HomeMy WebLinkAboutBuilding Permit #940-2016 - 85 FLAGSHIP DRIVE 3/7/2016Permit NO: % — 2-61
Date Issued: '311 11 (,e
BUILDING PERMIT
TOWNOF. NqRTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
RTANT: Applicant must complete all items on this
LOCATION of C)KJLT
Print
PROPERTY OWNER /\I G-- t - f Z, L L (_,
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes
Machine Shor) Villaae ves 626'-)
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
El Addition
0 Two or more family
El Industrial
ZrAlteration
No. of units:
VCommercial
gAepair, replacement
El Assessory Bldg
0 Others:
0 Demolition
D Other
0 §eptic 0 Well
0 Floodplain 11 Wetlands
0 Watershed District
L YWater/Sewer
I
S - P/,) /,w �/ S4 � uz, (,-7 -
Identification Please Type or Print Clearly)
OWNER: Name: /V /=- r4 e- I- C- - Phone: 2 1151 - ?-7 1 -43 8.2
V
jaress: A� A 00A IV" Is T 4.,a oavlZAI ��5j 0,/ 9.bl
CONTRACTOR Name: Phone: 751-1733-6367
Address: — 16S-4�,--4-e-40 8,0S,,-VAJ E7—
Supervisor's Construction License: Exp. Date:
k,
Home Improvement License: Exp. Date:
ARCH ITECT/ENGINEER Phone:
Address: 'Reg. No.
FEE SCHEDULE. BULDING PERMIT., MOO PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
it
Total Project Cost: $ 0? 0, 0 06 Q0 FEE: $ :,? �/6. 00 Vo
Check No.:. e2-cpi oi% - ReceiptNo.: 5c)0%-6
NOTE: Persons contracting with unregistered contractors do not have acces�,to the gu trantyfund
�Sb
ifAgent/OwneF—A&� �---77SigP_qtuii-6fcOritra6i
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Je
BUILDING PERMIT`;."
TqWN OF NORTH ANDOVER
APPLICATION FOR -PLAN EXAM I NATION` -
Permit No#: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on.this. page
LOCATION
Print
PROPERTY OWNER
4t, X
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Resi Jential
Non- Residential
El New Building
El One famil y
El Addition
'
El Two or more family
El Industrial
El Alteration
No. of units:
El Commercial
El Others:
0 Repair, replacement
El �ssessory Bldg
0 Demolitio n
�_d_sqptic [I,\/Vell
[I Other
[I Floodp El. Wetlands
lain
-n I hpd1;QlStrict
DhbGKIF I 1UN UI- WUMIN IV Dr- rF-1xr_Wr\
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
. I I
1_%UU1UC)0
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License:
ARCH ITECT/ENGI NEER
. D ate:
Phon
Reg. No'_
Address:
FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000-00 OF THE TOTAL ESTIMATED COSTOAS.ED ON $125.00 PER S.F.
FEE: $
Total Project Cost: $
Check No.: 7. ReceFptNq.i6
-ai�qoo to the guarantyfund
NOTE: � Persons contracting with unregistered contractors do',irot"Ita I ve
I
Location
No. Ch/0, Date
I /
Check# D(� -:� I
' r
TOWN OF NORTH ANDOVER
Certificate of Occupancy $/0 6)
Building/Frame Permit Fee Oyo
Foundation Permit Fee $-
Other Permit Fee $
TOTAL
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan 0 Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer El
Tanaing/Massage[Body Art El
SwhMning Pools El
well El
Tobacco Sales El
Food Packaging/Sales El
Private (septic tank etc. El
Pennanent Dwnpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
f17ZA,4!!9'—
PLANNING & DEVELOPMENT Reviewed On �-74fb SignatureL.
