HomeMy WebLinkAboutBuilding Permit #770-14 - 16 High Street Suite 201 4/22/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 7,?0-/4/ Date Received
Date Issuede, -r/ -a!/ /1
IMPORTANT: Applicant must complete all items on this page
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LOCATION? 'T 1A
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PROPERTY
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
El One family
El Addition
El Two or more family
El Industrial
jt�rAIteration
No. of units:
D Commercial
El Repair, replacement
D Assessory Bldg
11 Others:
El Demolition
El Other
❑Septic i e
plan.
E.WatershetlDistricf
1%VV&t&/Sbvv'er
DES
OWNER: Name: �A
ON OF WORK TO BE PERFORMED:
I Q<� PL z Q �_ 9 ti_' e ► '9 �
Please Type or. Print Clearly)
Address: OCA0 6 VfL-Q A
IC-QN-TTRA ':N
_'CA -L LI'RhoneA'l A'2:�.— a
Address. 1?3 C"�k4wo_
'i n_Wlic-e- ct \0
f"81.01 06 o nse..-C..S
Supervi§oj ,�truct
H, bme,_1hnp1qVement1'License:. Lxp-
at
ARCH ITECT/ENGINEER �TPA-sq-VC, Phone:
Address: 0-5::1 -
I C� Z..S �i', Reg. No.
FEE SCHEDULE. BULDINGPERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ C�_u _Lt_ FEE:$ Z,22- ?_2
Check No.: 7 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Aclen'fibwhe'D� i�,,:.:�-.�_�ignatdreof contractor..'.K
Plans Submitted Plans Waived ❑ �)Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
DATE REJECTED
El
DATE APPROVED
Reviewed on Signature
F
I
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
t
Conservation Decision: Comments
VP,I-er & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Us ooa Street
FIRE DEPARTMENT - Temp Dumpster on . ' ite yes. no
Located at::124 Main`Street:. -
Fire Depai-tment signatueldate - Z 7-Zo
.COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No,
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use
lJ Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
a Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases .if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be. subm;tted with the building application
Doe: Doc.Building Permit Revised 2012
Location /7 S -1L � 6
No. / %d — Date 9 �y
Check # / 7e%2
2'/516
TOWN OF NORTH ANDOVER
Certificate of Occupancy j'"
Building/Frame Permit Fee $1?�Z ?'Or
Foundation Permit Fee $
Other Permit Fee $
TOTAL
lf606ing Inspector
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 770-14 on 4/29/2014 Date: June 24, 2014
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 1 High Street, Building #6,2 "d Floor
MAY BE OCCUPIED AS Office Space - Accelleron_IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to: R.C.G. North Andover West Mills LLC
1 High Street
North Andover, MA 01845
Building Inspector
Fee: PrePaid $100.00
Receipt: 27516
Check :1703
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ACNUSf
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 770-14 on 4/29/2014 Date: June 24,-2014
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 1 High Street, Building #6,2 "d Floor
MAY BE OCCUPIED AS Office Space - Accelleron_IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to: R.C.G. North Andover West Mills LLC
1 High Street
North Andover, MA 01845
Building Inspector
Fee: PrePaid $100.00
Receipt: 27516
Check :1703
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CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 770-14 on 4/29/2014 Date: June 24, 2014
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 1 High Street, Building #6,2 "d Floor
MAY BE OCCUPIED AS Office Space - Accelleron_IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to: R.C.G. North Andover West Mills LLC
1 High Street
North Andover, MA 01845
Building Inspector
Fee: PrePaid $100.00
Receipt: 27516
Check :1703
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CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 770-14 on 4/29/2014 Date: June 24, 2014
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 1 High Street, Building #6,2 "d Floor
MAY BE OCCUPIED AS Office Space - Accelleron_IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to: R.C.G. North Andover West Mills LLC
1 High Street
North Andover, MA 01845
Building Inspector
Fee: PrePaid $100.00
Receipt: 27516
Check :1703
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Enter construction cost for fee cal -
North Andover Fee Cakulation
Construction Cost
$ 933940.00
m
$ -
$ 1,127.28
Plumbing Fee
$ 140.91
Gas Fee 100 comm.
