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Miscellaneous - 250 CLARK STREET 4/30/2018
Date ........"I....!.� .................. TOWN OF NORTH ANDOVER, PERMIT FOR WIRING This certifies that(r�ev4e.wc .................. .... ...................................................... has permission to perform ....CtM cK P !`-! ....................... ............. wiringin the building of ............. �91.......................................................................... at ...... .... ............. .................................................. , North Andover, Mass. Fee.ARS............. Lic. No. )1&5 ........... . . .�........ ELEC ICALINSP� EC R Check #� f/// Commonweakk of V7 aeaacLe� 2eioartment o/.}ire Jervicea BOARD OF FIRE PREVENTION REGULATIONS Print Form Official Use Only Permit No. I -�;w Occupancy and Fee Checked [Rev. 1/071 (leave,blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: _^% (" • ?,/ j City or Town of. Nof a2 To the Inspector of Wires: By this application the undersigned gives notice of his or her int tion to perform the electrical work described below. Location (Street & Number) 2� (� o a ���yP i— Owner or Tenant O ' Add Telephone No. caner s ress 1)� Is this permit in conjunction with a building permit? Yes ❑ No OR (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters. No. of Meters n«ucr, uuumonat aemu q aestred, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $200.00 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑✓ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: DIPIETRO HEATING & COOLING LIC. NO.:A18265 Licensee: ERIK PIERMATTEI Signature LIC. NO.: 40803E (If applicable, enter "exempt" in the license number line.) Address: 5 SOUTH SUMMER ST BRADFORD MA 01835 Bus. Tel. No.:978-372-4111 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L c.Tel�No 978-994-0725 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ M A' A \' The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): DiPietro Heating and Cooling Address: 5 South Summer Street City/State/Zip: Bradford MA 01835 Are you an employer? Check the appropriate box: Phone #: 978-372-4111 1.Q✓ I am a employer with 30 employees (full and/or part-time).* 2.❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.]' 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.' 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 1 I .❑✓ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other {Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t,Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors 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: Merchants Insurance Group Policy # or Self -ins. Lic. #: WCA9098545 Expiration Date: 07/25/2015 Job Site Address: 250 Clark Street City/State/Zip: N. Andover MA 01845 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains td aes o perjury that the information provided above is true and correct. Signature: Date: 03 -21.15 nt„t„o +4.9783724111 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 ACORD CERTIFICATE OF LIABILITY INSURANCE TM DATE(MM/DD/YYYY) 03/27/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COSTELLO INSURANCE AGENCY CONTACT NAME: Emily Costello PHONE97g 374.6352 aC, No Ext): (AIC, No): 978.521.5127 2 South Kimball St. PO Box 5248 Bradford, MA 01835 _ ADDRESS: ecostello@costelloinsurance.com _ INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Merchants Insurance Group i INSURED Joseph A Dipietro Heating & Cooling, Inc. Erik Piermattei— INSURER B: -- INSURER C INSURER D: S South Summer Street Bradford, MA 01835 _ { INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2014 renewal 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. WSR-1 LTR TYPE OF INSURANCE INSRL ull POLICY EFF I POU POLJCY NUMBER (MM/DDIYYYY MM/DD/YYYY LIMITS GENERAL LIABILITY CMP9153750 07/25!2014 i 07/25/2015 EACH OCCURRENCE 1$—I,00 -0,00--o r X COMMERCIAL GENERAL LIABILITY I DAMAGE 10 HEN I ED PREMISES (Ea occurrence I $ 100,000 I CLAIMS -MADE I� OCCUR I i MED EXP (Any $ 5,000 A —one _person) PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 F^GEN'L AGGREGATE LIMIT APPLIES PER: i PRODUCTS - COMP/OP AGG ($ 2,000,000 POLICY j PRO- r—I JECT LOG r— — —I s i s AUTOMOBILE LIABILITYMCA000003107/25/2014 07/25/2015BINtU 511,161-1: LIMIT (Ea accident) $ 1,000,000 ANY AUTO i BODILY INJURY (Per person) $ ALL OWNED SCHEDULED A AUTOS X AUTOS BODILY�raccident) I $ — ~� NON -OWNED X X E HIRED AUTOS ; . AUTOS _ �� i (Per accident) I $ ( $ X UMBRELLA LIAB OCCUR CUP9146014 07/25/2014107125/2015' EACH OCCURRENCEI $ 2 , 000,000 A EXCESS LIAR CLAIMS -MADE j I AGGREGATE $ 2,000,000 DED 7x TRETENTION $ 10,000 j I $ _ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY / N WCA9O98S4S�07/25/2014107/25/2015 i X - H-1 �_T_ORY LIMITS ER I ANY PROPRIETOR/PARTNER/EXECUTIV �Y A OFFICERIMEMBER EXCLUDED? - - N I A E.L. EACH ACCIDENT $ I L _ .---..__.T. _ 500, 0O _ -0 -0 - (Mandatory in NH) I i ( E.L. E.L. DISEASE - EA EMPLOYEE $ 5O0 0 I yes• describe under i DESCRIPTION OF OPERATIONS below — E.L. DISEASE - POLICY LIMIT $ f S00,000 II DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) icensed electrician is Erik Piermattei X VCR I Irm m i C nULUC11 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover AUTHORIZED REPRESENTATIVE 120 Main street North Andover, MA 0184S Emily Costello ©1988-2010 ACORD C PORA N. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name: ERIK F. PIERMATTEI Business: JOSEPH A DIPIETRO HEATING COOLING INC SANDOWN, NH NEW SEARCH **This Licensee has additional Licenses, click here to view them.** Licensing Board: ELECTRICIANS License Type: MASTER ELECTRICIAN TYPE CLASS: A License Number: 18265 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 6/25/2003 Exam Date: 6/19/2003 School: MARTIN ELECTRICAL ft This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Thursday, April 09, 2015 at 1:36:16 PM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ.asp?board_code=EL&type class-_A&lic... 4/9/2015 Date v r Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 2) No copy of current license 3) Insurance Binder not on file or expired 4) No Workers' Compensation Insurance Affadavit Form Please call with any questions 978-688-9545. Fax 978-688-9542 Workers' Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1.600 Osgood Street, Building 20, Suite 2035, North Andover, MA 01845 Location C"? � 0 No. t Check # 7 Date 7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit FeeCtr7,� �✓/ TOTAL $ Building Inspector A E O 5 as O Q0 U Ln a) Ln Y-1 O O m M V N Q V W OU O O m i Z U- OU c y 0 s N Y U aJ s U Q) s 4- 0 s Q) E 4- Q) v N m a� a O O U N N`i +) = - 4- 0 s a .3 a) a, N � c o U C a) m s a) } c C m L 4- O O Q) +� a) N 4- C O CU •> O tin +, O -0 v QJ U N O Z o V N N >, v � 3 aai N � Q Ln Y M L +� U � OE Ln N N o ~ O v C s a) 4- N 4-- a O N a) v > CL s O V � In v � Y — L �t 3 L O � a — -a a- V 0 o N a) � o v +� =3 > a) O O N L > O O a) O GO u M 0. QL. = .0 � to W V) r IA v y 0 s N Y U aJ s U Q) s 4- 0 s Q) E 4- Q) v N m a� a O O U N N`i +) = - 4- 0 s a .3 a) a, N � c o U C a) m s a) } c C m L 4- O O Q) +� a) N 4- C O CU •> O tin +, O -0 v QJ U N O Z o V N N >, v � 3 aai N � Q Ln Y M L +� U � OE Ln N N o ~ O v C s a) 4- N 4-- a O N a) v > CL s O V � In v � Y — L �t 3 L O � a — -a a- V 0 o N a) � o v +� =3 > a) O O N L > O O a) O Ln 0. .0 � to O N O N •' Q N o 0 CL �, x L O N L1 > to > U C +, O I� aJ N O > > (/7 Y C i\ Q Y a) LU Y 4J OO 0 U m 0O v Eo LQO Ln s w Ln 0 r-, H Z U- HCr- C-4 Z M Date.... ! ... ......... .. . ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that,.,,.., ................................... ....................................................................... has permission to perform"l ........ i.Y.L .. ............... �'�'r ..................................... wiring in the building .of ... /T-1 '4�Le UC- ... ............. ...... ... at ........ 22c3D ............................................................................................... /,-�4orth Andover, M. ELE4'r7 Fee.1215,e ....... Lic. NOA. N.V ....... -TmRi*C**ALiiE Check It Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official U Only Permit No. Occupancy and Fee Checked ev. 9/0-7 (leave blank) APPLICATION FOR PERMIT TO- PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 327 CMR 12.00 - (PLEASE PRINT.DVINK OR TYPE ALL 1ArFORMATI0JV Date: _ City or Town of -d: n N 1rY,= � t • To the Inspector of Wires: By this application the undersigned gives notice iofEiior her intention to perform the electrical.work described below. Location (Street & Number) Owner or Tenant lC F y k1 Telephone No.. Owner's Address SA?n1 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service A .....e / - Volts New Service AmW / Volts Number of Feeders and Ampacity -- - Location and Nature ofProposed Electrical Work: No. of Recessed Luminaires ofLuminaire Outlets �-- of Luminaires No. of Receptacle Outlets of Switches a of Ranges of Waste Disposer of Dishwashers of Dryers of Water KW Heata Hydromassage Bath-f'ir5s - - Overhead p Ilndgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters of CCU.-Susp. (paddle) Faos--- of Hot Tubs of On Bn of Gas B of Air l and TOW Applianc of Moto 0 asts be of Ale X or � •� � sa..�u � � 3 � EGr:'o Qu T1 r, . S .i- LZ a � rt N t: Td (n 1i� G ✓h i .e e .Estimated Value of Electrical Work: p ` ltac additional detail�fdesired or asreguiredbytheInspectorofWu,. (When required by municipal policy-) Work to Start:' I _ Inspections to be requested in accordance with MEC Rule 10, and upon completion INSURANCE GE: Unless waived by the owner, no permit for the p performance of electrical work may issue unless the licensee provides proof of liability insurance including rng "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov �Qe is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE L{ BOND ❑ OTHER ❑ (specify-) I certify, under Ure pait:s and penalties afpetjury, ilial the information on 'application is true and complete FIRM NAME: �wraE a �, LIC. Licensee: SSignat (lf applicable, enter "exempt " in the license nwxber line.) Vie' NO Address: // L�t3��ry sr- M�Doteer�f>1 l`hA atRla�1 Bus.Tel.No.: q-rsz 7'susT Security System Contractor License required for this work, if applicable, enter the license numberh ere: No.: OWNER'S INSURANCE WAIVER: l am aware that theLicensee does not have the liability insurance coverage required by law_ By my signature below, I hereby waive this requirement. I am the (check one) ❑ onormally wner ❑owner's agent Owner/Agent Signature Telephone No. PER1t TFEE. $ �1 MWINIAIC A I -ri. -�R J..Ej A 2 m4 k, NJ E-L;;E:IyCATmRIu'uCIANS ..,. ISSUES THE FOLLOWINGLfCENSE- j4- !uj AS A" REG JOURNEYMAN ELEC-TRTC'I,AN. JAMBES J CARRONE 16 LIBERTY " 'ST ju tAIDDLET' ON MA oi9g=186` 2833b `E' 07131116 -3 9797 979, .V5 - 516-5 The Commonwealth of Massaciusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M4 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual)'. SAm t 7 �A�t>;e�ti 1_CEC _ Address: 16 L, c;62r% s -r Phone k 979- -7--7-) S932' Are y an employer? Check the appropriate box: 1. I am a employer with 4 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance -1 required] 5. E] We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL .insurance required.] t - c. 152, § 1(4), and we have no employees. [No workers' comm insurance reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. E] Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box III must also fill out the section below showing their workers' compensation policy information. t Hor4eowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contiactors 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 ilie policy and job site information. Insurance Company Policy # or Self -ins. Lie. #: Expiration Date:, Job Site Address. ase) CLArztc rr u — A>Jibv r,—,L — City/State/Zip: M A - Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required unqo0ection 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 ' ri nment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against tlw vi ator Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ce c verage verification. I do hereby certify Phone #: of perjury iliac the information provided above is true and correct. 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)7/ Contact Person Phone Date .... ///L. S TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..6� 4 0 r"fe— . VI.I.S .............................................................................................. has permission to perform ..Y -e ") 6,,, 1 / / .................................. 7 ......... I ........... I .............................. wiring in the building of ....... 1—)r, )� . ......................... ...... . . ... at...... Andover, Mass. Fee -vo E� .../....5....cl......., ............ Lic. No. ................. ....... .. EL PUCAL INSPECTOR Check# 5-6 IL 1 10) _ Commonwealth of Massachusetts Official Use Onl _ - - =- Permit N°. ��Ga_ _ Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to b- performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION} Date:�� City or Town of: - AMilo To the Inspector of Wires -- By this application the undersigned gives notice of his or her intention to perform the electrical wort: described below. Location (Street & Number) a 5o CIA,Z)c S r— Owner or Tenant r-r� .Nr Ls+ni� ATA ICur Y b&J Telephone No. Owner's Address Is this permit in conjunction with a building permit? yes �✓ Purpose of Building M t».ru FArru & y./ L, Existing Service s / Volts New Service U10_- _ Amps 1pd / �G g- Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No; of Luminaires No. of Receptacle Outlets FNo.No. of Switches of Ranges of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KW Heaters No. Hydromassage Bathtubs � t. No ❑ (Check Appro 'ate eox Utility Authorization No. - Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrdsd No. of Meters _uJinir I'lALD - �rsI rf 71, r1%)I %h f f Completion of the No. of CeiL-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool ,Above . No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Space/Area Heating KW Heating Appliances KW No. of No. of Sims Ballasts of Motors Total I3P vin X raote may be ivatved by the Ins clor of Wires. No. of Total Transformers ICVA i Generators KVA �I i No. 011,124:11Kto Bane Unts3' g �^ FIRE AT.ARNS No. of Zones of Alerting Devices ofSelf-Contained :ctionlAlertina Devices i1 ❑ Municipal Connection - Q Other [riity Systems: ro. of Devices or Equivalent I Wit ing: 10. of Devir-c nrrit..:v..In..+ dttach additional detail ifdesired or as required by the Inspector of Wires Estimated Value of Electrical Work jaw2 When required by municipal policy.) tlkStWork to Start: Z Inspections _.L o� ( to be requested in accordance with MEC Rule 10, and upon completion IZYSCJRANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov ae is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [✓BOND ❑ OTHER I certify, under the pants and penalffes ofperjury, that the iino(rntatioti a t- aPPficadon is trite and complete FIRM NAME: LIC NO. ;a� G F Licensee: s , Signat (t(applicable, enter exempt ' in the license number line.) LIC. Address: L, rx.»ry S —i f� Bus. Tei. No.* 12 7 5 g 3 �s M no..�rf • 1 P7 A 14 to 4 777`Security System Contractor License required for this woQrk; if applicable, enter the license number here:. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent_ Owner/Agent Signature Telephone No.PERMIT FEE- $ /Sag , co v kr��C.1 The Commonwealth of assachusetts Department of Indaastriral Accidents {- Office of Investigations 600 Washington Street Boston, MA 02111 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Learibly Name (Business/Organization/Individual): Tamr—s J ifAyZMCAJF F LEC . Address: If, L � l ear!j S71 City/State/Zip:-m% - cJ fA& Phone #: T7 8' Aree u an employer? Check the appropriate box: 777 57-5`6 Type of project (required): 1. LJ 1 am a employer with 5 4. E]I am a general contractor and I have hired the sub -contractors 6. ❑New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. ❑;Demolition working for me in any capacity. employees and have workers' comp. insurance.$ 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] 3. ❑ 1 am a homeowner..doing all work officers have exercised their 1 L❑ 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 13. ❑ Other employees. [No workers' comp. insurance required.] 1 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: F>sr�+ Q 4 C– m7 Policy # or Self -ins. Lie. #; Expiration Date: 331 Job Site Address:Q$p QA21L 3-1 1t - tart Oo v g:t . City/State/Zip: MA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required rider 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 ' prisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day agarose v' ator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for/hs ce coverage verification. I do hereby certify u.. a4e.n n�and penalties of perjury that lite information provided above is true and correct. /1115/1 Phone#- 779 777 S 738�' Official use only. Do not write in this area; to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M C641MONWEALTH.Of MASSACHU sEiiS- BOARD OF E-LECTR•I C I ANS ISSUES THE FOLLOWING -LICENSE AS A REG JOURNEYMAN ELECTRICIAN' a JAMES J CARBONS :.W 16 1_.I BERTY ST; _ r; �J MIDDLETON MA 01949-1802 ` 28336 E 07/31/16 39791 Q COMMONWEALTH OF MASSACHUSETTS BOARD OF EL.ECTR I CIANS ISSUES THE FOLLOWING LICENSE AS A.;'> REGISTERED MASTER.,ELECTRICIAN M JAMES J CARBONS"`` z W.. 16 LIBERTY STREET _A2 U MIDDLETON MA 01949-1802 183501A 07/31/16_;:•.' 39798 4 �� - �,• •x a s• '.jasscichusetts - Department of Pub is SaTe'i Bob ird of Building ;= eguia-d- ns and St -2 der ds a _;cense: CS -093882 - JAMES J CARBONE 16 LI$ERTY:ST MI DDLETON MA 01949 — ,r Cf;MMISSIOnea 12/24/2013 STATE OF NEW HAMPSHIRE BUREAU OF ELECTRICAL SAFETY & LICENSING NAME:JAMES J CARBONE 1.11472 M 2. r 3. EXPIRES: 12/31/2014 OSHA *d U.S. Department of tabor Occupational Safety and Health Administration James Carbone has successfully completed a iCl,hour Occupational Safety anti Heattl. Training Course in Construction Safety & Health Jean C. Manoli 617-969-7177 12/7/07 (Trainer) (Date) Date .... :..-- ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING w This certifies that ,,,,Cq.l� 1 has permission to perform .............. c U /?t- L ff...'........... ��� wiring m the building of.......................................................................................................... 6C�&Ar at ...........J.�....................... ..................T.................North Andover, Mass. Fee.. 3. Z �'�Z.. Lic. No. I !� J5% .........!/<k�•l,G�> /-� r ELECTRICAL INSPECTOR 1 Check # I L Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. L t! l Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: '7 1 p 13- City 3.City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 10 so C LAjZ)e S,7 Owner or Tenant I(C y�N Cn a p_ F l i O I-ri- L AND A i W Telephone No41 7 L111!9 '59')A Owner's Address Is this permit in conjunction with a building permit? Yes [?f No ❑ (Check Appropriate Box) Purpose of Building CWU#A Ce -t^ L Utility Authorization No. - Existing Service 400 Amps / Volts Overhead ❑ Undgrd No. of Meters 1 New Service Amps /J OF Volts (f-O%rhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity NQ 1 CV4AtJb-E Location and Nature of Proposed Electrical Work: 17F mo pgt_ a _ F=,'t. 1=,70 N r- o 7Su1�f)�c�/L� r Completion of the follnwinn tnhle may ha wnived by tha Tn.cnectnr of Wira.e No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑o. rnd. grnd. -oTEmergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number I Tons IKW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs - Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 3o, opU . a (When required by municipal policy.) Work to Start: 7Ila I I-,, . Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liabiliy insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov rage is in force, and has exhibited proof of s me to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) X certify, under tliepains andpenalties ofperjury, tliat the information o tis application is true and complete. FIRM NAME:. LIC. NO.: 1 is 3 $ 0 A Licensee: �,.,�SignatureLIC.NO.: ')3330. (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.•, 4 7('777 Sq �ll Address: t 4 L- r3►L aT y S'r MIDO� T rO d.J M A Olq L4 =P`���9 t Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety' S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Fpp",TFEE: $Signature Telephone No.33fs •�% � ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an p electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: �r Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass ^ Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 13 r a� z -Z7— ( ✓Vj F t / , Inspectors Signature: - r Date: `EB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com J +. The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual): ,T An. ,t C T ria ,-2 3c4\j Address:, :_ M,opi_ r_ w /z VW da- 0114 ° Phone #: 975- -7-7-2 �Ql 'VV Are Xou an employer? Check the appropriate box: 1. M I am a employer with L 4. ❑ I am a general contractor and I _ employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. E] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they afire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lie. 4 Expiration J 5b Site Address: 9_�Q C1 A -i-) It City/State/Zip: 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=y ar imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day againstyp violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA fo surance coverage verification. I do hereby cert untJ�� and penalties of perjury that the information provided above is true and correct. 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. EIectrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: or, Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not producedacceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigatiions 600 Washington Street Boston, MA. 02111 Tel, # 617-727-4900 ext 406 ox 1-877rMASS.AFB Revised 5-26-05 Fay, # 617-727-7749 wwwanass,govfdia 110018 • TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING L 1 _ This certifies that.. has permission to perform ... � �J� � /�_m � .......... plumbing in the buildings of . .. % . .......... at.C`! . .G?.... -,..... ,North Andover, Mass. .. j . ` . . ... PLUMBING INSPECT61IR'(� Check# ���� f� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4 _ 1 CITY MA DATE ( PERMIT # ` JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS l TEL FAX j TYPE OR _ _ __ _ OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL © PRINT CLEARLY NEW: RENOVATION: © REPLACEMENT: Of PLANS SUBMITTED: YES 00 NO01 FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB F-7] CROSS CONNECTION DEVICE f _..,.__I 1 j...._...__! .-...__..._f .._:.__.._:1 ..r-_ _.! .l ...-.-v.-_. _..-. DEDICATED SPECIAL WASTE SYSTEM FI _ __..___...1 ._R I 1 ._.._..._. f ,..._...._._ (.--_--_I _.._.-_.f ... _---_l DEDICATED GAS/OIL/SAND SYSTEM ! f i _ DEDICATED GREASE SYSTEM �1 I i f J ___..__..I ( I .__. -_ ._ ___f _( ... _._.( �I DEDICATED _------ GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _-.._ DRINKING FOUNTAIN,l _-.-__I __...__! ._____f .._.___._� _._.__.{ _ _. _.( __.__ .! .. ____f _... FOOD DISPOSER �—i . - _..__f .__.____f .__-_._..f I ( f i ...._.._.__I....___..I .. _ __i FLOOR/AREA DRAIN f ! .....___i __..____( ..-..___.! _ __.-__.I INTERCEPTOR (INTERIOR) KITCHEN SINK --___-j LAVATORY (_ ._.-_J ._._....._1 _...___I __--_-__-� .--_J ! .:..._.__.f .._..-__f _ _f _,_-.__.I ROOF DRAIN .-__.__ ..._ I _J _._.__.J I ._...-_J �6 ...._-__f .....__.._f ___1 .l-_-__-( SHOWER STALL.___.� ____-J __.._.___I ( I ` I -- ---- ..____f _-_.._._.1 __.._._( __..___i ..__._f ____..... ._ _,_1 SERVICE /MOP SINK _ I.-_.___1 _ __-___I .-.__._._-_1 _ ( l ! E F___._Ii __.... __s _..� _.. _ .. TOILET 3 -- ..._( _...__.__f ..__.i ._-__._1-__v.___► .-____._l ____.J _..._I ..____.-.! ______E __.....-..i __..._.I _...--.._� __._..._f URINAL WASHING MACHINE CONNECTION _j _ ! - WATERHEATER ALL TYPES _J WAFER PIPING OTHER 1 __J __ ___i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES IP60 F]i IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Ej BOND�_i] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this application this permit waives requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true ac rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in I' ice th all Pertinent provision of the + FVlassachusetts State Plumbing Code and Chapter 142 of the General Laws. J' 3o IS PLUMBER'S NAMga� E . !' LICENSE # - SIGNATURE MPO/ JP 0 CORPORATION D# __ ; PARTNERSHIP 0# LLC Ek COMPANY NAME n� ADDRESS �x _ CITYSTATE �y/ --z j .ZIP �!� TEL FAX E CELL (EMAIL f� I H z° 0 F U W a w o F1 z NEl O ~ W W O W m ft Z LLI O a w co a W O w co p z a a � W a � U LL CL a N LLI s w LL. i O � z o � v J a � z �a a J a I The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations Uf 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly , r_rmo wv� Name (Business/Organization/Individual): Address:_ A &X City/State/Zip(&L2, Phone Are you an employer? Check the appropriate box: 1. ❑ I aa employer with 4. ElI am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic #:_ Expiration Date: " Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. Ido hereby pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill Out -Mi the event -the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of lndustrial Accidents Office of Investigations 600 Washington Street Boston., MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877,7MASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass.govldia wa I AO 0 ED LO i-- 0 Q) C) (f) Q) CD Q 0 LLI > < w U) Of •w w > W 0) Lu CY) LO TRAVELERS J� 8/2/13 Town of North Andover C/O Town Hall, Building Inspector's Office North Andover, MA 01845 Re: Water Damage Insured: M&T Co. LLC Property Address: 250 Clark St Claim Number: EWN4306 Date of loss: 3/11/13 Type of loss: Water Damage Dear Building Inspector: A claim has been made involving loss, damage or destruction of the above captioned property which may either exceed $1,000 or cause Massachusetts General Laws Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws Chapter 139, Section 3B is appropriate, please direct it to the attention of the undersigned and include a reference to our insured, policy number, claim number, date of loss and the location. Sincerely, Marc Krzywicki Property Claim Representative Travelers Casualty Insurance Company of America TOWN OF NORTH ANDOVER PERMIT FOR WIRING G— .........This This certifies that ..... e ..................................................................... . has permission to perform wiring in the building of.........,, y ...... Q.j .............................................................. at .......r) ... ......... 52- . . ............. North Andover, Mass. oa . ..... . .. ...... . Fee...12 Lic. No. ............ /KLECTRIC . AL .. IN . SPECf6R . el. /,;0- .......... Ch6cko � 70 P 112 22 Commonwealth of Massachusetts Official Use Only F Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: b 02 2z. 3 City or Town of: NORTH ANDOVER To the Inspector of Wires.- By ires.By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)_2 __570 0 % 1/ 5 f ��� — Owner or Tenant 1 ��/ 6A—) Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 0"' No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: y ( ' 0" Comnletinn nfthe fn Inwino tnhla mnv ha wnivad by tha hivnartnr of Wire.c. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans ✓ No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals:..... Number ' " ' .......r"""""..... Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of lectrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: O (_3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) t certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME. 5740', ! a c' e71% d y — ys c LIC. NO.: j,' D Licensee: te' c 4as� j a 1 Gg A —� (If applicable, enter "exempt" in the licens&Jnuml Address: a 5' L.;g�Nrl� S-15 *Per M.G.L c. 147, S. 57-61, security work rc OWNER'S INSURANCE WAIVER: I am Signature `/� � LTC. NO.: ,? o2 3 7-,b ?r line.) Bus. Tel. No.•, -7-el A ?Ll d 12 X4 Alt. Tel. No.: 4 Fe de :?- G 13? er' quires Department of Public Safety "S" License: Mwo. SSC O •- OO / Y 7-,, aware that the Licensee does not have the liability insurance coveraize•nozmally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ ` Inspectors Comments: Inspectors Signature: Date: FINAL INSPE TION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Commen Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com rl w The Commonwealth of Massachusetts - Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ���7 LXX <<j,4V-e rs�lT7 �fC d�'� , L2 C . Address:z City/State/Zip: �ls ZM U z 1,10 Phone Are you an employer? Check the appropriate box: 1. am a employer with )-- R 1 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. �ew construction 7. Plemodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is thepolicy and job site information. , 1. , Insurance Company Name:. U -t Cei /11 Policy # or Self -ins. Lic. 9:_ 2 1 0 1/2 Expiration Date: Y Job Site Address:.56 Uuflr �f� �i��-�i,���1JP/l City/State/Zip:�/��►? j 1� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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 u., 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 cero under the pal5s fnd penalties of perjury that the information provided above is tpue and Correct. one Official use only. Do not wri City or Town: Q in this area, to be completed by city or town official. Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Gouunonwealth, of Massachusetts Department of Industrial Accidents Office of Investigatiions 600 Washington Street Boston, MA, 02111 Tel, # 617-727-4900 ext 406 or 1-877,7MASSAIiE Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdia COMMONWEALTH OF MASSACHUSETTS A REGISTERED SYSTEM TECHNICIA ISSUES THE ABOVE LICENSE TO: RICHARD L COLANGELO 224 MAIN ST BOXFORD MA 01921-2227 2237 D 07/31/13 832328 Fold, Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS A REGISTERED SYSTEM CONTRACTOR I ISSUES THE ABOVE LICENSE TO: NORTH SHORE PROTECTION INC RICHARD L COLANGELO 25 WAVERLY ST 'y STONEHAM MA 02180-1614 1570 C 07/31/13 834309 Fold, Then Detach Along All Perforations Commonwealth of Massachusetts Department of Public Safety secuvitN sNstenx- S- I,icene License: SSCO-001475 RICHARD L COLANGELO 224 MAIN ST Boxford MA 419211 Expiration: Commissioner 04121/2014 (" �Date k ... ........................ I................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that j U (MPS has permission to perform ........... ...,,,,,,,,, ................ . ,wiring in the building of,.�}, �.!.... G� , ................................................ at ...2— `&2-�L � North Andover, Ma , ff................................................................. Fee. 4........ Lic. No.,. ............... .........................:....... . j > ELECTRICALINSPEcroR Check.. v F- Q __ Commonwealth of Massachusetts Official Use O - Department of Fire Services Penni N°. - Occupancy and lee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) APPLICATION FOR PERMIT TO- PERFORM ELECTRICAL WORK All wort: to be performed in accordance with the Massachusetts Electrical Code (?�MQ, 527 CMR 12.00 (PLEASE PRINT BV INK OR n -PE ALL MFOR1bIAT1OAO Date:—.... 41 I -d 13 City or Town of_ 2 To the Inspector of Wires. - By this application the undersigned gives notice of his or her irtienlion #o perform the electrical.v o& described below. Location (Street & Number) 50 C, q,2tc S o Owner or Tenant g \ i G, 147 La � —.,P Telephone No.. 17 S 6 a -9SW Owner's Address S4enr Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Boz) Purpose of Building Utility Aq&orization No. � Existing Servi New Service w g Number of Feeders and Ampacity Location and Nature ofProposed Electrical Work: g Pres Qr, t„ P Completion --the fill, table m be waived bV the or Wires. No. of Recessed Luminaires Na. of Ceil.-Susp. (Paddle) Fans o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tabs Generators A �. No. of Luminaires Swimmin Pool Above � Lr o. a mergeney g g � d- d. Butte Units No. of Receptacle Outlets No. of Oil Burners FIRE -ARM N . of Zones No. of Switches o. of Detection d No. of Gas Burners ' 'ces ~` ly Initis a No. of Ranges No. of Air Cond. Tons No. of Ale vices 1 m No.ofWasteDisp ers eat Pump Nu Tons N0 of nt h Totals: Detection/ ertiaa Devices Na. ofDisbwas rs Space/Area eating KW LOC21 E] unicipal 0 other onnection. " No. of Drye Heating plianees KW Security �y} No. Nom fI}e or Equivalent of Wa . No. of No. of Data gnsBallasts wing: No. Hydromassage Bathtubs No. of Motors Total a HP of Devices or E uivateat f,?nr. Telecommnnications Winn-aagg•• No. Devices Ol, of or -valent Attach additional detail rfdesirea( or as required by the Inspector of W -urs Estimated Value of Electrical Work: ,�'p Q o . o e {When required by municipal Pal poil� ) Work to Start -_1 l 3 • inspections to be requested in accordance with IAC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of Liability insurance including "completed operation" coverage or its -substantial equivalent The undersigned certifies that such cav Qe is in for ee, and has exhibited proof of same to the permit issuing office CHECK ONE: INSURANCE [✓BOND Q 1 y OTHER I certify, under the aims and in (Specify:) Ez�' Ec, . F penalties ofperjury, that the information on application is true and complete FIRM NAME: Twr►s= \ iz NO. Licensee: E \ a.v.�. Signa LIC_ NO (If applicable, enter ' exempt " in the license number line.) Address: % Bus. Tel. 4"7g777Sg3$ rr i,��,,,, �r �,��«n i r„rn argLaq- xSecurity System Contractor License required for this wo Alt Tel. No.: rk; if applicable, enter the license OWNER'S number here: INSURANCE WAIVER: i am aware that the Licensee does not have the liability insurance coverage normally required by law_ By my signature below, I hereby waive this requirement I am the (check one) ❑ owner Owner/Agent ❑ owner's!E t Signature Telephone No. Pl �"HTFEE�$j a r r 1% P Tile COMM& .Deprartnen Offic -- 600 Bo wl, Workers' Compensation Insurance Aff. Applicant Information -- Name (Business/Organization/Individual): Address: — M�o�+-pro City/State/Zip: LAA, Are on an employer? Check the appropriate box: 1. I am a employer with L 4. ❑ I= employees (full and/or part-time).* have 2. ❑ I am a sole proprietor or partner- lister ship and have no employees Thes working for me in any capacity. empl [No workers' comp. insurance coml required.] 5. ❑ We 3. ❑ I am a homeowner doing all work ofc myself. [No workers' comp. right insurance required.] t c. 15 COMP. *Any applicant that checks box #1 must also fill out the section below shcv t Homeowners who submit this affidavit indicating they are doing all war $Contractors that check this box must attached an additional sheet showing employees. if the sub -contractors have employees, they must provide their la of Massachusetts lustrial Accidents ington ,Street MA 02111 zss.gov/dia 1: Builders/Contractors/Electricians/Plumbers ;3-9—)4 - _YAMSS' 3-CAMtSW rte, JZ -__t IG L13r,.?T%( 57 Mkz0ltz7-atJ Phone #: 779 C V5 9 54 a Type of project (required): eral contractor and I 6. ❑New construction the sub -contractors ie attached sheet. 7. ❑ Remodeling -contractors have g, ❑ Demolition and have workers' irance.t 9. ❑ Building addition :orporation and its 10'. El Electrical repairs or a ive exercised their 11.❑ Plumbing repairs or a emption per MGL 12.❑ Roof repairs ;4), and we have no 1311 Other >'. 1No workers' workers' compensation policy information. hire outside contractors must submit a new affidavit indicating such. of the sub -contractors and state whether or not those entities have comp. policy number. I am an employer that is providing workers' compensation ins lanfe for my employees. Below is the policy and job si14 information. s' Insurance Company Name: — rz 2A T-rl. Policy # or Self -ins. Lic. #: v.,;. -os;^„ De a t - '' Job Site Address: C) A, C — N A Ao v >, Attach a copy of the workers' compensation policy declaration page (sh Failure to secure coverage as required under Section 25A of MGL c. 152 ca fine up to $1,500.00 and/or one- ar imprisonment, as well as civil penalties of up to $250.00 a day against violator. Be advised that a copy of this sta Investigations of the DTA foilfstirance coverage verification. Ido hereby cerAfy und�F tl pains and penalties of perjury that the inform R y/State/Zip: M 4 1 the policy number and expiration daii .o the imposition of criminal penalties c f a form of a STOP WORIC,ORDER and i fine t may be forwarded to the Office of above is true and correct. Phone #: 1 7 g 7 17 S l'5 �! Official use only. Do not write in this area, to be completed by city or town official I City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector mbing Inspector 6. Other loo , t1� lit Contact Person: _ Phone #:t ttor COMMONWEALTH OF MASSACHUSETTS Massachusetts - Department of Public Sat • • .':.: -.. Board of Building Regulations and Sranda -ELECTRICIANS �""AS A REG JOUi ME-YMA-N ELECTRICIAN License: CS -093882 ISSUES THE ABOVE LICENSE TO: ,titit. ' JAMES J CARBbNE JAMES .J CARBONE 16 LIBERTY,& MMDLET(* MA 01949 ". 16 LIBERTY ST = MIDDLETON . MA 01949-18;0 - — # Expl 28336 E 07/31/13 868652 Commissioner 12/24 COMMONWEALTH OF MASSACHUSETTS STATE OF NEW. HAMPSHIRE ` • • • - • • Lyt•T�i il'.ida : • • • s BUREAU OF ELECTRICAL. SAFETY & LICENSING ELECTRICIANS NAME:JAMES J.CARBONE REGISTERED MASTER ELECTRICIAN 1.11472 M ISSUES THE ABOVE LICENSE TO: 2. JAMES .J CARBONSj 3' t 16. LIBERTY STREET EXPIRES: 12/$1/2014 f1IDDLETON MA 01949-1 18350 A 07/31/13 868653 0 0 a� 0 Ca U N Cd F-) r` L = rn � I O � U 'ri 2 r N O O CoU Cn s~ Cd Date ..!!) [.I � \ 2.......... TOWN OF NORTH ANDOVER A PERMIT FOR WIRING This certifies that ................!!'�...�^��°- �....................................................... ..... has permission to perform�.a`- . �.� ... � . �' . i .!'n..... x.......... wiring in the building of .! .....:.......... :!A`J............................................... at ..�.��..........�c!..!...........................�.................. ,North Andover, Mass. 'Fee.. ........... Lic. NoZ... ....................... ...J................... ELEcTRICX INSPECTOR Check 10724 D a Commonwealth of Massachusetts official use only a Department of Fire Services PemutNo. Z BOARD OF FIRE PREVENTION REGULATIONS Occupancy andFee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code WC), 527 CMR 12.00 (PLEASE PMT ,INK OR TYPE ALL NFORMATIOA9 Date: r - City or Town of. NORTH ,ANDOVER To the Ins ector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)_ Q C j6 /' /,, /P / C' --/— Owner or Tenant Telephone No. �Jff (' fS,2 Owner's Address _ Sn 61/ e Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building °'ZRP— —/J LLQ 91 A O—t' Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters ew Service Amps / Volts Overhead ❑ _ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: iy1 �U Com letion ofthe ollowin table may be waived b the Ins ector No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total No. of Luminaire Outlets No. of Hot Tubs Transformers KVA Generators KVA No. of Luminaires Swimming pool Above ❑ In- ❑ o. o mergency ig ng rnd. rnd. Batter Units No, of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. ofZones No. of Switches No. of Gas Burners No. of Detection and ' No. of Ranges No. of Air Cond. TotaTons l Initiatin Devices No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW Totals: _....._. _.......... No. ofSelf-Contained No. of Dishwashers Space/Area Heating KW Detection/Alertin Devices Local ❑ Municipal ❑ Other No. of Dryers Heating Appliances I{yy Connection Security Systems:X• No. of Water KW No. of No. of No. of Devices orEquivalent Heaters Si s Ballasts Data Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices orE uivalent Telecommunications Wiring: OTHER: i � a�n %'.i ar � No. of Devices or E uivalent .4ftach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Lj,_ (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, nb permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) P fy:) Icertify, under thefil ins d penalties of erjar , that the ' f oration on FIRM! NAME: this application is true and corplEte. Licensee:Signature - LIC. NO.- � (Ifapplicable, enter "exempt" in a lic se n ember ne.) LIC. NO.: Q 9 62 77 Address: S Bus. Tel. No.: *Per M.G.L c. 147, s. 57-E1, se rity work requires Dep en ofPublic Safely "S"License: Alt. Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required Owner/Agent law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. SignatureTelephone No. PERMIT FEE: $ /--6/> W �'�ssecT•-� [ � � �+'aflefl—•[ � �e-inspecTZou x'equia'etT'($�'0.00) � j ] �'nspectors' camme�afs: . (�Cns�ee oxs' ignaiu�re �xto �sfisaTs) Pate 7c'assecT� [) iaileci- r ;ReAuspeetionrequired ($50.00)-•[ � Inspectors' co fs: s ectors'signature oinitials) Pate rPag I T;+ Ueff--j ] ?ate-insp ectim required ($50.00) -s' comments: r (lnspectors'ignatvxe-�oinifials) Pate 4• )WiS.PECT.tON—SEjt•ffCE: Passed-- f ) hSVectars' eomme3fs: )Failed— �iguature � �.o HAM: �e^x11SpeCtiOn X Date INS'EC'Z'XON-- OMS,: -- I 'assed--( IT+ailed• [ 7. ate inspectionxeguired ($50.00) • [ 7 aspectoxa' Coxnm.ents: asp ectoxs' signature x�o znifials) Date D OOR TAGg . TO BE MMED Q,-G—TAO LEFT ON )PITE+ NT .Ap., +��. T®MMSTECTE3D 19 NOT AMRA,RXn7,1i, AND A'aF YNq-PWvTrnx nir xm.nn xq'To nl"i, f,`HA cwn. . The Commonwealth of Massachusetts - Department of IndustriqlAccidints Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name Business/Oreanization/Individuall: /I Address: 0 City/State/Zip: Phone #:6 !!�Z ZZ Are you an employer? Check the appropriate box: 1. I am a employer with L4 4. ❑ I am a general contractor and I Type of project (required): ` employees (full and/or p -time). * have hired the sub -contractors 6 New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # 7• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. El We are a corporation and its 9 Building addition required.] officers have exercised their 10.❑ Electrical repairs or additions 3. E] I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑Roofrepairs insurance required.] t employees. [No workers' 13. [i Other comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they ai-e 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 their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name; Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a f ne 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 certlo under the pains and penalties ofperjury that the information provided above is true and correct. Sip -nature: Date: Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone . Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, - express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not producedacceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Iavestigations 600 Washington. Street Boston., MA 02111 Tel. # 617-727-4900 ext 406 or 1-877- MASSABB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 614 Date.... .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... `r' %1t'6— ............ 6 ....... T.t'6—�t . ....................................... ,has permission for g4sinstallation .... 2 .... �A-!,Anmo ... r-.QA,N.e-n. in the buildings of144.-. L rJe ............ at.:Z�D ..... 0 .. North Andover, Mass. Fee.11-4 ..... Lic. No. UK ............. MD.0....- . ............................................... GAS INSPECTOR Check #o "I(a6•c)J G TYPE OR PRINT CLEARLY &-�f-- Al Go MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE FOCT 3 2013 PERMIT # JOBSITE ADDRESS 1250 CLARK RD. BLDG 1&2 OWNER'S NAME FLIGHT LINEDATA OWNER ADDRESS FLIGHT LINEDATA TE 978-682-7767(TIM LESLI FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL E] NEW: [Z] RENOVATION: El REPLACEMENT: 0 APPLIANCES -1 FLOORS— BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER PLANS SUBMITTED: YES[] NO® BSM 1 1 1 2 1 3 1 4 1 5 1 6 1 X 8 1 9 1 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M OTHER TYPE INDEMNITY Q BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER E3 AGENT E] � I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my k edge and that all plumbing work and installations performed under the permit issued for this application will be inm ce with all P nt p vi ion f th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I JOHN MARSHALL LICENSE # 778 SIGNATURE MP [I MGF ® JPEI JGF ® LPGI 0 CORPORATION E]# PARTNERSHIP ®# LLC ®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST. CITY 131 WATER ST. STATE= ZIP 01923 TEL 1-800-322-6628 FAX CELL ; EMAIL �*Iv) HiQ ) �1 OACUL 1'L 3,- m/s/`3 -m/3/`3 a4u � X-S 4 C', e rl-wa( P-114-rlfq 0 c 3 1Y i Ri Fn v o rn M LI) En y ... to m \ \ D TT r m 1 D Ln - 5 UT o� m _ ill SIO03ll7fE 1Y ON The Commonwealth of Massachusetts Print F>�rrn Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite 100 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): EASTERN PROPANE & OIL Address: 131 WATER STREET /State/Zim DANVERS, MA 01923 Phone #: 978-750-6500 Are you an employer? Check the appropriate box: 1.21 I am a employer with 45 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. . ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.T required.] 5. ❑ We are a corporation and its 3:0 I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ .Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions. 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.0 Other GAS FITTING *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -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: ENERGI Policy # or Self -ins. Lic. #: EWGCD000080613 Expiration Date: 03/15/2014 Job Site Address: asoC1..�k 1 cc�l . ��d`5 d a` City/State/Zip: )t,, }+k A ^dMA, ANIS , Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).d 19t4 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 under the pains and penalties of perjury that the information provided above is true and correct. Phone #: 978-750-6500 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-1Personr __�-.�.__._ pt,�e #• ._._. _.__. 4 . I r NH477156 ACCOROr CERTIFICATE -OF -L I -ABI -L I TY INSURANCE DATE (MM/DD/YYYY) 3/1412013 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, sub ject.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 ' Commercial Lines — (800) 990-7465 Wells Fargo Special Risks, Inc. COMIAC- _ ---- T NAME: rFUn1"T2 DeSh2mal5 PHONE 603-559-1361 1 FAX 855-529-7684 IONoExt): AIC Na : E-MAIL donna.desharnais wellsfar o.com ADDRESS: g INSURER(S) AFFORDING COVERAGE I NAIC # 230 Commerce Way, Suite 230 _ INSURER A HDI -Gerling America Insurance Company 41343 Portsmouth, NH. 03801 INSURED INSURER B: - Eastern Propane Gas, Inc. — INSURER C : 28 Industrial Way INSURER D: - INSURER E: _ _ INSURER F Rochester, NH 03867 COVERAGES CPRTIFIr'ATF NIIMRFR• 01,5001-1:1 - REVISION NUMBER: See below. _ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 'TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH. RESPECT, TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE. INSURANCE AFFORDED BY.•THE POLICIES DESCRIBED HEREIN IS SUBJECT TO.ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR I . TYPE OF INSURANCE - I .. ADDL SUBR -. - POLICY NUMBER I POLICY EFF MM/DD/YYYY POLICY EXP - LIMITS fMM/DD/YYY.Y A � ISL GENERAL LIABILITY . - COMMERCIAL GENERAL LIABILITY ^ ICO CLAIMS -MADE � OCCUR - F-GGCDO00080613 - - 03/15/2013 03/15/2014 EACH OCCURRENCE I "a 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 250,000 MED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1,000,000 - GENERAL AGGREGATE I $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY n PRO- n LOC 1 $ A AUTOMOBILE LIABILITY j EAGCD000080613 03/15/2013 03/15/2014 I COMBINE Ea.cccdeDtSINGLE LIMIT $ 100,000 BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED BODILY INJURY (Per accident) $ PROPERTY DAMAGE I $ HIRED AUTOS AUTOS (Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB - CLAIMS -MADE 1 DED RETENTIONS. S A .WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE �I fV f OFFICER/MEMBER EXCLUDED? I� . (Mandatory in NH) NIA EWGCDOOD080613 03/15/2013 03/15/2014 x I WC STATU- OF H- T " - E.L. EACH ACCIDENT $ 1.000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT I $ 1,000,000 If yes, describe under DESCRIPT10N.OF OPERATIONS below A Excess Auto I EXAGD000080713 3/15/2013 3/1.5/2014 1soo.000excess ofS100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of coverage CERTIFICATE HOLDER CANCELLATION Any city/town in Massachusetts 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 1 ne AUuxu name and logo are registered marks of ACORD ACORD 25 (2010/05) (This mrtifimle molsms mnlfim 57]eid§ iswee m 3/14/2013) © 1988-2010 ACORD CORPORATION. All rights reserved. i01i0 Date.U.�,/..`?;1....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... �.......,.�" /� •c r�...................................... has permission to perform .>..1 ,\J (4 plumbing in the b/uildin sof. ,,.�!v 1144 ........ ............... . at .... 2.........1...�......;..... ........................ North Andover, Mass. Fee 6�.J.Y. Lic. No. .. ►.1'.......... .!..V 6............................................................. 2q 19�5�._M PLUMBING INSPECTOR Check # 11 % 1 1 ffk 14 ryt, -1 12- -:�, � �-., N N n1\W %-/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK lf,- CITY I I P,IMA DATE.- PERMIT # L u7i'� ( D JOBSITE ADDRESS S V_j� OWNER'S NAME )MK��-%9 POWNER ADDRESS _ TEL � 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL LQ EDUCATIONAL Q RESIDENTIAL 0 PRINT CLEARLY NEW: M—RENOVATION: � REPLACEMENT: 0I PLANS SUBMITTED: YES ® NOD( FIXTURES 7 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB v4 ! i i (____ I _ _ _( _.__.._..! CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM_f _ ------- !I DEDICATED GREASE SYSTEM.____J I -( _.( DEDICATED GRAY WATER SYSTEM I---_-_f f _f DEDICATED WATER RECYCLE SYSTEM I 1 .__.._._I __.._f DISHWASHER i .__..___. � ( ¢ I ! __._.� � ' DRINKING FOUNTAIN FOOD DISPOSER _-._ FLOOR/AREA DRAIN J -A __j _,_1 INTERCEPTOR (INTERIOR) __-! KITCHEN SINK VATORY PEDI'= =_.--____ ....___.....-_._W.-.-.__SOWER R OF DRAIN __J STALL ___.._f .-____ f _ _ l ._._._. ! ! -_._1 __.__._J _,__._J SERVICE / MOP SINK f __ -j ____-1 __-- ! -___.1 TOILET URINAL....___...I WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _f INSURANCE COVERAGE: I�have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY D BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 01'AGENT SIGNATURE OF OWNER OR AGENT T hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the issued permit for this application will be ince i ce with all Pertinent provision of the K4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ��' ,f'/'i� —(LICENSE # % _ ( SIGNATURE MP zi,--,JP Q CORPORATION FJI#=PARTNERSHIP LLC j COMPANY NAMEYU �%y111�171 ;I ADDRESS CITY STATE �,,,r� -` ZIP � -- - ._..._._..__ r i D21 S-I TEL % i3 FAX CELL �� EMAIL 1 N N n1\W %-/ N ❑ LLJ CL Lij w LL h t, r The Commonwealth of Massachusetts - Department of IndustrialAccidihts Office of Investigations 600 Washington Street Boston, MA. 02111 quo www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 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 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3 -Ell am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] r employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11. El Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other !Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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 #: 11 Information and Instructions y Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or lo'eal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please .fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permithicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts DepartmDnt ofladustdal .Accidents Office of Iuvestigations 600 Wasbi gton. Street Boston., MA 02111 ` QL # 617-727-4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax # 61.7-727-7749 www.mass.gov/dia ; e a O Z - Ly3431AO O (0 3 J. 1;�L�Oi � O N � 9 � ma •-CU � IIIVII�IY) F � y E -Y - p _ E (D O O W d oCLLLI .U) p oco.. >Q W a) o .W. W. > in o m e. rn o QLW U0o°o � Z pOj y c, N d J / r' 1 e (Enter construction cost for fee cal - I North Andover Fee Calculation Construction Cost 250 Clark Street 078-14 on 7/23/2014 Construct a new pre engineered building 158x60 0�1.0°TM4 . h N b 1 i �SSACHU`+ES CERTIFICATE OF USE & OCCUPANCY Building Permit Number 078-14 on 7/23/2013 Date: February 12, 2014 THIS CERTIFIES THAT THE BUILDING LOCATED ON 250 Clark Street MAY BE OCCUPIED AS new 158x60 mixed use airport service building IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: 250 Clark Street C/O W. Mansfield 250 Clark Street North Andover, MA 01845 Fee: PrePaid $100.00 Receipt: 26651 Check: 16684 f Building Inspector �j id w 0 tiN J:'���• V L 0 CL :�..>�� v c U) o > 0)r«- iv -�` C.-,; t V Q c � N O Ects o O O m i..v_n 3 m CL 0 CD a) w GOO v L rn tm 1- C _ a c = O Q �j •� N F– O y AW ujco ctsm y W 'a O O w LL •y d NC O N .�� tO Z W •� V r+ V O C V Q O�.O.OLr Q co O>:C N J .0 m2 civ o L- C o O F t w Q 0 U > 0 V) CO mc Z G cc Z W w CL W 1_- W CL w ry 0 O.. LLI 2N ,� O " `•� LLI Z �L CL N Z ( 1 a .I G T V (ZD Z R, {d{ z ��L Q Z LOU LU W rc LY! •4. p 'SWL,— = W a � �"�,ALT Lu LLI • , W V �'L• iy � to U®N76 0 C LL K LL Ln LL LL' LL m N ul tiN J:'���• V L 0 CL :�..>�� v c U) o > 0)r«- iv -�` C.-,; t V Q c � N O Ects o O O m i..v_n 3 m CL 0 CD a) w GOO v L rn tm 1- C _ a c = O Q �j •� N F– O y AW ujco ctsm y W 'a O O w LL •y d NC O N .�� tO Z W •� V r+ V O C V Q O�.O.OLr Q co O>:C N J .0 m2 civ o L- C o O F t w Q 0 U > 0 V) CO mc Z G cc Z W w CL W 1_- W CL w ry 0 O.. tiN J:'���• V L 0 CL :�..