shown below: `$80,11;8 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: 10% of total construction volume. 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 billed monthly in arrears. Total Construction Volume excludes permits and fees, which shall be paid directly by the Owner. Construction management labor, standard tools and equipment, and labor-related overhead are covered within the fee. Specialty tools or equipment and any trade labor supplied by J&K personnel shall be charged separately. If a project is terminated or suspended.by the Owner prior to completion, J&K shall be compensated for the actual cost of services provided prior to receipt of notice of termination or suspension from the Owner. 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. Pane 3 of 6 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: 1'Q%gOf'b�lleCl costs,unless otherwise a'_ r`,oveti'b 'the Qwner 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. 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. <<Se t+ mber;18, or:"such time that NotM60''nito Proceed is ivan b ';Owner, 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: Date ofSubstant((,Completion to be no later than NovemberA, 2015 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. Paque 4 of 6 4. Signatures r The Owner's representative is: Q t befr� anagdr Som rv��I I ��1 § 14.4 The Contractor's representative is: K ibran&off N9 Xt a This agreement is entered into as of the day and year first written above and is executed in at least three original copies, one for the Owner, one for the Contractor, and one for the Architect. I Owner Co tractor v_ SiChia e .. . Signature Printed Name and Titl Printed Name and Title CJ I K c Page 5 of 6 Corporate Benefits Audits Construction Estimate 9/18/2015 Schedule of Values Estimated Cost General Conditions $ 3,400.00 Demolition $ 4,000.00 Frame walls $ 2,500.00 Move Glass Walls from Converse and install $ 2.500.00 Insulation $ 500.00 Drywall &tape $ 7,500.00 Prime and Paint $ 7,500.00 Cabinets and Countertops $ 3,500.00 Doors &Windows $ 4,000.00 Flooring $ 16,800.00 Sprinkler Work $ 900.00 Electrical $ 6,885.00 Plumbing $ 500.00 HVAC $ 12,350.00 Subtotal $ 72,835.00 ,1K Contracting Fee $ 7,283.50 Total $ 80,118.50 I Page 6 of 6 The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Sheet, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Name(Business/Organization/Iudividual): � .yc VQ G--- �L . R e Address. J) _ City/State/Zip: kA G Y J'-_rtAj �Vo� Phone#: U Are you an employer?Check fit�le appropriate box: Type of project(required): 1 I am a employer with C.-,—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. b4 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition IFI I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 F1 Building addition 4.F]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.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14. 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. I 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 fiave employees,they must provide their workers'comp.policy number. lam an employer tfzat is providing workers'compensation insurance for my employees.'Below is thepolicy and job site information. Insurance Company Name: �� p — ) Policy#or Self-ins.Lic.#: ��" _ 3 1�— 11 —�Expiration Date: Z t 7 1.J Job Site Address: J �� �� -2 1 2" l City/State/Zip: Iv 4N 10 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date' L_ J Phone 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 Iocal 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 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 pennit/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 s 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 3/3/2015 7::22:03 AM PST (24T-8) FROM: 100005-TO: 16174799121 Page: 2 of 2 C�Rt7� CERTIFICATE OF LIABILITY INSURANCE DA3ouivow"M 3/3/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an sndorset ent. