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HomeMy WebLinkAboutBuilding Permit #976-15 - 136 OLD FARM ROAD 5/28/2015 �� i� BUILDING PERMITNORTy F q TOWN OF NORTH ANDOVER 3��stLEo.. 616�° APPLICATION FOR PLAN EXAMINATION p O" Permit No#: Date ReceivedArgo SgcHu Date Issued: !11) 6`1) s���� IMPORTANT:Applicant must complete all items on this page LOCATION 1 3 0.0 IPERTY' :Pant FRO - • OWNER IL N.��,i l ��<�`�"i.t1 3 :Pant100 Year Structure yes' MAP .PARCEL4_�� .:, ZONINGtDIS-TR Aistoric.District" F ,. : .Ma chore-Shop Village. yes TYPE OF IMPROVEMENT PROPOSED USE Residential � Non- Residential ❑ New Building One family ❑Addition El Two or more family ❑ Industrial fiAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition_ ❑ Other Se tic ❑ Wel � �, _ etfan- � Floodplain= sa. °UVatersh ❑ e_ l tnct�� ❑�N�ter=/Sewer � -_ DESCRIPTION OF WORK TO BE PERF RIVIED: S�Zvb 10 (arci(,!� r�+L' X�S (AL, ���ytiiGrlA �• `� �G'G�iiLj Cti ��� CSI jli III k - Identi kation- Plea e Type or Print Clearl _ OWNER: Name:__ %42; IQ /t,-6 r1,Y? Phone: IS -,,IAO -o 669 f Address: 86 'Contractor Nam- e:S rb'— 0iv►L;, Phone-. 70/? Email:ress C �- Ad d Add Supervisor's Construction,License L iO * �3 S-� 3 Exp: 'Date; _ Home Improvement L-icense:.. l �. ;;' A Ex Date:. Exp.. oZ ARCHITECT/ENGINEER Phone: 9 Address: Reg. No. ti FEE SCHEDULE;BULDING PERMIT"$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ ` ®� FEE: $ CPfi Check No.: Receipt No.: �nik NOTE: Persons contracting with nnre ed contractors do not have access to the r toy d r a _ ntrMffn 1 I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL i Public Sewer Tanning/Massage/Body Art ❑ Swfiu ing Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM LANNING & DEVELOPMENT Reviewed On Signature COMMENT'S CONSERVATION Reviewed on % Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes A Planning Board Decision: Comments Conservation Decision: Comments -Water& Sewer Connection/Signature&Date Driveway Permit ]DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPT�MENT� Mn on site yes rn�o� , Located at 124 Main Streets, ' FireDepartment-i.anat ru a/date ' i { L 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 DAN(-ER www= LITERATURE: Yes No MGL Chapter 166 section 21A—t- and G min.$10o-$1000 fine NOTES and DATA-- (For department use) I I 1 I I 1 ❑ Notified for p Call Email pickup _ Date Time Contact Name - __._ Doc.Building Permit Revised 2014 _ r' Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4 Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses � Copy of Contract 4 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 46 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 Per-mit-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 I Doc:Building Permit Revised 2014 NORTH own of t E 1, , ndover 0 � - 1 No. Ih ," ver, Mass, a- r 0 1. COCMIC"R WKu 04 0RAT E D PPS S tl BOARD OF HEALTH Food/Kitchen PER MIT T D Septic System THIS CERTIFIES THAT e✓�r ✓�� �' BUILDING INSPECTOR ................. ...........................................................:............................................ has permission to erect buildings on Foundation Rough to be occupied as ...�. .. .......rt:�-ICJ. ........ ...T��ZI,S.. . ......���`"��►................................... Chimney provided that the person accepting this permit shall in every respect nform 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI S Rough Service ......................:......................................................... Final BUILDING INSPECTOR 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. ACA Document AI05 Standard Form of Agreement Between Owner and Contractor for a Small Project where the Basis of Paymott is a STIPULATED SUM 1993 SMALL PROJECTS EDITION Because this document has important legal consequences, we encourage you to consrtlt with an attorml