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Home My WebLink AboutBuilding Permit #646 - 174 JOHNSON STREET 4/6/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO� Date Received Date Issued: v-tt�Eo .6 ry TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other C1 Septic -b Weil. ❑ Fl�iilalra ❑ V11ends C1t�tershd+strct C��VYir ter/Sewer . DESCRIPTION OF WORK TO BE PREFORMED: ification Pleasejype or Print Clearly) OWNER: Name: Phone: ,V,5"/fr7� ARCHITECT/ENGINEER 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: $.5�*0,cV FEE: $ Check No.: I Receipt No.: o NOTE: Persons contractin ith unregistered contractors do not have access t t e guaranty fund Signature of Agent/Ov#ier Signature of contracto(-- Lr *1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEV LOPMENT COMMENT 1A1194 L 4b0nrA CONSERVATIO COMMENTS DATE REJECTED 11 TE REJECTED DATE APPROVED IV t D DATE APPROVED DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 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 ❑ F Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 ❑ Notified for pickup - Date .......................... Doc.Building Permit Revised 2007 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 Li 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 o 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Locaxion / -� �/ -rj-- No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 1414P L/ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 12 -:I—� 5. 20'1 61 1 1� Building Inspector M The Commonwealth, of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):- Address: City/State/Zip:WPhone #:7� Ar�yan employer? Check the appropriate box: a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors !. El am a sole proprietor or partner - I on the attached sheet - ship and have no employees . working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ 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.] Type of project (required): 6. ❑ New construction 7. ['J Remodeling ; 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. EJ Roof repairs 13.❑ Other 2!g�5 4 *Any applicant that checks box #1 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_Ci % Policy # or Self -ins. Lic. #: Z dL ld �DYzfx Expiration Date:.t5'ry®7 Job Site Address: City/State/Zip: Al, 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 certify un er theipa,,slana lties of perjury that the information provided abb is true and correct QivnnfiirP• / / Date: ,IM l Oficial 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 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 -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 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 bur 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 or Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia z hl� I Ccm O•— � p� mm CD O� �3 O O p L r O d ii. cma c cc m C CD CL V y c C c � cy � C. 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C403 p LLI 0 U) LLI C4 oC W LLI V9 W N JJLF ";t:No.+I1!=iiflrgf7.l t r1 r%(7 JCiCfiftJF'G r BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 093190 Birthdate: 06/28/1964 Expires: 06/28/2009 Tr. no: 93190 Restricted: 00 DAVID BRABANT ROAD WILMINGTON, MA Commissioner AM FAXCOM PAGE 8 OF 23 0.5f -1-51200r,11:16:22 05114106 INSURANCE CERTIFICATE OF LIABILITY INSURANCE C� r:MGHffTS DA-rfi(MMW0NyM 05112ft BODLYKIURY S opet pm-) TION KOrIN ION MATTER 41--mF—ICATE1513GUIED AM^ CERTIFICATE ONLY AND CONFERS NO UPON HE CERTIFICATE Y� —surance -CIL HOLDER. TENS COMFICATE DOES NOT AMEND, EXT END OR _ I BEWS AL-(ER-rHE COVERAGE AFFORDED By THE POLICI I soejorzl Tumpike CT o6385 INSURERS AFFORDING COVERAGE NAIL aeo 444-3900 INSU A. A h Insurance C-OmPBr'Y Arch Environmental Pools INSURER., EMC InsumM9 Companies INSURER C. MA 01824-2821 FOR7HE 1 TSE .. ...................... ISSUED THE INSURED NAMED ABOVE 'rHjZ CaFrrWIK�'TS CO BE ISSUED OR �0. " � :: BELOW OR OTHER DOCUMENT vv" RF.W�EGT TO VVHK;" EXCLUSIONS AND ND17'"S OF sucm 114 IT TERM OR CONDITION 0=16mg-T TO ALL THE TERMS. EX ANY REWIREVEN; DESCRIBED HeIREIN