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HomeMy WebLinkAboutBuilding Permit # 3/29/2016 ------ %AORTH .. BUILDING PERMIT ,,leo ,, 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Ire. Date Issued: CHU$ IMIPORTANT: Applicant must complete all items on this page u. g"'Y" 'r r -60'5" Jr / g ggg "r11"§W' A gt. jow"ga 0%, Mile" NO TYPE OF IMPROVEMENT PROPOSED USE Residential , Non- Residential El New Building El One family El Addition 10,To or more family El Industrial ig-Afteration No. of units: �Z_ El Commercial 0 Repair, replacement E1 Assessory Bldg El Others: El Demolition El Other W" 6, pq Identification Please Type or Print Clearly) OWNER: Name: Ye,C 6 1AA-S- Z r1U.- 'HA, t Phone: (',4, 17 (6 ZS' Address: g r A 1k, 0 S 5 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMA TEDICOST BASED ON$125.00 PER S.F. $ 4 Total Project Cost: $ FEE-. Check No. + 4� Roo 50 k"I k) NOTE: Pei-sons contracting whh unregistered contractors(Io not have access to the guaranty fund Signature of Agent/Owner Signature ofcontra6t:6(�' Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans F -°°............ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools F1 Well El Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. F-1 Permanent Dumpster on Site El THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF ® U FORM DATE REJECTED DATE APPROVED PL NNING & DEVELOPMENT ElrA ENTS 1 �"/AZ CONSERVATION El F1 COMMENTS DATE REJECTED DATE APPROVED HEALTH F1 -F1 COMMENTS ZoningBoard of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature & Date Driveway Permit Located at 384 Osgood Street 11I"I"WN't T .......... it 31, ........... NORTH Town of Andover 0 L_z�a No. 6 MOW Q__ 11tr L 241 2z1L 0Zh ver, Mass T O LAKE .i ' ' COC NICNE WICK A �V ORATE D S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT R ,'' LLC BUILDING INSPECTOR ........................Gr...........es..... .... . . ...Nor ........ ........................ . .. ..... ... .. . .... Foundation has permission to erect .......................... buildings on ................ .. ��................. G........................... . .. a%%% • f ', Rough to be occupied as .. . .. ............ .....:........ .. .. ....... Chimney provided that the person accepting this permit shall in every respect conform to t e 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 LESS CONSTRUCTIOKSTARTS Rough Service ............ .... � f� .. :,. ......... 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. March 3, 2016 William J. Glasser, President Landmark Structures Corporation 282 Montvale Avenue Woburn, MA 01801 Re: West Mill Lofts Phase 2 Notice to Proceed I Dear Bill: This letter serves as a formal Notice to Proceed for the work described in the bid documents dated February 24, 2016 provided by RCG West Mill NA LLC and the proposal dated.February 26, 2016 provided by Landmark Structures Corporation. We understand work on mobilization and preliminary MEP design work has proceeded on a verbal authorization prior to this letter; and that the official Notice to Proceed date shall be recognized as�Gt Sincerely, ( David Steinbergh, Principal, RCG LLC i �yy West MITI Loffs Phase 2 Revision 2 7,( i i North Andover,MA �✓ �"�" vk January 20,2016 Number of units: 22 Gross SF: 19070 Value Note: Unit SF Demolition $29'8i; $1,321 SSE?F1x41/E. $1,321 Misc.Metal 92 Seismic Clips with anchors L� $1.52 $12,780 �s'rS�T "r $581 $0.67 Stair E Work(mist.metal and carpentry) $22,300 $1014 Delete Stairway EHandralls(by owner) $1.17 Rough Carpentry $11,000 , -$773 -$0.89 Finish Carpentry $11,000 4 $500 $0„58 Membrane Roofing $4 $$ ,000 $2,591 $2.99 ,500 205 Wood Doors $ $0.24 Wood Doors(savings to 2'8°) $45,000 $2,045 $2.36-$1,200 -$s5 Entrances&Storefronts -$0.06 Windows exclude $0 $0.00 Plaster/Gyp Board Assemblies $276,000 By Owner $0 $0.00$12,545 Tile $14.47 $49,649 $2,257 $2.60 Resilient Sheet Goods $46,180 $2,099 Underlayment(same system as Phase I) $172,202 $2.42 Carpet $7,827 $9.03 $23,408 $1,064 $1.23 Waterproofing behind Tubs $7,500 Painting $341 $0.39 Signage $56,000 $2,545 $2.94 $770 $35 $0.04 Misc.Specialties(below) $9,800 $445Fire Extinguishers $0.51 Restel-Speeiaitles- $0 $0.00 Toilet Accessories $0 $0.00 Closet Specialties $0 $0.00 Residential Appliances $0 $0.00 Washer and dryer BY Owner $0 $0.00 Kitchen Cabinets&countertop $89,000 By Owner $0 $0.00$4,045 Window Treatments $4.67 Elevator Work BY Owner $0 $0.00 Fire Protection Piping $27,652 Excluded $0 $0.00 Plumbing $250,000- $1,257 $1.45 Delete two Bathrooms(plumbing) -$7,000 $11,364 $13.11-$318 -$0.37 Delete two Bathrooms(other Items) -$3,000 -$136 $0.16 $310,000 HVAC $309,034 Electrical $14,047 $16,21 Electrical Service $14,091$64,506 y $2 932 $16.26 Building Permit � �2vn .pSi1 $3.38 General Conditions $1.182 $1.36 $254,000 $11,545 $13.32 O H&P adjustment 1-20-16 $6,848 $311 O H&P adJustment:Z-26-16 $0.36 Overhead $10,5 49800 40.11 Profit $61,500 $4,659 $5.37 Total $2,293,839 $2795 $3,22 $104,265 r -$120.29 There is a net increase to revision 1 of$92,454 _ t' `�T creZ&.aoa There is d net dease to revlsion 2 oto 291 b0; F-Vr '�z t_tr Cft - ✓ t, _ r _c C �L Landmark Structures Corp zZ375 OFFICE OF BUILDING INSMCTOR TOWN OF NORTH ANDOVER i PROJ ECT NUM • 1406002.21 PROdECTTITLE: Residential Units - Phase 2 Construction PROJECTLOCATM: 4 High Street, North Andover NAME OF BUILDItiI ' West Mill NATURE OF PROJECT: Residential IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, 1, Linda S. 80iley REGISTRATION NO. 10080 M BEING A REGISTERED PROFESSIONAL ENGINEEWARCHITECH HER4Sy CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ❑ ARCHITECTURAL D STRUCTURAL ❑ MECHANICAL ❑ FIRE PROTECTION CO ELECTRICAL ❑ OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS, 's , STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT i SHALL PERFORM THE NECESSARY PROFESSIONAL.SERVICES AND L3 EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS To DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH.THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review,for conformance to the design concept,shop drawings,samples and other submittals which are submitted by the contractor In accordance with the requirements of the construction documents. 2, Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction tion to become,generally familiar wittMhe progress and quality of the work and to determine,In general,If the work Is being performed in a manner consistent with the construction documents. PURSUANT TO SECTION 118.2.2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE-PROJECT FOR OCCUPANCY. 4' SUBSCRIBED AND SWORN TO BEFORE ME THISJ ('P-- -O DAYF<-: 1 ATUR— U ig SIL NOT RY PUBLIC MY COMM"*I . 8 A�allota P blIF R -- - - COMMONWEAIT+i OF MASSACHUSETTS My Commisslon.Expires_ Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 81h edition of the Massachusetts State Building Code,780 CMR, Section 107 Project Title:West Mill Phase 2 Date:March 21,2016 Property Address: 4 High Street,North Andover,MA Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: General renovations,add seismic clips I Kenneth Woods MA Registration Number: 39885 Expiration date: 6/30/2016 ,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': Architectural X Structural Mechanical 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. Upon completion of the work,I shall submit to the building official a`Final Construction Control Document'. Enter in the space to the right a"wet"or 1N OF�{ electronic signature and seal: 9cy KENNETH G WOODS O,t.�Gt3'fti� �SStON^ A Phone number: 978-985-6129 Email:kenwoods@comcast.net Building Official Use Only Building Official Name: Permit No.: Date: Version 06 11 2013 Initial Construction Control Document M To be submitted with the building permit application by a Registered Design Professional for work per the 8th edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: West Mill Phase 2 Date: 03/21/16 Property Address: 4 High St,North Andover,MA Project: Check(x)one or both as applicable: New construction x Existing Construction Project description: Apartments I,Andrew W. Arsenault, MA Registration Number: 50816 Expiration date: 06/30/16, am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning': Architectural Structural Mechanical Fire Protection Electrical x Other: Plbg 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: I. 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. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. ti1,a®F' Enter in the space to the right a"wet"or � AiNaREvr w. � electronic signature and seal: ( `arNAULT MEQ;HANICAL 1d4.50816 Phone number: 207-337-2473 Email: awallc@maine.rr.com Building Official Use Only Building Official Name: Permit No.: Date: Note I.