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HomeMy WebLinkAboutBuilding Permit #1112-2016 - 38 WELLINGTON WAY 4/25/2016 O0RTH BUILDING PERMIT 320ryI ,_F.D ^,� �eTOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 11 �/ Date Received Permit No#• � � 9q " gSSACHUs�t� Date Issued: 7/ I ORTANT:Applicant must complete all items on this page L©'CATION -= k PROPER TY0INNEF2» � en Pnn 100 Year .trupture _ yes61 PARCEL ZONING DISTRICTHistoric Distract Ma67Hin Shop Village _Yesj TYPE OF IMPROVEMENT PROPOSED USE Residential ' Non- Residential XNew Building )'One family ❑Addition ❑Two or more family ❑ Industrial El Alteration No. of units: [ICommercial ❑ Repair, replacement ❑Assessory Bid g ❑ Others: ❑ Demolition ❑ Other [] Septic '"1Nell ❑'FI'ooJplan. �Wetl`antls f 111/a#er shedDistr�ct DESCRIPTION OF WORK TO BE PERFORMED: (!20ajsr2uc� Mc-w 1) %_6 Be ,Roa w "12-NY �a�N C�JA ek r Identification- Please Type or PrintCfearly OWNER., Name: E ��t�u�. �Q�ye ��1 �n1"t'�a ��'ru� P h o n f �'7/ 3/ ?iO Address-272:71�)]q - 17 193 i f' ,74'"x` .. ` 2 3 A Phone Contractor Emil'.. E5sl 84 a `Address: cU�c.A �la � � 'D yy E :.: '4 v a _ Supervisor'sjCons truction LJcxp M r �+1 dY A y ExpDate; Home Improvernent!License ARCHITECT/ENGINEER t^ �,� �" Phone: �- Address, I .- . rJ S I (/rA A)AM 01F33 Reg. No 2`7 7 2S" 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: $ Ml_ Check No.: �-- Receipt No.: 367.t5 T NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund h,ature of A - , r771 e. _ � I Plans SubmittedY Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans, TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Sody Art ❑ Swimming Pools ❑ i Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On(_ I�"�) Signature_ COMMENTS Zn 2-G ( � ZI P 1 CONSERVATION Reviewed on Si nature —" . COMMENTS HEALTH Reviewed on 2Z Signature X�&Idl COMMENTS �e4 �6u,-1." o-r) A-S- , 3 �wIN 0 ZD 32� Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes V `��Planning Board Decision: Comments r� Conservation Decision: Comments- Water ommentsWafter& Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARtTMENT - Temp ®umpster n si es` g,A :no Located at 1x24.Main S reet� �K}� '_ � ` � I,#Fire tv Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions,;Z240S/ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) f I U Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. I Roofing, Siding, Interior Rehabilitation Permits 4, 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 t OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit f 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) �. Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 ` lie1 ' Location ! .. { No. / 1J" r Date ,/ _ if 00,i . - TOWN OF NORTH ANDOVER -' Certificate of Occupancy $ Building/frame Permit Fee $ Foundation Permit Fee Other Permit Fee $ " V TOTAL_ $ �s� R Check# " k ,Buildin9 Inspector r MESSI-3 OP ID: BC ACORL7" CERTIFICATE OF LIABILITY INSURANCE DATE03128120/6 03/2812016 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 endorsemen s. PRODUCER CONTACT Foster Sullivan Insurance NAME: Kelly Pappas 163 Main St arcO°Nn o EO):978-686-2266 ac No):978-686-6410 North Andover, nR' Foster Sullivan Insurance LLC ESS:kpappas@fostemullivangroup.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:ATAIN SPECIALTY INS COMPANY 17159 INSURED Messina Development Company,I INSURER B:ZURICH AMERICA INS CO 16535 277 Washington St Groveland,MA 01834 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ITR TYPE OF INSURANCE IND WVD POLICY NUMBER MM/DD EFF MMIDD EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS MADE XOCCUR CIP269351 08/14/2015 08/14/2016 DAMAGE ToRENTEIT— PREMISES Ea occurrence $ 100,00 MED EXP(Any one Person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY❑JEa F—] LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per acad. $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAS CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PERTH- AND EMPLOYERS'LIABILITY y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yyes describe under DESCRIPTION OF OPERATIONS below I I EL DISEASE-POLICY LIMIT $ B Builders Risk ER07711684 