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HomeMy WebLinkAboutBuilding Permit #298 - Lazer Craze 10/18/2007 (2) bUILUINka rr-MIVII i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * z4 yry Permit N0: 0 Date Received �SSACHV`'E� Date Issued: G� IMPORTANT:Applicant must complete all items on this page e '`awe "�` ': za '�'E',, i .s Si '�d sR'%•�,r'. F4 .� a,.t ,yyu "y ` '... 2f� L✓ Ia1}Y ��^ "° "�"T 4h^Y r a�`r", *fi' h�' tiaSf x w� x u Mre �� zwwawktu� r iyxr rn y.,w Msyv m r'�a a 3 �t a _vim � �,. ', eY x g.Ya � :�e .�'mt�3�^75�•-k- ate' �'�ry�„� s�y�`z ��'��y � - {'��� s� �zr��" �'wsasdfr ������^w4 A Mr�` �' a� "��'"�- 1,3��a'� '� � °-���+ '�`� r�� �������.�'� � �✓� -� � , 511-s- ,t�;•� "a � wwr�.. � ��t z.� ?H�,�* ��'1'.r S v `Po- � ,� �.� r ��,. b.a°-.&__ - �'r �, rb a. �".a�.. �.. TYPE OF IMPROVEMENT PROPOSED USE 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 3 0. I tr� � � n'�.� ;i,�cc �.<s ' ^�.�5;•:... ��a�_h<�.� '�'�' ,�� �„�°�. ��-� '�4u� DESCRIP ION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: ���� .�s Phone:7�/-(oD�-U`�3� Ad ess ' 'raA, s�1 '� n eh* f Cq.nk ak r s w t € r :W y k a u C fir;; ' ,�', �+,�v -r 4 �.:.£'.�,��,,xx�x�,.,,.���,�..,'l f,w �„ ' x ARCHITECT/ENGINEER�°�S1 �r�r�a � Phone:—'3 Address: /�-/k ��� S� l�lalg % IV. An-©vee /�I1Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �U Total Project Cost: $ - - y FEE: $ y-7 " /y3 I s"� 2 Check No.: Receipt No.: NOTE: Persons con acting with unregistered contractors do not have access to tl a guaran fund 7i o r vttyxYP'S'4Y".�I�t'la"CUlOf�0)'1tl'a`Cl~Q -.. f A.3'. Z`.YM �". Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TYPE OF SEWERAGE DISPOSAL i Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING &-DEVELOPMENT ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ . ❑ COMMENTS DATE REJECTED DATE A VED i HEALTH El COMMENTS Zoning Board of Appeals: Variance Petition PP etition No: Zoning Decision/receipt submittedY es Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nectio n/Sicinature & Date Driveway Permit Located at 384 Osgood Street � fPAIENTTenp��irscl �nif es r1 F m.'� 3`�• � �a���"� s �,�',�s�:�r c �� ��@i'.z 'i'at , x rss .,v F""; 3 x. ..„._ ' _ •. .. ,..}.� > :w, +d?' x - ... t 3 ate-akE d -,.'"j n a- 43"�z,^, .+� 411 ;a. .✓�'MdNTS k s Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.s10o-s100o fine NOTES and DATA— (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: 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/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 ❑ 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 i 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 I INAIA Docu ment A105 - 1993 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: September 5,2007 (Date) ADDITIONS AND DELETIONS: The author of this document has BETWEEN the Owner: added information needed for its completion.The author may also Hughes Entertainment have revised the text of the original 1600 Osgood Street AIA standard form.An Additions and North Andover,Ma 01845 Deletions Reportthat notes added Contact:Greg Hughes information as well as revisions to and the Contractor the standard form text is available from the author and should be Vantage Builders,Inc.,Subchapter S Corporation reviewed.A vertical line in the left 281 Winter Street-Suite 340 margin of this document indicates Waltham,Ma 02451 where the author has added necessary information and where for the following Project: the author has added to or deleted from the original AIA text. Lasercraze—Demising Project This document has important legal 1600 Osgood Street consequences. Consultation with an North Andover,Ma 01845 attorney is encouraged with respect to its completion or modification. The Architect is: GSD Associates,LLC 148 Main Street,Bldg"A" North Andover,Ma 01845 The Owner and Contractor agree as follows. Init 