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HomeMy WebLinkAboutBuilding Permit #437-2016 - 4 High ST Suites-301-307 10/6/2015 i BUILDING PERMIT of NORTI-r 6 �H .Ct LEU TOWN OF NORTH ANDOVER �� yy,. •- - 0 APPLICATION FOR PLAN EXAMINATION 1 1 2, 4 Date Received Permit No#: `�— � �gp�R�TEo�4a��5 SSACHUS� Date Issued: I d L IMPORTANT:Applicant must complete all items on this page LOCATION L4- I'�t C3 �, C'� r-1 j— 1 J o -77� Print 1 PROPERTY OWNER (Z- C—. k�5� t 1t Print 100 Year Structure yes no MAP J, PARCEL:ZONING DISTRICT: Historic District y no 02- �z)15 Machine Shop Village (2e no � /1761 TYPE OF IMPROVEMENT JFROPOSED LJ8E Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ptic ❑Welh fliFlo°otlpla n� C7 Wetlan s glNater hed ®str _ `i ��,�Water7Sewer DESCa2IPTION OF WORK TO BE PERFORMED: f�T4 '0 �3 Q T-- F 1 L\ C C rA Ly,� ` J (3 1 b , J-1 0 s Identification- Please Type or Print Clearly OWNER: Name: `1 iqvt V'J .S TGI N Q s^ G-H . Phone: Address:S C .,7 t 0 0 i L vpg I LW �0 rt 0 1-1 (t-3 N4- L.,�.- L _ Contractor Name: UJ t4i�-� Phone: Email: r V Kis L of r Z3 C�. ►'I�c;t(, c=i1 rn Address: '� v 1 14 2 ; C.-ti Supervisor's Construction License: Cf o 6 ,?3 `t- Exp. Date: 2-(. /1 Home Improvement License: Exp. Date: ARCHITECT/ENGINEER -S . H -Y� • Phone: Address: i � v n Kim _ _Reg. No. 0 i FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BIASSED ON$125.00 PER S.F. Total Project Cost: $ '�'.., 0 FEE: $ 2 00 Check No.: � � Receipt No.: NOTE: Persons contractin with unregistered contractors do not have access to the�uaranty fund s. 01 4..' actor I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 1 TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/Massage/Body Art ❑ Swimu3ing Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY � INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS I CONSERVATION Reviewed on Signature COMMENTS K HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Walter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: .,> ... Locate . FIREDEPARTMENT iTer'nD mps er�on►site, esur ` y# 84o0 sgood Street u t a. ( Lo ted at 124 Main#Street�, Ke D�epart�ment�s�i naturae/dater•.y,.`�.:' �.;€ � � S� COMM 1 � ;1.a,. , • • • .. � •,a,;a ',c t {. . ;i;S P�-•'v4 s. 4... 't a . ' �,�j. :t, ENTSr Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of 1lllleter 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) f Ll i i Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i 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 4 Building Permit Application 4. Workers Comp Affidavit 4. Photo Copy Of H.I.C. And/Or C.S.L. Licenses � Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4. Building Permit Application Certified Proposed Plot Plan 4. Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location 4_6,4�:7 ` No. f"' }/ Date ko 1� • • TOWN OF NORTH ANDOVER. • � L:ED' . Certificate of Occupancy $ �b[� Building/Frame Permit Fee $C_2�q Foundation Permit Fee $ Other Permit Fee �$a TOTAL $ Check# ding Inspector Y 2 47 ;x. Location 4 No. 1 ��— 2 c�l�D Date . - TOWN OF NORTH ANDOVER S GED .. Certificate of Occupancy $�� Building/Frame Permit Fee $ 9 ~� C Foundation Permit Fee $ Other Permit Fee $ ,aTct>a � TOTAL $ I Check# 2947 7 Building Inspector Ot HORTH 1N 3t�•:r�1O •AG O ° 'ji1�O��rr. rr�19 SSACNOSES CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 437-2016 on 10/6/2015 Date: December 14, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 4 High Street— Suite 305 MAY BE OCCUPIED AS a tenant fit up IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG NA West Mill,LLC 4 High Street ----- - - - - - - - ------- _ _ - - - - - --North Andover,MA-0-1845- -. Building In ector Fee: PrePaid$100.00 Receipt: 29477 Check : 2306 ro , NORTH v r� Town o t j over o . _ No. 3 : I h ver, Mass, D 6, 1. COCNIC"IWICK S ll BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ............. BUILDING INSPECTOR . : :.... . :.. e :..M:.�. ..... L ............................ ... .. / � C= .. � Foundation / has permission to erect buildings on .. . l�X! to be occupied as ...... �L�NC.. .T..... .......✓�J!vn�... :}:.`2` 0�-s ..'. . 