05/18/2015 05/18/2016 DESCRIPTION OF OPERATIONS/LOCATIONS f VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SAMPLE ACCORDANCE WITH THE POLICY PROVISIONS. "EVIDENCE ONLY STREET AUTHORIZED REPRESENTATIVE CITY,ST 00000 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of'Massaehusetts Department of Industrial.Accidents X Congress Street,Suite 100 ` Boston,M4 02114-2017 `t www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE, FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/bidividual):M SSS i&].a b P C1e 1 OP BVI&,PJ+ (:0 --roe Address:,2727 W h91`41 "a) 1E;+)ec5:f City/State/Zip 0/ S' Phone#: �� Are you an employer?Check the appropriate box: Type of project(required): 1.❑Tama employer with employees(full and/or part-time)."' 7. VNew con§truction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3..❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13. Roof repairs These sub-contractors hale employees and have workers'comp.insurance.t ❑ p 6.b<We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§1(4),and Nye have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box##1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who subniif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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-coriCraclors have employees,they must provide their workers'comp.policy number. - I ain an employer that is piovidiing workers'compensation insurance formy employees.'Below is the policy and job site information. Insurance Company Name: _ Policy#or Self-ins.Lia#: Expiration Date: Job Site Address: 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb under thepains andpenalties ofpejury that the information provided above is true and correct. Signcl—JA 4 Date: //=. 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions I Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract o Le, express or implied,oral or written." ` An employer is defined as"an individual,partnership,association,corporation or other legal entity,or'any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.". Applicants Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor'(s)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation.policy,please call the Department at the number listed below. Self-insured companies should•enter'their ' self-insurance license number on the appropriate line: City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.##617-727-4900 ext.7406 or 1-877-MASSAFE Fax 9 617-727-7749 Revised 02-23-15 www.mass.gov/dia ISI Home Energy Rating Certificate Property HERS Unknown Rating Type: Projected Rating Certified Energy Rater: Eric Wilder lot 138 Wellington Way Rating Date: 5/5/2016 Rating Number. N.Andover,NIA Registry ID.- Projected D:Projected Rating: Based on Plans - Field Confirmation Required. Estimated Annual Energy Cost Use MNJItu Cost Percent HERS Index: 52 Heating 37.8 $1191 46% General information coating 6.9 $97 4% Conditioned Area 2777 sq.ft. Hage Type Single-family detached Hot Water 4.2 5215 8% Conditioned Volume 24378 cubic ft. Famdation More than one type Lights/Appliances 23.6 $896 35% Bedrooms 4 Photovoltaics -0.0 $-0 -0% Service Charges $168 7% Mechanical Systems Features Total 72.5 $2567 100% Heating: Fuel-fired air distribution.Natural gas,96.0 AFUE. Cooling: Air conditioner,Electric,13.0 SEER. Criteria Water Heating: Instant water heater,Natural gas,0.97 EF,0.0 Gal T This home meets or exoeeds the minimian asteria for the fottowing: Duct Leakage to Outside 80.00 CFM75. Ventilation System Exhaust Only:60 cfm,21.0 watts. Programmable Thermostat Heat--Yes;Coot-Yes Building Shelf Features Ceiling Fiat R-37.0 Stab None Sealed Attic NA Exposed Floor R-30.0 Vaulted Ceiling R-32.5 Window Type U-Value:0.300,SHGC:0.280 Above Grade Watts R-21.0 Infiltration Rate Htg:3.00 Clg:3.00 ACH50 Foundation Watts R-0.0 Method Blower door test Eric Wilder CLEAResult Lights and Appliance Features 50 Washington St. Percent Interior Lighting 100.00 Range/Oven Fuel Natural gas Westborough,MA 01581 Percent Gari Lighting 100.00 Clothes Dryer Fuel Electric 508-328-2760 Refrigerator(kWh/yr) 557 Clothes Dryer EF 3.01 1998-184 Dishwasher(kWh/yr) 270 Ceiling Fan(cf n/Watt) 0.00 9901142 Q REM/Rate-Residential Energy Analysis and Rating Software v14.6.2 This information does not constitute any warranty of energy cost or savings.a 1985-2015 Noresco,Boulder,Colorado. The Home Energy Rating Standard Disclosure for this home is available from the rating provider. lk \ 11 Q IN, res C�0 21' � I I EXISTING FND. �N T.O.F.