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HomeMy WebLinkAboutBuilding Permit #510 - 471 ANDOVER STREET 12/29/2011L Permit NO: /® Date issued: 1; 4q /Y BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * - e Date Received .� -'�ppDRAreD �Pay45� IMPORTANT: Applicant must complete all items on this page _ F LOCATION R®PERTY O ER3. I/ c z D �t P Print MAP NO RARCEL'-.-,—,— ZONING;DISTRICT Historic District :yes _— Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building []One family ❑ Addition ❑ Two or more family ❑ Industrial P -Alteration No. of units: ZCommercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other WSeptic IRiftil ❑ Floodplpin D Wetlands ❑: Watershed►.District EMAtor/Sewe &d JESCWPTION OF WORK TO BE PR FORMED: Her (jl/Ijo ajl� v &Y� �de � figa#ion—PleasA Type or Print Clearly) OWNER: Name: 1 Jwl /ttiJl 4 IGS PL Pt Address: y�'q A4)0y S Z9__ //7/ - j k CONTRACTORName:- _d� JZ Phone -.,(a Adtlress Supervisn LC, icense . 7� ._ . ___Exp: `Date:, HmP+ImnroVement'License: %ok_g1 4_ _ _ _Exp Date: ARCHITECT/ENGINEER I U / I'' Phone: Address: Reg. No. FEE SCHEDULE., BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ /0. FEE: $ 1 Check No.: U 7 Zo Receipt No.: i q I S NOTE: Persons contracting with unregistered contractors do not have access to the gualp* 1 Signatureof A }ent/Owner .Signature-of:contractor LocationT%? TrY1�j�N.G� No. � o Date 0 f y } ^1• 4/ TOWN OF NORTH ANDOVER q Certificate of Occupancy $ Building/Frame Permit Fee $ ' / g Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2"v 249'+9 Building Inspector I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Swirnramg Pools ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS DATE REJECTED El DATE APPROVED 11 CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS 4 Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Com Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE�DEPARTMEI - Temp'Dumpster°on site yes - ._.no Located.at 124 MainStreet - - Fire'Departm, - t signature/date rnnnnnFN< <� 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 2008 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 ❑ 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) ❑ 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 ❑ 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 ❑ 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 2.2008 t dm , I r91d 1 S' i COO MateriallWork Order Order Number: C05685S Customer Name: Children's Medical Office of North Andover PC 7 RED ROOF LANE, UNIT 1 SALEM, NH 03079 Ansel Realty Trust PH: 603.898.0868 Address: 477 Andover Street FX: 603.898.0821 yWWV.BLACKDOGeUiLDERS.COM City/State/Zip: North Andover, MA 01845 Phone Number: (978)265-1621 Job No: PC AN -9988 Kitrhwn P. Rath Chance X Builders Change _:Plumbing riDti, GENERAL CONDITIONS . Tota! 01.003. - Administrative fee for small projects - 1 EA This fee address the initial set up of your project as well as labor associated with permitting. This item relates to small projects. 01.009. - Building Permit Fee Based on $ per 1,000 - 1 $M This item is the component driven by the cost of the project and adjust the price based on a fee per $1,000 of construction. Base permit fee should also be included in the proposal. SITE PREPARATION 02.221. Picture window removal - 2 EA Remove Picture window. This item does not cover patching or repair. 02.322. - Insulation removal, loose - 40 SF Remove loose insulation from open wall or ceiling 02.343. - Wall wood lath & plaster tear -out - 80 SF Tear out wall covering from -studs. Either one or both sides of studs based on design and sgft in estimate. 02.509. - Door & window moulding removal, 1 piece - 104 LF Remove trim on the interior and exterior. 02.905 - RRP containment and space preparation per space - basic - 2 EA , Provide labor and material to contain and. prep a given space up to 250 square feet. A basic space is one that has no obstructions to work around such as a room devoid of furniture. 4 EXTERIOR TRIM AND DECKS 10.030 - Install exterior trim on picture window- 2 EA SIDING 11.002. - House wrap, ADD per SF,- 100 SF Substitute house wrap for paper specified in siding installations on this and the following pages 11.004. -1/2 x 6 beveled cedar siding - 100 SF Install Cedar beveled siding on existing sheath or braced stud wall over air infiltration housewrap such as Tyvek or Typar. 1/2" X'6" siding installed horizontally. Includes starter strips, corner boards that will approximate existing style and 5/4 x 5/4 inside corners. Install with stainless steel nails. This item allows for the use of unprimed rustic stock or pre -primed finger jointed stock - Client's option Note: Blackdog Builders Inc. assumes no responsibility for "Cedar Bleed" or the 8/3/2011 1:06 PM Page 1 of 3 appearance of brown staining through the siding finish. Blackdog uses premium materials and the appearance of "Cedar Bleed" is unpredictable and not tied to specific conditions of construction or workmanship. 