HomeMy WebLinkAboutBuilding Permit #1013-15 - 94 FLAGSHIP DRIVE 6/9/2015 Y V
BUILDING PERMIT �ftI D
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION * -
Permit NO:/ ` y Date Received
f � �AATeD•PP`
Date Issued: lJ � 9SSA`"us��
RTANT: Applicant must complete all items on this page
LOCATION 94 Flagship Drive
Print
PROPERTY OWNER Nova Flagship Lac
--��7 Print
MAP NO-/ C-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 iflndustrial
C�,Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Q Septic ❑Well ❑ Floodplain ❑Wetlands Il Watershed District
El Water/Sewer
pt-4-,A5 S' 2e:�UrntA-r",75 . :5:«€ WCAl[ . ADO L.o•���G �o�-t�� HE7,z
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Identification Please Type or Print Clearly)
OWNER: Name: Nova Flagship LLC Phone: 978-685-4811
80 Flagship Drive,North Andover,MA 01845
Address: -
CONTRACTOR Name: Steven R.Webster Phone: 603-401-7601
Dutton&Garfield,Inc.
Address:. 43 Gigante Drive
Hampstead,NH 03841
Supervisor's Construction License: CS-039771 Exp. Date: 03/17/16'
Home Improvement-License: Exp. Date:
ARCHITECT/ENGINEER 3'OsEPR E. -rcra#,E Phone: 9'78- Z7&- 1%.0
Address: 17e P,4ay_5►• '50IEInL N.OEAbit11oiMA 0186Y Reg. No. 9D60
FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. J ^
Total Project Cost: $ `-t S4. 5.0 � FEE: $ �/ 75�
Check No.: �??;T Receipt N
NOTE: Persons contracting Ath unregistered contractors do not have access Yo the guaranty fund
Signature of Agent/O � , Signature of contractor
eusS S N1gtEs �^/•. 2. wcBSQ-6'L_.
Location
No. Date
. - TOWN OF NORTH ANDOVER
. Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee $
TOTAL $ "
Check#
uilding Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL '
Public Sewer ❑ Tauning/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 m D FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on_ Signature
COMMENTS
n
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
r
Conservation Decision: Comments
Y
Water& Sewer Connection/Si nature& Date Drivewa Permit
v
]DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTrMENT T4 nDumpst_er,gn4site,
s Ldcatedlaf;124IVIaintStceeta
'Fire�Department�sik nature/date '
r .t _ -
COMMENT°S,.
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA-- (For department use)
Ll Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
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
OTE: 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 I ECC Energy code
g6 Engineering Affidavits for Engineered products
OTE: 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
Final Construction Control Document
To be submitted at completion of construction by a
Registered Design Professional
Ye'•y( for work per the 8`'edition of the
Massachusetts State Building Code, 780 CMR, Section 107.6.4
Project Title: Central Metal Finishing Date:March 7,2016 Permit No. 1013-15
Property Address: 94 Flagship Drive,North Andover,MA
Project: Check(x)one or both as applicable: [X]New construction [X] Existing Construction
Project description: Renovation of the existing building as shown on the architectural drawings
I Joseph Tatone MA Registration Number: 9080 Expiration date: 8/31/2016 ,am a registered design professional, and
hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning:
Entire Project [X] Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project. I certify that 1,or my designee,have performed the necessary professional services and was
present at the construction site on a regular and periodic basis to determine that the work proceeded in accordance with
the requirements of 780 CMR and the design documents prepared by me and 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.
Not all work shown on the construction drawings has been completed.
Scope of work completed;
Demolition.
