HomeMy WebLinkAboutBuilding Permit #959-16 - 2350 TURNPIKE STREET 3/9/20164 \ 4
Permit NO:
Date Iss
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this
LOCATION
Print vX a:6�
_e
_ V
PROPERTY OWNER 'OLf v\_ r
Print J I
MAP NO: O_PARCEL:_M� ZONING DISTRICT: Historic District
f Machine ShOD Vi
yes no
ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
[] One family
11 Addition
11 Two or more family
0 Industrial
0 Alteration
No. of units:
WCommercial
XRepair, replacement
E Assessory Bldg
Ll Others:
, Demolition
)KOther
El Septic 11 Well
El Floodplain 11 Wetlands
El Watershed District
0 Water/Sewer
I
I I
-A' cJ e;t— A
Identification Please Type or Print Clearly)
C b_� & O�A, 7Z. t Phone: 7?'- r7a'� 7 'T
OWNER: Name:
Ll <T
Address: Z3 s7o
CONTRACTOR Name: 6 Phone: q7T-5-13-3300
Address: IA14 Din
Supervisor's Construction License:
Home Improvement License:
e�5 - 10-� Or3
Exp. Date: 0 Z.2
Exp. Date:
ARCH ITECT/ENGINEER Phone:—
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMA TED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ /60 /. /C� 5 -1 FEE: $ � C� 54 83
Check No.: At Receipt No.:
1 -4 -, ! E f -3 4 ! -5(2 ' ii�:Q=
NOTE: Persons contracting with unregistered contractors do not have access to the`gua1;(ftn7,fqnd
Signature of A ent/Owner Sicinature of contracto,
t%ORTH A
BUILDING PERMIT
TOM OF NORTH ANDOVER
APPLICATION FOR PLAN EXAM I NATIO,N`-i`-*.
Permit No#: Date Received'
US
Date Issued: IMPORTANT: Applicant must complete all items o6,thls.�page
LOCATION
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
El One family
El Addition
El Two or more family
11 Industrial
[I Alteration
No. of units:
El Commercial
0 Repair, replacement
0 Assessory Bldg
El Others:
El Demolition
El 0 ther
EI.Septic 0 Well
0 Floodp [ain El W lands,
p -Wqfi�rs ,ed: District,
p Vy8tqr(-
DESCRIPTION OF WUKK I U bt FtK1-UK1V1t:L).
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
At4t4nnee-
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date --
ARCH ITECT/ENGI NEER
Phone:
Address: Reg, Nlo�, -
' — ' 7
FEE SCHEDULE.- BULDING PERMIT: $12.00 PER $1000-00 OF THE TOTAL EST1PAATEaC0&1V.A-SED ON $125.00 PER S.F.
Total Project Cost: $ FEE-. $
Check No.: Receipt No:..:
NOTE: Persons contracting with unregistered contractors do not have, access. to the guarantyfund
Plans Submitted Plans Waived F1
Certified Plot Plan L1 'Sta'rnpe'd Plans L1
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art L]
Swimming Pools
well El
Tobacco Sales
Food Packaging/Sales El
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH
GOMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connectioni Permit
DPW Town Engineer: Signature:
LOcatea M4 USgOOCI btreet
s i
R, n -K
x Tk ki,�gn s�L t
HP
MM"Aft ak hfi�Wrrdi&ft
6
M M
Dimension
Number of Stories: Total square feet of floor area, based on �xterior 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.$100-$l 000 fine
Nu i t5 ana UA I A — (t -or aepartment use
Q Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
Building Deparbrrian
., t
1� ---p
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4. Building Permit Application
4� 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 .
