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HomeMy WebLinkAboutMiscellaneous - Exception (243)Lzr 0 / \ \ 7 / / / 0 D0 0 \ / 0 $ R 0 �k 0 / \ § = c 0 � (D \ / 0 m-' \ 0 co c / f / n 0/"' § 0) � / 2 f \/ » C n 0 M k � © _ 0 ' k - / � $ ° ' _ 0 ' f n c � 2 r ® o £ O ] . \ _ \ _ -M ¥ _ § \ 5 ° _ ] Q m 2" v 0 0 5 $ o 0 2 2" -n & = n j/ k /)/ /% E CL r 0 a 0 2 k 2 c - 9 - / g 2 L C) % 0 / ) ® ƒ 2 § § � 3 _ / 0 E / o °Ln § / F" Ln q J � w= m n tj o } \ D / / CD 7 / \ / \ ƒ . . f � \ 2 . o ® . / g a - Un I \ 0 \ J \ \ \$\% ƒ.- \ 2 f $ 0 I% 0 Z� m O 7� i \ / ƒ % / \ n \ f \ . / / § / / \ & ® \ � 0 0 G P 2 \ \`/ 0 § 0) � / \ k ƒ• \ f % \ ? M o w E /0 \ƒ \ o \ ƒ ) / a p % 0 o ] I v 0 Q- r Town of North Andover Office of the Planning DegartnMECT 15 F►l 4 1 G Community Development and Services Di Piton 3.600 Osgood Street � North Andover, Massachusetts 018451A G:;:',�;, Any appeal shall be filed within (20) days after the elate of filing this notice in the office of the Town Cleric. NOTICE OF DECISION Date., October 3, 2007 Date of Hearings: August 12, 2007, September 4, 2007,.and October 2, 2007 Date of Decision: October 2, 2007 Petition of: Thomson Brothers Industries (IBI), Inc., 210 Holt Road., North Andover, MA 01845 Premises Affected: 210 Holt Road, North Andover, MA within the Industrial -2 Zoning District, Assessors Map 34, Parcels L27, L38, L40 & Map 77, Parcel L14. Referring to the above petition for a Site Plan Review Special Permit from the requirements of the North Andover Zoning Bylaw, Sections 8.3, 10.3, and 10.31 and MOL C.40A, Sec. 9 So as to allow_ the construction of a 30,000 s.f'. recycling and solid waste transfer station, extensive grading, lighting pian, landscape improvements, drainage easement, and other improvements within the Industrial 2 Zoning District. After a public hearing given on the above date, the Planning Board voted to APPROVE A SITE PLAN REVIEW SPECIAL PERMIT based upon the following conditions: Forth Andover Planni oard Abutters J Richard Nardella, Chairman Bohn Simons, Vice Chairman Surrounding Tawris` Jennifer Kusek Tim Seibert, Alternate BIdg. ZBA Con/Com Health Fire Chief Police Chief Town Clerk DPW/Engineers TBI, Inc., 210 Holt Road • Site Plan Review Special Permit October 2, 2007 �''; V E The Planning Board herein approves the Site Plan Review Special Permit for the construction of a 30,000 s.E recycling and solid waste transfer station, 76 total parking spaces, extensive MW0115 "0019 16 plan, landscape improvements, drainage casement, and other improvements shown on the "Plans" as defined below. The project is located in the Industrial 2 Zoning District and is located_ oh �real'prpperty shown on the North Andover Assessors Maps as Map 34, Parcels L27, L38, L,40 &�fY�{(ay' 77, P' icel LI4 ♦ A 1 .� consisting of approximately 7.79 acres {339,332 s.f.) pf Land with approximately 9G4 1ineitr feet of total frontage on Holt Road. The Site Plan Review Special Permit was requested TSI, Inc., 210 Holt Road, North Andover, MA. This application was Fled with the Planning Board on July 5, 2007. The applicant submitted a complete application which was noticed and reviewed in accordance with Sections 8.3, 10.3, and 10.31 of the Town of North Andover Zoning Bylaw and MGL c.40A, sec. 9 During the review process, the Applicant and its professional consultants also submitted various revisions to the plans along with various supplemental memoranda and correspondence in response to requests by the Planning Board, the Board's peer review consultants, and by the various departments within the Town of North Andover that reviewed the project. All of these plans, reports and correspondence are contained in the Planning Board's files and are hereby incorporated by reference into the public record for this hearing. 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) On June 22, 2006, the North Andover Board of Health approved the Site Assignment Decision for the proposed 30,000 sq. ft. recycling.and solid waste transfer station to be located on 5.8 acres of land and shown on lots labeled 2, 3, and 4 on the "Plans" as defined below. The requirements and conditions contained within said Decision are hereby incorporated by reference into this decision and public record. 