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HomeMy WebLinkAboutBuilding Permit #544-15 - 350 WINTHROP AVENUE 12/11/20144 ry BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATI N 11 Permit NO: Date Received Date Iss TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential D New Building r] One family [I Addition 0 Two or more family t.j Industrial P�Alteration No. of units: )(Commercial El Repair, replacement n Assessory Bldg D Others: D Demolition D Other _Septic. ---0 -e11 El Flood I -Wet an s 0 :Watershed Distdid Water/Sewer 2-" MIA10ft WaI01 116MC)OU Of &XI) QA Li kolYvMAU71 ANDA WD 50 ] HINOE' Id[VOOZ -51A 12ECTPUCat, kloft- Identification Please Type or Print Clcarly) LEASW GWNER: Name: VQ( -1L'5 QW11MAJ 5-70V-65 A- LTr4- Arte CtJ)VV- Phone: (M) 103-L;97-0 A caress: ACTOR. Name*. Phone. .-9.14 -_- ARCHITECT/ENGINEER gA&HAan L. powcN I 61)tl(JAILS Phone. Sn)rT uvwz Address: Bent) -joAva ina ft,[M-tAVQ, 011 44170 Reg. No. 9320 FEE SCHEDULE., BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. 00 Total Project Cost: $ /()('P' Oa FEE: $-O -z . 4- :$ /00100 Check No.: Receipt No.: unregistered contractors do not have access guarantj-fund .NOTE: Persons contracting w9 e' :contractor -A� Signature; of > F-11, 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 a Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work a 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 L, Certified Surveyed Plot Plan ❑ Workers Comp Affidavit a 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) 4 ❑ Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a Copy of Contract ❑ Mass check Energy Compliance Report a 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 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 Dae: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 %IN •.a BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION' Print 0 PROPERTY OWNER Print 100 Year Structure yes no MAP _ __ PARCEL: ZONING DISTRICT- Historic District yes no Machine Shop Village yes no 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 ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Arlrlracc Contractor Name: _ __ Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: _ . _ Exp. Date: ARCH ITECT/ENGINEE 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: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner - Signature of contractor ti 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS CONSERVATION COMMENTS 4 HEALTH COMMENTS Signature Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located Jd4 usgooa Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Mr)TF4 anrd nATA — (For denartment use) No CD, 6on dF4 Lr -c �� r� cis. � S �—. ��.• � S' � a ❑ Notified for pickup Call Email e Date Time Contact Name i Doc.Building Permit Revised 2014 Building Departmeni 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 ❑ 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/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 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 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 Doe: Building Permit Revised 2014 w - . Location z�o W j h ► l '� No.� r�J Date { Check # c. U W ii U TOWN OF NORTH ANDOVER 100 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1 ` Building Inspector Client#: 106042 1141:.:0%%3 ACORDTM CERTIFICATE OF LIABILITY INSURANCE M/DDN 6/23DATE (M6123/2016 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 People's United Ins. Agency 850 Main Street NAME: Josephine Palumbo PHONE 203 338-3356 FAX PIC, No Ext): Alc, No): 844 801-9982 E-MAIL bo@Peoples.com Jose ne.aumo eo hi I P ADDRESS: p P Bridgeport, CT 06604 203 338-7900 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Travelers Property Casualty Co. 25674 INSURED Schimenti Construction Company, LLC INSURER B: RLI Insurance Company 13056 INSURER C: Charter Oak Fire Insurance Comp 25615 650 Danbury Road Travelers Indemnity Company 25658 INSURER D : Y P Y Ridgefield, CT 06877 (914) 244-9100 INSURER E : Shelter Point Life Insurance Co 81434 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 CONTRACTOR 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY VTC2JC08205A277TIL 6/29/2016 06/29/2017 EACH OCCURRENCE s2,000,000 CLAIMS -MADE � OCCUR PREMISES (Ea occur