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other'is chosen, provide a description. Version 06 11 2013 Initial Construction Control Document x To be submitted with the building permit application by a Registered Design Professional for work per the 81'edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: West Mills Phase 2 Date:3/18/2016 Property Address: 4 High Street,North Andover,MA Project: Check(x)one or both as applicable: New construction X Existing Construction Project description:HVAC HP System design for apartments. I Robert Loranger,MA Registration Number:29079 Expiration date:6/30/2016,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': Architectural Structural X Mechanical 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. Upon completion of the work,I shall submit to the building official a`Final Construction Control Document'. �LZH OF MASS9 Enter in the space to the right a"wet"or oe�' ctio electronic signature and seal: �� ROBERT LORANGER MECHANICAL 2907 Phone number:781-233-4808 Email:RLoranger@CSI-Engineers.com ����`` 0 Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other'is chosen, provide a description. Version 06 11 2013 OFFICE OF BUILDING INSPECTOR ` TOWN OF NORTH ANDOVER , GONML PROTECT NUMBER: 1406002.21 PROJECT TITLE: Residential Units - Phase 2 Construction PROJECT LOCATION: 4 High Street, North Andover NAME OF BUILDING; West Mill NATURE OF PROJECT: Residential IN ACCORDANCE WITH ARTICLE 118 OF THE MASSACHUSETTS STATE BUILDING CODE, 1, Linda S. Smilev REGISTRATION NO. 10080 BEING A REGISTERED PROFESSIONAL ENGINEERlARCHITECH HE CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ❑ ARCHITECTURAL n STRUCTURAL ❑ MECHANICAL ❑ FIRE PROTECTION ❑ ELECTRICAL ❑ OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE HEST OF MY KNOWLEGE,SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. a I FURTHER CERTIFY THAT('SHALL PER THE NECESSARY PROFESSIONAL.SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT, THE WORK IS PROCEEEDING IN ACCORDANCE WITH-THE DOCUMENTS APPROVED FOR.THE 13UIL.DING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for conformance to the design concept,shop drawings,samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become,generally familiar wi t*ft progress and quality of the work and to determine, in genal,If the work Is being pertomned In a manner consistent with the construction documents. PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, t SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE-PROJECT FOR OCCUPANCY. IQ ATUR SUBSCRIBED AND SWORN TO BEFORE ME THIS `QDAY OF, 19 GSL NQT RY PUBLIC s� PATRICIA E. BARKER MY COMMISS`I .- 3 Notary Public - - - COMMONWEALTfi OF MASSACHUSETTS - My Commission.Expires_ _. Initial Construction Control Document To be submitted with the building permit application by a off Registered Design Professional for work per the 81h edition of the V Massachusetts State Building Code, 780 CMR, Section 107 Project Title: West Mills Phase 2 Date:3/18/2016 Property Address: 4 High Street,North Andover,MA Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: HVAC HP System design for apartments. I Robert Loranger,MA Registration Number:29079 Expiration date: 6/30/2016,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': Architectural Structural X Mechanical 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. Upon completion of the work,I shall submit to the building official a`Final Construction Control Document'. �\,I}i OF Af.1$, Enter in the space to the right a"wet"or oz electronic signature and seal: ROBERT ` V LORANGER MECHANICAL .2907 Phone number:781-233-4808 Email:RLoranger@CSI-Engineers.com 0 Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other'is chosen, provide a description. Version 06 11 2013 Initial Construction Control Document u To be submitted with the building permit application by a W a Registered Design Professional for work per the 8th edition of the °mow¢ Massachusetts State Building Code, 780 CMR, Section 107 Project Title: West Mill Phase 2 Date: 03/21/16 Property Address: 4 High St,North Andover,MA Project: Check(x)one or both as applicable: New construction x Existing Construction Project description:Apartments I,Andrew W. Arsenault,MA Registration Number: 50816 Expiration date: 06/30/16, am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning': Architectural Structural Mechanical Fire Protection Electrical x Other: Plbg 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. Upon completion of the work,I shall submit to the building official a `Final Construction Control Document'. Cti OF Enter in the space to the right a"wet"or '�° lid. amu+ electronic signature and seal: =`i NDI?EVdr-.;,ENAULT M,&LHANICAL f40-50816 Phone number: 207-337-2473 Email: awallc@maine.rr.com Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other'is chosen, provide a description. Version 06 11 2013 Initial Construction Control Document To be submitted with the building permit