COMMENTS... dffi�t t 5ervte-4 kff�. - IsJdUvrto-� -tjiued u5e- WycgjjAj"gAe3Lrw
I --
4-xi? " 0 r Atn-i L (,eftzyr Atlez� C"O doC�, U pA.W-r
'!�04-05- �
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decfsion/receipt submitted yes
Ylanning Board Decision: Comments
$ 4
Conservation Decision: Comments
Water & Sewer Connection
DPW Town Engineer: Signature:
Located 384 Osgood Street
I U
03-
W 71, -
P !R
"A
�W, A
Te r�psie'Zrp
4i Eeii�
0 G e a 4 ��a i n �, 'f Z - k , -, r�- Y,
e i@ i ir
::� fta fo j
$ MEn,-#
Dimension
Number of Stories: Total square feet of floor area, based oh,,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.$100-$l 000 fine
NOTES and DATA — (For department use)
Q 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.
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
4. Floor Plan Or Proposed Interior Work
4. Engineering Affidavits for Engineered products
OTIE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4.� Building Permit Application
4. Certified Surveyed Plot Plan
,4. Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. �icenses
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
16 2012. 1 ECC Energy code
,& Engineering Affidavits for Engineered products
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
Doe: Building Permit Revised 2014
A
0RT"
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building, Permit Number 940-2016 on 3/7/2016 Date: March 30, 2016
THIS CERTIFIES THAT
THE BUILDING LOCATED at 85 Flagship Drive — Unit E
MAY BE OCCUPIED AS IN a tenant fitup ACCORDANCE WITH THE PROVISIONS OF
THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS
MAY APPLY.
Certificate Issued to: NETR, Inc.
85 Flagship Drive, Unit E
North Andover, MA 01845
BuilAing Inspector
Fee: PrePaid $100.00
Receipt: 30080
Check: 26791
Final Construction Control Document
To be submitted at completion of construction by a
Registered Design Professional
for work per the 8'h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Unit E / N.E.T.R Inc Office Renovation Date: 03/30/2016 Permit No, 9 �v —,),01 C,
Property Address: 85 Flagship Drive North Andover MA 01845
Project: Check (x) one or both as applicable: New construction X Existing Construction
Project description: Project work includes the interior refinishing of the existing office spaces — new paint, new
carpet, new laminate flooring, and repair of existing concrete floor in storage area. A small portion of a wall will be
removed, two door opening will be infilled and a new wall will be installed to divided an office space. Project will
maintain (no change) all existing plumbing services, lighting and fire alarm systems with as well as existing
sprinkler configuration.
L Robyn Parker, MA Registration Number: 20491 Expiration date: 08/31/2016 , am a registered design professional,
and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning:
X Architectural Structural Mechanical
Fire Protection Electrical Other: Describe
for the above named project. 1, 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, mid belief the work
proceeded in. accordance with the requ irements of 780 CM.R and the design documents approved as part of the building
permit and that I or my designee:
I . 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 perfon-ned the duties for registered desigD. 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.
Nothing in this document relieves the contractor of its responsibility regarding the provisi R 107.
ER&D4 �C,'
X A.
Enter in the space to the right a "wet" or
C
electronic signature and seal:
Phone number: 781-439-4774
Building Official Name: Perinit No
Versil on 06112013
Email: rparker@intentarchitects.com
Date:
Building Official Use Only
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CHU",
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 940-2016 on 3/7/2016 Date: March 30, 2016
THIS CERTIFIES THAT
THE BUILDING LOCATED at 85 Flagship Drive — Unit E
MAY BE OCCUPIED AS IN a tenant fitup ACCORDANCE WITH THE PROVISIONS OF
THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS
MAY APPLY.
Certificate Issued to: NETR, Inc.
85 Flagship Drive, Unit E
North Andover, MA 01845
Z� /El
'Building Inspector
Fee: PrePaid $100.00
Receipt: 30080
Check: 26791
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Enter construction cost for fee cal -
North Andover Fee Cakulation
Construction Cost
$ 20,000.00
m
$ -
$
240.00
Plumbing Fee
$
30.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
30.00
Total fees collected
$
400.00
85 Flagship Drive Unit E
940-2016 on 3/7/2016
-Tenant Fit Up
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Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8th edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Unit E / N.E.T.R Inc Office Renovation Date: 02/29/2016
Property Address: 85 Flagship Drive North Andover MA 01845
Project: Check (x) one or both as applicable: New construction X Existing Construction
Project description: Project work includes the interior refinishing of the existing office spaces — new paint, new
carpet, new laminate flooring, and repair of existing concrete floor in storage area. A small portion of a wall will be
removed, two door opening will be infilled and a new wall will be installed to divided an office space. Project will
maintain (no change) all existing plumbing services, lighting and fire alarm systems with as well as existing
sprinkler configuration.
