HomeMy WebLinkAboutBuilding Permit # 11/16/2016 .. ............... ...
BUILUNO PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No##: J Date Received A0RATenWIYF' ay
AcF1
Date Issued: 1 J
IMPORTANT Appheant xxaust complete all items on this page
y
sf—fir�
�L® Y,MAR
CAT�®N
PR®I'EFTY
F
� �
�"':!
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: Z4Qommercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
emolition ❑ Other
`❑ Se doME
11V 1I� / , ❑ Floodplain ❑'Wetlands VI((atersi�ed D strict r
/ `�z y .l', ✓ �F / �� ry-"'" .' .`' "' c �. 't i o r k a fi "'§ 'z�.,r r�i'x
❑lNaterlSewer ,fa
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name:l o t/t o z'jr rJOL-6 H Phone: 17
Address:-. J IT-C 10 c l` .JA I ,;,) rce-.Ywi C1 11 C) t 14—?
g.
{
f
Confiractor`Name�� � `��� �-yP�hone � �� ...
4 c� �"" ��,��"��` , .. ., �,I,F +: h �'✓ Y, � � v�+�r+. ?sa✓ Fez w e
'-
��
FSupervisor sConstruction�`Ricense ���� � Ex
at
Home°Improvement�License � � f � � _
ARCH ITECTIENGINEERf�) 0 6 4� t4 17�/ i --_ Phone:
Address:i1} Ap.,jr,,-�r nq'i ®6�t ��� __Reg. No. r
FEE SCHEDULE:BULDINC PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost. $ ., '� k 2S-- IEEE. $�
Check No.: r Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Sjgnature_of Agentfb;Wie Signature offcoritraptor.
own of T ove r
0
. �
No.
C, h ver, Mass
a LAK. .. ®/ • /& 0�
AYED }QR�~�5
U BOARD OF HEALTH
PERMIT .T LD
Food/Kitchen
Septic System
THIS CERTIFIES THAT �.... BUILDING INSPECTOR
,,... ....... .............. ...I........ . ..
?
has permission to erect .......................... buildings on .....7kC .. .........., ,to*.tv,....., Foundation
4
D. O.K. .............. . . ....... ...... .r 0..�...... Rough
to be occupied as .. Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Fina]
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
UNLESS C®NSTRUC STARTS Rough
Service
...... .. .. .. .. .. .,.. ............. FinalBUILDING INSPECTOR
GAS INSPECTOR
OccupancE Permit Require d to Occupv Buildin 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.
X Contracting LLC Proposal
4 High Strut, Suite 108
North Andover, MA 01345
617-592-6775 (Kieran)
781.254-2862 (Judy) Proposal Date: 11/15/2016
Proposal#: 203-66
Project: 50 High, 5th FI, Iv...
Rill To: Ship To
RCG West Mill NA LLC 5th Floor
Daviid Steinbergh Ivenix
17 lvaloo Street North Andover,MA 01845
Somerville, MA 02143
Description ask. HourslQty. Rats; Total
Demo Permit mm -.� - 348.00 348.00
Demo ail walls and flooring per st,►l^,mi fed derma f,�] rs 22;000 00;, 22;000.00;<
Dumpster fees 4,000.00 4,000.00
supervision 2;600 00. 2;600
Insurance 260.00 260.00
i
Total $29,208.00
Approved: _ (Initials)
SIGNATURE
i
The Comm anwea th a r,�Massuchusetts
INS-
2'Vee of?' Ivr gttgaflon '
,MWw6 MA 02111
�tywb��lnsa.gov/rtia
Workers' Compensation Insurance Affidavit, Builders/ContractorsfEle.etricians/Plumbers
Applicant Information _ _ Please Print Legibil
N&lne,(Busi{ness/Orgmizatiordlndivi.dual),—S � (4
Address.-S VS 09—t-_ - 4 c r1!_ 1�0(1 z1 ,-
p4 0 4
r --
city/State/zip: i0- a - � . 1hone
Are you an employer?Che.c.k the apprr,lykifil box- � Type of project(required);
1,Dd I ani a employer with
`k
• s_.! .�,.))S:l i;.i1E1� l;f)„T'CdetaS Sl1C�1
G. ❑New construction
i employees(fall and/or 11'4aib-contractors
.27.I am a s ole proprietor•orpartner-
ship
or'«�,r!o,,,c,djod sheet. 7• ❑Remodeling
ship and'have no employees have 8. Demolition
working forme iu any capacity. i-�'��r'[:ers'c.rjn-z o,kisorance• 9. Blrilding addition
i �Ta�voxl ers'comp.insurance :• _ O re arc:a corp,rs 1ion fw'd its
requixed.j cv'f6durs havf:e1er0sed their IO Electrical repairs or additions
t ora a homeowner doing all wuxl� 11.El I'lumhing repairs or additions
inysel :[No workers comp. ,„-t• 12,Q Roof repairs
msvrance required,]i +,,,C,workers' l3.0 Othex
'Cc
Ayiy applicant that cheukg box#1 inust also fill out these Orion{3e1gA'S�IOSV�,. i,�i'??Guars'UUnIpensatiGn policy information.
i Hnineowners who submit this affidavit indicating they o:a r3aing ,if werlc ir,n u,r,r;hiio outsiL contiactors must submit a new affidavit indicating such.
%t ]ntraotors that checkthis box must attached an additional sheet s o,,,i„g ihl;n!a Zoz.ol'fhe sub-contractors and their worieers'comp,policy information.
