HomeMy WebLinkAboutBuilding Permit #254-2016 - Suite 2101 5/1/2018 BUILDING PERMIT N F.D 16q-rw.
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TOWN OF NORTH ANDOVER 32 y� ,,. . .• •6
APPLICATION FOR PLAN EXAMINATION
Permit No#:
�j — Date Received Area
�SSHCHt15��
Date Issued:
IMPORTANT: Applicant must complete all items on this page e—
LOCATION 00 ® -(— eZ3 4 -Co
Print
PROPERTY OWNER 600 ILI C '16V
Print I 00 Year structure yes no
MAP PARCEL: ZONING DISTRICT:® D- storic District yes no
Machine Shop Village yes no
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
❑Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District
❑Water/Sewer
DESCRIPTION OF ORK TO BE PERFORMED:,,
t C--e-- C i
/Cp�
Identification- Please ype or Print Clearly
OWNER: Name: Phone: eO
Address: 0 tq Z � q
Contractor Name::1- z C `/Phone:
Email:
Address: r" CJ
Supervisor's Construction License: C)1-! -Exp. Date: O
el
Home Improvement License: Exp. Date:
i
ARCHITECT/ENGINEER Phone:
Address: ����.� S f �� ��l 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 t: $ FEE: $
Check No.: 2951 Receipt No.:
NOTE: Pers ns c tracting with unregistered contractors do not have access to the guaranty fund
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 Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
f
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
l fry
Planning Board Decision: Comments
Conservation Decision: Comments
Wafter & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
PAR�TMENT - r ontsi
FIRE DE , 1 , - Temp�tDumpste te° eyes. tno 1
Latedtat E124tMain�Stceet« _ _ _
Fre40;epartmeni,signature/date. __
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.$1o0-$1oo0 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
s -
Doc.Building Pennit Revised 2014
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
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
4 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
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 `�'y� �-�l-� G`�'�`�
No. � �/�'" /.� Date rI 3l l
. - TOWN OF NORTH ANDOVER
SLED
. . Certificate of Occupancy $
Building/Frame PermitFee d < I'D
� Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check#
Buil ing9nspector `
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF:SEW-ERAGE.DISPOSAL p
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' ❑ ❑ gni. /i5
COMMENTS
ONSERVATION Reviewed on – Si nature
— QIL
COMMENTS v�
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
•Pi9nning Board Decision: Comments
'Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Todv2 Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMf�iVT - Temp Dumpster on site yes -no-.
Located at 124 Mair Street
Fire-Department signature/date
COMMENTS ,1 �S
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 4 Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
Print 0,-40:D 100 Year Old Structure yes no
MAP NO: PARCEL: ZONING DISTRICT-- Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Ind trial
❑Alteration No. of units: ommercial
❑ RRe air, replacement ❑Assessory Bldg ❑ Others:
"Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCR TION OF WORK TO ERF RMED:
o� CC—C. l
Identification Please ype or Print Clearly)
OWNER: Name: / D hone:
J-,aUAddress: 4P�
CONTRACTOR Name Phone: '
Address:
Supervisor's Construction License: Exp. Date: �-
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: �� �lJl rReg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
1�
Total Project Cost: $ l C19 FEE: $
Check No.: Receipt No.:
NOTE: Persons contracts 'h ered contractors do not have access to the guarantyfund
;Signature of Agent/Owne Signature of contractor
Plans Submitted ❑ Plans ived ❑ Certified Plot Plan ❑ Stamped Plans ❑
�x0[TMI
OF aru xa�0,
iEFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number, 254-16 on 8131/15
Date: January 12,2016
THIS CERTIFIES THAT
THE BUILDING LOCATED' at 1600 Osgood Street, gait 2101, GSA
MAy BE OCCUPIED AS OF,FWE SPACE IN ACCORDANCE WITH THE PROVISIONS
OF THE MASSACHUSETTS S`P'ATE BUILDING CODE AND SUCH OTHER REGULATIONS
AS MAY APPLY.
Cerfiffieate Iss ned to: O'zzY Property GSA
1600 Osgood Street
North Andover,MA 01845
Buil g Irispect�oF
Pee: PPrePaid $100-00
Receipt: 29271 '
Check: 9931
I
i
li
i
�5. CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 25 -16 on 8131/15
Date: January 12,2016
THIS CERTIFIES THAT
THE BUILDING LOCATED at 1600 Osgood Street, Unit 2101, GSA
MAy BE OCCUPIED AS OFFICE SPACE IN ACCORDANCE WITH THE PROVISIONS
OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS
AS MAY APPLY-
Certificate
PPLY.Certif erste Issued to: Ozzy Property GSA
1600 Osgood Street
North.Andover,MA 01845
BuildiVnX, nsp or
Pee: Prepaid $100.00
Receipt: 29271 '
Check: 9931
n
r Final Construction Control Document
m
To be submitted at completion of construction by a
` d Registered Design Professional
for work per the 8t'edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: ILate: Permit No.
Property Address:
Project: Check one or both as applicable: ❑ New construction xisting Construction
Project description: 46-61 LL"
I 04LAA MA Registration Number: Expiration date: /Vw-, am a
registered 3esign professional, and I have prepared or directly supervised the preparation of all design ans,
computations and specifications concerning:
vV Architectural [ ] Structural [ ] Mechanical
Fire Protection [ ] Electrical [ ] Other:
for the above named project. I,or my designee,have performed the necessary professional services and was present at the
construction site on a regular and periodic basis. To the best of my knowledge,information, and belief the work
proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building
permit and that I or my designee:
1. Have reviewed, for conformance to this code and the design concept, shop drawings, samples and other submittals
by the contractor in accordance with the requirements of the construction documents.
2. Have performed the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine if the work was performed in a manner consistent with the
construction documents and this code.
Nothing in this document relieves the contract lily regarding the provisions of 780 CMR 107.
a► �Q
Enter in the space to the right a"wet"or b No.004
electronic signature and seal:
Phone number: t Email:
Building fficial Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
NORTIi
c w s c . . ve,. .
0 . 3
No. 11L
-
�,, h ver, Mass,KE
/
A- Qp 000"jCf4
ewjcK
�RAtED 01'
S V
BOARD OF HEALTH
PERMIT T L D Food/Kitchen
i
Septic System
THIS CERTIFIES THAT ...... :/�i.S� �'.. ... .� .. BUILDING INSPECTOR' J
.� ..L::.C'• .l'..
(/ ••• `_ Foundation
. ... ...: ,�1
has permission to erect .......................... bui dings on .c�: :.......::. 1.. �...............
ugh 0_e_
s
to be occupied as •••• •••••••••• ••••
..............�................��:.......... .........�..... .�.�...................................... Chimney I`
provided that the person accepting this permit s a in every respect conform to the terms of the application ina
on file in this office, and to the provisions of the odes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PP MBING SPE TOR
Rough `�'
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final �✓, ` ��,�16
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS. CONSTRUCTION RTS
........................................,........................................ Tina;
p
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
s
Until Inspected and Approved by the Building Inspector. Burner
Street No.
• Smoke Det.
Enter construction cost for fee cal - Nor'Ih Andover Fee Calculation
Construction Cost
$ 552,510.00 m
$ - $ 490.00
Plumbing Fee $ 828.77
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 828.77
Total fees collected $ 2,247.53
1600 Osgood Street Suite 2101
254-2016 on 8/31/15
Tenant Fit Up
i
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 552,510.00 m
$ - $ 6,630.12
Plumbing Fee $ 828.77
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 828.77
Total fees collected $ 8,387.65
1600 OSGOOD ST
r 1 NORTH
� � : 1cver
0
No.
o-'h , ver, Mass, IFISIZP �
9
coc_.'wJcw 1'
�d APR,A7EO
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T ��� Septic System
THIS CERTIFIES THAT ...... .d�... 5 ; �? ......:�.....�......•tf.�, .!`�'� ...�.�. .�............ BUILDING INSPECTOR
• ...
'
has permission to erect .......................... buildings on l��'�... �, .. ........0' ' CFoundation
.�.................
/7 Rough
tobe occupied as .......... . .. . . ...........`.:-..:........................................................................................... Chimney
provided that the person a epting this permit shall 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. CONSTRUCTIO ARTS Rough
.y�����''Z--�........................... Service
............... ..... . ....... ....
BUILDING INSPECTOR Final
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.