before.,signing it. Some states mandate a.cancellationpetiod or require othe7-specific disclosures, i7014dilIg Wa777ings for borne h7apimtretrrent contracts, when a document such as this will he used for Work on the(,tuner's person al res deuce. }'our attor fq should insert all language 7 egiri7 ecI ltr,tate or local lard to be included in this Agivemelit.Such statements MgJ1 IX 0771('reel ill the space Prottided belou),or if required lair laiv,abotw rhe_signatures of the paHies. This AGREEMENT is made: I7knt•7. May 27, 2015 BETWEEN the Owner: Kevin Martin 136 Old Farm Rd. North Andover, MA 01845 and the Coritractor.: Summit Design Build 29 Eames St. North Reading, MA 01864 for the following Project: Demo all existing railings and deckboards,frame new 4'x10'section of deck and new stairs as shown in drawings A-1,A-2,A-3,and A-4. Labor and materials as outlined in attached pricing proposal. Price also includes all drawings and conservation meetings. The Architect..is: N/A The Owner and Contractor agree as follows. CCopyright 3993 by The American Instiluie of mchuects, 1735 New York Avetnue,N,W-,Wa_shingion,D.C.2000fi-5292. Repmdwtion of the material herein or suhstantial(quotation of its provisions without the written permKsion of the AIA tiola(ei the(-opu-651hi lams of the UnlitA Si ate.s atxi will suhicct [lit:♦'ii)hlMe to IMI pvt>_smition. AIA DOCUMENT A705• 0WNEIt-CQN'i'RACT0R AGREEMFNT—SMALL PROJECTS I' Et7Pm7N•ALA°-©i993•TME N\i mni N L\n m-n OF.ARCJ im-CIS.'I,35 n`F ,YORK AvE':.LTF,,NX,WASHINGTON,A.C.XOXi-5292•WARNING:Unlicensed photocopying A105-1993 1 violates U.S.copyright laws and will subject the violator to legal prosecution. i ARTICLE 1 THE CONTRACT DOCUMENTS ✓ The Contractor shall complete the Fork described in the Contract Documents for the project.The Contract Documents consist of: .1 this Agreement signed by the Owner and Contractor; i .2 AIA Document A205,General Conditions of the Contract for Construction of a Small Project,current edition; ` .3 the Drawings and Specifications prepared by the Architect,elated and enumerated as follows: Drawings: A-1,A-2,A-3,A-4 Specifications: None .4 addenda prepared by the Architect as follows: None .5 written change orders or orders for minor change in the work issued after execution of this Agreement;and .6 other documenus,if any,identified as follows: Customer may request changes in the work, and if agreed to by contractor, same will be documented by a written change order, prepared by the contractor, which will document the changes to be made, the resulting change in the contracted price, and the anticipated delay in the completion of the work due to the change. In the event that the change order request delays the progress of the work, verbal approval from the client is sufficient to begin the change. Contractor shall not be obligated to perform any change in the work unless and until customer signs such change order. Customer agrees to make payment of 100% of cost of the change, as shown on the change order at the time of next milestone payment. AIA DOCUMENT A105 • OWNER-CONTRACTOR AGREEMENT—SMALL,PROJECTS E D)TION•ALA`-01993*THE AMERICAN INSTITUTE OF ARCHITECTS,1-735 NEW YORK AVFNt'E,N.�tii..�'ASttINGTON,n.C.2tk14G5292-WARNING:Unlicensed photocopying violates U.S.copyright laws and will subject the violator to legal prosecution. All 05-1993 2 ARTICLE 2 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION DATE The date of commencement shall be the date:of this Agreement unless othem ise indicated below.The Contractor shall substantially complete the Work not later than subject to adjustment by change Order. Work to begin as soon as permits are obtained (7rmn die dale or n"mber of calendar days after[be date of Commencemenl,) Work to be completed 6 days after start date ARTICLE 3 CONTRACT SUM 3.1 Subject to additions and deductions