1OTE: 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
IOTE: 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
Doe: Building Permit Revised 2014
I. I — 4
'-�Wl --T`Y�Ajf) UI -
Location r
No. C1 5-� /611 Date,3141/(/
Check
TOWN OF NORTH ANDOVER
Certificate of Occupancy $- (
1 qo
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $- P
TOTAL $
Building Inspector
Dimension
Number of Stories: Total square feet of floor area, based an Exterior dimensions.—
Total land area, sq. ft.: /aO
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 21 A —F and G min.$100-$1 000 fine
NOTES and DATA — (For department use)
Ell Notified for pickup - Date
Doc.Building Permit Revised 2012
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Sold -To (H 1) 1 11,tn k� L-tm j t-4
Street ZI ->
Ci ty
State Zip
ContactNarne:_ L—aic- 114
-P
Telephone Z7
Fax #:
E-mail Address E-Qtc Q'FIIA, Lf� AA i ji r(D. C 0
_j
Bill -To
(.Cu.stomer name wliere the invoice will be mailed, if different from above�
Ship -To
Street
elf
City
Stat ]p
Contact Name:
Telephone #
Fax #:
E-mail Address
P ayer
(Customer name who will i)ay the
W ; i � �: -1 S_ ---- I --- IT.
Job Number = 1!:1
1 11 1 11115 C."t'.1t A.—I
if different from above
NEFVBOOKINFo
Regional Sales Rep
SHEET
_ _I
Billab:1e Rate 61.!; S
61. f
-INF
S 1c) 1. 4
National Account Rep
Technical Rep
AutoQuote # . L- 2 -VS
AutoP.roposal N C) C)
Proposal Aniount $
I 2_.T
Roof Systern Code Pr__rPrzr __
'ImEa�s -c
7_q 1.itLT
1b 71
Percentage
Payment Terms
Start Date HNt-
Labors Hours Bid la3,5
Total Hours 3
Scan YES or
Warranty 9 Years
Tear off or NO
Deck Replacement
— YES ORdqD
D e ck Type..
Warranty Name
FL-t-iE Lt.,4A AKL, COAPOZ4110
InsulationType X-sc::,
-1
O-V� IIUIN — SQ. FT. SYSTEM WARRANTY
L4 -
. s-67 -,c> P C�
DEPARTMENT
FUNCTION
REFERRA
0< 0001
Facilities Dept
01
Site Contact
CALL
Call -In
0002
Purchasing Dept.
02
Purchasing Manager
COLD
Cold Call
0003
Sales Or-anization
03
Sales Mana-er
GOOD
Goodwill
0004
Maintenance Dept.
04
Personnel Mariauer
HBID
Hard Bid
0005
Administration
05
Billin-s Contact
REFL
Referral
0006
Roofing Department
06
Payer Contact
NATL
National Accounts
0007
Quality Department
07
Corp. HDQT Contact
SERV
Service
OOOS
Flooring Department
08
Office Contact
STOR
Storin Darria�e
0009
0010
Financial Department
Legal Department
09
Fin. Accounting Contact
TELE
Telemark-etin'a — HLQj4rj
10
Marketing TvIanager
TRAD
Trade Shows
I I
Maintenance Person
INDUSTRYT . YPE:
13
0 wn er
CUSTONI EP. TYPE
(Use the SIC List
on the Centranet)
14
General Manager
15
Plant 1%,13nage,
New National CLISLOIII,-r
17
Plant Engineer
EN
Existing National Cu
Old (,ntlqt
Is
Vice President
NR
o _�tojjjcj
NI'ew Reaininl Ctitom,,.
b -A
5-2Ob6
JOI/
Job Number: Reference Number:
Name: Flame Laminatinz Corporation Name: Flame Larninatin2 Corporation
Address: 2350 Turnpike Street Address: 2350 Turnpike Street
City: North Andover City: North Andover
State: Ma. Zip: 01845 State: Ma. Zip: 01845
Contact: Eric DiGrazia Phone: (978) 725 9527
Phone: (978) 725 - 9527 Building(s)/Section(s): Sloped Roof, Lower Roof, BqL
A escription o -Wbrk��,--',
Per Proposal Dated: CentiMark A -P 4 195966 - Project will be committed NOW and scheduled on or before May V
2016. Emergency Roof Repairs will be performed NOW by CentiMark at NO COST to Owner to help mitigate roof
leaks until project commencement in 2016.