=147.7' \ Lot 1 \ \\ EASEMENT \ \ \ \ EASEMENT \\\ � \ I S6>, N �\,.�NOF I►y1 I SS, MICHAEL q�'y J. N o SERGI m +' No.33191 y I SS% SURv-° I i THE HORIZONTAL SETBACK REQUIREMENTS OF LOCAL FOUNDATION Lo cA-r o N MS TO APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS.WETLANDS,EASEMENTS. CLIENT: M E S S I NA DEV. ORDERS OF CONDITIONSATC.)THIS DRAWING SHALL NOT BE USED THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE.EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN LOCATION: NORTH ANDOVER,MA. &SERGI INC.FURTHERMORE THIS DRAWING IS HE COPYRIGHTED PROPERTY OF CHRISTIANSEN&SERGI INC.AND ANY DATE: 5/19/16 SCALE: 1 u=40' UNAUTHORIZED USE IS PROHIBITED.CHRISTIANSEN&SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFORMATION CONTAINED HEREON. PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN & SERGI, INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX. 978-372-3960 D W G.N 0.:14036.001.017 Av Location 1 1 No—, Date 19 .fry • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ ' Other Permit Fee $ . TOTAL $ �_ 16 r° Check# �� '� 3 p /� ,J Building Inspector C `� d - Commonwealth of Massachusetts Sheet Metal Permit Date: Permit# Estimated Job Cost: $ goo Permit Fee: Plans Submitted: YES 0 Plans Reviewed: YES NO Business License# 7Applicant License# ig 42 Business Information: Property Owner/Job Location Information: Name: R,X 1*eCkC,,j G1 Name: loe7'Sl;40 Street: 1' lG��P /�G�/�lC Street: 32f We` h"1j ,4 4y44 , City/Town: f-ellr-l'r 1-14q City/Town: /L: A4J(0Pe,,' Telephone: 61Z� q7,3 7l Telephone: 677� Photo I.D. required/Copy of Photo I.D. attached: YES Ll---NO �----- Staff initis! J-1/ -1-unrestricted lice e J-2/M-2-restricted to dwellings 3�-stories or less and commercial up to 10,000 sq. ft./2-sfories or less Residential: 1-2 family Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq.ft, over 10,000 sq. ft. — Number of Stories: � Sheet metal work to a completed: New Work: ' Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: Location ✓ !l 1 No. Date #9 #' . - TOWN OF NORTH.ANDOVER Certificate of Occupancy Building/Frame Permit.Fee:. $117, Foundation Permit Fee $ Other Permit Fee $` TOTAL Check# Buildih Inspector. 3056 g ` - °" ''. �, '• },moi�...{• � -�i � �� J� A:... v. w C ' INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes ff/No❑ If you have checked Yn indicate th pe of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent Signature of Owner or Owner's Agent By checking this box ,1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for this application will be In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: 8Y EfMaster Title ❑Master-Restricted Cityffown ❑Joumeyperson Signature of Licensee Permit# ❑Joumeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.aov/dpl Inspector Signature of Permit Approval RAMEC-1 OP ID: LL A;Cd RO" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/08/2016 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 LISA Foster Sullivan Insurance "AME` CC Ext:?78-686-2266 ON FAX NII:978 163 Main St n" -686-6410 North Andover,MA 01845 E-MAIL certificates fostersullivan rou com Foster Sullivan Insurance LLC ADDRESS: 9 p. INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:MERCHANTS INSURANCE GROUP 112775 INSURED R.A. Mechanical,Inc. INSURER s:GUARD INS COMPANY 16 Lomar Park Suite 1 Pepperell, MA 01463 INSURER C: INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MWDD MMIDD/ GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CMP9153434 01/01/2016 01/01/201] A A T RELATE 100,000 PREMISES Ea occurrence S CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,001 PERSONAL&ADV INJURY S 1,000,00 GENERAL AGGREGATE $ 2,000,00 �GEN,*L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,00 POLICY 71 PRO- 1 LOC $ AUTOMOBILE LIABILITY _ I I CEOM�BIINdED SINGLE