HomeMy WebLinkAboutBuilding Permit #815-14 - 534 Chickering Road 5/12/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
�
Permit NO:Ti,iDate Received
Date Issued: 1�
�^ IMPORTANT: Applicant must complete all items on this page
- . LOCATION-
/� Print.
l PROPERTY OWNER l! —1 l e -0 c :.C4AR
�Q� Print 100 Year Old Structure yesCno
o
MAP NO: _PARCEIJ ZONING DISTRICT: Historic District yesno
Machine Shop Village yes
.TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ ition
❑ Two or more family
❑ Industrial
g ion
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRPTION� OF WORK TO BE PERFJyRIVI D
ri' X v ry 5 t " !�2 AJ"'— AA- C/- 0 CO Dries
Please Type or Print Clearly)
OWNER: Name: / 7i
Address: :�) N-YI 1 oAJ s
— t"n a7^6 :'� fit
CONTRACTOR Name: /Ul (-0 bgs rJ1eflrJC-4lW,,1 Phone: 975� -
Address:
Supervisor's Construction License: C '� so q3 Exp. Date: '3'/�/1ao ) S
Home Improvement License:
ARCHITECT/ENGINEE
. Date: I
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: $ S FEE: $ // L/
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the g ranty d
Signatu pf Agent/Owner ignature of contractor
Plans Submitted LJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Location �.{
No. v 1 , Date �� t
Check # 4 U1 ,
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee ski .P
Foundation Permit Fee $
Other Permit Fee $-I-
TOTAL
._TOTAL $
Buildi, g Inspector
.-..-Plans Submitted ❑ Plans Waived-[]:- Certified Plot Plan ❑ Stamped Plans 0
TYPE OF SEVMRAGED3SP_OSAL"
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
-Tobacco.Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc:_ ❑ - _:
Permanent Dutnpster on:Site ❑
THE_ FOLLOWING SECTIONS FOR OFFICE USE ONLY
- " INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE:APPR:OVED
PLANNING & DEVELOPMENT D Al
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
—
Water & Sewer Connection/Si nature & Date
Driveway Permit
DPW Toiv>! Engweer: Signature:
Located 384 Osgood Street
FIRE DE�.A TI�j'_NT - Temp Dumpster on site yes: no
:Located -at 124 Mair. Street
Fire Departure►+f signature/date`"
COMMENTS
Dimension -
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of. Meter, locatFon,;n ast or service cIr®p requires approval of
Electrical Inspector Yes No
DANGER -ZONE LITERATURE: -Yes No
MGL -.Chapter 166. Section 21A _F and G min.$10041000.fin.e
Doc.Building Permit Revised 2010
r-
Building Department
The fol owing is'a list of the required.forms to be filled outlor:the appropriate permit to be obtained.
Roofh-- g, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
o 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
o 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 apw• al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doe: Doc.Building Permit Revised 2012
Enter construction cost for fee cal -
North Andover Fee Cakulafion
Construction Cost
$ 91500.00
m
$ -
$
114.00
Plumbing Fee
$
14.25
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
14.25
Total fees collected
$
242.50
534 Chickering Road
815-14 on 5/12/2014
Bathroom Remodel
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N & B General Contracting
330 Merrimack St
3rd fl
Methuen, MA 01844
Phone # 1-978-689-90191-781-6... nbcontracting@verizonnet
Fax # 1-978-689-2011
Name / Address
Minco corp Chickering
534 Cuckering Rd
North Andover, Ma 01845
Ship To
Contract
Date
Contract #
2/12/2014
451
P.O. No.
Terms
Dae Date
Rep
Account #
FOB
Project
2/12/2014
Description
Total
Disconnect plumbing from sink, toilet, tub and shower valve.
9,500.00
Remove toilet, sink and tub and dispose.
Remove all lighting on wall and ceiling and dispose.
Remove all trim work on door and window.
Tear out all the on walls, ceiling, floor and dispose.
Tear out all wall drywall, ceiling drywall and remove all subfloor.
Tear out old shower valve, tub drain, sink plumbing and toilet supply and dispose.
Remove damaged framing under window as needed and install new framing.
Install new shower valve, new toilet shutoff and new shutoffs for sink.
Install new light fan combo in ceiling and 4 inch exhaust pipe to exterior.
Install new insulation on exterior walls and ceiling.
Install new tub and install new cement board on floor and on shower walls.
Install new blueboard and plaster on rest of walls and on ceiling.
Install new trim work on door.
Install all new tile on shower walls and on floor.
Prime and paint all trim work, walls and ceiling.
Install new vanity, sink, faucet, toilet, shower valve trim kit.
Install new vanity light and mirror.
Install new toilet paper holder, towel bar and soap holders.
FIRST FLOOR BATHROOM
low -
Tear down ceiling and dispose of materials.
Disconnect ceiling light fixture and dispose.
