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HomeMy WebLinkAboutBuilding Permit #546 - 575 TURNPIKE STREET 1/12/2012i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION i Permit N0: 7 Date Received Date Issued` IMPORTANT• Applicant must complete all items on this page LOCATION ) T&MDAixe Print - PROPERTY OWNER(:�('CG'�k6 ,-A j Unit # 1 Print MAP NO: oC PARCEL W ZONING DISTRICT: Historic District 7yesMachine Shop Village100 year-old structure TYPE OF IMPROVEMENT PROPOSED USE Residential : Non- Residential ❑ New Building ❑ One family El Addition ❑ Two or more family ❑ Industrial R'Alteration No. of units: ETGommercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition. ❑ Other g �® Septic MW W tFloodplaiu; ? ®W tlands „` ,;®Watershed UPS �tn DWater/Sewers t a - gat iX .� y, 74 ,�r,� �, 1 lviv yr vv �tcn 1 v ts� Yr;ttt1Jl�1V1 'll: � Q S lZientification Pleas a or Print Clearly) J OWNER: Name: �,� , `�' Phone: Address: CONTRACTOR Name: t�11 .I %dQ(-e-,,z Phone: �ag� Address: Supervisor's Construction Licenser Exp. Date: g� t Home Improvement License: �d5 p � Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ 710, az , FEE: $ I Check No.: Receipt No.:�- NOT�/• - o t actang with unregistered contrc�ctozs do c to the guaranty fund -- -+;. Signatu_r_e�of�contractor� •.�__ c.,•:��.��I f< 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 ❑ 4 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED i PLANNING & DEVELOPMENT ❑ 0 COMMENTS 4 - Zonihg 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: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date I COMMENTS _ o L Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: q ELECTRICAL: Movement of Meter location, mast or service drop requires approval roval of Electrical Inspector Yes No :::DAN ER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A -F and G min.$10041000 fine NOTES and DATA — For department use Doc:.Building Permit Revised 2011 June/mi — -r F 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 o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses Copy of Contract - o 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 h Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) I ❑ 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 ne 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 Doe: Doe.Building Permit Revised 2008mi Location r - �� t No. Date 40RT" TOWN OF NORTH ANDOVER e ; . Certificate of Occupancy $ ...___. ��ssACHUSEt'�' Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 24962 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents 79 Office of Investigations 600 Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (, Please Print Leg><bly Naive (Business/Organizationtlndividual): Address: City/State/Zip:a , c'- t SEL Phone Y an employer? Check the appropriate boa: Vu am a employer with ( Lf, 4. ❑ I am a general contractor and I (full and/orpart-time).* have hired the sub -contractors am a sole proprietor or partner- listed on the attached sheet I 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 required.] 3. 1:1.1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] `Any a^ralical t that checks box #i must also fill out the section bet.i. E��.u:..T :i.a Type of project (required): 6. ❑ New construction 7. ❑'Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other t Homeowners who submit this affidavit indicating they are doing all work and then hire utside 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' wmp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below, is the policy and job site information. Insurance Company Name: v v _ Policy # or Self -ins. Lic. #:M(1) Ca Q r� Q j� Expiration Date: Job Site Address:_ City/State/Zip: Attach a copy of the workers' compensation policy declarationa e (showing e P g ( wing 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 wellas 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 hereby certify under the at enalties` perjury that the information provided above is true and correct Si ature: Phone #: 97 �, ���( z'J-L E only. Do not wf:ite in this area, to be completed by city or town official n: Permit/License # hority (circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: 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 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 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 seine to sign and date the affidavit. The affidavit should be. returned to the city or town that the application for the per-unit or License is be 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 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investibations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass..gov/dia ACORV CERTIFICATE OF LIABILITY INSURANCE DATE.' (MMDDlYYY1) 01/12/2012 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(hes) 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 CONTACT NAME: NORTH ANDOVER INSURANCE AGENCY, INC. ac°, No. : (978) 686-2266 �,"� No); (978) 686-6410 Am Ess: efernandaz@nafins.com M.J. FOSTER INSURANCE SERVICES 163 MAIN STREET PROCE CUSTOMER ID .RODDEN CARPENTRY INSURERS AFFORDING COVERAGE NAICA NORTH ANDOVER MA 01845-2508 INSURED INSURER A MRCHANTB INSURANCE GROUP 23329 RODDEN CARPENTRY INSURER B :TECHNOLOGY INSURANCE CO 47 PRESCOTT ST INSURER C INSURER D / / INSURER E NORTH ANDOVER MA 01845- ItNSURER F 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. ILLTTRR TYPE OF INSURANCE APOLISUOR INSR WVO POLICY NUMBER POLICY EFF (MWDDIYYYY) POLICY EXP (MMIDDIYYYY) LIMITS A GENERAL LIABILITY BORIO54995 2/01/2011 2/01/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY / / / / -DAMAGE TO PREMISES EaENTED occurrence $ 500,000 CLAIMS -MADE 7 OCCUR / / / / MED EXP (Any one person) $ 15,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO LOC JECT / / / / $ A AUTOMOBILE LIABILITY MA7015515 7/16/2011 7/16/2012 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) BODILY INJURY (Per person) $ ANY AUTO / / / / BODILY INJURY (Per accident) $ ALL OWNED AUTOS X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS / / / / (Per accident) X NON -OWNED AUTOS / / / / $ $ UMBRELLA UAB OCCUR / / / / EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE / / / / AGGREGATE $ / / / / DEDUCTIBLE $ / / / / RETENTION $ $ B WORKERS COMPENSATION rWC3302016 1/01/2012 1/01/2013 X I VVC STATU-OTH- AND EMPLOYER6' LIABILITYUMTSER N YIN / / / / ANY PROPRIETORIPARTNE.ECUfNE E.L. EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? F—] N I A / / / / (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes describe under / / / / DESGIRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Aftacn ACORD 101, Additional Remarks SdredukN N more epeee Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 120 MAIN STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845- ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS026 (200909) The ACORD name and logo are registered marks of ACORD 11 �'r f IN M %.. i '. %70 1: .... z rn AWN d7Z "A 7- Kp 7';. LIN C7 til ,Q� �,� DC7 f IN M %.. i '. %70 1: .... z rn ,N d7Z 7- Kp 7';. LIN C7 til ,Q� �,� DC7 rnN 73 C7- Lp tl ol rA x o o w v v cn 0 U � w G O w O r�4 U G is. f� O U w O c4 i.=.. o U w w O C ti O C 'a' O a O H O coo q w Z 9 b co V) O 5, ft RE O 0 0 ZCD CL O y � C Ww+ — cm Ica O M y CD O 'E m m CD C2 0 C }r CD O � i Q a CMCC c o -0-0 c cCc CJ J .0 .0 CD Q V ` h c C cc CO2 D uj Yr Y/ W w 19 W U) o m c �`• c is C ti O C 'a' O v C.3 i `�aC O c ' c C := o ..: m a CF : C 0. H C 602 y0.. cmV �� Of t: C H m3 co cm co 'O T _ m O W 'D C H W H m E� CD Ca ' acs :mom `rl`�o m a Q :Is3 ID a c,* Lij •H dZ O C_ S •H LU �E o ca -v v CD cm C.7 CD a C2 '� O COD FE..� ` y = P Z S CL. m O 5, ft RE O 0 0 ZCD CL O y � C Ww+ — cm Ica O M y CD O 'E m m CD C2 0 C }r CD O � i Q a CMCC c o -0-0 c cCc CJ J .0 .0 CD Q V ` h c C cc CO2 D uj Yr Y/ W w 19 W U) Page t of RODDEN CONSTRUCTION 47 Prescott Street North Andover, MA 01845 (978) 687-2934 PROPOSAL License # 28538 Expires: TODAY'S DATE JOB NAME 1/9/2012 Orthopaedics Northeast DATE OF PLANS/PAGE #'S JOB LOCATION 11/18/2011 575 Turnpike St suite 11 North Andover Ma. 01845 We propose hereby to furnish material and labor necessary for the completion of: Supply materials and labor for office renovations as specified by Packard Design dated 11/18/2011. Work will be done on a time and material basis plus a fixed fee of 7,000.00. The fee is to be paid with 3500.00 at job start and 3500.00 at completion. All subcontractor invoices and all building materials will be billed at cost with no markup. Some specified job materials may be substituted, at owners approval, for cost effectiveness and better performance. Owners may be required to assist in moving some items such as file cabinets, wall attatchments, ect. if necessary. New construction will include a reception area wall approx. 8' across, with a corian transaction top and secretarial counter, and a sliding glass enclosure unit. Close in existing transaction area opening and patch as necessary. Cut in new cased opening to connect the new and existing secretarial areas. Remove and replace 2 counter areas in existing secretarial area. New counters to be corian and slightly larger than existing. Materials as specified. Paint and paper will inxclude the removal of all wall coverings. Oil prime and skim all walls. Prime plus 2 coats to all walls. Prep, oil prime plus 2 coats to all woodwork. Hang wall covering in designated areas. Clean and paint ceiling grid 2 coats. All materials as specified. All ceiling tiles will be replaced with 2x2 recessed in reception area and 2x4 lay in in remaining areas. Materials as specified unless otherwise noted. Remove and replace all flooring in the suite. Install mosaic in waiting room, office and 2 back rooms. Installation is direct glue. Dispose of existing carpet. Install mamoleum in 9 rooms. Prep and skim 3 rooms that have vivyl floors. Prep and skim 6 rooms that have carpet. Dispose of carpet. Owner to move heavy filing cabinets and various electronics as required. Materials as specified. Electrical will include supplying and installing new lighting as speced. Possible re-routing of wiring where new cased opening to be. Install various outlets and switching as required. All computer and phone system work by owner. Materials as specified. All necessary permits will be provided and all job debris will be removed. We propose hereby to furnish material and labor - complete in accordance with above specifications for the sum of: Estimated cost of seventy six thousand dollars ( $76,000.00 ) Payment as follows: 20,000.00 at contract signing. Other invoices paid upon submittalN All material is guaranteed to be as specified. All work to be completed in a substantial workmanlike manner according to specifications submitted, per standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tomado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. If either party commences legal action to enforce its rights pursuant to this agreement, the prevailing party in said legal action shall be entitled to recover its reasonable attorney's fees and costs of litigation relating to said legal action, as determined byLa co of competent jurisdiction. Authorized Note: this propo may be withdrawn by us Signature if not accepted whin days. ACCEPTANCE OF PROPOSAL The above prices, Signature specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature Payment will be made as outlined above. Date of Acceptance WWW.THECONTRACTORSGROUP.COM & Diane Dennis Enterprises © 2004 PROP-001a.doc Rev 10-04