$ 100.00
Electrical Fee
$ 140.91
Total fees collected
$ 1,509.10
1 High Street Building 6 Second floor
770-14 on 5/1/2014
Tenant Fit UP
CE 40oTN
tit e'-. =_. • oa
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$SICINSE
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 770-14 on 4/29/2014 Date: June 24, 2014
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 1 High Street, Building #6,2 d Floor
MAY BE OCCUPIED AS Office Space - Accelleron_IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to: R.C.G. North Andover West Mills LLC
1 High Street
North Andover, MA 01845
Building Inspector
Fee: PrePaid $100.00
Receipt: 27516
Check :1703
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UrrIlLit UI- ISUILUINU INSt'tt: I UK
TOWN OF NORTH ANDOVER
CONSTRUCTION CONTROL
IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE,
L- tCi4 'I • -5 ►M r lam. �jC_o REGISTRATION NO. 9 aQ &O
BEING A REGISTERED PROFESSIONAL ENGINEERIARCHITECH HEREBY CERTIFY THAT I
HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS,
COMPUTATIONS AND SPECIFICATIONS CONCERNING:
ENTIRE PROJECT ARCHITECTURAL 0 STRUCTURAL E] MECHANICAL 0
FIRE PROTECTION ❑ ELECTRICAL ❑ OTHER (SPECIFY)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEGE, SUCH PLANS,
COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS
STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRATICES.
AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY.
I FURTHER CERTIFY THAT I SHALL PERFORM THE -NECESSARY PROFESSIONAL SERVICES AND B
EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT
THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING
PERMIT AND SHALL. BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0
1. Review, for conformance to the design concept, shop drawings, samples and other submittals
which are submitted by the contractor in accordance with the requirements of the construction
documents.
2. Review and approval of the quality control procedures for all code -required contmiled materiels.
3. Be present at intervals appropriate to the stage of construction to become; generally familiar
with6the 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.
PURSUANT TO SECTION 116.2 ,2 1.SHALL SUBMIT WEEKLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR.
UPON COMPLETION OF THE WORK, 1SHALL SUBMIT A FINAL REPORT AS TO THE
SATISFACTORY COMPLETION AND READINESS OF THE PROJECT
fHiS DAY OF
MY COMMISSK
218410133
PROJECT NUMBER;
Acelleron Medical Products
PROJECT TITLE:
PROJECT LOCATION`
16 High Street, West Mill, North Andover, MA
Building Six, Floor Two
NAME OF BUILDING:
Tenant Fit -Out
NATURE OF PROJECT:
IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE,
L- tCi4 'I • -5 ►M r lam. �jC_o REGISTRATION NO. 9 aQ &O
BEING A REGISTERED PROFESSIONAL ENGINEERIARCHITECH HEREBY CERTIFY THAT I
HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS,
COMPUTATIONS AND SPECIFICATIONS CONCERNING:
ENTIRE PROJECT ARCHITECTURAL 0 STRUCTURAL E] MECHANICAL 0
FIRE PROTECTION ❑ ELECTRICAL ❑ OTHER (SPECIFY)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEGE, SUCH PLANS,
COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS
STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRATICES.
AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY.
I FURTHER CERTIFY THAT I SHALL PERFORM THE -NECESSARY PROFESSIONAL SERVICES AND B
EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT
THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING
PERMIT AND SHALL. BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0
1. Review, for conformance to the design concept, shop drawings, samples and other submittals
which are submitted by the contractor in accordance with the requirements of the construction
documents.
2. Review and approval of the quality control procedures for all code -required contmiled materiels.
3. Be present at intervals appropriate to the stage of construction to become; generally familiar
with6the 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.
PURSUANT TO SECTION 116.2 ,2 1.SHALL SUBMIT WEEKLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR.
UPON COMPLETION OF THE WORK, 1SHALL SUBMIT A FINAL REPORT AS TO THE
SATISFACTORY COMPLETION AND READINESS OF THE PROJECT
fHiS DAY OF
MY COMMISSK
Standard Form of Agreement between Owner and
RCG LLC where the basis of payment is the Cost
of the Work Plus a Fee without a Guaranteed
Maximum Price
The Owner and Contractor agree to the terms stated by this contract. This contract
supersedes any prior agreements, representations, or negotiations, oral or written. No
liquidated damages shall apply to this agreement. This contract consists of the following
documents:
1. Obligations of the Parties
2. Contract Sum
3. Project Schedule
4. Signatures
Exhibits
Exhibit A: Estimated Cost of Work
Exhibit B: Project Schedule
Exhibit C: Drawings
Page 1 of 6
1, Obligations of the Parties
Obligations of the Contractor:
The Contractor accepts the relationship of trust and confidence established by this Agreement and
covenants with the Owner to cooperate with the Architect and exercise the Contractor's skill and
judgment in furthering the interests of the. Owner; to furnish efficient business administration and
supervision; to furnish at all times an adequate supply of workers and materials; and to perform
the Work in an expeditious and economical manner consistent with the Owner's interests and in
compliance with all applicable governmental codes and regulations.