New mezzanine floor rough framing(designed by others)
New footings and structural steel install(designed by others) g
CMUsawcutting and door opening installations
New loading dock(designed by others) 4 i
New stairway and walkway rough framing No.
a
Enter in the space to the right a"wet"or OF
electronic signature and seal:
Phone number: (978)276-1960 Email:jtatone@jta-architects.com
Building Official Use Only
Building Official Name: Permit No.: Date:
Final Construction Control Document
To be submitted at completion.of construction by a
Registered Design Professional
for work per the 8h edition of the
Massachusetts State Building Code,780 CMR, Section 107
Project Title: Isloyik VtAGsy+W L L C, Date: 2l l(I lb Permit No. 10 13 15
Property Address: gt �'sy
Project: Check one or both as applicable: 9 New construction otExisting Construction
Project description: CCN SrMVyT 3 t 3 gF L VA V I PNr& Meir— tyD rrI o 0
LbN4'CIWGT 1?43a 9•F ��'�"�" irl,p�L. PFR. PtA�.ts.
I CQ fb 1 V,.( C, 13 i pa MA Registration Number: 4-795 Expiration date: 6 bo I l am a
registered design professional,and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning:
[ ] Architectural pQ Structural [ ] Mechanical
[ ] Fire Protection [ ] Electrical [ ] Other:
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. t0 OF AQf.. yG '
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. �a CAROLYN C.
BIRD a
CIVI
Enter in the space to the right a"wet'or 0.4793
electronic signature and seal:
Phone number: Email: �`o�y V G GaSGo�p�/G l�CG C'i r�s.Gott
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06112013
Final Construction Control Document
To be submitted at completion of construction by a
Registered Design Professional
for work per the 8''edition of the
Massachusetts State Building Code,780 CMR,Section 107
Project Title: W oVAL Ft,A&syV%-e LLC-, We: PemutNo.
Property Address: 94 V*i^GS%11PDg,,qEit j307.TA )63wdar. 018
Project: Check one or both as applicable: 9 New construction ItExisting Construction
Project description:_ CA)*3*MvC-,T 3l3 SF L-v^vtry& Dec *- fWD tT1yo
Gbt�t -r�.r�r lagsz Z''�'' ttaVL. ttF- PLAOSs
I Ca ro l yr[ $1 Cd MA RegistrationNumber: 4-7951 E)Vnution date: (o D i& am a
regiswed design profess�l,and I have prepared or directly s�vised the preparation of all design plans,
computations and specifications concerning.
] Architectural structural [ ] Mechanical
[ ] Fire Protection j ] Electrical [ ] Other.
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. � a OF r, 3
c
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. o CAROLYN C
BIRO
CM
Enter in the space to the right a"wet"or 0.4793
electronic signature and seal: o
Phone number: ZO-1- 547- -zom Entail: C4co1„ab 4GaSC.o�?ol�/Ca,4 r t� .G th
cci'r� o
Building Official use Only
Building Official Name: Permit No.: Date:
i
Version 06 It 2013
Final Construction Control Document
To be submitted at completion of constiuc ion by a
Registered riga ftvfe=ional
for work per the e edition of fire
Massachusetts State Building Code,780 OAX Semon 107
Project Title. Wo,^ V1.AofeSyyiy LLC Date: 11 ij, permitNo.
PmpertyAddress: 94 1.hG3mip t��it tib Aott 1* O)VAMR
Reject: Check one or both as applicable: tri New construction l tEltis g Construction
Projea description: %fVr 313 Sf L4MPU 9'a Doe*- Amp t,00&] _
&tasll ��- 1;�3z SP 2P" FLam. Fgr-
I CrO IVc1 C. F t PI MAR onNainber_ 4-195t Expiration date:—1.301& am a
wind d&gn pmf m n 4 m d I have prepared or dhwAy the preparation of all design plate,
eomputatioms and specifications conectniW
l Stractund [ MecbanM
[ ] Fire Proton I ] Electrical [ t
forthe.above named project IL or my desilpm have performed the necessM professionsl services and wm p esemt at the
construction site on a regdw and periedic basis.To the best of mq Iwowlefte,information,and beliefthe work
proceeded in accordance with the regrru mems of 780 CMR and fire design documents appmved as part of the building
permit andthat I or ray designee:
1. Have reviewed,for conforfmance to this code and tb--design conceA slop dmwimgs,samples and otter submittals
by the contractor in accordance with the requirements offiresonstroodon 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 beeomne generatly familiar with the
progress and quality of the work and to determine if the work vvas performed in s manner consistent vAth the
construction documents and this code.
