HomeMy WebLinkAboutBuilding Permit #521 - 312 BLUE RIDGE ROAD 1/29/2007Permit NO: 6P
Date Issued: : ' d
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
LOCATION 16 2�e Aad
Print f
PROPERTY OWNER �e�e � K -Y,- 70 A4
Print
MAP NO.:� PARCEL:,[ /�� ZONING DISTRICT: sP
TVPF. ANn iTCF. nF RITii,DINr HISTORIC DISTRICT YES ❑
FO
TYPE OF IMPROVEMENT
PROPOSED USE
Resi ntial
Non- Residential
❑ New Building
❑ tjCddition
Alteration
F One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
�Gsa�v,
Identification Please Type or Print Clearly) L4.� A 0�r.
OWNER: Name: /0N1 f er(? c;ht0 / &)Nela Phone:
Address: Jlo2 9�(/e 4,88 e 4,iZA10 AJV DA LPr A,/*
CONTRACTOR Name: Ale- 11-y qi.f" Phone: 618- yG,�-
Address:
c�
Supervisor's Construction License: S e5,5-11 -Z,3 Exp. Date: -;2-4a-7 / T
Home Improvement License: / S 6 3 3 Exp. Date: A
ARCHITECT/ENGINEER RAV Name: Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING RM/T: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost :$ -2 7 FEE:$ �e�5
Check No.: Receipt No.:
Page lof4
Location
No. 5d Date
TOWN OF NORTH ANDOVER
� 9
Certificate of Occupancy $
•Oj•�ns •�'.
CMusEt�
Building/Frame Permit Fee $ C) IT
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 3-4/3
K
19954
Building Inspector
TYPE OF SEWERAGE DISPOSAL
,❑✓/
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Public Sewer
Well F1Tobacco
Sales ❑
Food Packaging/Sales [I❑
❑
Permanent Dumpster on Site
Private (septic tank, etc.
Electric Meter location to
project
N UTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Ow 'Z -2 a ure of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE REJECTED
11
9
DATE REJECTED
FIRE DEPARTMENT - Temp Dumpster on site yes,
Fire Department signature/date
COMMENTS
A
n
Fl—
DATE APPROVED
DATE APPROVED
DATE APPROVED
no
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
Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
Require
Provides
Required
Provided
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
NOTES and DATA — (For department use
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created JMC. Jan.2006
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
Addition Or Decks
❑ Building Permit Application
❑ 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)
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
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:BPFORM05
Page 4 of 4
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' d 600 Washington Street
W� Boston, MA 02111
M www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
licant
Name (Business/Organization/Individual):
r,
Address:
City/State/Zip: 1-44Q- Phone #: 9 7 - W d' --
Are you an employer? Check the appropriate box:
L ❑ 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. ❑ I 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.$
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
insurance required.
Type of project (required):.
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 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: M 45S W Kr -f Co
Policy # or Self -ins. Lic. #: W L 2-7 � f _ .? S Expiration Date
o
Job Site Address:. 3 / Z 6'4/V-1 L , Nd l4PJ $* City/State/Zip: Q t' f' (C -1 -
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 coveraee verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
-ZR-ef
Phone #: 6 t'-%- / 9'? 0 - 7-p-3 j
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 #:
CSR MM
ACORD CERTIFICATE OF LIABILITY INSURANCE 9MCIN02
DATE (MMIUD/YYYY)
1 10/31/06
PRODUCER
John J Walsh Ins Agency, Inc
P O Box 4407
Salem MA 01970-6407
Phone:978-745-3300 Fax:978-745-9557
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC#
INSURED
M Scott McInnis
4 Alexander Way
South Hamilton MA 01982
INSURER A: Mass Wkrs Comp Assign Risk
INSURER B:
INSURER C:
INSURER D:
INSURER E:
COVERAGES
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 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
D
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD/YY
POLICY EXPIRATION
DATE MM/DD/YY
LIMITS
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE ?