And/or as follows: On the Body Shop & Lower Roofs, Flame Laminating will be responsible for the Unit Costs of wet
roofing/insulation damegd decking up to the first 10% (1,200 sq ft) If MORE than that needs to be replaced, it will be
done at NO ADDITIONAL COST to Ownership.
Purchase Price: $161,125
Purchase PO#:
Centimark Sales Rep: David Pineo
Office Location: #1800
Phone: (978) 513 - 3300
Bank Name:
Address:
Phone:
Trade References:
1. Trade Reference:
Address:
2. Trade Reference:
Address:
3. Trade Reference:
Address:
City:
City:
City:
Warranty to be issued in the name of-.
1. Flame Laminating Corporation
2.
Warranty Length/Yrs: 20 Years Total System Warranty
Payment Terms: 1/3 down - balance net 30 upon
completion Y"
Purc haser to initial acknowledgement of Payment Te
Account #:
Contact:
City:
State:
State:
Phone:
Zip
Phone:
Zip
Phone:
State: Zip
2 01 z
By my signature below, I certify that I have authority to bind the purchaser and have had the opportunity to review the terms of
this Agreement, including those set forth on the second page. On behalf of the Purchaser, I understand and accept said terms
and agree to be bound thereby; and acknowledge that a sample copy of the warranty has been provided for my review. I also
authori74 the release of credit information to Centimark Corporation.
Eric DiGrazia - Owner 0 —CL es
A�proved and acefpted*�—yPurcKaser Printed Name and Title Date
SUBJECT TO THE FOLLOWING TERMS AND CONDITIONS ON SECOND PAGE
INITIAL PAGE I
Vj-_'UUU
Z01 L
This Sales Agreement confirms the purchase of the services and work described in the CentiMark Corporation
Proposal to the Purchaser and the Sales Agreement. The Scope of Work is limited to what is stated in the
Proposal and Sales Agreement. Unless specifically stated other -wise, the Purchase Price does not include the
cost of perfori-ning the Work with union labor or at prevailing wage rates; nor does it include removal or
abatement of any hazardous materials, including but not limited to asbestos. Purchaser acknowledges that it is
responsible for obtaining any structural, engineering or other architectural analysis of the building(s) on which
the Work is to be performed.
Unless otherwise stipulated on the face herein, the Payment Terms covering this Sales Agreement are: One third
(1/3) down payment with balance due net 10 days from invoice. In the event Purchaser fails to pay any balance
when due; then the entire balance shall immediately be due and payable. A Service Charge of one percent (1%)
per month will be added to all Balances past due thirty days. This sale is subject to credit approval by
CentiMark and Purchaser hereby gives CentiMark express authority to check the credit references of the
Purchaser.
Any disputes or actions relating to or arising out of the Work to be performed pursuant to this Sales Agreement
shall be exclusively governed by the laws of the Commonwealth of Pennsylvania. Jurisdiction and venue of
any action or proceeding arising out of or relating to the Sales Agreement shall be vested in the state or federal
courts in Washington County, Pennsylvania. Purchaser irrevocably waives any objections it now has or may
hereafter have to the convenience or propriety of this venue.
The performance of the Work contemplated by this Sales Agreement shall be governed solely by the Ternis and
Conditions stated herein, and no other terms and conditions, order acknowledgement or purchase order or any
other documentation furnished by the customer shall be construed as an acceptance of any terms or conditions
contained in such document which are inconsistent with the Terms and Conditions stated herein, unless
accepted in writing by a Corporate Officer of CentiMark.
The only warranty to be provided by CentiMark to Purchaser will be the CentiMark Corporation Non -Prorated
Limited Warranty for the length of time stated on the face of this Sales Agreement, which terms and conditions
shall govern all warranty matters between CentiMark and the Purchaser herein. To be valid, any changes to the
Warranty must be specifically approved in writing by a Corporate Officer of CentiMark Corporation.