11.050 - Replace shutters - 4 EA Salvage and repair existing shutters. WINDOWS AND TRIM 13.050 - Harvey picture windows - 2 EA Color white, vinyl interior and exterior, standard grills between the glass, white hardware, double glazed, Low E, Argon Filled, Not tempered, Energy Star rated performance, new construction application for 2x4 wall condition, Options: ORED { a al INSULATION 17.000. R-11 3-1/2" insulation.- 80 SF Stapled to open framing or laid flat between studs. (Improve existing insulation in exposed wall) INTERIOR WALLS 18.010. - Replace wall board under window inside office - 1 EA MILLWORK AND TRIM 20.125.03 - Trim large unit - picture window - 2 EA Salvage existing interior trim and re -install. If interior trim can not be salvaged new trim will match as close as possible (does not include custom milled trim), Window to be Bay/Bow or Picture Window and is to be trimmed traditional sill style. Window to be ready for paint or other finish. PAINTING (NOT INCLUDED) 24.000. - Painting and wall papering is not included in this scope of work. (Client has a painter) - 1 EA CLEAN-UP 25.000.01 -Clean up interior job - 1 EA This item addresses the daily interior clean-up work associated with the project. 25.000.03 - Exterior Clean up per SF - 200 SF Clean up exterior job including the removal of old roofing and framing materials from premises. Clean-up does not include dumping fees. Costs per square footage of job. 25.007.03 - Heavy duty floor protection -carpet - 200 SF Provide materials and labor to cover the floor with plastic as well as a sheet material such as 1/8" masonite. This spec is most often used in an area where we will be doing extensive demolition and construction and the flooring is being saved. 25.011 - 3 cuyd soft sided dumpster - 1 EA Provide 3 cubic yard capacity container for construction debris. This container is for construction debris only. Blackdog is not responsible for damage or depressions in the ground or driveway cause by the container. As with all items in the proposal, please note the quantity of containers included with the proposal. Due to the difficulty in estimating debris volume, you will be charged or credited based on the actual number of roll off containers used. 8/3/2011 1:06 PM Page 2 of 3 Childrens Medical Office of North Date John Nic olson Date Andover PC Ansel Realty Trust &esign Consultant (xi Upon signing, 1 agree to pay for the above stated additional work, which is to be performed under the same conditions as specified in the original contract unless otherwise stipulated. (NOTE: This revision becomes part of, and in conformance with, the existing contract.) understand that this additional work will add 5 days to the completion date of my job. (initiat) "Payment is to be made as follows: Upon Receipt With next progress payment Upon Order X 50% Deposit/ 50% on Receipt 8/3/2011 1:06 PM Page 3 of 3 (No return of materials after 30 days -- Installed items ands eclat orders are not returnable Subtotal $10,704.86 MA Sales Tax (if applicable) $0.00 Balance: $10,704.86 *Total Due $10,704.86 Childrens Medical Office of North Date John Nic olson Date Andover PC Ansel Realty Trust &esign Consultant (xi Upon signing, 1 agree to pay for the above stated additional work, which is to be performed under the same conditions as specified in the original contract unless otherwise stipulated. (NOTE: This revision becomes part of, and in conformance with, the existing contract.) understand that this additional work will add 5 days to the completion date of my job. (initiat) "Payment is to be made as follows: Upon Receipt With next progress payment Upon Order X 50% Deposit/ 50% on Receipt 8/3/2011 1:06 PM Page 3 of 3 e 11 Cd w o :4D C � O i C H O vV r. •r C A ® COy=.+ O co co CF 4, d w3 ts Y i O •�•+ V j O a o o "r C C: - C, t4t: ID m O c : m 3 CD �c .� � C N W . y m a� h O m O V O.0 . CCD •C j y O .r.s : • C •� O (10 C. Q ` N .m C Q = ® w 3 o. o COO) ciLJLJ m om ~ yr C +r F. •iyA C O C OL3 CD c:l o= C A^ y a m.F o'O a N �O O i h CD Wcm co cc CI C, m O cm C �C N CD t 0 Z O J O .A -kM CO rm CO) CDO yc .9 m m a co CD CD i _Q Q. CL CL C Q Q c cccc v'FLCD J .� ca CD 0 CL V y R C C C CL COD is C4 W W 19 W C4 oo w° cin a a oCO w° a°4 U w o p. w W c� in w o � w�' u. W A W ao co Q cn o :4D C � O i C H O vV r. •r C A ® COy=.+ O co co CF 4, d w3 ts Y i O •�•+ V j O a o o "r C C: - C, t4t: ID m O c : m 3 CD �c .� � C N W . y m a� h O m O V O.0 . CCD •C j y O .r.s : • C •� O (10 C. Q ` N .m C Q = ® w 3 o. o COO) ciLJLJ m om ~ yr C +r F. •iyA C O C OL3 CD c:l o= C A^ y a m.F o'O a N �O O i h CD Wcm co cc CI C, m O cm C �C N CD t 0 Z O J O .A -kM CO rm CO) CDO yc .9 m m a co CD CD i _Q Q. CL CL C Q Q c cccc v'FLCD J .