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HomeMy WebLinkAboutBuilding Permit #463-2016 - 4 PEMBROOK ROAD 10/13/2015The Commonwealth of Massachusetts Board of Building Regulations and Standards . FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One- or Two -Family Dwelling This Section For Official Use Only Building Permit Number: '— Date Applied: � I' Building Official (Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Proerty Address: �] Aclo Assessors Map & Parcel Numbers 1.2�As e'rs 1.1 a Is this an accepted street? yes '/-no Map Number Parcel Number 3. Zoning Information: 4. Property Dimensions: Zoning District Proposed Use Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40, 1.7 Flood Zone Information: 1.8 Sewage Disposal System: § 54) Zone: _ Outside Flood Zone? Check if yeso Municipal o On site disposal system o Public o Private o SECTION 2: PROPERTY OWNERSHIP 1. Owner' of Record: NW(Print) City, State, ZIP Al )OCM Ar1Vp /K 9d10o,-A « 9703006331 No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK New Construction o Existing Building o Owner -Occupied 0 Repairs(s) o Alteration(s) o Addition o Demolition o AccessoryBldg. g o Number of Units Other o Specify: Brief Descriptio of Proposed // /f / // / '4G la Work2: z 1 l a 4a -I e- at, J r 1 Permit No#: Date Issued: C•w/ $ FORTH BUILDING PERMIT- °��4,�ED.:,;e TOWN OF NORTH ANDOVER o - :- APPLICATION FOR PLAN EXAMINATION Z- �o Date ReceivedRRTED IMPORTANT: Applicant must complete all items on this LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:_ HistoricDistrict yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building ❑ One family ❑ Two or more family ❑ Industrial ❑ Addition No. of units: ❑ Commercial ❑ Alteration ❑ Others: ❑ Repair, replacement ❑ Assessory Bldg ❑ DemolitionEl ther O ©pia s • �- 0 Sepf c r� n Wats .�: . � � z , • - • � ' , .� •rr, r•n n�ocll�IIIICII• OWNER: Name: Address: Identification - Please Type or Print Clearly Pho Contractor Name: Email: Address: Supervisor's Construction License: Home Improvement License: Exp. Date: Exp. Date: II ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund t°_0 nat' IrPtn, 'conVa +o Plans Submitted ❑ Plans Waived"❑ Certified Plot Flan ❑ Stamped Plans ❑ ;y TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Swim'ning Pools ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ .Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OPE m U FORM PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/SDriveway Permit DPW Town Engineer: Signature: Located 384 Street SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: o Standard City/Town Application Fee c Total Project Cost 2. Other Fees: $ List: 2. Electrical $ 3. Plumbing $ 4. Mechanical (HVAC) $ ---- 5. Mechanical (Fire Suppression) $ — Total All Fees: $ Check No. Check Amount: Cash Amount: o Paid in Full o Outstanding Balance Due: 6. Total Project Cost: $ �p� 9' % ® SECTION 5: CONSTRUCTION SERVICES 1. Construction Supervisor License (CSL) jf/! 90i4 J Ila Q3 9 �5� / License Number Expiration Date List CSL Type (see below) /2 Name of CSL Holder 02 �e// Type Description No. +and Street / U Unrestricted (Buildings up to 35,000 cu. Q Restricted 1&2 Family Dwelling _ City/Town, State, ZIP M Masonry n 3 / Telephone Email address L ed/M RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation D Demolition 5.2 Registered Home Improvement Contractor (HIC) 118;2 , 3 HIC Registration Number Expiration Date 2-1,;1l// `T i7��i HIC CompRy Name or HIC Registr t Name ` � f � /! _ %�� ®� �� No. and Street e�11e7.011 0'1,r3Y 9%a'3i2SSTJi�o City/Town, State, ZIP Telephone GD Email address SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... No ........... o r �. 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 Doc.Building Permit Revised 2014 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 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/Cross Section/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 TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 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 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: 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: Building Permit Revised 2014 Location T No.