2) The specific site is an appropriate location for the project as it is located in the Industrial 2 Zoning District and involves the construction of permitted uses within those zones. Specifically, the Zoning Bylaw allows in the Industrial 2 District the following use (North Andover Zoning Bylaw, Section 4.133(11)): Light manufacturing, including manufacturing, fabrication, processing, finishing, assembly, packing or treatment of articles or merchandise provided such uses are conducted solely within a building and further provided that such uses are not offensive noxious, detrimental, or dangerous to surrounding areas of the Town by reason of dust, smoke, fumes, odor, noise, vibration, light or other adverse environmental effect. 3) The use as developed will not adversely affect the neighborhood as the project is surrounded by other industrial uses and zoned properties and will not 'impact any residential areas or neighborhoods. In addition, the project provides for natural a vegetative landscaped buffer along the frontage of the properties to further insulate the building. All plantings and screening depicted on the approved plans referenced herein shall remain in perpetuity over the life of the project. 4) There will be no Nuisance or serious hazard to vehicles or pedestrians. The proposed parking lot design and accesslegress drives provide for adequate internal and external traffic Mow, safety, and sufficient pedestrian connections throughout the project and surrounding area. Traffic impact studies have been conducted for the project as part of the applicant's submittal to the Executive Office of Environmental Affairs (EDEA) and Site Assignment application to the North Andover Board of Health and Department of Environmental Protection Division of Solid Waste. The reviewing parties 2 TDI, Inc., 210 Halt Road Site Plan Review Special Permit October 2, 2007 concluded that the external traffic impacts will not significantly degrade the level of service at any nearby intersections. 5) In accordance with the terms and conditions of the Site Assignment Decision, the Applicant will fund tip to the $200,000 towards the installation of a traffic light at the intersection of Holt Road and Route 125 to mitigate traffic congestion. 6) The proposed recycling and solid waste transfer station contains architectural elements and treatments that are commonly present and consistent with structures typically constructed within the Industrial 2 Zoning District. Finally, the Applicant incorporated visual buffering and additional plantings to help mitigate the impact on the neighboring properties and streetscape. 7) The site drainage system and storm water management design are designed in accordance with the Town Bylaw requirements and Best Management practices, and has been reviewed by the outside consulting engineer, Vanasse, Plangen Brustlin, Inc. (VFIB). 8) The landscaping approved as a part of this plan generally meets the requirements of Section 8.4 of the North Andover Zoning Bylaw, 9) The applicant has met the requirements of the Town for Site Plan Review as stated in Section 8.3 of the Zoning Bylaw. 10) Adequate and appropriate facilities will be provided for the proper operation of the proposed use. 11) The prgject will provide for municipal water, server and utilities an the property to adequately address the needs of the project. 12) This Site Plan Review Special Perulit is conditional upon the submission and approval by the Planning Board of an appropriate Form A Application for Approval of an ANR Plan (Approval Not Required Plan) which combines the Map 34, Parcels L27, L38, L40 & Map 77, Parcel L14, totaling approximately 7.79 acres, into one parcel_ 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 but requires conditions in order to be fully in compliance. The Planning Board hereby votes to both grant the requested waivers as described in the Applicant's application, and also unanimously votes to grant approval of the Applicant's proposed project as described in the "Plans" and other supporting information described in the public record, provided the following conditions are met: SPECIAL CONDITIONS: 1) Permit Definitions: a) The "Locus" refers to the 339,332 s.f. parcel of laced with land fronting on Holt Road, as shown on Assessors Map 34, Parcels L27,1,3 8, 1,40 & Map 77, Parcel L 14, also known as 210 Holt Road , North Andover, Massachusetts. b) The "Plans" refer to tate plans prepared by Brovrm and Caldwell,. 48 Leona Drive, Suite C, Middleborough, MA 02346, entitled "Site Plan Review 2007, Prepared for TBI, Inc., North Andover, Massachusetts": 3 TBI, Inc., z 10 Holt Road Site Plan Review Special Permit October 2, 2007 Sheet 1 of 10, Revised 9125107; Sheets 2, 3, 4, 5 and 10 of 10, Revised 9112107; Sheet 6 of 10, Revised 9/14/07; and Sheet 7, S and 9 of 10, Revised 8/22107. c) The "Project" or "210 Molt Road" refers to construction of a 30,000 s.£ recycling and solid waste transfer station. d) The "Applicant" refers to TBI, Inc. as the applicant for the Site Plan Review Special Permit. 2) Environmental !Monitor: The developer shall designate an independent Environmental Monitor who shall be chosen in consultation with the Planning; and Community Development Staff. The Environmental Monitor must be available upon four (4) hours notice to inspect the site with the Planning Board designated official. The Environmental Monitor will be required to inspect all such devices and oversee cleaning and the proper disposal of waste products if applicable. 3) Construction Monitor: The applicant shall designate an independent construction monitor who shall be chosen in consultation. with the Planning Department. The construction monitor must be available upon four (4) hours notice to inspect the site with the Planning Board designated official. The construction monitor shall make weekly inspections of the project and file monthly reports to the Planning Board throughout the duration of the project. The monthly reports shall detail area of non- compliance, if any, and actions taken to resolve these issues. The designated monitor may not be applicant and/or developer. The weekly inspections and monthly reports provided to the Planning Department shall include the following: a) sits clearing; b) erosion control; c) drainage and detention structures; d) on-site water and sewer utilities; e) parking spaces and related pavement; f) newly constructed roadways/access ways; l;) curb cuts; h) retaining walls; i) site screening, landscaping And street trees: j) site restoration; and k) final site cleanup 4) PRIOR TO THE ENDORSEMENT OF THE PLANS BY THE PLANNING BOARD, THE APPLICANT MUST COMPLY WITH THE FOLLOWING CONDITIONS: a) The final plans must be reviewed and approved by the DPWand the Planning Depamnent and be endorsed by the Planning Board. The final plans must be submitted For review within ninety. (90) days of filing the decision with the Town Clerk. b) The final site drainage system must be designed in accordance with the Town Bylaw requirements and reviewed by the Division of Public Works. All storm water drainage control facilities utilized by the site shall be shown on the site plan. Storm water drainage calculations which support the design of the control facilities shown on the plan shall be submitted to the Department of Public Works for review and approval. Written confirmation of said review and approval by the Department of Public Works must be submitted to the Planning Department. 4 TBI, tne., 210 Holt Road Site flan Review Special Permit October 2, 200'7 c) A bond in the amount of fifteen dollars ($15,400) must be posted for the purpose of insuring that a final as -built plan showing the location of all on-site utilities, structures, newly constructed roadways/access ways, topography, and drainage facilities is submitted. The bond is also in place to insure that the site is constructed in accordance with the approved. plan. The form of security must be acceptable to the Planning Board. d) The Applicant, within thirty (30) days after this Decision becomes final, shall submit to the Planning Board for its approval an appropriate Form A Application for Approval of an ANR Plan (Approval Not Required Plan) along with an ANR Plan which combines the Map 34, .Parcels L27, L38, Lod & Map 77, Parcel L14 totaling approximately 7.79 acres. No construction activities authorized by this Decision on the Additional Land shall be commenced until the Applicant has (a) recorded said approved ANR Plan and (b) caused the title to the Additional Land to be combined with the Original Land, by recording a Deed for said Additional Land conveying the title to said Additional Land to Holt Road, LLC. e) All site plan application and escrow fees must be paid in full and verified by the Town planner. 