NOTICE
Purchaser acknowledges and agrees that Moisture may have entered into the building prior to
CentiMark's roof installation and/or repair of the roofing system, which may have resulted in Mold
Growth. CentiMark disclaims any and all responsibility for damage to persons or property arising from
or related to the presence of Mold in the building. By executing the contract to which this Notice is
affixed, Purchaser agrees to the following: 1) releases CentiMark from any and all Claims Purchaser and
Purchaser's insurer, employees, tenants and/or any other building occupant or invitee may have as a
result of such Mold growth; and 2) agrees to defend, indemnify, and hold harmless CentiMark from any
and all penalties, actions, liabilities, costs, expenses and damages arising from or relating directly or
indirectly to the presence of Mold on or in Purchaser's Building.
INITIAL PACE 2
Flame Laminating Corp. - North Andover, MA
.4-4-4.4 Construction Specification o-io�o-o,
Flame Laminating Corp.
2350 Turnpike St
North Andover, MA 01845
Specifications For CentiMark RoofBond Systein
0
Sections included: Body Shop, Lower Roof, Pitched Roof
Project Preparation:
Perform a pre -job meeting to determine jobsite logistics and safety requirements.
Furnish and install temporary rooftop chute assembly for debris removal.
Furnish and install proper safety equipment in accordance with Centimark's written safety program.
Safety Related
Furnish and install warning lines to identified areas associated with ground related roofing activities.
Store roofing materials in accordance with good roofing practices. Material placement will be to distribute weight
loads throughout the entire roof area. 0
The power lines along the Body Shop must be blanketed prior to the start of roofing work. The blanketing of the
power lines will be coordinated between the property owner and their service provider.
Surface Preparation:
Remove and dispose of EPDM roof systems down to the original B.U.R. The primary layer of roof will be spot
cored for deteriorated/wet insulation. If any is found, it will be removed and replaced at a unit price of $1.25 per
square foot per inch of thickness. Areas of removal will be approved by an Owner's representative. (Body Shop,
Lower Roof Only.)
Remove and dispose of the existing membrane. (Pitched Roof Only.)
Removal of existing roof will be limited to an amount that can be replaced the same day.
Inspect existing structural deck for deterioration.
Identify and remove structural deck not capable of providing an acceptable substrate for the installation of the new
roof. Furnish and install new deck at a unit cost of $8.75 per square foot. Areas of removal will be approved by an
Owner's representative.
The raised steel equipment supports will be cut up and removed from the roof. (Body Shop Roof Only.)
Remove and dispose of all skylights, the openings will be decked in with two (2) layers of 1/2" plywood and the
voids will be filled with rigid insulation boards.
Remove existing perimeter drip edging and dispose of debris. (Pitched Roof, Body Shop Only.)
Remove existing sheet metal copings and dispose of debris. (Body Shop, Lower Roof Only.)
Remove existing wall flashings to a workable surface and dispose of debris. (Body Shop, Lower Roof Only.)
CentiMark Confidential
0: view instructional video
Insulation Attachment:
Furnish and install a layer of V polyisocyanurate insulation, (R -Value = 5.6). This layer of insulation will be
mechanically attached to the prepared substrate utilizing FM Global (FM) approved 3" plates and fasteners.
Along the transition between the pitched roof and the body shop roof, a layer of 2" ISO insulation and a layer of
tapered insulation will be installed. The added insulation will allow water to drain more easily off the pitched roof.
Fumish and install tapered insulation at the roof drains creating a sump. (Body Shop, Lower Roof Only.)
Systent Application:
Furnish and install CentiMark 60 mil reinforced, TPO roof membrane
Position the TPO membrane over the prepared substrate and allow the membrane sufficient time to "relax" prior to
installation.
Install the new TPO membrane over the prepared surface by utilizing mechanical fasteners on 10 foot centers. (Body
Shop, Lower Roof Only.) 9
Mechanical attachment of the membrane shall be done utilizing a V wide polymer batten bar or 2 3/8" round seam
plates and FM Global (FM) approved fasteners. Maximum spacing 6" on center. (Body Shop, Lower Roof Only.)
