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HomeMy WebLinkAboutBuilding Permit #001-14 - 315 TURNPIKE STREET 7/1/2013 TOWN OF NORTH ANDOVER �+ APPLICATION FOR PLAN EXAMINATION Permit N0: 00/—ly Date Received / Date Issued: 7// 1� IMPORTANT:Applicant must complete all items on this page LOCATION-- - '36 fwlb !;JTe4 . Mor-A tfyVA- fel g'K- print, PROPERTY OWNER eES'(`tAyiGk oQ A PrinfJ 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District 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 Alteration No. of units: 9 Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition X Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 6(0,,\ Pro x} 114 8 D S F, Identification Please Type or Print Clearly) OWNER: Name: Phone:673\W35' © 3 Address: , 01 ? J CONTRACTOR Name: Phone: W 3 23 l j 1;91 1-� 5 , 03t�� _ - i Address: . D . &V W430 1y)aWt tL°s4ex 4 03(08 i Supervisor's Construction License: , , ( 6.;-v5i0n3 Exp. Date: 11 i Home Improvement License: /U A Exp. Date: N ARCHITECT/ENGINEER Mir4ij s e.1o5 , Phone: t�401+ Address: y.�o �-1�5�corI-�I,ndus�-r-� fel�d • Reg. No. _ 4� 1 C-7-14 � -�- FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ .2 J�7,39 FEE: $ 0-7�• — Check No.: -l.2 5',7 Receipt No.: 4?� NOTE: Persons contracting i h unregistere ontractors d o have a cess to the guaranty fund Signature of Agent/Owne Signature o contractor Plans Submitted ❑ lans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 1 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 r Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes r9 Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;! ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 MainStreet Fire Departmer:it signatureldate ,� L 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 2010 Building Department The foli?wing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofir g, 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 o 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) ❑ 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 apo-W period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recordii?w must be subm:tted with the building application Doc: Doc.Bui*'�iing Permit Revised 2012 Location 2)IC5 ��rryo,�� 6" - , No. C-01 ' �q Date 2 o 13 J • - TOWN OF NORTH ANDOVERi Certificate of Occupancy $� Building/Frame Permit Fee $ 7- 531 Foundation Permit Fee $ Other Permit Fee $ 1� TOTAL $ 3�1 Check# r it r // ``136ilding Inspector Date......7-1—/3............. NORTH TOWN OF NORTH ANDOVER L , —Edam, ' PERMIT FOR WIRING 8s�cINU This certifies that ............: E L�5.........6 T.................................. has permission to perform ...f'.17r e.......... ... /...�1 ..................... Jwiring in the building of......MCo �..7-6............................. at ... 5.7...........��ELE ....North Andover,Mass. Fee.13 D� ...!..—..Lic.N�11�3.7 ......... �...:..<.. ...................... CTRICAL INSPE Check# i r;� r //�� fi//r// Jf 1111� Official Use Only _ C.,om.motuueaGih of Wamac4udeth —7 p� c� Pennit No. `1 <P aUeftartmetaE o��irA�ervicea Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All lvork to be perfonned in accordance with the A4assachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRLI'T LYLVK OR TYPE ALL 1ATFORAIATIOINT) Date: 7/8/13 Cit-v or Town of. North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 315 Turnpike Street Owner or Tenant Merrimack College Telephone No. 978-837-5000 Owner's Address 315 Turnpike St North Andover Ma.01845 Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box) Purpose of Building Bookstore Utility Authorization No. both Existing Service 1200 amps 480 / 277 Volts Overhead ❑ Undgrd❑x No.of Meters 2 New Service 1000 Amps 480/2/77 Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacit-, Location and Nature of Proposed Electrical Work: Volpe Center Bookstore lighting and power,minor data and fire I alarm Cont letion of the ollowing table tnar be waived by the Ins rector of TT'ires. No.No.of Recessed Luminaires 7 No.of Ceil.-Susp.