application by a > Registered Design Professional for work per the 8th edition of the Massachusetts State Building Code,780 CMR, Section 107 Project Title:West Mill Phase 2 Date:March 21,2016 Property Address: 4 High Street,North Andover,MA Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: General renovations,add seismic clips I Kenneth Woods MA Registration Number:39885 Expiration date: 6/30/2016 ,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerningl: Architectural X Structural Mechanical 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. Upon completion of the work,I shall submit to the building official a`Final Construction Control Document'. Enter in the space to the right a"wet"ort11 Of�{ electronic signature and seal: G �o�� KEN WOODS O,c�Gt3TE�' �¢- �v �SStONAL Phone number: 978-985-6129 Email:kenwoods@comcast.net Building Official Use Only Building Official Name: Permit No.: Date: Version 06 I 1 2013 The Commonwealth of Massachusetts Department qfbidustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 wwwmass.govIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Orgaiiizatioii/Individual): Landmark Structures Corp. Address:282 Montvale Avenue City/State/Zip:Woburn, MA 01801 Phone#:781-376-1801 Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 ani a employer with 24 employees(Rill and/or part-time).* 7. F]New construction 2f]1 am a sole proprietor or partnership and have no employees working for me in 8. n,/ Remodeling any capacity,[No workers'comp,insurance required.] 9. El Demolition 1[j 1 am a homeowner doing all work myself,[No workers'comp.insurance required.]t 10 F]Building addition 4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole II.E]Electrical repairs or additions proprietors with no employees, 12.[:]Plumbing repairs or additions 5.E]1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F]Roof repairs These sub-contractors have employees and have workers'camp.insurance.t 6.F]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site ht formation. Insurance Company Name:Arbella Insurance Policy#or Self-ins.Lic,#:4220049658-01 Expiration Date: 1/21/2017 .................... Job Site Address:4 High Street City/State/Zip:North Andover, MA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofper jury that the information provided above is true and correct. Signature: Qkii- Date: -34),11 Phone N:781-37 801 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.Plumbing Inspector 6.Other Contact Person: Phone A4'--CPRI" CERTI I L I I I1"Y I DATE(MMIDDIYYYY) NSURANCE 1 2/12/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an 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 an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTNAME: Kim O'Shaughnessy G H Dunn Insurance Agency, Inc. PHONE (508)6 56-1400 FAX No.(508)656-1499 P.O. BOX 497 E-MAIL . ADDRESS: 64 Fairhaven Road INSURERS AFFORDING COVERAGE NAIC# Mattapoisett MA 02739 INSURER A Arbella Protection Ins. Co. 1360 INSURED INSURER B:Arbella Mutual Insurance Co. 17000 Landmark Structures Corporation INSURERC:Torus National Insurance Co. 25496 282 Montvale Ave INSURERD: INSURER E Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER:CL14121111736 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDID//YYYri MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 A CLAIMS-MADE OCCUR 850006344 /1/2015 1/1/2016 MED EXP(Any one person) $ 51000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE. $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO-JFCT F1 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 1020036348 01 1/1/2015 /1/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS '.. X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 C, X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION 42017D150ALI /1/2015 /1/2016 $ B WORKERS COMPENSATION XWC STATU- 0TH- AND EMPLOYERS'LIABILITY Y I N I TORY LIMITS ANY PROPRIETORIPARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) 9114 5501 15 1/21/2015 /21/2016 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) '.. Subject to policy forms, terms and conditions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN FOR YOUR INFORMATION ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE _ I David Dunn/KIM ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025lgn1no51 m Tho arYnpn nama and Innn nra ranicfarorl mnrkc of AnOP11 Massachusetts-Department of Public Safely Board of Building Regulations and Standards CorsYsuctior,auPeI--! r License: CS-084537 DENMS A CARSNb •;! 14 ARCADIA RDr BMLEWCA MA 01 r Expiration Commissioner 03/14/2017 „