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorseme a). PRODucER DUPONT INSURANCE AGENCY INC 18 COPELAND ST FA'L QUINCY,MA 02169 EarAe niquaERIS)AMOFMING COVERAGE NAIC e INSURERA: Liberly Mutual Fire Insurance 23035 �JKCONTRACTING LLC �URERn: 3WEYMOUTTHN MAT0221188 NBLIRER D IINSURER E: COVERAGES CERTIFICATE NUMBER: 23677622 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. I� POLICY EFF POLICY N Elm LRS L TYPE OF DANCE POLICY NUMBER COMMERCIAL GENERAL LIABLITY EACH OCCURRENCE E CLAIMS-MADE F-1 OCCUR PREMISES MeS MED EXP(Any oneperson) S PERSONAL a ADV INJURY S GENI AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S CT 7 LOC PRODUCTS-COMPIOPAr3G $ POLICY 7 JEE OTHER: `l!MZR1r1F=LIMIT S AUTOMOBILE LIABILITY IES 8001dwAt BODILY INJURY(Per peraw) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per seddert) $ AUTOSTNN OS RrV DAMAGE $ ddeirM HIRED AUTOS AUTOS B UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ S A wORKERScoISPE+BATION WC2-31 S-001696-015 2M 712015 2/17/2016 ATUTE AND EIMPLOYM'LJABLI Y E.L.EACH ACCIDENT $ 100000 ANY PROPRIETORIPARTNER�mcurNE YIN N N I A OFFICERIMEMSER EXCLUDED? ❑Y E.L.DISEASE-EA EMPLOY $ 100000 (Mandatory in NH) 500000 If yyeess deserbe under E.L.DISEASE-POLICY LIMIT oRM4(PTION OF OPERATIONS bebw DEBCWTION OF OK-MTWW J LOCATIONS I VBBCLEB(ACORD 101,AdMoml Remarks BdsdW%my be stedwd It more spoon Is raqulred) Workers compensation Insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. :ii,w.nr •- AlrT1rORIZED REPRESENTATIVE Lib Mutual Fine Insurance 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2011/01) The ACORD(tame and logo are registered marks of ACORD CERT NO.: 23677622 CLIENT CODE: 1644469 Lucy Gazfield 3/3/2015 10:19:07 AM (EST) Paqe 1 of 1 A6 d CERTIFICATE OF LIABILITY INSURANCE 7'"�"'°°"""' 3215 THIS CER7IFICATE 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 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOMER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policyooB) must be endorsed. If SUBROGATION IS WAIVED,subject to the berms 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 endorseme PROMICHt Maria Dupont Insurance Agency, Inc. PHONE 1B Copeland Street 17 376-0795 . (617) 479-9121 Quincy, MA 02169 15me du ntinsurancea en .corn INSURERS)AFFORDING COVERAGE NAIL• INSURERA:Main Street America MURED INSURER B: JK Contracting, LLC INSURERC: 31 Richmond Street INSURER D: Weymouth, MA 02188 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 / ACMD SUM LTR TYPE OF INSURANCE POLICYNUMBE! MMIDD/YYYY Lam A TE+T� � LIATY MPT7794M 2/10/15 2/10/16 EACHOCCURRENCE $ 11000,000 �( COMMERCIALGENERALLLABILITY DAM4GETORENTED $ 500,000 CLAIMS-MADE ❑X OCCUR MED EXP(Any one person) $ 10,000 PERSONALBADVINJURY $ 11000,000 GENERAL AGGREGATE $ 00 O0 GEN'LAGGREGATELIMITAPPUESPER PRODUCTS-COMPIOPAGG $ Z OO 000 POLICY F7 P LOC $ AUTOMOBILELIABIUTYWD, dent) $ ANYAUTO BODILY INJURY(Per pemon) S ALLOWN=D SCHEDULED AUTOS AUTOS BODILY INJURY(Per aeddeM) $ ROPERrY DAMAGE HIREDAUT0.S _DOS ED Pera ' t) $ S UMBRELLA W1BHLAIMS-MADE CCUR EACH OCCURRENCE $ EXCESS UAB AGGREGATE $ DED RETENTION WORKM COMPENSATION I WC STATU %H AND EMPLOYERS'LJABILITY Y I N ANY PROPRIETORIPARTNERIE)OWTNE OFFICEWMEMBER EXCLLDED? NIA E.L.EACH ACOCENf IMandabry in NN) E.L.DIS EASE-EA EMPLOYEE Kye8 describeunder DESdRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ CESCRIPTION OF OPERATIONS I U)CATKM I VEHICLES(Amch ACORD 101,AdMdor aI ftnv ft$e o*&,Ifmore spa b ngd md) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATM Bridget McGowan 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: apedranti@crowninshield.com Massachusetts -Department of aubi.::Safety Board of Building Regulations and Standards Con.truction S»pcn j%,or License: CS-03 r� IMRAN I WMW 4t r !r i 31 RICKKOND ST �Y1VI0UTH MA tEx 091261ticn 091 2812015 commissioner