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HomeMy WebLinkAboutBuilding Permit #660 - 492 SALEM STREET 3/15/2012Permit NO: — ---. ...L - TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: IMPORTANT: Applicant must complete all items on this pane Print/ PROPERTY OWNER ,01U O �ov� Print MAP NO: PARCEL: N1 ZONING DISTRICT: Historic District yes n Machine Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family ❑ Addition 0 Two or more family ❑ Industrial &-Alteration No. of units: ❑ Commercial 0 Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Se i � 3 � p c q-�We11 4 ' ' ®�F'lo`�odplain+ .� `Wetlands:! ; ®Watershed. �IDstricti Cl Water/S'ewer DESCRIPTION OF WORK TO BE PERFORMED: (Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: ��v2 _ ,d«'`1 �5T CONTRACTOR Name: 1�Iel5 /e///r --t- Phone: S-0 ?f dZ�_?1/, Address: C520 7G�//�J`�� i©. �/'✓JOtJ(5�, Supervisor's Construction License: Exp. Date: Home Improvement License: /z �z aiI Exp. Date: l ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE. BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cyst: $ /� zoo, o �J FEE: $ 11 �O Check No.: /6-6-7 Receipt No.: Off' NOTE: Persons contracting with unregistered contractors do not have access to the ouaranty 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 ❑ 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 MOTE: 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: Doc.Building Permit Revised 2008mi 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS 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/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street no Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For de ® Notified for pickup - Date Doc:.Building Permit Revised 2008mi ent use No -7-/ Location 1-14d No. /vo I f - .0/0 DatJh'�-/ 2,- e . TOWN OF NORTH ANDOVER 011-Sl'k 11 ..... .... Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Ito Other Permit Fee TOTAL Check # 25105 Building Inspector N m m m ,mww VI m v m _v y CD d C � 'v O C7 Z CO) 0 0 T2 • CL r c � � c CL y ac v mo o c v CD CDCL O rM Q CD CD CD mw C CD y a0 y -• o �CD I V! o 'v Z co O CD O CCD FA Crri cn cn n 0 cn 0 V 1 K 0 cn C 0 c?loa � Z a��m. N y »mom m yma� �. m ?o VD _1 m a?m = m -'INN c y �mm: a 7 N ; m 'O O c . . •-1 . . O Z R C O N, O ir C4 a � CL O � m O N o cn CL CD3 CO) p1 N dd . Um C � CO) O N = CD � O 0) CO) = ma CD 0 C2 cl N SCD: .� N : d oCD: _ go a'o ?H Rot O �• � Cp cn cn"tJ :; o m a. "i7 cp a 0 GE b Oj ro ?r O x G a. Gi d CJ *. OnO CD d Q 7d � v rl v z 0 Q 0 c �00 , QJi�A CMAUWUM Bathroom Proposal Don Foss 492 Salem Street North Andover, MA 01845 (C)978-683-7300 (H)978-682-3088 dbfraf@gmail.com March 10, 2012 Work to be completed includes: Acquire Building permit. Remove existing shower and tub. Cut out existing floor the where needed to accommodate new tub and shower. Frame new base for tub. Install new tub and shower. Install new custom panels for side and end. Complete any tile work needed. Repair and plaster walls where needed. Complete all plumbing. Disposal of all debris. Labor and Materials $ 6,500.00 Peabody Supply Quote # 270470 $ 2,550.00 Quote # 270708 (shower) $ 2,250.00 Total Labor and Materials $11,300.00 Terms: $ 3,700.00 upon signing of contract ( not to exceed 1/3 of total contra t price) Work to begin on 3 / /2 $ 7,600.00 when job complete Job to be completed /S - Submitted by: Chris Rivet MA Lic 4CS072173 HIC #139962 207 Winter Street (C) 508-265-3115 (H) 978-704-1165 North Andover, MA 01845 All Home Improvement Contractors shall be registered. Inquiries about a contractor relating to a registration should be directed to; Registration Division, Program Coordinator One Ashburton Place Room 1301 Boston, MA 02108 Tel: 617-727-3200 ext.25239 All building permits required will be the obtained by the contractor. Homeowners who obtain their own permits are excluded from access to the Guarantee Fund. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. DO NOT SIGN THIS CONTR Date 3' M "/pZ. Homeowner s Signatu Date / Contractors Signature. ARE ANY NK SPA S! /� MassaL'l1Usells - beI):!llment of Public Sare,t ; ` ✓fie "Uanirrw�au�ea,Lt��o� �aaac`u�6et�b �' Office o� Cnnsuaier Affairs & Business Regulation HOME4PROVEMENTCONTRtCTOR — IR6glstrlation 4{139962 Type• 1 q-xpiration: _978/2013 Individual i„ TOPHEfZ F RIVET ' CHRISTORHER RIVET 26 WINTER ST N. ANDOVER, MA 01`845 �(?al'(� 01 'Ruil'din�� Rf+�USittd(}1IS ii!!(l'�`��!( (l�!'(Iti_:� �oristruekion�Sulierviso� License License: CS .72173 Rest: ictecl to: 00 CHRISTOPHER F RIVET 207 WINTER ST N ANDOVER, 'MA 01845 ®w �. Expiration: 6/2/2012 Commissioner Tr#: 27092 Undersecretary Undersecretary The Commonwealth of Massachusetts Department o f frldustr ial Accidents Office of fnvestigatyons 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers Mlicant Information Name (Business/Organiza6on/indi Adual): Address:_*p City/State/Zip: U, Phone :�0 Fyo� .