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HomeMy WebLinkAboutBuilding Permit #641 - 21 LINDEN AVENUE 4/22/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: Y/ 2 IMPORTANT: Applicant must complete all items on this page LOCATION -1 fi•1EN A vc Print PROPERTY OWNER—E kNt ;11 11 t ,Print MAP 210—PARCEL. ZONING DISTRICT: Historic District yes (no o -Machine Shop Village yes TYPE OF IMPROVEMENT °� Residential Non- Residential New Building One family IMPORTANT: Applicant must complete all items on this page LOCATION -1 fi•1EN A vc Print PROPERTY OWNER—E kNt ;11 11 t ,Print MAP 210—PARCEL. ZONING DISTRICT: Historic District yes (no o -Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Two or more family Industrial Alteration No. of units: Commercial Others: placement Assessory Bldg Demolition Other Septic Well Floodplain Wetlands Watershed District ' Water/Sewer utst;rar i 1UN Ur wUKK TO BE PREFORMED: x1 & -tir0oyyi a�J hd- �--'— Identification Please Type or Print Clearly) OWNER: Name: F—f4 h( G -4d( Phone: 9D� (�b7�-( b0 Address: CONTRACTOR Name: C I IIA 4 Phone 9r)&-- ''t- W"2, Address:�i;� A7� t Supervisor's,Construction License: - $ Exp; Date: 2 /9-2,01Z Home improvement License: /5c*Yy Exp. Date -S- Y-, X318 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: $ /'/, $St . IJQ FEE: $ ( ) t Check No.: t 1 al- Receipt No.: 12 2-!q s-'�— NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund iure of Agent/Owner Signature of rontractnr 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS IHEALTH 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: 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 ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 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 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 2008 Location t No. Date TOWN OF NORTH ANDOVER 0 AL Certificate Occupancy $ of HU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22957 Building Inspector The Commonwealth of Massachusetts Department o f Industrial Accidents Office Of Lnvestigations 600 Mashing ton Street 4. BostonM4 02111 www•mass.gorl&a Workers' Compensation Insurance Affidavit: Builders/Contra �Ppllctors/Electricians/Plumbers cant information Name (Business/Organiza6on/Individual): �f Ir►'1 Address:_ aj3 City/State/Zip: M (i'h &J v� (�1� Phone #:. ci7� Are you an employer? Check the appropriate box: — l. ❑ I am a employer with 4. ❑ I am a general contractor e of project (required): 2. [�employees (full and/or part-time).* I am a sole and I have hired the sub-contractors❑Nein construction proprietor or partner- and have no employees listed on the attached sheet $ Remodelingship F for me in any capacity. Thesesub-contractors haveworking workers' Demolition[No workers' comp. insurance comp. insurance. 5.❑ We are a c orporation its Building additionrequired ] 3. ❑ I am a homeowner doing all and officers hake exercised their Electrical repairs or additions work myself. [No workers' comp. right of exemption per MGL c. 152 14 ( ), and have 11.❑ Plumbing repairs or additions g m�rance required.] t no e em to ees. , P Y [No workers or 12.❑ Roof repairs pns,T�� L_ comp. insurance required.] I3.❑ Other h A -T, -rr,.a nt that ehecLs box ul in ut L6(1.. ir�l oLi the section Showing. {-her n ort a s' Iioinebwners wiio sunmis this affidavit indicating the}, are doing ah, work and thei hire outside. contradtors mu t, submit a new affidavit indicating 'contractors that check this box must attached an additional sheet showing the affidavit avit indic name of the sub -contractors and such their workers' en _ g s _ . rsn� an emp oyer that Is Providingworkers com ensafion insurance or m employees. Below is the -� Ul in. formation. p f YPolicy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workers' compensation policy declaration age (showingCity/State/Zip: Failure to secure coverage as required under Section 25A Of MGL Page lto ththe e impositionolicy nber and expiration date). fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORKcriminal �RD���es of a of up to $250.00 a day against the violator. Be advised that a co ER and a fine Investigations of the DIA for insurance coverage verification. PY of statement may be forwarded to the Office of Td.. L---L-- V 7Jnuer me p ns and penalties of perjury that the info f mation provided above is true and correct 4fficiaCuse only. Do not write in this area, to be completed bj, citj, or town offciaL City or Town: Permit/I,icense # issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Eiectrical Inspector 5. Piumbi>z- 6. Other Inspector Contact Person: Phone #: Information an- d 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 t -Jae 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 apartnlents and who resides therein, or the occupant of the dwelling house of another who employs persons to do mamteeQance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be=cause of such employment be deemed to .be an employer." MGL chapter 152, §25C(6).4o states that "every state or local licensing agency shall withhold the issuance or i renewal of a_license or perniit-to operate a. business or to.'construct buiiduigs in the eotnmonwealth 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 comumanwWth nor:any of its political subdivisions shall enter into any contract for the :13 . orMance Of public. work unite 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 certificates) 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' comp ensation 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 insuranne coverage. .Also