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Home My WebLink AboutBuilding Permit #742-2016 - Suite 2101 12/18/2015�pt�OeRnTF 2 2,1 6 'qyO BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: l Z Date Received �4SSA`�� Date Issued: C HU I�i I5 IMPORTANT: Applicant must complete all items on this page LOCATION 1 060 ow0d ' + e O. "e Print PROPERTY OWNER l! Z Print MAP NO: PARCEL ZONING DISTRICT: Historic District yes n Machine Shop Villaae ves TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: BrCommercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic []Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer /- Identification Please Type or Print Clearly) OWNER: Name: D �' f Phone: Address: SbAbOAA 2)6 S)Dn f r' CONTRACTOR Name: Phone: t 6 as — Address: Pb17 66� lt6I I'Yl Ir� Supervisor's Construction License: �rg- Exp. Date: Home Improvement License:, 1� Exp. Date: `I � u ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. � Total Project Cost: $ 1, Ill 1 1 J 0 FEE: $ - �94 Check No.: 10(03 Receipt No.: Zany NOTE: Persons contractingw unregistered contractors do not have acceslio the gu"ty fund ,. W I '11�� /. m/ z 3 . c Plans Submitt-A 0 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swunimug Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Diunpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature Reviewed on Signature Reviewed on Signature i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments u Conservation Decision: Comments Water & Sewer Connection/signature Date Driveway Permit DPW Town Engineer: Signature: re -PARATM_ENT a �a f Street 4M, r Located 384 Osgood S t FI,RE�DE ,, , f_ ,T,empIDu tipster onsite .,yes:: �� r w ,�;' .ono ' E Lo� te-lat�12�41MaintS4reet4 } _ u 'FireD,epartnientTsignatu°re/clate,.,`1. 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, rust or service drop requires approval of Electrical Inspector lies No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) U Notified for pickup Call Email i I Date Time Contact Name Doc.Building Permit Revised 2014 No 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 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 4- Photo Copy of H.I.C. And C.S.L. Licenses 4, Copy Of Contract 4. Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4 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) 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 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: 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 1C_ — Location No. W2-2o\� . Date -14 e7 Check # I T ` TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ t�GiJ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Town No.142- PER THIS CERTIFIES THAT has permission to Andover Mass, )10mVjW to be occupied as ....... ..................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application 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. VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUM...IS......................................................... ` BUILDING INSPECTOR Occupancy Permit Required to Occupy Building Display in a Conspicuous Place on the Premises — Do Not Remove No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. BOARD OF HEALTH Foodf*tchen Septic System BUILDING INSPECTOR Foundation Rough mal PWMBIN iNSPECTO Rough Final ELECTRICAL INSPECTOR Rough Service I GASINSPECTOR Rough Final FIRE DEPARTMENT Burner Street No. Smoke Det Town Aa - PERMIT THIS CERTIFIES THAT v'-"* to .................................. has permission to erect ....... Andover Mass,bfte.j" to be occupied as ........1.>IA11. w+l1.Y.M.T ..,Jw". A-MIA1%A KlK..................