1, Robyn Parker , MA Registration Number: 20491 Expiration date: 08/31/2016 , am a registered design professional,
and I have prepared or directly supervised the preparation of all design plans, computations and specifications
concerning': Mechanical
X Architectural Structural
Fire Protection Electrical Other:
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 pjcject. 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:
I . Review, 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. 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. 107.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR
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 building official a 'Final Construction Control Document'.
Enter in the space to the right a "wet" or electronic signature and seal:
Phnn,- niimhp-r, 7RI-4-39-4774 Email: riDarker(-a)intentarchitects-com
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1. Indicate with an Y project design plans, computations and specifications that you preparva or airectly SUPUFYISM. 11 MIMI 13
provide a description.
Version 06112013
Enright, Jean
From: Enright, Jean
Sent: Thursday, February 04, 2016 11:14 AM
To: Brown, Gerald
Cc: mike@netrinc.com; Enright, Jean
Subject: FW: 85 Flagship Drive Unit E
Gerry,
Please read below. Michael was in yesterday and was directed to me by I believe Maura and Brian. I have spoken with
Michael and he has confirmed the "sales" component stated below is not onsite (there would not be customer traffic to
a showroom or retail sales store) and that he believes there is an adequate amount of parking spaces. Please let us
know if this Use is allowed in the zoning district. If it is allowed, and no new parking spaces are needed and there is no
change to the exterior or footprint then site plan review will not be required. Thank you.
Sincerely,
Jean Enright
Assistant Director
Community and Economic Development
Town of North Andover
1600 Osgood Street, Suite 2035
North Andover, MA 01845
Phone 978.688.9533
Fax 978.688.9542
Email: ienright@townofnorthandover.com
Web: www.TownofNorthAndover.com
t P. At . ,/ - . - C 41—Ae <
43Y7
To: Enright, Jean
Subject: 85 Flagship Drive Unit E
Hi Jean
I was the Town Hall yesterday checking the zoning for the above address . I'm buying the unit at Flagship drive and just
checking Zoning we are a heating and AC General business and want to make sure we are zoned properly for that in the
space we will have sales and service running out of the building as well as general administration paper work we will
store our equipment and parts in the building as well in the warehouse side. I assume we are good . can you please
ensure we are before I purchase Any questions please feel free to give me a call my contact info is below
Michael Cappuccio
1
L)
8K 410305 DPG
(5) All other apparatus and installations existing in the Building for
conunon use or necessary or convenient to the existence,
maintenance or safety of the Building.
d. Al' I other items listed as such in Massachusetts General Laws, Chapter
1193A and located on the Land as more part icularly described in Section 2
oftliis Master Deed.
Ilie DCCI.,'Xant reserves the right to grant and impose permits, licenses, covenants,
restrictions and easements over the Con. nion Areas and Facilities for utibities and other
purposes necessary for the proper opgrattiop of the Condominium and to construct thereon
sand place in operation for the benelit of the Condominium such. -works and facilities as
the Declarant deems reasoliable and appropriate' At such'timbs as the Declarant, its
successors, and assigns shall cease to own any Unit in'Condominium, the within reserved
rights shall vest iii the Condominium Trustees.
C6 Determination of Percentao Interest in 'Common E' en
lemen
The owners of each Unit shall be entitled to an undivided interest in the Coinnion
Elements in the percentage set fortli in Exhibit C for such Unit. 711e percentages of
interest of the respective Units in the Common Elements will be dettermined, upon the
basis of the approximate relation which the. fair value of each Unit on the date hereof
bears to the aggregate fair value of all the Units on this date or upor, the basis of the
approximate square footage of each Unit on the date hereof be= to the aggregate square
footage of all the Units.