be &xwe to sign and date the affidavit. The affidavit should be reamed to the city or town that the application for the p }t or license is being mques*.ed, not the .Denz*=ent of Industrial Accidents. Should you have any questions regardirxg 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 ' 3ob Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stampe=d 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 burn leaves etc.) said person is NOT required to complete this affidavit, The Office ofInvesfigations would hke 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.mumben... . The Cc mmonwtalth of Mamas husetts Department of Industrial Accidents Office of Iuwesiigations 600 Washington Street BQstQn, IIIA 02111 Tel. # 617-72.7-4900 ext 406 or 1-8 77-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 VrVrw.mass..govidia Proposal X y F Invoice _ GENERAL BUILDING AND CONTRACTING 93 Burroughs Road, North Reading, MA 01864 978-551-8020 Submitted To: Elaine Gillick Phone: 978-686-6060 Date: 02-23-2010 Address: 21 Linden Ave Project: Bathroom Renovation Location: First Floor North Andover, MA 01845 We hereby submit specifications and estimates for: -Demo and remove all ceilings, walls, trim, fixtures and flooring, including arch at shower. -Frame new soffit ceiling over tub, new opening for medicine chest in wall and replace 1 damaged floor joist. -Install new'/4" plywood subfloor over existing floor boards. -Install all plumbing for new toilet, pedestal sink and cast iron tub. -Install all wiring and switches for new GFCI outlet, vanity light and ceiling fan/light. -New fan to be properly vented to outside through exterior wall. -Install hardi backer board in shower area and blue board with plaster though out bath: -Install all tile, selected by owner, for tub area walls and bath floor. Tub tile to wrap window. -Install wainscoting, selected by owner, either tile or wood, on bath walls. -Install all trim at baseboard and door. -Install all bathroom accessories (towel bars, t.p. holder, shower rod, medicine chest, robe hook). -All debris from demolition and construction to be removed and properly disposed of, off site. Exclusions: Building permit fees, painting, existing door and window, cost of all fixtures, tile, grout and accessories, and anything not mentioned above. We Propose hereby to furnish materials and labor — complete in accordance with the above VQ specifications, for the sum of: , t P4.1 010 l� 4 r7y2 Fourteen Thousand Eight,Ilundred Fifty and 00/100 ( $14,850.00 ) Payment Terms: 50% down, 35% after all walls up and 15% upon completion. All work to be done in a workmanlike manner according to standard practices. Any alteration or deviation from the above specifications involving extra costs will become an extra charge over and above the estimate. All agreements are contingent upon strikes, accidents or delays �fyond our fontrol. Owner to carry all necessary insurances. Authorized Signature: Note: This proposal may be withdrav/ by us if not accepted within 2 % days. Acceptance of Proposal -- The above prices, specifications and conditions are satisfactory and hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined. 2.Zl �1 Date of Acceptance: Signature: _ r/j � �� �R CERTIFICATE OF LIABILITY INSURANCEDATE(MMID°'rM) 2/9/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION M.P. Roberts Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1060 Osgood .Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR North Andover, Mk 01845 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURED INSURERS AFFORDING COVERAGE NAIC # INSURERA. JIM INTRAVAIA DBA GENERAL BUILDING AND CONTRACTI : INsuREReMerchants Mutual Insurance Co 93 BURROUGHS RD INSURER B INSURER D NORTH ADING, MA 01864 INSURER E: COVERAGFR 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. AGGREGATE-11MITS-SHOWN MAY HAVEBEETTREDUCED BY PAID CLAIMS:` - INSR ADD - TYPE 01: INSURANCE POLICY NUMBERDATE POUCY EFFECTIVE POLICY EXPIRATION LIMITS EACH OCCURRENCE $ 11000,000 B GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑X OCCUR BOPI045421 2/15/10 ,2/15/11 DAMAGE TO RENTED PREMIE ence$ 50 000 ME DEXP (Ar yoneperson) . ..$_.. ,. 5..000 . PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE, $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER JMT POLICY PRO- LOC PRODUCTS -COMP/OPAGG $ . 2. OOO- 000 'ALITOMOBILE LIA13 UTY ANYAUTO(Eaaccider�) COMBINED SINGL E L IM rf $ ALL O WNE D AUTOS SCHEDULEDAUrOS BODILY or $ (P er person) HIRED AUTOS NON -OWNED AUTOS B eracci ent) $ (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY ANYAUlO � - AUTO ONLY - EA ACCIDENT $ - OTHERTHAN EAACC $ AUTO ONLY: AGG $ EXCESS IUMBRELLA LIABILITY OCCUR .. CLAIMS MADE EACH OCCURRENCE $' AGGREGATE $ $ DEDUCTIBLE RETENTION WORKERS COMPENSATION $ WC STATU- OTH- AND EMPLOYERS' LIABILITY ONYPROPRIMB R/PXCLUD IEXECUTNE Y_ OFFICERMIEMBER EXCLUDED? (Mandatory In NH) E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ 11 yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPFRA1nn1lc r I ne_'....�,�... ;f=RTIFICATE HOLDER':'- JIM INTRAVAIA ACORD 25 (2009/01) ----- -_-_– ­—..-111-1CMALrKVV1WUN5 CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BECANCELLED BEFORE THEEXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGA110N OR UAf31LLTY OF.ANY.KINQ_UPONJHE_INSURER,-ITS_AGENTS OR REPRESENTATIVES. / AUTHORIZED REPRESENTATIVE / .!.' PS / P R ,� ©1988 2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts - De ■� menf of Public yam ! Boar# of Regulations and 5! i|ai-d.s. 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