�/�� Are you an employer? Check the appropriate boa: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ,employees (full and/or part-time) * have hired the sub -contractors 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its ❑ .I am a homeowner doing all work myself [No workers' comp. insurance required.] t officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees_ [No workers' comp. insuranc Type of project (required): 6. ❑ New construction 7. J�rRemodehiig 8. ❑ Demolition 9. ❑ Building addition 10,❑ Electrical repairs or additions .1 LEI Plumbing repairs or additions 12•0 Roof repairs k -W,Iicaat that chF__ a requu ed ] 13.0 Other •.Us box �l mus, also ui cut :' e aectia_+ Homeowners who submit this affidavit indicating theydoing i ... r= at, worn and Then hire outside c r� "Contractors that check this box must attached an additional sheet showing the ontrac,a^ ;{,-y,,. submita new affidavit indicating such. same of the sub -contractors and their w rri nc l LLM an employer that is providing workers' compensation insurance for my employees. information. Insurance Company Name: r. r- ---.r ... L. Un. Below is the policy and job site Policy # or Self -ins. Lic. #:�'� 0/ O tion Dat��J70 Date. Site Address _��� Attach a copy of the workers' compensation policy declaration aae (showing City/State/Zip: /jfo; �Qiypov� �/ o /$yS Failure to secure coverage as required under Section 25A of MGL P 152canlead to policy number and expiration date). fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the forme imposition aSOf TOP WORK criminal and ofine f of up to $250,00 a day against the violator. Be advised that a copy of this y-ty �t maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification > r cuy L;UFU 3, lone of perjury thmt the information provided above is true and correct Official use only. Do not write in this area, to be completed by cite or town official J City or Town-Permit/License # Issuing Authority (circle one): 1. Board of Health Z. Buiidin; Department 3. City Town Clerk 4. Electrical Inspector 5. Plumbing 6. Other b inspector Contact Person: Phone #: Information an- d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every peon in the service of another under any contract of hire, express or implied, oral or written " An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association o$ other legal entity, employing employees. However the owner of a dwelling house having not more than three apartozents and who resides therein, or the occupant of the dwelling house of another who ,=ploys persons to do mainte;nnance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be cause 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 it license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of cotnpUance 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 anvil 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 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' comp enation 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 sire to sign and date the affidavit. The affidavit should be �,..tmued to the city or town that the application for thepert or License is be f F lag requested,' not the .Department of Industrial Accidents. Should you have any questions regardimg, the law or if you ai e rem ed 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 pmmit/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 bum leaves etc.) said person is NOT required to complete this affidavit- The ffidavitThe Office oflnvestigations 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 M&a sa&metts. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 0.2111. Tel. n 617-72.7-4900 =t406 or 1-8 77-M4SSAFE Revised 5-26-05 Fax - 617-727 7749 mrv7 7.mass.-Lyov/dia. ACC>RV CERTIFICATE OF LIABILITY INSURANCE OP ID NEMA TE DAo2/o7/ 2) 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 policy(ies) 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 Macdonald & Pangione Insurance P.O. Box 428 NAME: E: PHONE IFAX (A/C, No, Ext): (A/C, No): ADDRESS: 104 Main Street North Andover MA 01845 Phone:978-688-6921 Fax:978-688-5350 CUSTOMER ID#: CHRIS -5 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Preferred Mutual Ins Co 15024 Christopher Rivet 207 Winter St. INSURER B: INSURER C: North Andover MA 01845 INSURER D: PRODUCTS - COMP/OP AGG $2,000,000 INSURER E: INSURER F: LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSR V%fVDI POLICY NUMBER (MMIDDM/YY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY ` CLAIMS -MADE 141 OCCUR CPP 0180 57 01 05 09/26/11 09/26/12T_ EACH OCCURRENCE $1,000,000 PREMISES (Ea occurrence) $100,000 MED EXP (Any one person) s5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X l POLICY n PRO- LOC JECT PRODUCTS - COMP/OP AGG $2,000,000 Is AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS I COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) I $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ UMBRELLA LIAB EXCESS LIAB LJ ` OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIV OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA _ TORY LIMITS I ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder as listed below CERTIFICATE HOLDER . CANCELLATION Town of North Andover Osgood St No Andover MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TIVE ©1988-2009 ACORD CORPORATION. All riehts ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD