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HomeMy WebLinkAboutBuilding Permit #541 - 10 IRONWOOD ROAD 3/8/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION LLam . { fi i Permit NO:�J Date Received Date Issued: (� IMPORTANT: Applicant must copplete all items on this page LOCATIC3N I - ( n �''` Print PROPERTY OWNED V � 1CG P MAP NO:Ly-c— PARCEL: ZONING.DIST'RICT: Historic District yes n -Machine Shop V4fage yes no TYPE OF IMPROVEMENT PROPOSED USE Reside tial_ Non- Residential New Building One family Addition Two or more family Industrial Iteration No. of units: Commercial epair, replacement Assessory Bldg Others: Demolition Other Septic Well FloodplainWetlands Watershed [District Water/Sewer_ - DESCRIPTION OF WORK TO BE PERFORMED: i S C Cc l -SC vn �' ppm Ide 'ficati u Please Type r Tint Clearly) OWNER: Name: i� C3 hone: Address: �k v\, c uopp t4ADO F CONTRACTOR Name: \ c k M�T ti hone: Address: Supervisor's Construction License ) �,7 Exp. Date. �t Home Improvement License: Exp. Date: -irJ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ C FEE: $ Check No.:�n Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access�ty the jifilar my f d - ig nature of Agent/Owner Signature tof contracto l 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 tea►• 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 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 Reviewed on Signature C9MMENTS 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 p p t FIRE DEPARTMENT - Tem Dum stet 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 No MGL Chapter 166 Section 21A—F and G min.s100-s1000 fine NOTES and DATA— For department use I I f ❑ Notified for pickup - Date i ...._._.............._...�_._.............................—_.................................-----.............................._—............._...........-------------------- ---....._......----.......— ._........—---.................... Doc:.Building Permit Revised 2008 Location�� -yAJwQ4d No. Date V � v NORTH TOWN OF NORTH ANDOVER F p P s ; s Certificate of Occupancy $ '`- �� HuS Building/Frame Permit Fee $ �— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22541 Building Inspector tAORTH c Town Of 0 0 o LAKE o over, Mass., _ COC HICHEWICK yet ADRATED PPS` -`C.1 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System C. BUILDING INSPECTOR THIS CERTIFIES THAT Gl u .......r► .�............................. � ''..�....... .......................................................... Foundation has permission to erect........................................ buildings on ...I0.. ..—VIL(X...L.47..C�.47 ..........! .- Rough t0 b8 OCCUpled aS... .4h.14f. ........ A. '"''�1... ............. ... '1�1�1��. ..'f....1..J�L1... . IZ!( .. :...�.. Chimney provided that the person accepting this permit shall in every respe nform to the terms of the application ile in Final 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 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTR CTIO T Rough .......... ............................................................ — ..... . ....... . . ........... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR ugh 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 Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ACO-R- . CERTIFICATE OF LIABILITY INSURANCE ORTE(MLAl130/YYVY) PRODUCER -- 3/8/1 0 )EDWARD M. CONNOLx.Y INS AGCY TMIS C�ACONE IS ISSUED ASA UPON I OF INFORMATION 7 Linooln Street HHoLo AND CONFERS CERT No. bOE85 NOT AMS C�FiCATE PO Box 408 ALTMt TI—CO-EPA C�AF D BY THE POLICIIN HELOso W Westford? 14K 01886 MURED �--.-_ INS AFFORDING COVERAGE NAIC# MICHAEL BUSHNELL X)SA INSURERA; RCE INSURANCE CO ...... BUSHMLL CONSTRUCTION "AsIR+EaLA:7°►IG C !AMISS 89 MSADpW19ROOK ROAD n+suREac:VERMONT MQTUAI, xNS. CO. N. CHE MSpMUWn,, MA 01863 R4URERD:OPESTORN WORLD INS. CO COVERAGES I URERE. ANY THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITIiSTANDIN© MAY PERTAIN.TTHET. TERM OR IN INSURANCE AFFORDED DEO BY THE POLICIESCDESCRIBEHEREIN DOCUIS SUBJECT Nr WITH RESPECTTO L NE�MS THIS b CERTIFICATE D COMAY BE ISSUED OR NDITi0N8 Of SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, POLICY NUMBER =- GENERA LIABRITY LIMITS D COMMERCIAL GENERAL LIABILITY EACH 0O lR2IE NO E S -.000,000 NPP1203624 4/26/09 4/26/10 D g I+uAoueL_$ 5 00 CUIMSMAOE [}�occuR M®IXPp one 3 000 PERSDw�LBADVN"Y 3 11000,000 GENLAGGREBATELIMITAPPLESFek GBNERALAOORMATE A 2 000 000 PRa Loc FRODUCTs-0CMPaFAM s I,oQo 000 AUTOMOBILE LIAMLITY A MYAUTO P59831 9/13/09 9/13/10 CW161NHDSNQfiUMR = ALL OIM1NFA AUTOS �C SCHWULEDAUTOS IcOOI eNJRY S 100.000 HIRED AUTOS X NON-OWNED AUTOS BQ Pl�Y1�IRY q 300,000 FRCP d ,My) §E s 100,000 tONIA AUIOONLY.EAACCDINT t NTMI;R THAN A ACC 9 -� A1700KY; AGO S uABIun E4CHOCC LAMNCE 4 CLAMS MADE -. fGGR89ATE S 3 ! S WORKERSOOMPENSON AND E $ EMATI PLOYEW LAWLITY T ^ nNYPKOPR FAmTNEwEXEcumn WOOOS957339 NOFFICEZ EMB 6/2509 EXCLUDED? / 6/25/10 EL MCHAcci trr__ S 500 000 ePECMIeabw El,0101ASi-EAEMPLOYES S 500,000 DTHQ{ E L DIGEASE-POUCY LMIT 3 500 000 OMORIPTKMOFOPERATtONSrLOCATIONS/VEN1CLeS eXCLUMONSADDEDBYENDORSI?MBNT!SPECIALPROVIBIONS -job: 10 IRONWOOD ROAD NORTH ANDMR, MA CERONCATE HOLUR CANCELLATION TOM OF NORTH ANDOVER SHOULD ANY of THE MOVE DESCRIM POLICIES BE CANCO,LED BEFORE THB EX mmoN 1600 OSGOOD SPIFFY DAM THEREOF.THE ISSUIMG INOUMA WILL ENDEAVOR TO MAM,,90 DAYS wrom BLDG 20 STE: 2-36 NOTICE To THE CERT'RCATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SD SNA LL NORTH ANDOVER, Imo! IMPOM NO OBLIGATION OR LIABILITY OP ANY KIND UPON THE INSURER,ITS AGENTS OR ATTN: 8LDG. DEPT. , REPPIM MATIVft AUTHORIZQOREP 80TATIVE ACO��(�01l08) NANCY A. RIVET M ACORD C TIUN 1988 . i The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, 111A 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Le6><bIy Name (Business/Organization/Individual): C�D Address: City/State/Zip: I� Phone#:—q 7 — AFw an employer?Check the appropriate box: 1. am a employer with 4. Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ eu'construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. x . Remodeling ship and have no employees These sub=contractors have 8. ❑Demolition working for me in ancapacity. workers'Y ca acP ty rs comp.insurance. 9. Buildin ad [No workers' comp. insurance 5. El We are a corporation and its g dition required.) officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL l I.❑Plumbing repairs or additions myself. [No workers'comp. C. 152,§1(4),and we have no insurance required.] t employees- [No workers' 12.E]Roof repairs comp.insurance required.) 13.0 Other •.Any applicant that checks box Al must also fill out the section beto•, SnOR _TA•aon .nom L^�L WG'Ye_'S C� _cor:nn..ni:,... _ _' ^ . 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 anemployer that is providing workers compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ExpirationDate: Job Site Address: y� City/Stats/Zip: 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 c fy u der e p s and penalties of perjury that the information provided abi ve is true and correct Simature: Date,: Phone#: 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 Ins 6. Other Inspector 5.Plumbing Inspector 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 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 aupIication 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 bum 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 lnvestibations 600 Washington Street Boston,MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-72.7-7749 www.mass..gov/dia �v i I 1 4 u •- Massacbusetts- Depatrtment of Public Safet% Board of Building; Regulations and Standit"Is Construction Supervisor License License: CS 58872 Restricted to: 00 MICHAEL E BUSHNELL 89 MEADOWBROOK RD . N CHELMSFORD, MA 01863 ` Expiration: 3/31/2012 ('unuuisiunrr Tr#: 18684 -\ HOME AE CONTRACTOR ` y Registrat"On" 108952 Tr# 274351 Expiration: B/27f2010 TYpei'.,Fndiv,iduai BUSHNELL CONSTRUE f10N -(olchael Bushnell.,,.., 89 MEADO'WBROOI<`RO i�dn�inistratoi Chelmsford,MA 01863s - i BUSHNELL CONSTRUCTION 89 Meadowbrook Rd. -(978)256-4388 Chelmsford,MA 01824 Fed ID.#04 385762 Registration#108952 1/11/10 PROPOSAL SUBMITTED TO WORK PERFORMED AT Camille Sarrouff 10 Ironwood Rd North Andover,MA 01845 same SCOPE OF WORK Finish off existing basement according to conversation with owner will meet prior to start of job to confirm. This proposal will include the following: 1. Frame -Frame in walls as discussed according to building code - Frame in soffits around duct work and pipes in order to have a plastered ceiling - Frame in 2 closet - Rebuild stairs for skirtboards- 2. Insulation - All exterior walls will be insulated with 31/2" insulation 3. Electrical - Owners responsibilitys contractor to facilitate 4. Wall finishes - all walls will be insulated - 1/2" blueboard will be installed on walls and ceilings - Scimcoat plaster with textured ceilings will be applied to walls and ceilings 5. Woodwork finishes - All baseboard and door casings to match existing paint grade - All doors will be paint grade supply and install 6. Windows and doors - All doors will match existing styles r 7. Painting - Paint all new walls and woodwork prime and 2 coats of paint 8. Miscellaneous - Obtain building permit -remove all construction debris Total Estimate $14,500.00 Work will commence week of March 3 2010 and will be completeed week of March 25 2010 Payment Plan 25% deposit $3625.00 25% completion framing $3625.00 25% completion Plaster $3625.00 Balance upon completion $3625.00 All contractors shall be registered with the state of Massachusetts any inquiries shall be forwarded to Office oof Consumer Affairs Ten Park P1aza.Suite 02116 Boston,MA 02116 (617)973-8700 All warranties on the owners rights under the provisions of MGL c. 142A Owner has the right of 3 day rescission on this contract Any alteration or deviations from above specifications involving additional costs will be executed only upon written work orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado and all other necessary insurance upon above work. Workmans compensation and public liability insurance on above work to be carried by Bushnell Construction Do not sign this contract if there are blank spaces Owners A ceptance Respectfully}Submitted h Bus e 1