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HomeMy WebLinkAboutBuilding Permit #1281-2016 - 1160 GREAT POND ROAD 6/9/2016 J L � / t NORrH BUILDING PERMIT o t/ p� t�eo � *a�H TOWN OF NORTH ANDOVER - A ► ,, tPPLICATION FOR PLAN EXAMINATION * _ Permit No#:: Date Received gSsgAr cHus���� Date Issued:0 1 Q zo/az' IMPORTANT: Applicant must complete all items on this page LOCATION l2ooll S tl�o dL ( Z G o Ca/1-61f 71 Print PROPERTY OWNER 3/200ta LL a Print ° MAP �� 3 PARCEL: b6211 ZONING DISTRICT: Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑Two or more family ❑ Industrial ❑Alt ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: C emolition ❑ Other Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer - -- - - DESCRIPTION OF WORK TO BE PERFORMED: l2 EJb 1-44-7.j 0 A,,6 6 o u Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor ame: R b, CJPhone: Email: /b, Address: 10�— t •'J(-C.�` l `Z U- Supervisor's Construction License: S V� Z) -Exp. Date: Home Improvement License: /0 G Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$10008F THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3(, FEE: $ Check No.: 6 3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to t ze guaranty fund 8iqnature of Agent/Owner - -_- — — — - — - r 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks :6 Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses :rF Copy Of Contract 4. 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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 i 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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email f Date Time Contact Name Doc.Building Pennit Revised 2014 Y 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 e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori 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 FIR EDEPANMEN�T TempD;umpster onsite }yres� _ no � E 3,Located►at{124tMa m;cStreet. COMMENTS. - 1 ' Location No. 1��I `� Date • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �- --- Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ Check#it'llf 1 Building Inspector V Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 36,685.00 m $ - $ 440.22 Plumbing Fee $ 55.03 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 55.03 Total fees collected $ 650.28 1160 Great Pond Road 1281-2016 on 6/9/2016 renovate an office, convert a bathroom to an office to R TH Town of oUSE& - .� No. s air � i � h ver, Mass, C0C"1C«[w1cw 1' �,AS RATED P-le U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT .. ... .... ..x.10 BUILDING INSPECTOR has permission to erect ....... Foundation ................... buildings on ... ... . Rough to be occupied as ����...4*0= p,,, ...... ... ,�• Chimney provided that the person accepting this ermit shall In c � p p g p eve spec norm to her s e appllcatlon 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONST IO Rough Service .. .. .. .. ... ......... ...... Final BUIL NSPE OR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 Approved by the Building Inspector. Burner Street No. Smoke Det. RIC FLUET 02 BRIDLE PATH LAN�CTnvG, INC PROPOSAL METHUEN, MA Ol 844 Date Estimate# 5/24/2016 626 Name/Address BROOKSSCHOOL 1160 GREAT POND RD. N.ANDOVER,MA.01845 INFIRMARY Description 2ND.FLOOR BATHROOM;DIVIDE EXISTING BATHROOM TO MAKE ROOM FOR AN OFFICE.REMOVE AND CAP TWO SINKS,ONE SHOWER AND ONE TUB AS NECESSARY.DEMO AREA AS NEEDED.ADD WALL TO SEPARATE ROOM. PROVIDE ACCESS INTO OFFICE THROUGH EXISTING CLOSET.INSTALL NEW FAN IN EXISTING BATHROOM. SEPARATE LIGHTING.IN NEW OFFICE ADD LIGHTING,AND OUTLETS TO CODE.INSULATE EXTERIOR WALL,SHEETROCK ENTIRE OFFICE.INSTALL BASEBOARD AS NEEDED.PERMIT AND TRASH REMOVAL IS INCLUDED.$8525.00 FLOORING AND PAINTING BY OTHERS. PROPOSAL IS VALID FOR 30 DAYS. EXTRAS OR CHANGES TO BE COMPLETED AT A RATE OF$90.00/HR/MAN. MA.LIC.#50710 HIC.# 106620 FINANCE CHARGE OF 1& 1/2%PER MONTH FOR UNPAID BALANCES. PAYMENT SCHEDULE;AS WORK PROGRESSES Tota $8,225.00 Signature Phone# Fax# E-mail 978-685-7010 978-685-7010 RFC102@verizon.net Id.; t.t:?'i:`l� 1er�gb Saara/.-r ABee� �',. �e y, 4JI, r � �-`�,"'y' � R C!o Cho. 1• i Wf�,.• Ca lop Cs T �w o V 7reds�»$ YV — .r i N L—,,✓ .�J,j.a"l• ' a coAtid r�cflaar � � n _ ;Eel 8l yl •'i�' Revised S"�,a3/8B ter,•.. b'•x ^,e by n-.��e_'�. •' ' Wit'•nY' �,:• r .. th+�.Frvl iiw•}E%`. ';�, •�.; U$.� is ytia:?•17 1 RICHARD FLUET CONTRACTING,INC 102 BRIDLE PATH LANE ��P�{�+ pA , METHUEN.MA 01844 Date Estimate# 3/30/2016 615 Name/Address ' BROOKSSCHOOL 1160 GREAT POND RD. N.ANDOVER,MA.01845 INFIRMARY Description SECOND FLOOR OFFICE;REMOVE THREE CLOSETS.BLOCK OFF TWO DOORWAYS,REWORK TRIM AS NEEDED.PAINT WALLS AND TRIM.$3500.00 SECOND FLOOR BATHROOM;RELOCATE ENTRANCE DOOR TO PROVIDE ACCESS FROM HALLWAY,BLOCK OFF QLD DOORWAY,TAY,INSTALL NEW FAN/LIG.HT UNIT AND VENT OUT-,PLACE TRIM AS NEEDED.PAINT DISTURBED AREAS. $32GO,Q0 PATCH WHERE RADIATORS HAVE BEEN REMOVED$75.00/PATCH REPLACE 60 WINDOWS WITH I-IARVEY WHITE DOUBLE;HUNG CLASSIC VINYL REPLACEMENT WINDOWS WITH ENERGY STAR RATED GLASS.AND V2 SCREENS.ADD OBSCURE GLASS IN BATHROOMS AS NEEDED.$21,000.00 REPLACE TWO BASEMENT WINDOWS WIT14 HARVEY WHITE HOPPER TYPE WITH SCREENS AND ENERGY STAR RATED GLASS.5700.00 Total $28.460.00 Signature _ Phone# Fax# E-mail C' 978-685-7010 978-685-7010 RFC1020veriwn.net • . The Commonwealth o,¢'Massachatsetts .Department oflndustrialAccidents . . d I Congress Street,Suite 100 ' Boston,MA 02114-2017 �.` www mass.gov/dia ,�. Workers'Compensation Insurance Affidavit:Builders/Contractors/Elee.tricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/bidividual): Address: /c7 d- �j (�tlt' t'- tom•✓ r City/State/Zip: ORL(L7 Phone#: "11 Are you an employer?Check the appropriate box: Type of project()required): 1.[ !am a employer with �loyees(full and/or part-time).` 7. Q New construction 2. ]I am a sole proprietor or partnership and have no employees working for me in 8. Reinodeling any capacity.[No workers'comp.insurance required.] 3..Q I am a homeowner doing all work myself.[No worlcers'comp..insurance required.]t 9. ❑Demolition <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 F]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[J Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ t 13.n Roof repairs These siib-contractors hale employees and have workers'comp.insurance. 6.F1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑OtheY 152,§1(4),and we hay.no.employees.rNo workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. 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 prot-ido them workers'comp.polijcy number. t. fain an employer tlzat is providing worlcers'compensation insurance for my employees.• Below is'the policy and job site information. /� Insurance Company Name: ` ►, "l�(��"7— Policy#or Self-ins.Lie.#: n Ll 3 / Z' 03 Expiration Date: 31131 Job Site Address: )�(,l`�y �"/ City/State/Zip: V`l 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. X do hereby certify u er epains and na o peijury that the information provided above is true and correct. Sign Date: Il 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 Inspector 5.Plumbing Inspector 6.Other 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 o1116e, express or implied,oral or written." ` An employer is defined as"an individual,partnership,association,corporation or other legal entity,ox any two or more of the foregoing engaged in a joint enferprise,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 b6 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=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 Ifrdustrial 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 permit or license is being requested,not the Dep, artmnent 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"fob 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia OP ID:WC ,►coir©� CERTIFICATE OF LIABILITY INSURANCE A 051119 9/122 0 1 ) 0 5016 6 THIS CERTIFICATE IS ISSUED A$ 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 pollcy(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). PRODUCER CONTACT NAME: Segreve&Hall Insur.Assoc.Inc PHONE FAX 305 North Main St. aG Arc 14 Andover, MA 01810 ADDREBB: Michael L.Segreve PROPUCEkFLU ET-1 c sromrR ID a: INSURERS AFFORDING GOVERAOS NAIC to INSURED Richard Fluet Contracting Inc. INSURERA:Arbella Protection Ins. CO. 41360 102 Bridle Path Lane INSURER U.Commerce Insurance Co. 34754 Methuen, MA 01844 INSURER C INSURER D: INSURE';E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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, EXCUUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR GLICY TYPE OF INSURANCE POLICY NUMBER MM/DIJ�IVYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00( DAMAGE TO RFNTE A X COMMERCIAL GENERAL LIABILITY 8500034727 06/12/2015 06/1212016 PR MI Ea occurrence) $ 100,0011 CLAIMS-MADE FKOCCUR MED EXP(Any one person) $ 5,001 8500034727 06/12/2016 06/12/2017 PERSONAL&ADV INJURY .9: 1,000,001 GENERAL AGGREGATE $ 2,000,001 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,001 rZ POLICY D PRO- 7LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea eooident) ANY AUTO BODILY INJURY(Par person) $ 100,001 ALL OWNED AUTOS 20DILYINJURY(per acddenl) $ 300,001 B X SCHEDULEDAUTOS PROPERTY DAMAGE $ 100,001 X HIRED AUTOS XV1460 12/01/2015 12/01/2016 (PER ACCIDENT) X NON-OWNED AUTOS S $ UMBRELLA LIABOCCUR EACH OCCURRENCE S rXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE S RETENTION $ S WORKERS COMPENSATION YWC STATU- OER TH- AND EMPLOYERS'LIABILITY T YLIMITS A ANY PROPRIETORIPARTNERIEXErCUTIVE /N E.L.EACH ACCIDENT $ 500,001 OFFICER/M(Mandatory in ER EXCLUDED? NIA 4220051550 03/31/2016 03/3112017 E.L.DISEASE-EA EMPLOYEE $ 500,001 (Mandatory in NH) IDfraSsdunder RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,001 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach AcQR0101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION NORTHAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS, Building Deparment 1600 Osgood St. AUTHORIZED REPRESENTATIVE North Andover, MA 01845 ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD ale Cpa�ztr�za�trnea�/�-n�C�il/nJJnrc�rrJr'/l Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 106620 Type: lrExpiration: -7/24/2016 Private Corporation i RICHARD FLUET CONTRACTING INC. Richard Fluet 102 Bridle Path Lane Methuen,MA 01844 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards l.11lllll UCllllll au. 115(Ij �- License: CS-030710 RICHARD A FLUO rr> 102 BRIDLE PAUi METHUEN MA 8184 r' ' 7t , � Expiration Commissioner 04/22/2017 i I