� —201c Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $^� Foundation Permit Fee Other Permit Fee $ TOTAL $ Building inspector 0 `1 w LL oa O m G L Y Y —O O LCL a0+ T N '�.. a In Gcc a Z Z m G O N 3 LL to O W N G U _ r9 LL O a y� Z Z J d CA 3 CC _ LL O' a N Z U G J LU Oq 7 W N u _ � Ln _ N LL U Wa z a C7 00 3 1' _ LL Z Q W 0 LLJ _ LL N D m z N N .N N v Y O N D J z Z O ujJ .a w ti �I E �o O d Z N 0 rr� wI` 0-- - N •E in m CL F- i AWO �+ d M O CL a a� Q o c C' J cv •= OAy///y`��`; Z W V V1 Ch Q B 0 C N O 2 CL �a •• c y C> E Q. L y m y w � L C ' Cc c 3 CL O y J N C 0 y GD _ O y -0 0 O y Q -a 0 ... E 0 L 0 0 Z �_ 0 y O O t y = L Q. CD CD 0 m �0.. y •a a) ' Q V i 0 y _ L � •a = 0 Q 0 3 m C0 �+ 4 W = 'a +-• O O W E c� U i ~ t C Z CL 0 U Z O ujJ .a w ti �I E �o O d Z N 0 rr� wI` 0-- - N •E in m CL F- i AWO �+ d M O CL a a� Q o c C' J cv •= OAy///y`��`; Z W V V1 Ch Q B The Commonwealth of Massachusetts Department of Industrial Accidents -- Office of Investigations. { 1 Congress Street, Suite 100 Boston, MA 02114-2017 www- nass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A]2pUcant Information Please Print Legibly Name (Business/Organization/Individual): i Cl/-, i , (� cie. lan c/ uity/atate/Gip: /,,r/" Phone #: Are you an employer? Check the appropriate box: i S I am a employer with 1_ 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' comp. insurance required.l =_VA • Type of project (required): 6. ❑ New construction_ 7. '®=Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11.. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #I 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 workerscompensation insurance for nay employees. Below is thepolicy and job site information. I ; Insurance Company Name: Policy # or Self -ins. Lica #:16S& D UIS — ??SZ eg -V y -'Y Expiration Date: `0 Job Site Address: 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby cerci und$ the pains andpenalties ofperjury that the information provided above is true and correct. Phone #: 6/ 7r— Official 6 — 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 #• u�—«4 i� is:4� rrcun— 1-355 P0002/0004 F-852 DEHULLU BIOMES LLC 32 Benjamin Street Groveland, MA 01834 Tel: (978)372-5000 Fax: (978)372-8898 dehulluhomes0laol�com Contract #156 THIS CONTRACT made the .7 day of tt , 2015, by and between DehuUu Homes LLC Hereafter called the Contractor and John and Diana Clark, hereinafter called the Owners. THE OWNERS, without invalidating the Contract, may order changes in the work consisting of additions, deletions or modifications; the Contract Sum will be adjusted accordingly. Such Changes in the Work shall be authorized by a written Change Order signed by Owner and Contractor and payable upon signing of such Change Order. Any Additional Work will not commeace until the signing and payment of the Change Order. ALL MATERIAL. is guaranteed to be as specified. All work to be completed in a workmanlike manner and in compliance with all building codes and other applicable laws. Owners to cavy all necessary homeowners or builder's risk insurance. Our workers are fully covered by Workman's Compensation Insurance. WITNESSETH that the Contractor and the Owners for the considerations named agree as follows: The Owner shall pay the Contractor for the Contractor's performance of the Contract the Contract Sum of $16,970 (Sixteen Thousand, Nine Hundred and Seventy Dollars and no cents). A, down payment of $1,700 (One Thousand, Seven Hundred Dollars and no cents) is required to bind this agreement and is due upon the signing of this contract. The payment schedule will be as outlined on page three of this agreement. Each payment will be based upon invoices submitted by Contractor. The Owner shall make progress payments on account of the Contract Sum to the Contractor. Scope of Work The Contractor shall furnish all materials and perform all of the work on the property located at: 4 Pembrook Road, North Andover, MA Contract #156 John and Diana Clark Page 1 of 3 Ud-2U-" '1 b 13 : 4b r KUI41- 1-3bb N0003/0004 F-852 Work Performed - Kitchen Remodel - Location: 4 Pembrook Road, North Andover, MA according to the following specifications: a) All necessary permits b) Remove section of wall from kitchen ( non carrying ) to family room. Build arch similar to picture provided by owner c) Remove kitchen cabinets d) Install new kitchen cabinets - owner to supply e) Remove existing tile floor and underlayment f) Block off hutch area with sheetrock g) Remove trim, re trim kitchen window h) Remove kitchen sink, refrigerator, dishwasher, hood and stove i) Remove baseboard heat as necessary j) Re trim cased opening to entry way, remove electrical outlet and relocate if necessary k) Add .PVC vent to kitchen sink l) Install new appliances, relocate gas piping to new stove location, relocate electric for microwave, install new garbage disposal - owner to provide all appliances m) Disposal of all construction debris n) Install one toe kick heater to kitchen o) Install pre finished hardwood floors in kitchen, owner to provide all hardwood flooring p) Install six recessed lights q) Install under mount cabinet Lighting, owner to provide r) No.painting included Contract #156 John and Diana Clark Pare 2 of 3 08-20.;;15 13:46 FROM - Contract Price T-355 P0004/0004 F-852 The owner shall pay the contractor for material and labor to be performed the sum of $16,970 according to the following Payment Schedule. Payment One: Payment Two: Payment Three: Payment Four: Owner dm/ Ak Jopfi Clark Owner 40J Diana Clark E&)MENT &WEDULE Due at Contract signing Second Payment Due Third Payment Due Upon Completion $ 1,700 lzJ SwO $ 7,000 $ 6,570 $ 1,700 Contractor S Dehullu Dehu lu Homes LLC Contract #156 John and Diana Clark Page 3 of 3 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property, hereby authorizes ���� &4y Ila to act on my behalf, in all matters relative to work authorized by this building permit application. J; 61d/A�- f`/ Print Owner's Name (Electronic Signature) Date SECTION 7b: OWNER By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name (Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will gol have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss, 2. When substantial work is planned, provide the information below: Total floor area (sq. ft.) (including garage, finished basementlattics, decks or porch) Gross living area (sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for "Total Project Cost" Office of Consumer Affairs & Bdsiness Regulation { HOME IMPROVEMENT CONTRACTOR A Registration; 118273 Type: s Expiration <2/2N— 2•,017 Ltd Liability Gorporati I E a .D LLU HOMES-,, `_ i STEPHEN DEHUL'LU=� � 32 BENJAMIN STREET GROVELAND, MA 01834 Undersecretary 'License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 IAP �.� Not v ` lyd without signature t Massachusetts -Department of Public Safety poard of Building Regulations and Standards.. Constructioi Sulien•isor l & 2 Family i. License: CSFA-059703 ci rr.5 i� 9tt, Stephen M Dehully--.' `�- 32 Benjamin Street s. Groveland MA 01834 F 1 J11ilk Expiration Commissioner 0911412016 10/13/2015 02:13 FAX 9787940313 DURSO&JANKOWSKI INS AGCY 001/001 OP ID, CERTIFICATE OF LIABILITY INSURANCE D71T011111-1 /oomrY) „_ , /201 S THIS CERTIFICTI "; IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE IDD::l NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THAI C : RTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTA71VI ? OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If tl to certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and cion: idons of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holdlrr 11 lieu of such endorsement e . PRODUCER CONTACT Durso & Jankowe:ki I r t Agcy LLC PWQONE FAX 11 Saunders Stro at tL.. _ . Ncs): North Andover, IIIA (11.145 ADDRESS: Durso & Jankowalkl I r I,,. Agcy.- Ct1"TAMFB n1 of DEHUL-1 EitUll J�l'f0YY16S LL^- -� -,,..,._�...,.,,,-,,,.,,,,...,._,,.....,,---�--......W.._..—.-•-•-•�-•-•---,.�--- C 32 Eller i I min Street Grovel j nd, MA 01634 INSURER A: Hartford Insurance Co. INSURER 0: -- INSURER C: INSURER D: INSURER E: INSURER F! THIS IS TO crtwriF" INDICATED. NCTW ' CERTIFICATE AI+kY EXCLUSIONS AND C R ; R TYP1E0_ GENERAL LIAE I ;JTY 1AERCIAL I ,I CLAW S -M 1 GEN'L AGGREG+.TE _ + POLICY / AUTOMOSILP 1.1,1811 r ANY AUTO ALL OWNS D A( 1 SCHEDUL 2 ) Al / HIRED AU 10S NON -OWNS D A . UMBRELLk UA I EX( LUIS DEDUCTIEII. E RETENT+ 1:L, WORKERS COMIEN 9 AND EMPLOY051 L / A ANY PROPRIETI- R/P, I OFFICER/MEMEER E, I (Mandatory In el:;l) If yea• oaeerlbe under DESCRIPTION , F O .i DESCRIPTION OF OPIBRAT t No partner(,) have , No partne (s) sire i CERTIFICATE NUMBER: REVISION NUMBER - 'THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ASTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS I: ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IJDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I ISURANCB ADOL SUER POLICY NUMAFR POIOD/YVYY MMIDDIYYYY LIMITS OCCURRENCE S NERAL LIABILITY -EACH 1 PREMISES Ea eeourrenaa -- "- 9 )I° FJ OCCUR MED EXP (Any one anon PERSONAL & ADV INJURY S GENERAL AGGREGATE S PRODUCTS - COMP/OP AGG 3 HITAPPLIES PER: l; LOC E COMBINED SINGLE LIMIT (Ee eccidenq $ BODILY INJURY (Per person) S- $ BODILY INJURY (Per eccldenl) S +)9 PROPERTY DAMAGE (PER ACCIDENT) $ t8 OCCUR EACH OCCURRENCE S AGOREOAYE _ 6 CLAIMS -MADE 1 r10N 04LITY Y / N 'NER/EXECUTIVE LD? UDE NIA BS60UB9956M84414 10/25/2014 10/25/2015 WC STATU- OTH- 7QFi1_UMITS----- — E.L. EACH ACCIDENT $ 100,00 E.L DISEASE - EA EMPLOYEE $ 100,00 E.L. DISEASE -POLICY LIMIT $ 500,00 !LITIONSbelow 1.15 1 LOCATIONS r VEHICL0 (AtMah ACORD 101, Additional Remork■ Sohodule. I►mom ,pato a ropulrod) . :lected coverage----- overed by the workers'compensation policy." NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town o i North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Buil dir 11 Inspection Office 1601.1 0 : blood Street AUTHORIZED REPRESENTATIVE N601h it - dover, MA 01645 Durso & Jankowski Ins. Agcy, ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (20011/01) The ACORD name and logo are registered marks of ACORD