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HomeMy WebLinkAboutBuilding Permit # 4/20/2016BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: lea r /2 /� Date Issued: / / ' 0 /. Date Received IMPORTANT: Applicant must complete all items on this page LOCATION °Sv..:1 i 6 I0 \ �� a L, I N PA57g Print PROPERTY OWNER C. „,tlB Print 100 Year Structure MAP PARCEL: la tt ZONING DISTRICT: Historic District Machine Shop Village TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition Iteration ❑ One family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition : ❑ Assessory Bldg ❑ Others: �{/ ,a 4 f ,. ❑ Other .ra' f �'�� S cd /et r u ,c . a E r e, �,�,.�r�� r �j.. / ., F ,. J r r Se trc ❑,Well p �;l s f y r r fi't ❑Flood lain w Wetlands p �; �*' WatersUhed District ..,p � WQ1:,/Sewli,.r�''Y �''Y� fb �,5{ , .✓.,, �nf ...z F f N'. f' fat br„ '.f' '? ,''S�i4,�r .,'�,"- !/� r '..;:r r:..:. (', a.. O� rd m� -t. .,^iz.kMF. f�"�T ✓R�4In'rynik'v����rjk:;..,F.���7sr'�✓,f�>�Gf�"'.mYm`'`✓,.4",�" of : DESCRIPTION OF yVORK TO BE PERFORMED: 5 ki l ,q C) 1 ►S P << S N J pis c-r ea* - 'on - Please Type or Print Clearly Identifica OWNER: Name: Lo 4- Address: 1 C 0 6 Phone:6 cz 62 s Li St! klievkli Contractor Name: Email: k t . r - -eCo ems- Co rn Address:,ry 413" t f ( 4- 14t rcs-r 41V 0 a L(' t// Supervisor's Construction License: 0 66 .? ? - Exp. Date: 7l C A, Home Improvement License: Exp. Date: Phone: 6 l - Scl L—U� - ARCHITECT/ENGINEER I - 1 Vu L Phone: �'� to — 4 C(4 - Address:16 0 t1611► rine5 4- �'r ,, N Lc s kir% vzi Reg. No. 5 S FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ cl RI FEE: $ / ✓ . vJ Check No.: C-' 7/ Receipt No.: 0 6,r NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund e ati irQ of Agi=tlf _ � •nature of contractor Cl)• Cl) n O 0y CD 0 -0 CL CL >CQcn -a ® sit C ®o CD Q CD CD 0 CD CO CO v CD� CO CD - v 0 -aCD n 0 0 70 -1 CD 3 CD H' cOz dap 0/ palmn 2I0133dSNI maims m Cn 0 0 Cn C) -74 m cn 0 Cn VIOLATION of the Zoning or Building Regulations Voids this Permit. 0g'ao � CD Q-(DO C 0. 0 o =".� g �• 0 0 r+ Q c CD g CO ID' -0 5CD CD -C:$ �� 0<� C. - , 0 0y u, r OCD 0, v\ CD Cl) eftQ 0 O 0./. < OO 0s N CD O < O CD 0 W N I— N N n O COa o� CD 0. c 0 1VHl S3 OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL 0 SCITUATE. ' `._ 0- CIJ PROJECT NUMBER: 14-0682 'o\ MA ap. PROJECT TITLE: New England Inpatient Specialists 0\ TN OF M�e,'� PROJECT LOCATION: 120 Water Street, N. Andover, MA NAME OF BUILDING: East Mill NATURE OF PROJECT: Tenant improvement/fit out IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, I, c,IJAL p v1 • .AL-1 E (L REGISTRATION NO. 16 3la BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT STRUCTURAL ' MECHANICAL FIRE PROTECTION ' 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 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 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 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 to become, generally familiar with6the 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 116.2 .2 I SHALL SUBMIT WEEKLY , A PROGRESS RERT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING I SPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO T SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPP CY. t I7H. SUBSCRIBED AND SWORM TO BEFORE ME THIS I `I DAY OF NOTAR LBLIC `--- MY COMMISSION EXPI 2011, CHERYL L. BURKINSHAW Notary Public Commonwealth of Massachusetts My Commission Expires March 7, 2019 Are you an employer? Check the appr 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. El am a homeowner doing all work myself. [No workers' comp. insurance required.] t The Commonwealth of Massachusetts Department of .ndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly CO MT (i i i.. c: Name (Business/Organization/Individual): .+, . VC.0 1N 4,— , C_ Address:. S (T 10 g` I fI F1 4 N O 0 v 1 4 O i B keJ City/State/Zip: J- A rs 4 ov sw tt 0 I e triihone #: b I S"C L' �' S• ropriate box: • 4. 0 I am a general contractor and I have liked, the sub -contractors listed on the attached sheet. # These sub -contractors have workers' comp. insurance. 5. 0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and wehave no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. KRemodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.1:1 Roof repairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they tie 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 Their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 6 .S4 N c.1; I a I NJ alt1644 1.,(5- A 15-"tr" !`.f C— Policy # or Self ins. Lic. #: W 0 13 1 14-- Expiration Date: Z in/i ! Yob Site Address: / v° %prTS i'z' �� t r " Pao 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 o. 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 certi under the pains andpenalties ofperjury that the information provided above is true m nd correct. I' Signature: Date: Phone #: U 4— S q Z- 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 #: JKCON-1 OP ID: HS CERTIFICATE OF LIABILITY INSURANCE MM/D ( DATEE D/YYYI) 0M;Io016 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 DeSanctis Insurance Agcy, Inc. 100 Unicorn Park Drive Woburn, MA 01801 CONTACT PHONE FAX (A/C No Ext): (A/C, No): EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL # INSURER A :Star Insurance Company 012245 INSURED JK Contracting, LLC. 4 High Street Suite 108 North Andover, MA 01845 INSURER B: Selective Insurance Company 19259 INSURER C INSURER D : INSURER E : 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS B X COMMERCIAL GENERAL LIABILITY S2205113 02/10/2016 02/10/2017 EACH OCCURRENCE $ 1,000,000 DPREAMMISES (Ea AGEaRaENTEDocarrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEM_ X AGGREGATE POLICY OTHER: LIMIT APPLIES JECT PER: LOC PRODUCTS - COMP/OP AGG $ 3,000,000 $ AUTOMOBILE _ _ —(Per LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS AUTOS NON -OWNED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE accident) $ $ UMBRELLA UAB EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/N N N /A WC0853742 MA 02/17/2016 02/17/2017 ,OTH- STATUTE ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space le required) Evidence of coverage. • CERTIFICATE HOLDER CANCELLATION TO WHOM TO WHOM IT MAY CONCERN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORD 25 (2014/01) Massachusetts Department of Public Safety Board of Building Regulations and Standards ' License: CS-066334 Construction Supervisor KIERAN T WHEIAN 31 RICHMOND S WEYMOUTH MA- 02 N1 t O Commissioner Expiration: 09/26/2017