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HomeMy WebLinkAboutBuilding Permit #1276-2016 - 116 HIGH STREET 5/1/2018 v a'I I NORTH q 4td Lp BUILDING PERMIT of w- "YO TOWN OF NORTH ANDOVER y '' IN APPLICATION FOR PLAN EXAMINATION 7° o ey Permit No#: IZ 47 h Date Received Ar 0 ��SSgcHus�`��y Date Issued: IMPORTANT:Applicant must complete all.items on this page 5�Q.f� LOCATION I �Hi-nh LNo. A I(�aur MA o I SL4b Print r PROPERTY OWNER co Print 100 Year Structure es no MAP PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition QIT-wl'o or more family ❑ Industrial NIA'51teration No. of units: Z ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic El Well Floodplain ❑Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED:L/751t: 11 mendyatrbn o,f Kl-tc�nT ml ��� _ an c� oltnino room 7i)5 dapp , not /nduo(Q ej�rtrcat nrx4numbj��, T-t- Se ae=l t ) cJJ f 11 b2 nLL led Se no r � . Identification- Please Type or Print Clearly OWNER: Name: 1V(Q. C0-i-t • Phone: 4s-f E2014 Address: h Afo• o y Contractor Name: Q tlfAffifk6(rhone: Email: , rnm Address: / Supervisor's Construction License: CS— pit q 3-;�2 Exp. Date: 9 /si;/I a Home Improvement License: ( Exp. Date: I J ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ��, ©� FEE: $ 13" Check No.: ��f Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access the g aranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes C Planning Board Decision: Comments t Conservation Decision: Comments Wafter& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: ; -t^ -Located 4 Osgood Street F-,IRE�DEPART�VIENT ,Temp ®umpster on,ste ryes ono, Located�at'124�Mair,�Street Fife Department siygnature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doe.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roo ing, Siding, Interior Rehabilitation Permits Building Permit Application orkers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application � Certified Surveyed Plot Plan � Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location r No. L? -74- ar.� 09701 �"V1 U' Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check# Building Inspector r 4P 4 GSD Associates,LLC 146 Main Street,North Andover,MA 01845 Tel:978-688-5422 Web:www.gsd-assoc.com Architecture+Design+planning+Interiors+Development Consulting NEW2x8JOiS1S POSTDOWN - - @ 12"O.C. TO LVL HEADER EXISTING 20 RAFTERS EbSTING LVL TO Rom HEADER PROVIDE NEW HEADER 5 JACKSTUDS@YANDOW (2)2x6 MIN. NEW2x8JOISTS @ 12"O.C. NEW HIP BEAM 51/4"x 11114"PSL PROVIDE SOLID POST DOWN j10TE:NEW CEILING FRAWNG TO BE PROVIDE NEW HEADER 6 SUPPORTED FROM NEW 2x8 JOISTS JACK STUDS @ WINDOW (2)2x6Ilk Roof Framing L SCALE:1/4"=1'4" — �EXISTING LVLHEADER ` REMOVE EDSDNG NEW HEADER HEADER NEW POSTUNDERHIP HEADER Existing Partial Floor Plan SCALE:1/4"=1'-0" ;`�5:t'•_�'; ` I 7 Rear of First Floor 10, N Ark 116 High Street North Andover, MA 6-30-2016 Y S W & C Engineering, P.A. Structural Engineering Services 857 Wellington Road Manchester, New Hampshire 03104 e-mailed 7 July 2016 Mr. Gregory P. Smith GSD Associates 148 Main Street, Building A North Andover, Massachusetts 01845-2442 Re: 116 High Street North Andover, MA Roof Framing Design Dear Greg: Charges through 7 July 2016 for professional services related to the referenced project are listed below. Please let me know if you need additional information. 116 High St. hrs Analysis/Design 1.5 Total labor, this invoice 1.5 Hourly rate $100.00 Total for project to date $150.00 Previous invoices $0.00 Total this invoice $150.00 Thank you again for the opportunity to furnish my services. Very truly yours, 4W &W46tc Robert P. Brecknock, P.E. Contact Information: Phone 603 566 2988 e-mail swcengineering@comcast.net t GSD Associates, LLC 146 Main Street North Andover, MA 01845 #Il:(978)688-5422 www.gsd-aswc aom MONTHLY INVOICE BILL TO William McKay William McKay Construction 105 Massachusetts Avenue North Andover, MA 01845 Project Description: 116 High Street-Roof framing INVOICE NUMBER INVOICE DATE PAYMENT DUE DATE OUR PROJECT NO. BALANCE DUE 2016-0140 Jul 11,2016 Jul 11, 2016 16-071 $622.50 Basic Services Date Employee Phase Description Hrs Rate Amount Basic Services 6/20/2016 GS 20 Existing Construction site viist 0.50 $150.00 $75.00 Review 6/24/2016 CD 20 Existing Construction modeling existing conditions 1.00 $80.00 $80.00 Review 6/27/2016 CD 30 Schematic Design proposed plan 2.25 $80.00 $180.00 