0
Install the new TPO membrane over the prepared surface. Secure the membrane in place by welding it to the plates
utilizing induction methodology on 5' centers every 1 foot. The plates will be fastened to the roof purlins. This will
create a roof assembly whereby no penetrations shall be made to the membrane! (Pitched Roof Only.)
The thermoplastic membrane seams will be overlapped a minimum of 5", then hot air welded together. Weld width
shall be a minimum of 1.5" in width for automatic machine welding. Weld width shall be 2" in width for hand
welding. Upon completion of welding, each seam shall be probed to ensure proper securement. (P
HVAC Curbed Penetrations and Other Air Handlin Unit Details
(Body Shop, Lower Roof Only.)
Furnish and install at the base of the unit 2 3/8" round seam plates to the field membrane. Adhere a second piece of
thermoplastic membrane to the curb with bonding adhesive and install prefabricated -universal comers for
reinforcement. (Body Shop, Lower Roof Only.)
Pipes Less Than 6" In Dia eter
(Pitched Roof Only.)
Furnish and install new prefabricated thennoplastic pipe boot secured at the top with a stainless steel screw type
clamp fully adhered to the field sheet. (Pitched Roof Only.)
Stacks Greater Than 6" In Diamete
(Pitched Roof Only.)
Furnish and install a 60 mil, non -reinforced thermoplastic flashing, where applicable. (Pitched Roof Only.)
Miscellaneous Proiections
Furnish and install thermoplastic flashings to the roof projections. Upon completion of welding, each seam shall be
probed to ensure proper securement. (Pitched Roof Only.)
Furnish and install then-noplastic flashings to the roof projections. Upon completion of welding, each seam shall be
probed to ensure proper securement. (Pitched Roof Only.)
Furnish and install at the base of the unit round plates to be mechanically attached to the deck and the around the
perimeter of the projection. The membrane will then be attached to the plates via the induction welding process.
Install prefabricated universal comers for reinforcement. (Pitched Roof Only.)
Pipes Less Than 6" In Dia eter
(Body Shop, Lower Roof Only.)
CentiMark Confidential
view instructional video
Furnish and install new prefabricated thermoplastic pipe boot secured at the top with a stainless steel screw type
clamp fully adhered to the field sheet. 0
Stacks Greater Than 6" In Diameter
(Body Shop, Lower Roof Only.)
Furnish and install a 60 mil, non -reinforced then-noplastic flashing, where applicable.
Miscellaneous Projections
(Body Shop, Lower Roof Only.)
Fumish and install thermoplastic flashings to the roof projections. Upon completion of welding, each seam shall be
probed to ensure proper securement. 9 V-�
Sheet Metal Accessories:
Furnish and install new retrofit drain inserts into existing drains. (Body Shop, Lower Roof Only.)
Furnish and install new 24 gauge white then-noplastic coated metal gravel stop/drip edge with continuous cleat.
Standard Operating Procedures:
Employee Professionalism
All work shall be performed in a safe, professional manner in compliance with Centimark. policy.
Permits
CentiMark will supply the necessary permits for the project.
During permitting, the Town of North Andover may require the services of a certified professional. Any fees related
to obtaining permit approval are not included in CentiMark's proposal.
If the permit is purchased separately from the roof contract, CentiMark can submit all required documentation to
secure the permit on the owner's behalf.
Nightly Tie-In's
Depending on new roof system being installed, temporary water cut-offs are to be constructed at the end of each
working day to protect the newly installed roof system and building interior.
Clean Up
All work premises will be cleaned daily during the construction process and at the completion of the project.
Job Acceptance and Punch List
Conduct a post job walk through for final sign -off of ourjob completion form.
Warrant
Upon purchase of the roofing system, you become entitled to receive the benefits of single source responsibility
through CentiMark's comprehensive written warranty. This warranty protects your roof against defects in materials
or workmanship. If your roof leaks at any time during the warranty period, we will provide complete warranty
service.
Quote Name
Section Nam
Length
All Quotes.
All Sections.
20
CentiMark Confidential
(7o : view instnictional video
The Commonwealth of Massachusetts
Department of industrialAccidents
I Congress Street, SWte 100
Boston, HA 02114-2017
-www.mass.gov1dia
ex�s/Contr.,ictors/Fle�triciansfPliMbers.
Nyorker§', Compensation Insurance Affidavit: Build TING AUTjXORITY-
TO BE FILED WITH TM PER'�UT -M—_ b-+ I
Name, (B,,,i,,,�,,/Oigal3izationffndividual): I OCA-Ae_
Address:
City/State/Zip: VJUPI�lk Phone4-
Are you an era joye�j 6eck t& app6priate box:
Type ofproject (Vequired)v
V, a employerwith. (full andlor part-time).*
7. El NUVd6nstr�6tlon
1. am ___�mployecs
2.0 1 am a sole proprietor or partnership and ha'Ve no employees working formein
comp. insurance required.]
dellhg
8. Remo '
9. Demolition
any capacity. [go workers'
3.E] I am a homeowner doing all work royselt [No -workers' corap. insurance required.] t
10E] Building addition
to conduct all work on my property- I will
<1 I am a homeowner and will be hiring Contra' 'tors ro sole
either have w0rkers7 cO pensation insurance or arc
11.E]EjeeVicair airs oradditio-As
ppr
ensure that all contractors
proprietors with noa 0 1 yees.
jZQ:ptM-bjAg repairs or additions
5.F] I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These -contractors . h-6 e�aployee, and haw workers' comp. insurance -1
Kb6f re&irg
14.n Other-----.
sub
have exercised their right of bxemption per MGL 0.
6.Fj We are a corporatigii P[na iP. Off'c6rs. I
i comp. insurance required.]
I es. [No workers
iro Rl(A) and*eba�enoernpdyd
clow showing their'wOrkers' cOMP"sat'OnPo"ey'nformat'on.
*Any applicant that chOck§ -bbk #1 must also 0 out the section b 1 work and then hire outside contractors must submit I low affidavit indicating suck
I 'nij.�hi� thosqpntit�es�havc;
I who Ubl aM�a�lt indicating they are doing al ame of the sub -contractors and state wheXher OF Pot
TContractors that che 4�0jai d hn additional sheet showing the n
ck ox must attache
employees. If the sub contrac . to . rs ha.'Ve employees, they must provide their workers co -p. policy number.
ic nd)ob sit�
I am an employer that is providing Workers I compensation insurancefor my emplbyees. helow S t eP01 y a
information.
Insurance Company Name
(0 Expiration Date,
Policy # or Self -ins. Lie.
city/state/zip: MAI 01 d Ll
Job Site Address: J_3� 0 the policy number ind expiration date).
Attach a copy of the Workers' cOmpeu.satfou policy declaration page (showing
inal violation punishable by a fulb up to $1,500-00
Failure to Secure coverage as required under MGL c. 152, §25A is a crim fine of up to $250.0 0 a
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and 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.
ains and Ities ofperjury th at th e information provided above is true and correct
I do hereby certify under tkp %.
�t 11/_ P17 1, 3 / 3 /.z alor
� 7 T - �Y3_��o
fficial
o f
ficlal us, on,
j, Y. Do not write in this area, to he completed by city or town 0
City or Town:
Permit/License
issuing Authority (circle One):
1. Board of Health 2. Building Department 3. CityjTown Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Phone#:
Contact Person:
Information and Instrnctions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for theiK enip1byQes.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of
express or implied, oral or written."
An employer is'deffied as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enf6iprise, and including the legal representatives of a deceased employer, or the
receivek'6r, truitdd o1fan individual, partnership, association or other legal entity, employing empl6ypp9. - However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupa . dt 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 b6 deemed to be an employer."
MGL c i hapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of alicense or permit to opdrate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance covera,g6 ie4uired."
Additionally, MGL chapter 152, §25C(l) states'Weither the commonwealth nor any of its political subdivisions shall
enter intp any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of thi's chapter have been presented to the contracting authority."