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 145:26 on 09/18/2007 under Order No.1 0002879271 which expires on 2/23/2008,and is not for resale. User Notes: (3534305610) 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; .2 AIA Document A205,General Conditions of the Contract for Construction of a Small Project,current edition; .3 the Drawings and Specifications prepared by the Architect,dated ,and enumerated as follows: Drawings:See Attached Exhibit C—Drawing List Number Title Date Specifications: Section Title Pages .4 addenda prepared by the Architect as follows: Number Date Pages .5 written change orders or orders for minor changes in the Work issued after execution of this Agreement;and .6 other documents,if any,identified as follows: Exhibit D—Letter of Intent Executed by Gregory Hughes Inst. AIA Document A105TM—1993.Copyright©1993 by The American Institute of Architects. All rights reserved. WARNING:This Ale Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA`Document,or any portion of it, 2 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 14:35:26 on 09/1&2007 under Order No.1 0002879271 which expires on 2/23/2008,and is not for resale. User Notes: (3534305610) ARTICLE 2 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION DATE 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 ( )days ,subject to adjustment by Change Order. (Insert the date or number of calendar days after the date of commencement.) Substantial Completion:Entire project Twelve weeks from permit—Demising Project Six weeks from Permit ARTICLE 3 CONTRACT SUM §3.1 Subject to additions and deductions by Change Order,the Contract Sum is: Four Hundred Thirty Five Thousand,One Hundred Forty Three and Zero Cents ($435,143.00) §3.2 For purposes of payment,the Contract Sum includes the following values related to portions of the Work: Portion of Work Value($0.00) See Attached Exhibit A-Proposal dated September 14,2007 §3.3 The Contract Sum shall include all items and services necessary for the proper execution and completion of the Work. ARTICLE 4 PAYMENT §4.1 Based on Contractor's Applications for Payment certified by the Architect,the Owner shall pay the Contractor as follows: (Here insert payment procedures and provisions for retainage, if any.) IPayment Terms:N/30 from receipt of Application for Payment Retainage Terms:5%until project complete §4.2 Payments due and unpaid under the Contract Documents shall bear interest from the date payment is due at the rate of Prime Plus 4% 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.) ARTICLE 5 INSURANCE §5.1 The Contractor shall provide Contractor's Liability and other Insurance as follows: (Insert specific insurance required by the Owner.) Type of insurance Limit of liability($0.00) See Attached Exhibit B Vantage Certificate of Insurane §5.2 The Owner shall provide Owner's Liability and Owner's Property Insurance as follows: (Insert specific insurance furnished by the Owner.) Type of insurance Limit of liability($0.00) Builders Risk and or All $435,143 §5.3 The Contractor shall obtain an endorsement to its general liability insurance policy to cover the Contractor's obligations under Section 3.12 of AIA Document A205,General Conditions of the Contract for Construction of Small Projects. �I Init. AIA Document A105TM—1993.Copyright©1993 by The American Institute of Architects. All rights reserved. WARNING:This AIAe Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA®Document,or any portion of it, .3 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 14:35:26 on 09/18/2007 under order No.1000287927_1 which expires on 2/23/2008,and is not for resale. User Notes: (3534305610) §5.4 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 (Insert any other terms or conditions below.) 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.) DATE: DATE: OWNER(Signature) CONTRACTOR(Signature) (Printed name and title) (Printed name and title) LICENSE NO.: JURISDICTION: Init. AIA Document A105Tm—1993.Copyright c 1993 by The American Institute of Architects. All rights reserved. WARNING:This Ale Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIAe Document,or any portion of it, 4 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 14.3526 on 09/18/2007 under Order No.1000287927_1 which expires on 2/23/2008,and is not for resale. User Notes: (3534305610) Additions and Deletions Report for AIA Document A 105T"— 1993 This Additions and Deletions Report,as defined on page 1 of the associated document,reproduces below all text the author has added to the standard form AIA document in order to complete it,as well as any text the author may have added to or deleted from the original AIA text.Added text is shown underlined.Deleted text is indicated with a horizontal line through the original AIA text. Note: This Additions and Deletions Report is provided for information purposes only and is not incorporated into or constitute any part of the associated AIA document.This Additions and Deletions Report and its associated document were generated simultaneously by AIA software at 14:35:26 on 09/18/2007. PAGE This AGREEMENT is made: September 5,2007 Hughes Entertainment 1600 Osgood Street North Andover,Ma 01845 Contact:Greg Hughes Vantage Builders,Inc.,Subchapter S Corporation 281 Winter Street-Suite 340 Waltham,Ma 02451 Lasercraze—Demising Project 1600 Osgood Street North Andover,Ma 01845 GSD Associates,LLC 148 Main Street,Bldg'A" North Andover,Ma 01845 PAGE 2 Drawings:See Attached Exhibit C—Drawing List Additions and Deletions Report for 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® 1 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 14:35:26 on 09/18/2007 under Order No.1000287927_1 which expires on 2/23/2008,and is not for resale. User Notes: (3534305610) III Exhibit D-Letter of Intent Executed by Gre og ry Hughes PAGE 3 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 {days,subject to adjustment by Change Order. Substantial Completion:Entire project Twelve weeks from permit-Demising Project Six weeks from Permit 44 Four Hundred Thirty Five Thousand,One Hundred Forty Three and Zero Cents ($435,143.00) See Attached Exhibit A-Proposal dated September 14,2007 Payment Terms:N/30 from receipt of Application for Payment Retainage Terms:5%until project complete §4.2 Payments due and unpaid under the Contract Documents shall bear interest from the date payment is due at the rate of {-+-Prime Plus4% per annum,or in the absence thereof,at the legal rate prevailing at the place of the Project. Additns and Deletions Report for 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 14:35:26 on 09/18/2007 under Order No.1000287927_1 which expires on 2/23/2008,and is not for resale. User Notes: (3534305610) i See Attached Exhibit B Vantage Certificate of Insurane Builders Risk and or All $435,143 PAGE 4 DATE: DATE: Additions and Deletions Report for AIA Document A105TM—1993.Copyright ©1993 by The American Institute of Architects. All rights reserved. WARNING:This Ale Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA® 3 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 14:35:26 on 09/18/2007 under Order No.1000287927 1 which expires on 2/23/2008,and is not for resale. User Notes: — (3534305610) i Certification of Document's Authenticity AIA®Document D401 TM — 2003 I,Darla Brooks,hereby certify,to the best of my knowledge,information and belief,that I created the attached final document simultaneously with its associated Additions and Deletions Report and this certification at 14:35:26 on 09/18/2007 under Order No. 1000287927_1 from AIA Contract Documents software and that in preparing the attached final document I made no changes to the original text of AIA®Document