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HomeMy WebLinkAboutBuilding Permit #496-13 - 120 WATER STREET 1/7/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: —0 Date Received Date Issued: IZ-711 IMPORTANT:Applicant must complete all items on this page .P .--. LOCATION}- - 1� '�-- F - - - _ �- r i not FPROR,ERTY_,�®WNER_� 1'OQ�YearxOld�Structurei 'yes nod I MAPN© FARC:EL II ZONING DISTRICT Historic Dlstncf,. y nog 3. — Shop er no x Machines - - TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial 'Alteration No. of units: Commercial ?Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic-) ❑Weill ,� �'Floodplalnt�# ❑klNetlands WatershedfDlstrict - ❑�1Nater/Sewer..:, � ., . ti - - DE�C IPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: it —1KzS-1 NG-*• Phone: Address: l C,®N;TRACTOR,'N—,K v . _ _ r ��-- --- PFione µ -77 Address. ¢ - b Exp ®ate 1 Su a r#s�ConstructionLicense_ ^CUIS,O F _ --- Home�ImprovernentLicense:; . . Ezp ARW*HTEC-TIENGINEER � ��+ �L- Phone: } Address: 4 9• FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.0 S.F. Total Project Cost: $ ���Q � Q FEE: $ � 0 C? Check No.: Receipt No.: c�2 6 06 6 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund `Sig ature of�Agent%®wner� �ignatu,re�of�contraNctor .�.•.. Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans 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 - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments e� Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT _ Temp Dumpster on site yes no Located at:124 Main Street Fire Department signature/date COMMENTS I 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 - Date Doc.Building Permit Revised 2010 1 Building Department The fohowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers 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 NOTE: 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/Crossection/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 NOTE: 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 appal 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: Doc.Building Permit Revised 2012 II { I pl 1-7/- Location No. 7 16 Date . - TOWN OF NORTH ANDOVER e ;u Certificate of Occupancy $ s Building/Frame Permit Fee $ 60� Foundation Permit Fee $ Other Permit Fee $ ' TOTAL $ r Check# / ,�'l 26066 uild'ing Inspector Location No. Date 4 TOWN OF NORTH ANDOVER e y . CN, Certificate of Occupancy $ �� - Building/Frame Permit Fee $ , • Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Wt _ r,i 26129 V Building Inspector p '.0•T 32 •.e. .'.�pL ��SS�CHps 4r CERTIFICATE OF USE & OCCUPANCY TOWN OF NOR'T'H ANDOVER Building Permit Number 496-13 on 1/7/2013 Date: January 29, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 120 Water Street, Suite 208B MAY BE OCCUPIED AS Tenant Fit Up IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG-NA Mills LLC 120 Water Street North Andover, MA 01845 Building Inspector Fee: $100.00 Receipt: 26129 Check :1182 of poRT.,M CHR`'E4 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 496-13 on 1/7/2013 Date: January 29, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 120 Water Street, Suite 208B MAY BE OCCUPIED AS Tenant Fit Up IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: RCG -NA Mills LLC 120 Water Street North Andover, MA 01845 Building Inspector Fee: $100.00 Receipt: 26129 Check :1182 tAORTH . . Tow oAndover o No h ver; Mass, COCNICKl WICK 1' P BOARD OF HEALTH P, iE Food/Kitchen R-IM .1 T _ T 'Septic System LD THIS;CERTIFIES THAT .,.&. .. IAIA...... .' �i �s,,;. C BUILDING INSPECTOR has permission to.erect ,.:......:................. buildings on .,f (1.. :5�✓ !' :5� .... ..................................... _ Foundation to be occupied,as ......... : � ` p ..... .�........ ..���..