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Home My WebLink AboutBuilding Permit #1046-15 - 4 High Street Suite 202 6/11/2015 NRThO BUILDING PERMIT OF q TOWN OF NORTH ANDOVER o? APPLICATION FOR PLAN EXAMINATION Permit No#: /b "r/ Date Received � ArE ' �gSSACHUS�t�s Date Issued:_(o IMPORTANT:Applicant must complete all items on`this page i LOCATION �-(- �,I,[ .SUdE Print ^, PROPERTY OWNER CC, C(3, V ; \ -'A Print 100 Year Structure yes no MAP - PARCEL: ZONING DISTRICT: Historic District s` no a. Machine Shop Village no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more-family ❑ Industrial ,OAlteration No. of units: 9-Commercial ❑ Repair, replacement_ __ ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed' District ❑Water/Sewer DESCRIPTION OF AOfZK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name V46-ZV.e tl y Phone: Address: '7 V IIA l-v h uyw t C c5 Contractor Name: Phone: 6.177 -S 51 — b Address: Supervisor's Construction License:C� Exp. Date: q, Zh_ .� _ Home Improvement License _ _ - Exp. Date: ARCHITECT/ENGINEER fYci r�t !�)t GM t honer R -7 tF --SS 1 Address: v nr Q�y J Gln Reg. No. t oy 0 FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: -T — wo Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I' Signature of Agent/Own Si ature of contractor. --�- i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPB bF 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS N �r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes °fanning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located--3-84-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) I I ❑ Not foricku Call Email P p 3 1 Date Time Contact Name Doc.Building Permit Revised 2014 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses I E, Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And 1 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 Li Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o 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:Building Permit Revised 2014 Location No. ObDate TOWN OF NORTH ANDOVER Certificate of Occupancy $AM Building/Frame Permit Fee $ U Foundation Permit Fee $ " A' Other Permit Fee $ TOTAL $/0/0 Check#T, / Building Inspector I �F o<�•°TM q a ti A 40 3.•OjMr. r19 SSA[NUSE� CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number: 1046-15 on June 11, 2015 Date: June 29, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 4 High Street Suite 202 MAY BE OCCUPIED AS IN a tenant fit up ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG West Mill,NA LLC 4 High Street North Andover, MA 01845 00, Bui ding Inspector r Fee: PrePaid $100.00 Receipt: 28919 Check : T-010 ttORTF/ Town of It . Andover O - 0 t No. 16q(4r1!5 ti o h •ver, Mass, f.. 20145 coc -1111,�cw �.1 �,9 ADR�TED r'Pa,`'�5 S V BOARD OF HEALTH Food/Kitchen PERRI!cT T LD Septic System ,I LL� THIS CERTIFIES THAT BUILDING INSPECTOR ................................... ........................... .. ....... .................... ...... .............. ..�W!� �� Foundati has permission to erect .......................... buildings on ....... .................... 0/ to be occupied as y ......... ................. ......... .................................. ...... Chimne provided that the person accepting this permit shall in every respect conform to the terms of the application F al 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 o cr, z� i Service / ................. ..... i ? ............................ final �j� /G BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy.Buildin 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. . ;;z" • 'h + �r 'ji7 O'4r.. r••"49 SSACIIUStt CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number: 069-2016 on 7/15/2015 Date: July 30, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 4 High Street— Suite 205 MAY BE OCCUPIED AS a tenant fit up IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG NA West Mill,LLC 4 High Street North Andover,MA 01845 Building Inspector Fee: PryPaid $100.00 Receipt: 29067 Check : 2196 RTF/ %AO Town of ? E 11. Andover 0 b�l_ abqr ,.;... No. 14, -T h ver, Mass R C0C"1C"2W1Ck _ U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System �.