Search ▸ Agenda item attachment
An application was received from Ricky Zeng representing Moge Tee, requesting permission for a projecting sign at the premises numbered 605 Massachusetts Avenue approval has been received from Inspectional Services, Department of Public Works, Community Development Department and abutter
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605 Mass Avenue
917 682-0038
50 lbs
WOFilGRS COMPENSATION AND EMPLOYERS LIABILITY
INSURANCE POLICY
INFORMATION PAGE
I NSU RANCE
175 Berkeley Street Boston, MA 02116
lssued by LM INSI RAIiICE CORPORATION
27243
Policy Number
WCs-31S-389517-021 lssuing Office 016C
RENEWAL OF:
WC5-3LS-389517-020 lssue Date 02-18-21
Account Number 1-3895L7
1. lnsured and Mailing Address
NEWCCSIGNINC
2s9 QUTNCY AVE
Sub Account 0000
RrsK rD
000972540
QUINCY, MA 02169
Status 03 - CORPORATfON
Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXIENSION OF INFORMATION PAGE
2. Policy Period:The policy period is from 04-04-202J- to 04-04-2022 12:01A.M. standard time at the
lnsured's mailing address.
3. Coverage
A. Workers Compensation lnsurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here:
MA
B. Employers Liability lnsurance: Part Two of the policy applies to work in each state listed in ltem 3.A. The limits
of our liability under Part Two are:
Bodily lnjury by Accident $
1,000,000
each accident
Bodily lnjury by Disease $
1,000,000
policy limit
Bodily lnjury by Disease $
1,000,000
each employee
C. Other States lnsurance: Part Three of the policy applies to the states, if any, listed here:
SEE END WC 20 03 06B
D. This policy includes these endorsements and schedules: SEE EXIENSION OF INFORMATION PAGE
4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required below is subject to verification and change by audit.
Code
Premium Basis Total
Rate per $100
Estimated Annual
Classifications Number Estimated Annual Remuneration of Remuneration Premium
See Extension of lnformation Page
Minimum Premium $
500
(lfA )
Total Estimated Annual Premium $
2 , 083
Premium will be billed ANNUAL
Producer 000+0248/8
TAld FINAI{CIAL LLC
2OO LINCOLN ST APT 1
BOSTON ldA 02111
WC 00 00 0'l A
@ 1987 National Council on Compensation lnsurance,lnc.
WC 00 00 01 B (CA)
Ed. 07 10112011
All Rights Reserved
Page 1 of 1
Liberty Mutual"
AR
lnsured Copy
DN
9' - 3 9/16"
18' - 5 5/16"
13' - 0 5/16"
40' - 9 1/4"
17' - 5 3/8"
10' - 4 3/8"
3' - 3"
3' - 10 1/2"
3' - 11 1/8"
3' - 0"
7 15/16"
3' - 2 7/8"
9 7/16"
16' - 3 9/16"
10' - 2 1/4"
12' - 4 7/16"
2' - 2 15/16"
18' - 9 3/4"
5' - 5"
5' - 9 15/16"
7' - 6 13/16"
1' - 9 9/16"
4' - 6"
7' - 7 15/16"
6' - 7 13/16"
3' - 6 3/8"
6' - 1 1/2"
8' - 0 3/16"
11' - 7 5/16"
17' - 11"
18' - 9 3/4"
ARCHITECTURAL AS BUILT
SHEET NUMBER
DRAWN BY
SCALE
PROJECT NUMBER
PROJECT DIRECTOR
PROJECT MANAGER
SHEET TITLE
DATE
SEE COVER SHEET
ISSUES / REVISIONS
100% SUBMISSION
NO.