��� .................. provided that the person accepting this permit shall in every respect`conform to the terms of the application �n, . -. . on file in this office, and to-the.provi`sions..of the..Codes,and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING..INSPECTOR ^ VIOLATION:ofthe.Zoning or Building Regulations Voids this Permit. Rough �, AP Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR ` UNLESS CON STRUCTIONTARTS ,2 . .. l . u�yaNY _ /J�j Service -. ....... BUILDING INSPECTOR GAS INSPECTOR Y . , Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No. Lathing or-Dry Wall.To Be Done FIRE DEPARTMENT Writil'Inspected and' Approved by the Building Inspector. Burner Street No. I �t- 4 Smoke Det.. >, ,•��`� L 3 SEE REVERSE SIDE 1� �. . OORTH r 6Andover ` Y o - �:: 0 No: . z _ ��K. h h ver; Mass, % /5 . coc.ac«ew.cw 1. ��A�R^TEO U BOARD OF HEALTH Food/Kitchen Pli ;.. M Septic System LDI BUILDING INSPECTOR r ` � THIStERTIFIES'THAT ....,... ... �.),.:.... �i<.�-f... has,perrnls$,on to:erect ..;.....:...:.. 1 ..�:4 . buildings on . �` 04 Foundation� ..arils ��.. ........S. °��. ..�age to be occupied as_... ..... provided thatthe person accepting this permit.shall in every respedconform to the terms of the application 7Fin � . on file in tbis office, and to-the.provi`sions•.of the.Codes"and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING.NSPECTOR Rough ! VIOLATION:of the:Zoning or Building Regulations Voids this Permit. AP, /`2 / �3 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS-CONSTRUCTION TARTS z PA Service l 4 . - ............ .... ... .... BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous'Place on the Premises — Do Not Remove Fina' No. Lathing or Dry WaIL,To Be Done FIRE DEPARTMENT Gntil'Inspected and' Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Enter'construction cost for fee cal- North Andover Fee Calculation Construction Cost 24,090.00 m $ - $ 289.08 Plumbing Fee $ 36.14 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 36.14 Total fees collected $ 461.35 1 High Street - Mailing 120 Water Street 496-13 on 1/7/2013 Perform buildout per plans Suite 2086 o a SUITE 208B 1,200 S0.FT. IH � I ---------- ------------- ------: VrT77— �v F- iSECONDARY EGRESS /- PATH I EGRESS PATH,74' I ICA . m o o. coo --- �, LL ° 17 O L-- J �� p S. Oo0 � g No.10080 b C' MBURVMT MASS. kms, 1 Suite 2096-EGRESS PLAN �,. STANTEC ARCHITECTURE& ENGINEERING, P.C. Drawing Number 303 Congress Street,6th Floor EGRESS PLAN Project Issued 12/20/2012 A001 Boston,MA 02210 TEL:617 423 4252 2ND FLOOR-SUITE 2086 Sheet Issued 12/20/12 Project No. FAX:617 423 4333 Stantet www.stantec.com RCG,LLC-EAST MILL Scale 1/32"=1'0" 218410015 3.HH (3.11) 3.JJ 3.KK 3 LL 3.HH (3.11) 3.JJ 3.KK ILL I rt O O SCOPE OF WORK LINE I SCOPE OF WORK LINE I I I I I I I I I I I I I 90 I I I HVAC j OFFI qE j OFFICE j HVAC j I I I 208B-3 1 208611 1 j 2086-2 j 2086 3 j cr�� I L v I I I j I I j 2- I I I I I I I I I I I ALIGN I I ( NEW FULL HEIGHT I I WALL,CENTER W/ EXISTING BEAM ABOVE I WALLS TO I I ( I Suite 2088 I I I Suite 2086 REMAIN j 2086-4 I 2088-4 ✓, DEMOLISH EXISTING WALL I I I I I NEW COUNTER, LOWER AND UPPER I i I I I NEW FULL HEIGHT CABINETS.NEW SINK. WALLS AND 3-0" I TO MATCH BUILDING DOOR,DOOR TO STANDARD PANTRY I �I DEMOLISH I MATCH BUILDING CONFIGURATION I OPENING FOR NEW j STANDARD ENTRY DOOR I I I I 5'-21/2" I I I EXISTING I I 5'-0„ I I I I I WALL TO I I I I I I REMAIN I I D �� aaass. n Suite 2086 - Demo Plan 2 Suite 2086 - Floor Plan f 1/8" = 1'-0" 1/811 = 1'-0" STANTEC ARCHITECTURE & ENGINEERING, P.C. Drawing Number 303 Congress Street,6th Floor FLOOR PLANS Project Issued 12/20/2012 A100 Boston,MA 02210 Sheet Issued 12/20/12 Project No. TEL:617 423 4252 2ND FLOOR-SUITE 208B FAX:617 423 4333218410015 Stantet www.stantec.com RCG,LLC-EAST MILL Scale 1/8"-1'0" �r Standard Form of Agreement between Owner and Contractor where the basis of payment is the Cost of the Work Plus a Fee without a Guaranteed Maximum Price Date: December2$, 2012 ���� v Owner: URC ;;Nodh'A' do�er�M lls LLC s_ CIO .RCG LLCM ... . Iual+oo4Street ,Su�te110 I FWN" :; Contractor: JK�Con r c Wit LLC Y X31 Ric myon tr�eet ` Weymor�th `MA 021 8 �r a N � : > n' Architect: ">Stantec { Project Name: `Boston Jt demhit E , ° SF L� t V. The Owner,and Contractor agree to the terms stated by this contract. This contract supersedes any prior agreements, representations, or negotiations, oral or written. No liquidated damages shall apply to this agreement. This