HomeMy WebLinkAboutBuilding Permit # 6/11/2015 BUILDING PERMIT %AORTH -q+
16
0
TOWN OF NORTH ANDOVER 11
IN
APPLICATION FOR PLAN EXAMINATION 0
Permit No#: Date Received TED
Date Issued: CH
IMPORTANT: Applicant must complete all items on this page
LOCATION ItAl'y Ez: A� 621,q
Print
PROPERTY OWNER
yes
Print 100 Year Structure D no
MAP (fl& PARCEL: ZONING DISTRICT: Historic District
Machine Shop Village ��'� no
yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 11 One family
11 Addition El Two or more family El Industrial
9 ration No. of units: El Commercial
El Repair, replacement El Assessory Bldg 0 Others:
El Demolition El Other
1/111 r
DESCRIPTION OF WORK TO BE PERFORMED:
Z-&-Al Q V&- ::�229 1,a�S Ztil IL,: -DVAIfM-sz
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address: S7-
Contractor Name:
322��Rhone:
Email: rff,�n�(47P ,<N&e , 01,9A4
Address: PACA- 0"J.,7- /0/ 4,na>,qt14,W- _WY-- 0,14910
Supervisor's Construction License: -Exp. Date: 06-a9 —U/37-
Home Improvement License: Exp. Date: // - / 1,6
ARCHITECT/ENGINEER Phone: -6 ^r
Address: Z44U—Vi J/& Aa�Ct- _Reg. No. �e6�88
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $,&5: 7- 37—, 00 FEE: $
Check No.: Receipt No.:
NOTE Persons co cting with unregistered contractors do not have accesstothe guarantyfund
sicina
t%OR'TH
_town of , E .,
Andover
® , `•
No. _
Ver, Mass,
COCNICAWICK
�® RATEO
S u
BOARD OF HEALTH
Food/Kitchen
P F= �R I T ANIT LD Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT
................... .......j..................................... .................................................
Foundation
has permission to erect .......................... buildings on .J. ... ......... .......... ............................... g
Rou h
to be occupied as .......... ...... .. .... ...d",
............ .......�....... ............ e4...�.�i►t.f Chimney
provided that the person accepting this pehall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMITI IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESSCTI T Rough
............. Service
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Buildinga 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 Approvedy the Building Inspector. Burner
Street No.
Smoke Det.
Initial Construction Control Document
M
To be submitted with the building permit application by a
Z W
M Registered Design Professional
' d for work per the 8th edition of the
Massachusetts State Building Code, 780 CMR, Section 107.6.2
c �a
7Cf V.O
Project Title: 2ND FLOOR OFFICE RENOVATIONS Date: 05/29/2015
Property Address: 146 MAIN ST. NORTH ANDOVER, MA
Project: Check(x) one or both as applicable: [] New construction [X] Existing Construction
Project description: SCOPE OF WORK FOR THE SECOND FLOOR IS TO REMOVE THE EXISTING STAIR FROM THE SECOND FLOOR
TO THE FIRST FLOOR. INFILL EXISTING OPENING TO MATCH EXISTING FLOOR, AND RENOVATE THE INTERIOR FINISHES ON
THE SECOND FLOOR INCLUDING NEW CARPET AND BASE, PAINTED WALLS, NEW WOODEN CEILINGS IN PORTIONS OF THE
EXITING SPACE,AND PREPARE FOR NEW OFFICE PARTITION LAYOUTINCLUDING ELECTRICAL SWITCHES AND OUTLETS AND
DATA AND NEW LED LIGHTFIXTURES. THE EXISTING FIRE ALARM IS INTENDED TO REMAIN. THE EXISTING SPRINKLER SYSTEM
WILL BE REQUIRED TO BE MODIFIED.
THE 2ND STAIR/EXIT IS NOT REQUIRED IN AN B- BUSINESS USE WHERE THE COMMON TRAVEL DISTANCE IS LESS THAN 100'-0"
IN OCCUPANCIES WITH LESS THAN 30 PEOPLE, OR THAT ARE FULLY SPRINKLERED AND HAVE LESS THAN 50 PEOPLE. SEE
SECTIONS 1014.3,TABLE 1015.1,AND SECTION 1021.2 AND TABLE 1021.2 IN THE 8TH EDITION OF THE MASS CODE 780 CMR.