01
s BUIL
PROFESSIONALS
© 2020 AEC CONSULTANTS INC
www.asbuiltprofessionals.com
A DIVISION OF:
AEC
CONSULTANTS INC
[phone removed]
844 A S B U I L T
Essex & Massachusetts Ave
Cambridge, MA 02139
Designer
Designer
Project Number
Author
605 FIRST FLOOR
AB-10
1/4" = 1'-0"
1
Level 1 605
N
UP
40' - 8 1/8"
4' - 7"
12' - 9 3/16"
13' - 0 3/16"
10' - 3 3/4"
7 1/2"
3' - 1 3/8"
8' - 7 5/8"
6' - 1 7/16"
4' - 8 9/16"
19' - 5 9/16"
8' - 4 3/16"
7' - 10 7/8"
40' - 5 3/16"
11' - 11 7/8"
5' - 11 7/8"
17' - 11 3/4"
4' - 9 5/8"
8' - 2 1/16"
4' - 9 1/4"
5' - 11 1/8"
3' - 7 3/8"
6' - 8 1/2"
7' - 5 15/16"
17' - 9 13/16"
5' - 9 3/4"
3' - 2 7/8"
7 13/16"
14' - 2 7/16"
5 3/16"
4' - 11 3/4"
3' - 4 11/16"
3' - 0"
1' - 5 5/8"
2' - 11 5/8"
2' - 6"
2' - 1 3/8"
3' - 0"
10 7/8"
11' - 5 7/8"
2' - 9"
3' - 0 9/16"
3' - 0"
2' - 5 13/16"
ARCHITECTURAL AS BUILT
SHEET NUMBER
DRAWN BY
SCALE
PROJECT NUMBER
PROJECT DIRECTOR
PROJECT MANAGER
SHEET TITLE
DATE
SEE COVER SHEET
ISSUES / REVISIONS
100% SUBMISSION
NO.
01
s BUIL
PROFESSIONALS
© 2020 AEC CONSULTANTS INC
www.asbuiltprofessionals.com
A DIVISION OF:
AEC
CONSULTANTS INC
[phone removed]
844 A S B U I L T
Essex & Massachusetts Ave
Cambridge, MA 02139
Designer
Designer
Project Number
Author
605 BASEMENT
AB-11
1/4" = 1'-0"
1
Basement 605
N
Proposed
Existing
Specifications:
* 040 sliver aluminum panel w/ Welded 1”x1” Galvanized tubing frame.
* 040 black aluminum letter boxes 3” return w/ 1” black trimcap.
* 1/8” white acrylic faces.
* 3/4” stud mount standoff from panel
* Internal white led lighting illumination, UL Listed.
* Letter boxes to be mounted on the panel.
Sign installed in location shown on attached photo
This sign is intended to be installed in accordance with the requirement of Article
600 of the National Electrical Code and/or other applicable local code. This includes
proper grounding and bonding of the sign.
Side View
2” panel sign
3” thick
letter boxes
3/4” stud mount standoff
.040 x 3” ALUMINUM
RETURN
1/8” ACRYLIC
ALUMINUM CANOPY
3”
3/4” STUD MOUNT STANDOFF
23”
144”
13"
LED Channel Letter
Customer:
Company:
Phone:
Original: Revision:
Estimate($0 Means No Price):
Address:
City:
State/Zip:
File Name:
Job No:
X Date
Print Name
So Lim Ting
605 Mass Ave.
Cambridge
[phone removed]
MA 02139
03/29/2021
Moge Tee Cambridge
07290
This image is for general reference only, and may not accurately represent the actual product.
The undersigned, in his or her individual and official capacity, hereby certifies that
the quoted prices, designs, specifications, terms, and conditions are accepted . New
CC Sign is authorized to perform the work as specified.
NEW CC SIGN
259 Quincy Ave. Quincy, MA 02169
TEL: [phone removed] / [phone removed]
Fax: [phone removed]
[email removed]
NEW CC Sign ALL RIGHTS RESERVED
Moge Tee
LED Channel Letter
Customer:
Company:
Phone:
Original: Revision:
Estimate($0 Means No Price):
Address:
City:
State/Zip:
File Name:
Job No:
X Date
Print Name
So Lim Ting
605 Mass Ave.
Cambridge
[phone removed]
MA 02139
03/29/2021
Moge Tee Cambridge
07290
This image is for general reference only, and may not accurately represent the actual product.
The undersigned, in his or her individual and official capacity, hereby certifies that
the quoted prices, designs, specifications, terms, and conditions are accepted . New
CC Sign is authorized to perform the work as specified.
NEW CC SIGN
259 Quincy Ave. Quincy, MA 02169
TEL: [phone removed] / [phone removed]
Fax: [phone removed]
[email removed]
NEW CC Sign ALL RIGHTS RESERVED
Moge Tee
Proposed
Existing
Specifications:
* 040 sliver aluminum panel w/ Welded 1”x1” Galvanized tubing frame.