contract consists of the following documents: 1. Obligations of the Parties 2. Contract Sum 3. Project Schedule 4. Signatures Exhibits Exhibit A: Estimated Cost of Work Exhibit B: Project Schedule Exhibit C: Drawings i Page 1 of 4 1. Obligations of the Parties Obligations of the Contractor: The Contractor accepts the relationship of trust and confidence established by this Agreement and covenants with the Owner to cooperate with the Architect and exercise the Contractor's skill and judgment in furthering the interests of the Owner; to furnish efficient business administration and supervision; to furnish at all times an adequate supply of workers and materials; and to perform the Work in an expeditious and economical manner consistent with the Owner's interests and in compliance with all applicable governmental codes and regulations. The Contractor shall keep full and detailed accounts and exercise such controls as may be necessary for proper financial management under this Contract. The Contractor shall keep full and detailed records of all books, records, permits, licenses, correspondence, receipts, instructions, data, and drawings associated with the Project including all Subcontractor contracts, invoices, vouchers, insurances, lien waivers, and other correspondence. The Owner and Owner's Accountants shall have access to review, audit, and copy all Contractor documentation. The Contractor shall retain these documents for a period of three years after final payment. The Contractor shall maintain insurance at the following levels with the Owner listed as a co- insured: Type of Insurance Limit of Liability Cpmrrter+cta Geheral`Liab�h S 000 000.00, �� � yr _�. 0 01111 e Upon request, and at the cost of the Owner, the Contractor shall obtain a performance bond up to the total Cost of Work. Such costs shall be added to the Construction Volume. The Contractor understands that the Project'may be financed by a construction lender and, then, by a permanent lender. The Owner may assign any of its rights under this Contract to the construction lender and the Contractor hereby consents to any such transfer provided no such assignment shall relieve the Owner of any of its obligations under this Contract, unless agreed to in writing by the Contractor. The Contractor shall execute any certificates, lien waivers, releases, receipts, and other documents as may be reasonably required by the construction lender or permanent lender including a subordination of its mechanic's lien rights to the construction lender's and permanent lender's mortgage or deed of trust. The construction lender for the Project will be: OFAMEN r - ...d •..., ail Maw o3x F Obligations of the Owner: The Owner agrees to furnish or approve, in a timely manner, information required by the Contractor and to make payments to the Contractor in accordance with the requirements of this Agreement. Dispute Resolution: Claims, disputes or other matters in question between the parties to this Agreement shall be resolved by mediation or by arbitration. Prior to arbitration, the parties shall endeavor to reach settlement by mediation. Page 2 of 4 2. Contract Sum Cost of Work: The Contractor shall provide a detailed estimated Cost of Work to the Owner(see Exhibit A). The sum of these costs,including the fee is as shown below: Contractor's Fee: 10% of Total Construction Volume. Total Construction Volume includes all construction trades, general requirements, insurance, bonds and miscellaneous costs deemed necessary to perform the construction of the project, but excludes permits and fees. Permits and Fees shall be paid directly by the Owner. Construction management labor, standard tools and equipment, and labor-related overhead are covered "within the fee". Subcontractors: The Contractor plans to hire Subcontractors to perform the majority of construction associated with this project. The Contractor shall provide the Owner and Architect information on all of the bids received by Subcontractors and the names of the Subcontractors selected. Owner shall have the right to reject a proposed Subcontractor; however, in the event that this