A105TM—1993-Standard Form of Agreement Between Owner and Contractor for a Small Project where the Basis of Payment is a STIPULATED SUM,as published by the AIA in its software,other than those additions and deletions shown in the associated Additions and Deletions Report. (Signed) (Title) (Dated) AIA Document D401 n"—2003.Copyright©1992 and 2003 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 14:35:26 on 09/10/2007 under Order No.1000287927_1 which expires on 2/23/2008,and is not for resale. User Notes: (3534305610) f i; SOW o w d►n ✓ eaac/ucaelt Construction S ►yisocen standards License: CS 79454 B►rtj t ate: 2/26/1977 E�tp► 26/2009 Tr# 12181 Restf►Etion OOt' PATRICK IVI YARNED art 3 BEAVER BROOff BURLINGTON, MA 01803`- —'mac Commissioner Town of North Andover Construction Control Affidavit Project Number: 0662 Project Title: LaserCraze Tenant Fit-up Project Location: 1600 Osgood Street-2nd Floor-Building 30 at South East Entrance Name of Building: Osgood Landing Nature of Project: Tenant Fit-up for indoor recreational and Amusements In accordance with Section 116.0 Registered Architectural and Professional Engineering Services-Construction Control of the Massachusetts State Building Code, I, Lucio Trabucco Registration No. 7997 being a Registered Architect, HEREBY CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: / Entire Project Architecturaly Structural Mechanical Fire Protection Electrical Other(specify) FOR THE ABOVE-NAMED PROJECT AND THAT SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE 780 CMR MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETEMINE THAT THE WORKS 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, 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 state of construction to become, generally familiar with the progress and quality of the work and determine, in general, if the work i being performed in a manner consistent with the construction documents. �,��Eo ARS UNDER SECTION 116.4, 1 SHALL PERIODICALLY SUBMIT A PROGRESS REPORT, TOUGETHER WITH PERTINENT COMMENTS, TO THE BUILDING INSPERCTOR U v N .7997 COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE �S TON SATISFACTORY COMPLETION AND REDINESS OF THE PROJECT FOR OCCUPAN F. 0- CA— SUBP9RIBED AND SWORN TO BEFORE ME THIS I& DAY OF h -e-,- 007 ( MY COMMISSION EXPIRES J -e- NOTARY PUBLIC LISA MARIE JOHNSTON LISA lvi� ajF JOHNSTON NOT�' < �fz,E)DLIC COMMONWEARROFPUBLIC COMh,r; �i i 7F MASSACHUSETTS MY C MASSACHUSETTS MY CUr S;;C;ha LXPfRES 06'09/2011 .,,M��� COMMISSION EXPIRES 06/09/2011 ......+. :«ter..... CROSSFIELD ENGINEERING, INC. 921 SALEM STREET,GROVELAND, MA 01834 978-372-8880 FAX 978-372-8889 AFFIDAVIT ELECTRICAL DESIGN Permit No. To the Commissioner, Inspectional Services Department Ward Re: Laser Craze 1600 Osgood Street N. Andover, MA I certify that to the best of my knowledge, information and belief,the plans and computations accompanying the attached application concerning the locus referenced above, in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. Ott► OF Mq George W. Hale#24090 GINEER—MASS. REG. NO. GEORGE cy� W. HALE o i No. 240904. � Crossfield Engineering, Inc. j �F-ISTER�� ��Q COMPANY �SSIONAL 921 Salem St., Groveland, MA ADDRESS 978-372-8880 PHONE 099-06 9-3-07 CROSSFIELD ENGINEERING, INC. 921 SALEM STREET,GROVELAND, MA 01834 978-372-8880 FAX 978-372-8889 AFFIDAVIT MECHANICAL DESIGN Permit No. To the Commissioner, Inspectional Services Department Ward Re: Laser Craze 1600 Osgood Street N. Andover, MA I certify that to the best of my knowledge, information and belief,the plans and computations accompanying the attached application concerning the locus referenced above was designed in accordance with the requirements of the Massachusetts State Building Code 6th Edition and all other pertinent laws and ordinances. Allan R. Morris #13505 �. ENGINEER—MASS. REG. NO. H OF AA � A Crossfield