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HomeMy WebLinkAboutBuilding Permit # 7/24/2015 NORTk BUILDING PERMIT T F T V a�� - ,6IN APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received °�,.�5 RATE V �gceause Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Pri t �r PROPERTY OWNER --� J � ,A a �. � 1 ,- r Print 100 Year Structure yesn MAP PARCEL: ZONING DISTRICT. Historic District yes \noo Machine Shop Village yes t7o uµ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑ Alteration No. of units: XCommercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Otherti'°°tt"� 1/�� ,�,� / �/,/// � �, �,, o ,,�/Uetla ds/r //�/fji /❑ ,Watershed"Ristricf /ii��,,,,. i DESCRIPTION OF WORK TO BE PERFORMED: F µ. Identification Please Ty a or Print Clearly OWNER: Name. ��" ��" � /�f �J� �����y ;';:, "n � Phone: Address: . . n Q°„ � „, ' °» h ° w, � , (..;' r6 .. Contractor Name �.,�� �� ”. � ,�� o Phone: Email: !', :: .� ��w. '�” .��a .'... TI/V Addressor "i Cif Supervisor's Construction License " m, "" ,e� „a �..��� ,�'d,' Exp. Date: -Home Improvement License, ��., �` �- ,..� Exp. Date: �av,u ARCHITECT/ENGINEER Phone. ;r I '., �' �� e Address: � � � � - °fir 'ea ,� n�l` �'� ' eg 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: $ >` f% FEE: $ Check No.: Receipt No.: NOTE Persons contracting with unregistered contractors, 6,)wot have a' "0ess`4o the guaranty fund U/„F /„,,,, � � ,;..; ''!_.-.'-r r ,i. ;j.,..�, 1�� .,. / ✓1�N �N4,'dV?ldN1YY%' � Flans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/Massage/Body Art ❑ Swiimning 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 Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS 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 384 Osgood Street FIRE DEPARTMENTTemp Dumpster on site ,yes Lodate&at,1,24,,MaihStreet Firer b"k, rrientsigntui /date COMMENTS VkORTH _1 L own o f iidover No. 2,01 O LAHQ y Ver• Mass, I. COCHIC"aw'CH y�' / f �,9 A°f�ArED A�a �(5 BOARD OF HEALTH Food/Kitchen PF. �RmIT TU Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ..... has permission to erect .......................... buildings on ..��. ...... Foundation .. ... . ............................................... Rough to be occupied as ...... ...... .{... .......�fhalilin . .. ...,.............................. Chimney provided that the person accepting this permit 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 PERMIT EXPIRES IN 6 ® kHS ELECTRICAL INSPECTOR UNLESS S Rough Service ........ ...... ...... ..................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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 Approvedy the Building Inspector._ Burner Street No. Smoke Det. "Min k, POOLS AND SPAS, . Chapman Construction/Design Co. July 1, 2015 84 Winchester St. Page 1 of 3 Newton, MA 02451 EXHIBIT G6 77 RE: Edgewood Retirement Community 575 Osgood St. No. Andover, NIA 01845 ATTR: David Coffey, Assistant Project Mgr. Please find (2) attachments accompanying this letter, Known as Exhibit "C" First, is the signature page of the Contract signed 6/30/2015 between Aquatime Pools and Spas, Inc. and Chapman Construction. Second, is my original email quote for requested additional insurance coverage purchased ($2M Umbrella Coverage) as agreed to by Jason GrinacofF as a result of this 5/11/15, 8:53pm email. I have only a verbal approval of this additional insurance purchase and require written substantiation before finalizing coverage. This Exhibit "C" is the quoted cost of the additional insurance Umbrella ($3,000.00 -) less the amount of the MA Sales Tax included in the contract amount for materials used in the construction of the spa and previously included in the Exhibit "A' proposal ($508.44-). We had not been notified that this job was Tax Exempt Status when quoting. The NET result of Exhibit "C"would be an increase to the contract in the amount of$2,491.56+ Exhibit "C" will also include the Schedule of Values for which the payments are based. Each item represents a milestone in construction for payment and not necessarily the value of that specific phase of construction listed. SCHEDULE OF VALUES: 1. Mobilization Payment. . . . . . . . . . . . . . . . . . . . . . . 15%. . . . $ 5,588.70 Exhibit"C' Payment increased ins less tax credit). n/a . . . . $ 2,491.56 Mobilization Payment plus Exhibit"C" NET total. . . . . . . . .. . $ 8,080.26 2. Excavation, forming, shell plumbing completion , . 15%. .,. . $ 5,588.70 3. Steel Rebar completion . . . . . . . . . . . . . . . . . . . . . 10°x'0. . . . $ 3,725.80 4. Gunite shell completion . . . . . . . . . . . . . . . . . . . . . 40%. . . . $14,903.20 5. Tile and Coping completion . . . . . . . . . . . . . . . . . . 10%. . . . $ 3,725.80 6. Plaster Interior Finish completion. . . . . . . . . . . . . . 10%. . . . $ 3,725.80 TOTAL OF PAYMENTS (Exhibit's "A"and "C"). . . . . . . . . . . $39,749.56 Please find (2) pages of attachments. Please call if you have any additional questions. 89 RIVER ISD., HUDSON, NH 03051 o (603) 595-5915 - FAX (603) 595-5920 n. off RTI Cf,P,m1 c ErltiNtER.-aTEON OF Sf.JBCUINT ACT DOCUMENTS t6A The Submitract(Documents,exceft for Modtfications issued ufier excoution of this Subcontract,are enumerated in the s¢ectrons belov,. i, MIA This executed AIA Document A401.2007 Simidard Ct�tnrr orAgiecoient Bttwem Contractor and Subcontractor. 16.1.7„The prime Contract,consisting of the Agreement between Ovmcr and Contractor dated as first entered above and the other Contract Documents enumerated in the Civnur-Contractor Agreement. 16.1.3 The following lvtodihcations to the i'rimc Contract,if any,issued subsequent to the,execution or the Owner-Contractor Agreement ben r prior to the execution of this Agreement: NIfA MJA Additional Documents,if any,Panning part of the Subcontract L7ocuments: (List here any additional t10CUnierr(5 which are intended to form part of the Subcontract[Documents. (tequcros I'or proposal and the Subcontractor's bid or proposal should be listed here only if intended to be made heart of the Subcontract Documents) PelleSubcontractorshatt compo,with the Contractor's mosf(ft"ilolt(t General S(yigi,Polk.),,lattd inflow-Flit'Qualifi,Plan,conies gfwhich ar", available at rhe Contractor's o lee fiar review and copying. -I copy of tree Snbcantraclor's sqf r,tv progrtim arra.rt he suhmittetf to the Contractor. Tu(h� i"fus Agreement en red into as of the day,-q and year first v,rtit:an above. CI 11't �kL� t 'r I UC I IC)Ti/C7S SfGi f .a ,. n ACSU ;Wkq PO LS A4 "VIS-Y jc f L42 { trahara) � setinaPur ) t°� � � �a L + .y� ,_ 't�,yw,✓� _-______..�_._._.._. ��nntcdaam�� �}^ "" � �°� .,,: ^"" ��� �� ^' ' � c,ver�a alai itr�"✓" �, �� ._.._....____'C_ (Printed name and title and t rfc —T i(! AIA Document A4101-20707 modifikd r .. The Commonwealth of Massachusetts Department oflndustrialAccidems ui, r t f 5 X 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 PEPANHTTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): - �r ) � � E ��L/ �iSPA< , I NC Address: City/State/Zip: H L)' �`' Phone#: 260— Z ZZ- 0CnI Are you an employer?Check&e appropriate box: Type of project(required): j�(( 1. I am a employer with er employees(full and/or part-time).* 7. [1 Now construction 2. I am a sole proprietor or partnership and have no employees working for me in $, F!Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑ - 10 Building addition 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors-with no employees. 12. 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.iasruaacaJ _ , 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Mother 152,§1(4),and we have nq 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 submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must-attached an additional sheet showing the name 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 ispi'ovidingworkers'compensation insuran cefor my employees.'Below is thepolicy andjob site information. Insurance Company Name: Policy#orSelf-ins.Lie.#: J - - Expiration Date: a Job Site Address: 5 7-15 (7�001) -1— City/State/Zip: 61 45 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 certi�under the pain dpena ttes ofperjury that the it formation provided above is true and correct. Signature: / t �,r t f_ 7/�',���•ti Date: Y Phone#• �� "" .Z (2-V 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#: 7/14/2015 3 : 14 : 23 PM 8790 0 02/02 AC R' CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DOfYYYY) 07/14/2015 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 I OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. RTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to erms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the ficate holder in lieu of such endorsement(s). ER 04963-001 CONTACT NHAME: surance Associates LLC A/°NNo.Ext: (.978)681—5700 F�X sgood Street i EMAIL c.No.: (978)681-5777 ndover,MA 01845 ADDRESS INSURERS AFFORDING COVERAGE NAIC f INSURERA: A.I.M.Mutual Insurance Company 33/58 me pool & spas Inc INSURER 8SURER C er road Hudson, NH 03051 INSURER D: INSURER E: SUR COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TNHIISCIISTFTpo CEpR7T�IIFYTHTHAT pT'H�7E PgOLIICIIESOLO��FRIINMS�UNRTANrCEE LLISTTREDcBBELpOfTW��7HHApVE BBEEENCIpSSSUEEDCTTOpTRHE IINHSEURREDD N�A�,,MEEND ABBOTVHE�F�OgRPFTCHETPOLLII/C�Y� {P�ERrIIODD GERTIFIGATENMAY IBESILIE6GORNMAYEF ERTAIN, TFiE fNSUFtANCENAFFORDE� BYYTfiE PTOLAICIES OESCRIBEB HEREINTIS �UBJECT TOTAL? THECTERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE VDOL SUER POLICY EFF POLICY EXP I SR WVD POLICY NUMBER 4MILM/YEll (MILIC I'YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S PREMISES Ea occurrence CLAIMS-MADE OCCUR MED EXP(Any one person) S PERSONAL&ADV INJURY S GENERAL AGGREGATE $ �EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OLICY RO- pr rT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO Ea accident ALL OWNED SCHEDULED BODILY INJURY(Per person) $ '. AUTOS AUTOS BODILY INJURY(Per accident) S HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE Peraccident S S UMBRELLA LIAB OCCUR EACH OCCURRENCE 4 EXCESS LIAB CLAIMSMADE AGGREGATE S DED RETENTION $ yy Tq t� WORKERS COMPENSATION X TORY LIMITS EF AND EMPLOYERS'LIABILITY A ANc�rP-5SFecIErOeG'xFTIirRP(ECUTIVEY/N E.L.EACH ACCIDENT S 1,000,000.00 (M andatoryln NN) !! "�r^ AWC 100 7095092 2016A 1!3/2016 4131201C d E.L.DICGASE GA E1.[PLOYEE T 1,000,000.00 s CE�ll�l•�ONOFOPERATIONSbeloww E.L.DISEASE-POLICY LIMIT S 1,000,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Worker's Compensation Coverage Applies to Massachusetts Employees Only. CERTIFICATE HOLDER CANCELLATION 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 r�?, 1CORD 25 2010/05 ©1988-2010 ACORD CORPORATION.All rights reserved. ( ) The ACORD name and logo are registered marks of ACORD 9133 A CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DDlYYY1� 7/13/2015 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. FIMPORTANT: 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). tPRODUCER ::JA NTACT Lisa London ME: Insurance Associates ON o (g7B)6B1-5700 FAX Xs7s)bei-s777 Osgood Street MAIL a/c No:DRESS:lisal@mtminsure,com INSURERS AFFORDING COVERAGE NAIC//h Andover MA 01845 URERANautilus Insurance company INSURED INSURERS:Commerce 34759 Aquatime Pool & spas Inc INSURER C: 89 River Road INSURER D: INSURER E: Hudson NH 03051 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 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 ADOL SUER LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP MMIDD MMlDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I$ 1,000,0001 A CLAIMS-MADE FxJ OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ NN557837 4/25/2015 4/25/2016 MED EXP(Any one person) . S 5,000 PERSONALBADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY❑PRO- GENERAL AGGREGATE S 2,000,0001 X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S 500,000 B ANY AUTO BODILY INJURY(Per person) S ALL OWNED X SCHEDULED AUTOS AUTOS BCTPKH 1/1/2015 1/1/2016 BODILY INJURY(Per accident) S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS -ijPeraccldent S X UMBRELLA LIAR OCCUR $ A EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE $" 2,000,000 AGGREGATE $ DED RETENTIONS I I TBD EXCESS 7/13/2015 7/13/2016 S PER OTH- WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Is STATUTE ER ANY PROPRIETOR/PARTNER/D(ECUTIVE E.L.OFFICER/MEMBER EXCLUDED? ❑ N/A EACH ACCIDENT S (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYE S DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S )ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Phis certificate of insurance represents coverage currently in effect and may or may not be in compliance ,rith any written contract. :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THEEXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE P MacDonald CPCU, CICi�l ' ©1988-2014 ACORD CORPORATION, All rights reserved. :ORD 25(2014/01) The ACORD name and logo are registered marks of ACORD S02512Men11 Office of Consumer Affairs&Business Regulation pJ MEIMPROVEMENT CONTRACTOR `i egistration: 124884 Type: ,expiration: 9/8/2015 Private Corporation I 4quatime Pools Peter White 440 MIDDLESEX#102 TYNGSBORO, MA 01879 Undersecretary I 9Niassacriuset-ts - Department of Public Safer; Bc�rd of Building Rcgulations and Stan dards Construction Super%icer License: CS-059582 3 PETER F WHITE - 440 NMDLESEX,RD TYNGSBORO DOA 01$79< ,� l � Expiration Commissioner 07/26/2016