HomeMy WebLinkAboutBuilding Permit # 11/16/2016ILDING PERMIT
Ti\ OF NORTH AND VIER
APPLICATION FOR PLAN EXAMINATION
Permit No#: c c)
Date Issued:
a VA 11' f /041
Date Received
(TANT: Applicant must complete all ite
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
D New Building
Li Addition
YAlteration
U One family
El Two or more family
No. of units:
Li Industrial
E Commercial
E Repair, replacement
0 Demolition
LI Assessory Bldg
U Others:
E Other
[I Septic rj Well '
a Water/See / , ,,
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LI atets,, ,
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DESCRIPTION OF WORK TO BE PERFORMED:
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Identification - Please Type or Print Clearly
OWNER: Nattie:1„)1(4
Phone:10 ICT -i
Address: \O 13 ,tN,\, 1/45 0 S. ,c406" %AAA,
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Contractor Name: ONcnVM
Email: eia4Q tow\
Address:'t404.
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-lorne Irnpr,OV,,emen /License: Exp. Date:,
ARCHITECT/ENGINEER-. ,‘\ Phone:9' 7 e
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Address: 13S S t•1 Reg. No. (3 0 (s..
Total Project Cost: $ 2g
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
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Check No.:
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FEE:
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:
RCG North Andover Mills LLC
David Steinbergh
17 Ivaloo Street
Somerville, MA 02143
Description
Proposal
Proposal Date: 11/15/2016
Proposal #: 203-63
Project: 21 High, Suite 21...
Ship To
Est. Hours/Qty.
Rate
Total
Permits and C of O.
566.00
566.00
Demo, Remove curtain rail ,steel angles , steel beams,
kitchenette, carpet,etc. Bring to dumpsters.
3,400.00
3,400.00
Dumpsites [2]
1,400.00
1,400.00
Wall Framing, infill door, cut out entry door in another
location, frame conference room ,kitchen and it closet
walls.
1,500.00
1,500.00
Doors & Trim. Supply and install one new double door
to it closet. Re -use other doors on site, provide new
locks for offices and IT room.
1,600.00
1,600.00
Plumbing. Install new plumbing for kitchen,using old
sink and fixtures.
1,200.00
1,200.00
Heating & Cooling. Install vent into new conference
room.
350.00
350.00
Electrical & Lighting
9,300.00
9,300.00
Tele/Data
4,900.00
4,900.00
Insulation
100.00
100.00
Interior Walls, Board ,patch wall, tape ,sand
2,800.00
2,800.00
Cabinets & Vanities ,Remove and re -install
500.00
500.00
Painting, includes ductwork, and outside hallway wails
affected by construction.
4,200.00
4,200.00
Sprinkler Work, Install head in IT closet
450.00
450.00
Cleanup & Restoration
150.00
150.00
Floor Coverings
2,800.00
2,800.00
Supervision
3,465.00
3,465.00
Insurance
346.50
346.50
Approved:,._ (Initials)
Total
$39,027.50
SIGNATURE
thm C.!irllart)1 Document
illc building permit application by a
Pert Design Professional
lea ,,,fork per the edition of the
N'U:sacbrisetisaie Uoiktini Code., 780 CMR, Section 107
Project 'Vide: East ?Aiij DSA Date:, 11-15-16
21 Hic Nord:i ArAovet,
property Address:
Project: Check one or both x1pfhleNiwconstruciion X Existing Construction
Project deseription, T;,;mant 1:..)r OSA Suila 210 8, \ACC; Law Crnur Suit708R
Linda S. Stnilev
10080 Expiration date: 08-31-17 itin a
rq4i.vtereel pm?ssiono alltf fo n Oirceily ainervised the preparation of all design plans,
computations and specifications concf4ioiri?:
X Architectural
[ I Fire 1-.)roicction
tiOli.) al
I. Me:orient
Ntechimicat
Otticr
for the above named project and that to the bei,14.-t.t,- /avo,Oedgc, infermation, and belief such plans, computations and
specifications meet the applicithle. provisiont; of the Massachusetts State Building Code, (780 OAR), and accepted
engineering practices for the proposed project I un(lastand and agree that I (or my designee) shall petfOrm the necessary
professional seiviees and be titiescrit on the; construction site on a regular and periodic basis to:
1. Review, for conthrmance to lids code and the design concept, shop drawings, samples and other submittals by the
contactor in accordance with the l',.7.:qUirvmwnl:,-; of the eonoraction documents,
7. Pet -limn the duties forregisicred dt-Jiign proCey,:ionals in 780 CM: Chapter I?, 3s applicable,
3. Be tie cot at intervaN npinotuiai:o am ma 4.11.00o4aiGtion In become generally Thmniliai with the progress and
quality of the woilc and to determi•iw.it time. cork. a; being per lorrnrAl in a 11111111C-E consistent with the approved
construction documents and iaie
Nothing in this duenmeini rdievcs: tiC winr:ictor in- its .i_sponsibility regi,iraing the provisions of•780 CMR 10'7.
When required by the building ortioial, I 81aii ;:ohm
connneuN, in a UCti mu,ICCepa111,2 Io
rompletinil o t he walk, I H;r,lanit 10
Enter in the space to the right a "v,,e.t:"am
electronic sigilantre and ;,,:cat
Phone intrnbern.
978-518--993
. .
Building Official Name:
Veisikal 06_112.0 l3
Le.!if.didie.dfAcKil
ka5:31,11YPOITI
MASS
oils (sec item 3,) together with pertinent
(tatstriret ion Coriltol 1)0ettnterte,
Email.. •
tini-h(saarri-arch.con't
0 Mc tat 11c, (Joky
nait No.;
I VW.
The Commonwealth of Massachusetts
.Department o `' u1ustrigl Accidents
Office ;ray . rwestigations
On Washington Street
Basco,,, MA. 02111
www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
lectricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organ izationllndividual) : � le( CAI o Lail iv -
Address: L 1 Qg l
City/State/Zip: 1U _ AN 0 0 ks-)L { Hv OI1l S Phone #: 171--T91,-6-7-3-cc
—
1. gJ I am a employer with.
employees (full and/or part-time).*
2. ❑ lam a soleproprietor or partner-
ship and'have no employees
working forme in any capacity.
[No workers' comp. insurance
required.]
3. 0 I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
Are you an employer? Check the appropriate Fox:
4. Li I am a general contractor and I
have hiredthe sub -contractors
listed on the attached sheet. I
These sub --contractors have
workers' comp. insurance.
5. L, + We are a corporation and its
officers have exercised their
right of exemption per mat,
a, 152, §i(4), and we have no
employees. [No workers'
comp. insurance required.)
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12,n Roofrepairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information,
Homeowners who submit this affidavit indicating they aid doing all work and then litre outside contractors must submit a new affidavit indicating such,
tContractors that check this box must attached an additional sheetehowing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for any employees. Below is the policy and job site
information. II
Insurance Company Name:. S a .-.' ✓3 l N{L M1 W CAI M f raiArM
Policy ii or Self ins. Lie. if: IA. ' t`) tf''Z� Expiration. Date: .. i 7 / 7
Job Site Address: i i Get 4 V� k City/State/Zip: N- !g- tJ p CI Vi1 -r f
h.ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
t 'ailure to secure coverage as required under Section 25A 01'M L o. .152 can lead to the imposition of criminal penalties of a
ne up to $1, 500.00 and/or one-year imprisonment, us well es civil penalties in the foram 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,
IJ.C�I'-ice
t do hereby cent j under the piaiins and penalties q fpeij.wy that the information provided above is true and correct.
ignaiure: /L. - Date: li i f '
'hone #: I L - VT
' Official use only. Do not write in this area, to he cornaplaid iv thy or town official:
City or Town: _?errei Licexise
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3., CityJTowa 1erih, 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone 11:
JKCON-1 OP ID: CD
AWR
CERTIFICATE OF LIABILITY INSURANCE
DATE IMM(DD/YYYY)
07/2612016
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 pollcy(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
PRODUCER
DeSanctis Insurance Agcy, Inc.