(Paddle)Fans 0 Transformers 0 KVA 1 No.of Luminaire Outlets No.of Hot Tubs 0 Generators 0 KVA 155 Above In mg 3 \o.of Luminaires Swimming Pool rnd. Elornd. El 70.OT Units No.of Receptacle Outlets 7 No.of Oil Burners 0 FIRE ALARMS No.of Zonesexisting No.of Switches 6 No.of Gas Burners 0 No.of Detection and 0 Initiating Devices No.of Ranges 0 No.of Air Cond.existing Total No.of Alerting Devices 3 Tons No.of Waste Disposers 0 Heat Pump \umber Tons Kw No.of Self-Contained Totals: .. ........................ Detection/Alerting Devices No.of Dishwashers 0 S ace/Area Heating KW exlstin Local 'Municipal Other p g g ❑ Connection [I 0 Heating Appliances Security Systems:* No.of Dry ers g PP K�V No.of Devices or Equivalent 0 No.of Water 0 K«' No.of No.of Data Wiring: g Heaters Signs Ballasts No.of Devices or Equivalent 4 No.Hydromassage Bathtubs 0 No.of Motors 0 Total HP Telecommunications wirm : g No.of Devices or E uivalent Y OTHER: .4ttach additional detail if desired,or as required bt the Inspector of 1Eires. Estimated Value of Electrical Work: $64,355.00 (When required by nmmicipal policy.) Work to Start: July 9,2013 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation'coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing.office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certif p,under the pains and penalties of perjurt�,Haat the information ort this application is true aiid complete. FIRM NA14IE: Stellos Electrical LIC.NO.: MR-37 Licensee: Jim Stellos Signat r—' LIC.NO.: MR-37 603 (If applicable,enter "exenaLI"in the liCenSe marnber lirae.) Bus.Tel.No.: " 882-3126 Address: 125 North tastern Blvd Nashua NH 03 1 Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee docs not have the liability insurance coverage normally required by law. By my sigiature below,I hereby waive this requirement. I ani the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: R � 1 s HORTM O F 'i' 4i.o.rrt49 ss'AC R115E CERTIFICATE OF USE & OCCUPANCY . TOWN OF NORTH ANDOVER Building Permit Number 001-14 on 7/1/2013 Date: September 26, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 315 Turnpike Street MAY BE OCCUPIED AS Bookstore at Volpe Center IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Merrimack College g 315 Turnpike Street North Andover,MA 01845 Building Inspector Fee: PrePaid Receipt: 26545 Check : 125309 NORTH Town of E .' Andover - to 0h ver Mass �` -' 30 7 COCNIC Nl WICK y1. A�RgTED S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System i BUILDING INSPECTOR THIS CERTIFIES THAT ' Foundation has permission to erect ..... buildings on .......: ..:. ...........�..,.: ::.:.>.::.,:ars:..:::....................... r ;"%� f; / Rough' tobe occupied as .................::::............... : :: :...✓. .:....:.................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application in r��z�� 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 .............................:............... rFinal %- ry BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done :FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Location No. l / Date . = TOWN OF NORTH ANDOVER W Certificate f of $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#Ai 2kf ri �� ` f Building Inspector � CE,aoR7M 1h D '4•OW..•r•t19 SSACNa15E TEMPORARY CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 001-14 on 7/1/2013 Date: August 26, 2013 THIS CERTIFIES THAT CO Valid from August 26, 2013 to October 1, 2013 THE BUILDING LOCATED ON 315 Turnpike Street - MAY BE OCCUPIED AS a bookstore IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Merrimack College 315 Turnpike Street North Andover,MA 01845 Buil ing Insp ctor Fee: $50.00 Receipt: 26783 Check : 6283 a r PRO CON+ INCORPORATED Design and Construction Management August 26,2013 Gerry Brown—Inspector of Buildings North Andover Building Department 1600 Osgood Street North Andover,Ma 01845 Reference: Merrimack College-Volpe Athletic Center Expansion PCI Project#40-1346 Building Permit#001-14 Temporary Certificate of Occupancy Bookstore Dear Mr.Brown, Per our conversation,Pro Con Inc. is requesting a Temporary Certificate of Occupancy for the Bookstore at the Merrimack College Athletic Center Expansion(Building Permit#001-14)from August 26,2013 through October 1,2011 The Temporary