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HomeMy WebLinkAboutBuilding Permit #809-16 - 5 BOSTON HILL ROAD 1/14/2016✓a� 1�' "'r "'` `� u TOWN OF NI PERMIT Wow-ORTH NG ANDOVER P = APPLICATION FOR PLAN EXAMINATION Permit NO:�c Date Received Date Issued: IMPORTANT: Applicant must complete all items on this LOCATION -7) A ► i Print PROPERTY OWNER_._ -10 t OUM — \`-P- C LA. I P 1u SS _ o Print p MAP NO: �1 �`�PARCEL O? -� ZONINGI DISTRICT: V K Historic District yes Machine Shop Villaae ves TYPE OF IMPROVEMENT �w�r� �d off` �'� ef►�� �� a��e�nQ� wti�h n�u� o��S. etc 3 PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family a(Addition ❑ Two or more family ❑ Industrial a Alteration No. of units: IY\Commercial 0kRepair, replacement ❑ Assessory Bldg & Others: ❑ Demolition ❑ Other Te1Q co n-) ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer Y, t5,+ n9 _S\-�Y1d add (o cc 2�d�� 1�Qe.ciS Q�d 3 SurC�lc�r �jc 7=25 Tb r\R Q rl �e nnc\ , 4c ay rn o �. 1 t -e � � Sy + no C-0 q . X 0-4')6 cep \R C e W k}" 3 hIbc ►d ,tae C Cei 0Q 5 . ` 0 C.h 0.03 t ib c� C o LfN d SQR C 2 Identification Please Type or Print Clearly) OWNER: Name: �O�r {�vm I �ec�-z^� GUtCe�05S Phone: (PIS G--7 Address: yolk �g( num CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Home Improvement License: J Exp. Date: Exp. Date: ARCH ITECT/ENGINEERDGn NQmyY\ Phone: 1-7 r5 -SS --7, S SS3 Address:l(pe)C3 Mn -Reg. No. y0-720 FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S: r'. Total Project Cost: $, 000 FEE: $ 00`00 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund SignatGri� of Agent/Owner-�Ce WA Signature of contractor10 Location No. '�� 7 /� Date / i Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 4 r Bui ding Inspector BUNORTy ILDING PERMIT pF-ED 16 9tia TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 1K T i y Permit No#: Date Received �9SSgC vs���y Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic El ❑ Floodplai_n ❑°We#lands ❑ Watershed Distract i� Water%Sewer "' ' DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: - Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. ,z."l Total Project Cost: $ EE: $ Check Ne;.: Receipt No.: N01'Ei Persons contracting with unregistered contractors do not have access to the guaranty fund e Plans Submitted ❑ r 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 PLANNING & DEVELOPMENT Reviewed On )[I Signature_, COMMENTS �'h�rGwt�SS�o� rtvS��fitM Spec.��,,1, �rr��t +S Noi r0C 0,rld NSA-tG >10K&3s V-A %iy 5 �CSt ALT C1 uc� ,•�r�l to P w �J V CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Siqnature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes Plenning Board Decision: Comments Conservation Decision: Comments Water &Sewer Connection/Signature Date Driveway Permit DPW T,, wn Engineer: Signature: Located 384 Osgood Street FIREDEPAR�TMEI,VkTTemp,�Dumpster onsite-#yesu� ; ,s;� �,Lted�at',�12�,4�Mam�St eet ��` , -.. � Me 6p �17�� � ;�i.a �r 7. yt ,}.j ,. r�'�i t �r"S,; "r:�.'t � •,} ,���t 1. - ..-.,.,�R t. �-.�.-A.�,.,Q�.vz� a CbMMEN TS, v N C � 0 O n Z D oCL CL � � O � cam. vii vCD CL = CD CCD O ca W CDCD C CD CL O N. to M � v 0 z CD 0. �' o CD CD c� 1� ti z m V/ O CZ/� C'1 z cn V+ Z Z a m O m I X X y z O VI O O z O N N O O W CL N to c 0 U) 0 CL U) 3 0 —9 o vii ="<.m O o �•C-0 -0,–o o ? =' -0 :3V FD oo. _ o .� W n O N C (D 'O CD _Q O y O• = O CQ CL O N o D1 � • O =r O CD CD -0 0 co O 0z CD y :\ ort� =r 0 =r CL O < CD SCD U (D C. (D Sao � CD N rt n =~ O to 0 .� O O Err .+ S► S <D CD 3 CDN � CD 3 �y C.) 0, Do as � 0CU 0' o CL ami = CO) CD 0 m 3 � U O o rn N O -A cD D CCD 0 :C� rr • C O V7 V) co TO T N x T ,p T n Z7 T N T S O :3O j 7' O O N0 O rD _ < 7 Q rp (DD - ffDD 000 S n DCO S = Sf 7 ao S Q n O { p c�i� [`moi * m _{ l� (D rD m C C 3 3 W m D 3 ` D H W > n z H r O 3 A v m 0 m n z i -� 0 p O s 0 0 z .\ Green Mountain Communications • From: Town of North Andover, MA <noreply@viewpointcloud.com> Sent: Tuesday, July 18, 2017 7:41 AM To: Green Mountain Communications Subject: Allan Paduchowski commented on Inspection j Town of North Andover, MA Allan Paduchowski commented on Inspection for *Electrical Permit #22916 passed 1 W Final Construction Control Document To be submitted at completion of construction by a ' Registered Design Professional .