Nothing in this document relieves Ore contractor of its resp wdbility rn;VMhng the provisions of 780 CMR 107_ o CARt)LYltl C_
BIRD}
CM
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electronic S'lgnature and Seal:
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No. �d � 3 - /SAY C. h ver, Mass, 17z—1
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Food/Kitchen
PERMIT T// LD Septic System
THIS CERTIFIES THAT ............ � �`.....1.�./ ..:S.f"1. /.�.. �.�.......... ......................... BUILDING INSPECTOR
/ KFoundation
has permission to erect .......................... buildings on .......Jy... .... .....,�..........?":...'....!:�1...................
... Rough
to be occupied as ........ .......1 ........... ' ` .��c�,-- �F�ca�,c,a.:'"��``�... ... ::.�'��•�c
p ,sem ........ Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings iri the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
................... ..... -f %
....................... Service
"' Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy.BuildinRough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
. No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Initial Construction Control Document
r To be submitted with the building permit application by a
74 Registered Design Professional
for work per the 81"edition of the
4 ,J•�•y Massachusetts State Building Code, 780 CMR, Section 107.6.2
Project Title: Central Metal Finishing Date:05/22/15
Property Address: 94 Flagship Drive,North Andover,MA
Project: Check(x)one or both as applicable: [X]New construction f X] Existing Construction
Project description:Renovation of the existing building as shown on the architectural drawings.
i Joseph Tatone,MA Registration Number:9080 Expiration date: 8/31/2015,am a registered desigsi professional, and
hereby certify,to the best of my knowledge,information and belief,that I have prepared or directly supervised the
preparation of all design plans,computations and specifications concerning:
Entire Project [X] Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that 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 in accordance with the
Professional Standard of Care,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 accordance with the requirements of the construction documents. Such review shall not diminish or
relieve the Contractor of its submittal and other responsibilities.
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. The contractor shall be responsible for performing the work in accordance
with the contract documents and shall be exclusively responsible for its construction means,methods,sequences
and procedures,and for construction safety.
4. The performance of the services shall not require any special testing or inspections unless specifically stated in the
Code.
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' yEDgq��i
or electronic signature and seal: A E
No.
� 8
N OF
Phone number: (978)276-1960 Email: jtatone car jta-architects.com
Building Official Use Only
Building Official Name: Permit No.: Date:
NORTH TOWN OF NORTH ANDOVER
,`r`" °°4 OFFICE OF
° . BUILDING DEPARTMENT
1 r 400 Osgood Street
North Andover,Massachusetts 01845
��SSAc Nus�t.�h
D.Robert Nicetta, Telephone(978)688-95454
Building Commissioner Fax (978)688-9542
CONTROL CONSTRUCTION- SECTION 116.0 M.S.B.C.
CERTIFICATE OF ENGINEERING/ARCHITECTURE
BULDING INSPECTOR
TOWN OF NORTH ANDOVER
400 OSGOOD STREET
NORTH ANDOVER MA 01845
1, HEREBY CERTIFY THAT
THE BUILDING CONSTRUCTED AT
DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING
CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING:
AUTHORIZED SIGNATURE:
DATE:
REGISTRATION:
NOTE: ENGINEER"WET STAMP" MUST BE AFFIXED TO THIS FORM
Control Constm.tion Fonn revised 11.151004
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 I4EALTII 688-9540 PLANNING 688-9535
:
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Initial Construction Control Document
z
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8th edition of the
Sre J� Massachusetts State Building Code, 780 CMR, Section 107.6.2 `
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Project Title:Central Metal Finishing Date:05/22/15
s
Property Address: 94 Flagship Drive,North Andover,MA
Project: Check(x)one or both as applicable: [X]New construction [X]Existing Construction
I
Project description: Renovation of the existing building as shown on the architectural drawings.
