HomeMy WebLinkAboutBuilding Permit # 6/8/2016 (3) BUILDING PER
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TORN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:_ � � Date Receivedo "
c a aus���e
Date Issued: ?�
WP® T NT: Applicant must complete all items on this page
LOCATION o "
Print
PROPERTYOWNER lig
Print 100 Year Structure yes Fno
MAP PARCEL: ZONING DISTRICT:_ Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE -
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: �*ommercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
t7 Septics ❑1/Vell' ❑ Floodplain , Wetlands ' ❑ Watershed Distract
OUVater/Sewer ' ;
DESCRIPTION OF W9RK TO BE fflE F RMED:
r ° 6✓,V- V
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I entilxca$ion- Please Type or Print Clearly
OWNER: Name: � Phone: 2 �- � '���� 2
Address:
Contractor Na n ) Asir Phone: 6/? —
Email: v g� b` �� �,n , c
Address: ID-U- ne
Supervisor's Construction License: (7 06 Exp. Date: j Z
Home Improvement License: Exp. Date:_/ 6 /
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE;BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ 141CUOV-0 0 FEE:-$
Check No.: 6 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
F�
FORTH
Town of ndover
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Vel'' �.SS'
C OC KIC M@WIC K
.44
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BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT .. . . . . . ...................................................................................................... BUILDING INSPECTOR
..
has permission to erect .......................... buildings ........ . Foundation
. . Rough
to be occupied as ...... .. ..... ...Vci�ss
*v.&...Cr. . ..............................:.................................. Chimney
provided that the person acceptingpermitshall 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
EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTI ION Rough
mi6ervice
.. . ..... . .. . . .. ......
"""' Fina
BUILDING ECT
GAS INSPECTOR
Occupancy Permit Required to Occupy Bu Rough
Display in a Conspicuous Place on the Premises - Do Not Remove Final
No Lathing r Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
the Commonwealth of Masscichasetts
.Department of IndlustrialAceidents
F° X Congress Street,Suite 100
Boston,AM 02114-2017
www.rnass.gov/dza
Workers,Compensation.Insurance Affidavit:Builders/Contractors/Ei etxicians/Plumbers.
TO BE FILED WITH THE PERAHTTING AUTHORITY.
A licant Information Please Print Le 'bl
NaMe(Business/Organization/Xridividtid): C� '
.A.ddxess: ( S
City/State/Zip: V1 Phone#l:
Areyou an employer?Clreckt&appropriate box: 'Type of project(required):
1. am a employer with_. !_employees(full and/or part-time).* 'J. Q New construction
2. I am a sole proprietor or partnership and have no employees working forme in 8. Remo delitig
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3_Q I am a homeowner doing all work myself.[No workers'comp..insurance reduced.]t
10 []Building addition
4.Q 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 11.❑Electrical repairs or additions
prop'rzetors with no employees. 12.Q Plumbing repairs or additions
5.❑Tam a general contractor and I have hired the sub-contractors listed on the attached sheet. 1- . Roof repairs
These sub-contractors have employees and have workers'comp,insrrance.T
• 14. Other U t
6.Q We are a corporation and its of�cers have exercised their right of exemption per MGL c.
152,§1(4),and we have na.employees.[Na workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f Homeowners who submit#his affidavit indicating they are doing all work and then hire outside contractors rhust submit anew affidavit indicating such.
tContractois that check this box mustattached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. Ifthe sub-contractors have employees,they must provide their workeis'e4mp.policy number.'
fain an employer that ispidpidiizg-workis'compensation insurance for my employees.'Below is the policy and jo/i site
information.
Insurance Company Name: C C+ r —
Policy#or Self ins,Lic.#: A ll�/cjG� l Z' 1 Expiration Date:
fob Site Address: a ( q� 16 �X_? ' t j 0 City/State/Zip:
Attach a copy of the wor rs'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 WORD 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 DfA for insurance
coverage verification.
X do hereby cent' Vnder pai s milpenalties ofpeijuiy that the inforinationprovidend above is true and correct.
Si nature: Gt - Date: C SPhone# (� 7a`
Official use only. Do not sprite 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-065281
Construction Supervisor
PAUL BRUNO
109 CHESTNUT STREET
LYNNFIELD MA 01940�r �'.
�f t
commissioner. Expiration:
09/28/2017
r
0 DATE
AC" CERTIFICATE OF LIABILITY INSURANCE 4/4/(MIND
�)
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(les)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
certifigate holder in lieu of such endorsement(s).
PRODUCER NAME: Jean Sullivan, CIC, AIS
Burgip, Platner, Hurley Insurance Agency, LLC PHONE . (617)472-3000 FAX (617)472-7248
E7MAU14 Franklin St. ADDREss:jas@bphins.com
INSURERS AFFORDING COVERAGE NAIC 6
Quincy MA 02169 INSURERA:Hanover Insurance Company 2292
INSURED INSURERB:Safety Indemnity Insurance Co 3618
B & M Restoration & Contracting, Inc. INSURERCAcadia Insurance Company
218 Paris St INSURER D: !
INSURER E:
East Boston MA 02128 INSURER F:
COVERAGES CERTIFICATE NUMBERktaster Cert 2016-17 REVISION NUMBER:
THIS I§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.
