HomeMy WebLinkAboutBuilding Permit #592-2016 - 128 MILL ROAD 11/13/2015 {IORTH
BUILDING PERMIT OF�tt�c
TOWN OF NORTH ANDOVER o -
APPLICATION FOR PLAN EXAMINATION
JiNd
Permit No#: — �f°/ Date Received
SSACHU`+�
Date Issued: 1,2
M RTANT Applicant must complete all items on this page
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LOCATION
Pont
PROPERTY OWNER- �-�-r __.
y� Print 100 Year Structure yes no.
MAP PARCEA1 _ ZONING DISTRICT _ Historic District yes no
Machine Shop Village yes no
. .
TYPE OF IMPROVEMENT PROPOSED USE
Resid tial Non- Residential
❑ New Building Ane family
❑Addition ❑Two or more family ❑.Lndustrial
❑Alteration No. of units: ❑ Commercial
❑ Re air, replacement ElAssessory Bldg ElOthers:
D-ffemolition ❑ Other
CSeptic CNelh ElFloodplain Wetlantls ❑ Watershed,District
Water/Sewer
D SCRIPTION OF WORK TO BE PERFORMED:
�-@1 l4�r fey �C /4Ing Z�e%A%
/ICs o 2
Identification- Please Type or Print Clearly c
OWNER: Name: 1.�+c I Ian 3�o ,.a C k 14, Phone: 9Z&-Z-5 7--6 C(7.6
Address: / ( �
Contractor Name �-� V�'�Crti x 1, _ Phone. b
Email; w . ✓n �'.�... -�
Address: L
Supervisor's Construction License o b 3 Exp. Date: .
Homme Improvement License._-_-__� '`�' 3 7 _w Exp, Date.:
- - --- -
_ . -
ARCHITECT/ENGINEER Zd Phone:
Address: Reg. 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: $ S� 904.00 FEE: $ 1�`J
Check No.: Receipt No.: C;2-1`e
NOTE: Personsg with un a . tered contractors do not have access to the guafrf777
u
gnafureof Ag nt/ x _ Sign ture of contractor. _
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/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
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:Building Permit Revised 2014
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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
r
t
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
fDEPAR_TMENT T,ernpiDump,; ter��on 3noiosgooreet
- - �- -- -
s� site y,
llhbc�tb'di,atl.12.4MMain,,St�eet
'Fire Department signature/dafe;
ONIMENj _
i
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
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
� p )
❑ Notified for pickup Call Email
Date Time Contact Name I
Doc.Building Permit Revised 2014
Location < .1 6 ' /i J1 / d p
No. . 5911,7— 02a/ Date 1113115
• - TOWN OF NORTH AN ,
OVER
'
Certificate of Occupancy �$ C j
Building/Frame Permit Fee $ 9� y
Foundation Permit Fee $
-77
°P Other Permit Fee $
TOTAL $
Check#
296 S Building Inspector
i
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
115,902
.00 m
$ - $ 190.82
Plumbing Fee $ 23.85
Gas Fee 100 comm. $1 100.0.0
Electrical Fee $ 23.85
Total fees collected $ 338.53
128 Mill Road
592-2016 on 11/13/2015
Basement Remodel
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD� 1 AA Septic System
THIS CERTIFIES THAT .........�l ,�. .�.l.F'➢t.....
c6i,�i',�... BUILDING INSPECTOR
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. .. Foundation
has permission to erect ..... .............. buildings on .....k� K-01\ It'-mck.
p 1.�� �� r� ChRough
t0be occupied as ............................ ................................................................ Chimney
provided that the person accepting this permit shall in 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 6y N ELECTRICAL INSPECTOR
UNLESS. CONSTRUC A T Rough
Service
.............. ....... . ................. ...............................
Final
BUILDING INSPECTOR
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.