7, Floor and Site Plans
The verified floor Olatis of the building showing the I yout, loca 0 - it'
. a Ii n, an
members and dimensions of the Units and such inatters as are required by law, are
attached hereto as an Exhibit, The plan eniiflied "Existing Site Plan ofEighty Five
Flagship Drive Condominiums, N6rth Andover,.VA, dated June, 2006, ow-ner: Eighty
Five Flagship, LLC, Joseph Scott, Managing Me m-ber, 12 Rogers Road, Ravcrhill, MA,
prepared by R.A.M. Engineering, 160...Main Street, Haverhill, M.A" shall be the site plan
of the condominium.
1
81. Use of 1311Uding and Uni6-
"'he pui
follows: 1 posees for which'building and the Units are intended to be used are as
ThO Units are intended only for retail, commeg-cial, and industdal
pwposes, subject to the restilctions set Forth in paragraph 9 hereilL No
IJnit may hle used for residential purposes or in any maimer inconsistent
with the applicable zoning laws of the Town of North Andover.
3
15
85-K I PG 22 6
EXHIBIrir C
J),L'SCRrp,rjc)N. OF MITS
UNIT Dp_SICT.NATI0'jq
Lo—cation
Lerce
A
6,1452
11.4
4,70/77
4.8
c
6,496
11.5
D
fl��
5025
19
8.9
UE
6,. 7-17
10.9
F
6,453
11.4
G
6,024
10.7
6,069
10.8
7,574
13.A
K
3,514
6.2
14
4
1545Y
EXISTING SITE PLAN OF
EIGHTY FIVE FLAGSHIP DRIvE
CONDOMINIUMS
NORTH ANDOVER, MA
JUkF2M6
OVAIER
EIGHTY FIVE FLAGSHIP, LLC
JOSEPH SCOTT
MANAC414G MEMBER
12 ROGERS ROAD
HAVERHILL, MA
GRAN01' FCALF.
It
I
REFERENCE PLAN:
ESSEX NORTH REG. DEEDS
Zr
#8353
VI -11 LD�Dlrlr, RAMP
4e
AL'Iff D-�
1A.
LOT L & LOT 0
TOTAL AREA c i62.o5s so.FT.,
3.72 AQ*
. .4 ci . lWbers.
der5/Contractors/��ectrl ans/P
Workers compensation Insurance Affidavit: Bufl WHO
fTINGA
TO BE FMED WIT11 THE PF -RM'
Name ousiness/(Jikabizatioii/Iiidividual): /Y Z -
Address:,/
-7 —
City/State/Zip;
Ar ia employe, x�-�i4t& w6priatebox:
1.7. a emp ' ioyerwithgp_�Inp loyees (full andlor part-time).*
2. [] I am,a sole proprietor or partnership and have no employees working for me in
ally capacity. [go workers, comp. insurance required-] ed .1 t
3.0 1 am ahorneowner doing all wo"kinyseLt [No woIkers' comp. insurance requir ill
4.n I am a homeowner and will be hiring contractors to conduct all work on my property- I w
ensure that all �_ozrtraci&s qi#r have workers' compensation insurance or are sole
proprietors with �9, emp�66�
I 1 4 .. listed on the attached sheet.
' rfand I have hired the sub -contractors
5.Fj I am a general con"00, , .. , ee"andhaveworkers'comp. insurance.t
These sub -co rsh�V."�Vloy 3
. . a its oMcers have exercised their right of bxemption per MGL c.
6. n We are a corpor?494 PP -fl urance required]
I M -1 �vehaiie no emP dYdes�* LNo workers' comp. ins
Type otproject (ie0ir64
7. E]N6Vd6nstrd6tion
8. OlRemodelifig
9. rl Demolition
10 [j Building addition
11.0 Elec�ri9al xpp*s Or additiggs
I.&F
,,j pru-mbing repai,ri or additions
13,.E]Rb6kre�air§
0 out the section below showing their workers' compensation Policy informatiorr*
*Any applicant that ch�p)k§'_bbk#1 "' mi e afff indi tin di.