� A we� w1 all L Lt BUILDING INSPECTOR THIS CERTIFIES THAT .................................... ....................... .................. .. ................................. \\ Foundation has permission to erect .......................... buildings on .. .............!. .......*� ..,��!!'1.� S �� , C gh to be occupied as 1. .lf .... % ............................................................... Chimney provided that the person accepting this permit I in every respect conform to the terms of the application fin al 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 CONSTRUCTIO7,14 S Rough jService ...................... �a................... ::"1... Final V - � BUILDING INSPECTOR �> 1 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. �e Smoke Det\� r Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 753830.00 m $ - $ 909.96 Plumbing Fee $ 113.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 113.75 Total fees collected $ 1,237.45 4 High StreeT Suite 202 Tenant Fit Up 1046-15 on 6/11/2015 NORTH own of 2 ? E ndover o - No. 15 b 4t - ,� o h ver, Mass, (AAf. COCMIC Nl WICK �1. �.95°R�reo �Pa��S V BOARD OF HEALTH Food/Kitchen PER I T L D Septic System IrR!C. • THIS CERTIFIES THAT �Ar LLC BUILDING INSPECTOR ........................................................... . ... . .. ...... ....... ................'..... .. . ........ .. Foundation has permission to erect .................. buildings on ......4-04.. 1 ...............*.I. 64" ......................................................... Rough to be occupied as .......... .................� .... Chimney 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 CONSTRUCTION STARTS Rough Service ................. ..... :�trra.......................... 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. i I JK Contracting LLC Proposal 31 Richmond Street Weymouth, MA 02188 Proposal Date: 6/2/2015 Proposal#: 152 Project: Bill To: RCG LLC Seth Zeren, 21 High St, Suite 202, N.Andover, Mass 01845 Description Est. Hours/Qty. Rate Total Plans and Permits 1,000.00 1,000.00 Demo, Remove all carpet 2,500.00 2,500.00 General Conditions 3,000.00 3,000.00 Wall Framing 3,000.00 3,000.00 Doors&Trim 2,500.00 2,500.00 Plumbing[estimate] 4,500.00 4,500.00 Heating &Cooling[estimate] 10,000.00 10,000.00 Electrical & Lighting[estimate] 8,500.00 8,500.00 tel/data[estimate] 3,000.00 3,000.00 Insulation 1,200.00 1,200.00 Interior Walls, Drywall, tape ,sand. 6,000.00 6,000.00 Floor Coverings,[estimate] 12,000.00 12,000.00 Cabinets&Vanities 3,000.00 3,000.00 Painting, includes ductwork 6,500.00 6,500.00 Cleanup , final Clean 500.00 500.00 Sprinkler Work 1,000.00 1,000.00 Supervision 7,630.00 7,630.00 01 U� Thank you for the opportunity to bid this work. Total $75,830.00 •"-°"•".�•, OFFICE OF BUILDING INSPECTOR ;rte TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL, �tjsx�et PROJECT NUMBER: 1406002.24 PROJECT TITLE: 4 High Floor 2 Suite 202 and Common Areas PROJECT LOCATION: 4 High Street, North Andover NAME OF BUILDING: West Mill NATURE OF PROJECT: Tenant Fit Out IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, 1,. Londa 5. REGISTRATION NO.. 1nnRn BEING A REGISTERED PROFESSIONAL ENGINEERIARCHITECH HEREBY CERTIFY THAT i HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ❑ ARCHITECTURAL STRUCTURAL ❑ MECHANICAL ❑ FIRE PROTECTION ❑ ELECTRICAL ❑ OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE, SUCH PIANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL.ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for conformance to the design concept,shop drawings,samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become,generally familiar with6the progress and quality of the work and to determine,in general, If the work is being performed in a manner consistent with the construction documents. PURSUANT TO SECTION 116.2.2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. SUBSCRIBAp AND SWORN TO BEFORE ME THIS, DAY OF 19 PATRICIA E. BARKER NOTARY PUBLIC MY CCIIVIMIsb'i+QN Notary PublicCOMMONVVEAIT l OF MASSACHUSETTS My Commission Expires r: - _`24,2018 ACO D� DI1TE(MMIDDVYYYY) CERTIFICATE OF LIABILITY INSURANCE 3/2/15 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 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIRCAT'E HOLDER IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the pol)cypes) 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 