Engineering,Inc. 1 ® !1�0 COMPANY v oma' ALLAN ®� ROBERT 4 MOR i 921 Salem St., Groveland,MA w No.t ADDRESS 978-372-8880 "►®V.Vw PHONE 099-06 9-3-07 CROSSFIELD ENGINEERING, INC. 921 SALEM STREET,GROVELAND, MA 01834 978-372-8880 FAX 978-372-8889 AFFIDAVIT PLUMBING DESIGN Permit No. To the Commissioner, Inspectional Services Department Ward Re: Laser Craze 1600 Osgood Street N. Andover, MA I certify that to the best of my knowledge, information and belief,the plans and computations accompanying the attached application concerning the locus referenced above, in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. Allan R. Morris #13505 ENGINEER—MASS. REG. NO. a U Crossfield Engineering, Inc. Ur g COMPANY ms k��Z H OF yj� ®® s 0 � o° Mos A 6` 921 Salem St., Groveland,MA 4 C) �o "'s y ADDRESS s 9 /STEREd s/LANAIEN��®� 978-372-8880 `'•••••� PHONE 099-06 9-3-07 CROSSFIELD ENGINEERING, INC. 921 SALEM STREET,GROVELAND, MA 01834 978-372-8880 FAX 978-372-8889 AFFIDAVIT FIRE PROTECTION DESIGN Permit No. To the Commissioner, Inspectional Services Department Ward Re: Laser Craze 1600 Osgood Street N. Andover, MA I certify that to the best of my knowledge, information and belief, the plans and computations accompanying the attached application concerning the locus referenced above, in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. Allan R. Morris 913505 ENGINEER—MASS. REG. NO. Crossfield Engineering, Inc. I o D COMPANY ®► P F q �j M .'J AL ROSER 921 Salem St., Groveland, MA G M RIs ® ADDRESS N . 3305 /STER ONALEN�'\�� 978-372-8880 � PHONE 099-06 9-3-07 The Commonwealth of Massachusetts Department of IndusMal Accident. Office ofI'nvestigatiolls 600 Washington Street Boston, Mass. 021.11 Worken' Compensation Zt mance Affidavit .Name Vantage Builders, Inc, Location: 281 Winter St, Suite 340 City:` Waltham, MA 02451 phone: 781-895-3270 I am a homeovmer performing afl woik myself _I am a sole proprietor and have no oneworking in any capacity I am an employer providing workers'compensation for my employees working on this job. CompanyName: Vantage Builders, Inc. Address: 281 [minter St, Suite 340 City lialtham, MA 02451 Phone 781-895-3270 InsuranceCompany:Americal International Policy# WC 897-63-90 Group I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed belo'y who bave the Mowing workers'compensation policies: CompauyNama: Udall Tech Systems Address 94 River Rd City: Hudson, NH Phone 603--886-8797 InsuranceCompauy: Trawlers Ins. Poliayd WC731S225190024 Company Name: Plunkett Painting. Address; 11 Jackson St City, Hopkinton, MA 01748 phone 508--435-5234 Insumcecompany: Travlers Ins. palicy# VB--7528A77-5-04 Failure to sowro coverage as required under Section 25A ofMOL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one yews'imprisomnent as well as civil penalties in the form Of-STOP WORK ORDER and a fine of$1 fine u a day against me.I understand that a copy ofthis statement may be forrntarded m the Offico of Investigation ofthe DIA for coverage verification. 1 do hereby certify carder the pain and penalties of perfury drat the Info rwaHair provided above is[rue and correct. Signature. Date: PrintName: Phone# Official use onlyl Do ttot'write in this area,to be completed by Ciry or Tonin Official City or Town: Permit/Lieense# Contact Person:BUILDING,PLiWNG,F-LECFRICAI,INSPECTOR phone# 781—794—$071 ACORD CERTIFICATE OF LIABILITY INSURANCE OPIDKG °ATE(-- yym VANTA-1 09/21/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Capstone Insurance LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Suite 230 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Two Newton Place ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Newton MA 02458 Phone: 617-619-3300 Fax: 617-619-3301 INSURERS AFFORDING COVERAGE NAIC# NSURED �- MUMA- St. Paul Travelers Vantage Builders, Inc. NMRERR. AIG Insurance Companies John Connor