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HomeMy WebLinkAboutBuilding Permit #511-2016 - 77 BEAR HILL ROAD 10/23/2015�1(l�sys YveT S'CAwwtD Permit NO: � 1 � , 7zt Date Issued: ) b BUILDING PERMIT TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATIO no Date Received ' �a AA7eo PP`,g5 IMPORTANT: Applicant must complete all items on this LOCATION %�> Hl (G Print 4 , PROPERTY OWNER b li�I b Nl,-l i L.UV i�� '7 Print MAP NO: `PARCEL: ZONING DISTRICT: Historic District yesno Machine Shop Viliacie ves cn 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 f�, Well ❑ Floodplain ❑ Wetlands H Watershed District 11 Water/Sewer �- cv.4� / OWNER: Name: Address: /S // x ,5/ '<' " Identification Please Type or Print Clearly) Davi aeG r /4 l (2Q ovoft�, : 617 ala°-- 60()0 MA 0119Yct- CONTRACTOR Name: Phone: 97Y D5- U ez Address -2 + Supervisor's Construction License:{ $2 Exp. Date: (012-/(-) Home Improvement License: ( 20 { qq Exp. Date: «+(,rtara r11r6ms ARCHITECT/ENGINEER �I 4A14 't" a ra e, Phone: 9? g S39' 90-88 Address: 1 10( eg. No. `lDl 9v 01 yS FEE SCHEDULE. BULDING PR1M/T: $IAM PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $_ 1FEE: l $ Check No.: X-3131 Receipt No.: 2�i �i NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund k_ . 1 -0, BUILDING PERMIT o� No DrH� TOWN OF NORTH ANDOVER o� APPLICATION FOR PLAN EXAMINATION '' ~ Permit No#: Date Received SSAcHU5� 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 El q -P, is ❑ Well ❑ Floodplal Wetlands, D Ovate ,$11 jDistnct� WaterLLLSewer �� DESGKIPTION 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: No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ EE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I Location ` e�rcl k � " I No. i — 2-C)\ 50 Date b 2 Check # � 569. t TOWN OF NORTH ANDOVER i Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee f $ Other Permit Fee $ TOTAL $ Building Inspector a Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan 9 Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL, r Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiinuniug 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 m U FORM PLANNING & DEVELOPMENT Reviewed On �,�2� I� Signature_ �4i ✓��� COMMENTSG i 141 CONSERVATION COMMENTS Reviewed HEALTH.. Reviewed on a COMMENTS 4 -623-1--5 Signatu , &i� 5---r- , Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Commen Conservation Decision: Comments Water & Sewer Connection/Signature ®ate Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ,'FIREDEPiAR�TMEIVT ;Temp®umpsteronsite°'no T t�Locat'ed at 12�4(Main MS et; .� Fi`retDepartment s - �: , x„E , ►,.- �� . t � .. t ' «...° ter. .,....»,..--►_ �-.rte.. _ � ....._.rte-����.,,�.�. -COM jE-N 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: lies MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) LI Notified for pickup Call Email Date Time Contact Name Doe.Building Permit Revised 2014 it 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 OTE: 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 . IOTE: 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 TOTE: 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 w O H O CD Z W x ujW 0- Z •,v w 00 O CL CL CF)a �Ca J � ON Z i/V AAVY/W/\\ a C a C O RS w = Ca O •� L 1 -M 0. c :�cn : -En. Q. Q a) °w' c cc w wt � m o Cuml V i x V N o o U > _ gi b: U) N i ► _ -o O H O C yn as .0 O -CLO U U Q W CW W a N Val U G U.z Z Z' oQ Z Z w p Z v 0 cr Q m F- Q W J oc m O J W 6L N UJ co � a J W 2 T z U E j 76 t N a+ Y O O_ 3 =$ c6 3 O f0 O N O O L O O C O O O 7 LL N W K U i..L K iz W N 2' LL CD to V7 H O CD Z W x ujW 0- Z •,v w 00 O CL CL CF)a �Ca J � ON Z i/V AAVY/W/\\ a C a C O RS w = Ca O •� L -M 0. c :�cn : -En. Q. Q a) °w' c cc w wt � m o Cuml V i V N N � J m U > _ gi b: U) N i O _ -o O H O C yn as H O CD Z W x ujW 0- Z •,v w 00 O CL CL CF)a �Ca J � ON Z i/V AAVY/W/\\ a C � Z L�� Q. Q a) cc w m Cuml = — U E -I.- -I.- Uv te._=_u O '>a U) amW Q CO) as: ° ;� c H t4 .0 O -CLO U H O CD Z W x ujW 0- Z •,v w 00 O CL CL CF)a �Ca J � ON Z i/V AAVY/W/\\ a Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 48,125.00 m $ - $ 577.50 Plumbing Fee $ 72.19 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 72.19 Total fees collected $ 821.88 77 Bear Hill Road 511-2016 on 10/23/2015 1/2 Basketball Court rI'= 5 F O R T C O U R T Dave McGillivray 77 Bear Hill Road North Andover, MA 01845 Sport Court of MA P.O. Box 5178 Andover, MA 01810 Tel: (978) 474-4029 Fax: (978) 474-0135 sportcourtmaGcomcust.net a:wa. sportcourtmo.com Proposal valid for 30 days from: 10/15/15 a COMPONENT'S: 32 X 50 ( 1,600 sq. ft.) COURT Sport Court of Massachusetts hereby submits specifications and estimates for the above project: Includes the following options: Y Pro Adjustable Slam Basketball System(s) with 42" x 72" backboard. Reach will be - 36" or 48". 