Certificate of Occupancy will remain in effect until the signage is completed by the College,which is tentatively scheduled for October 1,2013 Should you have any questions on this information,please call. PCI has tentatively scheduled our final walk of the Bookstore with you on Monday 08/26/13. Thank you very much for your continued support thru this construction process. It has been a pleasure working with you and we look forward to a successful closeout process. Sincerely, 4W"'"W-v Lynn Kramer Senior Project Manager Cc: Dale Chase,file A Stebbins Company P.O.Box 4430 Manchester,NH 03108 603.623.8811 Fax 603.623.7250 www.proconinc.com Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 244,739.00 m $ - $ 2,936.87 Plumbing Fee $ 367.11 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 367.11 Total fees collected $ 3,771.09 315 Turnpike Street 001-14 on 7/1/13 Bookstore Fitout to the Volpe Athletic Center Expansion • o 7t; 125309 1► if — 1� m M&T.Ronic 10 4/220 lull hlanufT to es and Trade.Txu t Compan ernm: :; �c .Commercial Bmikine DISBURSING ACCOUNT C O L L E G E ***** 0011/2013 NOT VALID 315 Turnpike Street CHECK N0.:.0 12 5 3 O 9 AFTER 90 DAYS North Andover,Massachusetts 01845';;,; PAY Imo_ �. 1 • $*****3 , 037 . 00* Town of North Andover, M _ - --�'`• — ;: PRESIDENT 11' 1 2530911' 1:0 2 2000.0461: 98t, 58 20 3 5 711' 4 NO RT1y To wn of . ? EAndover No. �I � � :Y _ h , ver, Mass, A- COCNIC.RWICK 7�p�RAT E 0 S V BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System ��.�'�< <71�14e" 1'� f � BUILDING INSPECTOR THISCERTIFIES THAT ....................................................a//� r.e....................................................... + has permission to erect .......................... buildings on ...., ,f ...�. LIE". �. F........ ............... Foundation Rough to be occupied as .�6 SOO T� 57e-D-t, Chimney p' ..................... ............... .......... .................................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING.INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS Rough ..................................... Service ................... . . ........................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE t Building Permit Fee Calculations for Tenant Fit Up 06/10/13 North Andover, MA Cost of Work $244,739 x 0.012 = $2,937 + $100 C of 0 fee Total Building Permit Fee for the Bookstore $3,037 Dunkin Donuts Building Permit Fee: Cost of Work $204,144 x 0.012 = $2,450 + $100 C of 0 fee Total Building Permit Fee for Dunkin Donuts $2,550 PRO CONI,' Standard Estimate Report Page 1 I NT C O R P O R AT E D Bookstore/DD REVISED 6/7/2013 11:11 AM v Design and Constnwtion Manageme�at Total Description Quantity Amount Bookstore 00000 PROFESSIONAL SERVICES 00105 Reprographics 1,087 PROFESSIONAL SERVICES 1,087 01000 GENERAL CONDITIONS 01005 Field Superintendent 15,282 01019 Project Executive 1,280 01022 Project Manager 7,641 01025 Travel Expenses 1,109 01026 Project Coordinator 1,087 01040 Project Telephone Charges 435 01050 Temporary Power 01055 Temporary Water 01065 Temporary Facilities 229 GENERAL CONDITIONS 27,063 272.00 Labor hours 173.33 Equipment hours 01500 PROJECT SECURITY&SAFETY 01511 Barricades 272 PROJECT SECURITY&SAFETY 272 01600 PROJECT MAINTENANCE 01605 Daily Cleanup 1,108 01610 Waste Removal-Non Demo. 1,413 01615 Post Construction Cleanup 1,460 PROJECT MAINTENANCE 3,981 24.00 Labor hours 01950 DEMOLITION&ABATEMENT 01955 Selective Demolition 667 DEMOLITION&ABATEMENT 667 8.00 Labor hours 8.00 Equipment hours 02000 SITE WORK 02800 Site Improvements 109 SITE WORK 109 03000 CONCRETE 03010 Slab Concrete 4,380 03350 Concrete Finishes CONCRETE 4,380 05000 METALS 05500 Metal Fabrications 11,737 METALS 11,737 06000 WOOD&PLASTICS 06005 General Tools&Equipment 1,264 06125 Miscellaneous Carpentry 1,650 06400 Architectural Woodwork 7,770 PCO CON,' Standard Estimate Report Page 2 1 INCORPORATED Bookstore/DD REVISED 6/7/2013 11:11 ANI Des79n and Construction Managenteut Total Description Quantity Amount WOOD&PLASTICS 10,684 23.611 Labor hours 166.00 Equipment hours 07000 THERMAL&MOISTURE 07900 Caulking and Sealants 1,152 THERMAL&MOISTURE 