HomeMy WebLinkAboutBuilding Permit #737-2017 - 18 EQUESTRIAN DRIVE 1/25/2017- pL�11� \ � V\ r`�i i� a V ._ t.i.L: iG)C1e^t VA-�' Iris £'
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Identification Please Type or Print Clearly)
y
OWNER: Name- Yu -5c> '1-' 1 ro ko 5'�`1 cC q Phone:
'H
6
Address: E, 11..E ;r �'
-" ONTRACTOR' Ne %��1°I^ t on .»
tt { reSS
UperVl5tlr' Con tru-c Ab6n s Ex i to
H Imprcvrr�rt l.rc�r '" Ex
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: $ -61-2 FEE: $
Check No.- 9 -Ll t _Receipt No.:` /
NOTE: Persons contracting with unregister d contractors do not have access to the guaranty fund
Signature of Aent%owrier ture of contractor
' i
Permit NO:
Date Issued:
•
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this
LOCATION
PR.OPERTY�
Print,10.O�Year, Ol 01TL cturo: yes, nog
NIAP'N®,:; PARCEL;:_ Z_ONING;DISsTRICT+k__ . Histoncr®istnct yes no:
-
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
El Two or more family
❑Industrial
El Alteration
No. of units:
El Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
__ --,-. ,_,
❑ `Septic q�VVell
❑ Other
�„ _
Flogdplain; M Wet( Wd.
VVater-shed District;`
Water/Sewer:..
DESC:t 111 I IUN UI' WUMIN IV Or- rcRFwm'v'L-L,.
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
:
GONTRACT®R` NamePhone. - - -- a
r
Add�essi:
' Super.visor's Gonstructiori. License _1e _ _Expo Dato,
:Ir
ARCHITECT/ENGINEER
Phone:
Address: Reg. No
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $
FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Simpature of contractor : .
nature of A ent/Owner :: _
Plans Submitted ❑ p Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ��
Location r ey
No. -7? _ d 0/7
Date I - dS- - dO /-?
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $(d30.�''
Foundation Permit Fee t $
Other Permit Fee" $
TOTAL $
Check # ✓ ` % � � f /
J � r; 1 Building Inspector
r.
s .. '-
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
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
r
Conservation Decision:
Com
Comments
Zoning Decision/receipt submitted yes
!fluter & Sewer Connection/s;gnafiure Date Driveway Permit
DPW 'Ibw;! Engineer: Signature:
Located 384 Osgood Street
FIRE DEPAKTKENT - Temp Dumpster on site yes no
Located at 124 Mair., Street
Fire Departmer'it signature/date
COMMENT'
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions-
ELECTRICAL:
imensions_
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector lees No
DANCER ZONE LITERATURE: lies No
MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
NL) i t5 ana UA I A — (f -or clepartrnent use
U Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
Tine folowing is a list of the required forms to be filled out for the appropriate permit to be obtained.
I'Zoofing, 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
a Engineering Affidavits for Engineered products
N E: 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
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
10TE: 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 Torun Clerks office must stamp the decision from the Board of Appeals
that the apn,al 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
Doe: Doc.Bui"ding Permit Revised 2012
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 52,500.00
m
$ -
$
630.00
Plumbing Fee
$
78.75
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
78.75
Total fees collected
$
887.50
18 Equestrian Way
7737-2017 on 1/25/2017
Kitchen Remodel
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Proposal
Noreast Builders To. -Hiroko and Yuzo Shida
37Ashlawn Farm Rd 18 Equestrian Drive
New Ipswich, NH North Andover, MA
603 - 554 - 7,192 7
Furnish the following for kitchen renovation
Permit, Dumpster 1.000.
Demolition, cabinets, counters, pantry, flooring 3.500.
Larger 2 Andersen casement windows above sink. new header 3.500.
New triple Andersen casements at dining area 5.000.
Patch walls and ceiling where affected by demo 3.000.
Paint walls and ceiling 1.500.
New 3 1/4" hardwood flooring. Maple, oak. bamboo, or hickory,
kitchen dining. hall leading to deck 8.500.
Build corner wall at stove 1.000.
Install chimney hood with vent hookup 1.500.