>�� v c U) o > 0)r«- iv -�` C.-,; t V Q c � N O Ects o O O m i..v_n 3 m CL 0 CD a) w GOO v L rn tm 1- C _ a c = O Q �j •� N F– O y AW ujco ctsm y W 'a O O w LL •y d NC O N .�� tO Z W •� V r+ V O C V Q O�.O.OLr Q co O>:C N J .0 m2 civ o L- C o O F t w Q 0 U > 0 V) CO mc Z G cc Z W w CL W 1_- W CL w ry 7 y M GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation, Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain - pipe/stone/fabric filter/cover and outlet connection. FRAME: Fireblock - over girls/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters - watch bearing at walls. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to plate. Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger nails. Sill plates 2-2X6 (1 PT) w/sill seal. Girls - solid brick or steel plate bearing at foundations '/ " air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations, required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances - stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior (not in soffit). Firecode S/R wood frame of "0" clearance fireplaces & stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. '/ of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces - "proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing - Smoke Chamber - Finish Smooth parging, clean joints, 8" solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36" high, Baluster max space 4" on center. Over 8' above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re -inspection fee - $30.00 (Be Ready). Certificate of occupancy required prior to occupying structure I o ~ APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION pA cocwie :new - �'9ssgCH„sE��y BUILDING PERMIT # O'� ADDRESS/LOCATION OF PROPERTY: Z5b Nw-L 1 f� Map D 16 Parcel OWD Lot Number SUBDIVISION: DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE'STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to: ` �' `� - G •rN C O (,� �(� S �' e�c•� Address: 2-5b C IPtizL ` l 4-- _ t xvu l lNG TOWN ENGINEER, SITE PLA — DRIVE -WAY REVIEW ❑ CONSERVATION PLANNINGa���a�i� DPW -WATER METER SEWER CONNECTION tj DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW SIGNATURE File: Application for OC form revised Jan 2007/2011 ArL �V�-f I b -)U, - SN rA rA - >C' 1410- C O H . i � • r�: V O .\ a m CF E CL CD '�. E • 3 cc as _ 14 � � L N a' a E •r O { *z''• G; OZ 3y QNw G O , 63 o Q L L CC •O Q CO Or cc N .V m W '0O O LL CU) LU O N C E •V - �+ V W L Q (DC i V Q O M m U) N > iE C Hcc v O N .Q O Z. no z m ca z W w a W H W CL .N w N E Z O N O � N •E da CL O woo O CL C. cp Q O 0-0 O O �z O V tU !Q = is B ve, J W ti W til I O W 1 (1 W O d (("",VV N N Lu cc co u CL LaLi co CU tilb LLJ `%1 O C C _\ 7� 1 �. 7c N O LLL LLa' LL cr I.J.. V O cn LL LL CO t% U7 C O H . i � • r�: V O .\ a m CF E CL CD '�. E • 3 cc as _ 14 � � L N a' a E •r O { *z''• G; OZ 3y QNw G O , 63 o Q L L CC •O Q CO Or cc N .V m W '0O O LL CU) LU O N C E •V - �+ V W L Q (DC i V Q O M m U) N > iE C Hcc v O N .Q O Z. no z m ca z W w a W H W CL .N w N E Z O N O � N •E da CL O woo O CL C. cp Q O 0-0 O O �z O V tU !Q = is B Poe �..��c� 2+� ?1r�r>-v � )AY GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation, Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain - pipe/stone/fabric filtedcover and outlet connection. FRAME: Fireblock - over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters - watch bearing at walls. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to plate. Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger nails. Sill plates 2-2X6 (1 PT) w/sill seal. Girls - solid brick or steel plate bearing at foundations '/ " air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances - stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior (not in soffit). Firecode S/R wood frame of "0" clearance fireplaces & stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. '/2 of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces - "proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing - Smoke Chamber - Finish Smooth parging, clean joints, 8" solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36" high, Baluster max space 4" on center. Over 8' above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exteriorgrading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re -inspection fee - $30.00 (Be Ready). Certificate of occupancy required prior to occupying structure. .J� ARCHITECTURE INTERIOR DESIGN CONSTRUCTION/DEVELOPMENT ARC O P CAMBRIDGE OFFICE Principal David Benjamin Barsky — Architect Office of the Inspector of Buildings 1600 Osgood Street North Andover, Massachusetts 01845 ATTENTION: Gerald Brown — Inspector of Buildings PERMIT #: 078-14 ADDRESS: 250 Clark Street, North Andover, MA DATE: February 5, 2014 CONSTRUCTION CONTROL - FINAL REPORT In accordance with Section 107.6 of the Massachusetts Building Code, CMR780 Massachusetts Amendments to the 8h Edition of the IBC: t DAVID R BARSKY, being a registered professional architect, certify that I have performed the necessary professional services and have been present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit. I submit that the following items have been reviewed on site and have been performed in a manner consistent with the construction documents: 1. New building enclosure. 2. Interior layout and finishing of new office space. 3. Final inspection of all other areas. 429 CHERRY STREET NEWTON, MA 02465 TEL (6 17) 4 4 8-5 8 7 2 E-MAIL: dbarskyarcop@gmail.com Office of the Inspector of Buildings 1600 Osgood Street North Andover, Massachusetts 01845 ATTENTION: Gerald Brown — Inspector of Buildings PERMIT #: 078-14 ADDRESS: 250 Clark Street, North Andover, MA DATE: December 9, 2013 CONSTRUCTION CONTROL PROGRESS REPORT ARCHITECTURE INTERIOR DESIGN CONSTRUCTION/DEVELOPMENT ARC O P CAMBRIDGE OFFICE Principal David Benjamin Barsky—Architect In accordance with Section 107.6 of the Massachusetts Building Code, CMR780 Massachusetts Amendments to the 8"' Edition of the IBC: t DAVID B BARSKY, being a registered professional architect, certify that I have performed the necessary professional services and have been present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit. I submit that the following items have been reviewed on site and have been performed in a manner consistent with the construction documents: 1. Inspection of completed new building enclosure. 2. Inspection of interior framing for new office space. 3. Pre -final inspection of all other areas. 429 CHERRY STREET NEWTON, MA 02465 TEL (6 17) 4 4 8-5 8 7 2 E-MAIL: dbarskyarcop@gmail.com Fn = JLU LU = Q Q 0 CO L 'D O LL E ) TO N v Ln p z C) z m C +' C O LL w O C T C s U C LL O z Z m J d to O C C LL O LU d z Q u v W 'Lbn O C U N to C LL C O a z Q tw O W D LL H z LLJ G o~c W W 25 LL N j m O N N }' v Y O to Fo- �( O C �o C m � .24 Nom" O= 0 Ci L 3 N Cc O' J co cc O -a m c CL Cn Ma .N c :�.. 3 i Q CL d CD 5 F+ _ �. m '40 V O C Q L L CC = O N Q F- co cc W = 'a— O O c H c 'D '� w w vCD v V co Q. CD O, z G co Z W w CL W H W CL •N w •N H W W OG W C, rA I' pw,=—m9 1pjm f'_ a O _ �s \(� ° R R _N � \ : CL R \: ai O \tivl cm � O= 0 0 V y CL 7- m •� d R L o _ 0 > 0 1•--a O tm cc o� y `~ O `•doz c'� ma _ .r 3 c o> t0— CL CL a� fo °' J !� �c 0 c � 0 � O c = Q L ku) R •a ID � m W C -0 O O M 'N '� N = aO LU:2 -W C.) LU 0m•�L 0 Q. 0 -a m co CD w 0 .O 0 = _00.00 2 z Z W w CL W H W CL v 9 E S w 0 V) L (D N C :2 cl: O Z a co t 0 LL c m a N N coZLA J Cl. J \ i ? N C O > LU o 0 Q _C uE 0 0 t 0 OC 0 � 40 0 LL V1 LL of U LL LL C� LA LL C� LL m C, rA I' pw,=—m9 1pjm f'_ a O _ �s \(� ° R R _N � \ : CL R \: ai O \tivl cm � O= 0 0 V y CL 7- m •� d R L o _ 0 > 0 1•--a O tm cc o� y `~ O `•doz c'� ma _ .r 3 c o> t0— CL CL a� fo °' J !� �c 0 c � 0 � O c = Q L ku) R •a ID � m W C -0 O O M 'N '� N = aO LU:2 -W C.) LU 0m•�L 0 Q. 0 -a m co CD w 0 .O 0 = _00.00 2 z Z W w CL W H W CL v 9 E S w 0 V) L (D N C :2 Deval Patrick Govemor Thomas G. Gatzynts, R:E. Commissioner CONSTRUCTION CONTROL DOCUMENT Project Title: AIRPORT MIXED USE SERVICE BUILDI Date: 7-18-2013 Project Location: 280 CLARK STREET, NORTH ANDOVER, MA Scope of Project NEW MIXED USE AIRPORT SERVICE BUILDING In,accordance with SECTION 116.0-116:.4.2 of"the 6`I' edition of the Massachusetts State Building Code: 'DAVID B. BARSKY 10078 I, Mass. Registration Number: being a registered professional Engineer/Architect, hereby CERTIFY that I have prepared or directly :supervised the preparation of all design plans, computations and specifications concerning:. . ©.Entire Project D Architectural ❑ Structural Q Mechanical Fire Protection ❑ Electrical Q: Other (specify): for the above named project and that to the best of my knowledge, such plans, computations and specifications :meet. the :applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services and be present on the construction site on a.regular and periodic basis to determine -that the.work is proceeding in accordance with the documents approved by the building permit and shall be respo'nisible for the following as specified in section 1`16.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit, and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required;controlled. :inaterals, 3.. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and todetermine, in general, if the work is being performed in a manner consistent with the construction documents. I shall submit periodically, in a form acceptable to the .building official, a :progress report: together with . pertinent comments. Upon completion of the work. I shall subunit to the building official a final report as to the satisfactory completion and readiness of the project for occupancy. Signature and Seal of registered professional: (MM/DDIYYYY) ACOROB CERTIFICATE OF LIABILITY INSURANCE705,20/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the' certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: (978) 744-6433 Fax: (978) 744-3575 CONTACT Deb Tournas GERALD T MCCARTHY INSURANCE AGENCY, INC 92 NORTH ST P O BOX 839 PHONEFAX (978) 744-6433 c N�. (978) 744-3575 E-MAILADDRESS debbiet@gtmccarthy.com PRODUCER 6265 SALEM MA 01970 INSURER(S) AFFORDING COVERAGE NAIC # EACH OCCURRENCE INSURED DIGIORGIO & MESSINA CONSTRUCTION INC INSURER SAFETY INS CO INSURER B : ASSOC EMPLOYERS INS CO 2 DEBUSH AVENUE, UNIT C3 MIDDLETON MA 01949 INSURER INSURER D: CLAIMS -MADE I7 OCCUR INSURER E $ INSURER F PERSONAL & ADV INJURY 1L;UVtKAUE5 CERTIFICATE NUMBER: 23512 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, INSR TYPE OF INSURANCE ADD'L SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR WVD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES $ (Ea occuren0e) CLAIMS -MADE I7 OCCUR MED. EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ PRO LOC POLICY1:1 JECT A AUTOMOBILE LIABILITY 5021302 06/20/12 06/20/13 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON -OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION WCC500520501 11/01/12 11/01/13WC STATU- OTH AND EMPLOYERS' LIABILITY YIN I ER $ E.L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? 17 N/A E.L. DISEASE -EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CI=DTII=ICATCunl noo _ _ __ —• • • •• .•.... ..v..v�•. CANCELLA I ION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER, MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: �l 4WI�ORD 1 u �l� 25 (2x 09/09) 0198E-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r � � assachUsett oard or.gpil s _ pePartment. or ding Re Public Sar licenscti�n supen . tions and Stag ety, `�THONY e`}CS �38�6 "Sor 17 GEovSs BOA RGEo�., 7 Com missioper'.1*1 nb EXpiratio 11114120, 3 CONSTRUCTION CONTROL DOCUMENT` Deval Patrick Govemor Thomas.G.. Gatzunis, P.E. Commissioner Project Title: AIRPORT MIXED USE SERVICE BU.ILDIb Date: 7-18-2013 Project.Location: 250 CLARK STREET, NORTH ANDOVER, MA Scope of Proiect:: NEW MIXED USE AIRPORT SERVICE BUI"LOING In accordance with SECTION 116.0-116.4.2 of the e edition of the Massachusetts State Building Code: l DAVID B, BARSKY Mass. Registration Number: 10079 being a registered professional Engineer/Architect, hereby CERTIFY that 1 have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [] Entire Project []J Architectural ❑ Structural Q Mechanical Fire Protection ❑ Electrical ❑ Other (specify): for the above named Proiect and that to the best of my knowledge, such plans; computations and specifications meet. the applicable. provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. Furthermore, I understand and AGREE that I shall perform. the necessary professional services and be present on the construction. site on a regular and periodic. basis to determine that.the: work is proceeding in accordance with the documents approved by the building permit and shall be..responsible for the following_ as specified in section. 116.2.2: 1. Review of shop drawings, samples and other submittals of the contractor ;as required by the construction contract documents as submitted for the building permit, and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code -required controlled ;materials. 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, in general, ifthe work is being performed in a manner consistent with, the construction documents. I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent comments. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory completion and readiness of the project for occupancy. Signature and Seal of registered professional CONSTRUCTION CONTROL CERTIFICATION Scope of Project: New construction of a shallow foundation for a Pre -Engineered metal build_ ing Project location: 250 Clark Street, North Andover MA In accordance with section 116.0 of the Massachusetts State Building Code, I; Ronald F: Bukoski Mass Reg. # 32024 being a registered professional engineer hereby certify that I will be supervising the preparation of all design plans, computations and specifications concerning: Entire Project Architectural Structural X Mechanical Electrical . Fire Protection Other; For the above named project and that, to the best of my knowledge, such plans, computations and specifications will meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and applicable laws and ordinances for the proposed use and occupancy.. I will further certify that I or my qualified representative shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in section 116.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for building permit, and approval for conformance to the design concept. 2. Review and approval of the quality control procedure for all code required controlled materials. 3. Special engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards. Pursuant to Section 116.2.2,1 or my qualified representative shall submit periodically, a progress report together with pertinent comments to the building inspector. Upon completion of the work, I or my qualified representative shall submit a final report as to the. satisfactory completion and readiness of the project for occupancy, C«r . n BIIi(OSKI CIVIL Signed: n'fdt�- No.32024 Date:tQ ��Is�r�a'`< 7/ t ! � � 7 IST Page 1 of 1 ti 43 Standard Form of Agreement Between Owner and Contractor CAP105 Page 1 of 4 This AGREEMENT is made June '' ' �', 2013 (Date) BETWEEN the Party Engaging the Services of the Contractor ("Owner"): and the Contractor: The KEYW Corporation 7740 Milestone Parkway, Suite 400 Hanover, Maryland 21076 DiGiorgio & Messina Construction Co., Inc. 2 Debush Avenue Unit C-3 Middleton, MA 01949 for the following Project: New Engineered Metal Building located at 250 Clark Street, North Andover, MA 01845, Foundation and structural plans by Wentworth Partners Associates dated May 1, 2013 as Exhibit "A", Building plans by David Barsky -Architect dated November 2012 as Exhibit `B". Site plans by Williams & Sparages dated November 28, 2012 as Exhibit "C". The Owner and Contractor agree as follows to the scope of work. To include: work in existing aircraft approach area PP and will include new drainage, parking spaces, water main, relocation of existing propane tank, all disturbed areas to be loamed and seed once work is completed. Building to consist of Ceco Building Systems Metal Building System for the hanger/shop that includes the following: 1) Primary Rigid Frame Steel 2) Secondary Steel (Purlins and Girts) 3) . Hanger Door Framed opening and support 4) Window Framed Openings with Associated Trims. 5) Complete Roofing System (Standing Seam) 6) Complete Wall Panel System (Including Trims etc) 7) Insulation package for both Roof and walls. 8) Mezzanine with beef up to be loaded on our Rigid Frames 9) Anchor Bolt Foundation loading and plan. (Stamped) 10) Stamped Plans for Approval (submitted) Building also will have mezzanine installed for future use without stairs and railings, the mezzanine will be above offices but not accessible. All of building to have concrete slab with flooring in off ce portion areas as per plan, 18' x 50' hanger door to be provided by Schweiss Bifold, building windows to be vinyl clad bypass sliding units, all partition construction to be steel stud insulated with s windows tape, sanded and painted. Allowances provides for materials fmishes on attached Schedule of Values made apart herein as Exhibit "D". • Sprinkler System — supply and install standard wet sprinkler system to building code. ,at Standard Form of Agreement Between Owner and Contractor CAP) OS Page 2 of 3 • Electrical — Complete wiring to include: Office area install — 77 — 2 x 4 — 3 lamp drop in T8 light fixtures prismatic lenses, 14 — 3 way switches for lighting, 16 single pole switches, 7 exit / emergency light units, 6 exit signs, 100 - 120 volt outlets, dedicated circuit for alarm system, dedicated circuit for phone/data systems, 25 phone locations, 25 data locations, 14 exterior metal halide wall packs, 1 photo cell/relay systems for exterior lights, 1 fluorescent light at building passage way. 10 cord drops for open table area, 2 GFCI protected outlets in bathrooms, 3 GFCI protected outlets in Kitchen area, 2 wiring of fans in bathrooms, 4 wiring air handlers, 4 wiring A/C condensers. Machine shop install — 14 — 2 x 4 — 3 lamp drop in T8 light fixtures, 4 3 way switches, 2 exit/emergency light units, 5 3 phase 20 amp outlets for equipment, 9 120 volt 20 amp outlets for equipment, Garage Area Install — 15 Fluorescent T8 low bay light fixtures (must have 5' above aircraft),4 single pole switches for lighting, 10 — 120 volt outlets located a minimum of 5' from aircraft, 3 outlets for break/shear/drill press. Power and utility ducts — 2 - 3" empty ducts for phone/data from area of existing power transformer to machine shop wall near kitchenette, 1 400 amp 208/120 volt 3 phase service from existing transformer location to machine shop wall near kitchenette. Metering at transformer utility. Install 3 — 200 amp feeders to sub panels. • HVAC — Install two new 100,000 BTU gas furnaces converted to propane, Install two new 4 ton AC systems, all the duct. Machine shop HVAC and C&C Scrubber allowance of $4,500.00. • Plumbing - provide and install new plumbing and fixtures for two new water closets, fixtures to include three (3) new toilets, one urinal, two (2) new sinks, one (1) forty gallon electric hot water heater. Install one (1) drinking fountain (water bubbler). • Garage Heaters — Modine heater for hanger area, modine type PDP200 side wall vented. • Gas Piping — gas piping to modine heater and furnace. • Fire alarm — work to be done by existing fire alarm company Active Fire Alarm with an allowance of $12,000.00. • Ceilings — 2'x 4' Chicago suspended ceiling track with a 2' x 4' 769 cortega square lay -in ceiling tile. • Doors — hollow metal frame's with a maple/birch wood door and brush nickel hardware. • Flooring — bathroom floors, office space and hallways $9,000.00 allowance for carpet and VCT, rolling table area ESD flooring $8,200.00 allowance. • Painting — two coats of paint on hollow metal frames, wood doors prefinished natural clear finish, walls will be primed one (1) coat with two (2) coats of finish. • Bath accessories — mirrors, toilet paper holder, and bathroom stall partitions standard off white finishes. The following items are excluded from the contract: Exclusions: • Engineering and testing and related fees. • Winter conditions. • Any and all soil testing and compaction. ■ Permits and Fees allowance in schedule of values • Removal and disposal of any hazardous or contaminated soils • Removal of boulders or other obstructions greater than one (1) Cy ndwater or other material. • Work shall commence on or before • Any and all public utility and service fees for water, electric and gas, L Standard Form of Agreement Between Owner and Contractor CAP105 Page3of4 • Ledge removal • Exporting of materials. • Filtering and treatment of groundwater encountered. • As -built plans stamped by a registered professional engineer or surveyor. • Removal or relocation of any existing utility poles, wires, transformers or light poles. • Irrigation system. ■ Gas work. ■ Fire Extinguishers ■ Foam system or dry system in sprinkler. Qualifications: ■ OWNER shall provide sanitary facilities at no additional cost. • All utilities will be installed to within five (5) feet of the face of foundation, unless otherwise noted in the scope of work. • OWNER shall provide DiGiorgio & Messina Construction with adequate access. • This contract assumes that the project is open shop and non -prevailing wage. • This contract is based on working a five (5) day week, Monday through Friday, 7:00 AM to 3:30 PM. If directed to work beyond these times or during off shift periods, the OWNER shall reimburse DiGiorgio & Messina Construction for the additional cost of doing so. ARTICLE 1 THE CONTRACT DOCUMENTS The Contractor shall complete the Work described in the Contract Documents for the project. The Contract Documents consist of: .1 this Agreement signed by the Owner and Contractor; including plans Exhibits A, B, C, Schedule of Values referenced in Exhibit "D" and lien waiver Exhibit "E" .2 CAP205 Document, General Conditions of the Contract; .3 written change orders or orders for minor changes in the Work issued after execution of this Agreement. ARTICLE 2 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION DATE Job to start upon receipt of permits. Substantial completion of job to be twenty — four (24) weeks. ARTICLE 3 CONTRACT SUM 3.1 Subject to additions and deductions by Change Order, the Contract Sum is: One million five thousand nine hundred twenty one dollars and sixty eight cents ($1,005,921.68). ti Standard Form of Agreement Between Owner and Contractor CAP 105 Page 4 of 4 3.2 The Contract Sum shall include all items and services necessary for the proper execution and completion of the Work. Lien Waivers for subcontractors will be completed and supplied. No retainage to be held. ARTICLE 4 PAYMENT 4.1 Based on Contractor's Applications for Payment, the Owner shall pay the Contractor as follows: Payments shall be made within fifteen (15) days of application of payment request. First payment due upon signing of contract and ordering of metal building, monthly applications thereafter submitted beginning of the month based on work completed. 4.2 Payments due and unpaid under the Contract Documents shall bear interest from the date payment is due at the rate of 5%, or in the absence thereof, at the legal rate prevailing in Massachusetts. in the event that the Owner defaults on payment the Contractor shall be entitled to recover from the Owner its attorney's fees, expert fees and related costs. (Usury and requirements under the Federal Truth in Lending Act, similar state and local consumer credit laws and other regulations at the Owner's and Contractor's principal places of business, the location of the Project and elsewhere may affect the validity of this provision.) This Agreement entered into as of the day and year first written above OWNER CONTRACTOR Anthony Vessina Jr., President 2 Debush A e Unit C-3 Middleton MA 01949 . A, General Conditions of the Contract for Construction ARTICLE 1 GENERAL PROVISIONS 1.1 THE CONTRACT The Contract represents the entire and integrated agreement between the parties and supersedes prior negotiations, representations or agreements, either written or oral. The Contract may be amended or modified only by a written modification executed by the Owner and Contractor. 1.2 THE WORK The term "Work" means the construction and services required by the Contract Documents, and includes all other labor, materials, equipment and services provided by the Contractor to fulfill the Contractor's obligations. 1.3 INTENT The intent of the Contract Documents is to include all items necessary for the proper execution and completion of the Work by the Contractor. The Contract Documents are complementary, and what is required by one shalt be as binding as if required by all. 1.4 BOND Contractor shall furnish and keep in force throughout the contract period, a bond in the amount of $0.00. The bond shall name the Owner as obligee and shall be in such form and with such sureties as Owner may approve. Such bond is required before the Contract begins. 1.5 LIEN WAIVER Contractor shall provide lien waivers, in the form of attached Exhibit "E", with applications for all Payments, including, but not limited to, Progress Payments and Final Payment, ARTICLE 2 OWNER 2.1 INFORMATION AND SERVICES REQUIRED OF THE OWNER 2. LI If reasonably requested by the Contractor, the Owner shall furnish and pay for a survey and a legal description of the site. 2.2 OWNER'S RIGHT TO STOP THE WORK If the Contractor fails to correct Work which is not in accordance with the Contract Documents, the Owner may direct the Contractor in writing to stop the Work until the correction is made. 2.3 OWNER'S RIGHT TO CARRY OUT THE WORK If the Contractor defaults or neglects to carry out the Work in accordance with the Contract Documents and fails within a seven day period after receipt of written notice from the Owner to correct such default or neglect with diligence and promptness, the Owner may, without prejudice to other remedies, correct such deficiencies. In such case, a Change Order shall be issued deducting the cost of correction from payments due the Contractor. ARTICLE 3 CONTRACTOR 3.1 EXECUTION OF THE CONTRACT Execution of the Contract by the Contractor is a representation that the Contractor has visited the site, become familiar with local conditions under which the Work is to be performed and correlated personal observations with requirements of the Contract Documents. SUPERVISION AND CONSTRUCTION PROCEDURES 3.2. The Contractor shall supervise and direct the Work, using the Contractor's best skill and attention. The Contractor shall be solely responsible for and have control over construction means, methods. techniques, sequences and procedures, Subcontractors and for coordinating all portions of the Work. 3.3 INDEPENDENT CONTRACTORS The Contractor shall perform the Work as an independent contractor. The Contractor, its employees, subcontractors, agents and representatives are not employees of Owner, and no part of this Agreement shall be construed to represent any employer/employee relationship. 