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By -taws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MO THS UNLESS CONSTRU I S TS .................................. BUILDING INSPECTOR Occupancy Permit Required to Occupy Building Display in a Conspicuous Place on the Premises — Do Not Remove No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. BOARD OF HEALTH Food/Kitchen Septic System BUILDING INSPECTOR Foundation Rough im mal PLUMBIN6INSPECTO Rough Final ELECTRICAL INSPECTOR Rough Service GAS INSPECTOR L Rough Final FIRE DEPARTMENT Burner Street No. Smoke Det. v 0 C O 0 O CD 0 Z y CD O CL o Q �• y o jw vCD C< Q o C cr a rMPL co CD CD -' CL CO U) U) v m CC N CD v O H. Cl) O O CD 23 zm x O -v co CD < C � 0 2)--q r > CD m 0 CD 0 70 . r F _� n 3 O O N rt C T. m --a =4 O' OW CD -0 N Q �1 (D cp D CL U3 y -I- 03 W C CD C CD c <C U3 N CCD O N z D h o' O CD Nn �_ co < Q.Q— o CD �(nC QC• rN a Z rnrn Cl) im Cn 0 zm x -v co ;urn c Cn z Cn O CII C ) z z• cn m O < C � 0 2)--q r > CD m 0 CD 0 70 . r F _� n 3 O O N rt C T. m --a =4 O' OW CD -0 N Q �1 (D cp D CL U3 y -I- 03 W C CD C CD c <C U3 N CCD O N z D h o' O CD Nn �_ co < Q.Q— o CD �(nC QC• rN -0 -3 CD .= c r o -.. - DCD CD Amp: ci CL mow a� o N N W T AT N A T A T p(D = D) . c' 0) < c D�j c pOj S c c 'O O X,O (D ''�' S r) = 3 : S a n \ Z (D G Ln r+ rD p w n rm" O WN (D 7o G1 m C C 3 =j WO c N G n z M H rD cZi O r)LA N •p m m O m m -� 0 0 2 O O O� M fD A� 0 Oft Z` 0 d� vt a S -0 -3 CD .= c r o -.. - DCD CD Amp: ci CL mow a� o N N W T AT N A T A T p(D = D) . c' 0) < c D�j c pOj S c c 'O O X,O (D ''�' S r) = 3 : S a n \ Z (D G Ln r+ rD p w n rm" O WN (D 7o G1 m C C 3 =j WO c N G n z M H rD cZi O r)LA N •p m m O m m -� 0 0 2 O O O� M fD A� 0 Oft Z` 0 d� vt N N W T AT N A T A T p(D = D) . c' 0) < c D�j c pOj S c c 'O O X,O (D ''�' S r) = 3 : S a n \ Z (D G Ln r+ rD p w n rm" O WN (D 7o G1 m C C 3 =j WO c N G n z M H rD cZi O r)LA N •p m m O m m -� 0 0 2 O O O� M fD A� 0 Oft Z` 0 d� vt fD A� 0 Oft Z` 0 d� vt DJD -I5 -80-G-0032 Page 1 of 9 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24 & 30 D -I5 -BO -0093 . QNj 2T NO, 3. AWARDIEFFEGI'IVE 4.ORDER NUMBER 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE 5577 UUOO HATE DATE 08/26/2015 DJD -I5 -BO -G-0032 a. NAME b. TELEPHONE NUMBER (No collect calls) 8. OFFER DUE DATE I LOCAL 7. FOR SOLICITATION TIME INFORMATION CALL: 9. ISSUED BY CODE D -BO 10. THE ACQUISITION IS M UNRESTRICTED OR � SET ASIDE: % FOR DEA - Boston Division 23. ITEM NO, SCHEDULE OF SUPPLIESISERVICES QUANTITY UNIT 15 New Sudbury St, Rm E-400 0001 ❑X SMALL BUSINESS Q ELIGIBLEE UN ED WOMENSMALL BUSINESS DSBj DC -R THE WOMEN-OWNEDED Boston, MA 02203-0402 FURNITURE AS INDICATED ON ATTACHED ❑ HBUSSINESINES USMALL S O SMALL BUSINESS PROGRAM NAIcs:423210 EDWOSB QUOTE FOR CBI. ❑SERVICE -DISABLED SIZE STANDARD: $.1,000,000 60 VETERAN -OWNED SMALL BUSINESS S(A) 11, DELIVERY FOR FOB DESTINATION 112. DISCOUNT TERM UNLESS BLOCK IS MARKED FSEE NET 30 SCHEDULE 15. DELIVER TO CODE DEA - Lowell Task Force/C.B.I. (Group #1) 900 Chelmsford St, Tower #3 Lowell, MA 01851-8100 a13a. THIS CONTRACT IS A RATED ORDER UNDER DPAS 14. METHOD OF SOLICITATION (15 CFR 700) ❑ RFO ❑ IFB 16. ADMINISTERED BY CODE DEA - Boston Division 15 New Sudbury St, Rm E-400 Boston, MA 02203-0402 10 RFP 17a. CONTRACTOR] CODE 1043481341 FACILITY 157262619 18a. PAYMENT WILL BE MADE BY CODE I D -BO OFFEROR CODE RED THREAD SPACES LLC DEA - Boston Division Doing Businem As: 15 New Sudbury St, Rm E-400 RED THREAD 22 BOSTON WIIARF ROAM Boston, MA 02203-0402 BOSTON, MA 02210-1131 DUNS: 157262619 TELEPFIONE NO, 17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN QOFFER 18b. SUBMIT INVOICEgp-��-O� ADDRESS SHOWN IN BLOCK 18a UNLE: CHECKED 1 1 SEE ADDENDUM t_ J 19 20, 21. 