6/30/2016 GS 50 Construction high street plans review and markup 0.50 $150.00 $75.00 Documents 6/30/2016 CD 30 Schematic Design updating drawings 0.50 $80.00 $40.00 Basic Services Total: 4.75 $450.00 Basic Services Sub Total: 4.75 $450.00 Expenses Date Name Phase Expense Type Description 9!y Rate Amount Basic Services 07/11/2016 LV 50 Construction Consultant: See attached 1.15 $150.00 $172.50 Documents Structural Basic Services Total: $172.50 Expenses Total: $172.50 Invoice Total: $622.50 Expenses Include 15%Markup Please make payments to GSD Associates,LLC.Late payments are subject to penalty fees. Page 1 of 1 vutlbok Mail Search Mail and People 0 New I v Reply I v ® Delete o Archive Junk Sweep Move to v Categories v ••• Archive Re.- Wmc Betts Brian White 2 0 Greg Smith CC 1 C'h 6/30/2016 �v Chris Marshall You;Ceara Donovan(cdonovan@gsd-assoc.com) condo You replied on 7/1/201611:28 AM. COrreria Cote stamped 116 High St.pdf v Cutler Assoc 1 1 MB Dane rd Download Save to OneDrive-Personal Deprizio Bill,Brianne, employe 1 RE; 116 High Street Foster The existing 2x4 roof rafters are extreamely overstrressed,plywooding the sides of the 2x4's will not work structurally. Freil The plan shows adding new 2x8's at 12"o.c.over the entire roof rafter area,and installing a new Hip rafter as shown on the drat Gaffney Alternatively you can use engineered lumber for the roof rafters in place of the 2x8's they can be 1-3/4"x 7-1/4"LSL's @ 16"o.c. GTC we have shown the 2x8's on the plan helfrich 3 we also provided a minimum size for the two window opening headers that do not have any headers framed now. Holber All ceiling framing for a flat GWB ceiling can be supported from the new 2x8's holt bugbee Greg House search 4 I will follow up shortly with the framing for 37 South ave in Melrose Insurance Greg Jackson Lumber 1 job inquiries On Thu,Jun 30,2016 at 8:38 AM,William McKay<wmc3cons(a)msn.com>wrote: Judith Rd Great Thank you. Ken Laurette Get Outlook for Android Keyo KPI Levy 11 On Thu,Jun 30,2016 at 8:37 AM-0400,"Greg Smith" <gsmith@gsd-assoc.com>wrote: Loan 1 I did just get the information from the engineer last evening. Marin Marshall I am out of the office this morning but will send over the sketch this afternoon. mcevoy project I should also have the melrose information today. Melvin Greg Mike Flynn On Thu,Jun 30,2016 at 8:22 AM,William McKay<wmc3cons(a)msn.com>wrote: Mike Stanley Any news on the beam and drawings for that otherjob?Bill really wanted to get started on that ceiling at N, Mixon Get Outlook for Android Nappa Interiors NBPT Harbormaster Notary 3 Office 28 Celebrating 26 Years of Service Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 649437.00 m $ - $ 773.24 Plumbing Fee $ 96.66 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 96.66 Total fees collected $ 1,066.56 116 High Street 1276-2016 on 6/8/2016 kitchen remodel r 1 %AORT1y W, c . : ve: 'o 0 No. — * _Y _ e_. ,o h ver, Mass, rJ e- 2-o coc»Ic"tWICK 1. A�RArED Pp�`,�q5 S tl BOARD OF HEALTH Food/KitchenPERMIT T LD 4 Septic System THIS CERTIFIES THAT T. �t �� ................. BUILDING INSPECTOR . Foundation has permission to erect ........... buildings on ...1 `�"�� to be occupied as .�l.�.�. /p�i� Q...� .. ��11I..1,/. .,� /� '�... Chimney . Rough he provided that the person ac this permit shall 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TI Rough Service .. ... .... ...... . . ..... .... ....... Final BU G INSPE TOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. � 1C WELL[AM MCKAY CONSTRUCTION LLC. 18 Academy Ave Haverhill, MA 01835 # 978-361-6402 CONSTRUCTION CONTRACT This Construction Contract (hereinafter the "Contract") is hereby made on 3/7/16 by and between Matthew Cote (hereinafter"Client") and W McKay Construction LLC of 18 Academy Avenue, Haverhill, MA 01835 (hereinafter"Contractor") collectively referred to herein as the "Parties". ARTICLE 1 A. Contractor shall provide the following Construction Services (the "Project"), as agreed to in a signed Proposal related to said scope. B. Client engages Contractor and Contractor agrees to provide to Client all necessary service , materials, and labor necessary for the completion of the Project including, but not limited to , all building and construction materials outlined in the signed scope. Material estimate and all necessary tools and machinery needed for Project completion. All construction materials