HomeMy WebLinkAboutBuilding Permit #926 - 36 PATTON LANE 6/25/2012BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 9af� Date Received
Datelssued: 4�4ir-
1 0
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
Q Le �f a��
Addition
Two or more family
Industrial
6*999p==�—
No. of units:
Commercial
r�eplace�ment
Assessory Bldg
Others:
De�moRepair,
tio
li ion
Other
t,
__p ic� Well'
... . ... W6tland8-,--
Flobd'pla.in.
-,V atershed'Distict-
V 0
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
-M,� RE"DF-�- 4��, PER- PLAQ -Xk� F
V LOOTEC,J
Identification Please Type or Print Clearly)
OWNER: Name:
o�
61 -7 Z
ARCH ITECT/ENG IN EER LA - Phone:
Address: Reg. No
FEE SCHEDULE. BULDING PERMIT. $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Ox- Receipt No.:
NOTE: Person; contracting with unregistered contractors do not have access to the guarantv fund
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
L3 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
13 Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
u Building Permit Application
u Certified Surveyed Plot Plan
u Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
u Copy Of Contract
u Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
u Mass check Energy Compliance Report (If Applicable)
u 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
Li Photo of H.I.C. And C.S.L. Licenses
u Workers Comp Affidavit
Lj Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
NOTE: All d.umpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special pern-dt 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 2.2008
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
4t>
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
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 21 A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
Ll Notified for pickup - Date
. .... . . . . ........
Doc.Building Permit Revised 2008
Location,-?1�9—
N Dated2
TOWN OF NORTH ANDOVER
Certificate of Occupancy $—
Building/Frame Permit Fee $;W-ao—
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check S 15 (:7
25449 Building Inspector
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CERTIFICATE: OF LIABILITY INSURANCE
DATE (MM/DDIY`rM
03121/2012
_F
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 pollcy(les) 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 Phone: 978-346-8761 Fay. 978-346-9620
JOURNEAY INSURANCE AGENCY INC
8 WEST MAIN STREET
MERRIMAC MA 01860
CONT�c"- Journeay insurance Agency Inc
PHONE, -346-8761 IfF 0
(AVC, No EXII: 978 AX 978-346-9620
No):
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
GENERAL LIABILITY
INSURER A Technology Insurance Company
INSURED
JODD MICHEL CONSTRUCTION, LLC
INSURER B
C/O TODD MICHEL
109 WEST MAIN STREET
MERRIMAC MA 01860
INSURER C
INSURER D:
INSURER E
COMMERCIAL GENERAL LIABILITY
__1CLAIMS-MADE FOCCUR
INSURER F
COVERAGES CERTIFICATE NUMBER: 8194 REVISION. NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF. INSURANCE -LISTED BELOW HAVE BEEN:ISSUEb TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CON ITION VWW 66NTkACT 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,
INSR
LTR
TYPE OF INSURANCE
ADD'L
INSR
SUBR
WVD
POLICY NUMBER
POLICY EFF
(MWDDfYYYY)
POLICY EXP
(MWDDNYYY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
COMMERCIAL GENERAL LIABILITY
__1CLAIMS-MADE FOCCUR
DAMAGE TO RENTED
PREMISES (Ea occurence) $
MED. EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG $
__1
$
POLICY D JERCO� F-] LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO
ALL OWNED ----1SCHEDULED
AUTOS AUTOS
HIRED AUTOS �NON-OWNED
AUTO S
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
(per accident)
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
EXCESS LIAB
CLAIMS -MADE_
AGGREGATE $
6� IRETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
N/A
TWC3309278
02125/12
02125/13
WC STATU- OTH
TORY LIMITS ER $
E.L. EACH ACCIDENT $ 500,000
E.L. DISEASE -EA EMPLOYEE $ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT $ 600,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Ad�ltlonal Remarks Schedule, If more space Is required)
CERTIFICATE HOLDER CANCELLATION
Town of Merrimac SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Merrimac, Ma. 01860 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
.......................
Aftention:
Derek Journeay
ACORD 25 (2010/05) 0 1988-2010 ACORD CORPORATION. All rights resei;�e_d.
I ne AL;UKu name ana logo are registered marks of ACORD
TODD MICHEL CONSTRUCTION, LLC
109 WEST MAIN STREET
MERRIMAC, MA 01860
(978) 346-0464
CS LICENSE # 069490 HIC LICENSE # 138046
PROPOSAL
Michael and Heidi Yoken
36 Patton Lane
North Andover, MA
(978) 685-2729
Yokhmc@comcast.net
March 15, 2012
GOOD UNTIL: 60 Days
START DATE: TBD
END DATE: TBD
Thank you for considering us for your project. We propose to furnish all material and perform all
labor necessary to complete the following:
PROJECT DESCRIPTION: Materials and labor for the construction of the master bedroom
and bath as per plan by The Inside View, dated 12-19-2011.
