Loading...
HomeMy WebLinkAboutMiscellaneous - Foulds Terrace Bldg A-1Permit No#: 1 � )� Date Issued: ID00,,0 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 'IMPORTANT: Applicant must complete all items on this page h 1 �O_ •ww• w�I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ATwo or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial k Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septe Well®otlplain r tl"s'� ` 40 1NatersheM. d�Dtrict ,Wla M. DESCRIPTION OF WORK TO BE PERFORMED: tt5 V� I08 2 TI LP_ / 1 Iu S�A LA, A) I M Identification - Please Type or Print Clearly OWNER: Name: V oTt'' bk Ati D©Q-t 2 tq(Do VYUG Au al. Phone: ?7a- 6ap'- 3932 ARCHITECT/ENGINEER (IAR y s 11> e N Phone: M- � q/- Address: a,(o2 eSS(�-k 57- _Sr_\(_e i, Ma\ ®t9�0 Reg. No. q i FEE SCHEDULE; BULDING PERMIT. $1200 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ '5-g q FEE: $ (D Z-1,&;0- Check No.: Receipt No.: a zq�j NOTE: Persons contracting with unregistgred contractors do not have access to the guaranty fund 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 ❑ 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 Doc: Building Permit Revised 2014 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. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes sem; Planning Board Decision: Conservation Decision:_ Comments Comments Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: Located 364 Usgood Street 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 NOTES and DATA — (For department use) El Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 j R Locatio',Tyj le Py l— A No. �"' fj Date Check #!S 25204 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ -1 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 9�--4L4-� Building Inspector v 1• C � N 0 0 0 CD n Z N CD O CL o rF CL �• y 0 0 CD CL � c g (D CID '0 CD CL 0 CD 0 N. S• = CO (D � v 0 CO) z 0 O o CD B CD O D d O z O CD N O 7 co O CL (D co 0 N 2. cn y .0 CD o = ° w vi = :5. CDD 0 :CD an o =r mo v, ° rt FD O O rr Q O W 0CD CA o O O Q O N CD O n (O Q O rt �� O O� � rt (Oi =r C (D (D O < to O O N � O � Vl ' (D O 0 -j3CYa rt D (D y Q. O n Q O — CD 0) CD <. CL CD w A. r NI O (D D CD C.)(D CO)' cc c 0 O CD =r O• (D (D CnCD C� 0 DCZ) CD ' rt' ., 2 N 0 m m m cn 2 c � N M (OD — z O as o !moi x O OCO S Z T O CL X O UCO 3 m m D rn A O UU S C W Z p T O' n S 7 w O UCO S T O 7 O_ w c� V) (D n Ln L (1)(D 3 T O Q \ n S 3 W ° m i Cl) 0m �1 . 0 Tx cnV X m cn Z 0 O O z� � Z 2 cn Z a z M: 0 ;a. O D d O z O CD N O 7 co O CL (D co 0 N 2. cn y .0 CD o = ° w vi = :5. CDD 0 :CD an o =r mo v, ° rt FD O O rr Q O W 0CD CA o O O Q O N CD O n (O Q O rt �� O O� � rt (Oi =r C (D (D O < to O O N � O � Vl ' (D O 0 -j3CYa rt D (D y Q. O n Q O — CD 0) CD <. CL CD w A. r NI O (D D CD C.)(D CO)' cc c 0 O CD =r O• (D (D CnCD C� 0 DCZ) CD ' rt' ., 2 N 0 m m m cn 2 c � N M (OD — z O as o T N x O OCO S cl 'D^ N T O CL X O UCO 3 m m D t 6 V1 3 O ((D y N M (OD — z O Co C 3 ('D -n p mZ I T N x O OCO S cl 'D^ N T O V1 (D < X O UCO 3 m m D T O A O UU S C W Z p T O' n S 7 w O UCO S T O 7 O_ w W C ° z clO m O M V) (D n Ln L (1)(D 3 T O Q \ n S 3 W ° m i The Commonwealth of Massachusetts Departntent of fitdustrW Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print LeZibly Name (Business/Organization/individual): Address: 2 9 rn7sth�` 'Phone #: ,1-06-5-83-32L) Are you an employer? Check the appropriate bog: Type of project (required): 1. ® I am a employer with _3 0 4. Q I am a general contractor and I 6 Q New construction employees (full and/or part-time).