GENERAL LIABILITY
David C Bruett
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
AMA'GETO-RENTED--
PREMISES (Ea occurence) $
CLAIMS MADE D OCCUR
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
FGENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
POLICY n PROECT LOC
J
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY
(Per person) $
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident) $
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR CLAIMS MADE
AGGREGATE $
$
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
TORY LIMITS ER
A
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
WC2788735
08/19/06
08/19/07
E.L. EACH ACCIDENT $ 100000
—
E.L. DISEASE - EA EMPLOYE $100000
OFFICER/MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE -POLICY LIMIT 1 $500000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
0001003
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
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
Inovative Property
185 Squire Rd
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Revere MA 02151
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE ?
David C Bruett
ACORD 25 (2001108) .7 ACORD COP..PORATION 1988
HOME IMPROVEMENT CONTRACT
Agreement made as of this date January 24, 2007
Between: Tom and Gretchen Papineau ("Owner" or "Customer") of 312 Blue Ridge Rd., N.
Andover, MA 01845 and DOVETAIL KITCHENS, LLC ("Contractor") of 274 Main Street, Gloucester,
MA 01930 and MCINNIS CONTRACTING for certain remodeling work to be performed by Contractor
at property located at:
312 Blue Ridge Rd., N. Andover, MA 01845 (the "Property")
1. REMODELING WORK. The remodeling work to be performed pursuant to this Agreement is set
forth in Exhibit A which is attached to and forms a part of this Agreement and shall be referred to in
this Agreement as the "Work". The Owner shall pay Contractor therefore the amounts and at the
times as set forth herein. The Contractor shall have the right to use subcontractors in performance of
the Work.
The Parties understand and agree that the purchase of and payment terms for kitchen cabinetry, if
being purchased by Owner through Contractor, are the subject of a separate agreement/ purchase
order.
2. TIME OF COMPLETION. The approximate completion date of the project shall be 30 days from and
after the date of this Agreement set forth above. However any change orders, delays in materials to be
supplied by Owner or Work to be done by Owner and/or conditions discovered at the Property after
the Work commences or any other factors outside the control of Contractor might delay or otherwise
affect the completion date.
3. THE CONTRACT PRICE. The Contract Price to be paid to Contractor is as set forth in the Contract
Price and Responsibilities Schedule marked Exhibit. A attached to and forming a part of this
Agreement. The Parties agree and Owner understands and acknowledges that the Contract Price set
forth in Exhibit A is based on the aspects of the Property viewed by the Contractor prior to
commencement of the Work. If conditions are encountered at the Property which are subsurface or
otherwise concealed physical conditions or unknown physical conditions and if they would cause an
increase in the Contractor's cost of and/or time required for performance of any part of the Work, the
parties will negotiate an equitable adjustment in the Contract Price, such adjustment to be reflected
in a Change Order, and thereupon such increases will be added to and become part of the Contract
Price.
4. RESPONSIBILITIES. Exhibit A also sets forth material and work responsibilities between Owner
and Contractor. Anything that is the responsibility of the Owner to obtain or perform shall be deemed
not to be part of the Work to be performed by Contractor under this Agreement. In the event existing
walls and or ceilings are not level, the contractor will match existing conditions to the best of his
ability. Contractor is not responsible for pre-existing conditions beyond the scope of this contract.
5. PAYMENTS. Upon signing of this Agreement Owner shall pay Contractor one-half (i.e., 50%) of the
Contract Price shown on Exhibit A, with the balance of the Contract Price to be paid in full upon
completion of the Work. The work shall be deemed completed upon substantial performance of the
Work in a workmanlike manner and shall be sufficient grounds for Contractor to require final
payment from Owner. If payment is not made when due the unpaid balance shall accrue interest at
the rate of 12.00% per annum, which Owner agrees to pay as well as all costs, fees and charges
(including reasonable attorneys' fees) of collection. If payment is not received by the Contractor when
Page I of 2
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
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 11-22-06
www.mass.gov/dia
due, then, in addition to any other remedy available to Contractor, Contractor shall have the right to
stop or limit work or terminate the contract at its option. Stoppage, limitation or termination by
Contractor under the provisions of this paragraph or other termination shall not relieve the Owner of
the obligations of payments to Contractor for that part of the work performed and costs incurred prior
to such termination.
