HomeMy WebLinkAboutBuilding Permit #258-12 - 366 FOREST STREET 9/27/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: (;),5 2�- Date Received
Date Issued:
IMPORTANT:A plicant must complete all items on this page
LOCATION I L 6 Fi, S-�
Prin R
PROPERTY OWNER _i);,,4 Ccl,,, " Unit#
Print
MAP NO:1&PARCEL ZONING DISTRICT: Historic District yes
Machine Shop Village yes
100 year-old structure yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
16septic ❑ Well ❑Floodplain ❑ Wetlands ❑ Watershed District
a I
DESCRIPTION OF WORK TO BE PERFORMED:
(Identification Please Type or Print Clearly)
OWNER: Name: Phone R'1 LAE
Address: 3 {, l'y+tie S'r• a
CONTRACTOR Name: Phone: (k"t
Address:
Supervisor's Construction License: PSI-0 l�) Exp. Date: 0
Home Improvement License: � !)`$""t Exp. Date: A, Lq j t-2-
ARCH ITECT/ENG I NEER
ARCHITECT/ENGINEER t'�skr-� 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: $_ 'ZJ661tVbFEE: $ ZZ�
Check No.: (O Receipt No.: ag6724�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty f
igna ure o Agent/Owne Si nature of contractor
9_ __ ___
Location L�)�i / s✓
No. J Date
N°RTh TOWN, OF NORTH ANDOVER,
3 °t
� s
Certificate of Occupancy $
cNu9
t� Buildin /Frame Permit Fee $ �2
s� st
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # I ��
2 4 62 6 Building Inspector
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 0
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
HEALTH Reviewed on Signature
COMMENTS
I
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
i
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 05. Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street _ .
Fire Department signature/date
I
COMMENTS
Dimension
Q�
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
I 1
Doc:.Building Permit Revised 2011 June/mi
J
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
a Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o 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)
o 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
a 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 recordin
must be submitted with the building application g
Doc: Doc.Building Permit Revised 2008mi
j0RT#j
Town of
� o dover, Mass.,•a I
I�O COCMICHEWICK
7�ADf�ATED
R* M BOARD OF HEALTH
Food/Kitchen {
Septic System
'PE IT
BUILDING INSPECTOR
THIS CERTIFIES THAT.............. �.................... Foundation
has permission to erect............................. ... ..... buildings on . ....... ..... ...............................................�........... Rough
to be occupied as...... Chimney
. ....... .. .. . ....................................................................................................................
provided that the perso a opting this permit shall in every respect conform to the terms of the application on file in Final
this.office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6
' HS
ELECTRICAL INSPECTOR
UNLESS CONSTRVC S Rough .
................. .......................................
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE-DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
07/11/2811 87:45 9786833147 PAGE 01/01
4C
CERTIFICATE OF UABUTY INSURANCE 17/tml /2i0011
TWIS CERTIFICATE IS ISSUED AS A MATTER OF WORIIIIATION ONLY AND CONFERS NO won UPON TI(8 GERTi 4UM HOUML THIS
CERTIFICATE DOES NOT AFFTRMATIVMY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE APFORDBD BY INE POLK.9E$
SEtAW. THIS M7MATE OF INSWANCH DOES NOT 4:01i$TTTU'fE A CONTRACT BETWEEN nE I$Ml O RdLIRERM At"
HCRM
REPRESENTATIVE OR PRODUCER,AtM THE CEtTMATE 1WLDER
gn lhWUNT: It the cerORM ImMm Is w AUMTKINAL INSURED.tft 461k9(1M)must.AeandmWA N 81.19ROGA710N 18 WAMM,suwct to
go W.and oondalWa of the poBey,ee"n po m"may h':pft an h,m Wa o"L A SbUMOO on Ob"Itl8oabe d*"not costar rwft to tee
4 ft%to holder to ft"of
WNTACT
'RQOUCERNAME
M P ROSMS INS A=Y.. IVC (979)683-9073 (978)683-3147
1060 0agood Stzget "Adi@ obertslnsuvance.am
North Andc"r, DSA 01645 !oma AFFORDIS MWINAM
INSURE A:FROVID8NGi3 NEOTM
rwsmo mivm muRm $IIILDIDar3 ai RMGMLIM mmmma-MOMAMS INSVRANCE