by Change Order,the Contract Sum is: $22,106.27 (Twenty two thousand one hundred and six dollars and 27/100 cents) 3.2 For purposes of payment,the Contract Sum includes the following values related to portions of the Work: portion of Work Value Deposit due at signing of contract $5,000.00 Due on completion of deck $17,106.27 3.3 The Contract Sum shall include all items and services necessary for the proper execution and completion of the N'ork. AlA DOCUMENT A105•OWNER-CONTRACTOR AGRELMENT--SMA1r,PROJECTS S)MON-Ale•V1993•Tt'tEANIERICAN INST IT11 OFARCHUE•t."TS,7:35 N0'jYORK AVENUE,N.W..,VW4SHIN TON,D.C.2OW6-5292•WARNING:Unlicensed photocopying violates U.S.copyright laws and will subject the violator to legal prosecution. A105-1993 3 PAYMENT • 4.1 based on Contractor's Application.S for Pa}mlem certified by the Arehitect,the Owner shall pay the C oDtractor as follows: ' {Jlcm'Insrft/xrt�ntetrdprrsecviurvtarrr!/irotrfslaruf�rrrelerrt[rJye.ef�rt�l'.J . Check due at times outlined in article 3.2 4.2 Payments due and unpaid under the Contract Documents shall Iscir interest from the date payment is due tat the rate of 18% or in the absence thereof,at the legal rate prevailing at the place of the Project. wenn lams acrd"uirCrnenis larder the Federal rnnh hr Lending MI,sfirlktr slate and local Cwmtnwr crvdj1 lau'.s acrd sa her Mulatinns al ILrr,Orciter''s arrd Corr. tracior'sptinefpalplaces ofbiWti a the locallott of the Project and elseu'bere Wray cmc ct tix ralidih,ofibis prat-Won.) ARTICLE 5 INSURANCE 5.1 The Contractor shall provide Contractor's Liability and other Insurance as follows: (hut n spec ifit huitranee required hT tate Owner.) Complete liability and workers compensation insurance for the duration of the project Insurance provided by: JJ Murphy Insurance Agency 1 Centre St. Malden, MA. 02148 5.2 The Owner shall provide Owner's Liability and Owner's Property Insur=ance as follows: flrtseft speclfr'c huurarrcef erni%lb d lit the Owner.) 5.3 The Contractor shall obtain an endorsement to its general liability insurance policy to cover the Contractor's oblitatians under Paragraph?t.12 of AIA Document A205,General Conditions of the Contract for Construction of Small Projects.. 5.4 Certificates of insurance shall be provided by each party shoring their respective coverages prior to commencement of the Work. AIA DOCUMENT A105 • OWNNER-CONTRACTOR AGREEMENT—SMALL PROJECTS EDITION•AIA*•0199:1•11 tE AMGRICAN INSTITI VIF.OF ARCIitIFCl ,173.5 z NF.W YORK AVF,NUE,N.u'.,WASHINGTON,D.C.200065292•WARNING:Unlicensed photocopying violates U.S.copyright laws and will subject the violator to legal prosecution. AIO5-1993 4 ARTICLE 6 OTHER TERMS AND CONDITIONS •llrtxrY non•other lorms or carrrlitirnis halon.) None This Agreement entered into as of the day and year first written above. (ljrxquirtmd¢t•tate,hose+lcainccllatlon)xniod,diselonuesoro11X'rurrrnhrKsrnte+rrerrtsrd>a�111 dgnntur�&) May 27, 2015 O\RtNrR ` CONTRACTOR (t);na ureJ (Sigrtu/ vin Martin Summit .Design Build (Printed name,title and address) (Printeel natne,tirle and addmz) 136 Old Farm Rd. 29 Eames St. North Andover; MA 01845 North Reading, MA 01864 OCENSE NO. 083853 JuRISDICTION Massachusetts j l CAUTION: You should sign an original AIA document which has this caution printed in red. An original assures that changes will not be obscured as may occur when documents are reproduced. See Instruction Sheet for Limited License for Reproduction of this document. AIA DOCUMENT A105 • OVNER-CONTRACTOR AGREBIENT—Silt U FROJF„CTS F.DMO.N•AIA'•01993•THE AMERICAN 1Ng7 UrE 0F,ARCHITECTS,17,35 NFW YORK AV1 NUF N.W.,WASHINGTON,A.C.24W6.5292•WARNING,Unlicensed photocopying violates U.S.copyright laws and will subject the violator to legal prosecution. A105--1993 5 North.Andover MIMAP May 28, 2015 062 0-0109 034 9�0048 - 062;0-0116 #119 #116 03�5.0-0099 062.0-0117 #12 #124 7 062.0-'0118 #130 �#145 #1-3 035.0-0101 ...... f #140 —4 AL• 062.0-0119 035; 1 ... .. - . t 94Q001 #143' 062:0-0120 # 53 062:0=0.100#.-154035.'0-0-040,' 035.0=0102 Q35.9-0054 062.001-2-1 #160 035.0-0104 ' #1.70 9§M-0122 #171 1 3$.0- 64 035'.9-9,P62 A #180 R2 uAu 002.0"0.123- #177 03500099 #90 - - -126 t #485 #200 062.0-!-0124 010CF,46fi 464d,, j Al136 095.0-0040 #83 #05 #107 #,I:.lg #197 035.0-0066062 O 006;1; e. 062.0-0133 1035:0-0017 V35,0.�00.;�k-5 - SI 'Jfz."'---035.0-003'1 .a& 062. #150 35.0-m'0'080 #164 035.0-007 035.0-101078 035;0-0079 062.0.0064 ' .#11§3 062.9=0063 0,62.0-006-5, #1'14 #126 06�2 0-0,062 062.110- 66 #-1721, #.-17 6 #180 9200 062.0-006- 1 #2 #224 Ater Pro -1 n" 08 035.0-0 , Oj5-.0-0086 0.35,9FI01085 Q315-.0-4)Q04 , . I , 035.0-0083, 035.0-0081---_ Rail Line Wetlands Zoning Interstates Bu:ine! 1 District 0 Exempt Lands 0 Busine 2 District Horizontal Datum MA Stateplane Coordinate System,Datum NAD83, I s s st Meters Data Sources:The data for this map was produced by Merrimack SR Bninnei a 3 District Busine a! 4 District NORTH Valley Planning Commission(MVPC)using data provided by the Town of Roads a Genera Business District North Andover.Additional data provided by the Executive Office of t7s Easements I, Planne Commercial Dev 0LD ... Environmental Affaim/MassGIS.The information depicted on this map is n Comido Development Dist for planning purposes only.It may not be adequate for legal boundary C)MVPC Boundary 13 Corrido Development Dist 0 definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER E3 Municipal Boundary U Comdo Development Dist if- 1 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Zoning Overlay �nndu�ri r TH ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY L`El AdultEnte't ainment dus OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT IM Industri fl 3 District C3 Downtown Overlay District N Industri 31 S District ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Q Historic District THIS INFORMATION 0 Water Protection Reside ice 1 Distric4'.. Cow Reside i ice 2 District Et El Parcels 0 Reside ice 3 District 0 Hydrographic Features _�_de ce 6 Dis ncde ce 4 Distdc V 219 ft de ce 5 Dis tnci -- Streams oqe 'sidential District North Andover MIMAP May 28, 2015 " lie x _ r a; � t k ' f t w11 P7 9 ✓\t ¢' i r French Farm Road ` m ». jE Interstates —I —SR Horizontal Datum:MA Slaleplane Coordinate System,Datum NAD83, Meters Data Sources:The data for this map was produced by Merrimack -Roads NpRTN Valley Planning Commission(MVPC)using data provided by the Town of %t Easements f q North Andover.Additional data provided by the Executive Office of 0 MVPC Boundary 2.O t����� r�� � Environmental Affairs/MassGIS.The information depicted on this map is 3 L for planning purposes only.It may not be adequate for legal boundary ']Parcels f .»—• to definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING {t - THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY s .^ * OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT �► o�q »� �� i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION SSACHUS� �I 1"=219ft ~�° North Andover MIMAP May 28, 2015 034.0=0,048 ) 034.0-0046' . 062.0-0116 #119 #11 035.0-0099 062.0-0117 #127 #124 == 062.0-0118 { ..". #130 #14S ::'�icr..- aVF- #135 035.0-0101 :i- :-A& #140 :!'••... i;A. 062.0-0119 035.010001 062:0-0011.., #143' • :_ #115 .__::_-..,, :_:::.:'__ #148 ultr .._._. .. �.•.. :.-:' 062.0-0120 •'' #15 3 #103 - _ 062.0-0100#154 : .- . . 035:0=00_4A 035.0-0102 ,ic. ••h 4 Il� •_ 035.0-0054 =: #160 #120 --_ 062.0-01.1 35.0-0104 - ` #163'::_ -; _ 062.0-0122 #170 035.0-0064 035.0-0062 #114 • #171 vJu i+ 062.0-0123#177 #180 #90 035.0-0098 #126 =:_ , 035.0-0065 #100 #185 #200 Old Tarm•Road #136 // 062.0-0124 035.0-0046 1 #83 #95 / - #107 035.0-0066 #119 t 06' ':0-0061 #197 EE 062.0-0133 1 . 035.0-0017 035.0-0035 ..._ ._..••.::_:. � .__035_.0-0031 `a_..•'.::_:.:: �.6cr 0.6.3 0 O.0_7,8�. "_''• #150 062.0-000. 035.0-0080 i 1... #164 035.0-0077 035.0-0078 035.0-0079 062.0-0064 #163 062.0-0063 #114 #126 #140 062.0-0062 1062.0-0065 062.0-0066 #172 #176 #188 #200 062.0-00 #212 #224 4 035.0-0087 035.0-0086 035.0-0085 035.0-0084 035.0-0083 035.0-OOW 8 - Rail Line Interstates Hon-tal Datum:MA Slaleplane Coordinate System,Datum NAD83, -I Meters Data Sources:The data for this map was produced by Merrimack -SR AORTN Valley Planning Commission(MVPC)using data provided by the Town of Roads North Andover.Additional data provided by the Executive Office of %,Easements ? se 6a�0 Environmental Affairs/MassGIS.The information depicted on this map is O MVPC Boundary 3 .THE TOWN OF NORTH ANDOVER C1 - L for planning purposes only.It may not be adequate for legal boundary O t* definition or regulatory interpretationMunicipal Boundary ~ 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING - Trails - i THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY t s ^ # OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ❑Parcels �F noe ��♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF D Hydrographic Features '�l,po��x�o��t�aj THIS INFORMATION -Streams $$ACHU Wetlands 0 Exempt Lands 1"=219 ft "' ` 05/28/2015 09:53 7813210673 JJ MURPHY INS PAGE 01/01 DATE(MMIDWYM) c4R" CERTIFICATE OF LIABILITY INSURANCE F 5128/151 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: lithe certificate holder is an ADDITIONAL INSURED,the policy(es) must be endorsad. 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 endorsemen S• NT AOT PRODUCER N ME: Jamea J Murphy Insurance Agenc NE (781 324-4484 FAX No: (761) 321-Ofi73 One Centre Street 2nd Floor AD R6s: jimins@aol.com Malden, MA 02148 INSURE!%Sl AFFORDI40 COW UkGE NAIC0 INSURERA:WESTERN WORLD INSURED ----�.. -- ----- -- - �. INSURER B- Su=lt Design Build Inc• I URER C: 29 FAMES STREET INSURER D' NORTH READING, MA 01864 INSURER E: I NSURER 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. --.,— -- "- oIJCV EFF PYP LIMITS LTR _..._....__.,..,...—_....._..�-.. POUCY NUMBER MIDDIY MMrDWYYYY TYPE OF INSURANCEVWVD GENERAL LIABILITY NPP1403640 5/18/15 5/16/16 En CH000URRENCE $ 1 000 000 A DAMAGET TED $ LOO OOO COMMERCIAL GENERAL LIABILITY MED EXP I"bre eman) $ 5 000 CLAIMS-MADE �OCCUR p[-RSONALSADV INJURY S 1 000 000 GENERALAGGREGATE S 2 0300 000 PRODUCTS-COMPIOPAGG S 2 003 000 GEN'LAGGREGATE LIMITAPPLIES PER I$ POLICY PRO LOC INED SIN L rr AUTOMOBILE LIABIUTY Ecid a ecbrt $ BODILY INJURY(Per pewon) S ANY AUTO BODILY INJURY(Per accident) S ALLOWN£D SCHEDULED AUTOS AUNOOWNED PR RTY DAMAGE $ eracci era HIRED AUTOS _AUTOS S EACH OCCURRENCE $ UMBRELLA LIA13 OCCUR AGGREGATE S EXCESSLIAB CLAIMS-MADE S DED RETENTION$ WC STATU- OTH• MARKERS COMPENSATION AND EMPLOYERS LIABILITY YIN L.EACH ACCIDENT B �EBCDXECU7NE N I A�ICEMERELUDE E, .DISEASE-EA PLOYEE $ pVlandamry in NH) I!ve9 deecrlbeunder E.L.DISEASE-POLICY LIMIT $ DES6RIPTION OF OPERATIONSb81Dw DESCRIPTION OF DPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addldonel Ren afM Schedule,If more Space Is re4V red) CERTIFICATE HOLDER CANCI=LLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W 'SOWN OF ANDOVER ACCORDANOE WITH THE POLICY PROVISIONS. 1600 O$GOOD ST AUTHOR1aEb RE.PSRESENTATI�, NORTH ANDOVER, MA 01845 ! • �`�,• lig) f: 1 /./` � 1588�04b ASO D CORPORATION. All rights reserved. ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: = The Commonwealth of Massachusetts (2 Department of IndustrialAccidents M I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. lease Print Legibly Applicant Information 4- Name(Business/Organization/Individual): / -/ \ S Address: J [� Phone#: 7 City/State/Zip: Are you an employer?cheek the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New'ConstrAetion 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing an work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11. Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14.❑Other 6.❑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.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. d an additional sheet showing the name of the sub-contractors and state whether or not those entities have $Contractors that check this box must attache employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. ensation insurance for my employees. Below is the policy and job site I am an employer that is providing workers'comp information. / u Insurance Company Name: — Policy#or Self-ins.Lie.#: �C/�-5/f r4/jQ(? a0/q E iration Date: J4 Job Site Address: 166 V/u ,� /� k Cf City/State/Zip: //. Attach a copy of the workers'compensation 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 fine 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. I do hereby certify under the p 'ns and pe ties of perjury that the information provided above is true and correct. Date: S Signature: Phone#: - t 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 Phone#• Contact Person: 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(1)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 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 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 -14 Office of Consumer Affairs&Bus i es Rjar on OME IMPROVEMENT CONTRACTOR egistration: ,166.149 = xpiration: 4!2912016:, Type: Private Corporatic f SUMMIT DESIGN BUI D INC- w i MICHAEL COUGHLIN, 29 EAMES ST ` 5 't NORTH READING, MA 01864' Undersecretary Massachusetts -Department of public-Safety Board of Building Regulations and.Standards Construction Supervisor License: CS-083853 NHCHAEL S COUGHLIN j29 Eames Street } North Reading Mol 019 4'f ' Expiration 05/20/2016 Commissioner c �= -a E tL U- O .ac '5 1 - - i --- -_ S U M I T —j design build ,f J 29 Eames St. N. Reading, MA 01864 P:781.507.0135 j F:781.507.8015 a �{ .. Mm15'14"x 6<,'O MPOSIv DECK MG---^-r N _ ---h� Project No. 0415 M — tt Drawn By: MSC — _ gate: 04/22/15 101-45/8" / — Checked By: Revisions J SIA 7/8^ 4'-9 1/2" � -- No;tes: 191-91/21, PLAN r Am j �o I r i PLAN "R U CK � L / ———LINE OF DECK ABOVE � E > O - =LINE OF 50',NO BUILD � LLL P ExisTING FOOTINGIfO � If NEE:W FOOTING cc M O � t- z SU MIT / design build ' 29 Eames St. j N. Reading, MA 01864 l P:781.507.0135 F:781.507.8015 i i XISTING 12"FOOTINGS � Ii f I NEW 12"SONO TUBE I 48"BELOW GRADE Project N0. 0415 I �� I Drawn By: MSC I I in i I I / -------L— -------------------------- -J Date: 04/22/15 Checked By: 2'-9 1/4"T1'-3" 8'-4" 4 I2" i Revisions ---7 i NEW 8"SONO TUBE Notes: 48"BELOW GRADE TVI NEW STRIP FOOTING FOR ISTAIRS 10"DEEP / _4/ FOOTING PLANVp m' aAow2 FOOTING PLAN U ��/ I.L L > O aQ � CMZ SU MIT design build 29 Eames St. SIy yl�scaN I:ff T2Z LATERAL N. Reading, MA 01864 C:QWNE'GTOM AT ALL POSTS TYP. I P:781.507.0135 F:781.507.8015 I EXISTING 2X10 JOISTS 1611 O.C. I (2)2X 10 PT GIRDER ON EXISTING POSTS 11 'J1 NEW 2X8 JOISTS (2)2X 1G PT GIRDER 1211 O.C. a ON NEW 6X6 POSTS Project No. 0418 SIMPSON LSC STRINGER HANGERS(TYP.) — _ _ — _ = Drawn By: MSC Date: 04/22/15 NEW 2X6 JOISTS i12f1 O.C. Checked By: / Revisions Notes: .FRAMING PLAN / 154 .AA.E:1/owl=11,011 A"3 i FRAMING \ Q S= a) > fY A6 \\ \\ Al O s C w�rC\' g. \\ A3\ A2 i'' ce) Z NO � A5 G OU�D A4 _ -- — \\\ o S U M I T \ design build \ \\ DRIVEWAY -Q m 29 Eames St. Q N. Reading, MA 01864 2 �a• O P:781.507.0135 Q \ \ F:781.507.8015 4F AN �. C N eaense wus VQOPOQQD DQGK \J Q QTADt9 i Project No. 0415 SDNQOOM Drawn By: MSC Date: 4/22/15 PATIO Checked By: POOL Revisions Notes: SITE PLAN SCALE:1.1=40' Aw4 SITE PLAN 4 pf JJ � Location LA ov No.q,*�—t Date r . • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ _ U TOTAL $ Check# G " 8 4 L � Building Inspector i