5) PRIOR TO THE START OF CONSTRUCTION: a) A 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. b) All applicable erosion control measures must be in place and reviewed and approved by the Planning Department. c) It shall be the responsibility of 'the developer to assure that no erosion on the site shall occur which will cause deposition of soil or sediment upon adjacent properties or public ways, except as normally ancillary to off-site sewer or other 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. d) A pre -construction meeting must be held with the developer, their construction employees, Planning Department, Building Department, and Conservation Department to discuss scheduling of inspections, the construction schedule, and the process/method of informing the public of the anticipated activities on the site. e) The developer shall provide the Planning Board with copies of permits, plans and decisions received from all other North Andover Land -Use Boards or departments. In addition to receipt of these plans, the applicant shall supply the Town Planner with a letter outlining any and all revisions resulting from said permits, pians and decisions received from other town boards, commissions and departments that differ from the approved plans referenced in Condition 24. 6) PRIOR TO THE ISSUANCE OF A BUILDING PERMIT: a) Three (3) copies of the signed, recorded plans must be delivered to the Planning Department. b) One certified copy of the recorded decision must be submitted to the Planning Department. T13t, Inc., 210 Bolt Road Site Plan Review Special Permit October:!, 2007 c) The applicant shall adhere to the following requirement of the North Andover Fire Department and tate North Andover Building Department: I. All structures must contain a commercial fire sprinkler system. The applicant is required to extend lite sprinklers from the existing plant into the new addition. The plans and hydraulic calculations for each commercial system shall be submitted for review and approval by the North Andover Fire Department. Plans and hydraulic calculations for each commercial system must also be supplied to the Building Department. 7) DURING CONSTRUCTION; a) During construction, the site most be kept clean and swept regularly throughout the construction process, Dust mitigation, dewatering and roadway cleaning must be performed weekly, or more frequently as dictated by site and weather conditions and as directed by the Town Planner. Tarps shall be placed over any stockpiles to ensure that any dust is mitigated properly. b) The Board will strictly enforce the policy relative to the stockpiling of materials (dirt, wood, construction material, etc.) and must be shown on a plan and reviewed and approved by the Town Planner. Any approved piles must remain covered at all times to minimize potential dust and be required to install appropriate erosion control measures to mitigate potential impacts to Lake Cochichewick. Any stockpiles to remain for longer than one week must be covered, c) In an effort to reduce noise levels, the developer shall keep in optimum working order, through regular maintenance, any and all equipment that shall emanate sounds from the structures or site. d) The Town Planner will perform bi-weekly inspections of the site during construction to ensure that the developer is adlicring to the conditions set forth in the decision. S) PRIOR TO THE ISSUANCE OF A CERTIFICATE OF OCCUPANCY. a) The applicant must 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. Alternatively, the applicant andtor property owner may provide a bond, determined by the Planning Board, to cover the full amount of the landscaping materials and installation