1 Padding: Pole, Anchor, Backboard 1 Multi Sport Net Adjustment System Multi Sport Net ! bouble Metal Halide Lights ! Sport Sear Fun Pack 1 Painting of Basketball & Same Lines • Sport Court Power Some Flooring • Colors and layout as designed • Installation • 15 Year Mfg. Limited Warranty - Tile • 10 Year Mfg. Limited Warranty - Hoop and steel components • Freight - Salt Lake City, Utah • Sales Tax Please note; only components listed above are included in this contract. Any changes need to be submitted in writing and 'signed by the original contract signer and Sport Court representative. These changes may incur additional charges and/or cause delays in the original time schedule. Initial 11 S P O R T C O U R T Dave McGillivray 77 Bear Hill Road North Andover, MA 01845 Sport Court of MA P.O. Box 5178 Andover, MA 01810 Tel: (978) 474-4029 Fax: (978) 474-0135 sportcourtmaecomca st, net www.sporteourtmo.com Proposal valid for 30 days from: 10/15/15 SITE WORK: 32 x 50 Court Sport Court of MA hereby submits specifications and estimates for the above project. X Excavate and grade court area in preparation for court X Supply and Install 44 tons of I" crushed stone base X Supply and install form work for concrete pad X Supply and install 4" concrete base - 4000 PSI concrete with fiber mesh, and I" perimeter rebar with 1" per 10' sloping grade across the court. Pad will have a trowel finish. X Supply and install respective component anchors & sleeves. X Supply and Install 113 linear feet of 10' high black soft net fencing with 1 Nwalk gates NIA Concrete Pump VALUE OF PROJECT: $ 40,000 with Power Game Tile * Price doves not include additional site ►rork & options. Sce Pg. 3 PAYMENT SCHEDULE AS FOLLOWS: $1,000 INITIAL DEPOSIT TO PLACE YOU ON THE BUILDING SCHEDULE 50% UPON ORDER PLACEMENT (the $1,000 will be deducted from this payment) 25% UPON COMPLETION OF PAD 209'6 UPON DELIVERY OF MATERIAL BALANCE DUE UPON COMPLETION OF PROJECT Please note: the price quoted is based on agreed upon sighting of the court, as placed on the plot plan. If the location changes, and more work is necessary, pricing may need to be adjusted. $500 of deposit is non refundable. If contract is terminated all costs incurred by Sport Court prior to termination must be reimbursed to Sport Court. Sport Court of MA retains ownership of all components and flooring until the balance is paid in full. If payment is not received per payment schedule, a 1.5% per month interest penalty will apply. Upon default, customer shall be responsible for any and all costs of collection including reasonable attorney fees. Proposal pricing is valid for 30 days. ACCEPTANCE Accepted by: 'Da"c Date: Accepted for SC of MA by: Date: /D e /� S P O R T r- O u R T Dove McGillivray 77 Bear Hill Road North Andover, MA 01845 Sport Court of MA P.O. Box 5178 Andover, MA 01810 Tel. (978) 474-4029 Fax: (978) 474-0135 sporttourtmaecomcast_ net wnvw _ sportcourtma . corn Proposal valid for 30 days froth: 10/15/15 ADDITIONAL SITE WORK & OPTIONS: FENCING: In order to meet code for fencing the pool we can change the court fence to black vinyl coated and avoid having 2 fences. Two options are listed. Posts will be of heavier gauge steel with a heavier top rail to hang the wire from. The gate will need to have a self locking latch to meet code and this is one item we need to source -- price on the latch only is T80 With 9 Gauge. Black Wire - Add. $ 900 With b Gauge (heavier) Black Wire Add: $1,475 HOCKEY BOARDS: Supply and install 164 linear feet of single course 2" x 10" black plastic hockey boards. Add: $4,100 INFILTRATION TRENCH= Supply and install a P wide x 2' deep x 52' long infiltration trench along the back side of the court. Add: $ 950 ✓/_A MSCELLANEOUS ITEMS - Add fill to create an access route for the trucks from the driveway to the court area. Remove and dispose of the shed. Remove and dispose of a tree, shrub and 3 stumps. Add: $1,+600 ✓ * The plan is to strip off the loam and place it around the court and do a cut and fill to build the court. Itis possible that some additional fill may be needed to