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HomeMy WebLinkAboutBuilding Permit #541-2011 - 21 HIGH STREET 1/21/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: l'a011 Date Issued: Zl/1/ Date Received 'ANT: Applicant must complete all items on this LOCATION 'at \Ak Qy� �� Print PROPERTY OWNER C�- '�. �' s C)- ', t\ Print MAP NO: _PARCEL: Vb ZONING DISTRICT: Historic District(TR) no Machine Shop Village no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family 0 Addition 0 Two or more family ❑ Industrial Alteration No. of units: 0 Commercial 0 Repair, replacement 0 Assessory Bldg ❑ Others: 0 Demolition ❑ Other iD�Septc 0`Well ! (�►Floo am �Wetlan s� v+o 'WatershedtDistrict DESCRIPTION OF WORK TO BE PERFORMED: Pau l l z 140 q- � ZVZ— lmtj c,—' $ �m SA potj Identification Please Type or Print Clearly) OWNER: Name:g V � 0 -Zr G t r1 SIN YL G K Phone: .� V 0-0 —. a titis Address:Z� � \130, . 1- V -S i=' CONTRACTOR Name:Phone Address: At,,3w O gk- dynes i�-iat-\; 1 Vll°�S" S o1At (� Supervisor's Construction License: C ���a�� Exp. Date: (4, �'�\A Z—� �L • , r Home Improvement License: g \-kA Exp. Date: \ L ARCHITECT/ENGINEER C\ C " �\,S S.\00 tAL-Phone: �o�Z Address:. �� k*r 0, \�-�j►-�t�� �T'��stsrwc �� 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: $ Check No.: 0 0 16 21_. Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 DATE REJECTED PLANNING & DEVELOPMENT COMMENTS DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS a 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 ✓ Located at 124 Main Street i4l Fire Department signature/date COMMENTS we, 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 - Date Doc:.Building Permit Revised 2008 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) ❑ Muss 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: Doc.Building Permit Revised 2008mi Location No. may/ - 2 4ii Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ - Building/Frame Permit Fee $ 1'�1 G -1.� � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # %4.Z Z_ i 4 2359 wilding Inspector J �' 1 1 CO) m m m Cl) mm v F 'v C d — d CO)CD o d O n• r O C2. y o p CD CDCL O Q CDCD 0 CD p o0 3 C O V!� �O CO) co CD S- CA O CD Z o CD 0 CD C c Er ca O —•vioQ N aoSa .o to m � m C•7 O ca CO m'n= z o, °:o o 0 -M CL ^� CL = m CD -qa CD y p CO) —1 o CD : a o m 1 0 CD .:� C Sr ='a,: ' r a E o'm cn c C=D CD H cn m 'T1 o 1° not COD, O Cv CA zW � cn � o 1i1 CA C tp .. o ti • � y CA CO md CA •`' .....� , Ooma: Z O r�. o cn P: cnCD CD d o� o = Co N 9 c 4O � �1 O O Crl w "� oGa p= Pd oGc r C/ Irl Oov. 7d 7d h V O go. Permit Affidavit Project Number: Suite 211— TENANT FITOUT Project Title: EAST MILL Project Location: East Mill North Andover Name of Building: 21 High Street, North Andover Nature of Project: Commercial Tenant Fitout In accordance with section 116.0 of the Massachusetts State Building Code, I Jai Singh Khalsa Registration No. 6042 being a Registered Professional Engineer/Architect hereby certify that I will prepare or directly supervise the preparation of all design plans, computations and specifications concerning: Entire Project— Fire Protection HVAC Plumbing Electrical Other(Specify) ARCHITECTURE For the above named project and that, to the best of my knowledge, such plans computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and applicable laws and ordinances for the proposed use and occupancy. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in section 116.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for building permit, and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code required controlled materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standard listed in Appendix B. Pursuant to section 116.2,3 1 shall submit periodically, a progress report together with pertinent comments to the North Andover Building Inspector. Upon completion of the work, I shall submit a final report as to the satisfactory completion and. readiness of the Oancy. �\NGll k � y9< No. 6 1/20/11 Date On this20JL_, before me, the undersigned notary public, personally appeared k S1q=,N (name of document signer), proved to me through satisfactory evidence of identification, which were 14" lbtiE , to be the person whose name is signed on the preceding -o, attacted document, and acknowledged to me that he/she signed it voluntarily for its' stated purpo: e. My commission expires, NOTARY PBIC " `► ' �J61.� 76�Jt1 a I A r 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 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 I. 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 Gomrnercial' General Liabil� 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 shall be resolved by mediation or by arbitration. Prior to arbitration, the parties shall endeavor to reach settlement by mediation. Page 2 of 6 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 Kieran Whelan $125/hr Jason Downing $50/hr 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 Page 3 of 6 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: 1,0%`of Isilled dosis; (unless othe'n+uisea rowed b xthe ,Own'er P 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 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. January.l0`2Q�1;tir. such #ime:'tha# e" d" �s iven,hy.0uyeE 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: Qate bf su6stant�al Corti letion fo be;rto date' than Marci>i-31 2Q11 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 4. Signatures The Owner's representative is: ©avec# SteinberghManag r 1 CG North Antiou >� lilk i .0 �7 tvaloti Str�e#, St�i#e 1a0' Sa�r't�eiv�lle; �iA�i r�2��4:3 § 14.4 The Contractor's representative is: Kteran Whe�ari Cons�r�action�Supervisor RCG I.LC '17 lvatd'6 S rir6t, Sur#e f Somierville, aMA C�21°�13 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 Signa re Signature Printed Name and Tiflbj Printed Name and Title Page 6 of 6 4rYj..*tj /i. DSA Detection - Suite 211 Fit Out Schedule Estimated Cost 1/10/2011 Demolition Demo existing flooring in P -W -CR, demo men's bathrooms. $ 5,000.00 Doors & Windows Provide painted doors to new offices $ 2,000.00 Frame & Insulate Walls Frame and insulate new walls per plan $ 9,000.00 Tape/Prime/Paint Provide painted finish for all drywall finish walls per plan $ 3,000.00 Paint/Seal Concrete Flooring P -W -CR rooms $ 2,000.00 Plumbing Bathrooms per plan, recess kitchen $ 15,000.00 Electrical Provide dedicated, submetered electrical service with panel on Premises. Provide outlets and service to equipment locations and lighting locations to satisfy code and customerspecifications. $ 19,000.00 Sprinklers Update sinklers to satisfy code per plan. $ 1,200.00 HVAC Replace one heat pump and add zone dam er for Clean Room. $ 16,000.00 General Conditions Dum sters, cleanin , supplies $ 2,000.00 Subtotal Sub -total $ 74,200.00 RCG Builders fee RCG Builders fee $ 11,130.00 Total Total $ 85,330.00 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 n www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Pr><nt Le�><bly Name (Business/Organization/Individual): P L' G-- (� Address: 7 I p oq CC) 0 City/State/Zip: So Mei �' 4 pq 01( 4-? phone #: Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors Policy as new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: W L5 _<, e. Q Policy # or Self -ins. Lic. #: l✓ h% Expiration Date: -S7 Job Site Address: rpt or 4-1 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 $250.00 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 andpenalties of perjury that the information provided above is true and correct Sienature: P Offrcial use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): Permit/License # 1. Board of Health 2. Building Department 3. City/Town C16rk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Are you an employer? Check the appropriate box: 1.r I am a employer with 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* 2. F_1 I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work myself. [No workers' comp, right of exemption per MGL c. 152, § ](4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *Any applicant that checks box # 1 must also fill out the section below showin theirk t Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors Policy as new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: W L5 _<, e. Q Policy # or Self -ins. Lic. #: l✓ h% Expiration Date: -S7 Job Site Address: rpt or 4-1 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 $250.00 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 andpenalties of perjury that the information provided above is true and correct Sienature: P Offrcial