I Gregory P Smith MA Registration Number: #8688 (Architect) Expiration date: August 31, 2015,am a
registered design professional, and hereby certify to the best of my knowledge, information and belief,that I have
prepared or directly supervised the preparation of all design plans, computations and specifications concerningi:
[X] Entire Project [X] Architectural [ ] Structural [ ] Mechanical
[] Fire Protection [] Electrical [] Other:
for the above named project and that 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 in accordance with the
Professional Standard of Care, 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. Such review shall not diminish or
relieve the Contractor of its submittal and other responsibilities.
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. The contractor shall be responsible for performing the work in accordance
with the contract documents and shall be exclusively responsible for its construction means, methods, sequences
and procedures, and for construction safety. The performance of the services shall not require any special testing or
inspections unless specifically stated in the Code. When required by the building official, I shall submit
field/progress reports (see item 3.)together with pertinent comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `FinalC ontrol Document'.
Enter in the space to the right a"wet"or
electronic signature and seal:
MA,
Phone number: cell: 978-204-4770, office 978-688-5422 X203 rna . w ith@gsd-assoc.com
Building Official Use Only
Building Official Name: Permit No.: Date:
AIA MA&Insurance AODrove_d Version. Initial Construction Control Doc
/
�
�
Construction Control Document
Tbbesubmitted with the building permit application byu
Registered Design Professional
for work per the 8th edition ofthe
Massuo}nzuotto State Building Code, 700 CMR, Section 107.8.2 �
�
Project Title: 2ND FLOOR OFFICE RENOVATIONS Date: 05/29/2015
Property Address: 146 MAIN ST. NORTH ANDOVER, MA �
�
Project: Check(x) one orboth as applicable: [] New construction [X] Existing Construction �
�
Project : SCOPE OF WORK FOR THE SECOND FLOOR IS TO REMOVE THE EXISTING STAIR FROM THE SECOND FLOOR �
TO THE FIRST FLOOR. INFILL EXISTING OPENING TO MATCH EXISTING FLOOR, AND RENOVATE THE INTERIOR FINISHES ON
THE SECOND FLOOR INCLUDING NEW CARPET AND BASE, PAINTED WALLS, NEW WOODEN CEILINGS IN PORTIONS OF THE
EXITING SPACE,AND PREPARE FOR NEW OFFICE PARTITION LAYOUTINCLUDING ELECTRICAL SWITCHES AND OUTLETS AND �
DATA AND NEW LED OGHTBXTURES. THE EXISTING FIRE ALARM lSINTENDED TOREMAIN. THE EXISTING SPRINKLER SYSTEM
WILL 8EREQUIRED TOBEMODIFIED.
THE 2ND STAIR/EXITIS NOT REQUIRED IN AN B- BUSINESS USE WHERE THE COMMON TRAVEL DISTANCE IS LESS THAN 100'-0"
IN OCCUPANCIES WITH LESS THAN ]O PEOPLE, ORTHAT ARE FULLY SPRINKLERED AND HAVE LESS THAN 50 PEOPLE. SEE
SECTIONS 1O14.3,TABLE 1O15.1,AND SECTION 1021.2 AND TABLE 1U31.2INTHE 8TH EDITION OFTHE MASS CODE 780CMR.
IGF8gOrV PSmith M/\Registration Number: #8688 //\rCh\t8Ct\ Expiration date: August 31/ 2015, u000
registered design professional, and hereby certify to the best of my knowledge, information and belief,that I have
prepared or directly supervised the p/opuodiou of all design plans, computations and npcuifiouk000 coocecoiogr
[X] Entire Project [X] /\rubdecinrol |l Structural [l D400baoicol
[ ] Fire Protection [] Electrical [l ()tbec
for the above named projectand that such plans, computations and specifications meet the applicable provisions of the
Massachusetts State Building Code, (78OCMD), and accepted engineeringpractices for the proposed project. I
nudeniuod and agree that I(or my designee) shall perform the necessary professional services in accordance with the
Professional Standard ofCare,and bopresent oothe construction site ouuregular and periodic basis to:
l. 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. Such review shall not diminish or
relieve the Contractor ofits submittal and other responsibilities.
2. Perform the do1iom for registered design professionals in 780 CMR Chapter 17` as applicable.
S. Ropresent atintervals appropriate\othe stage ofconstruction tobecome generally familiar with the progress and
quality of the work and to deterinine if the work is being performed in a manner consistent with the approved
construction documents and this code. The contractor shall be responsible for performing the work bnaccordance
with the contract documents and obuD be exclusively responsible for its construction means, cuotbodu' uegounoea
and procedures, and for construction safety. The performance ofthe services shall not require any special testing oz
inspections unless specifically stated inthe Code. When required bythe building official, Ishall submit
field/progress ropnda(see item 3.)together with pertinent comments, bnu[hoo acceptabIS1official.
Upon completion ofthe work, Tshall submit tothe building official n 'Final t` �
Enter iuthe space tothe right u"vvct"or
uloo1n`uio signature and seal:
All
9bon000�hcr� C8��� 978-204-4770, office s~ w1-8SSOC.CODl �
'
Building Official Use Only �
Building Official Name: Permit No.: Date:
A-[A MA &Insurance AmzmmedNerqtw JhitialConstruction Control Dor
h---._' — .' ' ' ' /
Construction Management Agreement
THIS CONSTRUCTION MANAGEMENT AGREEMENT is entered into on June 01, 2015, by and between Gregory
Smith, 146Main St, North Andover, Massachusetts 01845(hereinafter referred asthe Owner),andVV|Nam McKay
Construction Management, 4 Powdermill Square,Andover, Massachusetts 01810(hereinafter referred as the
Manager).
RECITALS:
WHEREAS, Owner intends to construct 2nd Floor Office Renovations- 146 Main St. (herein after referred asdhe
Pnoject.) and desidesires to render general management services with respect thereto; and
WHEREAS, Manager has significant expertise and knowledge in connection with the management of construction
projects and desires tomanage the Project;
N{8N`THEREFORE, incon�derat�nofthe mutual covenants and promises hereinafter contained,the padbes
agree
— asfollows: �
MANAGEMENT OF PROJECT.In connection with the remodeling of the 2nd Floor Office Renovations- 146 �
Main St. located at 146 Main St., North Andover, Massachusetts 01845, Owner hereby employs Manager and
Manager does hereby agree to undertake all construction management obligations and services with respect to
the project.
DUTIES OF THE MANAGER. Manager's duties shall include,without limitation, the following:
a Consult and advise Owner on all aspects of the Project including the alternatives proposed by the
architect inthe design phase;
b. Consult with Owner inconnection with the preparation ofbudgets, reports,scheduling, evaluations,
cost estimates, in connection with the selection of subcontractors, materials, and issuance of permits;
DUTIES OF THE OWNER.Owner's duties shall include, without limitation, the following:
a. Direct Payment of all Consultants, Contractors,and Subcontractors to be employed on this project.
b. Direct payment ofaUcostsofthemateha|sond /abor. A||wmrkwiUbepaiddirectybytheOwner.
The Manager shall have no financial responsibility in the implementation and day to day management
ofthe project.
C. Coordination and implementation of the scope of work shown on the construction drawings.
WORKING HOURS. The parties acknowledge that Manager will devote amaximum o[4hours per week during
the construction and renovation phase.
COMPENSATION. Owner agrees bopay Manager for the sum of$300.00 per weekManager shall keep track of,
and account to Owner for, the number of hours which he works directly for the Project
TERM.This Contract will terminate automatically upon completion of the work and the Services required by this
Contract.
TERMINATION OF CONTRACT.This Contract will terminate upon completion nf the work and the Services
required by this Contract, or upon 7 days written notice of either party to this contract.
TRANSFER AND ASSIGNMENT OF CONTRACT.This Contract cannot betransferred orassigned hnanother
party not on the signature page, Any transfer or assignment will terminate this agreement immediately; 7 days
written notice hoeither party isnot required upon transfer orassignment.
INDEMNITY.Tothe fullest extent permitted bylaw, Manager shall and Owner shall mutually indemnify, and
hold harmless Owner and Owner's agents and employees, and Manager and Manager's agents and employees,
from and against all claims, damages, losses and expanses, including, but not limited to, attorneys'fees arising
out of or resulting from the performance or non-performance of his duties hereunder.
2nd Floor Renovations— 146Main St. North Andover, MA
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DEBRIS.Owner shall be responsible to keep the premises free from accumulation of waste,materials or rubbish
caused by any subcontractors operations.
DEFAULT.The occurrence of any of the following shall constitute a material default under this Agreement.
a. The failure to make a required payment when due.
b. The Insolvency or bankruptcy of either party.
C. The subjection of any of either party's property to any levy, seizure, general assignment for the
benefit of creditors, application or sale for or by any creditor or government agency.
d. The,failure to make available or deliver the Services In the time and manner provided for in this
Contract.
REMEDIES.In addition to any and all other rights a party may have available according to law, If a party
defaults by failing to substantially perform any provision,term or condition of this Agreement(including without
limitation the failure to make a monetary payment when due),the other party may terminate the Agreement by
providing written notice to the defaulting party.This notice shall describe with sufficient detail the nature of the
default.The patty receiving such notice shall have 14 days from the effective date of such notice to cure the
default(s). Unless waived by a party providing notice,the failure to cure the default(s)within such time period
shall result in the automatic termination of this Agreement.
FORCE MAJEURE. If performance of this CAgreement or any obligation under this Agreement is prevented,
restricted, or interfered with by causes beyond either party's reasonable control ("Force Majeure"),and if the
party unable to carry out its obligations gives the other party prompt written notice of such event, then the
obligations of the patty invoking this provision shall be suspended to the extent necessary by such event.The
term Force Majeure shall Include, without limitation, acts of God,fire,explosion, vandalism,storm or other similar
occurrence,orders or acts of military or civil authority, or by national emergencies, Insurrections, riots, or wars,
or strikes,lock-outs, work stoppages, or other labor disputes,or supplier failures.The excused party shall use
reasonable efforts under the circumstances to avoid or remove such causes of non-performance and shall
proceed to perform with reasonable dispatch whenever such causes are removed or ceased.An act or omission
shall be deemed within the reasonable control of a party if committed,omitted, or caused by such party,or its
employees,officers, agents,or affiliates.
ARBITRATION.Any controversies or disputes arising out of or relating to this Agreement shall be resolved by
binding arbitration in accordance with the then-current Commercial Arbitration Rules of the American Arbitration
Association. The parties shall select a mutually acceptable arbitrator knowledgeable about issues relating to the
subject matter of this Agreement. In the event the parties are unable to agree to such a selection,each party will
select an arbitrator and the two arbitrators In turn shall select a third arbitrator, all three of whom shall preside
jointly over the matter.The arbitration shall take place at a location that is reasonably centrally located between
the parties,or otherwise mutually agreed upon by the parties.All documents,materials,and information in the
possession of each party that are in any way relevant to the dispute shall be made available to the other party for
review and copying no later than 30 days after the notice of arbitration Is served. The arbitrator(s)shall not have
the authority to modify any provision of this Agreement or to award punitive damages. The arbitrator(s)shall
have the power to Issue mandatory orders and restraint orders in connection with the arbitration.The decision
rendered by the arbitrator(s)shall be final and binding on the parties, and judgment may be entered in
conformity with the decision In any court having jurisdiction. The agreement to arbitration shall be specifically
enforceable under the prevailing arbitration law. During the continuance of any arbitration proceeding,the parties
shall continue to perform their respective obligations under this Agreement.
GOVERNING LAW.This Agreement shall be construed in accordance with the laws of the State of
Massachusetts.
WAIVER OF CONTRACTUAL RIGHT.The failure of either party to enforce any provision of this Agreement
shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict
compliance with every provision of this Agreement.
NOTICE.Any notice or communication required or permitted under this Agreement shall be sufficiently given if
delivered in person or by certified mail, return receipt requested,to the address set forth in the opening
paragraph or to Such other address as one party may have furnished to the other in writing.