3.3 LABOR AND MATERIALS 3.3.1 Unless otherwise provided in the Contract Documents, the Contractor shall provide and pay for labor, materials, equipment, tools, utilities, transportation, and other facilities and services necessary for proper execution and completion of the Work. 3.3.2 The Contractor shall deliver, handle, store and install materials in accordance with manufacturers' instructions. 3.4 WARRANTY The Contractor warrants to the Owner that: (1) materials and equipment furnished under the Contract will be new and of good quality unless otherwise required or permitted by the Contract Documents; (2) the Work will be free from defects not inherent in the quality required or permitted; and (3) the Work will conform to the requirements of the Contract Documents. Contractor shall warrant all materials incorporated into the building from defect as well as the workmanship performed by or on behalf of Contract for a period of one (1) year commencing upon turnover to Owner. The provisions of this Article 3.4 shall apply to Work done by Subcontractors, as well as Work done by direct employees of Contractor, and are in addition to any other remedies or warranties provided by law. 3.5 PERMITS, FEES AND NOTICES 3.5.1 The Contractor shall obtain and pay up to allowance for the building permit and other permits and governmental fees, licenses and inspections necessary for proper execution and completion of the Work. 3.5.2 The Contractor shall comply with and give notices required by agencies having jurisdiction over the Work. If the Contractor performs Work that it knows, or reasonably should know, to be contrary to laws, statutes, ordinances, building codes, and rules and regulations without notice to the Owner, the Contractor shall assume full responsibility for such Work and shall bear any attributable costs, including both direct and indirect costs suffered by Owner. Excluding therefrom any existing conditions outside of the scope of work which are not part of this contract. JCLV 3.6 USE OF SITE The Contractor shall confine operations at the site to areas permitted by law, ordinances, permits, the Contract Documents and the Owner. 3.7 CUTTING AND PATCHING The Contractor shall he responsible for cutting, fitting or patching required to complete the Work or to make its parts fit together properly. 3.8 CLEANING UP The Contractor shall keep the premises and surrounding area free from accumulation of debris and trash related to the Work. The premises will be turned over broom cleaned. ARTICLE 4 CHANGES IN THE WORK 4.1 After execution of the Contract, changes in the Work may be accomplished by written Change Order.. The Owner, without invalidating the Contract may order changes in the Work within the general scope of the Contract consisting of additions, deletions or other revisions, the Contract Sum and Contract Time being adjusted accordingly, as mutually agreed to by owner and Contractor per the written Change Order. Such written Change Order shall provide for an extension of the delivery date, as reasonably determined by the Owner and agreed to by Contractor. 4.2 A Change Order shall be a written order to the Contractor signed by the Owner and acknowledged by Contractor to change the Work, Contract Sum or Contract Time. 4.3 DIFFERING SITE CONDITIONS: If concealed or unknown physical conditions are encountered at the site that differ materially from those indicated in the Contract Documents or from those conditions ordinarily found to exist, the Contract Sum and Contract Time shall be subject to equitable adjustment. 4.3.1 Upon discovery of said aforementioned "Differing Site Condition" the Contractor shall promptly, and before the conditions are further disturbed, give written notice to the Owner of (1) subsurface or latent physical conditions at the site which differ materially from those indicated in this contract. or (2) unknown physical conditions at the site, of an unusual nature, which differ materially from those ordinarily encountered and generally recognized as inhering in work of the character provided for in the contract. 4.3.2 The Owner shall investigate the site conditions promptly after receiving the notice. If the conditions do materially so differ and cause an increase or decrease in the Contractor's cost of, or the time required for, performing any part of the work under this contract, whether or not changed as a result of the conditions, an equitable adjustment shall be made under this clause and the contract modified in writing accordingly. Such writing shall provide for an extension of the delivery date, as reasonably determined by the Owner, as well as any changes in cost. . 4.3.3 No request by the Contractor for an equitable adjustment to the contract under this clause shall be allowed, unless the Contractor has given the written notice required; provided, that the time prescribed in (a) above for giving written notice may be extended by the Owner. 4.3.4 No request by the Contractor for an equitable adjustment to the contract for differing site conditions shall be allowed if made after final payment under this contract. k .. ARTICLE 5 PAYMENTS AND COMPLETION 5.1 CONTRACT SUM The Contract Sum stated in the Agreement, including authorized adjustments, is the total amount payable by the Owner to the Contractor for performance of the Work under the Contract Documents, 5.2 APPLICATIONS FOR PAYMENT 5.2.1 The contractor shall submit an application pursuant to the terms of the contract and be paid by owner within fifteen (15) working days unless otherwise stated in contract. 5.3 PROGRESS PAYMENTS 5.3.1 The Contractor shall promptly pay each Subcontractor and material supplier, upon receipt of payment from the Owner, out of the amount paid to the Contractor on account of such entities' portion of the Work. 5.3.2 The Owner shall not have responsibility for the payment of money to a Subcontractor or material supplier. 6.0 SU13STANTIAL COMPLETION 6.1 Substantial Completion is the stage in the progress of the Work when the Work or designated portion thereof is sufficiently complete in accordance with the Contract Documents so that the Owner can occupy or utilize the Work for its intended use. 6.2 FINAL COMPLETION AND FINAL PAYMENT 6.2.1 Upon receipt of a final Application for Payment, the Owner will inspect the Work. If the Owner concludes, after inspection, that the Work is complete and reasonably complies with the scope set out in the Contract Documents, and complies with any and all applicable permit requirements, the Owner shall issue a final certificate demonstrating acceptance of the Work. Only after such certificate is issued shall final payment become due. 6.2.2 For the purposes of this Contract, Phase 1 shall mean all work relating to the front office, the restrooms that are adjacent to the kitchen, the kitchen, and the storage/copy room.* Phase 2 shall mean all remaining work. *As further illustrated on the plan attached hereto and incorporated herein. 6.2 .2 Acceptance of final payment by the Contractor, a Sub -contractor or material supplier shall constitute a waiver of claims by that payee except those previously made in writing and identified by that payee as unsettled at the time of final Application for Payment. ARTICLE 7 PROTECTION OF PERSONS AND PROPERTY, INDEMNITY 7.1 SAFETY PRECAUTIONS AND PROGRAMS The Contractor shall be responsible for initiating, maintaining and supervising all safety precautions and programs, including all those required by law in connection with performance of the Contract. The Contractor shall promptly remedy damage and loss to property caused in whole or in part by the Contractor, or by anyone for whose acts the Contractor may be liable, and shall refund to Owner any reasonable attorney's fees or other related costs associated with such damage and/or loss caused by Contractor or those Contractor is liable for. 7.2 The Contractor shall indemnify and hold harmless the Owner and its respective officers, agents and employees from and against any loss, claim, damage, liability, and demands, on account of injury, loss or damage of any kind whatsoever, which arise out of or are in any way connected with this Contract, P " � rt- except to the extent any such claim stems from the acts or omissions of any of the Owner's officers, agents and employees. Such indemnity shall include such injury, loss, or damage which is caused, or is alleged to be caused, in whole or in part by, any action or fault of the Contractor and its employees, representatives or agents, as well as any of its Subcontractors. 7.3 The Contractor shall defend, at its sole expense, against any such liability, claims or demands, and shall assume all costs and expenses related thereto, including, but not limited to, attorneys' fees. In the event that Contractor does not exercise its authority to assume the sole defense, Contractor shall reimburse the Owner for all of its reasonable defense costs, including, but not limited to, attorneys' fees. 7.4 Notwithstanding the provisions of this Article 7, the Owner acknowledges that the Contractor does not have complete control over the Construction Site. Owner will continue to operate its business at the Construction Site during the term of this Agreement. Accordingly, Contractor's indemnification shall not extend to any loss, claim, damage, liability, and demands on account of injury, loss or damage of any kind whatsoever, which arise out of or are in any way connected with or attributable to any act, or omission of Owner, Owner's agents, officers and employees, unless such loss, claim, damage, liability and/or demand arises out of or is in any way connected with or attributable to any act or omission of Contractor. ARTICLE 8 MISCELLANEOUS' PROVISIONS 8.1 ASSIGNMENT OF CONTRACT Neither party to the Contract shall assign the Contract as a whole without written consent of the other, except that either Party may assign this Agreement without consent to any operating subsidiary, controlled affiliate of the assigning Party, or in the event of a change of control of a Party, or the sale of substantially all the business of a Party as part of a corporate merger, share acquisition, corporate reconstruction, spin-off, rearrangement or similar change. 8.2 TESTS AND INSPECTIONS 8.2.1. Tests. inspections and approvals of portions of the Work required by the Contract Documents or by laws, ordinances, rules, regulations or orders of public authorities having jurisdiction shall be made at an appropriate time. 8.2.2 The Owner shall pay for tests except for testing Work found to be defective for which the Contractor shall pay. 8.3 GOVERNING LAW The Contract shall be governed by the laws of the Commonwealth of Massachusetts. 8.4 INSURANCE 8.4.1 Contractor's Liability Insurance. Contractor agrees to keep in force, at Contractor's own expense during the entire period of construction on the project, and shall cause any Subcontractor of the Contractor to procure and keep in force such insurance as will protect Contractor and Owner from claims (i) under Workmen's Compensation and other employee benefit laws; (ii) for bodily injury and death; and (iii) for property damage that may arise out of the work under this Agreement, whether directly or indirectly performed by the Contractor, or directly or indirectly performed by the Subcontractor. The minimum liability limits of such insurance shall be $1,000,000/$2,000,000 general liability coverage. Contractor shall furnish Owner with a Certificate of Insurance from the company issuing the aforementioned policy of insurance, certifying that Contractor has such insurance in force. 8.4.2 Owner's Liability Insurance. The Owner shall be responsible for and at the Owner's option may maintain such insurance as will protect Owner from Owner's contingent liability to others for damages because of bodily injury, including death, which may arise from operating under this Agreement, and any other liability for damages which the Contractor is required to insure under any provisions of this Agreement. 8.4.3 Owner's All -Risk Insurance. The Owner shall effect and maintain insurance against all risks of direct physical loss upon the entire structure on which the Work of this Agreement is to be done to one hundred percent (100%) of the insurable value thereof. Such policy shall include the interest of the Owner, Contractor, Subcontractor and any Sub -Subcontractors in the Work and shall insure against fire, theft, extended coverage, vandalism and malicious mischief. A certificate of such insurance shall be filed with the Contractor. 8.4.4 Attorney's Fees: In the event of a dispute between the Parties under this Agreement, the Prevailing Party shall be entitled to recover from the other Party its attorney's fees and related costs. 8.5 SEVERABILITY AND WAIVER Whenever possible, each provision of this Agreement shall be interpreted in such manner as to be effective and valid under applicable law, but if any provision of this Agreement is held to be prohibited by or invalid under applicable law, such provision shall be ineffective only to the extent of such prohibition or invalidity, without invalidating the remainder of this Agreement. A waiver by either Party of a default or breach of a particular provision of this Agreement or the failure of a Party to insist upon strict adherence to any provision of this Agreement on one or more occasions will not be construed as a waiver or deprive that Party of the right thereafter to insist upon subsequent adherence to that term or any other provision of this Agreement. 8.6 SURVIVAL The following provisions shall survive the termination of the Contract: Section 1.4, Section 2.3, Section 3.4, Article 5, Article 7, Article 9, Article 10, and Article 11. 8.7 NOTICES All notices and other communications provided for in this Contract shall be in writing and shall be sufficiently given if made (i) by hand delivery or by facsimile, or (ii) by reputable express courier service (charges prepaid), or by registered or certified mail (postage requested) to the address for each Party set forth on page one (1 of the Standard Form of Agreaid and return ement between Owner and Contractor. 8.9 AUTHORITY; COUNTERPARTS Each person signing this Agreement represents and warrants that he or she is duly authorized and has legal authority to execute and deliver this Agreement. This Agreement may be executed in any number of counterparts, each of which shall be deemed to be an original instrument and all of which together shall constitute a single agreement. 8.10 ENTIRE AGREEMENT This Agreement constitutes the entire agreement between the Parties and supersedes any understandings, agreements, or representations by or between the Parties, written or oral that may relate in any way to the subject matter hereof. This Agreement shall be binding upon and inure to the benefit of the Parties hereto, their respective successors and permitted assigns. ARTICLE 9 DELIVERY: TIME IS OF THE ESSENCE Delivery requirements are essential to the success of the Owner. Failure to provide the Work in the prescribed period of time as defined by the Contract will result in losses to the Owner, including hangar rental fees, rent, and all associated fees therewith, as well as other potential direct and consequential losses. Contractor shall be liable for all such direct and consequential losses, including but not`aimited to the aforementioned, for each calendar day that the Work is not completed after the delivery date. 9.1 .1 If the contractor is delayed at any time in progress of the Work by, by labor disputes, fire, unusual delay in deliveries, abnormal adverse weather conditions not reasonably anticipatable, unavoidable casualties, delay in payment or other breaches under this Agreement by Owner,or any causes beyond the Contractor's control, or by other causes which may justify delay, then the Contract Time shall be extended by Change Order for such reasonable time as the parties may determine. 9.2 LIQUIDATED DAMAGES 9.2.1 Owner and Contractor recognize that time is of the essence and failure of the Contractor to complete the Work within the time prescribed herein, plus any permitted extensions by Change Order or writings relating to Article 4.3„ will result in the Owner suffering financial loss. In the event that the Contractor fails to complete the Work by the date prescribed herein, plus any permitted extensions pursuant to Change Orders or writings related to Article 4.3„ the Owner and Contractor agree that as liquidated damages, and not as a penalty, for any such delay in completion of the Work, the Contractor shall be required to pay the Owner in amounts consistent with those stated in Section 9.2.3. Such payments shall be for the passing of each calendar day that passes after the date upon which final completion of the Work was due. Owner may, at its own option, either deduct such amount of liquidated damages from any amounts due to Contractor or collect such monies due from the Contractor. 9.2.2 Damages for failure to complete the Work as scheduled are uncertain in amount and difficult to ascertain, and therefore Contractor acknowledges that it will be liable to pay the Owner such amounts as set forth herein, which both Owner and Contractor acknowledge as reasonable, as fixed and agreed upon damages for failure to complete the Work as scheduled, and not as a penalty. 9.2.3 In the event that the Contractor has not achieved Substantial Completion of the Work on or before the delivery date, then Contractor shall pay to Owner liquidated damages as follows: $350.00 per day for each calendar day or a portion thereof that Contractor has not achieved Substantial Completion of the Work. ARTICLE 10 TERMINATION OF THE CONTRACT 10.1 TERMINATION BY THE CONTRACTOR If the Owner fails to make payment when due or substantially breaches any other obligation of this Contract, following seven days written notice to the Owner, the Contractor may terminate the Contract, provided however, that Owner shall have the opportunity to cure such breach by remitting payment within the seven day period following the notice and recover from the Owner payment for Work executed and for proven loss with respect to materials, equipment, tools, construction equipment and machinery, including reasonable overhead, profit and damages. 10.1.1 The rights and remedies set forth in this Section 10.1 are in addition to any right to damages or other rights and remedies permitted by law. 10.2 TERMINATION BY THE OWNER �,.� 10.2.1 The Owner may terminate the Contract if the Contractor: 1. persistently or repeatedly refuses or fails to supply enough properly skilled workers or proper materials; 2. fails to make payment to Subcontractors for materials or labor in accordance with the respective agreements between the Contractor and the Subcontractors; or 3. disregards laws, ordinances, or rules, regulations or orders of a public authority having jurisdiction; 4. is otherwise guilty of substantial breach of a provision of the Contract Documents. 10.2.2 If any of the above reasons exist, the Owner, may without prejudice to any other rights after giving the Contractor and the Contractor's surety, if any, seven days written notice, terminate employment of the Contractor and may: 1. take possession of the site and of all materials thereon owned by the Contractor; 2. finish the Work by whatever reasonable method the Owner may deem expedient. 10.2.3 When the Owner terminates the Contract for one of the reasons stated in Subparagraph 10.2.1, the Contractor, shall not be entitled to receive further payment until the Work is finished. 10.2.4 If the unpaid balance of the Contract Sum exceeds costs of finishing the Work, such excess shall be first applied against any other amounts for which the Contractor is liable, and any remaining excess thereafter shall be paid to the Contractor. 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Qm H«°•D aac E E Q to c J u m o nwcL 0o om Zmcv r i0ao, a 6/ - M'Z n u ' : Q m v uo Otw av' = c c vm cca�'L` o 00LL- CL a t m u = ii ii f0 to to Q N c O .�• '4l tL0 0 't0 0C = d = E oo c to a l7 C7 vi 2 v .� w O a a V u U a ao ii � w to w w Q EXHIBIT "E" FINAL RELEASE, CERIFICATION AND INDEMNIFICATION AGREEMENT Owner: The KEYW Corporation and its predecessors, successors, employees, agents and assigns, Contractor: DiGiorgio & Messina Construction Co. Inc. and its predecessors, successors, employees, agents and assigns, Subcontractor and its predecessors, successors, employees, agents and assigns, Project: 250 Clark Street North Andover, MA 01845 In consideration of payment in full paid to Subcontractor by Contractor, and for other good and valuable consideration, the receipt and sufficiency of which hereby acknowledged, Subcontractor remises, releases and forever discharges the Owner, the Contractor, the Surety, and the Project from and against any and all debts, demands, actions, causes of actions, suits, accounts, covenants, contracts, damages, liens (including mechanic's liens), and any and all claims, demands, and liabilities, of every name and nature, both in law and equity, which the Subcontractor now has, ever had, or ever will have against the Owner, the Contractor, the Surety, or the Project, in any way relating to, arising out of or resulting from the Project, including but not limited to claims for payment for any work and labor performed, or either, or any benefits or assessments related thereto, claims for any materials, equipment or services furnished by the Subcontractor, and claims for any materials, equipment, services, supplies, and insurance furnished to, for or through the Subcontractor in connection with the Project. Subcontractor also remises, releases and forever discharges the Owner, the Contractor, the Surety, and the Project from and against any and all debts, demands, actions, causes of action, suits, accounts, covenants, contracts, damages, liens, and liabilities of every name and nature, both in law and equity, known or unknown. Subcontractor certifies and warrants that all persons or entities that furnished materials or equipment, and performed labor, or either, to, for or through the Subcontractor in connection with the Project have been paid in full and the Subcontractor further certifies and warrants that all taxes, benefits, assessments and bills of any other descriptive title for labor performed, materials furnished and equipment supplied to, for or through the Subcontractor in connection with the Project have been paid in full. Subcontractor agrees to indemnify and save harmless the Owner, the Contractor, the Surety, and the Project from all liabilities, damages, costs and expenses incurred, including reasonable attorney fees, for or on account of or in any way growing out of claims for payment for any work and labor performed, or either, or any benefits or assessments related thereto, and any materials, equipment, services, supplies and insurance furnished to, for or a through the Subcontractor in connection with the Project. The undersigned hereby represents and warrants to the Owner, Contractor, and the Surety that he has all requisite power and authority to execute this Final Release, Certification and Indemnification Agreement on behalf of the Subcontractor and that this Final Release, Certification and Indemnification Agreement is binding on the Subcontractor in accordance with its terms. Signed under the penalties of perjury this , day of 2013 Notary Public: (Print Name of Subcontractor) (Signature of Person Signing for Subcontractor) (Print Name of Signer) Its: (Print Title of Signer) Duly Authorized Commonwealth of On this _ day of , 2013, before me, the undersigned notary public, appeared roved to me through satisfactory evidence of identification, which was p , to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he signed it voluntarily for its stated purpose. Official Signature and Sea] of Notary My Commission Expires: 0 IR Conser atlon Services Group 50 Washington Street Suite 3000 Westborough, MA 01581 t 508.836.9500 f 508.870.5975 www.csgrp.com IECC 2009 Duct Tightness Verification Pass / Fail Date: June 3rd, 2013 Permit No.: Street Address: 96 Compass Point North Andover, MA 01845 Total conditioned floor area: 2,444 square feet HERS Rater: Conservation Services Group — Nicholas Abreu Certification Number: 8368122 Si nature: Builder: Trust Construction Builder Contact: Tim Barlow HVAC Contractor AJ Heating and Cooling Postconstruction test ❑ Total Leakage —12 cfm/100 ft' maximum allowed ❑ Leakage to outdoors — 8 cfm/100 ft2 maximum allowed Testing result: dm/100 ft2 Rough -in test Total leakage Air Handler Installed? ® Yes — 6 cfm/100 ft2 maximum allowed ❑ No — 4 cfm/100 ft2 maximum allowed Testing result: 2.7 cfm/100 ft2 Conservation Services Group © 2012 UM t f BUILDD14 Ir / 1 PROPOSOD 'f UPLAND ' BUILD;At�3 "C" CQEN SPACE a � EXtSTIXG FOU TIMON 6 / r— C24 SUMNO • * ratr -,\C23 UPc.AND C22 OPEN SPACE '`/ C21 a �' C21 ' V' C18 C17 CERTIFIED PlPLAN C20' Kn an= um mrm= 3iS=nY U= M CA's== SlfDM= M= 61 na RPrn' VM F�is KA ra fW 'DO PAF. TK rt4L' 'r= AS :MMM r= F�4t MAN M Z=* CHITS r== tn== M PMUI �E nacre =l 0 r¢i°� Mml it s. anttu a trP M Ct3tTD"ICJtT= 32 ice#-IMNSF 3y:Ant. 03 n FtCtTI!£it W= vial Ms FVY3= TMT TRF IIVCG`. =l SHOW MS r=9 =t=ATMY Fl== AY Tw VV= M Tm rix PATS a tAtm- P�a FATr.+ It C r i FOUND 1 1LON.AS— UIL ! ,,, BUILDI1' G 'W MERRIMAC CONDOMINIUMS ROUTE 114, NORTH ANDOVER, MASS, PROJECT ND NAND13 SCALE, 1'=4111 DRAWN BY, PCG I DATE, 3!4113 CHECKED BY, SC REVIUSED SHTs 1 Of, I c Conser atlon Services Group 50 Washington Street Suite 3000 Westborough, MA 01581 t 508.836.9500 f 508.870.5975 www.esgrp.com IECC 2009 Duct Tightness Verification Pass / Fail Date: June 3rd, 2013 Permit No.: Street Address: 98 Compass Point North Andover, MA 01845 Total conditioned floor area: 2,444 square feet HERS Rater: Conservation Services Group — Nicholas Abreu Certification Number: 8368122 Si nature: Builder: Trust Construction Builder Contact: Tim Barlow HVAC Contractor AJ Heating and Cooling Postconstruction test ❑ Total Leakage —12 cfm/100 ft2 maximum allowed ❑ Leakage to outdoors — 8 cfm/100 fe maximum allowed Testing result: cfm/100 ft, Rough -in test Total leakage Air Handler Installed? ® Yes — 6 cfm/100 fe maximum allowed ❑ No — 4 cfm/100 fl maximum allowed Testing result: 2.8 Cfm/100 ft2 Conservation Services Group © 2012 Pep Ma HLC==/ umm irrr a LOT a % U P L A N D OPEN SPACE EXWNa FOUXMTtON C24 BUcLMNO W C23 U P L A N 0 ,�' C22 cpEh sPac� C21©ol i r � PROM r , BU1La:X4" PROPMED EitJPl&A G T C21 • -�' • C18 C17 CERTIFIED PufrpLAN C20 KouumWE)='"P- T "!Y Lt= &0 CASCF=M MOM= M= W M ir-r=VM �m FLt= FM TM PM=. TfC MCCATIM AS SHM M r=2 IM MAX AStri' == tozcmmm KMA=m STi=m= m QTY LIQ WPM .m�� PIP TKm folT13=Tm n res-TT:e'ETmAmL = n ftxx m K= wrnr na F=VMM T!t'3T TFC Da=== VVWV WAS rM M ACMnATELY nrXMM VY FOUNDATION.A —BUILT . UILDING 'Aa mr-piadtM-Fo MERRIMAC CONDOMINIUMS ROUTE 114, NORTH ANDOVER, MASS, rot PROJECT NDNAND13 SCALE., 11=40' + DRAWN BYl PCG DATE, 3/4/13 x •� CHECKED BYE SC SHTr 1 REMSEDi OF, 1 50 Washington Street Suite 3000 Westborough, MA 01581 t 508.836.9500 Conser atlon f 508.870.5975 Services Group www.csgrp.com IECC 2009 Duct Tightness Verification Pass / Fail Date: June 3rd, 2013 Permit No.: Street Address: 100 Compass Point North Andover, MA 01845 Total conditioned floor area: 2,444 square feet HERS Rater: Conservation Services Group — Nicholas Abreu Certification Number: 8368122 Si nature: Builder: Trust Construction Builder Contact: Tim Barlow HVAC Contractor J&J Heating and Cooling Postconstruction test ❑ Total Leakage —12 cfm/100 ft2 maximum allowed ❑ Leakage to outdoors — 8 cfm/100 ft2 maximum allowed Testing result: Rough -in test Total leakage Air Handler Installed? ® Yes — 6 cfm/100 ft2 maximum allowed ❑ No — 4 cfm/100 ft2 maximum allowed cfm/100 ft2 Testing result: 3.9 cfm/100 ft2 Conservation Services Group © 2012 til 000, be "LX= FMOTM IXVXSXW.Rk Assmu"4LOTA fu UPLAND Ak OPEN SPACE b EXRMNG FOUNDAMN Cz4 ,, U P L A N D ow -OPEN SPACE C21 CERTIFIED Pw3fo"PLAN C20 No oma use usro r— PRa3omsunme lir ` 1 ,�JI�iJ �•- -.t`.r .•tr r•t � �.(.. ...- '�. •ail r: -,. .:•."...� dP •s:'Jsi �.J. i• .-♦ /.+ i♦ •.•i4 ;;i t :.t- I!. •.J .�i') 't I4i.AL '.1. •: •.i•: It'xi*;7 '+Ff -'JJMyJ ��!}(t'a i Y J'�.b •( M'7 Y op C18 C17 FOUNDATION..A,S-BUILT...BUILDING 'tA& MERRIMAC CONDOMINIUMS ROUTE 11.4, NORTH ANDOV'FR, MASS, PROJECT ND NAND1.3 SCALE- I,'a4G" DRAWN BY, PCG DATE, 3/411.3 CHECKED BYl SC SNT# 1. IREVIUSED OF I Dimension Y510 Number of Stories: Total square feet of floor area, based on Exterior dimensions. �fS l� Total land area, sq. ft.: -1 Lf -I j 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) ❑ Notified for pickup - Date ...... __............ ..__............ _—.. ____ _ __._ _.._...... __............ ..._...... _. _.._............... ...^............ _.._._--- ____.... _._.._..........._.._.............. _._... Doc.Building Permit Revised 2012 Location -2-.6w � No. '?7/-/— 1,-3� Check Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $2/J•�'d x Foundation Permit Fee $ Other Permit Fee $-- TOTAL _TOTAL $ ' e„ 3 U Building Inspector Enter construction cost for fee cal - North Andover F@e Calculation Construction Cost $ 259,148.00 m $ - $ 3,109.78 Plumbing Fee $ 388.72 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 388.72 Total fees collected $ 3,987.22 250 Clark Street 874-13 on 6/14/2013 Repair and Reno to Existing Office Space @ Airport C O H J 2 L.L o Q m L U "6 O LL E u N j..i O_ to o cc N z z mJ C O C : L.L tlO 7 w C E U _ LL cc O H Z z CC G d 00 7 OC _ LL a: O Z W W W 7 d' U (n _ LL C O a z OO 7 OGS _ LL Z LLI 2 a a W LU0 IL i m 0 N 41 N a+ N N Y O !n �. CLQ. CD as � cv N m ujW C +�- O O LL y0 O N O N 7 � w ' v v W v _ 5 O Ua m1 a' n F-+ 2 ccL C O 1— s *Z CL 0 0 Z O m C/ Z W w X LLIW a - ti cq 4a E O Z D � 0 0 -0 N •E m m CL t W O �+ v D O o CL a CL �a O v J � •N O = Z O V tU C CL W LLI W W 19 W N cc O Cc = C p 0 r • (,� cc .a: a C o= %A� E n C w. c �•°'m o c �v �Cl) " 3 I Cc N)" L m IC- 0)_ cu 'Sd O 1� rn A' O = `7 C `° oo =C z L CAn I `�• y C • e S. �. CLQ. CD as � cv N m ujW C +�- O O LL y0 O N O N 7 � w ' v v W v _ 5 O Ua m1 a' n F-+ 2 ccL C O 1— s *Z CL 0 0 Z O m C/ Z W w X LLIW a - ti cq 4a E O Z D � 0 0 -0 N •E m m CL t W O �+ v D O o CL a CL �a O v J � •N O = Z O V tU C CL W LLI W W 19 W N N 'S hese%Operator Card. rertnt t Number. 10020 9 �xpirdtttnDafe:l�t-Nov 2012 ' nthony V Messina 3r 17 Georgetown Rd Boxford; MA .01921 Date gf,Birth: 14 -Nov -1963 Eyes: Blue Hair: Blond WY ight: 195 lbs. Height: 6'0" Issued br National Marine Fisheries Service ? z ;Northeast Regional Office not official form of identification The Commonwealth of Massachusetts Department of Public Safety One Ashburton Place, Room 1301 Boston, Massachusetts 02108-1618 Phone (617) 727-3200 Fax (617) 727.5732 CONSTRUCTION CONTROL DOCUMENT Project Title: KEYW Corporation Existing Office repairs and renovation Date: 05/09/2013 Deval Patrick Governor Thomas G. Gatzunis, P.E. Commissioner Project Location: 250 Clark Street, North Andover, MA Scope of Project: Interior renovation of existing office space In accordance with SECTION 116.0-116.4.2 of the 6`h edition of the Massachusetts State Building Code: I, David B. Barsky Mass. Registration Number: 10079 being a registered professional Engineer/Architect, hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Architectural 0 El for the above named project and that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved by the building permit and shall be responsible for the following as specified in section 116.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit, and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code -required controlled materials. 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, in general, if the work is being performed in a manner consistent with the construction documents. I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent comments. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory completion and readiness of the project for occupancy. Signature and Seal of registered professional: The Commonwealth of Massachusetts Department of Public Safety One Ashburton Place, Room 1301 Boston, Massachusetts 02108.1618 Phone (617) 727.3200 Fax (617) 727.5732 CONSTRUCTION CONTROL DOCUMENT Project Title: KEYW Corporation Existing Office repairs and renovation Date: 05/09/2013 Deval Patrick Governor Thomas G. Gatzunis, P.E. Commissioner Project Location: 250 Clark Street, North Andover, MA Scope of Project: Interior renovation of existing office space In accordance with SECTION 116.0-116.4.2 of the 6ffi edition of the Massachusetts State Building Code: I, David B. Barsky Mass. Registration Number: 10079 being a registered professional Engineer/Architect, hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: El Architectural 0 Fff for the above named project and that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved by the building permit and shall be responsible for the following as specified in section 116.2.2: Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit, and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code -required controlled materials. 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, in general, if the work is being performed in a manner consistent with the construction documents. I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent comments. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory completion and readiness of the project for occupancy. Signature and Seal of registered professional: The Commonwealth of Massachusetts Department of InrlustrlalAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgaaization/fndividual): V- A C4t\S\-. C -d SNC - Address: U'n,y C�3 City/State/Zip:Vr-%k C&\'A� VMYA 4 \ S 1,(C, Phone Are you an employer? Check the appropriate box: Typo of project (required): 1. [y'am a employer with /0 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. El am a sole proprietor or partner- listed on the attached sheet. 7. [J Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. El Plumbing repairs or additions myself. [No workers' comp. c.152, § 1 (4), and we have no 12.❑Roofrepairs insurance required.] t employees. [No workers' nll. Other comp. insurance required.] *Any applicant that checks box #f 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 anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. XAS5U, Tri e"S Policy # or Self -ins. Lic. #: C� �'OC;S ZO �0 Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 maybe forwarded to the Office of Investigations of the DIA- for insurance coverage verification. I do hereby certify un under e pains andpenaldes ofperjury that the information provided above is true ant. d correct n - Simature: ! �' A Date: b—irj—Zo�� 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. PIumbing Inspector 6. Other - - - Contact Person: Phone Information and -Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,- express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If anLLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retum ed to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/lieense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Commonwealth of Massachusetts Department of Industrial .Accidents Office ofInvestigatlons 600 Washington Street Boston} MA, 02111 Tel, # 617-727-4900 oxt 406 or 1-877,MASS.AFE Revised 5-26-05 Fax 4 617-727-7749 'car VW.mace ansr/rj;a ACOROT' CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 05/20/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: (978) 744-6433 Fax: (978) 744-3575 CONTACT Deb Tournas GERALD T MCCARTHY INSURANCE AGENCY, INC 92 NORTH ST P 0 BOX 839 PHONE (978) 744-6433 (978) 744-3575 E-MAIL debbiet@gtmccarthy.com naESS PRODUCER 6265 C. SALEM MA 01970 INSURER(S) AFFORDING COVERAGE NAIC # $ INSURED DIGIORGIO & MESSINA CONSTRUCTION INC 2 DEBUSH AVENUE, UNIT C3 INSURERA SAFETY INS CO INSURER : ASSOC EMPLOYERS INS CO INSURER MIDDLETON MA 01949 INSURER D: GEN'LA GGREGATE LIMIT APPLIES PER: POLICY IrCT PRO LOC INSURER E $ INSURER F AUTOMOBILE COVERAGES CERTIFICATE NUMBER: 23512 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. NOTVVITHSTANDING 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, INSR TYPE OF INSURANCE AD TYPE SUBR POLICY NUMBER POLICY EFFLTR Poucv EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED SESJEF p ureacr $ CLAIMS -MADE 17OCCUR MED. EXP (Anyone person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'LA GGREGATE LIMIT APPLIES PER: POLICY IrCT PRO LOC PRODUCTS - COMP/OP AGG $ A AUTOMOBILE LIABILITY ANY AUTO 5021302 06/20/12 06/20/13 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE (Per accident) $ X HIRED AUTOS X NON -OWNED AUTOS $ UMBRELLA LIAROCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I NTf) WCC500520501 11/01/12 11/01/13 WC STATLL OTH $ E.L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETORIPARTNER/EXECUTNE OFFICERIMEMBER EXCLUDED? NIA E.L. DISEASE -EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) P`COTICIIIATC LIA1 non ver.. a we, 1 - -M GANCFLI ATInN TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER, MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: RD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and lono are registered marks of ACORn EXHIBIT "C" FINAL RELEASE, CERIFICATION AND INDEMNIFICATION AGREEMENT Owner;` The ItEYW Corporation and its predecessors, successors, employees, agents and assigns, Contractor: DiGiorgio & Messina Construction Co. Inc, and its predecessors, successors, employees, agents and assigns, Subcontractor and its predecessors, successors, employees, agents and assigns, Project: 250 Clark Street North Andover, MA 01845 Tn consideration of payment in full paid to Subcontractor by Contractor, and for other good and valuable consideration, the receipt and sufficiency of which hereby acknowledged, Subcontractor remises, releases and forever discharges the Owner, the Contractor, the Surety, and the Project from and against any and all debts, demands, actions, causes of actions, suits, accounts, covenants, contracts, damages, liens (including mechanic's liens), and any and all claims, demands, and liabilities, of every name and nature, both in law and equity, which the Subcontractor now has, ever had, or ever will have against the Owner, the Contractor, the Surety, or the Project, in any way relating to, arising out of or resulting from the Project, including but not limited to claims for payment for any work and labor performed, or either, or any benefits or assessments related thereto, claims for any materials, equipment or services furnished by the Subcontractor, and claims for any materials, equipment, services, supplies, and insurance furnished to, for or through the Subcontractor in connection with the Project. Subcontractor also remises, releases and forever discharges the Owner, the Contractor, the Surety, and the Project from and against any and all debts, demands, actions, causes of action, suits, accounts, covenants, contracts, damages, liens, and liabilities of every name and nature, both in law and equity, known or unknown. Subcontractor certifies and warrants that all persons or entities that furnished materials or equipment, and performed labor, or either, to, for or through the Subcontractor in connection with the Project have been paid in full and the Subcontractor further certifies and warrants that all taxes, benefits, assessments and bills of any other descriptive title for labor performed, materials furnished and equipment supplied to, for or through the Subcontractor in connection with the Project have been paid in full. Subcontractor agrees to indemnify and save harmless the Owner, the Contractor, the Surety, and the Project from all liabilities, damages, costs and expenses incurred, including reasonable attorney fees, for or on account of or in any way growing out of claims for payment for any work and labor performed, or either, or any benefits or Ma Z .00 .A V1 oo e ci 0 0 csi N co 0 tio —i IH C14 in 44 I 43 cu 'A m co > 0 I U:l IA m M .w 0 &n u m m Jm 40-.0 0 0 z w tg CL E w a ai tw Im 1 CL 0 C m E CL ty cu w m 4� :1 3 v JQ CL m . 0� 0- to - P [: 18'1 ; C. c I rz Cc, a C 0 U: CO S CL co fa 0 in tio I 43 cu 'A m co > 0 I U:l IA m M .w 0 &n u m m Jm 40-.0 0 0 z w tg CL E w a ai tw Im 1 CL 0 C m E CL ty cu w m 4� :1 3 v JQ CL m . 0� 0- to - P [: 18'1 ; C. c I rz Cc, a C 0 U: CO S CL co fa 0 A - La an ., 1 10. . ii co � )m. { \\!\ 4§ °, � ]\i \ \ )� { §\ \� � ® /) }[ .� � �(� 2\\ƒ �{ { :�$ƒ Jx , ., 1 10. . ii w 11 or 3. disregards laws, ordinances, or rules, regulations or orders of a public authority having jurisdiction; 4. is otherwise guilty of substantial breach of a provision of the Contract Documents 10.2.2 If any of the above reasons exist, the Owner, may without prejudice to any other rights after giving the Contractor and the Contractor's surety, if any, seven days written notice, terminate employment of the Contractor and may: 1. take possession of the site and of all materials thereon owned by the Contractor; 2. finish the Work by whatever reasonable method the Owner may deem expedient. 10.2.3 When the Owner terminates the Contract for one of the reasons stated in Subparagraph 10.2.1, the Contractor, shall not be entitled to receive further payment until the Work is finished. 10.2.4 If the unpaid balance of the Contract Sum exceeds costs of finishing the Work, such excess shall be first applied against any other amounts for which the Contractor is liable, and any remaining excess thereafter shall be paid to the Contractor. If such costs exceed the unpaid balance, the Contractor shall pay the difference to the Owner. This obligation for payment shall survive termination of the Contract. 10.2.5 The rights and remedies set forth in this Section 1.0.2 are in addition to any right to damages or other rights and remedies permitted by law. 9.1.1 if the contractor is delayed at anytime in progress of the Work by, by labor disputes, fire, unusual delay in deliveries, abnormal adverse weather conditions not reasonably anticipatable, unavoidable casualties, delay in payment or other breaches under this Agreement by Owner,or any causes beyond the Contractor's control, or by other causes which may justify delay, then the Contract Time shall be extended by Change Order for such reasonable time as the parties may determine. 9.2 LIQUIDATED DAMAGES 9.2.1 Owner and Contractor recognize that time is of the essence and failure of the Contractor to complete the Work within the time prescribed herein, plus any permitted extensions by Change Order or writings relating to Article 4.3„ will result in the Owner suffering financial loss. In the event that the Contractor fails to complete the Work by the date prescribed herein, plus any permitted extensions pursuant to Change Orders or writings related to Article 4.3„ the Owner and Contractor agree that as liquidated damages, and not as a penalty, for any such delay in completion of the Work, the Contractor shall be required to pay the Owner in amounts consistent with those stated in Section 9.2.3. Such payments shall be for the passing of each calendar day that passes after the date upon which final completion of the Work was due. Owner may, at its own option, either deduct such amount of liquidated damages from any amounts due to Contractor or collect such monies due from the Contractor. 9.2.2 Damages for failure to complete the Work as scheduled are uncertain in amount and difficult to ascertain, and therefore Contractor acknowledges that it will be liable to pay the Owner such amounts as set forth herein, which both Owner and Contractor acknowledge as reasonable, as fixed and 'agreed upon damages for failure to complete the Work as scheduled, and not as a penalty. 9.2.3 In the event that the Contractor has not achieved Substantial Completion of the Work on or before the delivery date, then Contractor shall pay to Owner liquidated damages as follows: $350.00 per day for each calendar day or a portion thereof that Contractor has not achieved Substantial Completion of the Work. ARTICLE 10 TERMINATION OF THE CONTRACT 10.1 TERMINATION BY THE CONTRACTOR If the Owner fails to make payment when duear Su! tanti41y breaches any other obligation of"ihis Contract, following seven days written notice to the Owner, the Contractar may termitiii' ethe,-Contract; Provided h6wever, that Owner shall have the, opportunity fit cure such bread by retriiiting payment within the s ve.�n clay penod: following'. a tciticc and recover from. me Owner, payment for Work executed and, for proven loss with. respect to materials equipment, tools, construction equipment and machinery, .ialdding- reasonable overhead,pro fit anct.datriages. 10.1.1 5 The rights and remedies set forth in this Section 10.1 are in addition to any right to damages or other rights and remedies permitted by law. 10.2 TERMINATION BY THE OWNER 10.2.1 The Owner may terminate the Contract if the Contractor: 1. persistently or repeatedly refuses or fails to supply enough properly skilled workers or proper materials; 2. fails to make payment to Subcontractors for materials or labor in accordance with the respective agreements between the Contractor and the Subcontractors; 8.4.3 Owner's All -Risk Insurance. The Owner shall effect and maintain insurance against all risks of direct physical loss upon the entire structure on which the Work of this Agreement is to be done to one hundred percent (1001/o) of the insurable value thereof. Such policy shall include the interest of the Owner, Contractor, Subcontractor and any Sub -Subcontractors in the Work and shall insure against fire, theft, extended coverage, vandalism and malicious mischief. A certificate of such insurance shall be filed with the Contractor. 8.4.4 Attorney's Fees: In the event of a dispute between the Parties under this Agreement, the Prevailing Party shall be entitled to recover from the other Party its attorney's fees and related costs. 8.5 SEVERABILITY AND WAIVER Whenevet possible, ea& Prov Ston ;of this eft eetive and vlid.under apleable 4w, -but by or invalid cinder applicable law,• such 'I upon strict. adherence `to any pxovts ota of this construed as a waiver or deprive that Party of the that term or any other provision of this Agreement, tmetit shall be interpreted in such manner as to be Provision of this Agreement is held to be prohibited 00 shall be ineffective only to the extent of such remat 40' of N4 Agreement. A waiver by either Of this Agreetnwtoir the failure of a Party to insist k0r tnCht On Otte or, more occasions will not be �ght thereafter to insist upon subsequent adherence to 8.6 SURVIVAL The following provisions shall survive the termination of the Contract: Section 1.4, Section 2.3, Section 3.4, Article 5, Article 7, Article 9, Article 10, and Article 11. 8.7 NOTICES 8.9 AUTHORITY; COUNTERPARTS Each person signing this Agreement represents and warrants that•he.or she is duly autilbrize,d,and has legal authority to execute and deliver this Agreement, This Agreement maybe.execufeti tri any number of counterparts, each of which shall be deemed to be an original instrument and all o which together shall constitute a single agreement. 8.10 ENTIRE AGREEMENT "Itis Ageemerit eanstittttes the entire ARTICLE 9 DELIVERY: TIME IS OF THE ESSENCE he Parties and supersedes any understandings, rttcn- or oral that may relate in any way to tg upon and inure to the benefit of the Parties Delivery requirements are essential to the success of the Owner. Failure to provide the Work in the ,prescribW penod of ttme as,tleftned y, the=Qontract y'ill result in losses to the Owner, including hangar rental fees, rent, 9nd11.sssctat�d fees• thereitha well as other potential direct and consequential 1psm•Contractor ski be Mable for all ch dtr t'attd consequential losses, including but not limited to the afotemetttton , ft�x each< 0n4r day that the ' ork is not completed after the delivery date. 7.3 The Contractor shall defend, at its sole expense, against any such liability, claims or demands, and shall assume all costs and expenses related thereto, including, but not limited to, attorneys' fees. In the event that Contractor does not exercise its authority to assume the sole defense, Contractor shall reimburse the Owner for all of its reasonable defense costs, including, but not limited to, attorneys' fees. 7.4 Notwithstanding the provisions of this Article 7, the Owner acknowledges that the Contractor does not have complete control over the Construction Site. Owner will continue to operate its business at the Construction Stte duift the tcrrri of thin Agreemeant. Accordingly, Contractor's indemnification sball not ectend to nylost, claim, damage, liaiiltty, d detzxattds. oh account o£injttry, loss or damage ot'any' kind whatsoeyet, which arise ,aut of or art in Myi ' way connected v4th or, attribcrtabl"e to atiy let, or orniss ort of i iwrter, O iner's ag tis, officers ;and employees, unless such lass, claim, damage; liability and/or demand arises out of or is in any way connected with or','attnimtable to; any ,act air omission pf Contractor. ARTICLE 8 MISCELLANEOUS PROVISIONS 8.1 ASSIGNMENT OF CONTRACT Neithtxr party-tt� the Cotitmet shall assign the'Contract as a whole without w. -ntteit conserit of the -other; excepti that either Pt"Itty may assign this Agreement without consent 'ttt any operating :subsidiary,. e+ ntrolied a iliateof"the assigning party; or ill tlie.event ef a ehartge of,, i oral .of.aWarty, or the See, o ° substantial! at1 the business of a Party as port" of 4 etrrpoxate; merger, share acquisition, corporate, reconstruction, spin-off, rearrangement or similar change. 8.2 TESTS AND INSPECTIONS 8.2.1 Tests. inspections and approvals of portions of the Work required by the Contract Documents or by laws, ordinances, rules, regulations or orders of public authorities having jurisdiction shall be made at an appropriate time. 8.2.2 The Owner shall pay for tests except for testing Work found to be defective for which the Contractor shall pay, 8.3 GOVERNING LAW The Contract shall be governed by the laws of the Commonwealth of Massachusetts. 8.4 INSURANCE :8,4»1 Contiactor's .Liability jnx4 ;cp, Contractor agr to keep in force, at Contractor's own expense during the ,o re period cif construction bfi time project, and' shall cause any Subcontractor of the Contractor to procuro:and keep 'in force suo`n insurance WWI. protect Contraetor and Owner, front claims t i under WdAmWsl Compensation and ether employee benefit lavas, (ii)for bodity injury and death; and (azfol• property damage that may arise out of the work under, this A.greemeh. wlaetherr directly -or tridirec tty performed by the "Contractor, or trectly",or indirectly perforrtted b"y the Subeontretcr, lytic rrtirrittxutx liability limits of such; i1=tanee shall be $1000,00042':,000 000 general liability coverage. Contractor shall furnish Owner with a Cettica#e :cif Insurance front the Botany issuing the aforementioned policy of insurance, certifying that Contractor has such insurance:,in. force. 42 UVvner s Lral}1litY Inourance The Owner shall be responsible for anti at. the Owner';, option may tmtatntaizt: such insurance as will protect Owner from 7wner`s Corttirt ent Iiabilrty to othexs for damages because ofb tlyinjurl!> including death, which may arose fram,operatingFunder Ns':Agrwrnent, and any other liability for 48rrtiagos, which the Contractor is required to insure under any provisions of this Agreement. v ARTICLE 5 PAYMENTS AND COMPLETION 5.1 CONTRACT SUM The Contract Sum stated in the Agreement, including authorized adjustments, is the total amount payable by the Owner to the Contractor for performance of the Work under the Contract Documents: 5.2 APPLICATIONS FOR PAYMENT 5,2.1 The contractor shall submit an application pursuant to the terms of the contract and be paid by owner within fifteen (15) working days unless otherwise stated in contract. 5.3 PROGRESS PAYMENTS 5.3.1 The Contractor shall promptly pay each Subcontractor and material supplier, upon receipt of payment from the Owner, out of the amount paid to the Contractor on account of such entities' portion of the Work. 5.3.2 The Owner shall not have responsibility for the payment of money to a Subcontractor or material supplier. 6.0 SUBSTANTIAL COMPLETION 6.1 Substantial Completion is the stage in the progress of the Work when the Work or designated portion thereof is sufficiently complete in accordance with the Contract Documents so that the Owner can occupy or utilize the Work for its intended use. 6.2 FINAL COMPLETION AND FINAL PAYMENT 6.2.1 Upon recetpt of a fin 61 A phcatilan 1. - Payament, the Owner will inspect the Work. If. the Owner concludes after In,speetign,that the Wbik 1s c6t plete and reasonably complies with the scope set out in the Coniract Do utrients, and compiles wJ I Any and all applicable permit requirements, the Owner shall issue a final certificate den�+ntratii aptance of the Work. Only after such certificate is sled s%a11 final payxnn# me`due 6.2.2 For the purposes of this Contract, Phase 1 shall mean all work relating to the front office, the restrooms that are adjacent to the kitchen, the kitchen, and the storagelcopy room.* Phase 2 shall mean all tel# aznn#Vb #lis further iou$,traicd tin the"piefo,"4 tached hereto and incorporated herein. x.2,2 A eptaric of`fihai payment by tide Can aettf�r a. Sub -contractor or material supplier shall constitute a+aaver o claims bythai payee except thosepreviausly made in writing and identified by that payee as unsettled at the tune oi'fihal ApPlicatian for �'ayment: I%0TECTION OF' PERSC11+la. D p"ERTY, INDEMNITY 7.1 SAFETY PRECAUTIONS AND PROGRAMS The Contractor shall be responsible for initiating, maintaining and supervising all safety precautions and programs, including all those required by law in connection with performance of the Contract. The Contractor shall promptly remedy damage and loss to property caused in whole or in part by the Contractor, or by anyone for whose acts the Contractor may be liable, and shall refund to Owner any reasonable attorney's fees or other related costs associated with such damage and/or loss caused by Contractor or those Contractor is liable for. 7.2 C001114ot9r shrd itiderfin4 and, hold harmless the Owner and its respective officers, agents and employees, from,�iid ag,wmt any,loss claim, damage, liability, and demands, on account of injury, loss or damage of. any kind whatsoever;, which arise out of or are in any way connected with this Contract, except to the extent any such claim sterns from the acts or omissionsof any of the Owner's "`yy agcn[s and emFtvyees. 110ty shall include such injury, loss, or damage which is caused, or is alleged to be caCtscdin whole:oi in part by, any action or fault of the Contractor and its employees, representatives tti"agents as,vell as, any of its Subcontractors. The Contractor shall confine operations at the site to areas permitted by law, ordinances, permits, the Contract Documents and the Owner. 3.7 CUTTING AND PATCHING The Contractor shall he responsible for cutting, fitting or patching required to complete the 'Work or to make its parts fit together properly. 3.8 CLEANING UP The Contractor shall keep the premises and surrounding, area, free from accumulation of debris and trash related to the Work. The premises; will be turned over broom cleaned. ARTICLE 4 CHANGES IN THE WORK 4.1 After execution Of the Contract, changes in the Work may 6e:aecvmtlished �y written Change' Orden:; The Owner, without invalidating the Contract may order changes in the Work within the general seope of the Contract consisting of:addit ons, deletions or other revisions, the Contract Sum and Contract. Time being adjusted accordingly, as mutually agreed to by owner and Contractor per the written Change Order. Such written Change Order shall provide for an extension of the delivery date, as reasonably determined by the Owner and agreed to by Contractor. 4.2 A Change Order shall be a written order to the Contractor signed by the Owner and acknowledged by Contractor to change the Work, Contract Sum or Contract Time. 4.3 DIFFERING SITE CONDITIONS: If concealed or unknown physical conditions are encountered at the site that differ materially from those indicated in the Contract Documents or from those conditions ordinarily found to exist, the Contract Sum and Contract Time shall be subject to equitable adjustment. 4.3.1 Upon discovery of said aforementioned "Differing Site Condition" the Contractor shall Promptly, and before the conditions are further disturbed, give written notice to the Owner of (1) subsurface or latent physical conditions at the site which differ materially from those indicated in this contract, or (2) unknown physical conditions at the site, of an unusual nature, which differ materially from those ordinarily encountered and generally recognized as inhering in work of the character provided for in the contract. 4.3.2 The Owner shall investigate the site conditions promptly after receiving the notice. if the conditions do materially so:differ, and cause ati increase or decrease in the Contractor's cost of, or the time required for= p0-rfur*xg, any Partofthe workunder this contract, whether or not changed as a result of the. conditions, an equitable adjustment shall be made under this clause and the contract modified tit. writing accordingly; Such writing shall provide for an extension of the delivery date, as reasq bly leteiminod,by the Owner, as well as any changes in cost. . 4.3.3 No requak by the Car tractor for an equitable atljucttnettt to fife contract under this clause shall be allowed, unless the Contractor has given the written notice required; provided, that the time prescribed in (a) above for giving written notice maybe extended by the Owner. 4.3.4 No request by the Contractor for an equitable adjustment to the contract for differing site conditions shall be allowed if made after final payment under this contract. ARTICLE 3 CONTRACTOR 3.1 EXECUTION OF THE CONTRACT Exeeuttcsn.;of the:"Contract by the Ccrri6ractor a,resrtsenthtion that the Contractor has visited the site, bew- fimilsar with local= conditions;under which, the Wmrk is to be performed and correlated personal of scrvatie ns wl :regnite. ents of the. Contract i ocumettfs., SUPERVISION AND CONSTRUCTION PROCEDURES 3.2: The Contractor shall.supervise and direct the Work, using the Contractor's best skill and attention. The Contractor ".. I — be solely responsibte for arid: have control over construction means, methods. iechnittu..1 sequetace #Pl �proc d" SubbO itraetisr� and for coordinating all portions of the Work. 3.3 INDEPENDENT CONTRACTORS The Contractor shall perform the *bf as an independent contractor. The Contractor„ its employees, subcontractors, agents and representatives arc not etttpl6yees of Owner, and no part of this Agreement shall be construed to represent any emp1oyd6dmp10yce relationship. 3.3 LABOR AND MATERIALS 3.3.1 Unless otherwise provided in the Contract Documents, the Contractor shall provide and pay for labor, materials, equipment, tools, utilities, transportation, and other facilities and services necessary for proper execution and completion of the Work. 3.3.2 The Contractor shall deliver, handle, store and 'install materials in accordance with manufacturers, instructions. 3.4 WARRANTY The Contractor warrants to the Owner that: (1) materials and equipment furnished under the Contract will be new and of good quality unless otherwise required or permitted by the Contract Documents; (2) the Work will be free from defects not inherent in the quality required or permitted; and (3) the Work will conform to the requirements of the Contract Documents, Contractor shall warrant all materials incorporated into the building from defect as well as the workmanship performed by or on behalf of Contract for a period of one (1) year commencing upon turnover to Owner. The provisions of this Article 3.4 shall apply to Work done by Subcontractors, as well as Work done by direct employees of Contractor, and are in addition to any other remedies or warranties provided by law. 3.5 PERMITS, FEES AND NOTICES 3.5.1 The Contractor shall obtain and pay up to allowance for the building permit and other permits and governmental fees, licenses and inspections necessary for proper execution and completion of the Work. 3.5.2 The Contractor shatl c om with and give,.,notices, re- aired by igen es hav ing ur sdiptiort over. tiae Work. If the Contractor perfrs 1�,r that tt knrws, dr reasortab), shouli.kztow y be ttttiary to lawn statutes, ordinances, building codes, and ndes. aiid regulations vithctut notice to; the Owncerr, the Contractar or such Work and shall bear any attrjhutable shall assume full responsibility fCosts, iacladirig.bcth.direct and indirect costs suffered by Owner. Excluding therefrom ar y roxisting conditions outside of the scope of work which are not part of this contract, 3.6 USE OF SITE General Conditions of the Contract for Construction ARTICLE 1 GENERAL PROVISIONS 1.1 THE CONTRACT The Contract represents the entire and integrated agreement between the parties and supersedes prior negotiations, representations or agreements, either written or oral. The Contract may be amended or modified only by a written modification exceuted by the Owner and Contractor. 1.2 THE WORK The term "Work" means the construction and services required by the Contract Documents, and includes all other labor, materials, equipment and services provided by the Contractor to fulfill the Contractor's obligations. 1.3 INTENT The intent of the Contract Documents is to include all items necessary for the proper execution and completion of the Work by the Contractor. The Contract Documents are complementary, and what is required by one shalt be. as binding as if required by A. t.4 BOND Contractor shall furnish and keep in force throughout the contract period, a bond in the amount of $5,000.00. The bond shall name the Owner as obligee and shall be in such form and with such sureties as Owner may approve. Such bond is required before the Contract begins. 1.5 LIEN WAIVER Contractor shall provide lien waivers, in the form of attached Exhibit C, with applications for all Payments, including, but not limited to, Progress Payments and Final Payment. ARTICLE 2 OWNER 2.1 INFORMATION AND SERVICES REQUIRED OF THE OWNER 2.1.1 If reasonably requested by the Contractor, the Owner shall furnish and pay for a survey and a legal description of the site. 2.2 OWNER'S RIGHT TO STOP THE WORK If the Contractor fails to correct Work which is not in accordance with the Contract Documents, the Owner may direct the Contractor in writing to stop the Work until the correction is made. 2 3 OWNER'S RICHT TO CARRYOUT THE . ORK. If the Contractor defaults or neglects to cry out the Work in accordance with the Contract Documents and faits wtthit a seven day period after receipt of written'notice from the Owner to correct such default Of neglect with diligence and promptness, the Owner may, without prejudice to other remedies, correct sueh deficiencies. In such case, a Change order shall be issued deducting the cost of correction from ,Payments due the.Cotytrtactor. Standard err -i + t: twow 6r, anc!'Cbntractor ,�;x�rn�t �fittesre�l; �t���:��`t��. tiny Siad year �t written abav (wl4tk �kc tviidd *jt �sidet` Standard Form of Agreement Between Owner and Contractor CAP105 Page 3 of ARTICLE 1 THE CONTRACT DOCUMENTS The Contractor shall complete the Work described in the Contract Documents for the project. The Contract Documents consist of: 1. this Agreement signed by the Owner and Contractor; including plans Exhibit A, Schedule of Values referenced in Exhibit B, and Lien Waiver referenced in Exhibit C. 2. CAP205 Document, General Conditions of the Contract; 3. written change orders or orders for minor changes in the Work issued ager execution of this Agreement. ARTICLE 2 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION DATE Work shall commence on or before signed contract. Substantial completion of job to be twelve (12) weeks after start date. ARTICLE 3 CONTRACT SUM 3.1 Subject to additions and deductions by Change Order, the Contract Sum is: Two hundred fifty nine - thousand one hundred forty eight dollars and zero cents (5259,148.00) 3.2 The Contract Sum shall include all items and services necessary for the proper execution and completion of the Work. Lien Waivers for subcontractors will be completed and supplied. No retainage to be held. ARTICLE 4 PAYMENT 4.1:Bastd on Oontraetor"s Aplicaioras far Payment, the Owner shall pay the Contractor as follows; Payments shall be made withiza fifteen (15) days of application of payment request. Four payments as. follows: 'l *r twenty five -percent (25%) upon mobilization,') 1 or twenty five ,,Percent. (25%) after Phase. 1 is conaplett l; and the final '/ or ;twenty five percent (2S°lo) upon Phase 2 clompietaan as defined in Article 6 hereafter in General Conditions of the Contract for Construction. 4.2 Payments due and unpaid under the Contract Documents shall bear interest from the date payment is due at the rate of 1.5%or in the absence thereof, at the legal rate prevailing in Massachusetts. In the event that the Owner defaults on payment the Contractor shall be entitled to recover from the Owner its attorney's fees, expert fees and related costs. (Usury and requirements under die Federal Truth in, "Lending Act, similar state and local consumer credit laws and other regulations at'the Owtaer's and Contractor+s principal places of business, the location of the Project and elsewhere may affect the:validity of this provision.) x Standard Form of Agreement Between Owner and Contractor CAP 105 Page 2 of 3 • Ceilings — 2'x 4' Chicago suspended ceiling track with a 2' x 4' 769 cortega square lay -in ceiling tile. • Doors hollow metal frame's with a maple/birch wood door and brush nickel hardware. • Window exterior — four (4) case windows to match existing or equal, • Kitchen cabinets and tops — construction grade cabinet with Formica top. • Glass windows conference room designed on site with an allowance of $1,500.00 • New office doors hanger area as noted on the drawings - hollow metal frame with wood door mapleibirch finish with brush nickel hardware. • Drywall partitions — steel stud insulted with sheetrock tape sanded and painted, • Flooring — hall, office, conference room areas carpet to be installed using commercial grade with glue down with an allowance of $10,000.00. VCT tile to be installed in kitchen and bath areas with an allowance of $1,000.00. ` Paxnhng iwci coats of palrlt.an IWllpvv rxtetal ftame8, wood doors prefinished natural clear finish, wars witl be pnmied onkt(' coat with two {2, a",+ f finish, ' Bath. aorlees rttirrpr;lt paper holder, and bathroom stall partitions standard off white finishes. The following items are excluded from the contract: Exclusions: • Except as provided herein, Permits and Fees — Allowance in Schedule of Values ■ Removal and disposal of any hazardous or contaminated soils, groundwater or other materials not created or caused by Contractor. • Gas work. Fire Extinguishers Painting Exterior Any work on the existing dry pipe sprinkler system above the ten foot (10'-011) ceiling in the front office area and above the metal ceiling above the thirteen foot plus (13'0" +) ceiling above the machine shop. • Knox boxes, access panels and standpipes ■ Painting of pipe or custom painting of sprinklers. ■ Fire or booster pump. • Any and all public utility and service fees for water, electric and gas. :ruction with adequate access. and non -prevailing wage. srk, Wnday;through Friday, 7:00 AM to 3:30 PM. la, o :sh11fi period the OWNER shall reimburse Standard Force of Agreement Between Owner and Contractor CAP105 Page 1 of 4 This AGREEMENT is made June 2013 (Date) BETWEENthe Party Engaging the Services of the Contractor ("Owner"): and the Contractor: The KEYW Corporation 7740 Milestone Parkway, Suite 400 Hanover, Maryland 21076 DiGiorgio & Messina Construction Co., Inc. 2 Debush Avenue Unit C-3 Middleton, MA 01949 for the following Project: Plans for existing building 250 Clark St North Andover, MA 01845 by David Barsky — Architect dated April 2013. Exhibit "A". The Owner and Contractor agree as follows to the scope of work. Pull all necessary p tarts far existing. building, scope to include all demo in specified areas and allowbeetireconstruction ;u offices ; per plans, allowances provides for materials. Schedule of values and allowances includes work being performed attai hed and made part to herein as Exhibit "B". Job time estimated at iZweeks �► Electrical scope front offaice area only installation of "82 - 2x4 3 lamp .drop in T8 tight fixtures wl prismatic lenses, Fivelo) emergency light units, Two (2) exit signs, Five (5) exit/emergency lightunite, Twelve {l2) away swtchesk Sixteen (16) singk pole switches, Two (2) bathroom: GFCI Protected. outlets, Two {2} cubical pciwer, locations, Seventy five (75) conv. Outlets on 10 circuits, Eighteen data/phone outlets. two (2): cat #5 wiring. only, Wiring for Two (2), bath fans, one {i) Kitchen exhaust fan, One (1):air handler and One (1) condenser. HVAC scope — Demo and relocate the existing furnace to new location, connect up to the exiWng duct, flue and ac piping, add and relocate grilles where needed in the lobbylreeeption arca; New system installed in the new space in the center of the building, the unit will be 1,00,000 BTU converted to propane; AC unit will be 3.5 ton. Permits and inspection included. • Plumbing scitpe • provide and install -new plumbing and fixtures for two new water closets, fixtures to include reusing ane existing toilet and hung sink from current water closet, two new toilets, ane:ttew sink, ane plastic mop sink and one: stainless steel kitchen sink and faucet. • Fire alatm -- work to be, dotteby existing fire alarm company Active Fire Alarm with an allowance of $12,00Q.0,0., Sprinkler, I addition and relocation of quick response chrome semi -recessed pendent _sprinkler beads below new hung ceilings and combustible concealed brass upright spdnkler'heads above the ceilings where combustibles area present (existing front office: area) Provtde.and install permit, fire protection pians, ydrauliccalculations, a new hydrant flow test,,&brication, pipe, bangers and sprinklers, Pv�" t%OR o� (J' ar 6 riafts : 9- eoemen'�w.eK 1` Arep e. elf �1fJrtitl r i l^._j�i`i PLANNING DEPARTMENT Community Development Division 1600 Osgood Street North Andover, Massachusetts, 61845 SITE PLAN REVIEW DECISION Any appeal shall be filed within (20) days after the date of filing this notice in the office of the Town Cleric. Date: May 7, 2013 Date of Hearing: April 2, 2013; April 16, 2013, May 7, 2013 Date of Decision: May 7, 2013 Petition of: Flight Landata, Inc. 250 Clark Street North Andover, MA 01845 Premises Affected: 250 Clarlc Street Assessors Map 75 Lot F Referring to the above petition for a Site Plan Special Permit, from the requirements of the. North Andover Zoning Bylaw, Sections 8.3,10.3, and 10.3 1, and M.G.L. c.40A, Sec. 9. So as to allow the expansion of an existing building from 9,525 sq. ft. to a total of 19,005 sq. ft., to provide additional office and R&D space as well as hanger space with expanded parking from 14 to 38 spaces, associated landscaping, installation of a larger septic system, stormwater management and installation of utilities in the Industrial 2 (1-2) Zoning District. After a public hearing given on the above date, and upon a motion by R. Rowen and 2nd by M. Colantoni to APPROVE the Site Plan Special Permit as amended and based upon the following conditions. The vote was 6 — 0 in favor of the application. Oi behalf of the No r Andover Planning Board John Simons, Chairman Richard Rowen Lora McSherry Michael Colantoni Dave Kellogg Lynne Rudnicki 250 Clark Road. Map 75, Parcel F Site Plan Special Permit --Expansion of Existing Industrial Building The Planning Board herein APPROVES a Site Plan Review Special Permit for the expansion of an existing building fi-onr 9,525 sq. ft. to a total of 19,005 sq. ft., to provide additional office and R&D space as well as hanger space with expanded parking fi•om 14 to 38 spaces, associated landscaping, instaIIation of a larger septic system, stormwater management and installation of utilities in the Industrial 2 (I-2) Zoning District. The project is located at 250 Clark Street, North Andover, Massachusetts 01845, Assessors Map 75, Parcel F within the hndustrial 2 (I-2) Zoning District. The parcel totals approximately 74,122 sq. ft. of leasehold area with frontage on Clark Sheet. This Special Permit was requested by Flight Landata Inc., 250 ClarIc Street, North Andover, MA 01845. The application was filed with the Planning Board on or about February 15, 2013. The public hearing on the above referenced application was opened on April 2, 2013, with additional hearings on April 16, 2013, and closed by the North Andover Planming Board on May 7, 2013. The applicant submitted a complete application, which was noticed and reviewed in accordance with Section 8.3, 10.3 and 10.31 of the Town of Noilh Andover Zoning Bylaw and MGL C.40A, Sec. 9. The Planning Board makes the following findings as required by the North Andover Zoning Bylaws Section 8.3 and 10.3: FINDINGS OF FACT: 1) The specific site is an appropriate location for the project as it is the expansion of an existing use and structure and will include provisions for the expansion of parking, improvements to the stormwater system that will improve the drainage on the lot, as well as an expansion of the septic system. 2) Based on input received from both the Planning Board, the PIanning Board's consultants, the applicant has provided sufficient stormwater management facilities to mitigate flow of storrmvater by providing two (2) Bio -filters with stone spillways to treat storrnwater runoff from the parking area and the addition. Roof runoff will be captured by deep stone -filled trench Iocated at the southern edge of the addition. This design will mitigate the flow of stormwater from the new parking areas and the addition, thus complying with the Planning Board's Site Plan Review standards. 3) Having received approval of the Septic Design Plan dated April 18, 2013 the project is in compliance with all Board of Health Department Regulations. 4) The site has sufficient space for parking and traffic circulation. The proposed warehouse and office use requires 27 spaces, according to the Town's Zoning Bylaw section 8.1 Off -Site Parking and the proposal includes 38 spaces. Because of its location at the Lawrence Airport, there will be no parking or traffic circulation impacts on surrounding neighborhoods. 5) Finally the Planning Board finds that this project generally complies with the Town of North Andover Zoning Bylaw requirements as listed in Section 8.3.5, but requires conditions in order to be fully in compliance. The Planning Board hereby grants an approval to the applicant provided the following conditions are met: SPECIAL CONDITIONS: 1) Permit Definitions: A) The "Locus" or "Site" refers to the 74,122 sq. ft. parcel with land fronting on Clark Street as shown on Assessors Map 75, Parcel F, and also known as 250 Clark Street, North Andover, Massachusetts. E 250 Clark Road. Map 75, Parcel F Site Plan Special Permit — Expansion of Existing Industrial Building B) The "Plans" refer to the plans prepared by Williams & Sparages, 191 South MainStreet, Suite 103, Middleton, MA 01949 entitled "Layout Plan in North Andover, Mass", 'dated February 7, 2013, as most recently revised on May 6, 2013 consisting of Sheets 1 through 4. C) The "Project" refers to the expansion of an existing building from 9,525 sq. ft. to a total of 19,005 sq. ft., to provide additional office and R&D space as well as hanger space with expanded parking from 14 to 38 spaces, associated landscaping, installation of a larger septic system, stormwater management and installation of utilities in the Industrial 2 (I-2) Zoning District. D) Tire "Applicant" refers to Flight Landata, Inc., 250 Clark Street, North Andover, MA 01845, the applicant for the Special Permit, its successors and assigns. E) The "Project Owner" refers to the person or entity holding the fee interest to the title to the Locus from time to time, which can include but is not limited to the applicant, developer, and owner. 2) Waivers; The Applicant has requested waivers from the following provisions of the Town of North Andover Zoning Bylaw, including Section 8.3.5.e (xix) — Traffic Study, (xxii) — Fiscal Impact, and (xxiii) — Community Impact. As part of this decision, the Planning Board has granted the above waivers, in that it has found that the Applicant has provided sufficient information as part of its application to address all traffic, fiscal, community, and other impacts. 3) PRIOR TO ENDORSEMENT OF PLANS A) The developer shall provide the Planning Board with copies of permits, plans and decisions received from all North Andover land use Boards. 4) PRIOR TO THE START OF SITE WORK OR CONSTRUCTION A) Three (3) copies of the signed, recorded decision and the recorded plans must be delivered to the Planning Department. B) The applicant shall designate an independent Construction Monitor who shall be chosen in consultation with the Planning Department staff. The Construction Monitor shall submit weekly reports during the entire duration of the project and must be available upon four (4) hours notice to inspect the site with the Planning Board staff. C) A detailed construction schedule shall be submitted to the Planning Staff for the purpose of tracking the construction and informing the public of anticipated activities on the site. D) A bond in the amount of five thousand dollars ($5,000.00) shall be posted for the purpose of insuring that the site is constructed in accordance with the approved plan and that a final as -built plan is provided, showing the location of all on-site structures. This bond shall be in the form of a check made out to the Town of North Andover. This check will then be deposited into an interest bearing bond account. E) All stornrwater management best practices shall be maintained as specified in the Stormwater Operations and Maintenance Plan that was submitted with the on February 7, 2013, revised March 26, 2013 and April 9, 2013, titled "Operations and Maintenance Plan 250 Clark Street". F) All applicable erosion control measures must be in place and reviewed and approved by the Planning Department. These measures must include erosion control to protect all existing and proposed catch basins and oil traps on the site or on the streets adjacent to the project: 250 Clark Road, Map 75, Parcel F Site Plan Special Permit— Expansion of Existing Industrial Building G) Yellow "Caution" tape must -be placed along the limit of clearing and grading as shown on the plan. The Planning Department must be contacted prior to any cutting and or clearing on site. All existing trees that will remain in the landscaped area are to be marked prior to the pre -constriction meeting. H) A pre -construction meeting must be held with the developer, their construction employees, Planning Department and other applicable departments, to discuss scheduling of inspections to be conducted on the project and the construction schedule. 5) DURING CONSTRUCTION A) Dust mitigation must be performed weekly, or more frequently as directed by the Town Planner, throughout the construction process. B) Any stockpiling of materials (dirt, wood, construction material, etc.) must be shown on a plan and reviewed and approved by the Planning Staff. Any approved piles must remain covered at all tunes and fenced off to minimize any dust problems that may occur with adjacent properties. C) It shall be the responsibility of the developer to assure that no erosion from the construction site shall occur which will cause deposition of soil or sediment upon adjacent properties or public ways, except as normally ancillary to off-site construction. Off-site erosion will be a basis for the Planning Board making a finding that the project is not in compliance with the plan; provided, however, that the Planning Board shall give the developer written notice of any such finding and ten days to cure said condition. 6) PRIOR TO A CERTIFICATE OF OCCUPANCY A) The applicant must submit a letter from the architect and engineer of the project stating that the builduig, landscaping, lighting and site layout substantially comply with the plans referenced at the end of this decision as endorsed by the Plarunung Board. B) All stormwater structures shall be cleaned, in accordance with the approved Operation & Maintenance Plan. 7) PRIOR TO THE FINAL RELEASE OF ALL SECURITY AND ESCROWED FUNDS A) The Planning Staff shall review the site. Any screening as may be reasonably required by the Planning Staff will be added at the Project Owner's expense. B) A final as -built plan showing final topography, the location of all on- site utilities, structures, curb cuts, parking spaces and drainage facilities, including invert elevations of all stormwater structures, must be submitted to the Planning Department. The as -built must be provided in paper form as well as in SDP (Standard Digital File) format. The as -built sliall also provide a calculation showing the increase in impervious area. The applicant must also submit a letter from the architect and engineer of the project stating that the building, landscaping, lighting and site layout substantially comply with the plans referenced at the end of this decision as endorsed by the Planning Board. 4 250 Clark Road. Map 75, Parcel F Site Plan Special Permit — Expansion of Existing Industrial Building C) The Planning Board must by a majority vote make a finding that the site is in conformance with the approved plan. 8) GENERAL CONDITIONS A) The contractor shall contact Dig Safe at least 72 hours prior to commencing any excavation. B) Gas, Telephone, Cable and Electric utilities shall be installed underground as specified by the respective utility companies. C) The hours for construction shall be limited to between 7:00 a.m. and 5:00 p,m. Monday through Friday and between 8:00 a.m. and 5:00 p.m. on Saturday. D) No open burning shall be done except as is permitted during burning season under the Fire Department regulations. E) If a dumpster is required once the building is occupied, the owner shall apply to the Board of Health for the appropriate permit. The location of the dumpster must be approved by the Planning Office. F) The provisions of this conditional approval shall apply to and be binding upon the applicant, its employees and all successors and assigns in interest or control. G) Any action by a Town Board, Commission, or Department, which requires changes in the plan or design of the building, as presented to the Planning Board, may be subject to modification by the Planning Board, 1-1) Any revisions shall be submitted to the Town Planner for review. If these revisions are deemed substantial, the developer must submit revised plans to the Plarming Board for approval. 1) This Special Permit approval shall be deemed to have lapsed after May 7, 2015 (two years from the date permit granted), exclusive of the time required to pursue or await determination of any appeals, unless substantial use or construction has commenced within said two-year period or for good cause, For purposes of this development, the developer shall be deemed to have undertaken substantial use or construction if the developer has begun any site grading or tree clearing. J) The following information shall be deemed part of the decision: Plan titled: Layout Plan in North Andover, Ma Prepared for: Flight Landata, Inc. 250 Clark Street North Andover, MA 01845 Prepared by: Williams & Sparages Suite 103 191 South Main Street Middleton, Ma 01949 Scale: 1"= 20' Date: February 7, 2013, last revised on May 6, 2013. Sheets: 1 through 4 250 Clark Road. Map 75, Parcel F Site Platt Special Permit — Expansion of Existing Industrial Building Architectural Plans: Prepared by: David Barsky -Architect 477 Concord Ave Cambridge, Ma 02138 Date: November 2012 Sheets: A.01 -A.07 Stormwater Report: 250 Clark Street Dated: February 7, 2013, last revised March 26, 2013 Operations and Maintenance Plan "250 Clark Road" Dated: February 7, 2013, March 26, 2013 and April 9, 2013 cc: Town Departments Applicant Engineer Abutters Assessor 0 Date: May 10 2013 Dear: Jill Mann As you know, the Planning Board issued a decision for the following permit: Flight Landata Inc Name of Applicant 250 Clark Street Location of Premises rrrrrrrararrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr� Your 20 -day appeal period will have passed at midnight on the following date: May 30.2013 1. Once the appeal period has passed, please pickup your Town Clerk -certified copy of the Planning Board's decision from the Town Clerk's office located at 120 Main Street, North Andover, MA 01845 (phone: 978-688-9501). 2. Please make a paper copy of the Planning Board signed Mylar. 3. Please bring the Town Clerk -certified copy of the decision & the signed Mylar (if required to be recorded) to the North Essex Registry of Deeds, 354 Merrimack Street, 3`d floor, entrance C, Lawrence, Ma 01843 (phone 978-683-2745), as the decision and Mylar must be filed at the Registry of Deeds as soon as possible. 4. Once this is completed please bring: a) copy of the certified decision; b) three (3) paper copies of the signed Mylar plans; c) the Registry of Deeds receipt to the Planning Department which is located at Town of North Andover, 1600 Osgood Street, Suite 2035, North Andover, MA 01845. Failure to file the decision and Mylar with the Registry of Deeds will result in your inability to exercise your special permit and/or definitive subdivision approval and your inability to obtain a building permit with the Building department. A Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the date on which the Special Permit was granted unless substantial use or construction has commenced or an extension has been granted by the Planning Board. If you have any questions, please feel free to call (978-688-9535) or fax (978-688-9542), during regular business hours. 20 Day Appeal Lettter for 250 Clark Street (sent with Decision) 0e) Date/7 / j...�/ .. . TOWN OF NORTH ANDOVER PERMIT FOR NGAS INSTALLATION o a This certifies that . .?"'?'.' ..� .. `-� . !'. . has permission for gas installation ./t<El!✓ ........ in the buildings of ..'.%��! f h.!� .. (.�.rt.!%G.??=-.......... . atIZ. ?....C..%GM A ..157-7. . , North Andover, Mass. Feee-�q. Lic. No.. 6. .....................\&. . GAS INSPECTOR Check # 7021 C MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:,/�©. _ , . ^Ji%� _.. Date: Permit#:_ Building Locatio ,,:;;;5�1.:../L ,rj _ _,.,. Owners Name*2-- ..- f�7%c1.eiiT Type of Occupancy: CommercialEducationals ,NResidentia, AZ New:! Alteration Renovation:m Replacement Plans Submitted:. Yes No' FIXTURES WW Y N D m w =0 O U to H W W UW' z J W z to O F- Z in w W N m C7 w to a O a W_ Luawww - a X a > Z U W Z J W >- W J H Q 1- Q O Z J (j m W O Z a O N= ~ F H W W W w I— I— 1— O U Q o a a 0 O W X W X a> O J O a O IX w 1— z w >> Q Q Q F- O SUB BSMT. BASEMENT 1 FLOOR / 2 FLOOR 3 FLOOR 4 1H FLOOR '5 FLOOR ,gw FLOOR mill 7 FLOOR 8 FLOOR _... _.,,.._ Check One Only Certificate # Installing Company Name �j j.r-0-�t _c or o 97. Address rt/PDQ/�yl ;City/Town�State:1 MA Partnershipatlon i Business Tel Fax �( Firm/Company',A.�.,,. Name of Licensed Plumber/Gas Fitter: ,�W,,, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes Na„� If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy; %Q Other tYp indemnity o of indemni I— r FBond '— OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Lj Agent Signature of Owner or Owner's Agent By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the nest or my rnnow[eage ana tnat all plumping work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: Plumber Title v Gas Fitter Signature of Lilensed PI ber/Gas Fitter 7 Master CitylTown'F w Journeyman / APPROVFO IOFFICF [ICF OId1 Vl LP Installer License Number: City/Town: /Y">�/ �6A,:,, tY7,4 Plumbing & Gas Inspector: Date: would like to cancel permit # For the installation of In my home/address C/0 Y -A Climate Designs, LLC has completed the installation under the existing permit. Work to be completed under the new permit will be the final inspection. Sincerely, VP RnGv\L.Q Locati _ c%r,ee. X2�- No. �'� Date �,. TOWN OF NORTH ANDOVER A Certificate of Occupancy $ Ija O Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 23466 Building Inspector Ot. NO eT:'1y it .. ;', ,, •. °or. a "> { CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 540 Date: September 21, 2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON 250 Clark Street, Flight Landata MAY BE OCCUPIED AS office space IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. 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Check the appropriatVixam 1. ElI am a employer with 4. a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Any applicant that check box #1 must also fill (jut the section below Type of project (required): 6. ❑ New construction 7. Remodeling 8. E] Demolition 9. ❑ Building addition 10. 11 lectrical repairs or additions 11. Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other ao.. irb -neu won:e ss compmensateon policy irfor--abcn. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site.. information. � Insurance Company Name: oW(e1^ 27\n SiAm , /-1- Policy # or Self -ins. Lie. #:_6 VC -70 2-3-7 y Q a UOG Expiration Date:_ Job Site Address:__ 2SQl atK City/State/Zip: N. Avidoverl d?A 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 u s and ties of perjury that the information provided above is true and correct - 1 Si ature: !� p / Date.: Phone #: q70 - 66 1 '36 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. PIumbing Inspector 6.Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 wvvw.mass.gov/dia ACCMV CERTIFICATE OF LIABILITY INSURANCEFDATE(MM/DDIYYYY) 2/16/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION A & K Fowler Insurance LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 200 Park Street North Reading, MA 01864 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. POLICY EFFECTIVE POLICY EXPIRATION DATE (MMJDDfYYYYI INSURERS AFFORDING COVERAGE NAIC # INSURED Lear Dev. Corp. 200 Park Street North Reading, MA 01864 INSURER A: Western World Insurance Compa INSURER B: Merchants Insurance Group INSURER C: AIM Mutual Insurance Company INSURER D: INSURER E: A. Boutin, CIC CISR UU V tKAI3tJ 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I SR INTR ADD'L INqRn TYPE OF INSURANCF POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE (MMJDDfYYYYI UMTS IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE A. Boutin, CIC CISR GENERAL LIABILITY _ EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GE NERAL LIABILITY NPP1234153 9/5/09 9/5/10 DAMAGE TO RENTED PREMISE Ea occurrence $ 50,000 MED EXP (Any one person) $ 1 000 CLAIMS MADE Fx_� OOCUR PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2 000 000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OPAGG $ 1,000,000 POLICY JECT PRO LOC AUTOMOBILE LIABI UTY B ANYAUTO 7AM0277014823 5/7/09 5/7/10 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ALL 0 WNE D AUTOS BODILY INJURY $ X SCHEDULEDAUTOS (Per person) X HIREDAUTOS BODILY INJURY $ X NON-OWNEDAUTOS (Peraccident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR CLAIMS MADE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y� E.L.EACHACGDENT $ 1,000,000 C OFFICERMIEMBEANY RIPART E EXECUTIVE AWC7023745012009 4/15/09 4/15/10 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yyes, describe under E.L. DISEASE -POLICY LIMIT $ 1,000,000 SPEaALPROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Insurance Verification ----'-'� v T9SS=1UU9 ACORD CORPORATION. All rights reserved. The AC ORD name and logo are registered marks of ACORD SHOULD ANY OF T HE ABOVE DESCRIBED POLICIES BE CA NCELLE D BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of North Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL North Andover, Ma 01845 ]Kerri IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE A. Boutin, CIC CISR ecnRn '3rIInnurn4l _ ----'-'� v T9SS=1UU9 ACORD CORPORATION. All rights reserved. The AC ORD name and logo are registered marks of ACORD Sub -Contractor List Electrician: Geoff Pike Electric Corp 67 Springvale Ave Lynn, MA 01904 HVAC: *WC Certificate Attached Dan Stevens HVAC 60 Bulfinch Road Lynn, MA 01902 *WC Certificate Attached Plumber: Parsons Plumbing and Heating 3 Fulton St Methuen, MA 01844 Tax ID: 04-3415637 ACORD. CERTIFICATE Y INSURANCE04-1 DA E PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PAYCHEX AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 210705 P : () - F:()- ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 308 FARMINGTON AVE FARMINGTON CT 06032 INSURERS AFFORDING COVERAGE INSURED INSURER A: Hart ford Casualty Ins Co INSURER B: G PIKE ELECTRICAL CORP INSURER C: 67 SPRINGVALE AVE INSURER D: LYNN MA 01904 INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'NS" TYPE OF INSURANCE POLICY NUMBER DA Y M!D mE I PpA Y MM"'DD N LIMITS 30 DAYS WRITTEN NOTICE (10 DAYS FOR NON-PAYMENT) TO THE CERTIFICATE Contemporary Builders, Inc 200 PARK ST HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. NORTH READING, MA 01864` AUTHOR ENTATIVE� GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $ CLAIMS MADE u OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY 5 GENERAL AGGREGATE I $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY I I JRCT I I LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) I ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE UARILITY AUTO ONLY - EA ACCIDENT 5 ANY AUTO OTHER THAN EA ACG $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR u CLAIMS MADE I AGGREGATE $ IS DEDUCTIBLE $ RETENTION S $ X WC TATU SJIMIT DER WORKERS COMPENSATION AND V E.L. EACH ACCIDENT $100,000 A EMPLOYERS'UAMUTY 76 WEG H07940 05/20/09 05/20/10 1.00,000 E.L. DISEASE - EA EMPLOYEE $1.00 ' E.L. DISEASE - POLICY LIMIT I S5 0 0 , 0 0 0 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VENICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Those usual to the Insured's Operations. UtKI IP'IUA It: MULUtK I 1 ADDITIONAL INSURED: INSURER LETTER- UANUELLA I IUIV AL:UKU Z5 -s (nai) 0 ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE (10 DAYS FOR NON-PAYMENT) TO THE CERTIFICATE Contemporary Builders, Inc 200 PARK ST HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. NORTH READING, MA 01864` AUTHOR ENTATIVE� AL:UKU Z5 -s (nai) 0 ACORD CORPORATION 1988 r DATE(ANdAOA'n"n ACO$QI. CERTIFICATE OF LIABILITY INSURANCE 1/6/200 ooucER THIS CERTIFICATE a ff4wo AS A MATTER of INFORMATION ONLY AND CONFERS NO MGM UPON THE CERTIFICATE Lib Insur&ra Agency, Inc. MOLDER. THN CERTIFICATE DOES NOT AMEND. RD OR MCI rose i6 Central Ave. ALTER THE COVERAGE AFFORDED BY THE Pou ,ynn, MR 01901 INSiJRERB AFFORDING COVERAGE NAICO 181-592-920-0 ; Stevens, Daniel R. � Pr ca l�tnal � d/b/a Dan Stevens Electric A EVAC "sem e. 8 Lfo In urea 60 anlfinch Rd. INSLIRHt Q Lyem, 14A 01902 INSURER D: NSVRER E THE INMED THE R�fC TE OR CCOONNDMON OF � CONTRACTORD THER OOCUMENT VMM RESPECTTOO P�M TTHIS PERIOD INDICATED. TE MAv � IOR MAY PERTAIN, TK INSURANCE AFFORDED BY THE SES DESCRY HERON 15 SUBJECT TO ALL THE TER41S, EXCLUSIONS AND CONDITIONS OF SUCH POLOM AGMEGATS LIWTS SHOWN MAY "AVE BEEN REDUCED BY PAID CLAW. — over , ..ore MAL LIABLRY COSMOERCIAL GecA L LwKITY CLAIwSw M 0 occult ICCP0063171-02 111/15/09 111/15/09 t AQORECATE LIWr APPLES PER ANVAUTO ALLOT MMATTOS SCHMULED AUTOS IIIRlD ATOS wa IMbLITY ANYAITO excESSM1Mb�iW LUMUTY OCCUR [D CLAWSMADE Dscuc?w RETENTION S WOES rail olN6AMONAsia EWLOVERV UAB0.RY B arf4cow4lowwo VCLUNW Electrical C,=tx&CtOr HVAC Contractor I COM8M SINGLS IJw I s (E. nc0dMAl BODILY"AIJRY = (Pn psnon) BODILYNJURY s (PanCddrfli PROPERTV DAMAGE t p«.00awnl AUTOONLV•EAACCwm Is DTHERTMAN EAACC I $ AUTOOIAr, AWG S CACN OCCURRENCE Is s s 081MCRI7884� 11/24/08 111/24/09 f.L.EACHACCIDENT Ed E.L. DISEASEE#s-0 - EA LOY s ContwWorary Sufiders, Inc. 200 Park St. North Reading, MR 01864 Pax: 978-664-8415 SHOULD ANV OF THE AMC DESCREED fOLIOEs K CANCELLED MR= TME EXPIRATION DATE THIEREDF, THE ISAINO NBURER MAIL ENDEAVOR TO MALZO DAYS WRITTEN NOTICE TO THE CERTIFICATE HDLOER NAMED To THE LEFT, BUT FAILURE TO 00 SO SMALL WOSE NO OBLIGATON OR LUWIUTV OF ANV MND UPON TIE NSURER. ITS AGENTS OR OACORD CORPORATION 01/06/2005 12:13 FAX 18766633147 M.P.ROBERTS INSURANCE ►BU01 CERTIFICATE OF LIABILITY INSURANCE 9MR44M USTEDBELOW HAVE BEEN MUEDTOT14:MMED NAMLEDABONEFORTHE POLICY PERIOD INDICATED. N01Wrt'►11TANOUG ANY REOLO 1/6/00 PRawoM THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION M.P. Roberts Inanrance Agency ONLY AND CONFERS 00 MGM UPON THE CERTIFICATE 3060 Osgood Street EXTENDOW BYTT POLICIES AL.�RTHEECCOVERAAGE AFFORDERTIFICATE D THE BEL North Andover, Nk 01845 A — INSURERS AFFOROBIG COVERAGE NAIL 4 �umm isum-L Iftrchants Mut al %range CO SHADN PARSONS DBA INSWeR a 802Brokeram In PARSONS Iy7d16anc i aEATlm MURERC r 3 FULTM 8M8! 4146U%R a ...... mz , MA 01844 INS R . THE PO1=SOF 9MR44M USTEDBELOW HAVE BEEN MUEDTOT14:MMED NAMLEDABONEFORTHE POLICY PERIOD INDICATED. N01Wrt'►11TANOUG ANY REOLO EW. TERM OR CONDITION OF ANY DOWRICT OR OTHER D=AlTR WRM RESPECT TO WHICH THIS C SITIFICATE VAY IE ISSUED OR My PERTAK TM MJRANOE AFFOROgI BY THE POLICIES DESCRIBED MOM IS SUBJEGY TO ALL THE TERMS. DULISION5 AND COIVTICM OF SUCH POI.CIES. A 41t MATE LIIM SHOWN MAY HAVE MEN REDUCED BY PAIDCiAW _ ^'PauarwM99l 4iLNtNartY EACH 000 00 A CMMMiRCYIIGGNEwLm9LXrY CCP9130023 6/27/06 6/27/09 s 100 0 0 eu►sAs NAGE ❑ OCCUR %ED aro am pwmI $ 5,000 PERSONAL&ADVINARY s 11000,000 _ GENERAL AGGREGATE !2,0pQ . ---000 tiMAGGTZ£GA76UWTAPPLESP£R PRODUCTS-COMPWAG6 i 2,000,000 Pa -Cy AuTOMORiUmurY CONBnm SPAILELMMT ANYA M IEG10C M) : _... ALLOVAftAUTOS . _ @0p� RY : SCHEDULED AUMS v�►P� aOGLYINJURY _ i NIRMAUTGL NONOWIEOAUTOS Prsockiwi+) P„ s GARACELVALIN AUTO Y-EAACCMM E OI•NERnUN EAACC i ANYAUM AUTO ONLY: ADO 3 rolf' iII IELLALMBEJPI EACH OCCURRENCE a AGGREGAna s Occas _ CLANS MADI s s 00=161E Camowilanca wC ATU• OTTi 8 ANY �ouT►� WCCSOCSI10012008 7/21/08 7/21/09 DOENr 500,000 �+oE�ortLloleaoT --I f : 50 0 E.L. .P LOW 500,000 0i1o"' DINER �ilCMki10NUFOERAl1OM6 1O011MISlY�ELBrlQOLUStON6A00®NiNDDI�IIIOIr) OIM1mn Certificate hold= is listed as an additional insured under General Liability policy fa:: 978-664-8415 SMUTA M IT OFTMAMPR ORICRrID►OLIVEr YECANG&JAD OWORE TNEEXPIRATON Cantesporary Builders OATS 140UW. TM ftWm IMBiE16t TALL 00MI OR To MAR A0 DAYS WNTIM 200 Park Street 111011 NE CEE nwcl rol(� �w SRR p sw►u North Roadiag, Dlal 01864 111won NO OELWIM OR Lwwlm TM p%&"K ITS AGENTS OR awam ENTM mrp, v�qJW'�M AUVQRI D KgRK F/TATAA= North r MA 91846 (978) SM073 AOORD 2S (20091M) ®1!1141-2009 AC rlghti rtssrvod. 1"w rw %mw m• ane 1090 SIT Tt gNROf00 w1M/RS Of AGORD February 24, 2010 James D. Smith, Architect 35 Lothrop's Ln. W. Barnstable, MA 02668 508-367-8920 Mr. Brian Leathe Building Inspector Building Department Town of North Andover 1600 Osgood St. North Andover, MA 01845 RE: Construction Control Affadavit Interior Remodel, Flight Landata Offices, 280 Clark St. Dear Inspector Leathe: This letter is to serve as my affidavit that I will perform construction control inspections on the proposed work at the corporate offices of Flight Landata at 280 Clark St. I will also provide an affidavit when I have done my final inspection and believe the work to have been completed and ready for occupancy. If you have any questions, please feel free to contact me anytime. Sincerely, James D. Smith, Architect, AIA Ld IL LO W z w co a - M LL LO m I�r LO LD co r - On LO O O O LD CD r- L 0 A= La cq O O O LD AlAs Document A105TM Standard Form of Agreement Between Owner and Contractor for a Small Project where the Basis of Payment is a STIPULATED SUM This AGREEMENT is made: February 10, 2010 BETWEEN the Owner: Flight Landata 250 Clark Street North Andover, MA and the Contractor: Lear Development Corp. 75 Main Street North Reading, MA for the following Project: Flight Landata 250 Clark Street North Andover, MA The Architect is: James D. Smith 35 Lothrops Lane W. Barnstable, MA The Owner and Contractor agree as follows. ARTICLE I: THE CONTRACT DOCUMENTS ADDITTONS AND DELETIONS: The author of this document has added information needed for its completion. The author may also have revised the text of the original AIA standard form. Any Additions and Deletions Report that notes added information as well as revisions to the standard form text is available from the author and should be reviewed. A vertical line in the left margin of this document indicates where the author has added necessity Information and where the author has added to or deleted from the original AIA text. This document has important legal consequences. Consultation with an attorney is encouraged with respect to its completion or modification. The Contractor shall complete the Work described in the Contract Documents for the project. The Contract Documents consist of- . I f:.1 This Agreement signed by the Owner and Contractor; .2 Qualification letter; Illustrates the contractors Scope of work .3 The Building Drawings and Specifications prepared by the Architect, James D. Smith and enumerated as follows: AIA Document A105TM — 1993. Copyright © 1993 by The American institute of Architects. All rights reserved. WARNING: This AIA ® Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA ® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document was produced by AIA software at 10:31:41 on 05/25/2005 under Order No. 1000167998_1 which expires on 3/9/2006, and is not for resale. User Notes: (280807682) Number Title Date A-1 Existing Conditions 1/29/10 Proposed Plans Reflected Ceiling Plan Specifications: Section Title Pages None .4 addenda prepared by the Architect as follows: Number Date Pages N/A N/A N/A written change orders or orders for minor changes in the Work issued after execution of this Agreement; and other documents, if any, identified as follows: ARTICLE 2: DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION The date of commencement shall be the date of this Agreement unless otherwise indicated below. The Contractor shall substantially complete the Work not later than TBD subject to adjustment by Change Order or Owner caused delays. Subject to receipt of payment for progress billing # 1, commencement of project will be TBD. Any delays caused by The Owner as a result of untimely payments, deliveries, responses, or unexecuted change orders shall result in a contract extension on a day for day basis at an additional cost of $000 per day. ARTICLE 3: CONTRACT SUM § 3.1 Subject to additions and deductions by Change Order, the Contract Sum is: $ 91,250.00 (Ninety One Thousand, two hundred and fifty dollars and 00/100) § 3.2 For purposes of payment, the Contract Sum includes the following values related to portions of the Work: n/a § 3.3 The Contract Sum shall include all items and services necessary for the proper execution and completion of the Work. AIA Document A105TM — 1993. Copyright © 1993 by The American institute of Architects. All rights reserved. WARNING: This AIA ® Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA ® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document was produced by AIA software at 10:31:41 on 05/25/2005 under Order No. 1000167998_1 which expires on 3/9/2006, and is not for resale. User Notes: (280807682) ARTICLE 4: PAYMENT § 4.1 Based on Contractor's Applications for Payment, the Owner shall pay the Contractor as follows: 20% of Contract due at the Signing of this document 30% of Contract due upon the rough mechanical inspection 25% of Contract due up in installation of sheetrock and carpet 25% of Contract due upon completion § 4.2 Payments due and unpaid under the Contract Documents shall bear interest from the date payment is due at the rate of (Prime + I%) per annum, or in the absence thereof, at the legal rate prevailing at the place of the Project. (Usury laws and requirements under the Federal Truth in Lending Act, similar state and local consumer credit laws and other regulations at the Owner's and Contractor's principal places of business, the location of the Project and elsewhere may affect the validity of this provision.) 4.3 All Change Orders are to he executed and paid for prior to actual work commencing. In the event that change order work commences without an executed change order form, The Owner shall assume full responsibility for all costs associated with additional work which will he billed at cost/plus 15% by the General Contractor. Failure to execute change orders and payment in a timely manner may result in additional delays. ARTICLE 5: INSURANCE § 5.1 The Contractor shall provide Contractor's Liability Insurance: § 5.2 The Owner shall provide Owner's Liability and Owner's Property Insurance: § 5.3 Certificates of insurance shall be provided by each party showing their respective coverages prior to commencement of the Work. ARTICLE 6: OTHER TERMS AND CONDITIONS The Following have not been included in the contract amount: • All work shall be performed utilizing non-union labor. • Permitting, state, local and federal back charges, fees and bonds are excluded. • Utility bills and charges are excluded. • Tap and/or impact fees are excluded. • Removal and disposal of haz-mat materials is excluded. • Police, Fire and Security details are excluded. • Building tie in fees, mall back charges not included at this time. • No structural work included at this time. AIA Document Al05TM — 1993. Copyright © 1993 by The American institute of Architects. All rights reserved. WARNING: This AIA ® Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA ® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document was produced by AIA software at 10:31:41 on 05/25/2005 under Order No. 1000167998_1 which expires on 3/9/2006, and is not for resale. User Notes: (280807682) • Casework and furniture by owner. • $4 a square foot tile allowance for new and old bathroom carried in bid • Unforeseen issues at new wall openings shall be identified to the Tennant and charged as a Time and material basis • Any work performed to the exterior of the building is not included in the bid and will be an extra charge • Owner will be responsible for the cost of all permits • Construction area in the hangar must be free of all property including planes, boats, equipment, cars, etc. Lear Development will not be responsible for any damage to these items during the construction process. • Alarm system and motion detector work is not included in this bid. Any work done to the existing alarm system will have to be done directly by the owners alarm system company. This Agreement entered into as of the day and year first written above. (If required by law, insert cancellation period, disclosures or other warning statements above the signatures.) :)11� C`\ I�V r M��It tur CONTRACTOR (Signature) (Printed name and title) (Printed name and title) AIA Document A105TM — 1993. Copyright © 1993 by The American institute of Architects. All rights reserved. WARNING: This AIA 0 Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA ® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document was produced by AIA software at 10:31:41 on 05/25/2005 under Order No. 1000167998_1 which expires on 3/9/2006, and is not for resale. User Notes: (280807682) Massachusetts - Depattmcnt of Public Safet% Board of Building Re-Ulations and Standards XW Construction Supervisor License License: CS 102321 Restricted to: 00 SHANE PERRAULT 2 VINE STREET MEDFORD, MA 02155 �i--�-- �- -� Expiration: 5/1/2013 ( unmi..i rocr Tr#: 102321 Restricted to: 00 00- Unrestricte 3 I G - 1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS a H 44 U] p OD , •r -I r -I . O �. E! • ,. tCf ro � -d a \61 0 p 44 `may' Lt.LL •3 L c� q U1 4 o 4'R v. u fkT Wn s o " W O A Ul V � C6 'b N O � •T u u h AD .' 