22, 23. ITEM NO, SCHEDULE OF SUPPLIESISERVICES QUANTITY UNIT UNIT PRICE 0001 Delivery Date: 11/14/2015 1.000000 EA $44,346.5000 FURNITURE AS INDICATED ON ATTACHED QUOTE FOR CBI. 60 24. AMOUNT s�,l� l'J0 See Continuation Sheet(s) 17:xr Rnerxe nral.'nr Ani � A,!(ttfurwt Sh:eix u� .Yeerxx:+rf') 25 ACCOUNTING AND APPROPRIATION DATA ::±26,TOTAL AWARD AMOUNT (For Govt. Use Only) DEA -2015-2015-S1 D-SA-5410000-DOM-G2-FAC-31014-FLD-5410804-2015 6 726.50 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1,52.212-4. FAR 52.212-3 AND 52.212•5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED X 27b, CONTRACTIPURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. 52.212-5 IS ATTACHED, ADDENDA ARE X ARE NOT ATTACHED 028. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN COPIES TO1129. AWARD OF CONTRACT: REF. OFFER ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER ALLTrEMS SET FORTH DATED . YOUR OFFER ON SOLICITATION (BLOCK 5) OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEETS SUBJECT TO THE INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH HEREIN, TERMS AND CONDITIONS SPECIFIED IS ACCEPTED AS TO ITEMS: 30a, SIGNATURE OF OFFEROR/CONTRACTOR 319. UNITED STATES OF AMEjICA (SIGN ,,gTURE OF CONTRACTING OFFICER) 30b. NAME ANO TITLE OF SIGNER (TYPE OR AUTHORIZED FOR LOCAL REPRODUCTION PREVIOUS EDITION IS NOT USABLE DATE SIGNED 31b.`N)ME OF THE Karnafel, Linda DR PRINT) 31c. DATE SIGNED p 7/.9 S"s STANDARD FORM 1449 (REV..022. 012) Prescribed by GSA - FAR (48 CFR) 53.212 DJD -15 -BO -G-0032 Page 2 of 9 19. ITEM NO. 20. SCHEDULE OF SUPPLIESISERVICES 21. QUANTITY 22. UNIT 23. UNIT PRICE 24. AMOUNT 32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE 33. SHIP NUMBER 34, VOUCHER NUMBER 35, AMOUNT VERIFIED CORRECT FOR 32a. QUANTITY IN COLUMN n HA5 nttN ❑ RECEIVED f-1 INSPECTED ❑ ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED: 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32c. DATE 32d, PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE 320. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE 33. SHIP NUMBER 34, VOUCHER NUMBER 35, AMOUNT VERIFIED CORRECT FOR 36. PAYMENT COMPLETE [:]PARTIALFINAL 37. CHECK NUMBER PARTIAL FINAL 38. Sill ACCOUNT NUMBER 39, SIR VOUCHER NUMBER 40. PAID BY 41a.1 CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 42a. RECEIVED BY (Print) 41 b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE 42b. RECEIVED AT (Location) 42c. DATE RECD (YY/MMODD) 42d. TOTAL CONTAINERS STANDARD FORM 1449 (REV. 212012) BACK DJD -15 -BO -G-0032 Page 3 of 9 Table of Contents Section Description Fane Number Solicitation/Contract Form............................................................................................................................. I Commodity or Services Schedule...................................................................................................................4 ContractClauses.............................................................................................................................................5 DEA -SAP -MATRIX DEA Simplified Acquisition Clause Matrix (MAY 2010) ................................. ...5 Listof Attachments.........................................................................................................................................9 The commonwealth of Massarch usetis Department of lndustrialAceldents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers, compensation Insurance �HEP �,px�GAUTHORITX .txicians/]'I.uznb TOBBMED � HTexs. Applicant Information Please Print Le ibly Name (Business/Organization/in.dividual)r VI CC ?!J .Addxess: O `i�cmc 13 Sz V-4 ,` aA #-1 cit or! I►. Z� t S�`'I' City/State/Zip: a 1 SS Phone #: ?7 -5 9 rl 4 el I" 7 Are yon an employer? Checkthe appropriate box: 1>9 I am a employer with-- _,mployees (full and/or pari-thae).