2nd Floor Renovations— 146 Main St. North Andover, MA
Page 2 of 3 2015-06-05 07:22
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SEVERABILITY.If any provision of this Agreement will be held to be Invalid or unenforceable for any reason,
the remaining provisions will continue to be valid and enforceable. If a court finds that any provision of this
Agreement Is Invalid or unenforceable, but that by limiting such provision It would become valid and enforceable,
then such provision will be deemed to be written, construed, and enforced as so limited.
AMENDMENT.This Agreement may be modified or amended in writing, If the writing is signed by the party
obligated'under the amendment.
The parties have hereunto set their hands the day and year first above written.
SIGNATURES.This Agreement shall be signed on behalf of Gregory Smith by Gregory Smith, Its Owner, and on
behalf of William McKay Construction Management by William McKay, its Owner.
OWNER:
I
Gregory Smith
By: Gregory Smith, Owner
MANAGER:
William McKay Gonstruction Management
By: William lMocKayGwner
i
2nd Floor Renovations— 146 Main St. North Andover, MA
Page 3 of 3 205-05-ns n7*22
2nd floor office renovation 146 Main St N. Andover
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Demolish portion of ceiling $1,170.00 $0
Remove ceiling&soffit in open areas and stair 2 MAN $100.00 $200.00 $0.00
Dumpster Rental 1 EA $650.00 $650.00 $0.00
Remove Suspended tile in Offices 1 MAN $100.00 $100.00 $0.00
Demo clg on 1st floor 40 sf $0.50 $20.00' $0.00
Remove Carpet 2 MAN $100.00 $200.00 $0.00
Demolish Stair framing and walls on 2nd floor $455.00 $0
Demolish stair framing,handrails and trim 0.5 MAN $100.00 $50.00 $0.00'
Demolish walls above 2nd floor to ceiling 1 MAN $100.00 $100.00; $0.00'
make safe opening 0.25 MAN $100.00 _ $25.00
Demolish lower walls on 1 st floor 0.5 MAN $100.00 $50.00 $0.00
Remove Oak Doors 0.2 MAN $100.00 $20.00, $0.00
Demo door in 2nd floor 0.1 MAN $100.00 $10.00, $0.00
Demo and clean up around perimeter of walls in office 1 MAN $100.00 $100.00 $0.00
General Clean up and fill Dumpster 1 MAN $100.00 $100.00 $0.00
Frame in floor at stair _ $459.30 $0
Joist Hangers 20 EA $1.60 $32.00 $0.00
New 2x 12 Framing 10 EA $10.00 $100.00, $0.00
3/4"Plywood/OCB subfloor 3 EA $14.10 $42.30; $0.00
LW Concrete topping slab 8.75 CF $4.00 $35.00' $0.00
Labor for Above 2.5 MAN $100.00 $250.00 $0.00
Demolish reception counter $20.00 $0
Remove countertop and low wall 0.2 MAN $100.00' $20.00 $0.00
$0.00 $0.00
Build soffit walls&Beams $800.36 _$0
Build Soffit along exterior for HVAC pipes 10 EA $2.10 $21
Build soffit along suspended ceiling 4 EA $2.34 $9
repair gwb around perimeter of offices where ceiling is 25 EA $10.00 $250
raised
Buckets of Taping Mud 2 EA $10.00 $20
Labor for tape and samd and install GWB 5 MAN $100.00 $500'
Build Box Beams at open ceiling area $799.80 $0
Trim edge 120 LF $0.69 $83
1x12 bottom 60 LF $2.15 $129
1x6sides 120 LF $1.15 $138!
Fix 1st floor ceiling trim 10 LF $5.00 $50
labor to build and install beams 4 MAN $100.00 $400
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Build Box Beams at open ceiling area _.. $465.75 ry $0
2x3 stud frurring 50 EA $2.10 $105'.