Plumbing and gas work. Owner supplies sinks and faucets 5.500.
Electrical work, supply 14 recessed can lights, move light at
table. islands outlets, 2 -puck lights, labor for under cabinet.
(Per Dream Kit. layout) Owner supplies under cabinet lights 7,500.
Cabinet and hardware install only 3,500.
Contractor's fee, travel, overhead 4,000
r�,9oe011"19Q Flov,C FOR /'R01V7 mopjr A of 37 00
Forty Nine Thousand Dollars $49,000.
To demo and lay new hardwood in entry room and closet, add 3,500.
Payment as follows: $5.000. deposit, then weekly progress draws
Authorized
Signature t
y VA
Accepted by
clients
-- ---- ----- .............
Accepted by /
clients --
Date i / -- i 7 --14=.D
Date 12 Z7/6
Date 12-44--201`6
The Commonwealth of Mctssc;ehusetts
Department of lndusft ialAccidents
M ^ r X CoWess Street, ,5 !M 100
d Boston, MA o21I4 2417
w www rnass.govldia
Wn'kkers' Co:oapensatzonTnsuxanedAEidavit:BTriXdexs/COAUTHORi7CY. czans/"lTnmbers.
TO BE M-11) 'TRE PERMU pTp�cP Print ]
Names (BusinesslOiganfaii0 Individual):_
CUr V\A
-A.dcTMess:
Phony #:
City/Stateaip:
Ars you an employer? ec1L tRe appropriate box:
1. Q I am a employer with employees (full and/or pazi isme)•
Z amasoleproprietorozpartumbipana�yenoemployeesWorld g for mem
�y capacf'Y. [Aoworkers' comp. insm-ance required.]
3.]Iam.ahomeownerdoingallworkmyseli[Noworkers'comp.instuancerequired.]!
4.F]I am ahomeowmer and V,0 be hir>ng contractors to conduct all work onmy property. IwiIl
ensurethat all couiractats eitherhav- workers' compensation in...r-Ge or are sole
proprietors with- no empioyeeS.
5.[-11 am a general con�ractorand Ihave biredthesub-confractors listed ontbe attached sheet
These sub-mritractorshav6 employees and have workms' comp. insman
6.Q WD me a corporation. and its offices baw exercised their rigbt pf exemption per MGL c.
have no employees. jNo workers' comp. insurance required_]
6.3- 8 !9'- WD -E
Type of project (require(1);
7. ❑ Nevi'c6nstri7.' UOn
g, emodeluig
9. Demolition
10E] Building addition
11.[] Electrical rep vs or additions
3-2.1 -PXuiai-49• repairs or additions
13•. n Ro6f repairs
14.n Other
152, WN( andwe -
*AnpapPlicanithat checl� box#1 must also fill out the sectionbelour showing their workers' compensationpolioy information
i Homeowners who submit•this a fidavitiudicatingthey are doing allworktanb ntham 0MLO sub chire outside, contractors and Siatewhethar orn�ottil m 1e e
!Contractors that check this box must attached additionalht pr de their workers' comp- Policy member'
employees. Ifthe sub -cos actOis have employ
ee
am an employer iliac isprovidingworkers' compensation insurancefor my employees. Below is tliepolicy andj�ob
site
X P
information.
Insurance Company
Policy # or Self -ins. Lie.
BxpirationDate;
City/State/Zip: iration date).
Job Site Address: e and 'XP
Attach a copy of -the Workers'
compensation policy declaration Page( r� nhal �-vioa� a Po punishable y a �nie up to $1,5 00-00
Failure to secure coverage as required under MGL o. hiss i §25the f 7s a and a fine of -4 to
and/or one-year imprisonment; as well as civil may forwarded to fibre Officeorm of a STOP O O ° of the DIA for insuran 0 a
day agaavnt the violator. A copy of this statementY
coverage verification.
c der tl pains and aloes of peduly that the information pr•ovaded move is true and correct
X do liereb 1
Official rise only- Do not wf rte in t7iis tr ea, to be corapleted by city or to tvn official
Perm t/License #
City or Town'
XssuingAnihoxity (circle one):ector 5.Plumbingluspector
1. Board offfealth 2. BufldingDepartm.ent 3. CiiylTown Clerk <d, BlecixiealXasp
6. Other
Phone #:
Contact Person•
Information and Instructions
Massachusetts General Laws chapter .152 requires all employers to provide workers' compensation for their eritpl5yees.