I . ,, ,_1 jeating they are doing all work pd then hire outside contractors must sub tanw davit ca g su
'I Homeowners who submit -this affi�a�it ind th so.pntiges�ha-ve
tCoritractors that check i�� �" �'jiisf attached bn additional sheet showing the name of the sub -contractors and statq wliptlier OX !lot 0
04 oyees, they must provide their workers, comp. policy number.
employees. Utho sub_c6niiac�tois have empl
elow is thepolley and)ob sit�
I am an employer that ispro-vidingivorkePs compensation !Mranceftr MY eynPlbyees'
information.
insurance Company Name'
Expiration 0,
Dat 2,
policy # or Self-ing. LiG. /_3
City/State/Zip--
Job Site Address- ng the policy number and expiration date).
Attach a copy Of the WOr.kers' compelisation policy declaration page (showi
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a filb 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 V50.0 0 a
Dy of this statement may be forwarded to the OfficO Of juvestigdtions of the DIA for insurance
day against the violator. A co,
�Yry5nqtinn_
?c under thepains andpenalties ofperjurY that the information proviaed above is trl, u.—
I Z. /I -
'Write in t1lis area, to be completed by city or town OfflclaL
Of
fleial use only. Do not
permit/License
City or Town: -
Issuing Authority (circle one):
1. ]Board of Ifealth 2. Building I)epartment 3. City/Town Clerk 4. Fjectrical inspector 5. Plumbing Inspector
6.�Other
Phone
contact Person:
olassachusetts
The Commonweauh o
Department of industrialAccidents
I Congress Street, Suite 100
Boston, mA o2114-2017
wvy mass. gov1dia
. .4 ci . lWbers.
der5/Contractors/��ectrl ans/P
Workers compensation Insurance Affidavit: Bufl WHO
fTINGA
TO BE FMED WIT11 THE PF -RM'
Name ousiness/(Jikabizatioii/Iiidividual): /Y Z -
Address:,/
-7 —
City/State/Zip;
Ar ia employe, x�-�i4t& w6priatebox:
1.7. a emp ' ioyerwithgp_�Inp loyees (full andlor part-time).*
2. [] I am,a sole proprietor or partnership and have no employees working for me in
ally capacity. [go workers, comp. insurance required-] ed .1 t
3.0 1 am ahorneowner doing all wo"kinyseLt [No woIkers' comp. insurance requir ill
4.n I am a homeowner and will be hiring contractors to conduct all work on my property- I w
ensure that all �_ozrtraci&s qi#r have workers' compensation insurance or are sole
proprietors with �9, emp�66�
I 1 4 .. listed on the attached sheet.
' rfand I have hired the sub -contractors
5.Fj I am a general con"00, , .. , ee"andhaveworkers'comp. insurance.t
These sub -co rsh�V."�Vloy 3
. . a its oMcers have exercised their right of bxemption per MGL c.
6. n We are a corpor?494 PP -fl urance required]
I M -1 �vehaiie no emP dYdes�* LNo workers' comp. ins
Type otproject (ie0ir64
7. E]N6Vd6nstrd6tion
8. OlRemodelifig
9. rl Demolition
10 [j Building addition
11.0 Elec�ri9al xpp*s Or additiggs
I.&F
,,j pru-mbing repai,ri or additions
13,.E]Rb6kre�air§
0 out the section below showing their workers' compensation Policy informatiorr*
*Any applicant that ch�p)k§'_bbk#1 "' mi e afff indi tin di.
I . ,, ,_1 jeating they are doing all work pd then hire outside contractors must sub tanw davit ca g su
'I Homeowners who submit -this affi�a�it ind th so.pntiges�ha-ve
tCoritractors that check i�� �" �'jiisf attached bn additional sheet showing the name of the sub -contractors and statq wliptlier OX !lot 0
04 oyees, they must provide their workers, comp. policy number.
employees. Utho sub_c6niiac�tois have empl
elow is thepolley and)ob sit�
I am an employer that ispro-vidingivorkePs compensation !Mranceftr MY eynPlbyees'
information.
insurance Company Name'
Expiration 0,
Dat 2,
policy # or Self-ing. LiG. /_3
City/State/Zip--
Job Site Address- ng the policy number and expiration date).
Attach a copy Of the WOr.kers' compelisation policy declaration page (showi
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a filb 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 V50.0 0 a
Dy of this statement may be forwarded to the OfficO Of juvestigdtions of the DIA for insurance
day against the violator. A co,
�Yry5nqtinn_
?c under thepains andpenalties ofperjurY that the information proviaed above is trl, u.—
I Z. /I -
'Write in t1lis area, to be completed by city or town OfflclaL
Of
fleial use only. Do not
permit/License
City or Town: -
Issuing Authority (circle one):
1. ]Board of Ifealth 2. Building I)epartment 3. City/Town Clerk 4. Fjectrical inspector 5. Plumbing Inspector
6.�Other
Phone
contact Person:
71 0
AC40RO CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
1 1/19/2016
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 William Tarpey
NAME:
Tarpey Insurance Group
PHONE (781)246-2677 )224-0973
-(A_/CNo Ext):
E-MAIL
ADDRESS: bill@ taxpeyinsurance. com
442 Water'St
INSURER(S) AFFORDING COVERAGE NAIC #
PO BOX 567
INSURER A:Travelers Insurance Cc 36161
Wakefield MA 01880-4667
INSURED I
INSURER B:Travelers Indemnit Cc of Conn 25682
INSURERC.Mt. Vernon Fire Insurance Co
New England Transport Refrigeration, Inc., N.E.T.R.
INSURER D :
165-A New Boston Street
INSURER E:
PERSONAL & ADV INJURY $ 1,000,000
INSURER F:
Woburn MA 01801
COVERAGES CERTIFICATE NUMBER:2016-2017 WC 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.
IN RI ADDq_SUBR OCY EXFT
L S P FFTPm
TYPE OF INSURANCE INSD I WVD i LIMITS
TR POLICY NUMBER I, moup C= I (mo/DD/YYYY)
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A
CLAIMS -MADE 7
X OCCUR
4T -CO -7B267228 -TIL -15
1
5/1/2015 1 5/1/2016
0
P 000
MED EXP (Any one person) s 5,000
PERSONAL & ADV INJURY $ 1,000,000
EN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 2,000,000
X PC CY 17 PRO- F ]
LI JECT LOC
PRODUCTS - COMP/OP AGG $ 2,000,000
Employment Practices Liab $ 100,000
OTHER
AUTOMOBILE
LIABILITY
I
MBINED SINGLE LIMIT
ra accident) $ 1,000,000
BODILY INJURY (Per person) $
A
i
ANY AUTO
ALL OWNED x SCHEDULED
AUTOS AUTOS
BA -7B268599-15 CNS
5/1/2015 5/1/2016
BODILY INJURY (Per accident) $
x NON -OWNED
HIRED AUTOS AUTOS
I
P
(PROPER DAMAGE $
e, .d7rt) I
-
Medical payments s 5,000
x UMBRELLA LIAB
I X IOCCUR
EACH OCCURRENCE s 5, 000 �0_00
A
EXCESS LIAB CLAIMS -MADE
i
AGGREGATE $
DED I X I RETENTION$ 10,000
4TSM-CUP-7B982979-TIL-15
5/1/2015 5/1/2016
S
WORKERS COMPENSATION
I rER__ — OTH-
B
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE D�
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
NIA
4TEUB-7F30931-1-16 1/1/2016 1/1/20 17
STATUTE71ER
E.L. EACH ACCIDENT 1 $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
F I DISEASE . P01 ICY LIMIT 1 $ 1,000,000
C
Employee Practice
EPL2008665C 5/1/2015 5/1/2016
1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
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
sa Mills/LISA
(V I Vititi-ZIU14 AUUKU UUKPUKA I IUN. Ali rignts reservea.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)
Mdssa6husetts - Depytment of Public SafetY
Board of Building Regulations and Standards
rvisor
Con-itruction Sue *
License: CS -059225
wV'TTS 1)
�87= NJ CWHEFS
N ANDOVER MA 01
Expirafton
0912812016
Commissioner
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