ence) s3001000 MED EXP (Any one person) $10,000 PERSONAL &ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 RO- POLICY X JPECT LOC PRODUCTS - COMP/OP AGG $4,000,000 $ OTHER: C AUTOMOBILE LIABILITY VTOCAP8205A308COF1 6/29/2016 06/29/201 (CEO OMBINED SINGLE LIMIT accident $1,000,000 BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident X NON-OWNED HIRED AUTOS fAUTOS B UMBRELLA LIAB X OCCUR RXL0806095 6/29/2016 06/29/201 EACH OCCURRENCE s4,000,000 AGGREGATE s4,000,000 X EXCESS LIAB CLAIMS -MADE I DED I I RETENTION$ Each/A_ $$6mm/$6mm A ZUPlOS8350916NF 06/29/2016,06/29/201 C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROFRIETOR/PARTNER/EXECUTIVE rY I N OFFICER/MEMBER EXCLUDED? 7N (Mandatory in NH) N / A VTC20UB8205A28916 (Other States) 6129/2016 06129/2017X 0TH - PTR SATUTE ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 C Contr's. Leased QT660222D4267COF16 6/29/2016 06129/201 $150,000 Per Item or Rented Equip. $500,000 Max/$1,000 Ded E NYS Disability DBL93588NYDBL 01/01/2016,12/31/20 NYS DBL -Statutory DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 107, Additional Remarks Schedule, may be attached if more space is required) ** Workers Comp Information ** D Travelers Indemnity Company Policy #VTRKUB8205A29016 (State of Mass.) Eff. Date: 06/29/2016 Exp. Date: 06/29/2017 WC Each Accident Limit: $1,000,000 (See Attached Descriptions) Town of North Andover 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 ACORD 25 (2014/01) 1 of 2 #S708467/M705764 tLLA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A410 C)Aj" l(5Pi%/wa ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JZPCT DESCRIPTIONS (Continued from Page 1) WC Policy Limit: $1,000,000 WC Each Employee Limit: $1,000,000 RE: Job #15-034, Kohl's #10535 (Remodel), 350 Winthrop Ave., North Andover, MA 01845 (Building Permit). SAGITTA 25.3 (2014/01) 2 of 2 #S708467/M705764 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 40,106.00 m $ - $ 481.27 Plumbing Fee $ 60.16 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 60.16 Total fees collected $ 701.59 350 Winthrop Avenue 544-15 on 12/11/2014 Kohl's Interior Remodel in beauty department Fil G /I n J Q LL G OC Q m v u Y \ 6 O LL Nm N Ln U O_ N p W Z Z J O m "O 7 LLL -C O 0 OC N C :E U - LL O W Z z a -C COD d' LL 0 W Z v J W .0 7 U i N Ln N C LL cc p w Z H t j O = !0 C LL Z W W G ui LL L i m o Z }+ CU N +' 4J N sE O O !C p •� L =a N V Q r N N a-. C • d d r) ` o +.r � OC V i V N O . � J N �r >_ " c 'N ° ay d O N C 0 N wQ E 0 CDCZ y O O . C L Q. Q d moi.. 0C. M O C = Q L L :Q CDujQ '� r rr 'n 'D V m LiJ C 70 +�-� O O LL N Cc N C N •O W v Q. o� CD co d > = c N M 0 F- t 0 . Q 0 0 O W a .cn z_ CD z 0 _J m E O O Z 0 0 .E m m CL .� o CD O Q O _ v_ J 0 0-0 O /CD Z W ci v) cts c 0 E Z U s CO) �- •N 2F-- Q X Z 4� = 0 O � �C W c W J CL Z �. m O v a� C O 0 N N t O �• z 0 a p J O 0 > E O O Z 0 0 .E m m CL .� o CD O Q O _ v_ J 0 0-0 O /CD Z W ci v) cts c 0 COSMETICS Elevated Acrylic 2015 PROJECTED AVG GC MODEL COST for Bldg Permit Valuation Value for ONLY (Does not include site specifics, location adj, etc...—and not to be Bldg Permit considered final construction costs) Line Item Number 01-B -- General Requirements 01100000-B -- Lump Sum General Conditions 01097500-B -- Taxes (State and Local) 01100200-B -- Contractors Fee 01100400-B -- Permits 01107000-B -- Storage Trailers - Dumpsters 01109100-B -- Final Clean 06-B -- Wood, Plastics, & Composites 06080000-B -- Fixture Installation 06100000-B -- Carpentry 06100001-B -- Demolition - Carpentry 09-B -- Finishes 09062000-B -- Gyp Bd Wall Installation 09062002-B -- Demolition - Gyp Bd Wall 09650000-B -- Floor Covering 09650001-B -- Demolition - Floor Covering 09912300-B -- Interior Painting Labor & Materials 21-B -- Fire Suppression 21130000-B -- Fire -Suppression Sprinkler Systems 23-B -- Heating, Ventilating, & Air Conditioning 23000000-B -- HVAC Installation 23000002-B -- Demolition - HVAC 23112302-B -- Demolition -- Fire Supression 26-B -- Electrical 26000000-B -- Elect -Service & Distribution 26310001-B -- Demolition - Electical 27-B -- Communications 27200000-B -- Elect - Low Voltage 27200002-B -- Demolition - Low Voltage Trade Notes TOTAL 52,655 40,106 Base Value for Permit 12,549 General Contractor Does not include 8,346 5,491 