ILT R TYPE OF INSURANCE ADD UBR POLICY NUMBER MMND EFF M/�D EXP LIMITS
LTR
GENERAL LIABILITY y N EACH OCCURRENCE $ 2,000,00DAMAGE TO RENTE15
x COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 500,000
ACLAIMS-MADE ®OCCUR HUS997647 /17/2016 /17/2017 MED EXP(Anyone person) $ 10,000
PERSONAL&ADV INJURY $ 2,000,000
GENERAL AGGREGATE $ 4,000,0901
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000
R POLICY JFCT
PRO LOC $
AUTOMOBILE LIABILITY y y EaideD SINGLE LIMIT 110001090
ANY AUTO BODILY INJURY(Per person) $
B ALL OWNED !_xWl SCHEDULED 6208157 1/6/2015 11/6/2016 BODILY INJURY(Per accident) $
AUTOS AUTOS PROPERTY DAMAGE
X HIRED AUTOS AUTOS R
NON-OWNED Per accident) $
PIP-Basic $ 81000
X UMBRELLA LIARR OCCUR y N EACH OCCURRENCE $ 5,000,090
A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000
DED g RETENTION$ 9055121 /17/2016 /17/2017 $
C WOOKERS COMPENSATION N -w WC STATU- 0TORY LIMITS TH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,090
OFFfCER/MEMBER EXCLUDED? FIN] N/A
(Mandatory in NH) C-20-20-003740-03 /10/2015 /10/2016 E.L.DISEASE-EA EMPLOYEE $ 1,000,090
If ye describe under
DES,RIPTION OF OPERATIONS belowE.L.E. DISEASE-POLICY LIMIT $ 1,000,090
D
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Contralct # 18122-422094-CPe-00002; Property Name- Royal Crest Estates(North Andover); AIMCO North
Andovgr LLC is additional insured per written contract
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
AIMCO North Andover LLC ACCORDANCE WITH THE POLICY PROVISIONS.
50 Royal Crest Drive
North Andover, 14A 01845 AUTHORIZED REPRESENTATIVE
C 01 ",
REQUIRED BIDDER.FILL IN ALL YELLOW BOXES
roparly: ,loyal Crest Estates(North Andover) B m M Restoration and Contracting
Project., 18122-2016 Building Envelope Work Paul Bruno
Bid DUE Date. 03/23/2016 by 6:00pm pbruno@bandmrestoratlon,com
1617156149go
Des ed tion qua DaM Dnit Ca Total Cost An6c3 atoll Start Hate Anttcl atoll Dura6an
Th 1t Flealting
1 Bonding 1 Ttwavall Flashing 1 IS 60;000.00 50,000m d3/29116
8120116 Tentative
2 Bing 2 Thm-wall Flashing 1 LS 50,000.00 50,000.00 5126116 TantaGve
3 Building A6 Thnwxall Flsalxi 1 LS 50,000.00 50,OD0.00 421116
4 Building 27 Thm-avail Flashing 1 LS 50,tMN1.00 5q,00D. 3 4/15/16 FlRST BUttAtNG
5 Mdetg 40 Tbnry ell Flashing A LS 50.000.00 50.000.00 511211
6 T01nua,vali Permit;6 Feaa 1 LS 3,000:00 3,000.00
Through,wallFlaablogZ;st 7bbd 268 0.00
Repolrdinii
Building 16 Grind and Repomt 1 lS i45,Ot1U.00 145{ 0-00 5115116 6128116
Bdldiag'Z1C ad and Repaint 1 LS 145,000-O 10D1 411011 5WI8FIRSTOULDING
0 _mg400dridand Repoint 145 '145,00MOO 1416.000.00 714115 016/16
7 Gdndand TlapointPomrtsl3Fees 1 FLS 5.220.00 5,220.60
Rapandt CaslTotsi 436,tl00.tl0
UnftPdcing
1 SIdled Mason A HR 7200 72.00
2 General I abor 1 HR 50.00 Saw
3Fxterlar Drywall Repiaaamaid 1 SF 25.00 25.00
4 Mark-up tementage for Overhead 1 LS 15.00 15.00
5 MadP Percentage for Profit ILS_ 15.00 15.00
inti Pricing Cast Total 177,00
�Hld;3hr
Base Bid Total 660,000.00
Additional Information ''....
Dad you provide OneAn6d led Start ogle and Durations as REQUIRED? es
Bidder Qualification Notes (OPTIONAL)
PMNIT NAME: Paul Bruno In order for your bid to be accepted you mud complete this bid form,prim',
sign,and dale it.It must then be scanned and emalled back,by the DUE '...
ITILE: President date and 6sne to the foltawingAimoo Project Representativasromao
addresses:
"Y "4 h i fY "i'I 1 P!,YfIS
r61Ci$1 A DATE:
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