1..... .. (p, Chimney provided that the person accepting thi ermit s all in every respect co form toof the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and AIA Construction of Buildings_in the Town of North Andover. PLUMiBING I'NSPEC71 R Rough � ,' I ��f��/•— (IY (3 C)o VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 62)-10 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR l UNLESS CONSTRUCTION TARTS ough '1 J .........,.. Service ........... ..... .CJ.'1::.... • .....�........................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. _ Smoke Deter � L 1 Ul � NA �a 011/ ✓( t J/ �� 61 M u�NORtH Ay o Sj w a ��SSAC•N15E1 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 437-2016 on 10/6/2015 Date: December 14, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 4 High Street— Suite 306 MAY BE OCCUPIED AS a tenant fit up IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG NA West Mill, LLC 4 High Street -Nor-th Andover-,MA-01845 - - - - - Building Inspector Fee: PrePaid$100.00 Receipt: 29477 Check : 2306 F N RTH own of 2 t. Al., i over o - to No. h ver, Mass, bet 6 2t t 6 CoCNICt4aw1c 7�A�R�ITED PP�,��y S V BOARD OF HEALTH Food/Kitchen PERMIT TD� ll 11 1 / Septic System THIS CERTIFIES THAT ........�c. �.6...W e�� �0 "� Lu_ BUILDING INSPECTOR d� � 6A. Foundation has permission to erect ..........................``buildings oncc........JJ � - g02, to be occupied as ..... >a( .. .t..... ... ...41.W Pz... .. �.:.... J....N. .. Chimney provided that the person accepting thl ermit s all in every respect co =ingo h s of the application .F nai on file in this office, and to the provisions of the Codes and By-Laws relae Inspection, Alteration and in Construction of Buildings_in the Town of North Andover. PLUMBING I1NSPECRough /4 J f R 1 VIOLATION of the Zoning or Building Regulations Voids this Permit. Fwe �),� Y(3 C)I,) Final ��. os( r� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS ough � " Service ........... ..... . .�. ..�..••.,,.........................•••••••••• • Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. _ Smoke Deter ,���� NUJ d �a I 7� lowli � ,sa.6 1z�11 -15 PJJ4 b. of,,O oIN ti 9 'lI O'4ree r•",9 ,SSAC MISES CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 437-2016 on 10/6/2015 Date: December 3, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 4 High Street— Suite 307 MAY BE OCCUPIED AS a tenant fit up IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG NA West Mill,LLC 4 HighmStr-eet North Andover,MA 01845 Building Ins�ector Fee: PrePaid$100.00 Receipt: 29477 Check : 2306 . NO Town of RTH \Ai dover C �h ver, Mass, 00 2 6 2,66 O LAH! 1. COC NIC Kl WICK �•9 Q°R�+reo �fP,�gS S U BOARD OF HEALTH -Food/Kitchen PERMIT T LDSepticystem THIS CERTIFIES THAT ,BUILDING INSPECTOR z Foundations' r has permission to erect ... buildings on .. 4.J.............. �� � (Rq7h to be occupied as .. T�'e.. ... ..1........ ........ Swl�n5...... ..�.1.... . ..�...�.'��..�....N.0.. Chimney provided that the person accepting t ermit s all in every respect co form to s of the application final . on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and . Construction of Buildings in the Town of North Andover. PLUMBING I' SPEC1'011 Jd�� `� �� VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough &R �) 00 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS ough - 44 ; Service ........... ..... ..r.*rrti✓••n ............................. Final �TBUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det tA,IU� Aar �6L 61av�-A r , � r r M Enter construction cost for fee cal - North Andover Fee Cakulaflon Construction Cost $ 203,890.00 m $ - $ 2,446.68 Plumbing Fee $ 305.84 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 305.84 Total fees collected $ 3,158.35 4 High Street 437-2015 on 10/6/15 Tenant Fit Up Suites 301-306 NORTH Town of EAndover 0 No. Z h ver, Mass, 6e, 6 2t(6 09L . 1. COC MIC Ml W IC H S V BOARD OF HEALTH _ Food/Kitchen PERMIT T LD 1 l 1 LLC (� Septic System THIS CERTIFIES THAT ........qC(5 ..J ((lq. �4?e .. '.�.` .....!--L`-- BUILDING INSPECTOR 4 -+1zz Foundation has permission to erect .......................... buildings on ......... ..........! :..,.... ... .. 