Fixture Install 1,839 Carpentry 1,016 Carpentry Demo 8,822 1,433 Framing/Drywall 800 Drywall Demo 4,981 Flooring 1,439 Flooring Demo 169 Paint - Sprinkler - HVAC 20,219 Electrical 17,695 2,524 2,719 Communications 1,945 774 Schimenti Construction Co., LLC 650 Danbury Road Ridgefield, CT 06877 Ph : (914) 244-9100 To: Town of North Andover 1600 Osgood St Guilding 20, Suite 2035 North Andover, MA 01845 Ph: 978-688-9545 Fax: 978-688-9542 Subject: Building Permit Application Package WE ARE SENDING YOU r; Attached r Shop drawings 17 Prints 17 Copy of letter r. Change order Letter of Transmittal Transmittal #: 1 Date: 11/24/2014 Job: 15-034 Kohl'9 Retrofit, N Andover, MA F Under separate cover via None the following items: r Plans r Samples r Specifications 177 Other Document Type Copies Date No. Description Application 1 Approved as noted r Submit —copies for distribution r` Building Permit Application Check 1 r" For review and comment In the Amount of $582.00 Memorandum 1 FOR BIDS DUE r" Description of Work To Be Completed Insurance Certificate 1 General Contractor (Schimenti Construction) CSL License 1 Photo Copy of License Affidavit 1 Worker's Compensation Insurance Affidavit Control Document 1 Initial Construction Control Document (Architectural) Control Document 1 Initial Construction Control Document (Electrical) Drawing Set 2 Construction Plans Cost Breakdown 1 Construction Cost THESE ARE TRANSMITTED as checked below: V, For approval 17' Approved as submitted r"' Resubmit _ copies for approval r For your use 17 Approved as noted r Submit —copies for distribution r` As requested r- Returned for corrections r Return _ corrected prints r" For review and comment 177 Other t! FOR BIDS DUE r" PRINTS RETURNED AFTER LOAN TO US Remarks: Please find the items listed above included in the attached package for approval. Thank you. Copy To: From: Beaule, Ryan (Schimenti Construction Co.) Signature: If enclosures are not as noted, kindly notify us at once. Page 1 of 1 ,a Massachusetts - n?par?r ent of Public Safety g' Board of Building regulations and Standards License: CS-093492 ROBERT G MCDOUGAL 1639 WILSON S';" Baldwin NY 115111 x^irapion i vrns�ri s= Y ger i 0511512015 Initial Construction Control Document To be submitted with the building permit application by a d Registered Design Professional for work per the 8`h edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: ;40kU5 INTr-VIb12 BEAU-fj p- Mooi5L Date: ii -N-14 Property Address: ;50 1NwTjAgop AV% nlor--ii-1 6KIneVa, MA Project: Check one or both as applicable: 0 New construction )( Existing Construction � Immo DC -) j qG �f 104 11/ee `y MA Registration Number: 507(-(P Expiration date: 6136/ 1(o , am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Architectural [ ] Structural [ ] Fire Protection Electrical [ ] Mechanical [ ] Other for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports (see item 3.) comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Constructior Enter in the space to the right a "wet" or electronic signature and seal: Phone number: (214) 4q) - q 306 Building Official Name: Version 06 11 2013 Email: �Hv_K ee 1y GP 121- 54. Co w► Building Official Use Only Permit No.: Date: Initial Construction Control Document To be submitted with the building permit application by a d Registered Design Professional for work per the 8h edition of the �•�'` Massachusetts State Building Code, 780 CMR, Section 107 Project Title: gQ1.1U5 1NTrQ10V- 13EAkA-TV t2 Mooi:L Date: 1i-Iq-i4 Property Address: ?,SC WiNyk,oP AVE.-Woy-114 &NnOVEX , MLS Project: Check one or both as applicable: ❑ New construction Existing Construction (ee�MoM-� Project description: MINOR IN Telzipt 12oMoOCL OF EXISTiMti k:QIA 'S 3EAiATY AREA L45o Srl ; MIN012 LINOCl2 11 L\13 CLCC791CAL WORM, ; NO ALTLKATIOAI OF S-EOr- LXTEI21012 I EICAUACD L. 13oWEN MA Registration Number: 2328 Expiration date: x-31-15 , am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: rA Architectural [ ] Structural [ ] Fire Protection [ ] Electrical [ ] Mechanical [ ] Other for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building Enter in the space to the right a "wet" or electronic signature and seal: Phone number: /7iie1 '477-3451 rt 3.) together with pertinent r,.D• AR�yi Document'. Ve and n • �, io . : '• Jy. q1�4' �•••`�SS2V 1 of Mx Email: (OKYTA CI ' 5WA M e keI, - Cowl Building Official Use Only Building Official Name: Permit No.: Date: Version 06 11 2013 The Commonwealth of Massachusetts Ln Department of Industrial Accidents 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 Le0bly Name (Business/Organization/Individual): Address: t'� � 0 City/State/Zip; Phone #: / el �zv — %/ 0 Z) Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ?. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. JJ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C�?fir ��l7C/��z/IL�G�/c'F3/✓Cr�1 Policy # or Self -ins. Lie. #: aZ11 — ;Y.;),0 fz12 Expiration Date: Job Site Address 5() l�//V/�l/��/i/Ll City/State/Zip:�i71/(�dt/,�% /yam• (�/[� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify uAider the pains andpenalties ofperjury that the information provided above is true and correct. 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, 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 f_or 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 Zevised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia ACORO® CERTIFICATE OF LIABILITY INSURANCE `� DATE (MM/DD/YYYY) 11/18/2014 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 Kesten-Brown Insurance, LLC 277 Fairfield Ave - 3rd FL Bridgeport CT 06604 CONTACT Robert Resten NAME: PHONENo, IF AX IC No: (A1C, AE-MAI.RKesten@kbiins.coDDREL m INSURERS AFFORDING COVERAGE NAIC N INSURERA:Travelers P & C Co of America 25674 INSURED Schimenti Construction Company, LLC 650 Danbury Road Ridgefield CT 06877 ,(914)244-9100 INSURERB:RLI Insurance Company 13056 INSURERC:Charter Oak Fire Insurance Co 25615 INSURERD:St. Paul Fire & Marine Ins Co. 24767 INSURERE:Travelers Indemnity Company 5658 INSURER F: CnVFRAr.FS CERTIFICATE NIIMRFR•6/29/14-15 Mast, -r- RPn Pwal 01=111CI(lIU IUI IMRCD. 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER EFF MMIDDY/YYYY EXP MM/DDY/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_1 OCCUR C2J-CO-8205A277-TIL-14 6/29/2014 6/29/2015 DAMA T ENTED PREMISES Ea occurrence $ 300,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 4,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ A _X ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS J -CAP -8205A308 -TIL -14 6/29/2014 6/29/2015 BODILY INJURY (Per accident) $ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Per accident $ NY Motor veh law enforcement $ B UMBRELLA UAB X OCCUR (Lead) RXL0805961 6/29/2014 6/29/2015 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 D j{ EXCESS LIAB CLAIMS -MADE DED RETENTION$ Each Loss/Agg. $ $5MM/$5MM (Excess)ZUP-10S8350914NF 6/29/2014 6/29/2015 E C(MandatoryOFFICER/MEMBER WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE - N F�(CLUDED? in NH) N/A RRUB-8205A29-0-14 (MA) C20UB-8205A28-9-14 �(Other 6/29/2014 6/29/2014 6/29/2015 6/29/2015 X I WC STATU- OTH- CRY LITS I I ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below States) E.L. DISEASE -POLICY LIMIT $ 1,000,000 A Contractors Leased/Rented T -660 -222D4267 -TIL -14 6/29/2014 6/29/2015 $150,000 Per Item Limit/ Equipment/Statutory NYDBL irst Rehab -NY DBL #935891/l/2014 12/31/2014 Max Total$500,000,$,1000Ded DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: Job #15-034, Kohl's #10535 (Remodel), 350 Winthrop Ave., North Andover, MA 01845 (Building Permit). - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Building 20, Suite 2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Robert Resten/JPP ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD Construction Company MEMORANDUM TO: Town of North Andover - Building Department FROM: Schimenti Construction Company, LLC DATE: 11/24/14 RE: Kohl's Cosmetic Department Update - North Andover, MA Description of work: • Install temporary barricades at perimeter of work area. • Remove and dispose of existing wall and gondola fixtures in the cosmetic department. • Cut and remove 8" to 10" wide sections of the concrete slab to install new in floor electrical outlets and conduit. • Infill concrete trenches and replace damaged ceramic floor tile. • Install new wall and gondola fixtures. • Install new ceiling mounted department sign. • Remove barricades. 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