2x3 box beam/soffits 10 EA $2.10 $21'
1x3 furring 25 EA $1.59 $40'
labor for framing furring 3 MAN $100.00 $300
Install new fight fixtures $2,346.27 $1,353
Ordered New LED recessed fixtures 42 EA $19.47 $818 $825
Ordered New housings 7 EA $35.47 $248 $248
Ordered New dimmable Switches 9 EA $18.26 $164 $164
Ordered New Outlets 10 EA $11.59 $116 $116
New wiring 2 MAN $500.00 $1,000
Install Toilet rm Base Cabinet $200.00 $192
New Cabinets&Faucets _ 2 EA $100.00 $200 $192
Install cabinets 1 MAN $0.00 $0'
—': install wood ceilings $2,893.00 $0
Wood Ceiling 1200 SF $1.89 $2,268'
Nails 1 EA $25.00 $25'
Installation of wood ceilings 6 MAN $100.00 $600
Stain for ceiling 5 qts $7.77 $39
rags 1 EA $22.00 $22
spray Stain on clg&wipe 1 MAN $100.00 $100
Tung oil cig 1 MAN $100.00 $100'
Sprinkler repair _ $2,750.00 $0
Retrofit heads for new ceiling plan 1 EA $1,750.00 $1,750
Add drain and extension line so access into pit is not 1 EA $500.00 $500
required
1st floor sprinklers at stair _ 1 EA $500.00 $500
Flooring _ $2.725.16 $0
Existing Carpet to be installed in Office/s(verify Qty) 1 EA $25.00 $25
New Carpet tile 864 sf $1.69 $1,460,
New Vinyl cove Base 5 EA $80.00 $400
Adhesive 1 EA $100.00 $100
New resilient Flooring at Kitchen 120 sf $2.00 $240
labor for Carpet&Base 5 MAN $100.00 $500
Other Items $8,685.00 $0
French doors to replace solid OAk 3 EA $225.00 $675
Paint for walls 12 ga $35.00 $420
Painting all walls 5 MAN $100.00 $500
,: �. S_ `,„ l �7 l t.. e, w ,. �,7:, t 1.. n r.. ,t...... �,*. :�. a w., Y r t r F .�'.. .:r, n:+w _:.�•.� t
metal mesh guards around perimeter """' � - ��-' - -"^+
4 MAN $100.00 $400:
spray foam
5 EA $6.00 $30'
Window repair of sills 20 EA $48.00 $960
Labor for Window repair of sills 10 MAN $100.00 $1,000
Paint exterior 4 MAN $100.00 $400
Paint for exterior 1 EA $350.00 $350
Repair/Rebuild Front entrance 1 EA $1,500.00 $1,500
Replace Rear Exterior door 1 EA $167.00 $167
Rebuild Door trim at exterior rear 1 EA $500.00 $500'
Labor for door and trim 4 MAN $100.00 $400
Repair trim 1 MAN $100.00 $100'
A&M Hardware Brackets 21 EA $23.00 $483
countertops 2 MAN
$100.00 $200'.
Frame low walls 2 MAN $100.00 $200'
Oak trim
MAN $100.00 $0,
low walls,GWB&Finish 3 MAN $100.00 $300
Outlets on walls 1 MAN
$100.00 $100'
Subtotal __ $24,0$0 $23,770
Contingency 5% $1,202
Budget
$25,232'.
The Commonwealth of Massachusetts
F Department of IndustrialAccidents
ti r 1 congress Street, Suite 100
Boston,MA. 021142017
9�. www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING.A.UTHORITy- Please Print Le 'bl
ApWicantinformation G
NaMe(Business/Organization/individual): GV G
Address:
City/State/Zip:
Phone#: ` 2 —3
Are you an employer?Cheel,the appropriate box:
Type of project(required);
em to ees fiill and/or part time).* 7. ❑New'construction
1.[]lam a employer with 1? y (
2.❑1 am a sole proprietor or partnership and have no employees Working forme in $. remodeling
any capacity.[No workers'comp.insurance required.] 9. ❑Demolition
3.[]I am a homeowner doing all work myself,[No workers'comp,insurance required]" 10 F1 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 12^❑Plumbing repairs or additions
proprietors with no employees.
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
13..F]Roof repairs
These sub-contractors have employees and have workers'comp.insurance J 14.❑Other
6.0Te are a corporation and its,officers have exercised their right o£exemption per MGL c.
152,§1(4),and we haven'employees. surance required.]
iNo workers'comp.in
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i Homeowners who c bs boxmust attached an additional sh egshowing the name of tl eutside sub ors must s and state whether or no h.
all work andthen hire those ent ties have
contrdavit indicating such.
actor
tContractors that the k
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
X am an employer that is pr•ovidingwor•Zcers'compensation insurance for•my employees. Selo1v is thepolicy and job site
information.
Insurance Company Name:
Expiration Date:
Policy#or Self-ins.Lia#:
City/State/Zip:
Job Site Address:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
on punishable by a fine up to
0-00
Failure to Secure coverage as required ascivil er l penalties in the form of a is a STOPnal 1WORK ORDER and a fine of up to $200.00 a
and/or one-year imprisonment,as weP
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance
coverage verification.
X do hereby certify under tlzepains and aloes of perjury that the information provided above is true and.correct
Date: AD
Si nature:
tozPhone#: r r
offrcial use only. Do not write in this area,to be completed by city or town official.
Permit/License#
City or Town:
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Phone#•
Contact Person:
RD
AC ® CERTIFICATEOF LIABILITY INSURANCE DA1 12/DDAY5
THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED UY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certificate holder Is an ADDITIONAL INSURED, the policy09s)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement On this Certificate does not confer rights to the
certificate holder In Ileu of such/endorsement(s).
PRODUCERNON—TvLica jondon
MTM Insurance A860C$atet3 PHONE .
(978)681-5700 FAX
No,1978>ti81-5777
1320 Osgood Street ADD Baal@mtminaure,com
IN6UFIER S AFFORDING COVERAGE NAIC p
North Andover MA 01845 INSUR6RAX9Sex Insurance Com an
INSURED
INSURER 0:
Willialb McKay Construction Management LLC INSURERC:
4 Powder Mill Sq, Suits 101
INSURER D
Andover INSURER E:
MA 01810 INSURER :
COVERAGES CERTIFICATE NUMBER:15-16 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE 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
CERTIF)CATE MAY BE ISSUED OR MAY PERTAIN, 7HE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN ,5 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
1AUTOMOBILS
TYPE Of INSURANCE ooi POLICY PIO�L p P
POLICY NUMBER LIMITS
COMMERCIAL GENERAL UABWTY
EACH OCCURRENCE g 1,000,000
CLAIMS•MADE OCCUR Curfence f 100,000F MISE$ ��2=341 5/31/2015 5/31/2016 MEDEXP(An onepeggn) S 5,000PER$ONAL$ADVINJURY S 1'000,000EN'L AGGREGATE OMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000POLICY�JECT LOC
PRODUCTS-COMP/OP AGO E 1,000,000
OTHER:
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LIABILITY
1151_D S E UM IT S
ANY AUTO
AUTOS JED AUTOSULED BODILY INJURY(Pw person) S
NON-O'MVED BODILY INJURY(Peraccltlenl) S
HIREDAUTOS
A�pg PR R 7Y DANA
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UMBRELLA LIAR, OCCUR
"CESS UAB EACH OCCURRENCE S
CLAIMS-MADE
AGGREGATE S
0 ETENTI
WORKERS COMPENSATION S
AND EMPLOYERS'LIABILITY Y 1 N PE.L
TAT ER
ANY PROPRIETORIPARTNERIEXECUTIVIR
OFFICRRIMEMBER EXCLUDED NIA ACH AOCIDENT(MentlabarydascIn NH)and ISEASE.tlasC 1be under EA EMPLOYE D PTION OF OPERATIONS baloowSEASE-POLICY LIMITA Equipment Floater 2CU2341 5/31/2015 5/31/20AGaoreEquipment 810,000bfe $500
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD IVI,AddlRonal KemaAte Schaoulp,may be vttached if mgrs apace Is nIqurred)
Re ,Tob: 146 Main St. North Andover, MA, 01404$, 2nd Floor Office
This certificate of inaUV&nce represents coVOrAge Currently in effOOt and may or may not be in compliance
with any written Contract,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
384 Oagrood St. ACCORDANCE WITH THE POMGY PROVISIONS,
North Andover, MA 01045
AUTHORIZED REPRESENTATIVE
M Laorenza/SAMANT
m 1988.2014 ACORD CORPORATION, All rights reserved,
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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