4jv ,� 0 Z � a cu b -d •HI f4 .ri p Ili 3 N ::j b v u ►� N > U] u N u cd 5 ro b � u c ►m F1 O F=4 0 h a z � a A � c v � o u z a 0 m a A O x O w v cn a c G p w m O a -Cr. U w" a m—cz rs: w" a w x a: cn w d tov w w w w cA z cn Q O co r W o as c OO v GJ .n C d ea ev m C ca m y a Yd m Q s C m x tsv ...ID Z �jo C t16- om O aFcoca =0 � ` Ss cm �O ID E fA W ` 4 O� GO v/ h 3 `� FL m V= y H C=u EGO vCD 0 cm !yl H D m CC • coGO a .� o `► v N O O A Z V� c0 Q � v � m C •p = m •. LLJ c0 � r=...�= t LL m m !2E •O �..' LO c Z W, 5 IS o VO O m C L4 d mCLM O :0 _ S arm O Z O U C/) r O O Q L O 'S w Z CD o. O y cm CA CD D O 0 gCOD m m L- 0 CD H = CL _ .�... CD O C O L Q Q d CL �a COD C o *-0 c Q Q v J .� CL O •�+ C Z ca CL V CO) Q C C C _Q CL CO2 G 0 Datel . ........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................... ?..I......................... ll-� ........................................ has permission to perform ........... 'Of ��-�. wiring in the buildinj . ........ . .......................... at . .......... ...... . . ....... North Andover, Mass. Fee/r;Z5 ............ Lic. No. ............... ;E ICAZ LN6 Check# 855 � r Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. — BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked�2 [Rev. 1/07] APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: I.— i�� City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her ffintentionnA perform the electrical work described below. Location (Street &li;�� Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building NO ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity and Nature ofP�oposed Electrical C,om tetion of the followin table may be waived b the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Sus No. of Total p. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- o. o in rgeney tg g rnd. rnd. ❑ BatteryUnits — No. of Receptacle Outlets No. of Oil Burners FIRE AL ARMS No. of ones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number .Tons KW No. of Self -Contained Totals: Detection/AlertingDevices No. of DishwashersSpace/Area Heating KW Local ❑ Municipal Connection ❑Other No. of Dryers Heating Appliances KW Security Systems:* No. of water No. of No. of Devices or Equivalent Heaters' No. of Data Wiring: Si s Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total Hp Telecommunications Wiring: OTHER: No. of Devices or Equivalent 1 Estimated Value of Electrical Work: to Attach additional detail if desired, or as required by the Inspecr of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER I certify, p ❑ (Specify:) under thepains andpenalties of perjury, that the information on this application is true and complete. FIRM NAME: ilk YA-r'- c� r<„ ��l �, A , , -� IC - Licensee: LIC. NO.: -70 Signature (If applicable, enter ” empt " in th license number line.) ' NO.: T l Address: C't G VVI ('('?�i7C' Bus. Tel. No.: �tfr t'(! *Per M.G.L c. 147, s. 57-61, security work equines Dty Alt. Tel. No.: N5 l,r5 License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Lecens e does not have,the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. S r The Commonwealth of Massachusetts i 1 Department of Industrial Accidents .�' Office of Investigations f 600 Washington Street .�4 Boston, MA 02111 {' 1 www-mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers Applicant lnfnrr..afin.. Name (Business/Organization/individual): Address: City/State/Zip: Phone Are you an employer? Check the appropriate box: 1. ❑ 1: aro a employer with 4 ❑ I am a general contractor and I Type of project (required): employees (full ancUorpgrt-time),* 2. ❑ 1: am a.sole proprietor have hired the sub -contractors listed 6. ❑ New construction 7. or partner- on the attached sheet. $ ❑ Remodeling ship and. have no employees working for me any capacity. These sub -contractors have 8. (] Demolition .in [No workers' comp. . insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.] 3. ❑ I am a homeowner doing officers have exercised their 10. F1 Electrical repairs or additions all work myself. [No -workers' comp, right of exemption per MGL C. 1.52, § 1(4), and we have no I I -M Plumbing repairs or additions insurance r required.] t �1 ] employees. [No workers' 12.[] Roof repairs comp, insurance required_] I3.❑Other *Any applicant that checks bob# t r must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating ;Contractors that check this box must such. attached an additional sheet showing• tike nam_of the sub-contr c o a and their workers' comp. P Policy irformadon. I ant an employer that is providing workers' compensation insurance for my employees; Below is the policy and job site information, Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: . City/State/Zip: 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 under the pains and penalties ofperjury that the information provided above is true and eorred cial use only. Do not write in this area, to be cr►mplated by city or town officio( City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information a ind Instructions ` Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. *However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dweiling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work =til acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation. affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not'the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, pleas,: call the Department at the nu-nber listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which tiA ill be used as a reference number. in addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.govIdle Date. Of TOWN OF NORTH ANDOVER o PERMIT FOR PLUMBING ,SSACHUS� This certifies that /.�«.► has permission to perform ...:.` ........... . plumbing in the buildings of .................... at ..2 ......j -0.. � ........ � .......... , North Andover, Mass. Fee .'2 3...... Lic. No.. C -,a . ......... . ....... . PLUMBING INSPe6TOR Check # � � i I PIXTIIR C MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING Cit /Town: dover Y Date: 101/15/2009 Permit# -�. Building Locatic 250 Clark St Owners Name:'9ht Landata Type of Occupancy: Commerciale Educationah Industrial InstitutionalResidential�/ A/ New: Alteration: Renovation Replacement: 1/ Plans Submitted: Yes ' No PIXTIIR C INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liabilityinsurance olic p YA Other type of indemnity 1 _ Bond 0 OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner 11Agent By checking this box ❑; I hereby certify that all of the details and information submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and ins ations ed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State P! in C e an a ,r 142 of the General Laws. By Type of License: Plumber Title Gas Fitter Master Cityrrown Journeyman APPROVED (OFFICE USE ONLYI LP Installer of Licensed Plumber/Gas Fitter License Number: 9875 W W Z ~ N N N V M = 0 W O W V to H 1-- N W W W Z I— N W U.8 W z o W m O Q~Q z iY 0 FQ- CL H W W � z M a X tL Lu IXW V Z W W O W Z_ = N W O G M H W O W d� W W Z W L) o c i'L N _j O C9 Q~Q =_ a~ m W O > no g o Z �a O ~ F O uNj Z W> Q 3 Q s Q '0 a oc I— >> 3 0 SUB BSMT. BASEMENT 1 FLOOR I 2 FLOOR 3 FLOOR 4 FLOOR STWFLOOR 6 FLOOR VH FLOOR 8 FLOOR -,"• __ �... Installing Company Name: Climate Design Heating AC L L.0 Check One Only Certificate # i �_ _ Address:i 5 South Summer St CityITown � Bradford State: MA Lid Corporation [w2884C r Partnership LI Business Tel: 978-373-9999 Fax r- Firm/Company:. Name of Licensed Plumber/Gas Fitter:i Glenn Bosteels INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liabilityinsurance olic p YA Other type of indemnity 1 _ Bond 0 OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner 11Agent By checking this box ❑; I hereby certify that all of the details and information submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and ins ations ed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State P! in C e an a ,r 142 of the General Laws. By Type of License: Plumber Title Gas Fitter Master Cityrrown Journeyman APPROVED (OFFICE USE ONLYI LP Installer of Licensed Plumber/Gas Fitter License Number: 9875 NORTh • OL 9 SSACMUS� Date �..c:;?-3'..��...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that�.`./ ........` } ...............`....................................................... has permission to perform wiring in the building of ....... ?:'-�'� :...................... -.b. � ..................f.... . North Andover Mass. at .......... (�........ .............. Fee!�"�...G ... ..... Lic. No4,0e 1. ? �............ criac INSPE R Check # 9298 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /2; L 00 Occupancy and Fee Checked f Lev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.000 WORK (PLEASE PRINT INWK OR TYPE ALL PVF0)?,jf O City or Town of. NORTH ANDOVER pate: By this application the undersigned gives notice of his or her intention to To the Inspector workes Wires: below. Location (Street & Number) :, J (� C �^ S' Owner or Tenant �� � yh„i• Lk�►�5�`� ' Owner's Address s' Telephone No. Is this permit in conjunction with a building permit? Yesn ' Purpose of Building l ,. Ll� NO ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires Corn letion o the ollowin No. of CeiL-Sus p. (Paddle) Fans table m be waived bY the Ins ector of Wires. No. of No. of Luminaire Outlets No. of Hot Tubs Transformers Total KVA No. of Luminaires swimming Pool Above❑ In- d. Generators KVA o. o mergency g No. of Receptacle Outlets p� d• No. of Oil Burgers g Babe Units No. of Switches � . �`-h`IS No. of ?.ones No. of Gas Burners No. of Detection and No. of Ranges No. of Air Cond.otal Init,a Devices No. of Waste Disposers eat PTons ump umber Tons KW No. of Alerting Devices Totals: o. of elf -Contained No. of Dishwashers Space/Area Heating KVF' Deteetion/Alertin Devices Municipal No. of Dryers Heating A Appliances Local ❑ Connection Other o. of Water Heaters' KW No. of No. of Security Systemic:* No. of Devices or E uivaleat Signs Ballasts. Data Wiring: 40. Hydromassage Bathtubs No. of Motors Total Hp No. of Dices or E uivalent Telecommunications Wiring; ETHER No. of Deviceic nv- r.,..:—l— Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start - a �lL_ Inspections to be requested in accordance with MEC Rule 10, and upon completion INSURANCE COVERAGE: Unless waived by the owner, no Pmt for the performance of electrical work may issue unless the licensee _provides proof of liability t3 insurance including completed operation" coverage or its substantial equivalent The fined certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (�/�OND ❑ OTR I comfy, under the pains and penalties o e13 ❑ (Specify:) FIRM NAME: . fP I ry, that the information on this application is true and complete. f�'J,Q � I eG ^r� •� ` CU Licensee:Cj Q tSiatureLIC. NO.: a (If applicable, enter. , exem t in the license number line.) / LIC. NO.: Address: ') Bus. Tel. No.; *Per M.G.L c. 147, s. 5 -61, securi��rwires D OWNER'S INSURANCE W apartment of Public Safety "S" License: Alt. Tel. No.: AnrER: I am aware that the Licensee does not have the liability Lic. No. required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑owner coverage normally Owner/Agent Signature ❑ owner's agent Telephone No. PERMIT"'`' I I The Commonwealth of Massachusetts 04 ! Department of Industrial Accidents Qjfice of investigations a.a 600 ff r hind ton Street gosl:`orc, MA 02111 Workers' Compensation Insitrance Affidavit.- BWlder /Contractors/Electricia Applicant Iaforn ration ns/Pinmbers Please Print LeQibl Name (ausjn dGrMi28f7onAndividuaJ): l=lPcCC/ ) Address: i J �,•y,,� City/State/Zip: L��,,:. UrSc�i Phone # Are you an employer? Check -the appropriate box: I • am a employer T of withType ___2_ 4. ❑ I am a general contractor and I p�1 (ret{airef�: 2. Qernployees (full and/orpart-time).*have I am .s.so}e proprietor or hirede s� 6. ❑New construction partner- ship and have no employees listed on the attached sheet t 7. ❑ Remodeling working forme .in any capacity, These sub -contractors have worker,' insurance. g' Q Demoiitien [No workers' comp. insurance comp. 5. ❑ We are a corporation and its 9• ❑ Building addition required ] 3. F1Electrical I am a homeowner doing all work officers have exercised their 10 Q or additions right of exemption MOL TYself. [No -workers' comp. insurance Per 1 I ..Q c. IS Plumbing repairs or additions 2, § I (4), and we have no d ] t .employees. [No workers' 12.❑ Roof repairs 'Any applicant char comP• insurance-mquired_] 13.Q Other 1 H__j dtbmi this ff t mast also fill out the section below showing their workers' bomponsetion Poi icy information. omeowners who submit this atitli suit indicating they am doingall �'O 4Cantructors that and then hue outside contractors must submi check this box must etrached an additioual sheet showing. t a new affidavit indicating such 6 e rtEme of thG svb.cotteeF p_d {�..� 1 w. E. I ant an employer that is' m ' " ,�`=:p f;I iniaMunion. l ormatiort, p tg workers compertsatlon fnssrrrancefor �' enrptoyeeS; � r1ow is the policy ata h ,rite Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date. Job Site Address: Attach a copy of the workers' City/State2tp- eom PeomtiOD 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 er annina fine up to $I,500.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WO 1 Penalties of a' of UP to 5250.00 a day against the violator. Be advised that a c RK ORDER and a fine Investigations of the DIA for insurance coverage verification, copy of this statement may be forwarded to the Office of Ido hereby cerin under the pains and penalties o ' ffP er!w' that the inYormatiDn provided above is true and co Si ttae: rreet Phone Date: U Ofjl`IcW use only. Do not write uz this area, to be completed npP . by. do or town official City or Town: Issuing Permit/License # b Authority (circle one): I. Board 6.Othei• of Health 2. Building Departmeut 3. City/Town Clerk 4. Electrical inspector S. Plumbing Ins r pecto Contact Person: Phone #: �i r March 17, 2010 James D. Smith, Architect 3 5 Lothrop's Ln. W. Barnstable, MA 02668 508-367-8920 Mr. Brian Leathe Building Inspector Building Department Town of North Andover 1600 Osgood St. North Andover, MA 01845 RE: Interior Remodel, Flight Landata Offices, 280 Clark St. Dear Inspector Leathe: I understand you had told Lear Construction that it would be alright with you if they used wood to frame the new offices at Landata as long as you had a letter from me, now that we know the existing building is framed completely with wood. This letter is to certify that I see no issue with the new construction being of wood, particularly given that the building has sprinklers. If you have any questions, please feel free to contact me anytime. Sincerely, James D. Smith, Architect, AIA Date ../,:� `1,14/. ...... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION this certifies that ...S`.c � a ....� �. N ................ . has permission for gas installation .. F�-.a N f9 ! ............. in the buildings of 1' (0 J."k. /-/.-/ .......... at ...... , North Andover, Mass. Fee..- .a �� Lic. No../. ? YG �, ...... GAS INSPECTOR Check # L 73u1,1 MASSACHUSETTS UNIFORMAPPLICATONFORPERMITTODO GAS RI TING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations _ 70 C,(A r 1( 5 f Permit # Amount $ Owner's Name New Renovation Replacement Plans Submitted ❑ (Print or typ Name I r S� r_ 5 �G Address ) i� U o --, • S q Name of Licensed Plumber or Gas Fitter S i 1 /1./ "., Ay 5 Check one: Certificate Installing Company ❑ Corp. Partner. 11;r YCo. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No V If you have checked 3es, please ' cate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the -licensee does not have the Insurance coverage required by Chapter 142 of -the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town •APPROVED (omcEusEONLY) Signature of Licensed Plumber Or Gas Fitter 0 Plumber 1 a-LJ6 Br— Fitter License Number Master ElJourneyman - � w a o W F4 O U D C4 tf F• rig EW tx p 4 O O W F - d P� O W - H Ri W a4 ] U MG-MO. WU cU< Y A CUz7 aOFr 0 SUB-BASEM ENT Q.zo O BASEMENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLO O R 7TH. FLOOR 8-THOOR (Print or typ Name I r S� r_ 5 �G Address ) i� U o --, • S q Name of Licensed Plumber or Gas Fitter S i 1 /1./ "., Ay 5 Check one: Certificate Installing Company ❑ Corp. Partner. 11;r YCo. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No V If you have checked 3es, please ' cate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the -licensee does not have the Insurance coverage required by Chapter 142 of -the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town •APPROVED (omcEusEONLY) Signature of Licensed Plumber Or Gas Fitter 0 Plumber 1 a-LJ6 Br— Fitter License Number Master ElJourneyman The Commonwealth . � h of llfassachusetts Department o f Industrial Accidents Office of Investigations 600 Washington Street Boston, A" 02111 www mass gov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Annhranf inf.,.-.r..,�:,.,. Name (Business/Organization/Individual): b AraJ,.�S Address: City/State/Zip: ,r`� -e r Ii,y. — ,r) !S o i � 4 y Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 0ployeesand/orpart-time).* have hired the sub -contractors m(full 2,a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' c9mp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other vuc i.uc sccuc^ De!O!?� Sn^!y!Yb T. ^ar C: C:':; ' CQm:3eRS:.*.I�JEi pO1SCy :nforma-hon. 1 Home eowners 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance information. for my employees Below is the policy and job site Insurance Company Name: AS Sac., eNi c') Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: L) City/State/Zip: 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 under thepains and penalties of perjury that the information provided above is true and correct Sionature: ✓n Date.: -1 hxt 1. , Phone #: F ial use only. Do not write in this area, to be completed by city or town offciaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. PIumbing Inspector Phone #: Information and Instructions . V `� Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or. other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or.the occupant of the dwelling house of. another who employs persons to .do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter .152,- §25C(6) also states that "every state or local licensing'agency shall withhold the issuance'or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of coxnpliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work uncal acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please 511 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with.no employees -other than the members or partners,. are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be. returned to the city or town than the application for the pereitor license .s being requested, not the Department of Tndustrial Accidents. Should you have any questions regarding the law or if you are required to .obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a- space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to -thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington, Street Boston, KA 02.111 Tel. # 6.17-727-4900 . ext 406 or 1-8 77-MASSAFE Revised 5 -26 -OS Fax # 6.17-727-7749 www.mass._govfdia Date .... `�....� :..(� ... a s f NOR7M , "� TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING 41 Thiscertifies that............................................:.............................................. has permission to perform .. -.:.. 7 % ' ... 61 wiring in the building of ......... p.:. �- ............................................................ S v (�,�(; at ................. �...................................................... ,North Andover, Mass. Fee . ........ Lic. No. .................................. ELEGTRicAL MpECTOR Check # /7- ✓ 45 0 THEC01 MONWEALTHOFMASSACHUSETIS Office use only DEPARTAffi 'OFPUX1CSAFEH Permit No. BOARD OFFIREPREVEWONREGUTAHONSR7CM 12:00 Occupancy & Fees Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 f (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires The undersigned applies for a permit to perform the electrical work described below. Location (Street b Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes[::] No ®..• (Check Appropriate Box) Purpose of Building Utility Authorization N Existing Service AmpsVolts Overhead Underground No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work SPr; g r,4--4 6 f} -;1'4E_ No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA is _ round eround No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets 1 No. of Gas Burners FIRE ALARMS No_ of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No_ of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No: of Dryers Heating Devices KW El Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP i IFA C -Q. • .r n::• • • •• • • I • itr D► 1 i•1,0111,r ON .1 Rough // /!y ah�eofDearicaI $ •" • r . , ,r., u. o z - AlTei No. OWII'SINSURANCEWAMT,I awatetha ftLmwdoesrlothavetheir>ammcow agecritsataualegtuvalaYasw4medbyNigmc lusettsGertaalUws and thatmysigr ahueonthispemritapplicationwaivl?sthisregtmmult (Please check one) Owner Agent . Telephone No. PERMIT FEE Signature ot Uwner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Afdavit Name Please Print Location: Cit ry Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City. Phone #: Insurance. Co. - Policy At Company name: Address City- Phone # Insurance Co. Policy # Failure to secure coverage as required. under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1, 500. oo arxYor one years' imprisorrrent -welLas_c 7 penatiiesmlheivun-da-SIQPY4DRICARD)=Rarx/-aficie-d-(S1D0 DD)-aiday agaitffw I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do hereby cwW under the pains and pernallies of pegwy that the information provided above its ave and correct ` Signature Date r Print name Phone.# Official use only do not write in this area to be completed by city or town dficiar City or Tawn PerrrrdAker s nct El Building Dept ElCheck f immediate response is regured [J Licensinq Board E] Selectman's Office Contact person: Phone #. E] Health Department F1 Other Location 2 SZ CSA Q K ez-,� No. Date 3r T- ' 7926 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fe CY $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP 4J0. LOT NO. I 2 RECORD OF OWNERSHIP :DATE BOOK :PAGE 1 ZONE SUB DIV. LOT NO. 7 LOCATIONd �( �s�. PURPOSE OF BUILDING 'o/ 'CF — c uA�C�f.�/O✓-diet OWNER'S NAME fp N�,� •�/J NO. OF STORIES l SIZE bWNER'S ADDRESS/3/ CleN 6ywr YT/ /r � O 1�J SSG O �?-s-G� / BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME [ w SPAN DIMENSIONS OF SILLS "' POSTS DISTANCE TO NEAREST BUILDING DISTANCE FROM STREET DISTANCE FROM LOT LINES — SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION w! IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE �({s IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONSIV�lts�6O� (i(JO r% QN/� 3 PROPERTY INFORMATION l LAND COST SEE BOTH SIDES `L .�- �{cvSti fA'<< (GBitl� EST. BLDG. COST `:!190 f9 PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR AUTHOR f AGENT F E E PERMIT GRANTED 19 qS INSPECTOR OWNER TEL. # i CONTR. TEL. N CONTR. LIC. # d f 3 7 3 H.I.C. a BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION _ —{ 8 INTERIOR FINISH CONCRETE PINE d 1 _ 2 I3 CONCRETE BL K. BRICK OR STONE HARDW D— PIERS PLASTER DRY WALL UNFIN _ 3 BASEMENT AREA FULL If FIN. B'M'T AREA '/ '/t 1/1 FIN. ATTIC AREA _ MO B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS II 9 FLOORS CLAPBOARDS B 1 2 �_ 3 _ _ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ HARD\V'D COMMCN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON MASONRY ATTIC STRS. 8 FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I�POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I GAMBREL FLAT I HIP BATH (3 FIX.) MANSARD TOILET RM. (2 FIX.) SHED WATER CLOSET _ _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING I) 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 8 COLS. STEAM STEEL BMS. 8 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2m! _ let 13rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. in CN r4 O IM04 �1 �: co Si c H O C �• V V \J n c :eaR c Co o o i m Ea :mCE '++ o n CA : 0 m s 1 o T o Q: Z n n.m c l� n • N �(Am N y .CD3 CD m a m + N R CD CD 0 nC3 i zy= C C Oct m o� 3 Q • �•�z ;ec�o a y nc H o C y,,, Fo- n •+ N O �0.. W c �r=•+�Z LL o D .. c .. 'N •n= cc= C O y-.. O °C •E w = w N v m wo o2 c Vi n O O :a FE•O cc y •O F- t .2n4m J z 0 U rn 0 W CO O co L O O v Z CD O. O CO) CO tm CO) O. - O — yMMO SMMO W W CD 0 CD CL y... CD R � O i � CD 0 o CJ M 00. CL tmQ •Y CY C.3 J� CL. ZCD CD 0 CL C..2 CO) c C R CO)CL 0 z 0 Q ''LU^ VJ Z 0 U pe� LU CL cc F - z w Q LU . J Z uj Q cr LLI W U) u ti LE N C C/) .a LQ C ° '� G wo 1:4U y G m w O (� twu o � m w O U W � (n c w o 9o4 m w w W v cm' � 2 V) 0 i o cn O IM04 �1 �: co Si c H O C �• V V \J n c :eaR c Co o o i m Ea :mCE '++ o n CA : 0 m s 1 o T o Q: Z n n.m c l� n • N �(Am N y .CD3 CD m a m + N R CD CD 0 nC3 i zy= C C Oct m o� 3 Q • �•�z ;ec�o a y nc H o C y,,, Fo- n •+ N O �0.. W c �r=•+�Z LL o D .. c .. 'N •n= cc= C O y-.. O °C •E w = w N v m wo o2 c Vi n O O :a FE•O cc y •O F- t .2n4m J z 0 U rn 0 W CO O co L O O v Z CD O. O CO) CO tm CO) O. - O — yMMO SMMO W W CD 0 CD CL y... CD R � O i � CD 0 o CJ M 00. CL tmQ •Y CY C.3 J� CL. ZCD CD 0 CL C..2 CO) c C R CO)CL 0 z 0 Q ''LU^ VJ Z 0 U pe� LU CL cc F - z w Q LU . J Z uj Q cr LLI W U) 1 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section*******r*********y* APPLICANT: Phone 6oi- 16 LOCATION: Assessor's Map lumber Parcel subdivision /,9, / Lot(s) P19treet �y �l� ��l - St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit C-�_rire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date lw W Q N 0 W CID � J a 0 O V- � v Q W m N Q a LU U) COm m Com' V) 7 uj Ce .7� "T_ d tJ � H F'- J FOLDAL:ll LING_- hZ 0 Z SJJ e - U k` +4 H-? 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