if weather conditions do not permit the completion of the landscaping prior to the use of the parking area. b) The Planning Staff shall approve all artificial lighting used to illuminate the site. All lighting shall have underground wiring and shall be. so arranged that all direct rays from such lighting falls entirely within the site and shall be shielded or recessed so as not to shine upon abutting properties or streets. The Planning Staff shall review the site. Any changes to the approved lighting plan as may be reasonably required by the Planning Staff shall be made at the owner=s expense. The applicant must submit a letter from the architect and engineer of the project stating that the building, signs, landscaping, lighting and site layout substantially comply with the plans referenced at the end of this decision as endorsed by the Planning Board. All site lighting shall provide security for the site and structures however it must not create any glare or project any light onto adjacent residential properties. c) The commercial t=ire sprinkler systems must be installed in accordance with referenced standard NFPA 13D and in accordance with 180 CMP, Chapter 9 of the Massachusetts State Building Code. Certification that the systems have been installed properly in accordance with the above 0 TBI, Inc., 210 Holt Road Site Plan Review Special Permlt October 2, 2047 referenced regulations must be provided from both the North Andover Fire Department and the North Andover Building Department to the applicant. The applicant must then provide this certification to the North Andover Planning Department, d) Any and all signage plans for the site, which have been provided to the Planning Board during the site plan review process, were presented for the materials of the signage only. This includes any and all signage relative to the Site Assignment Decision incorporated as part of this decision. Any signage plans must conform to Section 6, Signage and Outdoor Lighting Regulations of the Town ofNorth Andover Zoning Bylaw and must be approved by the Building Department. In no way is the applicant to construe that the Planning Board has reviewed and approved the signage pians for Zoning Compliance as that is die jurisdiction of the Building Department. All additional permits must be obtained bythe applicant prior to construction. e) In accordance with the Site Assignment Decision, TBT shall develop a clear route trap for all trucks (inbound and outbound) that will be distributed to drivers, faxed and emailed. The route will clearly direct drivers to 1-495 and the Route 125 Connector access/egress point. Further, all trucks entering and exiting the facility shall follow the designated route except when performing collection in North Andover, br unless an exception applies pursuant to Hoard of Health trash truck regulations. 9) 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 -sits utilities, structures, curb cuts, parking spaces, roadway/access way construction, drainage structures, and facilities must be submitted to the Planning Department. The applicant must submit a letter from the architect and engineer of the project stating said items substantially comply with the plans referenced at the end of this decision as endorsed by the Planning Board. 10. The requirements and conditions contained within the Site Assignment Decision dated .lune 22, 2006 and issued by the North Andover Board of Health are contained in the Planning board's files and are hereby incorporated by reference into this decision and public record. The applicant shall comply with all conditions and requirements said Decision. Any non-compliance with the requirements and conditions of said Decision shall violate this Site Plan Review Special Permit 11. In accordance with the Site Assignment Decision, TBI shall contribute up to $200,000 towards the installation and construction of a traffic light at the intersection of Holt Road and Route 125, Monies not already utilized for the engineering, installation, and/or construction of the traffic light will be placed into an escrow account with the Town by the applicant. Said amount shall only be utilized by the applicant or Town for the purpose of installing and constructing the signalized traffic light at a future date. 12. All site work and external construction activity shall be limited to between 7:00 a.m. and 7:00 p.m. Monday through Friday and between 8:00 a.m. and 5:00 p.m. on Saturday. 