use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): Permit/License # 1. Board of Health 2. Building Department 3. City/Town C16rk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: ACORD- CERTIFICATE OF LIABILITY INSURANCE 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 6;02,2010""""' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE MARKETING AGENCIES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 306 MAIN STREET WORCESTER, MA 01608 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. LIMITS 508 753-7233 INSURERS AFFORDING COVERAGE NAIC # INSURED RCG LLC INSURERA Wesco Insurance Company 25011 INSURER B: 171valoo Street, Suite 100 Somerville, MA 02143-3656 INSURER C: INSURER D: INSURER E: COMMERCIAL GENERAL LIABILITY 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. INS IM KDWL N TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDD—DATEMM/DD POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY $ DAMAGE TO RENTEDPREMISES (Ea CLAIMS MADE OCCUR occuffence) A� MED EXP (Any one Parson) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ POLICY PRO-- LOC CT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per p—) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Peraccident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC $ ANY AUTO AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR ❑ CLAIMS MADE $ DEDUCTIBLE $ RETENTION $ A WORKERS COMPENSATION AND W WC3010833 05115110 05/15/11 X OR STATUS LIMITS OTI EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE -EA EMPLOYEE s500,000 OFFICER/MEMBER EXCLUDED? YES descnbe UndefS E.L DISEASE - POLICY LIMIT 1 $500,000 SP ECIyes, AL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT i SPECIAL PROVISIONS FOR INFORMATIONAL PURPOSES LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 2(j_ DAYS WRITTEN M TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL W NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVE ACORD 25 (2001/08) 1 Of 2 #S188839/M188838 1 GCE - 0 ACORD CORPORATION 1968 Location o7/ //� i'`we/ �. I�S� �F7-V Date NOR, TOWN OF NORTH ANDOVER °> Certificate of Occupancy �$ Buildin /Frame Permit Fee $ su„usa 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0/O w 2 4 LL,/Building Inspector w i n e44 t CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Peririit Number 541-2011 Date: Maroh 30, 2011 THIS CERTIFIES THAT THE BUILDING LOCATED ON 21 Hi Street, .2nd floor, North Andover, MA DSA Detection MAY BE OCCUPIED AS tenant build out IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate, WOO to t Fee: 100.00 : Receipt: 24004 RCG - NA Mills, LLC 21 High Street North Andover, MA 01845 Building Inspector m m X m VI m mm C c��0 m O S" a N � :m o o y CD Hma=. = Z �b y -4 0 .=-r � .d.► . m C T CD = O m'y p y p •M s' m CA ,` m a o,c O = 0, -. -, Er o' =Er .'a-: C/) ^ C CD .y oa l J O p' y f'? O N cm _: N �7 CD t0 ` N Co OFF O oma: z O ®oma z ,CD �� o� . m �L •�� C/) w N b r N't_Co. _� o6 = CD. 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LW o Ilk &n ¢� � , c� Z o x 0 c ►s u KHALSA DESIGN INCORPORATED Architects & Engineers 17 lvaloo Street, Suite 400, Somerville, MA 02143 .017-591-8682 / f. 017-591-2086 ARCHITECTURAL FINAL AFFIDAVIT March 31, 2011 City of North Andover, Inspectional Services Department North Andover, Massachusetts RE: DSA DetectionTenant Fitout, East Mill, 21 High Street, North Andover, Massachusetts Khalsa Design Inc. has visited the above referenced project during the construction period, and has provided construction related services in conformance with the Massachusetts State Building Code, Controlled Construction Section, 780 CMR §116.0. 1 verify, that to the best of my knowledge, information and belief, that the building has been constructed in substantial conformance with the construction documents for the project. The detection of, or the failure to detect, deficiencies or defects in the construction during review by this office does not relieve the contractor or its subcontractors of their responsibility to correct all deficiencies or defects, whether detected or undetected, in all parts of the work, and to otherwise comply with all requirements of the Construction Documents. Mass Registration Seal # 6042 Then personally appeared above named Jai Singh Khalsa made oath that the statement made by him is true. Before Me, Cie ''� �s= Mme. M i i1 