—
j �a:i an employer that is providing workers, fnsh rance for mp ernpigyeay. Below is the pokey and job life
CD y
:1 'oyance Company Name a5 'i,, S ( d U
' -Uy i#or Self ius.L.ie. _ - �'Z� Mhz .con
ft
Sit � _ Z Ghr /�r _ / r�rDcl iSt. !ip;.._..L.�
,litach a copy of theworkers'eotnl;eaasatiar�� �xc:�;ri;s.irii°a: >: r..,4;r;a(s:l Uyl in -,'W,policy number and eKpiratiou date).
Fail-are to secure coverage as required.uader•SoUlon.25A o, .1.2 can lead to the imposition of criminal penalties of a
Rao up'co$X,500.00 and/or one.-year imprisonment; L, ..iv',!�j �.�lties in the form of a STOP WORTS ORDER and a fine
of up-to$250.40 a day against the violator. Be;
JKCON-1 Op ID:CD
CE Tgg ICA,rE // F LIABILITYINSURANCE ,.
DATE(MM013NVYYI
0712612016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
I BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,ANT)THE CERTWiCATE HOLDER. -
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polloy(ies) must be endorsed, If SUBROGATION 13 WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in Ifeu of such endorsement(s �a
CONTACT
PRODUCER NAME AIC NO: '
jDaSanctis Insurance Agcy,Inc, PNdra FAx'
1100 Unicorn Park Drive
Woburn,MA 01801 AUDRE
INSURERS)AfFDRDING CQUERAGE „ „„ „MAIC S
INSURER A;Star Insurance COMPS_nY... --.._ '092245
INBURED...__._...._...
X19259
JK l Selective Insurance Company.
4 High Street Suite 108 INsuRER c
North Andover, MA 01845
INSURER D: .............._... ,, _....
f#NSUR£R E '
I INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEf1 BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUt RDArFirT. TERM OR CON71TiON CIF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTI)=tCATE MAY BE ISSUED OR MAY PERTAIN TI4F !4SURANCE AFFORDED 13Y THE POL'.CIES DESCRIBED HERE,`N IS SUBJECT TO ALL THE TERMS,
LTR
EXCLUSIONS AND CONDITIONS C>F SU H F 0. t� I.;�Ii' t; -TOWN MAY HAVE BEEN REDUCED BY PA[D CLAIMS.
AC]bL$rFiF oOLIGY£FF POLICY E%P LIMITS
TY OF INSURANCE yti _- F POLtL'Y NUhtSEH [M.M.DP:fYYY Fs7M1bO1VYYV)
Ia ' X '.COMMERCIAL 0£NERAL L#ABI.tTY _ EACH OCCURRENCE $ 1,000,00
01
0A&11 AOET0FPERT:o.._..._..�...- —'-- 100,000
- - - X' CCCUR 5221}5313 02/1012016:02110/2017 p tEui ti s rra.or�cu ranee -$ . ._._.
i �LF.IhhS-R1ADE ,
_ 10,000
V O EXP Sfinr a g8rson) 5
PERSONAL S ADV INJURY S 1.000,000
0 NL AUGREGAJ E LIA1.T APPLIES PEI{....., ENrRAL AGGREC4 5 _ 3a000>00
X . POLICY ;PRO- Loc
PRODLIG7s COM,)OP AGG a 3,000,00
jEc"IOTHER' _ — ».•.-_ .v.�_ 5
AUTOM061LE LIABILITY CGM INED 51NGL LIMIT
- ...,ANY AUTO DCDlLY INJURY iPer perSU I 5
ALL OWNED SC-IBODILY N
EUULK) JURY(Per+3c.ci:fen'.):5
_.i AUTOS AUTO N _' --
$
.NON-OWNEr Pena dan�kh3Aert=
HIRE-0 AUTOS AUTOS
j UMBRELLA L1A8OCCilf2 ;EACH OCGURRFNCF
EXCESS LIAR CLAlMS-NADE' AGf.,REGA-F ;3
l T�
X WORKERS COMPENSATION E TT I
AND EMPLOYERS'LIABILITY - � L7F_. _,,,, ER ........
A ?ANYSROPRI£70r7r ARTNERr-cci{LC''.Ir''d� Y'N:'tx�A VVC085374`2 071171201S 0211712097 Ft F.ACF kGCIC°NT S 100,00
' '.4FFIC£RIMEMBER E7.^t.JDEb'r .. .............._,...
IMandutorY In NR)
—- MA L rns�Asc•EA r+ Lovrs s,..._.._.,_,_.._.__. 100,00
I M yae.doscr�ba untlar
{D6SCRIP'fION OF 4PERATIORS na'eTw„' _ L.I..GISEASE•POLlCYLIR111' ¢ �I>fQ>��
,f DESCRIPTION Of OPERATIONS r LOCATIOO I VEHICLE'S (ACORO SAj,Adniiional Rrmarhx Schadu#e,may to uttdehod if more apace is roqulmd)
"ADDITIONAL INSURED LIMITS ARE 1V0 GREATER THAN THOSE REQUIRED BY WRITTEN
CONTRACT""Illustration of Coverage; Towel of Nor0l Andover is add'I ins'd as
respects to the GL policy,
I
CERTIFICATE HOLDER CANCELLATION
a NC)RTI kA• I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL HE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS,
43 High Street
N.Andover,!VIA r4 01845 !AUTHORtzWo PRESENTATIVE
l
i✓1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACCORD narrle and logo are registered marks of ACORD
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
i_.icerRse: GS-066334 .
W
wy
KIERAN Y�l HELAN -
31 RICHMOND STREE3
WEYMOUTH MA 0219$
i.
L v� LJL Expiration:
ommissioner 09/26/2017
i'