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 employerfi defined as "an individual; partnership, asso dation, corporation or other legal entity, or 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 Estee 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 op erate a business or to construct buildings in the commonwealth for any
applicaAtwlzo has not prodaced-acceptable evidence of compliance with tate insurance coverage xeq &ed."
Additionally, MUL 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 =b=cortractor(s)mrne(s), addresses) and phonenumber(s) alongwiththeircertificate(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 au LLC or LLP dogs have
employees, a policy is required. be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
b e returned to the city or town that the application for the permit or license is being requested, not the D apartment of
Industrial=Accidenis. Should you have any questions regarding the law or if you are xequired to obtain a workers'
compensatiorl policy, please call the Department at the number listed below. Self-inmredcompanies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
PIease be sure that the affidavit is complete and printed legibly. The Department has provided a space atthe 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 p ermit/license number which will be used as a reference number. lir addition, an applicant
thaf must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) 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 b e provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be fifled out each
year. Where ahome owner or citizen is obtaining alicense or permit notrelated 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 MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
vim■ %a on ■vr ■ 1� v■ ■ ■ ■pwv■I n1/n3/9n17
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(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
Trust One Insurance Agy, LLC
PO Box 123
NAMINT CT Margaret Saari
PHONE FAX No):603-899-2338
ac No Ext : 603-899-9990
Margaret Saari
Margaret Sari
E-MAIL SS: psaari trustl insurance.com
INSURERS AFFORDING COVERAGE NAIC #
POLIO EXP
INSURER A: Concord Group Insurance
A
INSURED Charles Saari, DBA
Noreast Builders
INSURER B:
INSURERC:
37 Ashlawn Farm Rd
INSURER D:
New Ipswich, NH 03071
INSURER E:
INSURER F
%+VVCKAVC3 CERTIFICATE NUMRFR- ocvlmnM w IMlcco
l-161 RA:
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.
ILTR
TYPE OF INSURANCE
ADL
UB
POLICY NUMBER
MM/DDtYYYY
POLIO EXP
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
--IJAMAGE
CLAIMS -MADE rj�] OCCUR
20005333
08/07/2016
08/07/2017
TO
PREMISES Ea occurrence) $ 50,000
X Business Owners
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 2,000,00
X POLICY ❑ PRO ❑LOC
JECT
PRODUCTS - COMP/OP AGG $
OTHER:
AUTOMOBILE
LIABILITYCO
MBINED SINGLE LIMIT
Ea accident) $ 300,000
A
BODILY INJURY (Per person) $
ANY AUTO
20005323
08/04/2016
08/04/2017
ALL OWNED �( SCHEDULED
BODILY INJURY (Per accident) $
AUTOS AUTOS
X
HIRED AUTOS X NON -OWNED
AUTOS
PROPERTY DAMAGE $
Per accident
UMBRELLA UAB
OCCUR
EACH OCCURRENCE $
EXCESS UAB
CLAIMS -MADE
AGGREGATE $
DED RETENTION $
$
WORKERS COMPENSATION
PER OTH-
AND EMPLOYERS' LIABILITY Y / N
STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICEWMEMBER EXCLUDED?
N / A
E.L. EACH ACCIDENT $
(Mandatory in NH)
If yes, describe under
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
PROPERTY 3,00
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
nretlrli.wrr 11n. ..�..
ve11�v{-VLM I Iv1\
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Yuzo and Hiroko Shida
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
18 Equestrian Drive
ACCORDANCE WITH THE POLICY PROVISIONS.
North Andover, MA 01845
AUTHORIZED REPRESENTATIVE
Margaret Saari
0oard of w
License: 73161
14-A
CHARLES E SAARI
37 ASHLAWN FARM ROAD t ,r
NEW IPSWICH NN 01307'
� \�1
"
Otrti'.
CoMmissione' r
1112512017