The Contractor shall keep full and detailed accounts and exercise such controls as may be
necessary for proper financial management under this Contract.
The Contractor shall keep full and detailed records of all books, records, permits, licenses,
correspondence, receipts, instructions, data, and drawings associated with the Project including all
Subcontractor contracts, invoices, vouchers, insurances, lien waivers, and other correspondence.
The Owner and Owner's Accountants shall have access to review, audit, and copy all Contractor
documentation. The Contractor shall retain these documents for a period of three years after final
payment.
The Contractor shall maintain insurance at the following levels with the Owner listed as a co-
insured:
Type of Insurance Limit of Liability
ComnercratGenetal t.rabli $1,000;000 QO r `
f
Upon request, and at the cost of the Owner, the Contractor shall obtain a performance bond up to
the total Cost of Work. Such costs shall be added to the Construction Volume.
The Contractor understands that the Project will be financed by a construction lender and, then, by
a permanent lender. The Owner may assign any of its rights under this Contract to the construction
lender and the Contractor hereby consents to any such transfer provided no such assignment shall
relieve the Owner of any of its obligations under this Contract, unless agreed to in writing by the
Contractor. The Contractor shall execute any certificates, lien waivers, releases, receipts, and other
documents as may be reasonably required by the construction lender or permanent lender including
a subordination of its mechanic's lien rights to the construction lender's and permanent lender's
mortgage or deed of trust. The construction lender for the Project will be:
Obligations of the Owner:
The Owner agrees to furnish or approve, in a timely manner, information required by the
Contractor and to make payments to the Contractor in accordance with the requirements of this
Agreement.
Dispute Resolution:
Claims, disputes or other matters in question between the parties to this Agreement shall be
resolved by mediation or by arbitration. Prior to arbitration, the parties shall endeavor to reach
settlement by mediation.
Page 2 of 6
2. Contract Sum
Cost of Work:
The Contractor shall provide a detailed estimated Cost of Work to the Owner (see Exhibit A). The
sum of these costs, including the fee is as shown below:
Change Orders:
The Contractor does not guarantee the Contract Sum in any form. In the event of changes to the
Contract Sum, the Contractor will present written changes to the owner for costs that exceed the
Contract Sum in the form of a Change Order. The Contractor will review all Subcontractor Change
Orders before submittal to the Owner and Architect and make a recommendation for payment or
non-payment. The Contractor's Fee will be calculated including any approved Change Orders.
The Owner, Architect and Contractor will negotiate disputed Change Orders in good faith,
Contractor's Fee:
10% of total construction volume. This includes pre -construction and project management
services, and field personnel and associated management overhead.
The fee is based on actual costs incurred, with final true up, and is billed monthly in arrears. Total
Construction Volume excludes permits and fees, which shall be paid directly by the Owner.
Construction management labor, standard tools and equipment, and labor -related overhead are
covered within the fee. Specialty tools or equipment and any trade labor supplied by J&K
personnel shall be charged separately.
If a project is terminated or suspended by the Owner prior to completion, J&K shall be
compensated for the actual cost of services provided prior to receipt of notice of termination or
suspension from the Owner.
Subcontractors:
The Contractor plans to hire Subcontractors to perform the majority of construction associated with
this project. The Contractor shall provide the Owner and Architect information on all of the bids
received by Subcontractors and the names of the Subcontractors selected. Owner shall have the
right to reject a proposed Subcontractor; however, In the event that this leads to a higher Cost of
Work, the Owner shall pay for the difference. The Contractor reserves the right to reject any
Subcontractor, even if it is the lowest bid; and to dismiss Subcontractors from the job that have
been previously approved by the Owner.
Payments:
The Owner shall make progress payments on the Contract Sum according to the Requisition
process described below.
The Contractor shall, at the conclusion of each calendar month on the project, present to the
Owner an application for payment (Requisition) for costs incurred during that month. The
Requisition shall include all invoices, vouchers, partial releases of liens, expense reports, and any
other evidence to support the validity of the Requisition amount. The Contractor may requisition
for completed, but unpaid work based on an expectation of payment upon receipt of funds. The
Owner, the Architect, or their representatives shall be afforded five (5) business days to review
such application and question the Contractor about its contents. In the event there are no
disputes, the Owner shall pay the Contractor within 10 business days of receipt of the Requisition.
Payment by the Owner does not represent that the Owner or Architect have made a detailed
examination of the documentation, inspection of the work, or verification of the accounting.