* 2. Q I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet 7. Q Remodeling ship and have no employees These sub -contractors have g, Q Demolition working for me in any capacity. employees and have workers' insurance.t 9 Q Building addition [No workers' comp. insurance comp. 5. Q We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. Q I am a homeowner doing all work officers have exercised their I1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Q Roof repairs . insurance required.] t c. 152, § 1(4), and we have no 13.0 Other L01 Ili 00033 employees. [No workers' - conn. insurance required.] *Any applicant that checks box #1 mut also fill out the section below showing their workers' compensation policy tntormauon. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors trust submit a new affidavit indicating such. tr-ontractors that check this box must attached an additional sheet showing the narm of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees; they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: P C (-\b N C', C% - -- - -- - ---- -- - Policy # or Self -ins. Lie. #: l.t) CA (2> I ( a.D -:2.9 - 01Q Expiration Date: 6 - ;�-O - )_0 (S� Job Site Address: City/State/Zip: At)_q A 1J1>QV Z, Yf rOl Sq -2' 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 DTA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Phone #: Scoff- X83- g9gq 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. PIumbing Inspector 6. Other Contact Person: Phone M elbolm CERTIFICATE F LIABILITY INSURANCE DATE/D 09/0044/22014014) 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(les) 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 E. J. Wells Insurance Agency Div of HUB International New England LLC 275 Great Road Acton, MA 01720 CONTACT NAME: E. J. Wells Insurance Agency alto" o Ext, 978.392.4567 ac —N.): 978-392-9696 E-MAIL ADDRESS: PRODUCER CUSTOMER ID It: INSURER(S) AFFORDING COVERAGE NAIC# INSURED Vareika Construction Co., Inc. 219 Walnut Street West Bridgewater, MA 02379 INSURER A: Union Insurance INSURER B: Acadia Insurance Co. INSURER C: The North River Insurance Co IN D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 14-15 Std 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YY POLICY EXP MM/DD/Y LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fi-I OCCUR CPA 0092564-2 06/20/2014 06/20/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE ( RENTED PREMISESS Ea occurrence) $ 250,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS MAA0092568-2 06/20/2014 06/20/2015 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ X X X BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) $ $ C UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE 581-103022- 06/20/2014 06/20/2015 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 10,000,000 X DEDUCTIBLE RETENTION $ 0 $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEF—I OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WCA0112029-2 06/20/2014 06/20/2015 X I TORY LIMITS OT ER E.L. EACH ACCIDENT $ S00,000 E.L. DISEASE - EA EMPLOYEE $ S00,000 E.L. DISEASE - POLICY LIMIT $ 500, 000 A Stored Materials CPA0092564-2 1 06/20/2014 06/20/2015 $200,000 Any One Job Site $200,000 Temp Off Premises DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101 Additional Remarks Schedule if more space is required) -4-14 Job: Window replacement, exterior doors & frames 697-3 Vorth Andover Housing Authority is additional insured with respect to the General Liability where required by written contract. CERTIFICATE HOLDER CANCELLATION North Andover Housing Authority One Morkeski Meadows No., Andover, MA 01845 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 f(), Paul Co Co71 kZ I ��I��I_�•Z�] l ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD All rights reserved. �( Massachusetts - Department of Public Safety J Board of Building Regulations and Standards Construction Supervisor L_bense: CS -076563 ; ROBERT G VAREJKA 86 Bedford Street.; Lakeville MA 02347 Expiration 12/18/2015 Commissioner IER-CONTRACTOR AGREEMENT OMMONWEALTH OF MASSACHUSETTS - DEPARTME 0SIEGANDICOMMUNITY DEVELOPMENT This agreement made this 4" day of September, 2014 by and between