�r for work per the 8th edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: N Andover MA Date: May 08, 2017 Property Address: 5 Boston St, North Andover, MA 01845 Project: Check (x) one or both as applicable: New construction X Existing Construction Project description: Verizon Wireless telecommunication facility (AWS) installation on an existing building. Install new antennas and associated radio equipment on building facade. I Daniel P. Hamm, MA Registration Number: 40720 Expiration date: 6/30/18, am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Architectural Structural Mechanical Fire Protection Electrical X Other Describe: Entire Project for the above named project. I, or my designee, have performed the necessary professional services and was present at the construction site on a regular and periodic basis. To the best of my knowledge, information, and belief the work proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building permit and that I or my designee: 1. Have reviewed, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Have performed the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work was performed in a manner consistent with the construction documents and this code. 4. This inspection report assumes that the antennas and antenna mounts were installed according to specification. The physical inspection of the antennas and antenna mounts was completed at grade level. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. Enter in the space to the right a "wet" or electronic signature and seal: c Phone number: (978)557-5553 Hudson Design Group, LLC 1600 Osgood Lndg, Bldg 20N, Suite 3090 North Andover, MA 01845 OF DANIEL P. HAMM CIVIL NO -40720 Email: info@hudsondesigngroupllc.com Building Official Use Only Building Official Name: Permit No.: Date: Version 06 11 2013 N< CD N CD• 0 n CD n l.� r Z C=.a N --I0, O vi, rt CD C TI C O O rt Q 171 .+ S CD W n O. N p. N c M � -i cD cD 2 o Q �, -� D 1 O 0 -� to a = rt a n O vs O O W CCD D CD � Z N A C E. CD -A- CD 0-0 zz Z-0 cccoU �O rb Cl) CCD Ootn:� 0 M cCD a n`ib. Z� Qasto p 0� c0 V1— oo ocCD--.••� < y O cr CD rU'0CD CD 4 1 CD 01 z 29 •V! .+ CD a CD C O CD _ > (� •� -1 =� m N _ v (, p x y O Z �'� CD �s CD� 0 0 . � � o -h O G) > r. CD D CD C Z' D � ►°s cn O -0 � @'a: < m • c " CD —ni 0. a) o CL QM Ln 7r ry 0 Ln m Z p 03 CD =� o D z T ;o D'4 S ^ Z �^ 0 -n � VI [D � n fD 7o 00 S � m n '° D r MLA 0 T � ;v Oq S C Z +n 0 T � (') 3 7 rD K :;o d4 S -n 7 CD - �. W C G cZi m 0 V1 �. f1 N G 3 T d rr S =3W O o O m _ ;r - i` September 22, 2015 Bell Atlantic Mobile of Massachusetts Corporation, Ltd., d/b/a Verizon Wireless 400 Fnberg Parkway Westborough, MA 01581 Attention: Network Real Estate RE: Verizon Wireless Rooftop Installation 5 Boston Street North Andover, MA 01845 Dear Network Real Estate Manager: Through a leasehold interest Verizon Wireless has radio equipment, antennas and ancillary equipment located at the above referenced site. I have been informed that Verizon Wireless will be replacing the existing antennas and adding the additional remote radio heads with ancillary junction boxes as depicted on the attached construction drawings by Hudson Design Group, LLC. dated 09/01/2015. I understand that there will be nine (9) remote radio heads with corresponding junction boxes and ancillary connecting cables installed at the site after the completion of the project. As an authorized agent I hereby consent to this work and authorize Verizon Wireless to apply for any and all permits that may be required for this project. Sincerely, 15 4eni Farnum 397 Famum Street North Andover, MA. 01845 September 1, 2015 verimn 400 Mberg Parkway Westborough, MA 01581 RE: Structural Assessment Site Name: Site Address: To Whom It May Concern: N Andover MA 5 Boston Street North Andover, MA 01845 Hudson Design Groupi.c l Hudson Design Group LLC (HDG) has been authorized by Verizon Wireless to perform a structural assessment on the existing antenna mounts located at the above referenced site. Based on our evaluation, we have determined that the existing antenna mounts ARE CAPABLE of supporting the proposed antenna loading at or near the proposed locations. Reference the HDG drawings dated September 1, 2015 for the proposed equipment locations. This assessment was conducted in accordance with EIA/TIA-222-G, Structural Standards for Steel Antenna Towers and Antenna Supporting Structures, Massachusetts State Building Code (8th edition), International Building Code 2009, and ASCE 7-05. This determination was based on the following limitations and assumptions: 1. Equipment and locations should not deviate from the construction drawings without written approval of the engineer. 