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2-M Construction
Billerica, MA
Tel: 617-839-2032
THIS AGREEMENT, made as of Nov 10, 2015
Between the Owner: Stella Chistyakov
And the Contractor: Paul Vercellini
Billerica, Ma 01821
(617) 839-2032
Home Improvement License#: 138378
Mass. Builder's License#: CS 083641
For the project: 128 Mill Rd North Andover
ARTICLE 1. CONTRACT DOCUMENTS
The contract documents consist of this agreement, construction documents, specifications, and
allowances and all change orders or modifications issued and agreed to by both parties. All the
documents noted above shall be provided to Contractor from Owner
ARTICLE 2. SCOPE OF WORK
2.1 The Contractor agrees to build the above mentioned addition and or install fixtures
attached there to in N Andover, Massachusetts according to, contract documents that were
submitted to building dept, and permit issued on these documents only. All work must conform
to local and state building codes.
ARTICLE 3 . TIME OF COMPLETION The projected completion due is approximately ( 4 weeks)
from the first day of construction. NOTE: Change orders and/or unusual weather might delay
or otherwise effect the completion date.
ARTICLE 4. ALLOWANCES:
4.1 Home owner has$ 1,000.00 allowance for 2 exterior doors
DESCRIPTION OF WORK
5.1 .All work performed by 2M Construction and or any contractor hired by 2M Construction is
to be done to Massachusetts state building code. 2M Construction is responsible for all
building materials needed to complete project, and all paying of sub contractors hired by 2M
Construction only. All trash removal as well.
5.2 BUILDING SCOPE INCLUDES : Supply and install 2 exterior doors, door to garage to be fire
rated per building code. Install ceiling medallion supplied by homeowner. GYM AREA SCOPE:
Demo existing shelving in proposed gym area. Frame new walls to create gym space, Insulate
wall on foundation side of proposed gym area. Supply and install all building and finish
materials needed to create proposed gym. Blue board & plaster walls in this area, ceiling to be a
drop ceiling, will try to match what's in existing basement area as discussed. Frame for walk in
closet, size roughly 7'x7'. NOTE : Any custom built in shelving will be a additional cost to
homeowner as this was added after agreed proposal price. Supply and install rubber ( gym
rated)flooring in gym area color TBD.Trim out window by basement exterior door. Supply labor
& materials for paint for all proposed work mentioned above, paint to be Bengamin Moore
Regal Select
5.3 ELECTRICAL INCLUDES: N/A
5.4 PLUMBING INCLUDES: N/A
5.5 HVAC INCLUDES: N/A
5.6 INSULATION TO CODE: Exterior foundation wall only
5.7 Blue board Plastering: Walls&soffit areas to be smooth, closets to be textured finish
5.8 PAINT: To be Bengamin Moore ( Regal Select) 1 coat of primer and 2 coats of finish on
walls &trim NOTE: Any colors that may take more than 2 coats of finish will be added cost to
contract price.
HOMEOWNERS RESPONSIBILITY
Paying of any contractors not hired by 2M Construction
Selecting of exterior doors style/door handles
Paint colors
ARTICLE6. PAYMENT SCHEDULE
PAYMENT ONE $ 5,000.00 upon signing of contract and project beginning
PAYMENT TWO$ 2,500.00 after rough inspection is completed by building inspector
PAYMENT THREE $ 3,500.00 after blue board & plaster is complete
PAYMENT FOUR$ 3500.00 when gym flooring and finish work begins
PAYMENT FIVE $ 1,400.00 after final inspection is completed by building inspector
NOTE:
ADDED COST TO ORIGINAL AGREED PRICE FOR ADDED SPACE WITH WALK IN CLOSET
$ 550.00
ARTICLE7.THE CONTRACT PRICE
7.1 The contract price of the project is $15,900.00 subject to approve change orders
Please note: Any changes the homeowner decides on before or during project may result in a
change of the total cost and change the finish date
ARTICLE 8. MERGER CLAUSE
The agreement represents the entire agreement of both parties and supersedes any prior or
oral or written agreement. All changes must be writing and agreed upon before work can be
performed.
Owner �f Paul Vercelli ni(2-M Construction)
Owner
11/13/2015 09:56 FAX 7813959454 Bates Insurance R0002/0002
DATE(MM1DE'YYYY)
`' '° CERTIFICATE OF LIABILITY INSURANCE
11/13/15
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.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) 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:
Bates Insurance Agency Inc. PHONE FAX
92 High Street, Suite el (A&N ' (781) 396-4985 NO: (7e1) 395-9454
Medford, MA 02155 ADDRESS: Joan batesins.coin
INSURERS)AFFORDING COVERAGE NAIC q
INSURER A:Preferred Mutual Insurance Com
INSURED INSURER B
2M Construction INSURERC:
Paul Vercellini INSURER D
4 Berry Street
INSURER E:
Billerica, MA 01821 INSURERF:
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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
-- - -- .....r..------- -..
INSR AODL SUB R POLICY EFF POLIf.Y EXP ...... ........ .
LTR TYPEOFINSURANCE POLICY NUMBER MlDDIY MINIDDYYYY UNITS
p, GENERAL LIABILITY BOP0100718249 7/5/15 7/5/16 EACHOCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000
CLAIMS-MADE lx�OCCUR RED EXP(Any ore person) $ 10,000
PERSONAL&ADVINJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000
X POLICY D
PRO- LOC $
AUTOMOBILE UABIUTY COMBINED IN LELIMIT
a accident $
ANYAU10 BODILY INJURY(Per person) $
ALLOWWD SCHEDULED BODILY INJURY(Per accidenl) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIREDAUTOS _AUTOS eraocident
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
OED RETENTIONS $
WORKERS COMPENSATION WC STATU OTH-
AND EMPLOYERS'LIABILITY Y I N
ANY PROPRIETORIPARTNERIEXECUTIVE NIA E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? —` -'—
(Mandamry in NH) E.L.DISEASE-EA EMPLOYEE $
Nyes,tlescribe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHI CLES (Aftech ACORD 101,Adclitional Rernarks Schedule,ff more space is requi red)
128 Mill Road, North Andover
CERTIFICATE HOLDER -CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
Building Department
North Andover, MA AUTHORIZED REPRESENTATIVE
1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The AC ORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail:
The Commonwealth of Massachusetts
F Department oflndustrial Aceidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
"` www mass.gov/dia
sy' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAUTTING AUTHORITY.
Applicant Information Please Print Ledb
Name(Business/Organization/Individual): e
Address: G �f
City/State/zip:�� C ✓1 C c, At 1 Phone#
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with • employees(full and/or part-time).* 7. 0 Ne nstruction
2.� am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 []Building addition
4.❑I 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.insurance.$
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c.
14.0 Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1'mu.st also fill out the section below showing their workers'compensation policy information
Homeowners who subriiif'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.
I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information. a
Insurance Company Name: t ��/11c) �LA Ue-e,
Policy#or Self-ins.Lie.#: �? D 1 s X 60 _ Expiration Date: o
Job Site Address: ,�� Y)-1 i ( I 'ed City/State/Zip: v V> CXIa
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 ce-rLML under theains nd pe alties of perjury that the information provided above is true and correct.
Si ature: )aADate: 1 D ' '
Phone#: f ,?r 2 ��
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#:
s
Informati®n 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
ever 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 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 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 ro riate 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 pen-nits 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 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-NUSSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
d Business Regulatio .
Office of Co 10 Park Plaza and
5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 138378
Type-. DBA Tr# 264640
-= Expiration: 3/28/201,7
2M CONSTRUCTION -------------- f------- - -
PAUL VERCELLI
4 BERRY ST.
01821 `
------ —
BILLERICA, MA to meet "1 Lost Card
Update Address and return cFaJr Emp ry reason for change.
Address
[-i Renewal
SCA 1 •s 2OM-05/11
e�c///of'�r�JJ"� "�" License or registration valid for individul use only
��' Regulation a" ,, office of Consumer Affairs&Business Regulation before the expiration date. If found return to
_d office of Consumer Affairs and Business Reg
} SME IMPROVEMENT CONTRACTOR Type, Suite
138378 t0 Park Plaza-Suite 51.70
�t- %Expiration
3/.,I- - 7- DBA Boston,MA 02116
2M CONSTRUCTION 1
PAUL VERCELLI __
4 BERRY ST.
-`•'` " ` Not valid without signature
BILLERICA,MA 01821
- Undersecretary
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