Remodel Master Bedroom
Remodel closets; crown molding, chair rail, and 2 1/4" prefinished hardwood flooring in hall and
master bedroom, and finish trim, as per plan.
Remodel Master Bath
Add floor tile, tile shower wAs and base, install new vanity, crown molding, toilets, and interior
finishes.
By Homeowner
Shower door
Tiles and tile materials (Installation by TMC)
Cabinets and countertops (Installation by TMC)
Closets to have carpet (Installation by Homeowner)
Painting
OTHER SERVICES:
Building Permit
Liability Insurance
Workers Compensation Insurance
Removal of Debris
Page 1 of 2
PRICE: Todd Michel Construction, LLC, agrees,to do all work as described above for a total
price of $19,800.00 LNIineteen Thousand, Eight Hundredand 00/100 Dollars).
Payments to be made as follows: (To be determied)
Please note: IRS Form W-9 (Certification of Taxpayer.,ID Number) will be finmished by
Contractor with first billing or by request at any time following the signing of this contract.,
Contractor's signatur�.���... Date:6, 7
ACCEPTANCE OF PROPOSAL Timely decisions and selection of any products and fixtures
that are the responsibility of the Owner must be provided in a timefi-ame 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 pen-nitted 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 are satisfactory and are hereby accepted. Todd
Michel Construction, LLC, is authorized to do the wor as specified. Payment will be made as
stated above.
Owner's signature: Date:
ONVNERIS RIGIITS AND BENEFITS:
The owner may have 3- day cancellation rights under one or more of Mass. Gen. Law Chap. 93,
Sec. 48; Chap. 140 D, Sec. 10; and Chap. 255D, Sec. 14.
The owner is entitled to certain rights and benefits under Mass. Gen. Law Chap. 142A.
Page 2 of 2
6
A�64---G "d
Vf i%
H OME lk�7p,.IROVEIVIENT CONTRACTOR
Registratl6n: A-158046 Typb:.
piration: 3 Private '!!ppr:�� g,
- - --------
U!VIC
T
0 -
TODD MIdHEL
109 WEST MAIN S
MERRIMAC, MA 018
Underse&a1U..ji
---- --- . . ......
-A-z- Viassachusetts - Dep.mime'rn of Public Safeti
Board of Buildin- Rtgulations and Stand.ards.
Constructionr'Su.pervisor License
License: CS 69490
TODD R M],.CHEL
109 WEST MAIN ST
MERRIMAC, MA.01860
Expiration: 12/29/2012
ommissioner Tr#: 10458
'4� .
The Commonwealth ofHassachusetts
Department ofIndustrialAccidints
Office ofInvesfigations
600 Washington Street
Boston., MA 02111
vwwmass.govMa
Workers' Compensation Insurance Affidavit: BuRd-ers/Contractor8fFIectriciansfplumbers
Ap-plicant Information Please Print Legibly
Namc @3usin essfOrganizationffndividual):-TDDID �&7(14FL_ WPSTP�7ZbQ\ LL-(
Address: 101 PAT�j S7-
City/sfate/Zip: M&M -0 -AC VA k phone '17 qG '(2-'
Are you an employer? Check the appropriate box:
1. KI am a enaployer with –:n> 4. El *1 am a general contractor and 1
Type ofproject (required):
6. n New QoAst . ruction
employees (fiffl and/or -part-time.).*
2. [11 am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. x
7. X Remodeling
F—V
ship and:have no employees
These sub -contractors have
8. El Demolition
working for mein any capacity.
workers' comp. insurance.
9. El Building addition
[No workers' comp. insurance
5. El We are a corporation and its
ME] Electrical repairs or additions
required.]
3. El I am a homeowjier doing all work
officers have exercised their
right of exemption par MGL
I L[I Plumbingrepairs or additions
myself. [go workers' comp.
c. 152, §1(4), and wohaveno
12.QRoofrepairs
insurance required.]
employees, [No workers'
13. El o ther
romp. insurance requiredj
'Any applicant that checks box#1 must also fill out the section bel6w showlfig their workers' compensation olioy information.
P
T Homeownerswho submit this affidavit indicating they are doing ell worle and then hire outside contractors must submit anew affidavit indicating such.
tContractors that checkthis box mustattached an additional shoot slio�ving the name of the sub -contractors and their workers' comp. policy information.
am an ein
,ployer that 1sp.-oVialng workers' compensation insurancefoTmy employeex Below is thepolley andjob site
infoTmation.
Insurance Company Name% Co
Policy # or 8 elf -ins. Lic. 4:7WC 33 (DC12_7 S Expiration Date: 2-- ?-S-
Job Site Address... '3(;, PATrOQ Pity/StatelZip: 00RH
Attach a copy of the workers' compensationpolley declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of`MGL c. 152 can lead to the imposition oftrin3inal penalties of a
fine up to $1,500.00 and/or ono-yearimprisonment, as weltas civilpenaltics in the form of a STOP.WORK ORDER and a fine
of up to $250.00 a day against ffio violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Y do hereby certji� utiderthepains andpenaltles ofperjury th at the infarmationproviffed above is true and correct.
TOOL 2,2— — ?-On
I( ::;, LJ2L
Of
ficial use only. Do not write in Als area, to he com
,pleted h
.y cl(p or to wn offilcial.
City or Town: PermitffAcense 9
Issuing Authority (circle one):
I-BoardofRealth2.)3u!ldlngDep,grtment3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact
Phone 0:
Information and Instructions
Massachusetts General Laws chapter 152 requires allemployers to provide Workers' compensation for their employees.
Pursuant to this statute, an employeeis dofmod as "....everyperson in the service of another under any contract ofhire,-
express or implied, oral or written.,,
An e7n a 0 t! n cotPoration or other legal entity, or any two or more
Voyeils defftied as "an individual, partnership, sso la 0 ,
'of the foregoing engaged in ajolut enterprise, and including the, legal representatives of a deceased employer, or the
receiver or trusfee of an Individual, partnership, assocqation 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. o rcupaut of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the gro-aii ds or building appurten ant thereto shall not b o c aus a. of s u ch empl oym ent b o do em ed to b e, an onaployer.
MGL chapter 152, §25.C(6) also states that "every state or local hGensing agency shallwIthhold the issuance or
renewal of a license or permit to operate a business or to constiruct buildings in the commonwealth for any
applicant who hasnot produced -acceptable evidence of compliance with the Insurance coverage requ.lred?)
Additionally, MOL chapter 15�, §25C(7) states "Neither the commonwealth nor any ofits political subdivisions shall
enter into any contract for the performance ofpublic, work until acceptable Wdonco of compliance with the insurance
requirements of this chaptorhave bBenprosented to the contracting authority."
Applicants
Please fill out the, Workers' compensation affidavit cOMPIOUY, by Checking the boxes that apply to your situation and, if
necessary, Supply sub-contractor(s) name(s), address(es) andphono number(s) along withtheir certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
mehibors or partners, are notrequired to carry workers' compensation insurance. Han LLC orLLP does have
employees., a policy is required, Be advised that this affidavit maybe submitted to the, Department of Industrial
AccidontsfoTcon��atio,uofinsurancecovorage. Also be sure to sign and date the affidavit. he affidavit should
be returned to the city or town that th"o application for the permit or license is being requested, not the, Dep art m*ent of
Industrial Accidents. Should you have any questions regarding the law or if you are requited to obtain a workers,
compensation policy, please. call the Department at the number listed below. Sol ared companies should enter their
self-insurance license number on the gpropriate line.
City or Town Officials
Please, be sure that the affidavit is complete and printiedlogibly. The, Department has provided a space at the bottom
of the, affida-vit 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 & penuit/liconso num
bor which will be used as a reference number, In addition, an applicant
that must submit multiple pormit/license, applications in any given year, need only submit one, affidavit indicating current
Policy information (ifnecessary) and under "Job Site Addross'; the applicant should -write "all locations in (city or
tow.n.)."A co . f(i s o n
pyofthea davit that has been officially tamp d ormarkedby the city ortow mayboproiFidodtoiha
applicant as proof that a valid affidavit ii on file for fature permits or licenses. Anew affidavit must be fffleLd out each
year. Mere a home owner or citizen is obtaining a license or*p_drmit not related to any business or commercial -venture
(i.e. a dog license or p* ormit to bum leaves etc) said person is NOT required to complete this affidavit.
The Office OfInvestigations would like to than1c you in advance. for your cooperation and should you have any qaostions,
please do not hesitate to give us a call,
The Department's address, telephone and fax number:
Tho Com
monw. oajth of M
De-padment of Industdal Acoldouts
offloe of 11westigation .
6W Wa�Wvoa Stoa
Buton�,MA02111
Tel, # 617-7-2,7, 900 oxt 406 or 1-877�UASs"
4 j3
Revised 5-26-05 Fay, # 617-727-7749
ITM71TW� --rX.-