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HomeMy WebLinkAboutBuilding Permit #702 - 119 OLD FARM ROAD 6/16/2009 NORTI1 BUILDING PERMIT J1 TOWN OF NORTH ANDOVER 03 4 - - APPLICATION FOR PLAN EXAMINATION * ; 00 b n b i U O V � O Permit NO: Date Received ' g0gAr 0 Date Issued: �VJ v I �SSAGHUS�� IMPORTANT:Applicant must complete all items on this page c tO-C LOCATION PROPERTY OWNER &.w.4xv Print ,f e urs Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential New Building Onefamil Addition Two or more family . Industrial Alteration No. of units: _ Commercial Repair,4!q%acement Assessory Bldg Others: Demolition Other Septic Well floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO E P E ORME -4 - _r _/ . "p, f . -le eIg ��/ �✓ Identifi n ca 'o Please Type or Print Clearly) p YP Y) OWNER: Name: .�P�7 loud Phone: 9/�s x6f3-7os'9- Address: l f G�� CJCC9c1 " CONTRACTOR Name: Joe ci, cr — Phone: Zze fk Address: zw . Supervisor's Construction License: �G c 'd Exp. Date: /2d/Zai ' Home Improvement License: f V-rl}-'15 Exp. Date: Z a O ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS ON$125 R S.F. Total Project Cost: $ G FEE: $ O Check No.: /U J Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund gnature of Agent/Owner Signature of contractor:.. ,/, i 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 i 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 A 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 DEPARTMENT -Temp Dumpster 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.$100-$1000 fine NOTES and DATA— For department use) i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 Wiffi 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 L3 Two Sets of-=Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract -u 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 General Contractor ESTIMATE Contractor/Supervisor Lic. #065280 Joe Blanchet Home Improvement Lic. # 145193 124 Lake Street Fully Insured Haverhill, MA 01832 978-994-6134 Date of Estimate: June 8, 2009 Client Name: Jeff&gosemarie Buxton Job Location: same Address: ?b9v[ farm rd. N.Andover Ma Phone: 978-683-7055 Description of Work: remodel 2nd floor master bathroom Remove tub sheetrock around tub area. Install new tub and dura rock on walls and put corian up. Remove tile on floor and plywood under tile. Install %2 dura rock on the floor and then tile. Remove and reinstall new vanity with sink Install medicine cabinet. Remove and install new toilet Painting: paint walls and ceiling 2 coats Debris: A.B. Custom Carpentry will responsible for removal of all debris into rental dumpster. Permits: Permits needed for construction are: building and plumbing Owner Responsibilities: supply all fixtures paint tile and grout Additional Work: Any alteration or deviation from above specifications involving extras or vendor price increases will be discussed and will become an added charge over and above the estimate. Work performed at $55.00 per hour/per man Laborers will be $22.50 per hour/per man. Total Cost of Estimate: $0700.00 Payment: A deposit is required before work can be started. Starting payment will be '/2 f- 0 1 and Last payment due after final inspection. !/�!—�� 4e 2v ��mtowners Sign ture Date �Lo C) P Yl0 General Contractor ESTIMATE Contractor/Supervisor Lic. #065280 Joe Blanchet Home Improvement Lic. # 145193 124 Lake Street Fully Insured Haverhill, MA 01832 978-994-6134 Date of Estimate: June 8,2009 Client Name: Jeff! osemane Buxton Job Location: same Address: 169 F�` farm rd. N.Andover Ma Phone: 978-683-7055 Description of Work: remodel 2nd floor master bathroom Remove tub sheetrock around tub area. Install new tub and dura rock on walls and put corian up. Remove tile on floor and plywood under tile. Install 1/2 dura rock on the floor and then tile. Remove and reinstall new vanity with sink Install medicine cabinet. Remove and install new toilet Painting: paint walls and ceiling 2 coats Debris: A.B. Custom Carpentry will responsible for removal of all debris into rental dumpster. Permits: Permits needed for construction are:building and plumbing Owner Responsibilities: supply all fixtures paint tile and grout Additional Work: Any alteration or deviation from above specifications involving extras or vendor price increases will be discussed and will become an added charge over and above the estimate. Work performed at$55.00 per hour/per man Laborers will be$22.50 per hour/per man. Total Cost of Estimate: $700.00 Payment: A deposit is required before work can be started. Starting payment will be %2 o and Last payment due after final inspection. ZUv meowners Sigture Date i n�na Stands Gff�v• gegulat►o S adding ervigOr L►cense Board of B tion Sup C°nstruc 65280 L►ceAsaaaCS te' 91�p11963 Tr# 7199 girthda x 91201209 1 E.;�ytrat►on.. str� tip 00 BLANCH JOSEPH G o Commissioner 124 LAKE ST `"- HAVERHILL,MP'OA LTi ( g "d Scan ar S JJ of Bw me9u at►oiis an CTOR Board T CONTRA HOMEIMPROV EMEN 45193 Registra090:,1 iration 1212212010 Tr# 28046 Exp individual Type JOSEPH T BLACHE BLANCHET JOSE12PH Administrator 4 LAKE ST 08311 ATKINSON,MA VIIVV ••a•_... (JNICIMivuuu•...•, p/� 6 009 dSt3iLL7►it>w CERTIFICATE OF LIABILITY INSURRAN�E ISSUED AS A MATTER OF INFORMATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Circle Business Insurance Agency Toc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 247 Newbury St. I NAICM Danvers, NA 01923 INSURERS AFFORDING COVERAGE - 17-7030 IN FRA: SCOttSdAle IAeurance INSURED Joseph $lanchet INsuRER B: Z C RICAN 124 Lake Street INSURER C: Haverhill, M& 01832 INSURER D: INSURER E ,978- 94-6134 TEEM TME POLICIES MENTINSURANCE T RM OR LISTED CONDIg p OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT O WHICH THS CER IFICATE MA BE ISSUED OR ANY REQUIRE (�{AY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH PDLICIEB.AQ0 EOATELIMITS$HOWNMAYHAVEBEEN REDUCE DHYPAIDCLAIMS. E THE POLI CYEXPiRATiON LIMT$ POLICY NUMBER PATE MMIDD/YY DATE MiNtDDM EACH OCCURRENCE S 1 000 000 GENERAL LIABILITY PREMISES(Ea ocemnoe' s 1 000 000 1 COIm aFtelALGENIwRALLIABILITY .MEDEXP(Anyo^eperm^) b CLAIMSMADE Ri OCCUR PERSONAL GADVINJURY S '1 000.00 X cLs1416404-08 4/x/48 9/1/09 GENERAL AGGREGATE S 2 000 0 0 PRODUCTS-COMP)OPAGO $ 2 00 000 GIN.L AGGREGATE LIIMrT APPLIES PER: POLICY JECT r LOC I COMBINED SINGLE LIMIT g AUTOMOBILE LIABILITY ANYAUTO I 1 ALL OWNED AUTOS Ber00foon) S SCHEDULED AUTOS 80DILYINJURV S HIRED AUTOS (PeraWdent) NON.OWNEDAUTOS I PROPERTY DAMAGE f I� (PgreCVde^tl AUTO ONLY-EA ACCIDENT S I OTHER THAN EA ACC S AWAUTO ;AUTO ONLY: GARAGE LIABILITY ACiG S EACH OCCURRENCE S EXCESS&NORELLA LIABILITY AGGREGATE S OCCUR C,CLAIMSMADE II 3 DEDUCTIBLE S RETENTION S JC T RY ARIArIT I TH WORKERSCDMPENSATIONAND IE�,EACH gI;CIDEN7 E l0O,000 EMPLOYERS'LIABILITY UB-56170190 9/6/08 9/6/09 ANY FROPRtETORA,%REIFFJlECUTIVEE.L.DISEASE-EA EMPLOYE S ZOO OOO a I OFFICERM EMKOt MILUDED" Hi yp tlWCflDeu^30( E.L.DISEASE-POLICY LIMIT S 500.000 SP CIA PROVISIONS below OTHER I DESCRIPTION OF OPE RATIONS 1 LOCATIONS t VEHICLES I EXCLUSIONS ADDED SY ENDORSEMENT 1 SPECIAL PROVISIONS I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL1O DAYS WRITTEN j 1600 Osgood Street Building 20 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Suite 2-36 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TME IN ITS AGENTS OR North Andover, NA 01845 REPRESENTATIVES. Attn: Brian AUTHORIZED REPRESENTATWE Fax# 978-688-9542 C ACORD CORPORATION 1988 ACORD 25(2001/08) NORTH c OVM Of over 0 0 No.W 'Z 4...�.. C% dover, Mass., • �L ' O O LAKE COCKICKEWICK 7�ADRATED 10kP�,`�C5 `r E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT... %.. ........Our...... 6v%b........................................ ......... . . . .................................. Foundation forp has permission to erect............................. ......... buildings ons.................. Rough ��............�........... to be occupied as.......A& Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file 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 ©� 1p PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU N S T.S Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. Thr° Commonwealth ofMassachusetts f Departm of of Industrial Accidents Office of Investigations r 600 M a�shinvinn Street Boston, MA 02111 wmmsgovldia . Workers' lww Compensation Insitrance Affidavit: Budders/Contractors/Electriciaflxs/Plumbers A iicant nfor Imation. Please Print Lembl Name(Business/organizafion/Individual):_ T�t A/11A�(,/L� Address' ? — ti S'`f- City'State/Zip: /4 J Phone Are you as employer?Checkthe appropriate box: L P-1 am a employer with 4. ❑ I am a genera[contractor and I Type of protect(regatref�. employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction . 2.❑ I am.a.sole proprietor or partner- listed on the attached sheet,I 7. ❑Remodeling ship and have no employees'. These sub-contractors have working for me in any capacity, workers' comp.insurance. 8' Q Demolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9• Q Building addition 3.❑ required.) officers have exercised their 1Q•❑Electrical repairs oradditions I am a homeowner doing all work right of excrrrption per MGL 11.❑Plumbing repairs or idaitions myself [No workers'comp. c 152, §I(4),'�d we have no insurance uired. _t 12.❑Roof repair s I ] .employees.[No Workeas' COMP. is tstisancx uired. 13•[].Other n4 ) 'l+iry appficerit tient checks bob{�f must also fiii out the section Irdow showing their ccorkera'aompensatioa policy infmmatioa t Homeowners who submit this affidavit indicating they are doing an wor}c end that hee outside contractors ;COritraCtew that cheek this box roust•�nh.A an additional sheet sho;v must submit a new affidavit indicating such. mg•the name orthe sub-connectors and their woric r %con:•,,. !am an employer tont u providurg:workers'compensation - r pc..-,minrmetion. information. mP �risurance for my ernploYee� Below it the policy aad job site . Insurance Company Name: r rc 1(le- em C Policy#or Self-ins.Lie.#: Expiration Date: ------------ Job Site Address: Attach a copy of the workers' cora nsafion City/StatclZip: Vi e, , O - Pe 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 fire imposition of criminal fine up to$1,500a an one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER rated 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. 1 do hereby certify ander the alas and penalties ofPerJWY tfial the information provided above a true and eorrecL 5i tra•e: / . Phone Official use only. Do not write in this area,m be completed b or town n Y .f}icral City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Piumbing Inspector 6.Other Contact Person: Phone#: I Information a. nd Intstructions Massachusetts General Laws chapter 152 requires all emp 3 oyers 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 includir-kg the legal representatives of a deceased employer,ar the receiver ortrustw of an individual,partnership,associatiori or other leL�entih,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 maimt�enance,construction or repair work an 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 steal!withhold the issuance or renewal of license or permit to operate a business or tte construct building in the commonwealth for any applicant who has not produced acceptable evidenceaJ7 compliance with the insurance coverage required." Additionally, MOL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfomzsrrce of public work until acceptable evidence of comptiancx with the insurance req==eft of this chapter have bean presented to the corttractarg authority." Applicants Please fill out the workers'.compensation•affidavit compimtely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s),address(es):Mind phone number(s)along with their certificate(s)of insr mce. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required,tu carry workers'coirrpensafinn insurance. Van LLC or UP 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 retied to the city or town that the.application for the permit or license is being requested,notithe 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 numberlisted bolow. Self-insured companies should enter their self-insurance license number on the'approprke fine. City or Town Officiais Please be sure that the affidavit is complete and printed legibly. The Department hes 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/Iicense number which w-til be used as a reference number. In addition,an applicant that must submit multiple pennit/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 writo"all locations in (city or town)."A copy of'the affidavit that has been officiaily stamped or marked by the city or town may be provided to the appiicant as proof that a valid affidavit is on file for futam permits or licenses. A now affidavit must be filled out each year. When:a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a flog 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 Lmv. esttigations 600 Washington Strt:et Boston, NLA 02111 TeL #617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7741 Revised 5-2b-QS www,mass.gov/dia Location No. --?O - Date 6 - /6 -0f MORTM TOWN OF NORTH ANDOVER ►o- s s , Certificate of Occupancy $ sCMUs t� Building/Frame Permit Fee $ d Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22`► L2 Building Inspector