Page 3 of 6 61
At the completion of the project, the Owner shall make a final payment to the Contractor based on
a final Cost of Work with a truing up of fees. If further corrections to work are required that are not
covered under warranties with Subcontractors, or that are not the outcome of negligence or poor
workmanship by the Contractor, the Owner shall pay the Contractor for any work associated with
performing the corrections based on the hourly rate agreed to in this contract.
Retainage:
The Owner shall not hold back any fees to the Contractor to ensure completion of the work. The
Contractor will be expected to hold back fees from Subcontractors to ensure their performance
based on the terms below:
lE'ecl coats unless'ci herwise .:roiieti ld ..ttie�Owner $. �..
Termination of Contract:
The Owner shall reserve the right to terminate or suspend the Contract at its sole discretion.
Within 15 days of termination or suspension, the Contractor shall present an accounting of all its
costs incurred for reimbursement by the Owner. If the Owner elects to proceed with the project
without the Contractor, the Owner shall have the right to assume the Subcontracts and
agreements related to the Project.
3. Project Schedule
Date of Commencement:
The Contract Time shall be measured from the date of commencement. The date of
commencement of the Work shall be the date of this Agreement, unless a different date is stated
below or provision is made for the date to be fixed in a notice to proceed issued by the Owner.
A .rtt.23, 2014 or such time thatlUotificatonto.Proceeds. iven b Owner
Contract Time:
The Contractor shall provide to the Owner a Project Schedule (see Exhibit B). This Schedule is
based on assumptions reached prior to the signing of this contract, which assumptions the
Contractor shall attempt to clarify in the Schedule. However, the Schedule always assumes the
Owner and the Architect respond promptly to requests for information and do not request any
significant changes to the construction program. In the event that Owner or Architect find any
discrepancies withtheSchedule or its Assumptions, they will promptly notify the Contractor, who
shall make adjustments to the Schedule as necessary.
According to the attached Schedule, the Contractor shall achieve Substantial Completion of the
entire Work as follows:
: 9-114E
Date of Su'iistantrai;Com letion,to beciiater than June 1'S m,r
The Contractor does not guarantee the date of completion. However, the Contractor shall not be
entitled to additional fees based on delays in the project unless those delays can be shown to
incur extra costs for the Contractor and were caused by the actions or requests of the Owner or
Architect.
The Contractor shall present an updated Project Schedule to the Owner and Architect on a weekly
basis for their review.
Paae 4 of 6
4. Signatures
The Owner's representative is:
i;auid�S,t in ergh; Managdt
�G�G�LL'C
1Iffy Sue ty S i*0 04
Sprne� Ie,MA_02'[
§ 14.4 The Contractor's, representative is:
Kieran Whelan
J&K Contrac'ting ` C
31 Richrnond�Street,_
Weyrrauth,._{�A E��188
This agreement is entered into as of the day and year first written above and is executed in at
least three original copies, one for the Owner, one for the Contractor, and one for the Architect.
Owner
Contra
_
i maturei
nature
'T
r. \ 1 IWW-` ti— �\d I W L i t4
Printed Name and title
Printed Name and Title
Page 5 of 6
Y\,V4�---
Schedule of Values
Acelleron Medical Products
General Conditions
$
6,000.00
Demo, inc carpet
$
7,000.00
Frame board and tape
$
8,000.00
Paint
$
8,000.00
Flooring[Allow]
$
25,000.00
Electric [Allow]
$
8,000.00
HVAC [Allow]
$
3,000.00
Doors,frames,Hdw
$
2,000.00
Repair and re -tile bathroom floors
$
3,000.00
Durock and tile over bathroom
walls $ 8,400.00
Plumbing [labor] $ 2,500.00
Sinks,tops,fixtures [allow] $ 4,500.00
Sub total $ 85,400.00
Construction fee,10fo $ 8,540.00
Total Construction Cost $ 93,940.00
Permit $ 1,128.00
Page 6 of
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards .
r„
I Construction Supervisor
License: cv!!6 34
I
ISERAN T WHEJAN
31 RICHMOND 5f
WEYMOUM MA
7
Expiration
0912612945
'I Commissioner
NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston., Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I (we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
LIBERTY MUTUAL FIRE INSURANCE COMPANY
NAME OF INSURANCE COMPANY
175 BERKELEY STREET, BOSTON, MA 02116 (617) 357-9500
ADDRESS OF INSURANCE COMPANY
WC2-31 S-601698-014 2/17/2014-2/17/2015
POLICY NUMBER EFFECTIVE DATES
NAME OF INSURANCE AGENT ADDRESS PHONE #
31 RICHMONT STREET
JK CONTRACTING LLC WEYMOUTH MA 02188
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER