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HomeMy WebLinkAboutBuilding Permit #624 - One High Street 4/15/2010Permit NO: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this pate LOCATION tA&1�t' M M4 0t'9PA5� � Print PROPERTY OWNER 'HkNJ5Ui? - , (Cpl'1Ve. �P) Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Additioil Two or more family Industrial Iteratio No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer ON OF WORK TO BE PERFORMED: . Y VaAi DIA-4poiA FU 4' G'V" ,;AAi Identification Please Type or Print Clearly) OWNER: Name: Scot' T %v110A.,V V4 Address: hone: l$ `15b_ 3175 start, T-Cvy CONTRACTOR NameQ. C*t,1 t1_1 J #FSC . I t4C Phone: 6 (1 r 9�0 1-' o24)0 Address: #SEe Qt;jL6" MA 02.1 al Supervisor's Construction License: s0$" Exp. Dater Is 11 Home Improvement License: ..... M Fyn nate- ARCHITECT/ENGINEER 1a1r4yr4Lk% JleptAvie4 Atir, to fpm Phone: <ol'j -350'050 Address: 300 A, St . fk?9cz*,1 . MA; 0=0 Reg. No. 4$23 FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $3�} . ' FEE: $ 41,4 . 00 Check No.: "3 0 _. o� 7 Receipt No.: ;X� M NOTE: Persons contracting with unregistered contractors do not have access t th u, Signature of Agent/Ow)-/tA-"ASignature n of contractor 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH ' . COMMENTS 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: FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signatureldate COMMENTS Locatea 3t94 usg000 Street no 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 ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 VM 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/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) ❑ 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: Doc.Building Permit Revised 2008 Location ///7 No. Date - <XA-/ /d TOWN OF NORTH ANDOVER 0 4B Certificate of Occupancy $ Building/Frame Permit Fee $ S CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # -3 0 7 22967 Buhing Inspector 16 w w o a c v e w z z A z go w a u 0; 0 a Z w a po p „� c o r w° a ou E U Cd w a rx Cd w cx w" w W x r. w' o v v Q cn ui z o :mc �t L X" c •- .sem M C E a `, o� o t. CL (A u:JE .. v C C o c mm Z :caL a L C3 C=MH V: m V� •� �: m ' N A o E O W aC� m Z): :v,mCID" s �o c `.act m ga V y o O oa Z aw cm coao c = o d 03 N N W C v t O 'fl AD � C r... •� H .;; O. Z A c O W A� v _v .vi O C.3 o O o co H a on o F- 210 t 0 CL 4.. m � I ul uj U) W W LLI W N t%ORTH TOWN OF NORTH ANDOVER OFFICE OF M BUILDING DEPARTMENT co t 400 Osgood Street y�a.� North Andover, Massachusetts 01845 D. Robert Nicetta, Building Commissioner Telephone (978) 688-95454 Fax (978)688-9542 CONTROL CONSTRUCTION - SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 01845 I Carolyn Hendrie THE BUILDING CONSTRUCTED AT 1 High Street Y CERTIFY THAT DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: Building 14, Selected Renovations to Floors 2 & 5 for Converse, Inc. AUTHORIZED SIGNATURE: DATE: April 6, 2010 REGISTRATION: 4 8 2 3 NOTE: ENGINEER "WET STAMP" MUST BE AFFIXED TO THIS FORM `, Control Construction Form revised 11.15.2004 HOARD OF APPFALS 688-9541 CONSERVATION 688-94;30 1 [EALTH 688-9.540 PLANNING 688-9535 Massachusetts - Department of Puhfic Safct% 9 Board of Building Regulations and Standards Construction Supervisor License License: CS 56087 Restricted to: 00 STEPHEN M TERRENzi 1.2 ENDICOTT STREET NORWOOD, MA 02062 Expiration: 3/5/2011 ( nm�i••iuner Tr#: 12500 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/El lectricians/Plumbers Applicant Information Please Print Legibli, Name(Business/Organization/Individual): J. Calnan & Associates, Inc. Address: 1250 Hancock Street, Suite 302N City/State/Zip: Quincy, MA 02169 phone#: (617) 801-0200 Are you an employer? Check the appropriate box: 1. X❑ I am a employer with 5 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 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. employees and have workers' [No workers' comm. insurance comp. insurance. required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152; §1(4), and we have no employees. [No workers' comp. insurance required.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I l .❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other 'Any applicant that checks box 91 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp, policy number. 1 ant an employer that is providing, workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ohio Casualty Insurance Policy # or Self -ins. Lie. #: XW05 3119 614 Expiration Date: 10 _1/2 010 Job Site Address: I Ainh Stmt City/State/Gip: 14. WOW, "h01545 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 WORIC 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/011 for insurance coverage verification. 1 do hereby cern yttd r ainsIiV penrr 'eslof periury that t/te information provided above is tru5 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 S. Plumbing Inspector 6. Other Contact Person: Phone #: ffnformati®n and ffnstr ct.ons 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, S25C(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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial. Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen -nit 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 pen-nit/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-MA.SSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia ACCORD CERTIFICATE OF LIABILITY INSURANCEIDA E( 2 ) 009 PRODUCER Phone: 781-681-6656 Fax: 781-681-6686 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Driscoll Agency, Inc. 93 Longwater Circle P.O. Box 9120 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Norwell MA 02061 POLICY EFFECTIVE DATE MM DDIYYYY POLICY EXPIRATION DATE MM DD INSURERS AFFORDING COVERAGE NAIC # INSURED J. Calnan & Associates, Inc. President's Place, No.Tower 3 1250 Hancock Street INSURERA:Nat' 1 Fire Ins Co of Hartford 20478 INSURER B: Everest National Insurance Cc INSURERC:Ohlo Casualty Insurance Co. INSURER D: Quincy MA 02169 INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADDT POLICY NUMBER POLICY EFFECTIVE DATE MM DDIYYYY POLICY EXPIRATION DATE MM DD LIMITS A GENERAL LIABILITY INS2095325239 10/1/2009 10/1/2010 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE ( RENTED PREMISESS Ea occurrence) $ 100,000 CLAIMS MADE Fx_1 OCCUR MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 X In(, Conl7ractual X Inc. X, C, U GENERAL AGGREGATE $2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 POLICY X PRO- LOC A AUTOMOBILE LIABILITY ANY AUTO SAP2095325225 10/1/2009 10/1/2010 COMBINED SINGLE LIMIT (Ea accident) $1000000 BODILY INJURY $ (Per person) X ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ X X HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANYAUTO AUTO ONLY: AGG $ B EXCESS I UMBRELLA LIABILITY 7108000071-91 10/1/2009 10/1/2010 EACH OCCURRENCE $10,000,000 X I OCCUR F—I CLAIMS MADE AGGREGATE $10,000,000 $ DEDUCTIBLE $ RETENTION $ 0 C WORKERS COMPENSATION YIN AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE XW053119614 10/1/2009 10/1/2010 RY S X G R MA RI CT N' X WIMU E.L. EACH ACCIDENT $500000 OFFICERIMEMBER EXCLUDED? ❑ (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $500000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT 1 $500000 A OTHER INS2095325239 10/1/2009 10/1/2010 Leased or Rented $100,000 Conractor Equipment DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Evidence of insurance for work performed within the Insureds scope of normal business operations. Notice of cancellation provision is 30 days, except 10 days applies for non-payment of premium. *SAMPLE* USA ACORD 25 (2009/01) 11110110, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE f.c ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OF created with pdfFactory Pro trial version www.pdffactory.com IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009/01) OF created with pdfFactory Pro trial version www.pdffacto[y.com J. CaInan S& Associates C ON S T R U C T I ON M ANA G E R S Project: Converse - Bldg. # 14-5 - Kitchen 117 Reconfiguration Address: One High Street N. Andover, MA SCHEDULE of VALUES March 24, 2010 Division 01000 Project Requirements CurrentTrade - . 669 02070 Demolition NIC 06400 Finish Carpentry & Millwork ALLOW 5,520 09250 Gypsum Drywall 895 09650 Resilient Flooring ALLOW 700 09900 Painting & Wall Covering 600 11450 Residential Appliances 1,848 15300 Fire Protection NIC 15400 Plumbing ALLOW 750 15500 HVAC NIC 16000 Electrical ALLOW 1,000 16400 Tel/ Data Building Permit ... 1 NIC $11,982 144 General Conditions 4,422 Pre -construction Services NIC Architectural / Engineering Fees NIC Design Reimbursable NIC Utility Fees NIC Testing NIC Construction Contingency 0.00% 0 Bond NIC Insurance General Liability 165 Insurance Builders Risk NIC Construction Management Fee: 836 ei11J. CaInan & Associates C ON S T R U C T I ON M ANA G E R S Project: Converse - Bldg. # 14-2 - Kit. To Office / New Kitchenette Address: One High Street N. Andover, MA SCHEDULE of VALUES March 19, 2010 Division 01000 Project Requirements CurrentTrade - . 1,249 02070 Demolition 758 06400 Finish Carpentry & Millwork 5,115 08050 Doors, Frames and Hardware ALLOW 825 08800 Glass & Glazing ALLOW 360 09250 Gypsum Drywall 4,430 09650 Resilient Flooring 296 09680 Carpeting 1,407 09900 Painting & Wall Covering 1,574 15300 Fire Protection ALLOW _ 1,215 15400 Plumbing 3,184 15500 HVAC ALLOW v 655 16000 Electrical 393 1ANI 16400 Tel/ Data Building Permit Subtotal 270 General Conditions 7,816 Pre -construction Services NIC Architectural / Engineering Fees NIC Design Reimbursable NIC Utility Fees NIC Testing NIC Construction Contingency 5.00% 1,527 Bond NIC Insurance General Liability 321 Insurance Builders Risk NIC Construction Management Fee: Total 1,620