1,152 08000 DOORS&WINDOWS 08050 Doors And Hardware 1,483 08350 Overhead&Coiling Doors 17,605 08800 Glazing 7,483 DOORS&WINDOWS 26,572 09000 FINISHES 09250 Gypsum Wallboard 24,689 09650 Resilient Flooring 1,114 09680 Carpeting 8,683 09900 Painting 6,471 FINISHES 40,958 10000 SPECIALTIES 10300 Fireplaces 9,346 10400 Identifying Devices 10522 Fire Extinguishers&Cabinets 610 SPECIALTIES 9,956 1.00 Labor hours 12000 FURNISHINGS 12500 Window Treatment 12600 Furniture 15000 MECHANICAL 15301 Fire Protection 2,391 15501 Heat,Ventilation,&Air Conditioning 30,352 MECHANICAL 32,743 16000 ELECTRICAL 16010 Electrical Systems 73,380 ELECTRICAL 73,380 Bookstore 244,739 328.611 Labor hours 347.330 Equipment hours June 6, 2013 Town of North Andover Building Dept. Attn: Mr. Gerald Brown 1600 Osgood Street. North Andover, MA 01845 Re: Volpe Bookstore @ Volpe Athletic Center Merrimack College - 315 Turnpike Street RE: Architectural Design Affidavit Dear Mr. Brown, In accordance with 780 CMR, the Massachusetts States Building Code 8th Edition and the 2009 International Building Code, I, Miguel Santiago Yelos San Martin, Massachusetts Registration No. 30391, being a registered architect hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specifications 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. �gf ,�K L ilk Y 1A =u y OF June 6 2013 De n.Pr© 5J'ohal's Seal FInitial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8rh edition of the Massachusetts State Building Code-,780 CMR, Section 107.6.2 Project Title: Merrimack Bookstore Date: 4-25-2013 Property Address: Merrimack College,Volpe Center,315 Turnpike St., forth Andover, MA 01845 Project: Check(x)one or both as applicable: New cumstruction XX Existing Construction Project description:The project is an interior renovation to a portion of retail space 108 within the volpe center at merrimaek college to provide for a bookstore tenant The scope of work includes placement of interior partitions(full height and partial height),placement of a cashier counter,a ventless fireplace,a folding security grille with associated structure,a rolling overhead security grille,lighting fixtures and a plan layout for the bookstore's retafi display fixtures as well as associated finishes. The project contains no exterior,building envelope,plumbing or mechanical scope. All associated building structural and utility systems are existing to remain. I,Miguel Yelos San Miguel,MA Registration Number: 30391 Expiration date:201318/31 ,am a registered design professional, and.hereby certify that I have prepared or directly supenr sed the preparation of all design plans, computations and specifications concerning : Entire Project x Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that such pians,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that 1(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: I. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals thy the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and duality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. When required by the building official, I shall submit fieldlprogress reports(see item 3.)together with pertinent comments,in a form acceptable to the Building official. Upon completion of the work,I shall submit to the building official a `Final Construction Control Doc � Enter in the space.to the right a"wet"or electronic signature and seal: Phone number:409-2494555 Email:mMiguel Yelos San Martiniguel@,ysindesign.com r Building Official.Use Only Building Official Name; Permit No.: Date-: Note 1.fndicate%vith an'x'project design plans.computations and specifications that you prepared or directly supervised.If'other'is chosen, provide a description. Trial Version 10-109 2012 r 1• Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction SuperN icor License: CS-050393 DALE E CHASE 17 TOBEY HILL RD WEARE NH 032$1 Expiration Commissioner 11/06/2014 The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): r0 J Address: C) City/State/Zip: Phone#: ra —0 I Are you an employer? Check the appr priatebo Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.+ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.[& Other1e,--% f:&QU, comp,insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance CompanyName: Policy#or Self-ins. Lic.#: V 1 J `(� 1© —��jExpiration Date: Job Site Address: �.� f City/State/Zip: c }� Attach a copy of the workers' compen ation policy declaration page(showing the policy number and expiration da e. O `4✓ 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 atyl penalties of perju I that the information provided above is true and correct. Signature: GA v Date: I 0 UU 14 ,3 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#: A CERTIFICATE OF LIABILITY INSURANCE 3/29/20113) 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 olic ies must be endorsed. If SUBROGATION IS WAIVED,subject to p Y1 ) J 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: Danielle Rice THE ROWLEY AGENCY INC. PHOAIC,NENo. (603)224-2562 FAC, C No):(603)224-8012 139 Loudon Road E-MAIL driceQrowle a enc com ADDRESS: Y g Y P.O. BOX 511 INSURERS AFFORDING COVERAGE NAIC# Concord NH 03302-0511 INSURERA:The Travelers Indemnity Co INSURED INSURERB:Travelers Property Casualty Co. Pro Con, Inc. INSURERCNational Union Fire Ins. P.O. BOX 4430 INSURER D: INSURER E: Manchester NH 03108 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 REDU CED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrenceL_ 300,000 A CLAIMS-MADE Fx�OCCUR TC2KCO-8207A049-13 4/1/2013 4/1/2014 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 POLICY X PIFCTRO X LOC $ AUTOMOBILE LIABILITY EOa aBINEDiSINGLE LIMITccide 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED TJCAP-8207A050-13 4/1/2013 4/1/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DEC) I X I RETENTION$ 10,000 BE 013812067 /1/2013 4/1/2014 $ B WORKERS COMPENSATION VTJUB - 8207AO62-13 X ICSTATU- OTH- AND EMPLOYERS'LIABILITYFR LIMITq ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 3A States: NH, CT, MA E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) I, NY, ME, VT, NJ 4/1/2013 4/1/2014 E.L.DISEASE-EA EMPLOYE $ 11000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Volpe Athletic Center Expansion, Merrimack College. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Commonwealth of Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. Department of Industrial Accidents 600 Washington Street AUTHORIZED REPRESENTATIVE Boston, MA 02111 Danielle Rice/DJR ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 nninns m Tho AP.r1Rr1 name anri Inn^aro ronieforori mnrlrc of Arnpin ��Zo DATE A CERTIFICATE OF LIABILITY INSURANCE 3/29/2013) 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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Danielle RICE THE ROWLEY AGENCY INC. PHONE (603)224-2562 acNo):(603)224-8012 139 Loudon Road AODRIE :drice@rowleyagency.corn P.O. BOX 511 INSURERS AFFORDING COVERAGE NAIC# Concord NH 03302-0511 INSURERA:The Travelers Indemnity Co INSURED INSURERB:Travelers Property Casualty Co. Pro Con, Inc. INSURERCNational Union Fire Ins. P.O. BOX 4430 INSURER D: INSURER E: Manchester NH 03108 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 REDU CED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYY MM/DDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 A CLAIMS-MADE OCCUR TC2RCO-8207A049-13 4/1/2013 4/1/2014 MED EXP(Any one person) $ 51000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 POLICYFX PRO X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 11000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED TJCAP-8207AO50-13 4/1/2013 4/1/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED I X I RETENTION$ 10,000 BE 013812067 4/1/2013 /1/2014 $ B WORKERS COMPENSATION VTJUB - 8207AO62-13 X I WCSTATU- I OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVEY/N 3A States: NH, CT, MA E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBEREXCLUDED? FN-] N/A I pry, ME, VT, NJ 4/1/2013 4/1/2014 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Volpe Athletic Center Expansion, Merrimack College. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Danielle Rice/DTR --� � ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025l7mnns M The ArrlRrl ntamc nnr1 Innn arc rcnicfcrcrl mnrlrc of arni l