4.?.............. . /� A �,, l S c ^� 1 ... ....... Rough to be occupied as .. l .�JY fes!\.. ... ..1........ ........�L.�J�J! �.td• ......... a0v....................... Chimney provided that the person accepting thl ermit s all in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough ........... ..... .a.Fr...�..,��.... .,....,,�.................................. Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER �'>' •� CONSTRUCTION CONTROL PROJECT NUMBER: 1406002.36 PROJECT TITLE: 4 High Street Floor 3 Build-Out PROJECT LOCATION: 4 High Street, Suite 201, North Andover NAME OF BUILDING: WeSt Mill NATURE OF PROJECT:_Tenant Fit Out IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, 1, Linda S. Smiled REGISTRATION NO. 10080 BEING A REGISTERED PROFESSIONAL ENGiNEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ❑ ARCHITECTURAL R STRUCTURAL ❑ MECHANICAL ❑ 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 controlled materials. 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, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. IGNA UR e RIB71�WORN TO BEFORE ME THIS OF ol. ARY PU C MY COMMISSION EXPIRES#,?,� I JK Contracting LLC Proposal 31 Richmond Street Weymouth, MA 02188 Proposal Date: 10/6/2015 Proposal#: 185 Project: Bill To: David Steinbergh, Suites 301, 306/hallway,West Mill N.Andover, MA 01845 Description Est. Hours/Qty. Rate Total Plans and Permits 2,436.00 2,436.00 Demo 9,000.00 9,000.00 , Seal brick 2,500.00 2,500.00 Roofing, Flashing 500.00 500.00 Doors&Trim 22,000.00 22,000.00 Plumbing 5,000.00 5,000.00 Heating &Cooling 25,000.00 25,000.00 Electrical & Lighting 20,000.00 20,000.00 Insulation 7,000.00 7,000.00 Interior Walls 30,000.00 30,000.00 Floor Coverings 30,000.00 30,000.00 Painting, includes taping 30,000.00 30,000.00 Cleanup& Restoration 2,000.00 2,000.00 Supervision 18,544.00 18,544.00 Thank you for your business. Total $203,980.00 The Commonwealth of Massachusetts Department of IndustrialAccidents tl 1 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 Legib Name(Business/Organization/Individual -JQWI�fc�M4 G L,L_ C-- Address: C txmo w CJ City/State/Zip: Phone 4: Are you an ployer?Check the appropriate box: Type of project(required): 1. am a employer with 4=r employees(full and/or part-time).* 7. ❑New COnStruCtiOri 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs 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. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *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 state whether or not those entities have employees. If the sub-contraciors 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: �( V GV CT r Policy#or Self-ins.Lic. Expiration Date: l3 Job Site Address: c <r—la C 1 �► ✓L. City/State/Zip: ► " ^' 11/ (/��'`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 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 and penalties of perjury that the information provided above is true and correct. Signature: Date: l b / Phone#: , Z i 6 —7-7 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): 6.1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 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"...everyerson in the service of another under an contract of hire p Y 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 foi 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' compensatiori'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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia I Ac & CERTIFICATE OF LIABILITY INSURANCE '�"'°°�""' 3215 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 ADD171ONAL INSURED,the policy(les)must be endorsed. H SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A dalament on this certificate does not confer rights to the certificate holder in lieu of such erldorseme PRODUCER WVTMaria Dupont Insurance Agency, Inc. P E 18 Copeland Street 617 376-0795 . (617) 479-9121 Quincy, MA 02169 100me@dupontinsuranceaaenc!ir.com INSUR3 S AFFORDING COVERAGE NAIC 0 INSURERA:Main Street America INSURED INSURERS: JK Contracting, LLC INSUReRC: 31 Richmond Street INSURER D: Weymouth, MA 02188 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 WrTH 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. .