100 Unicorn Park Drive
Woburn, MA 01801
.
INSURED
JK Contracting, LLC,
4 High Street Suite 108
North Andover, MA 011345
CONTACT
NAME:
PHONE ....., .,.,.,
EMAIL
ADURES5;.
PAX
INSURER(S) AFFORDING COVERAGE .,,. ,., ..[ NAIL #
I uRERA;Star Insurance Company..__ 1012245
INSURER a: Selective Insurance Company if9259
INSURER C •
INSURER D
jj INSURER E'
II INSURER F
REVISION NUMBER;
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE :,JSTED 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. INS! RANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
f EXCLUSIONS AND CONDITIONS OF SUCH POLIO. ES L:iv tTa S-KO'.'VN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
...... - .. '.-"...._ - ..'..... ............._
1NSR', 'ROLL 31 U'- ... ..... - _ _.... POLICY EFP ' POLICY E%P.
i LTR TYPE OF INSURANCE • laj.yc7 Y„',C; POLICY NUMBER LMWDD:IYYY( . (MM1DO)YYYY) ' LIMITS
I B X GOMMERC!AL GENERAL LIABILITY EACH OCCURRENCE
namAciP
LMMS NAOE i X occ n S2205113 02/10/2016 ', 02/10/2017 FZEW FSa a gccu Sree;
— '/ D EXP (Any one us=son}
E.J.PERSONAL $AOV INJURY
•
GUM AGGREGATE LIMIT APPLIES PSI! GENERAL AGGREGATE
• X POLICY • .' Pao- PRODUCTS COMP/OPAGC
OTHER'
• $ 1,000,00D
r s 1004000
S 10,000
E.._.._.... _.. 1,000,000
5 3,000,000
- C 3,000,000
AUTOMOBILE LIABILITY COMBINED SINGi.= LIMIT
ANY AUTC• BODILY INJURY (Pa, oersarl
, ALL CANNED S -.,. CHEDI:LEC t
BODILY INJURY Ter accident)
AUTOS AUTOS
NON-owNEc PAOPERYY.AMAGE
I ;HIRED AUTOS Ail T Ofi •, 'Par acclaara,
1 ,
• S
- $
....- .__..__._..—___..
$ .
S
$
UMBRELLA LIAR OCCUR I EACH OCCURRENCE
j '' EXCESS LIAR CiAIMS•MADi' , AGGREGATE
j $
; S
j DEC : ! INETENT:ON $ i $
' WORKERS, COMPENSATION _)(_ PER ., aR H
I AND EMPLOYERS' LIABILITY Y N .._ ._.,.,
A ' ANY FROPRIETORiPARTNErsr5XL i - r.L --- WCFSb';742 02i17/2018 02f17f2017 EA. SAC! ACCIC$N
'OFF,CER1�MEMSESExc;.JrED, N • h A
—
i (Mandatory in NR) i..- 'MA E L DISEASE • EA EMPLOYEE:5.......__,
' If yes, dascribe ur..Ger .
!DESCRIPTION OP OPERATIONS neaw : E.L. CISEASE • POLICY LIMIT '
..,.--
s 100,0001
_.,..^...^.. 100,000
S 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES ACORD 101, AddiiIona! Romania Schndule, may be enriched i1 more apace is roqurred}
"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
Town of North Andover
43 High Street
N. Andover, MA 01845
NORTHA•
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZratF'REPRESENTATIVS
ACORD 26 (2014/01)
1988.2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-O'6334
SS:Jpervisor
KIERAN T WHELAN
31 RIC1HMOND STREET'
WEYMOUTH MA 02488,
..omrnissioner
Expiration:
09/26/2017