_
c
q s�
Total
o ,
Signature
05/11/2014 22:14 9787940822 PAGE 01/01
KADF CERTIFICATE OF LIABILITY INSURANCE °"'E`M"'°°""^''
THS 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 POUCIE,S
BELOW. TMS CERTIRCA7F OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE
REPRESENTATIVE OR PRODUCER, AND THE CERTIRCATE HOLDER ISSUING INSURER(S), AUTHORIZED
IMPORTANT: (f Itle certifrcaee holler Is ®n ADDITI AL 1 URED, mo poliey(ea) must be endorsed. ff SUBROGATION IS WAIVED, subject to
the terms and conditiorn of the Policy, certain policies mfaf®
may require an endorsement A Srrrent on
CerffCat* holder In lieu of such endorsemen e). this certificate does not confer rights to the
PRODUCER
.Armand P. Michaud Insurance Ag Cia Sabulla
105 Haverhill Strutftj
978 685-2549 FAX Na: (97Bj 79a-oe22
Nmthuen, HA 01844
IMS!M-�_AFFOAD2n CLOMAOE
INSURED -- --- --- ------.._.. .__ IN$U I A;Wetst@rn Heritage Ins Co
Nicolas Hranchi *+a IPISUREii B : —
N & B General Contractimg INSURQiC: - —
12 Fax -lay Street INsuRERD
Methuen, 'MA 01,844INSURFRE: —
VVC kkiICS CERTIFICATE NUMBER: REVISION NUMBER.
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE uSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTVV THSTANDIVG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS ANDCONDITIONIS OFSUQi POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAW
TYPE of IN41 eoearm - - -
A I GENPAALLIARnnY
COMMERCIAL aENERALLMOJTY
CLAIM MADE I �J OOCUR
GEN'L AGGREGATE LIMITAPPUE•S PF, R
AUTOMOBILE LWBU ITy
ANY AUTO
ALLOWNED SCHEDULED
AUTO$ AUTOS
HIRED AUTOS MON-OV MED
AUTOS
uMBriEUALIIUs occuR
EXCERSLIAs CLAIMS awDE
AND EMPLOYER W LIABILITY YIN
OFRCERMEwERQCCLUDEDXEdJTK N/A
(Maneamry In NMI
SCP0934182 I 3/18/14 3/1s/1s
DESCRIPTION OF OPERATIONS I LpQpnpN3 / V®aC1,E$ (Atlaeh ACpRp 7O1 q�Ilorlel �� SMletl�da. iP morp aRm hs
978-686--9542
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LIMTs
1. , 000 , 000
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100,000
yoro P1
rOCCURRENCPRENCqA�GGs
.000ADV
IN000000c6r2,000
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000,000 _
BODILY INJURY (Por p9mon) $
BODILY INJURY (per a ,Td -) $
PERRY D pE $
,?racciRenq ... .
EACH OCCURRENCE $
914OULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVIERED IN
Town of North Andover ACCORDANCE WITIM THE POLICY PROVISIONS_
Building Department
1600 Osgood Stxeet AUTIfOfiZED REPRESS TATIVE
North Andolrer, NA 01845
Tricia Sabulis
®1988-2010 ACORD CORPORATION. All fights reserved.
ACOR0 25 (2010/05) The ACORD name and logo are registered marks of'ACORD
Phone. (978) 685-2549 Fax: (978) 794-0822 E -Mail: triciasabuli8@michaudinsu n0Q.com
XThe Commonwealth ofMassachacsetis
Department of Industrial Accid nts
4191 Office of Investigations
quo 600 i3'ashington. Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Buildens/Conti°actors/Electricians/Plumbers
Applicant Information Please Print Leaibly
Name (Business/Orgmi'zatlon/In,(Rvidual): /(/ 1 (L I cam/ INJ C� Aja
Address:
City/State/Zip:
Are you an employer? Check the appropriate box:
Type of project (required):
1, ❑ I am a employer with.
4, ❑ I am a general contractor and I
6. ❑ New constructionkigpl
loyees (ffiffl and/or part-time).*
have hired the sub -contractors
listed on the attached sheet.
7• EJ Remodeling
2. am. a sole proprietor or partner
ship and'havano-employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.g.
Building addition
[No workers' comp. insurance
5. El We are a corporation and its
10.[] Electrical repairs or additions
TPquired.]
3. ❑ I am a homeowner doing all work
officers have exercised.their
right of exemption per MGL
11. ❑Plumbing repairs or additions
myself [No workers' comp.
c. 152,§1(4), and we have no
12.0 Roofxepairs
�. a
iusuraacere ed
employees. [No workers'
13.❑ Other
comp. insurance required.]
'Any applicant that checks box #1 must also fill out the section bel6w showing their workers' compensation policy information.
T -Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees Below is thepolicy andlob site
information.
Insurance Company
Policy # or Self ins. Lic. #;
Expiration Date;
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 requiredunder 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 line
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.
Mo Hereby
that the information provided above A s true and correct.
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. EIectrical 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 iii 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 ofan 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 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 ofpublic 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 numbers) 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 au LLC or LLP does have
employees, apolicy is. required. Be advised that this affidavit maybe submitted to the Department of ludustrial
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
thatmust 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 afiidavitis on file for future permits or licenses. Anew affidavit must be filled out each
year. Where a homeowner or citizen is obtaining a license ox permit not related to any business or commercial venture
(i.e. a dog license orpermit to burn leaves etc) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance fox 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:
Tho CQoawtealtb, ofassa.,rhUsPs
Dep ftetat ofladusWal Accidents
ofllce 001VestigaUous•
690 Wasbiugtm Street
BoAQn, MA. 02111
. �`e�, # �].7�7�7�4.�Q0 e� 4Q� Qx Z-�`�`�•:N.��.�`�
Revised 5-26-05 Fax # 617-727-7749
www.za5s,gev1dia.
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