2. HDG is not responsible for any modifications completed prior to and hereafter which HDG was not directly involved. 3. All structural members and their connections are assumed to be in good condition and are free from defects with no deterioration to its member capacities. 4. All antennas, coax cables and waveguide cables are assumed to be properly installed and supported as per the manufacturer requirements. 5. All components supporting the Verizon equipment are assumed to be designed to all applicable codes and design for identical to or larger than the current loads. Please feel free to contact our office should you have any questions. Respectfully Submitted, Hudson Design Group LLC Michael Cabral Structural Dept. Head p: 978.557.5553 f: 978.336.5586 a: 1600 Osgood Street, Building 20 North, Suite 3090, N. Andover, MA 01845 p: 413.588.8139 f: 413.517.0590 a: 116 Pleasant Street, Ste 302, Easthampton, MA 01027 Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 80' edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Number: n/a Project Title: N Andover MA Date: September 15, 2015 Property Address: 5 Boston St, North Andover, MA 01845 Project: Check (x) one or both as applicable: New construction X Existing Construction Project description: Verizon Wireless telecommunication facility (AWS) installation on an existing building. Install new antennas and associated radio equipment on building facade. I Daniel P. Hamm, MA Registration Number: 40720 Expiration date: 6/30/16, am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning': Architectural Structural Mechanical Fire Protection Electrical X Other: Entire Project for the above named project and that to the best of my knowledge, information, and belief such plans, 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 I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accprdance 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 quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress 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 Enter in the space to the right a "wet" or electronic signature and seal: Phone number. (978)557-5553 Email: in Hudson Design Group, LLC 1600 Osgood Lndg, Bldg 20N, Suite 3090 North Andover, MA 01845 Building Official Use Only Building Official Name: Permit No.: Date: Control Document'. Note 1. Indicate with an `x' project design plans, computations and specifications that you prepared or directly supervised. if `other' is chosen, provide a description. Version 06 11 2013 The Commonwealth of Massachusetts fu = Department of Industrial Accidents > I Congress Street, Suite 100 Boston, MA 02114-2017 r www mass.gov/dia y Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Awlicant Information Please Print Leaibly Name (Business/Organization/individual): Structure Consulting Group Address: 49 Brattle St. City/State/Zip: Arlington, MA 02474 Are you an employer? Check the appropriate box: Phone #: 781-791-7724 LQ I am a employer with 50 employees (full and/or part-time).* 2.❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.[:][ am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.[:][ 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 proprietors with no employees. 5.❑ 1 am a general contractor and 1 have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance.t 6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition ] 0 ❑ Building addition 1 I.❑ Electrical repairs or additions 12. []Plumbing repairs or additions 13.❑Roof repairs 14. E]Other Telecom r,,1.7 aNrnwaui ulal cuccxb DVx it 1 Must also rrl Out rte secuon OeJOW 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 Company Name: Twin City Fire Ins Co. Policy # or Self -ins. Lic. #: 76 WEG GB2651 Expiration Date: 1-3-17 Job Site Address: 5 Boston Hill Rd. 'City/State/Zip: North Andover, MA 01845 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 hereby cerhfy�fi#der thelabil,#d aloes of perjury that the information provided above is true and correct. 781-791-7724 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. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 Contact Person: Phone #: 11 ACOR& CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDNYYY) 10/5/2015 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 CONTANAME: CT Mike Ta. Tarpey Insurance GroupPHONE (617) 527-6070 AX No: (617)527-1980 AIL ADDRESS:michael@tarpeyinsurance.com 343 Washington Street INSURERS AFFORDING COVERAGE NAIC # X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR INSURER ANorfolk & Dedham 23965 Newton MA 02458 INSURED INSURER B: Structure Consulting Group, Inc. INSURER C: 49 Brattle Street INSURER D: INSURER E: Arlington MA 02474 INSURERF: GUVtKAtatJ CERTIFICATE NUMBER:2015-2016 Term REVISInN NUMRFR- 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF IMMIDD POLICY EXP MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 5,000 R0105555 10/5/2015 10/5/2016 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- X POLICY ❑PRO F-1 LOC JECT GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 _ BODILY INJURY (Per person) $ 20,000 A ANY AUTO ALL UTO AUS OS X AUTOS SCHEDULED 91022321A 1 6/2015 / 1/6/2016 BODILYINJURY(Peraccident $ 40,000 ) X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE Per $ accident Medical pavrnents $ 5,000 X UMBRELLA LIABX OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 A EXCESS LIAB CLAIMS -MADE DED I X I RETENTION 10,000, $ U0908417A 10/5/2015 10/5/2016 WORKERS COMPENSATION PEROTH- I I AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N I A STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION For Informational Purposes ACORD 25 (2014101) INS025lgntantt SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Tarpey, VP, CIC, LI ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE LAS DATE(MM/DD/YYYY) R054 1 /G /�n1 C V THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISv 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 SUBROGATIONIS 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 PAYCHEX INSURANCE AGENCY INC 210705 P: F:(888) 443-6112 PO BOX 33015 SAN ANTONIO TX 78265 CONTACT NAME: PHONE (AIC, No, EA): (AIC, No): ( 8 8 8) 443-6112 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Twin City Fire Insurance Company 29459 INSURED INSURER 13: COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑OCCUR INSURER C : STRUCTURE CONSULTING GROUP, INC INSURER D' 49 BRATTLE ST INSURERE: ARLINGTON MA 02474 INSURER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVEFOR 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 TYPEOFINSURANCE ADDL SURR POLICYNI/MBER POLICYEFF M/OD/TT17 POLICYEXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑OCCUR EACH OCCURRENCE S DAMAGE TO I PREM SES Ea oaurmnce S MED EXP (Any ane person) $ PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT ❑LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ OTHER: 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTO NON -OWNED AUTOS PROPERTYDAMAGE (Per accident) S S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS DAB CLAIMS -MADE AGGREGATE S DED RETENTION E $ A WORKERS COMPENSA770.Y ANDEMPLOYERS'LURILITY ANY PROPRIETOR(PARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory In NH) ❑ N/A 76 WEG GB2651 01/03/2016 01/03/2017 PER OTH- X STATUTE ER E.L. EACH ACCIDENT 11,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMB 11 , 0 0 0 , 0 0 0 DESCRIPTION OF OPERATIONS/LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Those usual to the Insured's Operations. v IVt$tf-ZUT4 AGOIZD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE Town of North Andover, MA DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTA nVE 1600 OSGOOD ST NORTH ANDOVER, MA 01845 �'� "� / v IVt$tf-ZUT4 AGOIZD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts - Department of Public Safety Board of Building Regulations and Standards Con%truction Supcnisor License: CS -078888 (7 3-1 r John G McGillicudky -- ' 65 Governors RoaB Milton MA 02186 Expiration Commissioner 07/11/2016 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 Ido MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine [MOTES and DATA — (For Ll Notified for pickup Cal rtment use ail 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 4. 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 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/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 TE: 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 E: 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. 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