HomeMy WebLinkAboutBuilding Permit #501 - 32 OLYMPIC LANE 3/25/2009Permit NO: J '
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
; +o
TYPE OF IMPROVEMENT
PROPOSED USE
Residential .
Non- Residential
❑ New Building
Ty[ One family
❑ Addition
❑ Two or more family
❑ Industrial
til Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
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DESCRIPTION OF WORK TO BE PREFORMED:
2_ 'E�CLU Rs ')P4\ / .0 J_O S C''° r /CSS F1r" P 6-rZ
Identification Please Type or Print Clearly)
OWNER: Name: 13 M0.61 .D q 'TrZL,G\/ Kt'a VA14 Phone: 8716 3-3>-7 6(Z1
ARCHITECT/ENGINEER 0A t Phone:
Address: Reg. No.
FEE SCHEDULE. SULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ aG FEE: $ r(
Check No.: ,S Receipt No.: r_ lg$g�
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
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
DATE REJECTED DATE APPROVED
a
DATE REJECTED DATE APPROVED
❑ ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer C.,,on a Lon/Signature & Date Driveway Permit
Located at 384 OsgoodZFe i
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 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
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract -
❑ . Floor Plan Or Proposed Interior Work
o 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)
o 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
o 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
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NORTH TOWN OF NORTH ANDOVER
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ACORD DATE (MMIDDNYYY)
CERTIFICATE OF LIABILITY INSURANCE 1 03/24/2009
PRODUCER Phone: 978346.8761 Fax 978346-9620 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
JOURNEAY INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
8 WEST MAIN STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
MERRIMAC MA 01860 1 THE COVERAGE F o ED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE I NAIC #
INSURED INSURER A: American International Group
TODD MICHEL CONSTRUCTION, LLC INSURER B: National Grange Mutual Insurance Co 14788
C/O TODD MICHEL INSURER C:
109 WEST MAIN STREET INSURER D:
MERRIMAC MA 01860
INSURER E:
�.vYCRIiVCO
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.
"LTR SSR
INS"
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE
POLICY EXPIRATION
DATE
LIMBS
GENERAL LIABILITY
MP14196F
04/01/09
04/01/10
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE[j] OCCUR
DAMAGE TO RENTED
PREMISES qqr e e $ 500,000
MED. EXP (Any one person) $ 5,000
B
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO LOC
POLICY r
PRODUCTS-COMPIOP AGG. $ 2,000,000
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
ANY AUTO
(Ea accident) $
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS
(Per Pew) $
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY $
Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS I UMBRELLA LIABILITY
OCCUR a CLAIMS MADE
EACH OCCURRENCE $
AGGREGATE $
$
DEDUCTIBLE
RETENTION $
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
WC893-83.95
02/25/09
02/25/10
*C STATU- OTHER
E.L. EACH ACCIDENT $ 500,000
A
ANY PROPRIETORfPARTNERIEXEWTME
OFFICER/MEMBER EXCLUDED?
Kyas, describe unWr
E.L. DISEASE -EA EMPLOYEE $ 500,000
E.L. DISEASE -POLICY LIMIT $ 500,000
SPECIAL PROVISIONS Wort
OTHER:
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
rFRT1PI(1ATF uni nco
TOWN OF NORTH ANDOVER
TOWN HALL
NORTH ANDOVER, MA.
Attention:
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 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS
AGENTS OR REPRESENTATIVES.
�.�
i
The Commonwealth of Massachusetts
:. 1/z
Department Of 1ndustria1 Accident,
Office o
ff f 1�nvestigations
600 W
ash ineton Street
Boston, MA OZIll
Workers' Compensation Insurance
W1VYC'. �SS.e OV/dtQ
Af€ iday.it:
Builders/Contra:ctors/Eleetricians/Pi
Ap Iieant Information umbers
._, P}ease Prinf LeaibiF,
Name (Business/Organization/individual): ( 0DQ!� MMU hp AMU }-SL_
Address: `
o ct
CC,1•,-STIaC�Tz�j�
!
City/Siete/Zip: JACRRLMAL (tilQ pyo phone 7
b c L_(2
Are you an employer? Check the appropriate box: r
1. I an a employer with ❑ Type
_
4. of project (required):
I am a ger feral contractor
? • ❑employees (full and/or part-time).*
I am a sole
and I .
have hired the sub -contractors
6• New construction
proprietor or partner-
ship and have no employeese
listed an attached sheet # 7• ❑Remodeling
These
working for me in any capacity.
sub -contractors have
workers' S. ❑ Demolition
comp. insurance.
[No workers comp. insurance
' P
5. 9
❑ We are a corporation and its ❑Building addition
3. ❑required.]
I am a homeowner doing all work
officers have exercised.their
richt rs
J 0•0 Electrical repairs or additions
-ht
myself. [No workers' comp.
insurance
ex
exemption Per MGL 11.❑ Plumbing repairs or additions
c 1(4), and we have
required_] t
no
employees. [No workers' 12,❑ Roof repairs
comp in 13
sur'ance. required.] •❑ Other
*Any a_ow eant_that checks box #I .must also fill out the section below showing their workers compensation poli,} infntmation.
t ontr ,ton tS who Check
this box -rn..* . InCiiCattR� they are doir:g l.c,,,r: tcf Even hi" outsiae uwnvac(urs• roust submit a neve atndavit indi
IContraetors Thal ehec}; this box "must attached an additional sheet show the name .of f? e sub c�azetors and their wo '
�tm� scat.
t art ar. employer that is Providing workers' contperyration i nets' come. ool icy infottt�ion,
infnrmatio2 assurance for my employees. Below is the oft
P cy and job site
Insurance Company Name: �L�
— e"1
Expiration Date.
Job Site Address:
Attach a copy of the workers' compensafaon ot4tf;�QcrCity/S�/Zip: %� • ,Q1)0V&t
P the policy number and expiration date).,
Failure to secure coverage as required under Section 25A of
fine up to $17500.00 and/or one-year imprisonment, as well MGL c. 152 can lead to the imposition of criminal penalties of a
of up to .1250.00 a day against the violator. Be advised that a copy penalties the form of a STOP WORT; ORDER and a fine
Investigations of the, DIA for insurance coverage verification. may of this statement may be forwarded to the Office of
I do itornfm —wo;4. .
1 _.— penalties of perju"' t' za the inforinafinn provided above is true and correct
Offecial use only. Do not write in this area, to be comp[e1le�d by city or town ojlcia[
City or Town:
Permitfucense #
Issuiao Author'
25 -n
ft my (circle one1:
I. Board of Health 2. Building Department 3. Citylrr,wn
6. Other Clerk 4. Electrical inspector 5. Piumbin.,
Inspector
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 "...ever -y 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 inclucii-ri.g 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 ap artznents 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 as. r 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 o. f 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 comps-etely, by checking the boxes that apply to your situation and, if
necessary' supply sub-contractorm
s) name(s), address(es) ad phone n umber(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' compensafion insurance. if an LLC or LLP does have -.
employees, a policy is required_ Be advised that this affid-a-vit may 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 regrBi-rding the iaxal or if you are required to obtain a workers'
.compensation pblicy, please call the Department at thenuinber:I.-&-d below. Self-insured co,,;,,anies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the'en-davif is complete and printed legibly, The Department has provided a space at the bottom
of the affidavit foryou to fill out in the event the Office of investigations has to contact you regarding the applicant.
Please be sure to fill in the permitAicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permMicense applications in arty 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 starnped 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 Iicenses, A new affidavit must be filled out each
year. Vdhere. a home owner or citizen is obtaining a licemtt 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 chis 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 cail.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department Of Lmdust ial Accidents
Office of favestigations
600'WashLington Street
Boston; SIA 62111
Tel, 4 617-727-4900 C�7t 406 or 1-8:77-MASSAFE
Revised 5-26=05
Fax 4 617- 7-22 7-774 9
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TODD MICHEL CONSTRUCTION, LLC
109 WEST MAIN STREET
MERRIMAC, MA 01860
(978) 346-0464
CS LICENSE # 069490 HIC LICENSE # 138046
PROPOSAL
SUBMITTED TO: Bernard and Tracy Kavanagh DATE: January 24, 2009
ADDRESS: 32 Olympic Lane GOOD UNTIL: 60 Days
North Andover, MA START DATE: TBD
PHONE: (978) 337-6121 END DATE: TBD
Thank you for allowing us to quote your project. We propose to furnish all material and perform
all labor necessary to complete the following:
PROJECT DESCRIPTION:
First Floor
Kitchen, etc.:
• Cut and reinstall kitchen bench and padding
• Install hardwood crown molding to match existing in kitchen and hallway
Note: Hardwood molding provided by other, installed by Todd Michel Construction,LLC
• Furnish and install preprimed crown molding in family room, mudroom, and bathroom
• Remove and reinstall vanity centered in bathroom
Second Floor
Master Bedroom and Bathroom:
• Removal of existing closet
• Install two Harvey windows with Lo -E glass and retrim
• Frame new closet as per plan
• Frame for a new gas fireplace
• Skimcoat plaster, ceiling, walls, patching, etc.
• Install a new master bathroom door with reverse swing
• Install a new walk-in closet door
• Install new door trim and base trim
• Install new preprimed crown molding in master bathroom and hall
• Install crown molding in master bedroom
• Install cabinetry and moldings and accessories
Note: Cabinetry by other
• Install frosted film and cover walk-in closet window
Page 1 of 3
OTHER SERVICES PROVIDED BY TODD MICHEL CONSTRUCTION, LLC:
APPLICABLE INSURANCES
BUILDING PERMIT
ASSIST SUB -CONTRACTORS
CUT AND PATCH HAND HOLDS
REMOVAL OF DEBRIS
SERVICES NOT INCLUDED IN THIS CONTRACT:
PAINTING
FLOORING
ELECTRICAL
CABINETRY
CLOSET SHELVING
GAS FIREPLACE, GAS PIPING AND FLUING
PRICE: Todd Michel Construction, LLC, agrees to do all work as described above for a total
price of $12,900.00 (Twelve Thousand, Nine Hundred and 00/100 Dollars).
i ff f
Payments to be made follows: 35;9 when �trrt,���o� c�•��/��
ZZ-71VW 15500"0 when cabinets are installed
,?/6 VrS �0 when job is completed pending Punch List
Balance upon completion of Punch List
Please note: IRS Form W-9 (Certification of Taxpayer ID Number) will be furnished by
Contractor with first billing or by request at any time following the signing of this contract.
Contractor's signature: Date:
ACCEPTANCE OF PROPOSAL Timely decisions and selection of any products and fixtures
that are the responsibility of the Owner must be provided in a timeframe reasonable to the
progression of the job. Todd Michel Construction, LLC will work with the Owners to provide
the highest quality products within the schedule and budget of the project, but is not responsible
for job delays caused by Owners' failure to provide specific instructions, products, or product
selections.
To the extent permitted by law, if the Owners are in default due to failure to pay according to the
Disbursement Schedule, the Owners are responsible for any collection costs, attorneys' fees,
court costs, and all other expenses of enforcing the rights of Todd Michel Construction, LLC
under this agreement.
Note: Any hazardous materials uncovered during demolition and required to be removed by
licensed professionals will require additional fees not included in this contract.
The above price, specifications, and conditions e�are satisfactory and are hereby accepted. Todd
Michel Construction, LLC, is authorizedi' J he �v as specified. Payment will be made as
stated above.
Owner's si
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