should be new and of the highest quality, unless previously specified by the Client. C. Contractor shall provide the construction services for the Project at the property located at 116 High Street, North Andover, MA 01845. D. The Contract shall be comprised of the following: this Construction Contract, Plans, Specifications, Addenda, Drawings, Photos, Proposal, materials estimate if applicable all signed and witnessed all of which are attached hereto and are a pP 9 part of this Contract as exhibits. ARTICLE II A. Contractor will be scheduled once deposit is received. B. In the event that Client and Contractor agree on changes to the Project after this Contract is executed, the Parties will agree to new time deadlines that are reasonable in light of the modifications and that schedule change will be signed and witnessed and become a part of this Contract. B. In the event of unavoidable casualties, Contractor shall properly document both the event and the impact of the event on Project completion. Documentation shall be presented to Client in a timely manner. ARTICLE VI A. If Contractor fails to correct defective work or persistently fails to supply materials or equipment in accordance with the Contract documents, Client may order Contractor to stop the work or any portion thereof, until the cause for such order has been eliminated. ARTICLE VII A. Free access to the work and the Project site shall be granted by Contractor to Client, the designated agents of the Client, and all necessary public authorities. B. Contractor agrees to keep the premises clean and orderly. Contractor shall remove all debris as needed during the hours of work in order to maintain work conditions free of health or safety hazards. ARTICLE VII A. Contractor shall conduct its activities in a professional manner and adhere to reasonable wishes of Client in relation to its working schedule. Additionally, Contractor's work shall adhere to and be in compliance with both the Standard Practices of the Trades and any relevant Manufacturers Specifications. B. Contractor shall protect all work adjacent to the Project site from any damage resulting from the work of Contractor and shall repair or replace any damaged work at its own expenses. Contractor shall take all precautions to protect persons from injury and unnecessary interference or inconvenience. ARTICLE IX A. Client agrees to hold harmless, indemnify and defend Contractor and each individual or entity that is an agent, affiliate, partner, officer, or stockholder of same against any and all claims, losses, liabilities, damages, and expenses, including legal fees, fines, judgments, settlement amounts all made in connection with , or arising from errors in any representation or warranty made by Client under this Contract, any breach of the Contract by Client, or any omission or negligent act or error by Client in connection with this Contract, provided by such negligent act, omission, or error was not done at the direction of Contractor. B. Contractor agrees to hold harmless, indemnify and defend Client and each individual or entity that is an agent, affiliate, partner, officer, or stockholder of same against any and all claims, losses, liabilities, damages, and expenses, including legal fees, fines, judgments, settlement amounts all made in connection with , or arising from errors in any representation or warranty made by Contractor under this Contract, any breach of the Contract by Contractor, or any omission or negligent act or error by Contractor in connection with this Contract, provided by such negligent act, omission, or error was not done at the direction of Client. ARTICLE X A. Contractor is responsible for insurance to protect against any property damage, bodily injury, death, or other claims for damages that may result from the commission of the work, including general liability insurance and workers compensation insurance for its employees and/or subcontractors. Contactor will supply Client with said Certificates of Insurance before the Project begins. B. COVERAGES: (Apply only to actual work performed as set forth in contract) 1. Structure: For a period of one year after the date of completion, the floors, ceilings, walls and other internal structural components of the dwelling, which are not covered by other parts of this Limited Warranty, will be free of substantial defects in materials or workmanship. 