HomeMy WebLinkAboutPermits - 10 HIGH STREETPermit No#:'d1 ' - 1 -
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATIO[ ,
Date Received.�.1
Date Issued: /29 -
IMPORTANT: Applicant must complete all items on this page
LOCATION t 1`4 , C H£ T (jrAr- s:r Pt i '01 i iY/Acti i tei(
PROPERTY OWNER C- C- Pnn
c� Prinf 100 Year Structure
MAP 4 PARCEL: b ZONING DISTRICT: Historic District
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Machine Shop Village
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
*Alteration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
'commercial
❑ Repair, replacement
0 Demolition
❑ Assessory Bldg
0 Others:
❑ Other
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�t�LKIPTION OF WORK TO BE PERFORMED:
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tkS A k 11 ,1 t`-c pert- rk Trig GN fl-) ytit e nO P Curt'
Identification - Please Type or Print Clearly
OWNER: Name: r k1Ng coN Phone: I l ' 6
Address: gu t L is l ✓v 1 v ‘o'pi,ild-z (i3 c L t 4-
IC: w is poi" --
Contractor Name: _ z� Phone: (.5 t l -6 �- � — (Y3
Email: L' r rt. ,.y G 47-6 Te.
Address: - a r I Le- i4t a l - , i�I C L d
c
Supervisor's Construction License: e4 6 6 23 Exp. Date: r 72_ b 7
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER $ A f, 7 ' ems Phone: 7 —
Address: (CC g I'+t - ( Reg. No. `0 Cr
FEE SCHEDULE: BUL.DING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F_
Total Project Cost: $ 0 t +'�"Xk
FEE: $
Check No.: 2.5.3j3 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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JK Contracting LLC
4 High Street, Suite 108
North Andover, MA 01845
617-592-6775 (Kieran)
781-254-2862 (Judy)
Bill To:
Attn: David Steinbergh
RCG LLC
17 Ivaloo Street
Somerville, MA 02143
Description
Est. Hours/Qty.
Proposal
Proposal Date: 9/12/2016
Proposal #: 203-54
Project: 10 High St, Painti...
Rate
Total
Building Permits,and C of O.
580.00
580.00
Demo
1,500.00
1,500.00
Masonry
1,000.00
1,000.00
Wall Framing
2,500.00
2,500.00
Doors & Trim, Includes glass store front entry
5,200.00
5,200.00
Plumbing
6,000.00
6,000.00
Heating & Cooling, Ductwork only.
2,500.00
2,500.00
Electrical & Lighting
4,000,00
4,000.00
Tele/Data [Estimate 1,500.00]
1,500.00
1,500.00
Insulation
300.00
300.00
Interior Walls, Board.
800.00
800.00
Interior Walls, Tape ,Compound ,sand
1,000.00
1,000.00
Millwork & Trim
0.00
0.00
Cabinets & Vanities
0.00
0.00
Floor Coverings,[ Ceramic tile on bath floor, subway tile
on walls]
4,200.00
4,200.00
Painting, Including ductwork, pipes.
4,500.00
4,500.00
Cleanup & Restoration
300.00
300.00
General Conditions
1,000.00
1,000.00
Supervision
3,630.00
3,630.00
Insurance
393,00
393.00
Total
$40,903.00
Project Title:
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
VVest Mill - Studio #306 - Painting With a Twist
Property Address: 10 High Street, North Andover, MA .
Project: Check one or both as applicable: 0 New construction
Project description: Tenant fit -out
Date:
09-12-16
X Existing Construction
Linda S. Smiley
MA Registration Number: 10080 Expiration date: _087317 am a
registered design profevional, and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning:
X Architectural •
[ Fire Protection
[ J Structural
[ Electrical
[ I Mechanical
[] 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 theproposed 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 ibis 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. 13e 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 tie s tess reports (see item 3.) together with pertinent
comments, in a form acceptable to the building off '
Upon completion of the work, I shall
sub
Enter in the space to the right a "wet" or
electronic signature and seal:
Phone number: "'
C-fr 97F3-r 18-99n
OliStr ction Control Document'.
i• nda@saam-arch.corn
Building Official Claus Only
ilding Official Name: r.)1116( No.: flak::
Veniion 06_11.)013
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: BuildersfContractors!Electricians/Plumbers
Applicant Information Please print Legibly
Name(BusinessIOrgan"rzation/Individual): K k,4r.rik4i4eal Co -
Address: .cu t Le 14( C5H . . f v4 0 Z k
City/State/Zip: - A At 00Ifan— t flies- Phone if: t-7 " — b
Arereyouyoan employer? Check the appropriate box:
1. L .t ara a employer with
employees (full and/or part fill e),*
2. ❑ I am a sole proprietor or partner-
ship and'have no employees
wolIcing for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' camp.
insurance required.] t
4. ❑ I am a general contractor and I
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors 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.]
Typo of project (required):
6. ❑ New construction
7. Ntemodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roof repairs
13.0 Other
'Vow applicant that cheeks box#/ must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they the doing all work and then hire outside contractors crust 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 thrills providing workers' compensation insurance for my employees. Below is the policy and job site
information.c
Insurance Company Name:. [ ( t LS 3 i 104 '(th t4 v. •
Policy # or Self ins. Lie. if: W e 0 s ? )- Expiration Date: 2,1 iG-)
14 i t'a- H ( � 1~ ' r�! el a cr �n--•- City/State/Zip: i4 • r1N10 a V' ��. t /ice} (71 �'
Jab Site AddressL
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 anchor 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 cert15) under the pains and penalties of perjury that the information provided above is fue and correct,
Signature:
, `.�" Date: c f (z if 6
_ 666
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. Plumbing Inspector
6. Other
Contact Person:
Phone #:
JKCON-1 OP ID: CD
ACRE)
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
certificate holder in lieu of such endorsement(s).
PRODUCER
DeSanctis Insurance Agcy, Inc.
100 Unicorn Park Drive
Woburn, MA 01801
INSURED
CERTIFICATE OF LIABILITY INSURANCE
JK Contracting, LLC.
4 High Street Suite 108
North Andover, MA 01845
E
CONTACT
NAME;
! PHONE
4AIC No. Ext.):
EMAIL
I ADDRESS:
FAX
LAX, Noy
DATE IMMIPDIYYYY)
07/26/2016
INSURERS)
INSU�?�R 3) AFFORDING COVERAGE NAIC i!
INSUREh1A:Star insurance Cam an 1012245
INSURER E ; Selective Insurance Company 19259
INSURERC' __........... ............._- „-,..__.._.t._
INSURER I : .............
#NSURER E _,_,..,....._. ..,.,.__-__—.......__.--
INSURER F
MBER:
COVERAGES t.crt r lrivra I k\ - - •
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
_ — ,__—r...._ _... ._.__ . .. .'AUDL•BUBR'_.. .. _ POLICY "'FF POLICY EXt LIMITS
POLICY PERIOD
TO WHICH THIS
ALL THE TERMS,
TYPE OF INSURANCE jNstr WYVO POL[CY NUMBER IM.MOrtYYYi 11.011— 001YYYY)
LTR
B X ; COMMERCIAL GENERAL LIAB4;.tTy EACH OCCURRENCE
5 1,000,000
5 100,000
X S2205113 02/10/2016 '- 0211012017 pA 3 qa: oks nnce, :
CLrIFAS-MF.^aF OCCUf�
10,000
....
{ , MwDEXP (Any une Varsanl.,.....;.s,._._...-----._,.._..
6 1,000,000
'_-- PERSONAL & AD'J INJURY -
: CEN L AGGiEGA E LIMIT r f SUES PER GENERAL AGGNEG4 F - 3,000,0{1i0
. ic... CL4CY :PRO .... on PRGOt}L TS COVIr'fi)PAGG 3,000,000E
P F - ... a ......,... .._.�_._..__._
• OTHER'
AUTOMOBIL£.LIABILI'TY COMBINED SINGLE LIMIT
(£a acconli
$
AN‘.." Ali r.::;. . _-._..
AL.. (=`INFO SCHEDULED be/G!LY INJURY w accident) I
5
_., AUTOS AUTOS
. NON -OWNED PROPERTY DAMAG • I.
$
HIRED ALTOS - AUTOS - IPeracrEcnt, .....
j UMBRELLA LIAB OCCUR ' t EACH OCCURRENCE
S
I 1 EXCESS LIAR CLAIMS -MADE � AGGREGATE. --_--
?_.
i REFCNT'ON^s -
5
I MD :PER OT i•
WORKERS COMPENSATION - x ' PEER T'r . ER !AND EMPLOYERS' LIABILITY _.....
02/17/2017 r L EACh AGCIDEN r
A IAN? PROPRIETORIP RTNSPiEXECO V Y f— WC0853742 02/171201 S •
N ',' N A
..-. .,_._,
s 100,000
I OFFICER1MEMEER EXCLUDED; :
. .)VIA 1 =L DISEASE • �4t�,P1.C7Y1"C
C..
5 100,000
_ ..,
#M+Indalory Ni NH) -- ..
....,... ..._.
500,000
!Pr yin. desaizo under El. DISEASE • i>OLfCY Limn
OF OPERATIONS LE'c�'
!DESCRIPTION
DESCRIPTION OF OPERATIONS i LOCATIONS t VEHICLES (ACORD 101, AdoitioSa€ Remarks Schadula, may Ue attacrlod II more space Is roqulrecl)
"ADDITIONAL INSURED LIMITS ARE NO GREATER THAN THOSE REQUIRED BY WRITTEN
CONTRACT" Illustration of Coverage; Town of North Andover is add'I ins'd as
respects to the GL policy,
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF: NOTICE WILL BE DELIVERED IN
I ACCORDANCE WITH THE POLICY PROVISIONS,
Town of North Andover
03 High Street
N. Andover, MA 01845
NORTHA-
CANCEL
AUTHOR12 'ft PRESENTATIVE
2 G& . ia#444.
1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01}
The ACORD name and logo are registered marks of ACORD
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-066334
Construction Supervisor
• KIERAN T WHELAN •
31 RICHMOND STREET.
WEYMOUTH MA 02188,
' Commissioner
Expiration:
09/26/2017
^7.7/7;e tnurrrrr'/rinrrrIN n` C=/<73;rrr'/rr.ir,//; [.
Office of Consumer Affairs & Business Regulation
j2HOME IMPROVEMENT CONTRACTOR Registration: '171393 Typo:
Expiration 311.5/2018 Individual
KIERAN WHELAN
KIERAN WHELAN
31 RICHMOND ST
WEYMOUTH, MA 02188
Undersecretary
License or registration valid for individual use only
''before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation.
10 Park Plaza - Suite 5170
Boston, MA 02116
Not valid without signature
C_/e .*;, ma)rrefer( //4 alCD/7, Jig rfJef//
Office of Consumer Affairs & Business Regulation
HOME IMPi4COVEMENT CONTRACTOR
Registration;;' 171 393 Type :
Expiration_; 3/1512018 Corporation
JK CONTRACTING LLC'
KIERAN WHELAN
31 RICHMOND ST
WEYMOUTH, MA 02188
Undersecretary