the NORTH ANDOVER HOUSING AUTHORITY hereinafter called the "Owner", and VAREIKA CONSTRUCTION, INC., hereinafter called the "Contractor". Witnesseth, that the Owner and the Contractor, for the consideration hereinunder named, agree as follows: ARTICLE 1. SCOPE OF WORK: The Contractor shall perform all Work required by the Contract Documents for exterior window and door replacement at the 667-3 Elderly Housing Development prepared by Nilsson + Siden Associates, Inc., acting as and referred to in the Contract Documents as the "Architect". ARTICLE 2. TIME OF COMPLETION: The Contractor shall commence work under this Contract on the date specified in the written "Notice to Proceed" and shall bring the Work to Substantial Completion within 75 calendar days of said date. Damages for delays in the performance of the Work shall be in accordance with Article 9 of the General Conditions of the Contract. ARTICLE 3. CONTRACT SUM: The Owner shall pay the Contractor, in current funds, for the performance of the Work, subject to additions and deductions by Change Order, of the Contract Sum of TWO -HUNDRED THIRTY-SEVEN THOUSAND THREE -HUNDRED DOLLARS ($237,300). ARTICLE 4. THE CONTRACT DOCUMENTS: The following, together with this Agreement, form the Contract and all are as fully a part of the contract as if attached to this Agreement or repeated herein: The Advertisement, Bidding Documents, Contract Forms, Conditions of the Contract, Specifications and Drawings enumerated in the Table of Contents and all Modifications issued after execution of the Contract. Terms used in this Agreement which are defined in the Conditions of the Contract shall have the meanings designated in those Conditions. ARTICLE 5. REAP CERTIFICATION: Pursuant to M.G.L. c.62(c) §49(a), the individual signing this Contract on behalf of the Contractor, hereby certifies under the penalties of perjury, that to the best of their knowledge and belief the Contractor has complied with all laws of the Commonwealth relating to taxes, reporting of employees and contractors, and withholding and remitting child support. ARTICLE 6. WORKER DOCUMENTATION CERTIFICATION: In accordance with Executive Order 481 the undersigned further certifies under the penalties of perjury that the Contractor shall not knowingly use undocumented workers in connection with the performance of this contract; that pursuant to federal requirements, the Contractor shall verify the immigration status of all workers assigned to such contract without engaging in unlawful discrimination; and the it shall not knowingly or recklessly alter, falsify, or accept altered or falsified documents from any such worker(s). The Contractor understands and agrees that breach of any of these terms during the contract period may be regarded as a material breach, subjecting the Contractor to sanctions, including but not limited to monetary penalties, withholding of payments, contract suspension or termination. ARTICLE 7. VALIDATION: This Contract will not be valid until signed by the Department of Housing and Community Development. In Witness Whereof, the Parties Hereto Have Caused This Instrument to be Executed Under Seal. 'CONTRACTOR z AWARDING AUTHORITY VAREIKA CONSTRUCTION, INC. NORTH ANDOVER HOUSING AUTHORITY Name of Contractor Name of Housing Authority 219 Walnut Street, Suite B One Morkeski Meadows, W. Bridgewater, MA 0237 North Andover, MA 01845 Address Address By. B Signaritre and Seal rgnature and Seal President ° Title Title Witness Attest: / If a Corporation, at t t:h notarized copy of the orporate Vote authorizing Signa o sign Contract. = Ifsigned by s eone other than a Housing Authori Board m �attach, copy of ry Certified Bo d Vote authorizing the signatory to sign Contract. DEPARTMT OF HOU & COMMUNITY DEVELOPMENT By: Under eeretary. Designee Date: � �i COPS DHCD 9/2014 Owner Contractor Agreement