2. Systems: For a period of one year after the date of possession, the plumbing, heating and electric wiring systems will be free of substantial defects in materials or workmanship. 3. Roof: For a period of one (1) year after the date of roof installation, the roof will be free of leaks caused by defects in materials or workmanship, but not those caused by ice back-up. C. EXCLUSIONS FROM COVERAGE: We specifically do not assume responsibility for any of the following items, each of which is specifically excluded from this Limited Warranty: 1. Defects in appliances or pieces of equipment which are covered by manufacturer's warranties including furnace and hot water tank. 2. Damage due to ordinary wear and tear, abusive use, misuse or lack of property maintenance of the dwelling or its component parts or systems. 3. Defects which are the result of characteristics common to materials used. 4. Defects in items installed, supplied or work done by you or anyone other than by us or our subcontractors at our order. 5. Cracks in sheetrock due to settlement. 6. Any loss or injury due to ground water. 7. Loss or injury due to elements, including, but not limited to weather and other acts of God. 8. Conditions resulting from condensation on, or expansion/contraction of materials. 9. Your failure to properly care for lawns. 10.Consequential or incidental damages. 11.Due to large trucks, equipment, dumpsters, etc., driveway may crack, create divots etc. Also during construction, lawn may be damaged. Contractor is not responsible for the same. ARTICLE XI A. Contractor will be responsible for obtaining all the necessary permits and licenses to fulfill the services specified in this Contract. ARTICLE XII A. Contractor is responsible for maintaining proper work, safety and environmental protection standards. Contractor agrees to hold Client harmless for all fines from federal, state or local agencies and regulators. Contractor will work in compliance with all standards required by EPA, OSHA and other applicable federal agencies. Contractor will be responsible for paying all fines and judgments levied by these agencies resultant from the performance of this Contract. ARTICLE XIII A. The relationship created between the Parties shall be limited to that of independent contractors. Neither party shall undertake any actions that would imply or seek to establish, any partnership, ownership, employment, joint venture, or trust relationship between the Parties, except by amendment to this Contract. ARTICLE XIV A. Any dispute or claim related to or arising from this Contract, its performance, breach, interpretation, validity, or enforceability, shall be exclusively(except as provided below) resolved by final binding arbitration before AAA American Arbitration Association utilizing AAA Commercial Arbitration Rules. B. The arbitrator shall be selected using AAA procedures. The arbitrator shall render a written decision within thirty calendar days of the hearing. The arbitrator may award attorneys' fees or punitive, incidental, consequential, treble, or other multiple or exemplary damages. C. Awards shall be final, binding, and non appealable with the exception of the grounds for appeal guaranteed by the Federal Arbitration Act and applicable laws. All awards may be filed with one or more courts, state, federal or foreign having jurisdiction over the party against whom such award is rendered or its property, as a basis of judgment and the issuance of execution of its collection. ARTICLE XV A. Both Parties are expressly prohibited from assigning this Contract or any rights or interest flowing therefrom. Assignment will only occur with the express written consent of both Parties. B. This Contract contains the entire agreement and understanding between the Parties and supersedes any prior or contemporaneous written or oral Contracts, representations, and warranties between them respecting the subject matter of this Contract. C. This Contract will be interpreted and enforced under the laws of the State of MA, without regard to conflict of laws. IN WITNESS WHEREOF, the Parties hereto execute this Contract: CLIENT Authorized Signature 01177-/ Cfl Name and Title CONTRAC OR IiA Authoriz d ignatu t 'tit Name and Title License # 179265 W MCKAY CONSTRUCHON LLC aS ACADEMYAVENUE EAS MA®aB35 PHONE*978-891-2303 PROPOSAL 2/29/16 Project name: Matthew Cote 116 High Street