f;5 SUWECT PERTAIN. THE INSURANCt AFFORDED By THE POLICIES 6;1; iCIE 5 AWREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. gTYPE OF IIfIURA1ICE pmXvN TL�WWR EACH OCCURRENCE Simp'm 8SEERAL LIABILITY ZAG1"079M ��tl 5101000 XC064WWAL GMMF7UBLrry MED EXP (My OM P -C1) SU ,hO.QMS WE OWAS PERSONAL &AVV INJURY SIM,OD r7 "Ro- r-1 Lor. U7AGWLF LMLrTy ANYALITO ALL OvvwEv AUTOS CKDULEri AUTOS HIRED AUTOS U x NotOWNEU AUTOS t GARAM LIAWLITY l ANY ALTO wvmwmW -- I•AGGREGATE 5 OCCUR F] CLAM MADE 4A S SS S 7113LE L:EUUC S S OW1 j 1 keTENTION xYYC Aw 05114106 OW14107 V40RKIMS COMMNSAMON AND ZaAW—C-191014700 ELL EACH ACCIDENT 4SIGO0000 31PLOVERSUA8110'ry ANY pROPRIETCRIPAIRTNERIEXECUTINS F -L REM. EA EMP gA 31000 000 OFFICEk&OLUIEREXCLUDED? LA dw4rMewdor DISEASE Mm LUT M BOSIONSIbilaw ELL mm-- - $000,000 Buildings Commercial 3X24970 05114106 05114107 $150,000 Opp CPERATICKS I LOCATIONS IVMCLES /FXCLUNOWS AWED Sy E"M3UWff' SPEC" HtMa"S of insurance EnviromnlIfIt8l P001s 1848 Rivemeck Road Chglr,iftrd, MA 01824-n21 71MOSUwY91l 11LLWLVW=79w& -AD- DAYSwwrfed -101"F.CWMCATLHOLDER NAMED T07MLEFT, BUT FMLUV"roDO30SMALL NO OBUQATION OR LIABILM OFANT X" UPON THE MSUFSR rTS AGENTS OR KlAK a ACORD 02 073646 pftWU=-Cl2~A98 SIIUUU 05114106 05114107 COMBINEUSINGLELIMrT x100,000 CEO soddert) j - BODLYKIURY S opet pm-) BODLYINJIURY S PROPERTY DAMAGE S (per acciomm IMMONLY-EAACCO A= S wvmwmW -- I•AGGREGATE 5 OCCUR F] CLAM MADE 4A S SS S 7113LE L:EUUC S S OW1 j 1 keTENTION xYYC Aw 05114106 OW14107 V40RKIMS COMMNSAMON AND ZaAW—C-191014700 ELL EACH ACCIDENT 4SIGO0000 31PLOVERSUA8110'ry ANY pROPRIETCRIPAIRTNERIEXECUTINS F -L REM. EA EMP gA 31000 000 OFFICEk&OLUIEREXCLUDED? LA dw4rMewdor DISEASE Mm LUT M BOSIONSIbilaw ELL mm-- - $000,000 Buildings Commercial 3X24970 05114106 05114107 $150,000 Opp CPERATICKS I LOCATIONS IVMCLES /FXCLUNOWS AWED Sy E"M3UWff' SPEC" HtMa"S of insurance EnviromnlIfIt8l P001s 1848 Rivemeck Road Chglr,iftrd, MA 01824-n21 71MOSUwY91l 11LLWLVW=79w& -AD- DAYSwwrfed -101"F.CWMCATLHOLDER NAMED T07MLEFT, BUT FMLUV"roDO30SMALL NO OBUQATION OR LIABILM OFANT X" UPON THE MSUFSR rTS AGENTS OR KlAK a ACORD 02 073646 -., . „/�ie '�o%carh� •o�.:A�1a6Gau%ir6aCl6 ' »caeri of BuildW9 Regulations and Standards License or registration valid for indMdul use only - HOA:E l TROVEMENT CONTRACTOR bef e B found return to: Standards ns and i x7083 One Ashburton Yhee Rm 1301 _ =" 12008 Boston, Ma. 02108 - -t8 Y �.�don VZ wg qo /-f RO?�i'I Emv:NMER � S A -1� rEvr Evsrl8igK , Riverrsacac90, -:; — zfcrd, WIA 048'4 Deputy Administrator Not valid w�ithont L 1,111, L, BEL �T son A'a -fit yxn —t 77 11 \1 �N, hd A'a -fit yxn —t IRS as Nh h°d '516 4 ( r cif v5 '`C K, ��dj ��', �' 1 '�•� t, �o• i�i� Af i. -"� • ��'+ � : �. ��;� fib y .ul+r<�� +�� ' .r� � a� ��' 444... -` -- -.. I` � ' � � _�,. �:awrs•M'"=�="� ; s gtjsti .,r ��ri � �1 �� •S pw lk fop At T � - �£ r w 4 .+.. 7" • �.¢-'-,,. Lir � -= En D To: Lorraine Davis 174 Johnson Street N. Andover, Ma 01845 (978) 687-0628 (978) 590-5010 Design Excellence (l U4 o4 —(An ond gouefi 184R Riverneck Road - Chelmsford, MA 01824 Pool Remodel Bid • Remove concrete decking and proper disposal Labor and machine time included • Remove coping stones and tile around perimeter of pool • Install new tile (to be chosen) • Clean and prep interior of pool for new plaster • Form and pour new stamp concrete deck approximately 1550 sq. ft. includes cantilever edge and etched coping around perimeter • Install new plaster (white) • Equipment upgrade to salt system with hand held remote • Install new spa in deck area by back door. To be 7' 6" diameter with 6 jets and tied into new equipment Total Package Price: $ 53,500.00 Discounted Price: $ 52,000.00 Contract Payment schedule for iob estimate: DEPOSIT AMOUNT: $10,000.00 AMOUNT DUE DAY OF START: $16,800.00 AMOUNT DUE DAY OF ( .: Ti L E $10,800.00 AMOUNT DUE DAY OF DECK: $10,800.00 AMOUNT DUE DAY OF START UP: $ 3,600.00 Buyer: Date %Q 40 E.P.I epresentative:Date17 800-696-6976 MWEWR 978-256-0200 no 184R Riverneck Road 978-256-6620 FAx ""r'"IT°T°""` Chelmsford, MA 01824 •P • POQ iX T