169 90XV D STEMT INSURER C.WAIW INSURANCE
INSURER '
ROM ANDOM, Dpi 01845 e E
IHS F
COVERAGES CERTIFICATE NUMER REVISION NUMBEk
THIS 18 TO CERTIFY--KAT TME POLICIES OF INSURANCE LISTED BELOW"Ave BEEN MSiUER TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWMISTANDING ANY REOUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wrm RESPECT TO WHICH IM
CERTIFItIATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY TETE POLICES DESCRIBED HEREIN FS SUBJECT TO ALL THE TERMS
EXCLUSIONS AND=4orfIM OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAW
WAITS
13SNERAL LWLIIY rssuRaflCE era I o EACH OCCL%qANCE s 1 000 000
7t COIhnAERcw. u LUaBILrTY PRE1�S7=1i ooawer4o s 100,000
oLM&MA>E ®OCCUR mw Ehw "wm vffw) s 5.000
A CPP0060969 11/22/10 1/22/11 Pmmoma aADVNJURY s 1,00 '000
GEWRAL Ac,GRMTE $ 2,000,
000
Mn A REc,ATe to Aa�PLaEs PER: PNOOUots-CompiopAw s 2,000,000
Pour n im ED= LAWTs
AUTOMODU LUaNM W=15001r- 1,000 000
ANYAM i/28 J11 01/x3/12 90DILY PQURY(Per a�+I s
MCA701360 8 Donn Y auuaY(�,eh�e�hrl ;
8 AI�iT° � � :
HIRE(1 Auras AUTOS
Ipu1 LLA LaRO UR EACH OCCURRENCE s
ExCEss LIAS C� Atiti�ATE S
ow fxrlONs WaRKM s
SATwN R . nh7 ER
'
AND MWLO1M LIABLITY TIN E.L.EACH ACOMW i 500
C NIA ' 10=2133'7507/01/11 7/07./12
whodem In EL o� -� s 500,000
te9
n neww sk DISEASE-Pa7LIGY t*T s 500 r000
DESCRIPTION OF OPERATIONS I LOCAYM I VEHICLES{AMe1Rt ACORD 1Ct,AtlMbnhi Re1M1*ks SrJheellRe.K mase npeoe B 1
CERTIFICATE ER CANCEL-i A
TCM OF NOR= Al OMM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
HOREB At4DOVER, 3% 01845 THE EXPIRATION OATS THEREOF. NOTICE WILL BE OOMRED IN
ACCORDANCE WRH THE POLICY PROVISIONS.
AL A
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19WWlQACMCORPORATI0N. Aliftlftreeermd,
At„ORGx5t2010�5) The ACORO name and Wp are raffisuaed market of A00RD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,NIA 02111
U www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busirms/Organization/Individual):
Address:
City/State/Zip: y`i,,, GstL<j Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
r0i am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.Q I am a sole proprietor or partner-
listed on the attached sheet $ ? Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. . 9. E] Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs o-r additions
required.] officers have exercised their
3.❑ I im a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.Q Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp.insurance required.]
'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 their workers'comp.policy inforrrration-
I am an employer that is providing workers'compensation.insurance for my employees. Below is the.policy and,job site
information.
Insurance Company Name: ��� �o1�S Ci
Policy#or Self-ins.Lie.M k<--a �C 2.133"'1 Expiration Date:��,
Job Site Address: Z L 1 City/State/Zip: t-Jw t
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.
I do her y certify and and pen f jT that the information provided above is true and correct-
Si afore: Date:
Phone#: `t
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/Ucense#
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#:
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 shalt 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-contractors)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 5-26-05
wwwmass.gov/dia
169 Boxford Street
North Andover,MA01845
�y • PH:978-688-6335
Building Contractor • FAX:978.6MXXM
Proposal
To: Lauren Day
366 Forest Street AD Hare improverrat Contractors and Subcontractors
North Andover, Ma 01845 or Chapter
142A of the general taws,must be registered wr h the
Commonwealth of Massachusetts.!Inquiries about
registration and status shatd be made to the Director,Hare
Improvernent Contract Registr2tiat,One Ashburton Place,
Froarc Kevin Murphy Room 1301,Boston,MAA 02108.(617}727 85%
Cc:
Date: 9/15/2011
.lob: Bath/bedroom remodel
Date of plans: 8/11
Architect: Owner
Location: same
Section I-Work Schedule
Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified here in
writing contractor will begin work on or about 9/15/11.
Barring Delay caused by circumstances beyond Contactors control,the work will be completed by 11/15/11.The owner hereby acknowledges
and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as
violations of this agreement.
Section 11-Warranty
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of 1 year
following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or
damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job,
including cleanup,the Contractor shall,at his own expense,forthwith remedy, repair correct,replace,or cause to be remedied,repaired,or
replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in
connection with the agreed-upon work.
Section III—Scope of Work
Page 1 of 4
fteVEM Mi muphy Page 2 of 4
Building Contractor
169 8o)ffmd street
North Andover,MA 01845
PH:97868&5335
FAX 978688-X)00(
General
Proposal is to add three fixture bathroom on second floor,expand existing dormer, and finish closet area in front
of bedroom. Building permit will be provided by contractor. No allowance has been made to provide any building
plans, board of health approvals etc
Demolition
Existing closet area will be gutted.
Building
Frame, roof, and siding material will be provided to extend existing dormer wall , to end of house
approximately 2-3 feet) . Interior petitions will be built as shown on owner's plan. No allowance has been made
for any window units.
Plumbing
Plumbing required to add bath on second floor will be provided. It is assumed the pvc pipe that was previously
installed, will be used. No allowance has been made to repair / replace that existing line. Owner to supply
plumbing fixtures. Copper pan for tile shower will be supplied by contractor.
Electrical
Electrical work required to add bath to meet code will be provided. Bath fan/light unit will be supplied/installed.
Owner to supply surface mounted fixtures. No allwoance has been for any worts to existing electrical service.
Heating/Air Conditioning
Existing baseboard heating will be relocated as required. No allowance has been made for any a/c work.
Insulation
Renovated areas will be insulated to meet code.
Plaster
Renovated areas will be blueboarded and skimcoat plastered.Walls will be smooth. Ceilings to match existing.
Interior Trim/Doors
Pre-primed interior trim and doors will be supplied and installed to match existing.
Painting
Interior and exterior painting will be provided. One coat of primer and two coats of finish will be applied to all
painted surfaces.
McVEM Umn7Iluy Page 3 of 4
Building Contmctor
169 Boxford street
North Andover,MA 01845
PH:9786865335
FAX 97&68&X)00(
Flooring
Hardwood floor will be patched and refinished as required in bedroom. Tile floor will be supplied / installed in
bathroom area. Shower floor and walls will be tiled. An allowance of$6 per square foot has been included for
tile materials.
Waste Removal
All demolition/construction debris will be disposed of by contractor.
Items Not Included
There has been no allowance made for any plumbing fixtures, shower doors, vanities, countertops, or surface
mounted light fixtures.
I
Page 4 of 4
Building Contractor
169 Boxford Street
North Andover,MA 01845
PH:978S885335
FAX 97868&X)00(
Section IV-Price Schedule
We hereby propose to furnish material and labor-complete
in Accordance with above specifications for the sum of... ... ...... ... ...... ... ... ... ... ....$ 26,800
Payment to be made as follows:
Percents etltem Description Amount
1 Permit obtained $2000
2 Exterior complete $8000
3 Plastering complete $10,000
4 Job 100% complete $6800
Total 4 1 $26,800.00 19 i
"Notice:No agreement for Horne improvement contracting work shall require a down paw(advance deposit)of more that one4hird of the total contract price of the total amorud of all deposits or
payments which the contractor must make,in advance,to ander ardor otherwise obtain delivery of special order materials and equipment,whichever is greater
Contractor. Kevin Murphy
189'Boxford Street
No.Andover, MA 01845
Registration No: 101874
Section V-Acceptance
Acceptance of Proposal—I have read this document and accept the prices, specifications,and conditions stated. I
understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified.
Payment will be made as outlined above.
You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this
transaction cancellation must be done in writing
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Signature Date—%-15A I
Signature Date