* 040 black aluminum letter boxes 3” return w/ 1” black trimcap.
* 1/8” white acrylic faces.
* 3/4” stud mount standoff from panel
* Internal white led lighting illumination, UL Listed.
* Letter boxes to be mounted on the panel.
Sign installed in location shown on attached photo
This sign is intended to be installed in accordance with the requirement of Article
600 of the National Electrical Code and/or other applicable local code. This includes
proper grounding and bonding of the sign.
Side View
2” panel sign
3” thick
letter boxes
3/4” stud mount standoff
.040 x 4” ALUMINUM
RETURN
1/8” ACRYLIC
ALUMINUM CANOPY
4”
3/4” STUD MOUNT STANDOFF
23”
144”
13"
Existing Lightbox ( change the facade ONLY)
Customer:
Company:
Phone:
Original: Revision:
Estimate($0 Means No Price):
Address:
City:
State/Zip:
File Name:
Job No:
X Date
Print Name
So Lim Ting
605 Mass Ave.
Cambridge
[phone removed]
MA 02139
03/29/2021
Moge Tee Cambridge
07290
This image is for general reference only, and may not accurately represent the actual product.
The undersigned, in his or her individual and official capacity, hereby certifies that
the quoted prices, designs, specifications, terms, and conditions are accepted . New
CC Sign is authorized to perform the work as specified.
NEW CC SIGN
259 Quincy Ave. Quincy, MA 02169
TEL: [phone removed] / [phone removed]
Fax: [phone removed]
[email removed]
NEW CC Sign ALL RIGHTS RESERVED
Moge Tee
36"
54.50"
14.80"
6.50"
Proposed
Existing
Specifications:
* Existing Light Box (change the facade ONLY)
* 3/16” white acrylic sheet
* apply sliver color vinyl.
Sign installed in location shown on attached photo
Sign Sample:
New CC Sign &Aluminum Inc.
259 Quincy Ave. Quincy MA 02169
Tel:[phone removed]
ccsignboston@yahoo. com
Customer
Moge Tee
605 Mass Ave.
Cambridge MA 02139
So Lim Ting: [phone removed]
[email removed]
lnvoice
07290
Date
312912021
invoice
07290
P.O.#
Terms
Item
Description
Qty
Rate
Total
Sign
LED Channel Letter:
- 23"x144" SliverAluminum Panel
- 4" Sliver Aluminum return letter
2
2800.00
5600.00
Acrylic Sheet
Existing Lightbox:
- 36"x54.5" Acrylic Sheet
- Sliver Vinyl
2
300.00
600.00
PERMITFEE
not include permit fee, will refund over pay.
estimate
1000.00
INSTALLATION dvBs
E No
350.00
I
Tax
387.50
Signatureorcrient: /J
g lrtl*t
Total
7e37.s0
SignatureoftheSale t.*"q;,..J
"^r", ? (Z\ l>\
,|
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
_
Address:
City/State/Zip:
Phone #:
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
† 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-contractors 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:
Policy # or Self-ins. Lic. #:
Expiration Date:
Job Site Address: 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 required under 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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 (check one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing
Inspector 6. Other
Contact Person:
Phone #:
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12. Roof repairs
13. Other
1. I am a employer with
employees (full and/or part-time).*
2. I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers’ comp. insurance
required.]
3. I am a homeowner doing all work
myself. [No workers’ comp.
insurance required.] †
Are you an employer? Check the appropriate box:
4. I am a general contractor and I
have hired the sub-contractors
listed on the attached sheet.
These sub-contractors have
employees and have workers’
comp. insurance.‡
5. We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers’
comp. insurance required.]
New Cc Sign Inc.
259 Quincy Ave.
Quincy MA 02169
[phone removed] /857-205-5678cell
I
2
I
Sign
Liberty Mutual
WC5-31S-389517-021
04/04/2022
605 Mass. Ave.
Cambridge MA 02139
SIGN
04/05/202[phone removed]
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 of hire,
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 for 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’
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
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 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center, 2 Avenue de Lafayette
Boston, MA 02111
Tel. [phone removed] or 1-877-MASSAFE
Fax [phone removed]
www.mass.gov/dia
Revised 7-2019
City