13. All existing plantings and screening depicted on the approved plans shall remain in perpetuity over the life ofthe project, jTBI, Inc., 210 holt Road Site Plan Review Special Permit October 2, 2007 12. The contractor shall contact Dig Safe at least 72 hours prior to commencing any excavation. 13. Gas, Telephone, Cable and Electric utilities shall be installed underground as specified by the respective utility companies. 14. No open. burning shall be done except as is permitted during burning season under the lire Department regulations. 15. No underground fuel storage shall be installed except as may be allowed by Town Regulations. 16. Tile 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. 18. All snore storage is to be removed as needed to provide sufficient access throughout the site and to ensure the proper safety of vehicles and pedestrians. Snow storage shall not result in the loss of parking spaces except during removal operations. The Town Planner shall direct the applicant to remove snow to an offsite location if it is determined that onsite snow storage is insufficient. 19. The Planning Board expects that the project will be built in accordance with the herein referenced plans and specifications and in full accordance %frith the design elements and features displayed and discussed during the Public Hearings. Any revisions shall be submitted to the Town Planner for review in accordance with Section 8.3.8 of the Zoning Bylaw. if the Town Planner in his/her sole discretion deems these revisions to be substantial as defined in Section 8.3.8, the applicant must submit revised plans to file Planning Board for approval. 20. This Special Permit approval shall be deemed to have lapsed after October 2, 2009 (two years from the date permit granted) unless substantial use or construction has commenced. Substantial use or construction will be determined by a majority vote of the Planning Board, 21. The following information shall be deemed part of the decision: Plan titled: Site flan Review 2007 Prepared for TBI, Inc. North Andover, Massachusetts Prepared for: TIM, Inc. 21014olt Road North Andover, MA Prepared by: Brown and Caldwell 48 Leona Drive, Suite C Middleborough, MA 02346 Scale: I"=40' and I"=30' Date: duly 2447, Various Revision Dates Sheets: l of 10., Revised 9125107; 2, 3, 4, 5 and 10 of 10, Revised 9/12/07; 6 of 10, Revised 9114107; and 7, 8 and 9 of 10, Revised 8/22/07 Report titled: Site Plan Review Application TBI, Inc. Recycling Facility and Solid Waste Transfer Station A i TR t, Inc., 210 Holt Road Site Plan Review Special Permit October 2, 2007 North Andover, NIA Prepared for: TBI, Inc. 210 Holt Road North Andover, MA Prepared by: Brown and Caldwell 48 Leona Drive, Suite C Middleborou6,h, MA 02346 cc: Town Departments Applicant Engineer Abutters 9 I'll E -D 2007 OCT 15 Flit �l 1 N O N L}!. p Q 0 H J 0 O N -v U) O w U W 80 N Q � J W a� 0 Q ad f0 0 O O EO EO O UO J M N O O Y U O J m O O O co O ch N O 0 0 M O O N D JI W U Q d w <D 0 0' I . . is y cc LO 0 NNl 1u),.10€ in p U r 10 U#M 0 "• € o IM OO _C0OO 1 +a {U)00 dC14U O CO E N N d Z ,W O O to Lq c O.tq• Lj CO In Q .. ' Z ,o ,rte � U) co m & pk S i c QC Z� C 0 i O O W'C's O QILL J J ai i J �N morn O 'oO pULLQQ H oo z 0 C, H c�U .. 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NORTH ANDOVER, MA. 01845 ATTN; BRIAN THOMSON RE; A-1 FENCE BUILDING ROOF REPLACEMENT SCOPE OF WORK; 1) REMOVE EXISTING TAR AND GRAVEL ROOF SYSTEM DOWN TO METAL DECKING 2) REMOVE AND REPLACE 300+/- SQ FT OF METAL DECKING AT REAR CORNER 3) MECHANICALLY ATTACH NEW R-20 INSULATION BOARD TO METAL DECKING 4) INSTALL A NEW .060" EPDM FULLY ADHERED ROOF SYSTEM 5) SHOP FABRICATE AND INSTALL NEW ALUMINUM PERIMETER EDGE METAL AND REAR GUTTER SYSTEM 6) PRICING FOR METAL DECK WORK WILL BE SUBTRACTED FOR USE OF BUILDING OWNERS DISPOSAL CONTAINER COST; $9,500.00 (WITHOUT CONTAINER) $9,000.00 (WITH CONTAINER) ANDOVER