leads to a higher Cost of Work, the Owner shall pay for the difference. The Contractor reserves the right to reject any Subcontractor, even if it is the lowest bid, and to dismiss Subcontractors from the job that have been previously approved by the Owner. Payments: The Owner shall make progress payments on the.Contract Sum according to the Requisition process described below. The Contractor shall, at the conclusion of each calendar week on the project, present to the Owner an application for payment(Requisition) for costs incurred during that month. The Requisition shall include all invoices, vouchers, partial releases of liens, expense reports, and any other evidence to support the validity of the Requisition amount. The Contractor may requisition for completed, but unpaid work based on an expectation of payment upon receipt of funds. The Owner, the Architect, or their representatives shall be afforded five (5) business days to review such application and question the Contractor about its contents. In the event there are no disputes, the Owner shall pay the Contractor within 10 business days of receipt of the Requisition. Payment by the Owner does not represent that the Owner or Architect have made a detailed examination of the documentation, inspection of the work, or verification of the accounting. At the completion of the project, the Owner shall make a final payment to the Contractor based on a final Cost of Work with a truing up of fees. If further corrections to work are required that are not covered under warranties with Subcontractors, or that are not the outcome of negligence or poor workmanship by the Contractor, the Owner shall pay the Contractor for any work associated with performing the corrections based on the hourly rate agreed to in this contract. Retainage: The Owner shall not hold back any fees to the Contractor to ensure completion of the work. The Contractor will be expected to hold back fees from'Subcontractors to ensure their performance based on the terms below: i0IEL � Si iY Page 3 of 4 J Termination of Contract: The Owner shall reserve the right to terminate or suspend the Contract at its sole discretion. Within 15 days of termination or suspension, the Contractor shall present an accounting of all its costs incurred for reimbursement by the Owner. If the Owner elects to proceed with the project without the Contractor, the Owner shall have the right to assume the Subcontracts and agreements related to the Project. 3. Project Schedule Date of Commencement: The Contract Time shall be measured from the date of commencement. The date of commencement of the Work shall be the date of this Agreement, unless a different date is stated below or provision is made for the date to be fixed in a notice to proceed issued by the Owner. Oec100111 2 201,orsuchiLMfi",tha#"Not,,!cat o to 'roceed fs even b`Owner s f ✓' Contract Time: The Contractor shall provide to the Owner a Project Schedule (see Exhibit B). This Schedule is based on assumptions reached prior to the signing of this contract, which assumptions the Contractor shall attempt to clarify in the Schedule. However, the Schedule always assumes the Owner and the Architect respond promptly to requests for information and do not request any significant changes to the construction program. In the event that the Owner or Architect find any discrepancies with the Schedule or its Assumptions, they will promptly notify the Contractor, who shall make adjustments to the Schedule as necessary. According to the attached Schedule, the Contractor shall achieve Substantial Completion of the entire Work as follows: Datef'-StbstantfI Crim letion to be nia Iati�r an Februa' " 1 2013 ' 4. Signatures The Owner's representative is: Da�VS e�ni'i`-- Manag r Andov�M1IIs,LG 17 Ivaloo Street, ite 00 5omery Ile,yMA 0210 § 14.4 The Contractor's representative is: C�eran Wh n JK Go t t�racIafingLLC 1 �chMan�d Street W�eymoith, . '0218g' Owner Contractor S nature Signature 124 Cr/Vzke46C LJ Mu -- Printetf Name and Title Printed Name and Title Page 4 of 4 1� ■ Boston Indemnity Estimated Cost ISI Schedule of Values 12/26/2012 