Loading...
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 1� -", 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 W-11 Z 0 CL 2) CL > 0 00 CL m 0 (D 5-0 cm CD 57 (A 'a CD 0 r-lik 0 7 OWA (1) M 0', 0� U) "S I 0 r_ 0 CD 0 =r CD (D (D U) 0 z 0 0 (D W 0 =r CD N 0 0 w CD cc U) 0 E U) CD 0 0 a -*I -q 0 " 0 0 r .r U) S CD Cl) Ct (D CL 0 V CD 0 0 CL M 0� --n (D 0 0 CL 0 Fn CD Cl) 0 CD CD 1"D > CL 0 U) Sl CD CD (D'a M t7 0 < (a 0 o r. A U) Z CD 0 0 -9 cr c (D C-) rL 0 o C. L 9E 150) < CD CD U) CD CD 0. to 0 CD CD -0 3' m 0 0 > (D CD 0 -1 0 CL . c00000f �ilo C WNW 3 0 (D (D X, M CD -n 21 :3 0 r 0 0 c 3 (A -n m 0 0 CL z r- m m ;o (D (D 0 > Cl) ic M Cl) m m 0 0 m 0 m 0 C) M N x z 0 cri m Cl) z (Z� z z Ec ft .0 cn, 0 z 3: cn cn m 0 0 W 0 =r CD N 0 0 w CD cc U) 0 E U) CD 0 0 a -*I -q 0 " 0 0 r .r U) S CD Cl) Ct (D CL 0 V CD 0 0 CL M 0� --n (D 0 0 CL 0 Fn CD Cl) 0 CD CD 1"D > CL 0 U) Sl CD CD (D'a M t7 0 < (a 0 o r. A U) Z CD 0 0 -9 cr c (D C-) rL 0 o C. L 9E 150) < CD CD U) CD CD 0. to 0 CD CD -0 3' m 0 0 > (D CD 0 -1 0 CL . c00000f �ilo C WNW 3 0 (D (D X, M CD -n 21 :3 0 r 0 0 c 3 (A -n m 0 0 CL z (D :3 CL m a) 0 s rn V r- c (D (D 0 > m V > V m m mz 0 m 0 m 0 m 0 > r- N 0 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 IS 0 z rmfL U) CD 0 CL A) = 0 CL c 5" > "a 0 0 CD CD 0 m 1:3 CD CD 0 CD CL CD 5-0 cc CD 0 z CD 0 0 P -IL 0 �(D a 0 CD "AR 0 F— z 0 =r 0 0 X CD 2. CL CD 00 0 75i Er =r 0 4. ICDr r -L o o ID C.) r M M Lo 0 5.,r- = �L is. T. 0 0 r- CL 0 ft =4 T 0 CD CA U) F -i S-P"o CD X CD CL A) 0 co U) 0 ca)) =r (D ID 0 =r - 0 .30 U) Zo 0 =r =r (D f. : CL 0 =r 5. CL 0 to U) 0 RL 0 jw rL U) m C.) 0 0 > ;:z 0: :M: CL V �-io AF4 LA (A 3 0 (D 0 ai c qQ 21 ;a 0 .-,Tl n �o =5 0 c 3 -n 0 C: Ln M -n 0 0 M 0 z r) (D m A (D CL 0) rL M r* 0 0 Cl) Cl) 6) m r- m M r, , 0 ca C: 0 M (D w X m z Cl) ;u m > cn 0 > E a ic .z 0 LA V m z z 2 Ci) m Cl) 0 m m z 6: 2 N 0 0 m o "AR 0 F— z 0 =r 0 0 X CD 2. CL CD 00 0 75i Er =r 0 4. ICDr r -L o o ID C.) r M M Lo 0 5.,r- = �L is. T. 0 0 r- CL 0 ft =4 T 0 CD CA U) F -i S-P"o CD X CD CL A) 0 co U) 0 ca)) =r (D ID 0 =r - 0 .30 U) Zo 0 =r =r (D f. : CL 0 =r 5. CL 0 to U) 0 RL 0 jw rL U) m C.) 0 0 > ;:z 0: :M: CL V �-io AF4 LA (A 3 0 (D 0 ai c qQ 21 ;a 0 .-,Tl n �o =5 0 c 3 -n 0 C: Ln M -n 0 0 M 0 z r) (D m A (D CL 0) rL M r* 0 0 6) m r- m M r, , ca C: rD (D w m > Ln > m 2 > K LA V m z 2 0 m 0 m m z N 0 0 L%M 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 9 LU x LL 0 0 co a aj -0 0 0 E Ln .2 CL a) 0 z z ED 0 0 U- tw 0 w cu E = U U- 0 u LU CL 4A z z CL to m 0 iz 0 u LU CL IA z LU to 0 a) (n Ll- 0: 0 LLI CL (A z to 0 cc c U- z LU LU LU U. a " :3 6 z 4' a) cu 41 (u 0 w 0 E 0 Cc C Cc 0 CLO CL CD cc 0 Ch 0 E CL Pop, CD 0 F= Cc E cn Cc CD 4) r 0 Cc CD 0 > 0 co A cc a mum,: E- : = < CO) 0) A 0 0 'c*n z 0 LA o 0) > o r- 2 1�-- = CL 0) CL 4) 4) :5 0 r cc 0 U) 0 r c CL 4) ujc 4) c = UJ 0 — . 