- LTR TYPEOFINSUR/WCE VARD POUCYNUMBERVAPLWff% 2MYYY Lam Ataa►ERALLIABruTM MPT7794M 2/10/15 2/10/16 EACH OCCURRENCE $ 11000,000 X COMMERCIAL GE NE PAL LUIBIUTY CWWG-E RENTED 6 500,000 CLAIMS-MADE OCCUR MED EXP Moro pereon) $ 10,000 PERSONALBADVINJURY $ 11000,000 GENERAL AGC6tEGATE E00 00 GEMLAGGREGATELIMITAPPUESPER PRODUCTS-COMPIOPAGG 6 2.000,000 POLICY JERT PLOC S AU ��LUU31LIiY .1.1 dIN11 111111 de't $ ANYAUTO BODILY INJURY(Per peison) 6 AALLOOWNED SCHEDULED BODILYINJURY(Per accident) $ AUTOS DAMAGE HIREDAUTOS _AUTOS Peracdddeent) 6 S UNBRELLALUIB OCCUR EACH OCCURRENCE 6 MCESSUAB CLAIMS-MADE AGGREGATE $ DED RETENTION WORKERS COMPENSATION I WC STATU arH. AND EMPLOYERS'UABILJTY Y/N TfXZY a ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT OFFICE MEMBER EXCLUDED? � NIA (lrardatory In NH) E.L.DI -EA EMPLOYEE rKyes describe under sdRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 6 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(At4eh ACORD 101,AdMUonal Rernrb Solve".K nen spa Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE W11H THE POLICY PROVISIONS. • AUTNORIZED REPRESENTATIVE Bridget McGowan ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: apedranti@crowninshield.com ".3/3/2015 7:22:03 AM PST (GMT—U) r'ROM: lUUUUD-2'U: 1bl/47yylYl rnyw; 4 WL .k 0111E CERTIFICATE OF LIABILITY INSURANCE - sr�no,s TNIS CERTIFICATE 3 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFM NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNMY AMEND, EXTEND OR ALTER THE CMERME AFFORDED SY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHOMMEED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER IMPORTANT: E ttta coram"hoMw In an ADDITIONAL INSURED,tta pdkw(bo)must be ondorsed. K SUBRO"MM m WANED,"JM to the Loreto and Dondttlorte of 09 po ft,osrtaht policies may requlro an ondorsentant. A atstartwnt on this owtMata doss not confer rights to the ma "OF--a holds in But of such andarmamnVal. Pltomm DUPONT INSURANCE AGENCY INC 18 COPELAND ST QUINCY,MA 02169 9wC� olrtatt� JK CONTRACTING LLC 31 RICHMOND STREET �' WEYMOUTH MA 02188 rMlat®!e COVERAM CERTIFICATE NUMSM 236MU REVISION NUMBER THIS 18 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN B8LIED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITMANDING 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 18 SUBJECT TO ALL THE TERMS, EXCL.USIONB AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PND CLAIMS. PER Us TV"OF/tatadillu pCmvLast• COMM 3LLT11LONIM LUAaam► EACH OCCURRENCE a CIAWMADE ❑Ocane rr®eIw on. s PBIsoNIL a ADV INJURY Il GM AGOISS TE LIMIT APPLIES PER: GENSM AQOREOATE Ill POLICY p SIP& E]Lao PRODUCTS-CDMPOOPAGO OTHER s AWORIONaa WALRY s ANY AUTO BODILY KAKf(ParALL AUTO AUTOS HIRED AUTOS P$C88M= BODILY 9VUIY(Pr eoddtr 4 a Al1Tba a s aLL9adLALIAa OAR E.ACHoccLssENCE s ElICE Lm CLAL111MADE I AGGREGATE mom AND�C�erMY 1 2=20`15 1 Y/N ir � I� MEXECUTIVE�p�1(>� �N!A El.d1CFIACCmENT 10000D pwrtdtlxy in No EL DISEASE-d1 EMPLOM a 1011000 Worm" NBbokw EL DIsum-POLICY UMIT 500000 Deedtl CN DF CPBtATt l LAL:ATWA t Vt NMM gaoao Ml,Ad=s l Rmseft aalydW,uar In aeadmI9=aoao.n eagdhm* WDr wm companastlon Inaurartce applrea ordy to tfie worlters Dn Iowa of to amts of MA. This oamHlCata Canals and supataed°D s'e�i p Wo Wy Wwod caral�catsa,Dn a,shay mMoto workm mnp nedon c vmp. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ADM DEBCIIIBED POLICIES BE CANCELLED BEFORE THE 110PRATf011 DATE THEREOF, NOTICE WILL BE DELIVERED IN MEOW ACCORDANCE WITH THE POUCY PROVWOI& •:41:wr.r AUT11010110LAwW It�adlNiwTMa Mutual Fire Insurance CJ •19MM14 ACM CORPORATION. All r1p19ls reserved. ACORD 25(2014101) The ACORD nonce and hto ane rsglstenad nmft of AMD CL's! NO., 29677622 CL:1011'P 0=1 1611469 Lucy 6asLioLd 9/9/2011 10:19:07 M (23T) raga 1 or L f Massachusetts Departmerxt of Public Safety t Board of Building Regulations and Standards License: CS-066334 Construction Supervisor KIERAN T WHELAW 31 RICHMOND STR WEYMOUTH MA-02 Expiration: Commissioner 09/26/2017