LIMIT $ 1,000,000 .. A I ANY AUTO 1MCA0000008 01/01/2016 01/01/2017 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S X HIRED AUTOS X AUTOS PER ACCIDENT n I $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,00 A EXCESS LIAB HCLAIMS-MADE iCUP9145434 01/01/2016 01/01/2017 I AGGREGATE is 1,000,00 - DE I RETENTION$ I Is WORKERS COMPENSATION 1 WC STATU- I OTH- AND EMPLOYERS'LIABILITY I (TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/" RAWC759194 01101/2016 01101/2017 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. RA Mechanical Inc 16 Lomar Park Ste 1 Pepperell, MA 01463 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD br e 4 7 - i n e y t;`i �y.t•`'� ..1 i .eL-+. .,. zz The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 03111 ivww.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers ADolicant Information Please Print Le�7ibly Name %Bus;ness,'OrQaniza[ioniindividual;: Cit,r.StaieiZip: ire you an em plover'' Check the _ aporonriate box: Type of orofec: reauire l: aID ^C1oVer -Vit i l _ atTl 1 Jene:al ntiaC:c, in nava ;n1IeQ :he sub-,:on[rac:ors _^:cio��ees (full and/or oar:-bine';.` _ am _ so'te oroori ter 7r ar:ne: isre..on 'he a[tachea shee.. ��. eceiinJ �,,io and :ave no =)ievees nest sub con,:ac:ors Nave e.T_oiiticn rnoiovees anc '`:ave worK.-rs' �orcng fcr ;ae '.n anc .-acacit_,. ;. 3uiidin�adeitcn nce _ctnp. nsurance.- — - o Wor:<ers oma. insura — %ti e are a cororadon Ina ':a ;n -�•ricai r - , !dditiens iiulIel_i -. — — or c rs .^,ave :cisec :heir _ -Dy pairs r adcie ns horneow•ner soinJ ii Acr:c — _ .a,:. = c cZl; ' C. '•.vOr'.•: rs _ is �v^•JC _..e^ptii7n per �l'L ` X Ci airs :lav; ":O _ :'.1�lov"t5 o 'NOr:ie._, _ , ,o. nsurancz c uire n ane icanl:bac.: eca aox ='. :nus; ,iso .`iii :it sec::cn -eiow ;how,ns'::^,e::-.vor ers _ moensarun .pile: .nlor aeon. oneowners ono suomu :his ainuav,;.nuica..nz _,re Zomz ill .vor,.:Tanu :ire ,umde_.,.,.:ac:crs .,.use suc^r:_ ._ ,. ... ac: al.a_. rs.., , _..tc:. .nls ;ox must_uacn2c in_�cc,.:onai .pee.sricw no nam- ;i.at ,uo- nc:ac:ors..and,,..__ n novees. .. >uc-uonr;ac:ors nave c, o,ovens. :ne- mus:rov;ue cne:r .von(ers _omo. -c' :numoer i am in '_!np(ov'er iitat_:J providin; Ivore:-s' compensation insurance r�r my :.'ripiovees. Bei0iv L� :jre,70iiC7.1nd 00 site n�ormaroa. i :nsuranc2 Ccrcanv Mane: l - — Poiic_: =or Sci_- ns. Lac. JZAW C 7 Fqj 9' � .:rira[ion Date:_j/ /.7V-f 7 :cb Site .�ddiess: �1�!/I /�'/ ��T t=irl;Sia[e; in:�, C attach a copy of the workers compensation poiicv declaration page ;showing the poiicv number and expiration date;. Failure :o secure coverage as required uncle: Section __,5A of YIGL c. li=can lead :o the Lmposicion of c-ilrainal oenaiues of a fine un to 31.300.00 and/or one-year imt;risonment.as Weil as cavil penalties in the form of a STOP ;VORK ORDER and a fine of up :o SZ50.00 a day against the vioiator. Be advised that a copy of:his statement may be fonvarded to 'he Office of Invesrisations of the DIA for insurance coverase ,enncanon. I do hereby—cerniy,zinder the airs and penalties of perjury that the information provided above is true and correct. Si ature: Date: AZ� / Phone 4: -7 / Official.use only. Do not write in this area, to be completed by city or town officiaL i i . City or Town: Permit/License i Issuing Authority (circle one): � 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other I Contact Person: Phone#: 'u„"•..LaBa--•�+c� ..,F^ ''wy"' _'.t•�.t �.'ns �., 'x.'a,^^ 'q�2,y '"z1.�ry v`•r "n'`. ."':.u&, '�'", "�sL..T---••�' .,a^a• '.L.a_.`yM1 ...0 l�`a����x�"�'�•^.-sr•• '��.'�T•k� ��jc- S'*-a * . �-'�2 � � -S ,'' ,�........,,.�-•� ����'.'++�..+- �^:'���r�;E�,�s�' , �..- _�,� a'�`a•?m:�-•-.•• �.rs+.••..••i_..,.-.x ._.+a.^_ r t s: �._ �•.••k^'�tt^�fi-"��.~.t���k � �.��- .� •...-c �`�.�.-.-a2e,.�=.c''t�..�•��'�t,.�.r���p�. a *. DRIVER'S, LICEN SE- M �4d NUMBER �b :SB 893F �.. . _ a- "mss TTE x a r €altltD J 1 a 657 MAMMOTH RD DRACUT,MA 01826-4349 - � :,-..COMMONWEALTH OF MASSACHUSETTS. e o o o g a HOARD:OF SHEET<METAL WORKERS ISSUES TSE FOLLOWING L" (CENSE AS A MASTER. UNRESTRICTED .Q z .DONALD J OUELLETTE �. 44 WI LLARD ST LOWEL L mA 01850-13225 4W 0 /28/16 26q-: ' -a 9 l n i