bring the court up a little to make the step elevations kvork in 3-7" (21" total) increments from the pool deck. It's assumed that we can make a ramp to get all the trucks to the site of the court without bucketing material or pumping concrete. Inspections are done by the hour, Price does not include removing anything from the site other than what is listed above. These item is left as to be determined once vie start excavation. r SITE WORK "KITTY GRITTY" `+o that each customer of Sport Court of MA fully understands what to expect regarding the court construction to be undertaken, vve provide this detailed summary. i. Sport Court of MA cannot promise any firm dates for any phase of construction or completion. Out - timeline is affected by weather conditions. y. Some court location% have poor construction accessibility. These are conditions that exist, and that we slid not create. SC of NIA will do everything reasonably possible to protectyour property and minimize any mess and annoyance. SC of N -IA will clean up the construction and access area after construction is cc}mpteted and remove all its' ev£css construction materials and w2stes: We will rough grade around the court. Fine grading and seeding is your responsibility, as is the repair to the access route. 3. If fences or swing sets need to be renin%ed for access, the% vti ill need to be re -;assembled by others. 4. This price includes allowances for disposing of the topsoil on site. if the soil heeds to be removed from the property. an :additionat trucking & disposal fee ti.ill appiv,. 5. The price for construction is based on the assumption that a concrete truck can access the site without needing to pump the concrete. If, clue to the layout of the site. the trrrclt cannot directly access the site, a concrete pumping fee will apply. This charge will be SI,550 - S1,850. depending on the sine of the court. It is a State regulation that an area needs to be provided on site for the excess concrete from the gravity struts or tvr'tlrin file pump pipes to be disposed of. t'i'e normally do this in the vicinitt of the court — if V'011 leave a preferred site please specify. 6The light will be wired from the top to the base of the pole. It is the homeowner's responsibility to bring power to (lie base and have it connected. ?. Construction of your court iv ill require a Kubota, concrete truck, andlor pump access. These vehicles weigh up to 70.000 pound;. SC of NIA cannot be responsible for driveway, walkvyay, or yard (iamafie caused by inadequate sub -grade or other conditions beyond our control. F.ver,v' effort will be made to minimize damage. .Landscaping, drivevvaay, or walkway patching is your responsibiliq. S. Concrete vviII usually crack. The function of the steel is to keep the concrete tied tightly together, it does Trot prevent cracking, q. Repair of sprinkler sistems and dog fences disturbed by the building process is the homeowner's responsibility. tti. Every town is different with regard to whether a building permit is required or not, and they are the responsibility of the homeowner. Sometimes there arc lot line setbacks, lighting, or fencing regulations that need to be abided try. Wetland's have their oven set of rifles - town and state wide. Should you need ;additional planning to address wetland or appeal issues, we will refer you to an engineering thin for their expertise. All cng ineerino fees, and costs associated with obtaining the permits, and the permit fees will he ,your responsibility. I L If you choose to do sa batting cage the netting; for the cage will need to conic down in the fall to avoid snow damage. 12. Occasionally during the site Ni ork process. large rocks, ledge, stumps, and/or unexpected debris that have been buried become obstacles for the exca%ation cre%v. Prices do not allow for the removal of debris. large rocks. unsuitable material, or ledge. Initial The Commonwealth of Massachusetts . Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: Ul �6 4 4 City/State/Zip: T)< Phone #: f7 Are 71a..a n employer? Check the appropriate box: Type of project (required): 1. employer with _employees (full and/or part-time).* 7. New construction 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. F1 Demolition 3..0 I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 F1 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. F1Electricalrepairs or additions proprietors with no employees. 