6. WORK QUALITY. All work shall be completed in a workmanlike manner.
7. CHANGE ORDERS. A Change Order is any change to the Work, including any changes to the
Contract Price as noted in Section 3, above. All change orders need to be agreed upon in writing,
including cost, additional time considerations, approximate dates when the work will begin and be
completed, and signed by both parties. Additional time needed to complete change orders shall be
taken into consideration in the project completion date.
8. HAZARDOUS MATERIALS, WASTE AND ASBESTOS. Both parties agree that dealing with
hazardous materials, waste or asbestos requires specialized training, processes, precautions and
licenses. Therefore, unless the Work includes the specific handling, disturbance, removal or
transportation of hazardous materials, waste or asbestos, upon discovery of such hazardous
materials the Contractor shall notify the owner and allow the owner to contract with a properly
licensed and qualified hazardous material contractor. Any such work shall be treated as a change
order resulting in additional costs and time considerations.
9. ARBITRATION OF DISPUTES. Any controversy or claim arising out of or relating to this contract, or
the breach thereof, shall be settled by arbitration administered by the American Arbitration
Association under its Construction Industry Arbitration Rules, and judgment on the award rendered
by the arbitrator(s) may be entered in any court having jurisdiction thereof.
Witness our hand and seal on this day of , 20
CONTRACTOR:
DOVETAIL KITCHENS, LLC, MCINNIS CONTRACTING
BY:
Manage (butof personally)
11
By execution of this document, I agree to have read and fully understand all statements, terms and
conditions of this document
h
Owner: Owner:
Deposit Received: Date: Ck#: Amount:
Page 2 of 2
r J
Tom & Gretchen Papineau
Kitchen Estimate
Description
EXHIBIT A
1 Permits & Fees
2 Demolition & Removal
3 Plumbing to disconnect existing fixtures
and install new fixtures per plan
4 Electrical - add circuits as needed
wire appliances and undercounter lights
5 Undercounter SS kitchen sink
faucet and soap dispenser
6 Undercounter SS bar sink and faucet jeltkrll
7 Countertops - Granite
8 Hardware Allowance
9 Cabinetry per attached plan
Red Birch, Autumn Bronze
10 Carpentry - Cabinet Installation and
hood vent
Total
Estimate/
Cost Allowance Total
$ 350 $ 350
$ 1,750 $ 1,750
$ 1,250 $ 1,250
$ 1,500 $ 1,500
$ 1,000 $ 1,000
$ 500 $ 500
$ 5,000 $ 5,000
$ 400 $ 400
$ 29,500 $ 29,500
$ 2,500 $ 2,500
$ 33,750 $ 10,000 $ 43,750
* Above estimate does not include appliances, tile backsplash, flooring and light fixtures.
• sy,-._ - ✓/+� .�,,,,,,ta,�,ea�l� a`',/�ivataciu�ae�d
i ?• BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 051123
Birthdate: 02/27/1957
Expires: 02/27/2007
Restricted: 00
M SCOTT MCINNIS
4 ALEXANDER WAY
S HAMILTON, MA 01982
• .;off � ✓lr.�. -�a»vnw.uacalf/ : o�.���aavac%uvellQ•
-�\ Board of Building Regulations s:ndStandards
HOME IMPROVEME14T CONTRACTOR
Registration: 145633
Expiration: 2/16/2007
Type: DGA
McINNiS CONTRACTING
SCOTT MCINNINS
4 ALEXANDER WAY
C.G..
HAMILTON, Ma 01982
- Administrator �
Tr. no: 9808.0
commissioner
Licen. a or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One A ihburton Place Rm 1301
Burton, 1A4a 02108
`� Nctvalid.with : ignature