Initial Construction Control Document
To be submitted with the building permit application by a
M d Registered Design Professional
for work per the 8th edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: ' Date: l
Property Address:
Project: Check one or both as applicable: ❑ New construction Existing Construction
Project description: % <
AgiXereVesign
MA Registration Number: Expiration date: am a
professional, and I have prepared or directly supervised the preparation of all design pifins,
computations and specifications concerning:
[Architectural [ ] Structural [ ] Mechanical
V] Fire Protection [ ] Electrical [ ] Other
for the above named project and that to the best of my knowledge, information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted
engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
a
Upon completion of the work,I shall submit to the buil al Construction Control Document'.
w. U
Enter in the space to the right a` vet"or
electronic signature and seal: I.-
Phone
Phone number: ��� �� �� (�/ fr ��•! ✓j • C�C/�',
Buildin Off al Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
DOWGIERT CONSTRUCTION CO. INC.
616 ESSEX STREET
LAWRENCE, MA 01840
978 685-0306 fax 603 458-1090
-- CONTRACT
Customer
Name 1600 Osgood St-LLC Ozzy Property Mgmt Date 8/11/2015
Address 1600 Osgood St. —
City North Andover _ State MA ZIP 01845 _ _ Job Name GSA space _
Phone interior build out
qty Description T Unit Price TOTAL
Supply necessary material and labor to build out appoximatel
4,600 sf of space as per plan by Rumpf Associates.
Price includes :
Framing of new walls,wire mesh installation, drywall and
taping. Reinstall lighting, install new electrical outlets as per
plan. Reinstall ceiling using as much existing material as
possible. Install 1 VAV and redo heat registers as needed.
Clean duct work in GSA space. Rework sprinklers as per
new layout. Install kitchen and sink. Rework fire alarm and
emergency lighting as per new layout. Install flooring and
cove space as per specs. Paint walls, trim and woodwork as
needed.
Install cameras, security alarms and piping for data wiring.
Install 2 Mitsubishi AC units.
1 Total contract price $552,510.00 $552,510.00
1/3 to be paid at start of work
1/3 to be paid within 10 days after rough inspections
Final balace to be paid upon substantial completion.
*See attached cost breakdown
*Price does not include architectural or engineering costs
and is based on plans dated 7/9/15. If changes are made,
pricing will be adjusted accordingly.
SubTotal $552,510.00
Shipping & Handling $0_00
TOTAL $552,510.00
Office Use Only
The Commonwealth oflMlassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,M4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibly
Name(Business/Organization/Individual): Zr
Address: 9
c®
City/State/Zip:_ 6 /�o Al ,/f/�� Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.d'I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. R:dmodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. g ❑Building addition
[No workers'comp.insurance 5. El We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L[]Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs
insurance required.)t employees.[No workers'
comp.insurance required.) 13.❑Other
*Any applicant that checks box nl must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workerscompensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:_ 6 f 4
Policy#or Self-ins.Lic.#: . 1,/0(( 5]E -7 t' .7 Expiration Date:
Job Site Address: QeZ City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido Hereby cerfifv under the pains andpenalties o perjury that the information provided above is true and correct. -
Sim0: Date:Date: �
6
Phone#:
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.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"...every person in the service of another under any contract ofhire,-
express or implied,oral or written."
An employeiis 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 Iegal 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-contractors)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
eml l ces,«holicy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. ThE au:davit shcwld
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'
compensation 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
-P-lease be sure that-the affidavit is-complete-and printed legibly. The Dep— meht has-provided a sP a--ce—
at hebottom
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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Com
monwealth of 1\4 a�hvs it -
Departmevt of Industrial.Accidents
Office ofIavestigations
600 Washington Street
Boston,MA 02111
TO,#617-727-4900 at 406 or 1:-877:MASS.AFB
Revised 5-26-05 BaY,#617-727-7749
wwwaass.gov/dia
CERTIFICATE OF LIABILITY INSURANCE DnTEpaMro°m�wi
5/28/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CUMFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NESATMMY AMEND, EXTEND OR ALTER THE COVMA E AFFOROFA BY THE PATES
BELOW. THIS CBR.TIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT SE'TWEEN THE IMINC INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CEIMCATE MOLDER.
IMPORTANT: n the aertiki is hoMer IS an ADDITIONAL,INSURED,ft policy(lea)Must I*a Wlarsad. If 9URROGATICN 19 WAIVED,s0jaat to
ff*twm and oond1 lona of We pol ft,cwWn pollclas mey mWra an a ularsameaL A ab belnent on this o941111a a domm not confer dgw to TOTE
Caniflaate holder In itsu of such ffi! s.
