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HomeMy WebLinkAboutBuilding Permit #583 - 240 CHARLES STREET 4/1/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: b Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page µ LOCATION 1-1L'�' �} nnt„ z PROPERTY t3WNERl•�-cc ,r Caw«n.� f Pnnt MAP NO: PARCEL: ZONING DISTRICT. Historic Distract yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial �l er No. of units: Commercial Repair, replacement Assessory Bldg Others: ernolitio Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: n Identification Please ype or Print Clearly) OWNER: Name: Phone: cos s.\L x Address: CONTRACTOR Name; P-�V'., .,. Phone: Address: L-\ -o Wt-\\ j Supervisor's Construction License: --!t t.Z Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEERI k cn(n '� (�h �A� Phone: J-£�W- >J3S- Address: S e 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: $ 1�� (o��, �o� FEE: $ Check No.: . �l� Receipt No.: s'�?° t' q,�fd NOTE: Persons contract1ttg wit nregistered contractors do not have ccess to trh gu a Signature of Agent/Owner Signature of contract Location No. � Date �U MORTM TOWN OF NORTH ANDOVER f �,y O? • • Oow b ; 9 ` ♦ i ( _ Certificate of Occupancy $ a Building/Frame Permit Fee $ /4-0 Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ Check # 22690 `Building Inspector i Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS VF Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes, no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - 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) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Li 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 2008 NORTH ONO " L over QQ O No. o _ LAE dover, Mass., �A COC H,CHEW ICK A. S RATED 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System i BUILDING INSPECTOR THIS CERTIFIES THAT...........� �' r� r�...!`t�� .��. f....- ��'f!!.!.`.!�' `'I�t... ....�� ✓.+.�t .................... Foundation has permission to erect........................................ buildings on .,;?4 'Z�......c�...��.�..... �S.... ........................... Rough to be occupied as....... Co.4-4(. �'�� ...'....4?b�..�'..-��. �-�<^:.... ��'�""r, C ey . . .... ..........rfco .................... n provided that the person accepting this permit shalrin every respenform to the terms oft application on file in ina 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. AUMBING IN OR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough V- -ddkr-i� ........ ....... Service BC7ILDG INSPECTOR al 3. 1d// Occupancy Permit Required to Oaupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do .Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT; Until Inspected and Approved by the Building Inspector. Bumex �� - � Istreet No."` 3— SEE REVERSE SIDE smoke Det. i 2- 1v MvMhusim50 CONSTRUCTION YEARS Building Excellence since 1960 February 7,2011 Mr. Gerald Brown—Inspector of Buildings Town of North Andover—Building Department 1600 Osgood Street North Andover,MA 01845 Re: GLSD WWTP Energy Efficiency Upgrade Contract#2009-2,CWSRF#3295 Subj: Certificate of Occupancy—Permit Number 583 Dear Mr.Brown: This letter is forwarded as part of an Application for Certificate of Occupancy for building permit number#583.The structures in question are the Blower and Fan Building and the Riverside Pumping Station at the Greater Lawrence Sanitary District Waste Water Treatment Plant.These locations were constructed under the construction control provisions included in Article 116 of the Massachusetts State Building Code.The Engineer of record for the project,Fay, Spofford& Thorndike,LLC,performed construction control activities throughout the construction of the facility. This correspondence is forwarded as an Affidavit the Methuen Construction Company constructed the facilities per the contract documents provided by the Owner,the Greater Lawrence Sanitary District,and the Engineer of Record,Fay, Spofford&Thorndike,LLC,as well as per the direction of the Engineer's on-site field representative. We trust that this document,along with the completed application form and construction control affidavits satisfies the requirements to obtain the Certificate of Occupancy. If you have any questions or require any additional information,please feel free to contact Jay Spooner,Project Manager,at 603-328-2234 or Herb Vogel Superintendent at 508-726-6010. We thank you and the rest of your staff at the Building Department for your cooperation during construction of this facility and look forward to successfully completing future projects in the Town of North Andover. Very truly yours, Methue Construction CO.,In Aae0S7mJds Senior Vice President Enclosures Methuen Construction Co., Inc. 140 Lowell Road Salem, NH 03079 Phone: 603.328.2222 Fax: 603.328.2233 %vujuviiet'i uescni •. •u p►ORTy 0: ec ,°1y0 APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION �9 CHu CH BUILDING PERMIT # SSAs� ADDRESS/LOCATION OF PROPERTY:L4 t-CA Map Parcel Lot Number SUBDIVISION: DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: FIVE(5)DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS($20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to: Cy Address: L»loLc_k1 ROUTING CONSERVATION ❑ PLANNING ❑ DPW-WATER METER ❑ SEWER CONNECTION ❑ DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCYANSPECTION REQUEST DPW SIGNATURE File:Application for OC form revised Jan 2007 FAY,SPOFFORD&r THORNDTKE ENGINEERS 5 Burlington Wbods. rr Audingtor,MA 01803 ` 5 7611 Free:800.8358666 T:781.221.1000 F:781.2291I15 Since 1974 WWw"faiDCcom February 9,2011 Mr. Gerald Brown. Town of North Andover Building Department 400 Osgood Street North Andover,MA 01845 Subject: Greater Lawrence Sanitary District CWSRF No. 3295 Energy Efficiency Upgrade Projects Contract 2009-2 Building Permit Number 583 Dear Mr. Brown: Concerning the subject building permit, we advise that Fay, Spofford. & Thorndike (FST), the Engineer of Record,designed.this project in accordance with the Massachusetts State Building Code and applicable Federal Regulations. In addition,FST provided part-time onsite inspection.of the work(controlled construction)throughout the construction of the project. Very truly yours, FAQ',SPOFFORD& THORNDIKE,LLC By �' N'— tylo— Meredith S.Zona,P.E.,LEED AP Vice President cc: Richard Weare, Greater Lawrence Sanitary District Jay Spooner, Methuen.Construction S:''JG-026 GLSD1Construction Phase4lVACPeT tsTST Bldg Permit Final.doc ENGINEF.I:S - Pi-hNNf.RS - SCIENTISTS ................_... .........._........... ....... . .... ._....... 71us1cdParu+aslnr Dcs;tr5nlnuon. GENERAL BUILDING NOTES/CHECKLIST-NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation, Footing, Foundation,Frame,-Insulation,Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stone/fabric filter/cover and outlet connection. FRAME:Fireblock-over girls/plates between floor joist Penetrations for plumbing,heat,elec,etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls.. Ridge&Hip-Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. Joist hangers-fully nailed wl hanger nails. Sill plates 2-2X6(1PT)w/sill seal. Girls-solid brick or steel plate bearing at foundations "air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations.required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min.22x30 w/3'headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0"clearance fireplaces.&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. of required glazing shall be openable. Bedrooms required min.20x24 egress window or door. Vent attic spaces-"proper vent",soffit and required ridge vents. _ Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber-Finish C Smooth parging,clean joints,8"solid @ combust. Z� DECKS: Lag to house, provide flashing. css Rails min.36"high, Baluster max space 5"on center. Over 8'above grade,use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48",Conc. pad at stair base. J i' L FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. � ! zs' Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspection fee- $30.00(Be Ready). . M " \� Certificate of occupancy required prior to occupying structure. FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained.This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANTi&eta kAwcciucr!–s.9 ;ate 7,te,e-T PHONE ASSESSORS MAP NUMBER SIS LOT NUMBER - 0,7N-Rr"= Nn. 9 LOT NUMBER STREET C N-W C c—� 5`h?� – STREET NUMBER ca� OFFICIAL USE ONLY FORNBESEMEN RECOMMENDATIONS OF TOWN AGENTS ........................................................................... DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED . CON vfENTS DATE APPROVED TOWN PLANNER DATE REJECTED CON&[EENTS DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT COAT,mrZ e i AP,V-*L Teclli ,neec r 6.11 vl� DATE APPROVED FIRE DEPARTMENT /Not, DATE REJECTED CONIl�IEN'I'S RECEIVED BY BUILDING INSPECTOR DATE L-l2-On FAY,SpomRD& THORNDM ENGINEERS 5 Burlington Woods r— � Burlington,N1A01803 _r Toll Frce:800.835.8666 � [ �� T:781.221.1000 F:781.229.1115 Since 1914 WV"N"Ifitinc.corn February 23,2010 Mr. Gerald Brown Town of North Andover Building Department 400 Osgood Street North Andover,MA 01845 Subject: Greater Lawrence Sanitary District CWSRF No. 3295 Energy Efficiency Upgrade Projects Contract 2009-2 Building Permit Dear Mr.Brown: In anticipation of obtaining a Building Permit for the subject contract, we advise that this project conforms in all respects to the Massachusetts State Building Code and applicable Federal Regulations. In addition,Fay,Spofford&Thorndike will be providing part-time onsite inspection of the work(controlled construction)during construction. Very truly yours, FAY,SPOFFORD&THORNDIKE,LLC By Meredith S.Zona,P.E.,LEED AP Vice President cc: Richard Weare,Greater Lawrence Sanitary District SNG-026 GUMConst action Phase\HVAC\Permits\NABuildingPennits Contract2.doe ENGINEERS - PLANNERS - SCIENTISTS Trusted Part ners for Design Solutions I � NORT1y TONNM O ^ �R. L over 0 No. QQ - �. LA E dover, Mass., COCHICHE W ICK �d ADRATED `r BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ' �d�c�l.. ...:9 f 1.�.a.nV.AC: ...... ..............%. ..�.�` s ... ... : Foundation has permission to erect........................................ buildings on. 7Q ?..... . !^lc's... .......................... Rough to be occupied as........(�. ea Gaal' �Co!?+� Chimney .nr. "....G .... .......... .........- ............rfco�nfio�rm�..... ... ...... ....Z.provided that the person accepting this permit shairin every respe to the terms of t application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR . UNLESS CONSTRUCTION STARTS Rough .............................. .. ........... . ._...'................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FIRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID MS DATE(MMIDDIYYYY) METHU-1 1 01/05/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE DeSanctis Insurance Agcy, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 36 Cummings Park ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Woburn MA 01801 Phone:781-935-8480 Fax:781-933-5645 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: CNA Insurance Companies INSURER B: National Union Fire Ins. Co PA Methuen Construction Co. , Inc. INSURER C: Travelers 01899 40 Lowell Road INSURER D: Salem NH 03079 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LON TR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD PDATEOLICY(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A X COMMERCIAL GENERAL LIABILITY U2077573167 07/01/09 07/01/10 PREMses(E $100,000 CLAIMS MADE ®OCCUR MED EXP(Any one person) $151000 X Blkt Contractual PERSONAL BADV INJURY $1,000,000 X XCU Hazards GENERAL AGGREGATE 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY X JE� LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 A X ANY AUTO 02049381064 07/01/09 07/01/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED ALTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE S (Per axident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO FA ACC S 2 OTHER THAN AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE 5$11,000,000 B X I OCCUR ❑CLAIMSMADE BE1223020 07/01/09 07/01/10 AGGREGATE 3$11,000,000 S RDEDUCTIBLE $ X RETENTION $10,000 $ WORKERS COMPENSATION AND X TORY LIMITS ER A EMPLOYERS'LIABILITY WC174023092 07/01/09 07/01/10 E.L.EACH ACCIDENT $1 000 000 ANY PROPRIETORIPARTNEWEXECUTIVE r OFFICERIMEMBEREXCLUDED? CT,De,RI,NA,NH,HD,NJ,VA E.L.DISEASE•EA EMPLOYE $1 000,000 K ea describe Under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1 000 000 OTHER C Builders Risk QT660221D3498TIL09 07/01/09 07/01/10 Limits $1,087,616 Deduct $5,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RE: Energy Efficiency Upgrade Projects Contract 2009-2 CWSRF-3295, 240 Charles St., N. Andover, MA."ADDITIONAL INSUREDS LIMITS ARE NO GREATER THAN THOSE REQUIRED BY WRITTEN CONTRACT" Greater Lawrence Sanitary District, Fay, Spofford, 6 Thorndike, LLC and their officers, directors, partners, employees, and other consultants and subcontractors are listed as additional CERTIFICATE HOLDER CANCELLATION GREAT-4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Greater Lawrence NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Sanitary Dristrict IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 240 Charles Street North Andover MA 01845-1643 REPRESENTATIVES. AUTHORIZED RERESENTATIVE G ACORD 25(2001108) © ORD CORPORATION 1988 � ,� �r Vit{ �"��f 1�REd S NAME M�e;�uen Cons,trucion Co. , Inca O�ID M3°r DA'I�����JQ5%'10 insureds as respects to the GL, Auto, & Ufa policies. Wsiver of Subrogation applies to the GL, WC, Auto, b Umbrella policies. i ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DD DATE(M PRODUCER METHU-1 12 29 09 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION DeSanctis Insurance Agcy, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3 Cummings Park HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR urn MA 01801 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 7- ine:781-935-8480 Fax:781-933-5645 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: CNA Insurance Companies Greatgr Lawrence Sanitary INSURERS: District; Fay, Spofford & Thorndike, LLC INSURER C: 240 Charles St. N. Andover MA 01485 INSURER D: COVERAGES INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWRNSTANDING 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. AMOK PUFW& LTR INISR1 TYPE OF INSURANCE POLICY NUMBER DATE MMIDDrMOATS M LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s2,000,000 CLAIMS MADE r OCCUR PREMISES Eaooareric� i�:__��__ -_ ..MED One i---------- A R Owner/Cont Prot. TBA 01/04/10 07/01/10 PERSONAL a:AOV"Ry : GEKL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE s 2 Q00 000 POLICY JEC LOC PRODUCTS-tOA 0&.AG4"i AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT t ALL OWNED AUTOS (Ea accKl" SCHEDULED AUTOS BODILY INJURY HIRED AUTOS (PerP-on) $ NON-0WNEDAUTOS BODILY INJURY = (Per soodent) i PROPERTY DAMAGE S (Per acdden!) GARAGELWBILRY ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC S AUTO ONLY: AGC, S EXCESSAIMBRELLA LIABILITY EACH OCCURRENCE _ OCCUR ❑CLAIMS MADE AGGREGATE S DEDUCTIBLE S RETENTION 3 S WORMERS COMPENSATION AND S EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT s OFFICER/MEMBER EXCLUDED? Nyesdesoilbe ice E.L.DISEASE-FA EMPLOYE $ SPECIAL PROVISIONS below OTHER E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS r LOCATIONS/VEHICLES I EXCLUSIONS AODED BY ENDORSEMENT/SPECIAL PROVISIONS RE: Energy Efficiency Upgrade Projects Contract 2009-2 CWSRF-3295. Designated Contractor: Methuen Construction Co., Inc. CERTIFICATE HOLDER _ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATI01 DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN Greater. Lawrence NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 5aiiitary Driatrict 24 0' Charles 'Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURM ITS AGENTS OR North AndOver MA 01845/1643 REP ENTATIVES. A 0 D REPRESENTATIVE ACORD 25(2001108) _ ®A'ORD CORPORATION 1981 i The Commonwealth o Massachusetts Department of Industrial Accidents amceoflnuesdoations �~ 600 Washington Street, lit'Floor Boston,Mass. 02111 Workers'Compensation Insurance Affidavit:Building/Plumbing/Electrical Contractors Aplp not information: Please PRINT leitibly name: Methuen Construction Co. Inc. address: 40 Lowell Road city Sal m state: NH zip: 03079 phone# 603-328-2222 work site location(full address): ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition Lx l 1 am an employer providing workers'compensation for my employees working on this job. company name: Methuen Construction Co Inc i address: 40 Lowell Road I_City: Salem, NH 03079 phone#: 603-328-2222 iinsurance co. policy# ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'compensation polices: �I company name: address: i City: phone#• insurance co. policy# company name: address• city: phone#• insurance co. oHe V# Attach additional sheet if necessary_ Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the pain and penalties of perjury that the information provided above is true and correct. Signature Date 05/06/09 Print name Joseph A. Barbone, Jr. Phone# 603-328-2222 (Irofficial use only do not write in this area to be completed by city• or town official city or town: permit/license# []Building Department Elcheck if immediate response is required []Licensing Board ❑Selectmen's Office L(,-� ntact person: phone#; ❑Health Department isedsepL2-0,. p ' ❑Other stu s c t t s Dj tment Of PUblic S tlt d. of Buili(fing l C arld CoJnstructibn -S: perv:" r License LicenseLicensem CS 76248 Restricted to: 00 HERBERT T P"' 'V0G--"E,-.,----jL,19 SAM, P SON .,8T- M,ETH'U',E,N,, ',AO1-:84-4 P r Expiration: 9/25120 1 - Tr#w 2435 -- - - _- ------------