INDUSTRIAL SERVICES INC. DATE AUTHORIZED SIGNATURE 6dLId DATE I IT 1d 10 WILLIAM DR. PELHAM, NH 03076 TEL; 1-888-957-7663 FAX;1-603-635-7843 andoverindustrialservicesinc(&gmail.com The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance davit: Builders/ContractorsNIectriciansIPliumbers Applicant information )Please Print Legibly Name(B.usiness/organizafion/Individual): Address: City/State/Zip: ;CAQAOV) Phone 11�1 j�Pk 7. Are ou 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 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.] fi employees. [No workers' comp.' insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.gRoofrepairs 13.❑ Other xny applicant that checks box #fl 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 isproviding workers' compensation insuranceformy employees Below is ihepolicy andjob site information. - , Insurance Company Policy # or Self-ius. Lic. #: AIW C— Y3Y?VV,5 Expiration Date: rob Site Address:%7,illlkir F.11 City/State/Zip:,0,&ac•C-,e 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. Ido Hereby &r -t under the pains ,%djenalties of perjury that the information provided above is true and correct. Date: /-A Phone fiat, % Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense Issuing Authority (circle one): x. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone � db Ac --"R" CERTIFICATE OF LIABILITY INSURANCE DA POLICY NUMBER POLICY EFFECTIVE DATE MMID POLICY EXPIRATK)N DATE MM/DD 122 /10/10DDIYY/201 10 PRODUCER (508) 699-7511 FAX: (508) 695-3957 GENERALUABILITY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION R.S. Gilmore Insurance Agency, Inc. 27 Elm St. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 126 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ® OCCUR 00001398701 N. Attleboro MA 02761 DAMAGE TO RENTED PREMISES Ea ocaarw= INSURERS AFFORDING COVERAGE NAIC # INSURED Andover Industrial Services, Inc. $ 1,000,000 INSURERA:Admiral Insurance Company INSURERB:ACE Property —& Casualty 10 William Drive INSURER C: _$ 2,000,000 INSURER D: Pelham NH 03076 INSURER E: COVE 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 05UCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR AIDDL NSR TYPE F INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMID POLICY EXPIRATK)N DATE MM/DD LIMITS GENERALUABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ® OCCUR 00001398701 3/28/2010 3/28/2011 DAMAGE TO RENTED PREMISES Ea ocaarw= $ 50,000 MED EXP (Any one person) $ 5f000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE _$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- LOC PRODUCTS - COMP/OP AGG $ 2 000,000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS . SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO - $ _ AUTO ONLY: AGG EXCESS/UMBRELLA LIABIUTY OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? FN] STATU- OTH- X TORY I I TSJ I ER E.L. EACH ACCIDENT $ 100 ,000 E.L DISEASE - EA EMPLOYEE $ 100,000 (Mandatory in NH) If es, describe under SPECIAL PROVISIONS below NWC C45834505 12/14/2009 12/14/2010 E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES/ EXCLUSIONSADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Campanelli Associates Construction Corp., Campanelli Associates Management Corp., Campanelli Tri Gate GS LLC and Campanelli Tri Gate Properties LLC are additional insured under the general and automobile liability coverage as required by written contract. /�Cf1T, r,A�Tr •,w• ��e� (978)475-8778 Campanelli Associates Construction c/o A & M Roofing Services, LLC 123 Tewksbury Street Andover, MA 01810 A/`r1Dfl 9C Onnnir%4 Vf1,� V LLLI1 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Corp. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE 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 AUTHORED REPRESENTATIVE Tim Gilmore/ABRYAN W T assts-ZUUa ACUKU cURPORATION. All rights reserved. INS025 (zoosol> The ACORD name and logo are registered marks of ACORD M07/15/2010 18'.59 FAX A. Dell.,jimlent Of Public SACCO Board of Ppuill(J'IllcT RegUlliti(Ins ""'(1 Statul.0 tis ConstrucUon SupervisOf License License-, CS 74147 ROBERT P POULt4 6 COUNTRY- CLUBWAY, NORTON, MA •02766 Expiration' 611712012 Tr#' 29363 [aool/ool