North Andover, MA 01845 Scope of Work: Main area • Provide permits. • Demo existing kitchen, dining room and mudroom down to bare studs including the ceiling and dividing wall. • Disconnect all of the appliances and bath fixtures prior to the start of demolition in the kitchen and the bathroom. • Plumbing price also includes new laundry box with hot and cold water supply shut off in 2nd floor apartment. • This plumbing pricing does not include any fixtures as prices based on client choices vary greatly. This amount can be added in the form of an extra work order once chosen. • Create new 10' opening to living room. This will require a structural engineer for approval from building department. • Insulate wall and-ceiling in new kitchen and dining room area per code. • Install %" blueboard and plaster in new kitchen and dining area. • Supply and install new prefinished hardwood floor throughout dining area and kitchen. This will not match existing floors. • Supply and install new kitchen and island as per accepted layout and design. • Plumbing for new kitchen as per layout. • Installation of new standing and running trim. • Installation of new recessed lights and pendants over island. • Supply and install of granite countertops as per client. • Replace existing entry door and hardware. • Update trim on all openings in existing living room. wMCFAx c®xSTRUMON LLC igACADEMYAVENUE HAVE MA01835 PHONE#98491-aso3 PROPOSAL 3/2/16 Project name: Matthew Cote 116 High Street North Andover, MA 01845 Scope of Work: GARAGE • Removal and disposal of existing wood floor. • Backfill exterior with % crushed stone, compacted at 8" levels. • Estimated fill is for 2 feet. If it's a deeper depth there will be an additional charge that will be added to the Contract in the Form of an Extra Work Order. • Pour 6" slab of concrete reinforced with netting. • Make necessary control cuts for concrete. • Install 2 new garage doors, lift system keypads and any trim necessary. Please see attached literature on doors for specifications. If you should change style or door choice this may increase the price and this will also be represented via Extra Work Order. ** Please note: Disposal will be done daily to a dumpster provided by WMC. All WMC work will be completed in a timely and clean manner and in observance of OSHA regulations." TOTAL : $ 9,838.00 LG/i/ L l 4 Scope of Work: New Bath at Front Entry • Move door to living room over as much as possible to allow for relocation of bath wall to create acceptable space in bathroom. • Move new bath wall, re-frame and install blueboard. • Install %" blueboard and plaster on all walls affected by framing changes. • Install plumbing for new sink and toilet in new bathroom area. • Install tile floor and grout in new bathroom. • Install new door and new cased opening at living room. This includes baseboard and any other trim inside the new bath and match existing outside. Scope of Work: Second Floor laundry • Removal of all piping to existing laundry room in next door unit. • After construction is roughed in we will provide all materials and labor to supply rough plumbing to new kitchen, bathroom and laundry room. This includes all hot and cold water feeds as well as any necessary drainage work needed. • Frame in new laundry room in second floor apartment. • Apply %2" blue board and plaster to new walls. • Install louvered bi-fold door and related trims. • Install new plumbing hook ups for laundry room. Please note: This price includes all materials except, the for the new bathroom, kitchen and bathroom sink, kitchen appliances. Daily cleaning will be performed by WMC to a WMC provided dumpster. All work will be done in accordance with OSHA regulations. TOTAL : $ 54,599.00 4w4cKavnstruction LLC Matthew Cote h I 1 " i � 1 Co . . _ 258" 30" 45" ---75" 791" 7;" ' 24"_119, �35' _ - -- s G i 1 I ry —71 } CO r. co y m w c� 126" 40- 216" ; 258" 30" 45"- �` —75" � 79" 2g" 79 48 E" —129-1" 67 �2 "�191� 35�g"—�}'-- I rs , +f. �r n t i o � _ 0o 18,3 " 29 7 "t 1$.6tt 33" 3311 i --66" 4� „ -- ` 126" -- 40=11 216" The Commonwealth of Massachusetts z Department of Industrial.Accidents .:: - d 1 Congress Street,Smite 100 Y a Boston,MA.02114-2017 www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE MED WITH THE PERMITTING AUTHORITY. Applicant Information PleasePrintLedblY Name(Business/Organization&dividua]): �� MC (.ltd CJ 1`�-�Vll�'t"f CLQ L�r�-C .Address: IS Asad i'nw Ay_ City/State/Zip: 1 ( �Wcffphone##: q1$ gR 1 a 3 Are u an employer?Checkth'e appropriate box: Type of project(required): 1. VI am a employer with_,,�employees(full and/or part-time).' 