Applicants
Pleasb fill out the Workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if
nece�saxy, supply s4b--'contractor(s) name(s), address(es) and phone munber(s) along with their certfflcate�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 orLLP do'e's have
employees, a policy is required. 13e advised that this affidavit may be submitted to the Department of fmdustrial
Accidents for corifinnation 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 requ�steq, not the Department of
IndustrialAccidents. Should you have any' questions regarding the law or if you are req*ed to obtain a -��6rkcrs'
compensatior! policy, please call the Department at the number listed below. Self-insured companies shoWd enter their
self-insurahe'o 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 permit/license number which will be used as a reference number. Jh addition, an applicant
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "fob 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 orpermit not related to any business or commercial venture
(i.e. a dog license or permit to bum 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
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
CENTCOR-01 MUDALIARTA
OIL— 4IL—RA11C
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDNYYY)
TYPE OF INSURANCE
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE M OCCUR
4/2912015
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 BYTHEPOLICIES
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 13 WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME: certificates@willis.com
Willis of Pennsylvania, Inc.
c/o 26 Century Blvd
PHONE, -7378 ,A (888) 467-2378
[A/C No Ext), (877) 945 No):
P.O. Box 305i9l
E-MAIL
Nashville, TN 37230-5191
ADDRESS:
I-, INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA:Arch Insurance Company 11150
INSURED
INSURER B: Zurich American Insurance Company 16535
INSURERC:
CentiMark Corporation
12 Grandview Circle
INSURER D:
Canonsburg, PA 15317
INSURERE:
INSURER F : I
GENERAL AGGREGATE S 4,000,000
MCViZIUN NUN)brK:
THIS IS TO C E POLICIES
� . -.513TIFY THAT TH - -OF INSURANCE 1-15TED-BELO LV HAVE BEEN1 SSUED. TO THE -INSURED NAMED-ABOVEFOR THE.POLICY.PERIOD
IN61 ED. 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.
INSR
LTR
A
TYPE OF INSURANCE
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE M OCCUR
ADDL1SUBR[_
INRD
V1rVn
POLICY NUMBER
IIPKG8900709
—P70—LI
CY EFF
(MM/DDNYYY)
05101/2015
—TO—LICYEXP
(MM/DDfYYYYI
05101/2016
LIMITS
EACH OCCURRENCE $ 2,000,000
DAMAGE TURSRTEU-
PREMISES (Ea occurrence) $ 300,000
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
JECT FTI LOC
GENERAL AGGREGATE S 4,000,000
PRODUCTS - COMPIOP AGG s 4,000,000
OTHER:
$ —
A
AUTOMOBILE
T
X
LIABILITY
ANY AUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
11PKG8900709
05/0112015
05/0112016
COMBINED SINGLE D—MIT
(Ea accident) $ 2,000,000
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
—PROPERTY —DAMAGE
(Per accident) $
$
B
X
UMBRELLA LIAS
EXCESS LIAB _
�]
OCCUR
CLAIMS -MADE
AUC930387913
05/0112015
05101/2016
EACH OCCURRENCE $ 10,000,000
AGGREGATE $ 10,000,000
A
DED I I RETENTION$
WORKERS COMPENSATION
AND EMPLOYERS' LIABI I" Y/N
ANY PROPRIETOR/PARTNERIEXECUTIVE -
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If Kes
Wesc ibe under
D RIPT'ION OF OPERATIONS below
NIA
11WC18900609
05/01/2015
—
05/0112016
OTH. $
X I PSTEATUTE ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - FA EMPLOYEE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
Workers' Compensation Policy I 1WC189006og (AIDS = All Other States except CH, WA, ND, WY which are insured through state funds).
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.
AUTHORQED REPRESENTATIVE
Li6l__
(D 1988-2014 ACORD CORPORATION. All rights reserved.
,I -L- -4 A �nnn
I
1IM Massachusetts - Department of Public Safety
.-card of Building Rcgulationss and Standards
�orj,truchhrjn Supervisor
License: CS -102083
DAVED M YOUNG-�-
15GREAT LDD
WEYMOU MA
Expiratio
Commissioner 10/211201A6