12. [A Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ - 13. E] Roofrepairs These sub -contractors have employees and have workers' comp. insurance.1 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ❑Other 152, § 1(4), and we have nq 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 submit 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 -cont ei6rs 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. �, Q % [�� Insurance Company Name:a rte/' ���it ! ` 1 f --n _ Policy # or Self -ins, Lic. #: V/ t l QU ' Expiration Date: 3 /' Job Site Address: �-� &CY- L` ►�gd / " City/State/Zip: G'' " 1 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 cer ify under thepa'ns and penalties ofpejjury that the information provide//d /ab722-7 iss trr e and correct. Sienature: e�, _ Data: !" v iI n - i 2 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 #: Information and Instructions 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 of Hire, 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 -contractors) name(s), address(es) and#one 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. Anew 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 bum 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 # 617-727-7749 Revised 02-23-15 www.mass.gov/dia OP ID: COHA 'Ak "r CERTIFICATE OF LIABILITY INSURANCE DATE07124/201 Y) 07/24/2015 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 Phone: 978-688-6921 Macdonald & Pangione Insurance P.O. Box 428 Fax: 978-688-5350 104 Main Street North Andover, MA 01845 Donald Schemack CONTACT NAME: NAME: Hannah Courtemanche AAI CISR ' a°Nl o E n :978-688-6921 (FnAi_cLNo): 978-688-5350 ADDRESS: hannah@mpins.net PRODUCER ^-- CUSTOMER ID #: DGCON-1 INSURER(S) AFFORDING COVERAGE NAIC # INSURED D G Contracting, Inc ID 646648 428 Pleasant St North Andover, MA 01845 INSURER A: Travelers Prop & Casualty CL 25674 INSURER B: Safety Insurance Company 39454 INSURER C: National Liability &Fire Ins 05117/2015 INSURER D: _ INSURER E: _300,000 D EXP Any one person) S 5,000 INSURER F: COVERAGES CERTIFICATE NUMBER: RFVICIOKI KIIMRFP- 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. ILSSR I TYPE OF INSURANCE ADDLBR POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD/YYYY LIMITS A GENERAL LIABILITY X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR X I ( 680-1553R18 05117/2015 05/17/2016 EACH OCCURRENCE S 1,000,400 LAMAUL: TO RENTED PREMISES Ea occurrence) $ _300,000 D EXP Any one person) S 5,000 [PERSONAL&ADV INJURY S 1,000,000 �; _ -i GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 71 POLICY I A I JEcT L1 PRO LOC PRODUCTS - COMP/OP AGG S 2,000,000 S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) BODILY INJURY (Per person) S ALL OWNED AUTOS BODILY INJURY (Per accident) S B X SCHEDULEDAUTOS 3116538 07/12/2015 07/12/2016 PROPERTY DAMAGE S (Per accident) X HIRED AUTOS X NON -OWNED AUTOS S fI I I I I I I S X UMBRELLA LIAB X OCCUR CH OCCURRENCE S 1,000,00 A EXCESS LIAB CLAIMS -MADE CUP -009C153321 05/17/2015 05/17/2016 _ �AGGREGATES 1,000,000 DEDUCTIBLE S S RETENTION SWORKERS � C NSATNOER AND EMPLOYEMPRSEL ABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE IN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under NIAI I V9WC640862 03/3112015 03/31/2016 X ORY I ITS E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE S 1,000,000 E.L. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS ! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Re: 70 Possum Road, Weston MA. Additional Insured: Alan Rottenberg, Martin Glazer as Trustees of 70 Possum Road Realty Trust c/o Goulston and Storrs, PC, Andrew and Melissa Janfaza, LLC and the Legasse Group, LLC \.GKI Ir -n -Alt HULUtK f'Ak,rrCl r Ar,nk, ACORD 25 (2009/09) v I VSS-zoos ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Sport Court of MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P O Box 5178 ACCORDANCE WITH THE POLICY PROVISIONS. Andover, MA 01810 AUTHORIZED REPRESENTATIVE ACORD 25 (2009/09) v I VSS-zoos ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety "Wil Board of Building Regulations and Standards License: CS -001821 Construction Supervisor 1` DAVID P GULEZIAN 428 PLEASANT S7 NORTH ANDOVER MA 0184bNJ ' 'z Expiration: Commissioner 10102/2017 V Y, '40 Ar/ftr µ: i?ifict tar fonsns»tr ©iratrs & f3usinca� tteg�iafs`stn ROME IMPROVEMEW CONTRACTOR Oeglstrjtlon, 120199 Tara: g kxpiratten: 111112015 Individual DAVID OULUIX-4 DAVID GULEZIAN 42$,PLEASANT ST NORTH ANDOVER, MA 0 845 Undwrtrtbry