DSURERC Hartford Insurance 281 Winter Street - Suite 340 �DaERD Waltham MA 02451 P,iSURER E' •__ COVERAGES THE POLMSOF P.SUR k=STED ErUMAM.YE EEEN LSSUEDTOTh'E CSURFD f:AYEDAAME FOR TRE POLGY PERDOCAaCATED WW.9HSTA%W4 A!fYREOU;REWFNT.TERV ORCONDRttR.JOF Aw CONTRACTOAOIY.ER DOW ue1TStim RJ3JiCT TONFfCHTHS CEMWCATE WAY EE MSU,DOR u.AYPERTA I.THE NSV-WrE FFEDRDEDBYTHE FOUCJFS DFSGRSO HERFLTJ tS YJWMTTOALLTNE TERM FYC MOO A.W COna7"asOFSuCH POUCU AODREGATE LW SSWVM WAY HAVE BEEN RMXFDRf PAC CtAV3 NSR POUDY EFF POLICYERP.TATDR LTR Nilo TYPE fh<LNSIANYGE Pat=AIIRSER VATEMMIM CATF&MUDYT, LOM GMERAL UASLTY EACH OCCURRENCE $ 1,000,000 DAvaEroRERTm A X OOVVEPCVifA:FAAIUASLRY DTC0463D9837ZND06 12/01/06 12/01/07 PRflv6ESAEAo�J s 300,000 CWIS RADE X❑OCCUR WFD EJto V.TfA-xPf/AaiY $5,000 _ PERsorLSAn.NRraf S 1,000,000 C.MMAI AW.REGATE S 2,000,000 6 0 AAIC.REGATE WJT APF UES PER PRODUCTS•OOUP.OPAM f 2,000,000 1-1 Poucr X ,ECT PRo LDC EBL 1,000,000 auro6waTETD�aTATr oovsxEDs_vGJEuvrT s 000000 A X AfrrAWrD DTA0810463D9849COF06 12/01/06 I2/01/07 'E'*'d6� 1,000,000 ASLbA::F.O W1TOS BODIVRIJURY SCFEDUMDAWTOS UM+ ) Pssy N:REOAUTOS EODLv OWRr HONQ4tfDANOS Ahr yC[rq y PROPERTY OAVAVE tFH• -V S GARJIDELIARAITY AVTOO\LY-EAACPDEAT y ANYAIfTO OTHERTRA% EARA y AUfOOh4Y AGO $ PICESSVWRELlAUABL Y - EACHOOCUJLREfd:E $$6,000,000 A X-1 OCCUR F-1 CM"SMADE DTSMCUP463D9850TIL06 12/01/06 12/01/07 AGGREGATE s$6,000,000 S OEOUGTSlE S X RETEMION $10,000 E NVFNFRS406mET:SAM4ANO X WCSTATU- OTTI- E6-wYFR9 UAsuff IORYt1VfIS TH _ B WC8976390 12/01/06 12/01/07 ELTArNaccDEHr s$500,000 Aw P RGPR:ETDR PARTATR ExTC JTA� oFF>tERteExEFR EEnuDEm aFea.e+ea¢su w EL DLSEASE-EAEUnCleEE s $500,000 sPEcuLFwassasEro E DS[ASE-POUCYLLWJT s $500,000 O ER C Domestic Package 09SBAUP3565 12/01/06 12/01/07 BPP $100,000 OESSFPTIONOFOYTNATIONF!LOCATIONS f VEl6ttE51 FJIOLUS:ONS FODEygYENDORTEYNTf SPEry1LPR0\951IX:5 Project Location: L=amrRambae-.TenantzLitqut 1600 Osgood Street North Andover, MA 01845 Additional Insured: Ozzy Properties, Inc 1600 Osgood St, LLC, Hughes, Entertainment, Inc Salem Five Cent Savings Bank CERTIFICATE HOLDER CANCELLATION SHOULDAwWTHEAWa UESCRZMPOUCrpy BECA'6CE'LLEUREFO-HEEXFWATGR DATETHEREOF,THEISWiR0 LN6ANFRµRA ENTIEAVORTDVXL 30 TMYSµ1UTTm Ozzy Properties, Inc HOTDW E TO THE CERICATE HOLDER RA4,EOTO THE LEFT.RUT FA4UREro DOSO SH121 1600 Osgood St LLC JLTOSEHDOS[AATDNG2LIA9AATYOFAw low lrDY THE NSILREIL TTS AOENiSOR REDRESFMA7Tl4S Andover MA 01810 AUTHORIZED REPJJHMATNT ACORD 26(2001108) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the Issuing insurer(s),authorized representative or producer,and the certificate holder,nor does It affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 26(2001/08) NORTH ® of _: Andover C x No. ..,.,. o dover, Mass., LAKE COCKICKEWICK 7,p0RATED 7 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System C{. c/ BUILDING INSPECTOR � 0�THIS CERTIFIES THAT Ae.��......4� ........ t ...... J ...........✓.................... Foundation has permission to erect........................................ buildings on .,,�4A!. .......:7/ Q Rough h to be occupied as ./.G,: G'�+n1.. /�f`!' r�/..' .... <�� .� ? ......................... Chimney, c provided that the person accepting this permit shall in every raspec conform to the terms of the application on file in Final 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 STARTS Rough e ..................... ............... ...... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in. a Conspicuous Place on the Premises — Do Not Remove Final No LathingD Wall To Be Done or � FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Location �6 0 ascl d o s No. a 9c� Date. Z© /7 D MOATM TOWN OF NORTH ANDOVER •, - O � 9 Certificate of Occupancy $ cMuEta' Building/Frame Permit Fee $ s� s Foundation Permit Fee $ Other Permit Fee $ TOTAL / Check #. ��f , 20704 Building Inspector