HomeMy WebLinkAboutBuilding Permit #800-14 - 28 EMPIRE DRIVE 5/7/2014t� - b NORT�
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: �`� Date Received '`,,,`�•�4:
V
Date
IMPORTANT: Applicant must complete all items on this
LOCATIONS OX /_1 c
Print
PROPERTY OWNER CAPS J��
Print
MAP NO:/
PPARCEL:![ZONING DISTRICT: Historic District yes
Machine Shon Villaae ves
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
0 Addition
0 Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
0 Assessory Bldg
❑ Others:
❑ Demolition
0 Other
❑ Septic 0 Well
0 Floodplain ❑ Wetlands
❑ Watershed District
Water/Sewer
Identification Please Type or Print Clearly)
OWNER: Name: CA/_r' ,2dye�F4 Phone: 508-g5H-Z/J:J
Oddress: -WZ8 bf.1tig
CONTRACTOR Name -Phone: 1,2bF-oc51/r3 / -6
To bert MtSS1,VA- -- -- --
Address:
-`7 W A!WlAyS-f ( as U67 -A N p M A a-183 %
Supervisor's Construction License:,. Exp. Date: ,/
Home Improvement 'License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT.- $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ as FEE: $ 1"
Check No.: k Receipt No.: 21%-V
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
[Signature of Agent/owner Signature of contractor �j
0-1. eol4r
Location g-- tl
No. -,8m—ti
Check # I
27550
Date� �L k,
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
Plans Submitted° Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public SewerTanning/MassageBody
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 ❑ ❑
COMENTS
CONSERVATION ■ ■
COMMENTS
DATE REJECTED
HEALTH
COMMENTS
DATE APPROVED
El
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
Located at 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signatureldate
COMMENTS
:.-Dimension-
Number
.Dimension -
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land -area, sq. ft.:
ELECTRICAL: -Movement-of. Meter location; rriast-or service drop requires approval of
.Electrical Inspector Yes No
DANGER ZONE LITERATURE:. =Yes No-
MGL-Chapter-'166.
oMGL-.Chapter• 166. Section21A=F and G min.$10041000.,fine
1 yit5anaISAIA—p-ora
® Notified for pickup - Date
Doc.Building Permit Revised 2010
use
Building Department
=The fol o " is'a=list ofIhe required,.forms to be_filled out-for.:the.appropriate. permit to .be obtained.
Roofivg, Siding, Interior Rehabilitation Permits
o Z Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/O'(C'.S. L L'icen'ses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster..permits require sign off from Fire'De.partment prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
a Certified Surveyed Plot Plan
o Workers Comp Affidavit
a Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
a Mass check Energy Compliance Report (If Applicable)
a 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)
o Building Permit Application
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
❑ Mass check Energy Compliance Report
o 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 apodal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Permit Revised 2012
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 159750.00
m
$ -
$
189.00
Plumbing Fee
$
23.63
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
23.63
Total fees collected
$
336.25
28 Empire Drive
800-14 on 5/8/2014
Finish Basement
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Office of Consumer Affairs & Business Regulation
U'VME IMPROVEMENT CONTRACTOR
egI tration:: ,1.64829 Type'
piration: 1 111.1;9 2D15 Private Corporatio
MESSINA DEVELOPMENT.?COMPANY INC.
ROBERT MESSINA
277 WASHINGTON
GROVELAND, MA 01834 Undersecretary
Massachusetts - Department of Public Safety
Board of BuildingRegulations g tions and Standards
Ccinstruction Supervisor 1 & 2 Familv — -
License: CSFA-102931 a
i ROBERT A MESSj�TA
{ 277 WASHINGTON STREET) }
Groveland MA OF834
Expiration
Commissioner 08/31/2014
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
"•" www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): pi-.' Regs/u m
Address: 27 7 NAS 11,oc. -oA1 s f i�cL-7L
City/State/Zip: GknU&LAu 17 M A -ll 1 l? : y Phone #: q -2F- F9/ -3 / 9a
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2.1WI am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.1
required.]
❑ :I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § l (4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. 5a Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F] Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*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.
$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.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Job Site Address:
Expiration Date:
City/State/Zip:
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.
Ido hereby certi under the pains and penalties of perjury that the information provided above is true and correct.
,f 451, Date: 5A
Phone #: De- 09/ -319"0
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 #:
j' 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-contractor(s) 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 burn 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 Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013
Fax # 617-727-7749
www.mass.gov/dia
MASSACHUSETTS HOME IMPROVEMENT CONTRACT
Homeowner Information
Christopher and Stephanie Frazier
28 Empire Drive
N.Andover, MA 01845
508-958-2169
Contractor Information
Robert Messina
277 Washington Street
Groveland, MA 01834
978-891-3190
HIC # 164829 Expiration: 11/19/15
Any inquiries in reference to this contractor relating to registration should be
directed to:
Office of Consumer Affairs and Business Regulation
Ten Park Plaza, Suite 5170
Boston, MA 02116
Phone: (617)973-8700
Work to be provided by the Contractor for the Homeowner:
Finishing of basement(see attached plan for dimensions)
All framing to be 2 x 4 walls.
All wiring to meet or exceed MA building code.
Each room shall have separate switches for lighting.
Each room to have 1- 2' x 2' ceiling light in approximate center of room.
Each room to have 1— 6' electric baseboard heat and separate thermostat.
All insulation will meet MA building code.
Page 2
HIC Contract
All walls will be blue board with plaster finish.
Finish will match existing woodwork on first floor of home (baseboard, doors, trim,
windows & doors) 6 panel solid doors, Schlage passage sets in brushed nickel.
Existing stairway will be completed with pad and carpeting. Both rooms will be
carpeted.
The choices of carpet will be selected, by the homeowner, from the samples within
the allowance(25.00 per sq.yd. includes pad & labor), at Jackson Flooring.
Trim to be painted white to match the existing first floor trim and one color to be
chosen for the walls. Wall color will be chosen from contractor's samples.
All duct work to be framed, plastered and boarded.
Suspended ceiling will be 2' x 2' tiles, white rail system and standard flat panels.
The dehumidifier will be built in with permanent drain to the furnace condensate
pump.
The existing water service and clean out will be located in the closet in room 1.
Thermostat location will be determined.
All required permits shall be obtained by the Contractor.
Warranty: All materials including workmanship shall be under warranty by the
Contractor for a period of one year from the date of completion.
✓`
Page 3
MC Contract
Proposed Start and Completion Schedule: 5/9/14-6/30/14
Date when contractor will begin contracted work: 5/9/14
Date when contracted work will be substantially completed: 6/30/14 or before
The Contractor agrees to perform the work, furnish the material and labor
specified above for the total sum of. $15,750.00
Payments will be made according to the following schedule:
$ 5,000.00 upon signing this contract.
$ 8,000.00 by the completion of: installation of finish carpentry and
painting.
$ 2,750.00 upon completion of all work described in this contract.
NOTICE OF CANCELLATION
The homeowner may cancel this transaction, without penalty or obligation, within 3
business days from the date of the signing of this contract.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
5/ D
omeowner U Date
Home er Date
Contractor a e
fl
IB