I Joseph Tatone,MA Registration Number: 9080 Expiration date: 8/31/2015,am a registered design professional, and 3
hereby certify,to the best of my knowledge,information and belief,that 1 have prepared or directly supervised the
preparation of all design plans,computations and specifications concerning: }
Entire Project [X] Architectural Structural Mechanical !
Fire Protection Electrical Other:
for the above named project and that 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 in accordance with the
Professional Standard of Care,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 accordance with the requirements of the construction documents. Such review shall not diminish or
relieve the Contractor of its submittal and other responsibilities.
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. The contractor shall be responsible for performing the work in accordance
with the contract documents and shall be exclusively responsible for its construction means,methods, sequences E
and procedures,and for construction safety.
4. The performance of the services shall not require any special testing or inspections unless specifically stated in the
Code.
i
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" �iE0Ag0
or electronic signature and seal: �eH E. ��>E•
:
� O � a i
NO. k
9
OF i
1
Phone number: (978)276-1960 Email: jtatone@jta-architects.com
Building Official Use Only
Building Official Name: Permit No.: Date:
q N
Plans Submitted ❑ 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
DATE REJECTED DATE PPROVED
PLANNING & DEVELOPMENT ❑ ❑ ` 3 /5�
COMENTS '� `✓ / _ .�2,�c
CONSERVATION ❑ ❑ 2',
COMMENTSV.
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑ 109
COMMENTS I�
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date $I✓jt/�u?.W �2�f5 Driveway Permit
Located at 384 Osgood Street
FIRE D. ART NT - Temp ump r on ite yes no
Located at 124 Main Street
Fire Department signature/date s •�—`S�i� e,.t_ �l
COMMENTS ,� 1 ,G -
Dimension
Number of Stories: Z Total square feet of floor area, based on Exterior dimensions. t3,3yL
Total land area, sq. ft.: e1,3314
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
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❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
DOIAPSTEZ '0 12MM CKPIOZ
Com S-nn� c,-1 a�
T_3D Zo! (P
�_ Then C 6mmonwealth Of Nlassachuse is
a
Department of Fire Services
O.rice of the State Fire Marshal
P.O.Box lo23State
pRoad,Stow,M.4 D1775
PERMIT Date:
Norah Andover Permit No
(City of Town) (IFApplicable.) Dig Safe Number
In accordance with the provisions of M:G.L.l 4 8 Chapters,Q_as provided in section S�U 34 sin Da�
This Permit is granted to: Ain!
Full name of person,Frm or Corporation
Permission to locate dumpster for construction/renovation/demolition of building.
Continents: dumpster. must be . 25 from structure if unable to place with required
F,estr"ti0°s:clearance dumps-ter must be covered with plywood or tarp end of 'work -day
at ,¢
(Give lccntio by street and no.,or desen such manner t rovied adequa-identification of location)
.FecPaids 50.00 Fire Chief
This Permit will expire- O'L (Signature of offical granting permit) Offical grantingpermit (Title)
N° FD 10467
nate l5a� ..-1,
NORrAj qti
a�' •�' °°p TOWN OF NORTH ANDOVER
0 RECEIPT
9SS4CHUS�t
This certifies that.... �l.T� `n,,,�••.C.a.. iC/�'c/ .. �•�?••.
haspaid.,,5 .........................................................................
for... . /? .. .. .............................................
Received b / i �% rap
�f fi
Department....../.... /........................................................................
WHITE: Applicant CANARY:Department PINK:Treasurer
The Commonwealth of Massachusetts
Department of Industrial Accidents
u Office of Investigations
1 Congress Street, Suite 100
e
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Dutton & Garfield, Inc.
Address:43 Gigante Drive
City/State/Zip: Hampstead, NH 03841 Phone #:603-329-5300
Are you an employer? Check the appropriate box: Type of project (required):
1.❑ I am a employer with 4. ■❑ I am a general contractor and I
employees (full and/or part-time).