* ?.E1 'am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3. Q T am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. [:]1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers' compensation insurance or are sole proprietorswrthnoempoyees.----•------_----••---�--___.._____�_ _�_._.-__ .... __ .... 5.01 am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors hale employees and have workers' comp. insurance.1 6. Q We are a corporation and ifs officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have nq e�ployees. [No workers' comp. insurance required.] Type of project (Ie4uired): 7. 0 New constructions 8.�Remodelirig 9. Demolition 10 [] Building addition 1I.❑ Electrical repairs or additions 12: E] Plumbing-repairs.or additions.,... 13. Roof repairs 14. Other *Any applicant that checks box #1 must also till out the section below showing their workers' compensation policy information. 1 Homeowners wfio cheGstib ii 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 athached an additional sheet showing the name of the sub-confixactors and state whether or non those entities have employees. lfthe sub -contractors fiave employees, they must pzovide their workers' comp. policy number. site ees.' Below i - X am an employer tTiat is pi�6vidii�g workers' compensation insurance for my employs thepoll andcjo/i information. Insurance Company Name: �Ge►i ' 1'r'� �r �.aVt 1-"`��K�'^� `-4�`� Policy # or Self -ins, Lic. Expiration Date: rob Site Address. l (D o D C 5ecy&e1 S-," 2A City/State/Zip: 01 .Attach a copy of the workers' compensations policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 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. X do hereby cernnder. _ fy upains andpenalties of peiftir that the in pf ovided above is true and correct. N1 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): i 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. )Electrical Inspector s`. PIumbing Inspector 6. Other Contact Phone Information and Instructions Massachusetts General Laws chapter 1.52 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract 6fliire, 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 ofthe 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 o£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 coutractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance: Uimited-Diability-C-ompanies-(LL-C)-or Limited L-iaWlity Tartnerships (LLQ.') with no emp oyees other than o 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 Iirdustrial Accidents fok confirmation ofinsurance coverage. Also be sure to sign and date the ahidavit. The'affildavit'should be retained to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self iir'sured companies should'entertheir 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 Evestigations 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 peimit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "rob 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 (Lo. 