0 EL 2D co CL M :E 0 Lu E CD 0-0 0 MO c am cc 0 L.. c 0 &. CL 0 0 E L- CD 0 0) 0 0 z 0 0 0 LU Z z Co C U) Cl) z cc) U) m z z Lk) cr) Lu w F- CL U) z X. 0 W Cl) Cl) w ui -J* CL z :3 Cb 2 0 E 0 z 0 E T CL 0 cc CL w 0 0 r-Amil 0 0. 0 0 00 L- L- 0 CL CL Cc Cc -J -0 0 4) z CL U) c 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 0-0 --- ------ -- cab) LL 0 z U z Lu U -j Z Lu �p t -00 QA.1 N-1 + 00 7z oo < LU I: aZ LU lu U.i LU z z t r Z C) 0 LU LU z LU LU LU z z z z 0 Lu -r U - LL 0 QD U -i U 91INK15 0 0i + 00 At 7Z C, T oo all —%4 3 < LU cn En LU I: aZ LU lu U.i LU z z t r Z C) 0 LU LU z LU LU LU z z z z 0 Lu -r U - LL 0 QD U -i U 91INK15 0 0i + 00 At 7Z C, T oo all —%4 3 < LU 0 Q z 0 z uj z(L OE p (f) U- C\j z z 0 Z) CD Q LU X 00 U.j U < Lu Lu 0 U.1 (L M I LLJ T- U -1 i ca 0 Lr) Lo Z) C\j ED — C\i z U -j 0 > z uj CO uj 0 - co 2 0 u 0 Ln U -i v (Y) LU z 0 z 0 u Ck/ 0 0 j IL LL LU u C) z (3) N Q) ED LLJ 0) C\j 0 ro r) LU C) 0 u Ld lu IL LU 0 < U-1 66 < < LU o < < < a U uj 0- U-1 0 < LU Lu > > < < 0 u U -i < 9 u -j > 00 LU lu < 0 Lu i L-/ 1: z T) iLj — u < uj Z LLJ QD z Lu < 00 < < z �i 9 m a-/ UJ il- U < uj LIJ > C z z < < C) LU z t 0 aj uj a/- a-/ I: r -j < [)Z < 0 _3 T) = U- < z 30 U -J 0 u 0 U -i 0 < U-1 < UJ u < LU ui > Z Z ui z 'LL)i L �- 1: U- 0 0 z < z z (r) 0 2 (f) U a- ui D Z— U -j U -i < Lb LU U) 11 a/- ui tL �-) 1: (r) LLJ z U -j 00 aj r z z 0 P: Q z < u Z/ qw� z<nLu C) Ln ui 0-/ Z .. - -1 0 -,- Z LU 0 ooqu-.�t�- zm<z<o z LL 2� < a 0 - w --j Ll LL < z LU -j �: LL lu Lli 0 U-1 < U -j z o LU lij Z (Z) '�: < -j � t 1: 0- < g2 Z) 2 Z Lu 0 -1 )(f) z z 0 2 u uw oz 10 u- < 0 z 2/ 0 Lu -j o z Lij z Z C) -j — 2zz Z: o < Lu 0 0 2 LL 0 u --Jj 0 9 —> "- z 027 0 0 < z C) — — j a/- < LL z < 0 0 IL L 0 Lu 0 U IL iL LL 0 (L 0 Z Z 0-0- U U U 00 0-/ -1 rl\ Lu olu J LL LU 0- n U- _-3 NU z z z u u u 000 N 0 u t t h 0 C) C C) c (Z) C z z z 0- < < Z) IL 0- u m =) u u Q) U U 0 o C) X t coo (f) (f) (f) IT IT u 0 co u . 0) Ln N Z-0 M U -j - - LU --k _j -s,-- 2 LU z WL < Q) Z) 0 m I: U 0-'() 11- Z LU (r) 0 Lu �i < Lu u ol (j/ 0 > LO < Z 0 co - j= Z Lu z < 0 (f) a/- Ef LL -j 0 ag: > z (n Lli wl LU (L 0 LU < — I-- R 5)- :>: a-/ —� < < C) 0 < Z (j) u �: Lu < IL z �- le z uj LU ui z t= 0 LL Lu LU w — W IL w w < u p co 1: Lu Lu ---) 0 L6 6 f,� U, r 0 U-1 u < cy) q: (,) 0-/ r 5 (UQ < U- LL < 0 0 0 Ld LU < CY) LU CL/ 00 0 C) 0 Lb r) 0 ,-., LLJ 0 Q) (L/ �- 0 0 o z < U- < Q Z 0 m 620 > Lu< 0 0 ED u 7ib LO C\j v ED (10 U -i u 0 I %A 7 o Q 71% -j P. 10 A OR- a- CIL coo> jp 0 qua 00 00 S 4 OA Do Ci) -44 Z5 4. VL . 4- 00 00 us 00 uml 00 �p =00 Ul *A 00 At M� 00 A Q t VI < -00 Z LL 0 0 LU Lu - 7- U - LU us 95 ED C) uj Z LL- -i I _j z _r < < v LILJ UJ LL- LJ 0 Lij LL z (j) 0 I (S) z Q t VI < -00 + < rl- < us 95 %A _r U- oo + < rl- < T) Lzu 27 0 z 0 T- LL - 0 0 < ro Lu Z r� r- 0 -j -U u < < 2 FZ rN (v Lu 0 LL N Lu LL 0 -- (n z 2 > > 0 LL - %S> Z5 + %A 11 0 %A f. 3 + 00 Ck At, us 7Z oo P7 e-