erldorseme PRODUCER CONTACT NAM: Maria Dupont Insurance Agency, Inc. PHONE 18 Copeland Street E 617 376-0795 : (617) 479-9121 Quincy, MA 02169 AD me@dupontinsuranceagency.com INSURE 8 AFFORDING COVERAGE NAIC 0 INSURERA:Main Street America INSURE INSURER a: JK Contracting, LLC INSURERC: 31 Richmond Street INSURER D: Weymouth, MA 02198 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 CERTFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONCITIONS OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SIR AM SUM LTR TYPEOFINSURANCE POIJCYNUMBER Pw A NF" (APOWUMMI Lam A GMERAL LIABILITY MPT7794M 2/10/15 2/10/16 EACHOCCURRENCE E 1,000,000 XCOAMAERCIALGENER4LLIABIUTY DAMAGE RENTED $ 500,000 CLAIMS-MADE F7X OCCUR MED EXP(Ary one person) $ 10,000 PFRSONALBADVINAIRY $ 11000,000 GENERAL AGGREGATE $ 2 OO 00 GEN'LAGGREGATELIAeTAPPUESPER: PRODUCTS-COMPICIPAGG S 2,000,000 POLICY P LOC $ AUTOMOBILE LIABILITY aaeddent $ ANYAUM BODILY INJURY(Per person) S ALTOWPED SCHEDULED BODILY INJURY(Per accident) $ HIREDAUTOS _AUTOS AUTOS NON-OPROP ereadd�eM AMA� $ $ UWIREILAUAB [7OCCUR EACH OCCURRENCE $ EXCESS LIAB CWMS-MADE AGGREGATE $ DED RETENTION WORKERS COWENSATION I WC STATU I OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNERIE" NIA E.L.EACH ACO DE Ni OFFICE WMEMBER EXCLUDED? (Mandabry in NH) E.L.DI EMPLOY Mdescribeunder RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTIONOFOPERATIONSILOCATIONS IVESCLEB(Mich ACORD 101,AdmtlemlRanarkeSohad:da,ffnweapsaiangUred) 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. • AUTHOMMD REPRESERTATM Bridget McGowan 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: apedranti@crowninshield.com ..3/3/2015*7:22:03 AM PST (GMT-8) FROM: 100005-TO: 16174799121 Page: 2 of 2 i DATE(MeloomYY) CURt7'e CERTIFICATE OF LIABILITY INSURANCE 3WO15 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), REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. s SUBROGATION IS WAIVED,certificate does not confer rights 60 the subject to the to.. and conditions of the policy,certain policies may require an endorsement. A statement on this certificate holder in lieu of such endorseme s. PRODucm DUPONT INSURANCE AGENCY INC 18 COPELAND ST PHONE FAX No: QUINCY, MA 02169 E-MAIL IN 8 AFFORDING COVERAGE MAIC i URERA: Liberty Mutual Fire Insurance 23035 aXCONTRACTING LLC waRwmc; 31 RICHMOND STREET WEYMOUTH MA 02188 a'OURIERD: NSURERE: COVERAGES CERTIFICATE NUMBER: 23ST7622 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 RESPECTWHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO HE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. owl POLICY EFF LILY EXP LIMITSL TYPE OF N81AtANCE POLICY NUMBER COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F�OCCUR S MED EXP(Any One person S PERSONAL&ADV INJURY S GENLAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ •ECT 7 IAC PRODUCTS-COMFNOP Af3G $ POLICY❑ OTHER: SiNuLe LIMIT AUTOMOBILE LIABLrIY ° I S BODILY INJURY(Per person) S ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per acddWa) $ AUTOS AUTOSD PR RrY DAMAGE $ NON-OWNE (Pot vacmed) HIRED AUTOS AUTOS $ UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS LIM AGGREGATE S S p 0 A 1e01 +sATION WC2-31 Sfi01696-015 2717/2015 2!17/2016 TUTIE AND EMPLOYERS'LABLITY Y/N100000 ANY pROPRETOWPARTNERIEXECUTN ❑Y NIA 100000 E E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? (Man�Y in NN) E.L.DISEASE-EA EMPLOYE S Ifyyaass deserbe under El.DISEASE-POLICY LIMIT 500000 DESCRIPTION OF OPERATIONS bebw DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(ACORD I(",Addlfansl Ramsrlu Sdhadule,may be slashed If mom spsas is mgLdnad) Workers compensation Insurance coverage applies only to the workers compensation laws of the state of MA. This certificate canals and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE Vkq H THE POLICY PROVIMONS. .�; AUTHORIM REPRESENTATIVE UCLA""" Uberly Mutual Fire Insurance ®1968-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are mglstered narks of ACORD CERT NO.: 23677622 CLIENT CODE: 1644469 Lucy Garfield 3/3/2015 10:19:07 AM (EST) Page 1 of 1 Department c:f Pubi,=.safety husetts -Dep s Massac tankard rd of Building Regulations and Boa construct" Supersr License: CSW.334 ` MRpN T WHELAN� 31 RICHMOND ST , WEYMOUTH MA 52,,,„ 0912612015 Cornmissioner