PRODUCER
M P ROBERTS INS AGCY INC NAMN }.
North mover, MA OI845 (978)683-8073 x(97$)683-3147
1060 Osgood Street &&.B4anie1le@ >*o?sertsinsuraaae.eom
-
MSISIEI" Arortol10 _ KAM
1N$uRER A•MliI HANTS INSURANCE
INSURED DOWGIERT CONSTRUCTION COMPM' INC. wsuRE a• _
175 MWT AVE INsuRER 0:
SAIJW, M 03079 91211RER0,
INSURER 6;
INS F:
COVERAGES CERTIFICATE NUMBER: RIE-VASION NUMBER:
MIS I$TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE LNSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITNSTANOM ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIZ THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED MEREW IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE VIEN REDUCED BY PAID CLAIMS.
AUDI. DUN"
TYPE OF WSURANCE I,CY LIMn'8
X corav"AL 40ML Losum TACH OCCURRENCE s 1,0009000
CLAIMS MADE OCCUR PREMISES Ea murtaiR l os) b . li]0
DOPOOSS768 03/23/13 03/22/16 MEDKXP(Anyoneaew) I 5 000
C PERSONAL&ADVINAIRY s 1,000,000
GEN'L AWRFGATE LIMIT APPLIES PER; GENERAL AGCY GATE s 2 000,000
X POLICY n ED Loc PRODUCT S,COMPrOP A�iQ 2,Q 0 0, Q
OTHM e
AUTOMOBILE LlAen,m
MIS _^ $ 1 000 000
ANYAUTOBODILY INJURY IPgt aereonj S
A AnuLia°s"�° PX
SCHEDULE° CAP005151000 03/23/15 03/23/16 AUTOS L3OOILYINJURv(Pet aeeidanll s
$ WIRED AUTOS AVrO8 D $
QS Pet
w s
g UMBRELLA LIAR $ OCCUREACH 22CURRdN92 i 7"000,000
C EXCESS LIAS CIAIM£rMADE UDDGQ05I3$600 03/23/15 03/23/16 AGGREGATE s
DEP RETEIMONs $
WORKERS COMPENSATION
ANO EMPLOYERS'LIABILITY
IN
GFMUMNEU AAS aum� Y�MIA DOivC5571?7 0/26/14 0/$$/15 E.L.EACHACCIOEW s 1,000,000
I""""t'In"'"► ELL OISBASE.EA ENPLOYI' S 1,000,000
� scR l o r RATIONS WOW s�,olaEasE-POLICY carr $ 1,000,000
3ESCRIPTION OF OpERAT10NS t LOCATIONS 1 VEHICLES (AOORp lOt.Adtllma{el RdxarNar Ed+edMe.ntey be af�hod Nf mow�ape;s,aq,:ae[�
t'l CERTISICAT,$ HOLDER 7$ WHO AS AUDITIOMT, INSURED AS PER THE TERMS Or THE
MITTEN CIDNx"3tACT AM AS PER THEIR INTEREST IN THE INSURM,S OFERAT2ox5 IJV A PR?.I[%RY
IND NON-CONTRIEMORT BASIS
FAX: 603-458+-1090
,!MFICATE HOLPER CANOE TION
OZZY PROPUTIBS INC 1600 OSGOOD SM L D ANY OF THE ABOVE IFRIBE POLMSS ire CAANC.DEELL�E E
ST 1440 DUNDEE OI ICE PARK LLC BE
Dt%MTX STATION LLC DUNDEE ACCORDANCE WITH THE POLICY PROVISIONS.
R$OSPRING =4 HERITAM PLACE LLC jKIiQRrWJ?
31 SONE ST LP ZORCON LP c/o OZZY oofgl��
PROPERTIES 1600 OSGOOD ST NO.ANDO
01980.201+4ACORI)CORPORATION, All rights roomed.
iCORD26(2014101) The ACORD name and Itgo at registered matt of ACORD
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-048040
TADEUSZ DOWG,ER '
175 BRADY AVE: t
SALEM NH 03079
I ' �
✓.�+.��J " "'�� Expiration
Commissioner 10/29/2015