� ca CD 0 CL V y R C C C CL COD is C4 W W 19 W C4 The Commonwealth ofMassachusetts Department oflndustrialAccidents Office oflnvestigations' 600 Washington Sheet Boston, MA 02111 5� www.mass govl dia Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers licant Information Plea CP Ari1n+T_oR:1,1. Name (Business/Organization/Individual):Viet f Address: Address: . City/State/Zip: // 0 ---M Phon 0� Are you an employer? Check . e appropriate box:ro 1. I am a employer with � n 4. ❑ I am a general contractor and I - project (required): employees (full and/or part-time),* 2. ❑ I am a sole proprietor or have hired the sub-contractorsEl listed construction partner- ship and have no employees on the attached shgget. tmodeling These sub -contractors have 01molition working for me in any capacity, [No workers' comp, insurance workers' comp, insurance. 5. ❑ We are a corporation and its ilding additionrequired.] ❑ I am a homeowner doing officers have exercised their ctrical repairs or additions3. all work [No workers' comp. - right of exemption per MGL c. 152, § 1(4), and we have mbing repairs or additionsmyself. re uired. r ] noinsurance employees. [No workerscomp, of repairsq insurance required ] er *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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 information. I am an employer- that is providing workers' compensation information. insurance for my employees Below is thepolicy and job site Insurance Company Name: &d/7 16,41'i?tt Policy # or Self -ins. Lic. #: V69 �cll Z Z n Expiration Date: Job Site Address:_ t:� 7 /I� X11 ✓Wl City/State/Zip: 4/ ,�q��- //jt- 01 gyl, 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 ofMGL 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 $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA, for insurance coverage verification. Ido Itereby certify undue the Official use only. City or Town: i9e_ - 0$ ofperjury that the information provided above is true and correct. .Do not write in this area, to be completed by city or town official Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 5 4. Electrical Inspector 5. Plumbing 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 "...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 ments and who resides therein, or the occupant of the owner of a dwelling house having not more than three apart 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 numbers) along with their certificates) 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 (ifnecessary) 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 bum 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: Me Conn-noj—rwcaltd o.i ldfassac'aosetts Deparftuent of Industrial Accidents Office of Investigations 600 Washington Street Boston, NfA 02111 Tot. # 61.7.7274900 ext 406 ox 1-877 MASSAFE Revised 5-26-05 Fax # 617-72`77749 www.mas5.gov1dia. I DATE __777] AWnl CERTIFICATE OF LIABILITY INSURANCE 07/12/2011) PRODUCER 603.424.9901 FAX 603.424.3203 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Brown & Brown of N H, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 309 Daniel Webster Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 1510 Merrimack, NH 03054-1510 INSURERS AFFORDING COVERAGE j]NAIC # INSURED Black Dog Builders, Inc. INSURERA: Merchants Insurance Group 7 Red Roof Lane Unit #1 INSURER B: Salem, NH 03079-2984 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 A DD' NqRr TYPE OF INSURANCE GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR POLICY NUMBER CMP9152639 - POLICY EFFECTIVE 07/01/2011 POLICY EXPIRATION 07/01/2012 LIMITS EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 100 000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC JECT AUTOMOBILE LIABILITY ANY AUTO CAP9267558 07/01/2011 07/01/2012 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 ALL OWNED AUTOS BODILY INJURY $ person) A rXXX SCHEDULED AUTOS(Per HIREDAUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ - - OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY X OCCUR CLAIMS MADE C-UP9143959 07/01/2011 07/01/2012 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 $ $ DEDUCTIBLE FdRETENTION $ 10, 00$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WCA9097912 07/01/2011 07/01/2012 X WCSTATU- X OTH- TORY LIMIIS E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ - 500,000 LA ANY PROPRIETOR/PARTNER/E' ECUTIVE OFFICER/MEMBER EXCLUDED. If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS 'ERTIFI ATE H LDEH ^^ ' 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 MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. For Insured's Reference AUTHORIZED REPRESENTATIVE Q Jennifer Kokol i s/CM4 �v b ACORD 25 (2001/08) ©ACORD CORPORATION 1988 I Failure to possess a current edition of the Massachusetts State Building Code Is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS 'ou Massachusetts - Department of Public Safety Board of Building; Regulations and Standards Construction Supervisor. License One- and Two- Family Dwellings License: 6S 75668 11A I C H AE l I V I IE7fi4?�V 57 HO(3 } AQBURN, --G- —jam Expiration: WM/=3 ('ommis9ioe Tr#: 14733 I _ ttrl� 1�11f���y N(I�N� tom. ;: 17 qf� r. l I i IViICHik�l� �lVl�l��� '�Q� i - I i