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-AMSSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE I DATE fM17/9ni 1fYY) TU&GEfMFICATE 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 CERTIFICLU HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX LTB INSURANCE AGENCY INC 85 WILMINGTON ROAD (A/C, No, Ext): (A/C, No): E-MAIL BURLINGTON, MA 01803 ADDRESS: 776SP INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY INSURER B: LION SERVICES INC INSURER C: INSURER D: I I MCDONALD ROAD INSURER E: WILMINGTON, MA 01887 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 WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MM\DD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE S ( RENTED PREMISES REMISES (Ea occurrence) $ ED EXP (Any one person) $ ERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: 7ENERAL AGGREGATE $ POLICY [—] PROJECT LOC DRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) BODILY INJURY (Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS-MADE DEDUCTIBLE $ RETENTION $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YIN UB-OG168465-15 07/16/2015 07/16/2016 XWC STATUTORY LIMITS JOTHER E. L. EACH ACCIDENT $ 1,000,000 ANY PROPERITOR/PARTNER/EXECUTNE rN-1 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSJVEHICLESIRESTRICTIONS!SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. 1600 OSGOOD STREET LLC, HERITAGE PLACE LLC, ZORRON LP, 21 HOWE STREET LP. CERTIFICATE HOLDER CANCELLATION OZZY PROPERTIES INC, DUNDEE OFFICE PARK LLC, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL B DELIV D C/O OZZY PROPERTIES IN ACCORDANCE WITH THE POLICY PRO 1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION- All righte fe§erved. r�� +�y,Frncttrrre,i�lj r. _ �1 _ _Office of ConsumerAffairs� jt [r'J.Jrrr/r,,,fx, X BIISIReSg ME Regul�tiou IMPR(WEMENT CONTRACTOR egistration: 173813 XPir4tion: DBA' 11/15T?Q#7Pe' " LION SERVICES JAIME LAYON "f 11 MCDONALD RD WILMINGTON, MA 01887, 4�7``�"-3� Un7eriecmfary a -invent of ubtic Safety M Massachusetts - D_P p d Standards Board of Builc ing Reputations. Nt Construction Supen isor # .i cense: CS -108082. r - JAIME I LAYON ,-` - —r rl 11 MCDONALD ROAD Wilmington MA 01887 Expiration 03/06/2018 Commissioner /v 0 D o N ° X A 0 -j F (z�tF <DN mWz G ° mz O A m o m 7 (D N t=u O C mm m o❑❑❑ m O ; 1 m n O 0 0 N I I n 0 2 ti ro d r, A z 1600 Osgood Street N fD� rnm 2 p l w�y x �s i. iD nNi o wzr� O Z y 16 .4 1-2-14 n *mom m 7 F0 O o- m < myo m v ==f 0 mD O r_zmc' OOTIx. o�� o �< -- -axo A =i<AO SHEET 7JTLE c Tmc Ix (7 K Z ••'00 `e E N m C m �z�b""F��-yOm j�mm E •�� tOf\t { N Ar Zm OryN 000 C { m>000 CD W T Aj x581 `zm C1 o a�_m3.5h cn TmNAN A ;00 z = 0 r N secure t=u O C PROJER NAME 8, ADDRESS Jessica McLaughlin o❑❑❑ � a O ; 1 m ZC I I A ; d r, A z 1600 Osgood Street N fD� rnm p l w�y x �s nNi o wzr� x 16 .4 1-2-14 n *mom No.Andover.MA O o- m < myo 0 ==f r_zmc' OOTIx. o�� o �< -- A =i<AO SHEET 7JTLE c ��. (7 K m �z�b""F��-yOm � E tOf\t { N A Z OryN XS { x581 `zm vg2p o a�_m3.5h cn ;00 0 -n .� 7( x n z -1 m z z ° T O O0z 0 z rn rn r .. e o z m 'o wmm O °Y�0 Aa-zii SNoi N< t N G � e � o III �N 0 D x f1#O TO mm W pm r CI CA z09* Z= Z Cm " A N mzv rN �z0 = m = z 0 z v C) N y \ o ni -n z z17- En rn D mz Z xsi.z Z-1 Ov Z m0 C pNwptyii yOAS A f 0 �V O x N A O O z 0 Zy 4 O C,� z m "N -n (D n N m 01 OM �OM 7 m<7 mz3o O (D AZO 0 CD O N 3 W W m CD z C W � 710 �� III III 710 � 30'-9" FURN DIIVk--!- 00 mm m 71 ��II Vl to A, U!,V m Ao � N I rn� •� �E AA IIt ____ F�' �W II 2 00 m m 71 i 4 m m m z z N AN V - =n A n m 0 A nW I' -S 4Zm wTN �m X00 l m Cl) S m 0� XO w -n z OX mD_3 zXO <O 3G �m z O n 2 D U) -n x 0 K O z < m z --I 0 m G z O T 0 0 z < m z 0 T 70 O i flit X_m :�. 5-)zm n�Gn zz= mr)ZD m D Z°jN Z W { m D m X0 K Q { t W m m • y m D � <n m= D OU) n < 7% o O K O T o� o PROJER NAME 8, ADDRESS Jessica McLaughlin o❑❑❑ � a I I xx S-,5 p o N' d r, 0 # 1600 Osgood Street o ma� mo0 ° 3 =z gm:��F9 x 16 .4 T N No.Andover.MA O o- m < myo o m N"m� �¢^ o�� o �< SHEET 7JTLE c m �z�b""F��-yOm � E vg2p o a�_m3.5h cn 7( x p Am. -S o omei �6 G 3 n a '' 0