* have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. aRemodeling
ship and have no employees These sub-contractors have 8. [Demolition
workingfor me in an capacity. employees and have workers'
Y p tY 9. aBuilding addition
[No workers' comp. insurance comp. insurance.+
10. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its ❑ p
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.171 Other
comp. insurance required.]
*Any applicant that checks box#I 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.
♦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: Firemen's Insurance Co. of Washington
Policy# or Self-ins. Lic. #:WPA517670310 Expiration Date: 11/1/15
Job Site Address: 94 Flagship Drive 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify unfler,the pains and penalties of perjury that the information provided above is true and correct.
Si ature: sIrwo-i /I, wan yAgSoa;i✓r Date: S- 28-7-015-
Phone#: 603-3295300
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#:
ACC D® CERTIFICATE OF LIABILITY INSURANCE I
DATE(MMfDD/YYYY)
�.•� 10/23/2014
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.
,MPORTANT: 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 AME : T Pauline Proulx
Infantine Insurance PHONE (603)669=0704
cN :
P. O. Box 5125 EMAILESS
Appg
.pproulx@infantine.com
INSURERS AFFORDING COVERAGE NAIC#
Manchester NH 03108 INSURER A:Firemen Is Ins Co of Washington 21784
INSURED INSURERS:
Dutton & Garfield, Inc. INSURERC:
43 Gigante Drive INSURER D;
INSURER E:
Hampstead NH 03841 INSURER F:
COVERAGES CERTIFICATE NUMBER:14/15 Master 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.
ILTR TYPE OF INSURANCE AD L S POLICY EFF POLICY EXP LIMITS
POLICYNUMBER WDD MM/DD
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTE15-
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 300,000
A CLAIMS-MADE FXI OCCUR X Y PA517669910 1/1/2014 1/1/2015 MED EXP(Anyone person) $ 15,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICYF_X1 PRO FX]LOC $
AUTOMOBILE LIABILITY EOMaBINdBD nt)SINGLE LIMIT 1,000,000
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED X Y AA517670110 1/1/2014 1/1/2015 BODILY INJURY(Per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNEO PROPERTY DAMAGE $
AUTOS Per accident
$
X UM13RELLALIAB X OCCUR EACH OCCURRENCE $ 5,000,000
A FEXCESS LIAB CLAIMS-MADE AGGREGATE $` 5,000,000
DED I X I RETENTION$ 10,000 X Y CUA51767021O 1/1/2014 1/1/2015 $
A WORKERS COMPENSATION A States: MA, NET TORY WC STIMIT OH-
S AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNERfEXEcunVE N/A E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBEREXCLUDEDT �PA517670310 1/1/2014 1/1J2015
(Mandatory in NH) E.L.DISEASE-FA EMPLOYE $ 1 000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 11000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 1D1,Additional Remarks Schedule,if more space is required(
MASTER WORDING FOR CERTIFICATES:
It is agreed and understood that ( ) is included as additional insured on General Liability,
Business Auto and Umbrella when required by written contract. General Liability applies on a primary and
non-contributory basis when required by written contract. Includes Completed Operations Coverage for
Additional Insureds. Waiver of subrogation applies to General Liability, Business Auto, and Umbrella
when required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Dutton & Garfield, Inc ACCORDANCE WITH THE POLICY PROVISIONS.
43 Gigante Drive
Hampstead, NH 03841 AUTHORIZED REPRESENTATIVE
Charles Hamlin/PP1 G f(�• "" / ir:{ •�
ACORD 26(2010106) O 1988-2010 ACORD CORPORATION. All rights reserved.
INS025(2oioo5)Oi The ACORD name and logo are registered marks of ACORD
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-039771Alft
STEVEN R WEBS,OR '
26 PORT WEDELN ,°
WOLFEBORO NU 0��8`9��t
Expiration
Commissioner 03/17/2016
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