General Conditions $ 1,000.00 Demolition $ 2,500.00 Carpentry $ 1,800.00 Drywall &tape $ 2,000.00 Prime and Paint $ 2,000.00 Materials: Framing, Drywall and Glass $ 2,400.00 Flooring • $ 2,500.00 Custom Woodwork $ - Cabinetry &Countertops $ 1,200.00 Plumbing $ 600.00 Sprinkler Work $ - Electrical $ 1,200.00 HVAC $ 3,700.00 Cleaning & dumpsters $ 1,000.00 Sub-total $ 21,900.00 JK Construction $ 2,190.00 Total $ 24,090.00 i I OFFICE OF BUILDING INSPECTOR '� TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL ys.Kwha PROJECT NUMBER: 218410015 PROJECT TITLE: 2nd Floor Suite 208B PROJECT LOCATION: Water Street, N. Andover NAME OF BUILDING: East Mills NATURE OF PROJECT: Corporate Fit Out IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, I,-Linda-5__, SMUey REGISTRATION NO. _1QQ8Q BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ❑ ARCHITECTURAL ® STRUCTURAL ❑ MECHANICAL ❑ FIRE PROTECTION ❑ ELECTRICAL ❑ OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE, SUCH PLANS, ' COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 I. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become,generally familiar with6the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY ,, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCC PANCY INRY RIBED D SWORN TO BEFORE ME THIS t DAY OF SIGNATURE; IL IC MY COMMISSION EXPIRES Y13 The Commonwealth of Massachusetts Department of Industrial Accidents 02 Office of Investigations 600 Washington Street Boston,MA 02111 >� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �-- Please Print Leizibly Name (Business/Organization/Individual): J � . f�\'y'uv� C-1 I QAddress: � L `` r3 City/State/Zip: yo,4,4" , X-\vq Z t�� Phone#: Z— Are you an employer?Check the appropriate box: Type of project(required): 1.79 I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ? Remodeling shipand have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. F am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'reformation. hsurance Company Name: L (;-OA-T ?olicy#or Self-ins.Lie.#: L `L I - �l —0 l _Expiration Date: L 3 lob Site Address: �I-d -1�W}J`J""- City/State/Zip: 616N, C- -V��-i, attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 fine if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of asvestigations of the DIA for insurance coverage verification. do hereby c rtify under the pains and penalties of perjury that the information provided abov is true and correct. ii nature: '- Date: 1 17 1 'hone#: Official use only. Do not write in this area,to be completed by city or town official. i 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#: 1 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, express 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 enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an 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-contractor(s)name(s),address(es)and phone number(s)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. Be 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 returned 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-insured companies should enter their self-insurance license number on the appropriate line. 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 stamped 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE fZevised 5-26-05 Fax# 617-727-7749 www.mass,gov/dia F NORTH own o 6Andover O _ M `n No. h ver, Mass, / -71 _ coc N1c MewIcK AERATE D S u - BOARD OF HEALTH Food/Kitchen . PERMIT L ,D Septic System ��:.... ..h .... BUILDING INSPECTO R THIS CERTIFIES THAT ... . . .eI ^ ................. . .....,,......... Foundation has permission to'erect ........................... buildings on .1'�q 1..e.. ' Rough h to be occupied as .(.,.'..:..rul............/ ....... Chimney provided that the person accepting this permit.shall in every respect conform to the terms of the application Final on file inthis 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 CONSTRUCTION TARTS Rough Service, ............ ...... r,�4,.c. �f`. "z""`..d'.............................. Final BUILDING INSPECTOR A GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. SEE REVERSE SIDE