7. []New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, �emo delilig any capacity.[No workers'comp.insurance required] 9. F!Demolition 3..Q I am a homeowner doing all work myself[No workers'compAusurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.C1 Electrical repairs or additions proprietors with no employees. 12..[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and Nye have na.employees.[No workers'comp.insurance required.] �; *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who snlimiE this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have . employees. If the sub-contraetors have employees,they must provide their workers'camp.policy number. I am" an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. _� /1 Insurance Company Name: IP f 6 44(' d 1 r a 1�e C 0 to )Q 11 Policy#or Self-ins,Lie.#: �NC���©C� Expiration Date: 3/a 9 / 77 lob Site Address: I /�l I�� City/State/Zip: Mo 0• Aa �(/.0f (45 Attach a copy of the workers'c6pensation 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 WORK ORDER and a tine 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 DIA for insurance coverage verification. Ido hereby certify u erfhepai an allies ofpei jury that the information provided above is true and correct. signafore: Date: UZI /I Phone#: 2;V, 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, expres' or implied,oral or written." An,employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enf6rprise,and including the legal representatives of a deceased employer,or the receiver or trustee of aft individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and-phone numbers)along with their certificate(s)of insurance. Limited.Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you.•are required to obtain a workers' compensation policy,please call the Department.at the number listed below. Self-ibsured companies should'entertheir ' self-insurance license number on the appropriate Eno— City City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617•-727-7749 Revised 02-23-15 www.mass.gov/dia WILLI-6 OP ID: LANK ACORO' DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/02/2016 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 CONTACT Macdonald&Pangione Insurance Phone:978-688-6921 PHONE Kim Landry FAX 104 Main Street Fax:978-688-5350 ac Nrr Ext:978-688-6921 A/c Nc:978-688-5350 North Andover,MA 01845 EMe Lisa Ross ss:kim@mpins.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Guard Insurance Group INSURED W Mckay Construction,LLC INSURER 6: Billy 18 Academy Avenue INSURER C: Haverhill,MA 01832 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. ILTR TYPE OF INSURANCE L SUOR POLICY NUMBER MM/DDY EFF MM/DD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY = PREMISES Ea occurrence $ CLAIMS-MADE F—I OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO ECTLOC $ AUTOMOBILE LIABILITY Ea MIaccNED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident) $ AUTOS AUTOS ( ) f 1 1 $ NON-OWNED PROPERTY DAMAGE HIRED AUTOSAUTOS Per accident $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS UAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITSER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N MWC700002 03/29/2016 03/29/2017 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? El N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Matthew Cote THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 116 High Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �e�o=ni.T�rd�irveall�of'C�/�/�a.l�ac�t�drf/a . OfTice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: 179265 Type: Office of Consumer Affairs and Business Regulation xpiration: 7/10/2016 LLC 10 Park Plaza-Suite 5170 -� Boston,MA 02116 W. MCKAY CONSTRUCTION LLC. i WILLIAM MCKAY 18 ACADEMY AVE, HAVERHILL,MA 01835 U dem rse�tnry Not valid without signature .t Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-089332 Construction Supervisor P— WILLIAM M AY 18 ACADEMY AVENUE HAVERHILL MA 01835 =xpiration: 1 `Commissioner 0310812018 Unrestricted-Buildings of any use group which 35 000 cubic feet 991m3 of contain less than ( ) enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: wwx.Mass.Gov/DPS