HomeMy WebLinkAboutBuilding Permit #768-2017 - 595 CHICKERING ROAD 2/13/2017,far e 101atlY 5�a��r of %&0RT "�ti
BUILDING PERMIT 3? d•:�• .:.' '•°
TOWN OF NORTH ANDOVER
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APPLICATION POR PLAN EXAMINATIO
1 Date Received �°
Permit NO:
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Date Issued: %
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IW--ORTANT: Applicant muA complete all items on this page
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Identification Please Type or Print Clearly)
OWNER: Name: Malcolm Beal Phone: 978-746-1339
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ARCHITECT/ENGINEER Phone:
Address: Reg. No. '
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ '�,OeC • O e FEE: $ 9 �. Oat
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
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Permit NO:—
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
r
Date Issued:
PROPOSED USE
Residential
IMPORTANT : Applicant must complete all items on this page
0 New Building
0 One family
0 Addition
El Two or more family
D Industrial
0 Alteration
No. of units:
0 Commercial
LOCATION -
D Assessory Bldg
El Others:
0 Demolition
0 Other
El Septic M W611
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. OW
PROPERTY RE
yes no
MAN-'NO'_PARCEL:.
-T, 40
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00PO
y
m
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
0 Addition
El Two or more family
D Industrial
0 Alteration
No. of units:
0 Commercial
0 Repair, replacement
D Assessory Bldg
El Others:
0 Demolition
0 Other
El Septic M W611
[O"Fflobdplaih Ei Wkl5hd's',
(D Watershed DiS-triG
DESCRIPTION OF VVUXK I U 5t VtK1-Ur,'v'r-u;
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
AAA --
ARCH ITECT/ENG I NEE
Phone:
Address: Reg. No. --
FEE SCHEDULE. BULDINGPERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $
EE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
den zwSi nature of confiractor
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Plans Submitted ❑ Plc,._—VVAived D Certified Plot Plan 0 Stamp'e'-d Plans El
- - T
Location 'SqS- Chir big A , rr n �> .
No. COT( - �1,01 `)
Check #
Date 61 - ! - 01-0 < 7
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $� ,
TOTAL $
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE:OY-SEWERAGE DISPOSAL
Public Sewer ❑
Tanuing/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
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No:
z. Planning Board Decision:
Comments
Zoning Decision/receipt submitted yes
Conservation Decision: Comments
9
Water & Sewer Connectiongnature � Date Driveway Permit
DPW T'owz Engineer: Signature:
FIRE:.DEPAKTMENT - Temp Dumpster on site yes
Located at'124 Mair.,' Stre7ct
Fire Departmerit signaturefdate
COMMENTS
T
Located 384 Osgood Street
no
v�
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions -
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter 1®cation, 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
B Notified for pickup - Date
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Doe.Building Permit Revised 2010
Building Department
The fol?owing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ BCailding 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
DOTE: 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
10TE: All dumpster permits. require sign off from Fire Department prior to issuance of Bldg Permit
In all cf.- sus if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the app, -al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must bp- submitted with the building application
Doc: Doc_Buhding Permit Revised 2012
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AC -1 CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYI()
01/20/2017
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: H the certificate holder is an ADDITIONAL INSURED, the policy(fes) 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
Caleb Kirby
American Family Financial Group LLC
34 Crystal Avenue
Derry NH 03038
NAME: Caleb Kirby
PHONo Ext : 603 432 2944 ac, No): 603-432-4732
(A/C
ADDRESS: ckirby@amfamfinanciai.com
INSURER(S) AFFORDING COVERAGE NAIL #
INSURER A: Farm Family Casualty Insurance Company
INSURED
Malcolm Beal
27 Trull Brook Lane
Tweksbury MA 01876
INSURER B:
INSURER C:
INSURER D :
INSURER E:
INSURER 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.
INSH LTR
TYPE OF INSURANCE
INSR
WVD
POLICY NUMBER
MM/DD
M wDDMfY
LIMITS
A
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ® OCCUR
Select Business Package
2001 X 1276
08/05/2016
08/05/2017
EACH OCCURRENCE $ 1,000,000
PREMISES (Ea occurrence) $ 100,000
MED EXP (Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER:
POLICY JE o- LOC
PRODUCTS-COMP/OPAGG $ 2,000,000
$
AUTOMOBILE LIABILITY
ANYAUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
Ea accident $
130DILY INJURY (Per person) $
BODILY INJURY (Per accident) $
Per accident $
1 11 UMBRELLA LIAB
EXCESS LIAB
HOCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED I I RETENTION$
$
WORKERS COMPENSATION
IA
AND EMPLOYERS' LIABILITY y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If yesdescribe under
DESCRIPTION OF OPERATIONS below
NIA A
T
TORY LIMIT S ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYE $
E.L. DISEASE - POLICY LIMIT $
I-V
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DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required)
Carpentry - 595 Chickerning Rd (125) North Andover, MA
Email: hubbardcarpentry@hotmail.com Attn: Samuel Hubbard
Town of North Andover
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
North Andover MA
Caleb Kirby
ACORD 25 (2010/05) 0 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
t�fie (()tI-9s"7t(tWe"714ft u-1777,allac,,,mel/
Office of Consumer Affairs & Business Regulation License or registrationvalid for ind'n�idul use only
OME IMPROV CONTRACTOR before the expiration date. If found return to:
egistration 183855 Type: Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Expiration:.; 11/17/2017 individual Boston, MA 02116
MALCOLM G. BEAU'
MALCOLM BEAL
27 TRULL BROOK LANE
TEvvKSBURY, MA 01876 Undersecv - re aryy Not valid without signature
r
Massachusetts Department of Public Safety.
Board of Building R
`V- 11 g egulations and Standards r ;
d,2
License: CS-086893
Construction Supervisor.
MALCOLM GBM
27 TRULL BROOK _
TEWKSBURY MA 0
J
Expiration:
Commissioner 10/03/2017
The Commonwealth of Massachuseds
Department of IndustrialAccidents
M r X Congress Sheet, ,5`icite YO®
Bostoa, MA 02114-2017
www.mass govtdia
• Wavkers' Comp en.saiion Insurance A ffldavii:Builders/C� AUTT�O s7.ti�X. dcians/Plmmbers.
TO BE]�jj,E+z3WXTHT7 PEl�1V 'm—oaPrinf 1
' llCan$.�n2orrA.a�uu
Name (Busiuws/Orga� ontlndividua�:
City/Siate/Zip:_
Axe you an employer?
M
the appropriate box:
dt 8-4hone #:
1.❑ I am a employer with employees (full and/or Part-time)-,
2.�am a sole proprietor orpaTtamb'P andhaveno employees vaorking forme in
any capaoity. INoWorken. comp. insurance required.]
3.Q -workmyseIf [Noworkere comp. insuramerequired.] i
I am ahomeowner doing a11
4.FlIamahomeownerm wMbehiidagconttactorstoconduczallworkonmyproPmty-'WM
ensure that aI1 coniraci�ors eitherhave workers' compensation insurance or are sole
proprietorswithno eu 6g ees.
5_❑I am a general con44ctorand Ihave hiMithesub-contractors d �Cea�tiached sheet
Thesesub-coniraotorshave employees mdhavewadc=' comp.
5,❑
We= a corporation. and rfs,offfcers have exercisedtheir "gbt of'exemption d_1 c.
ted' kava no employees. [No workers' comp. insurance required ]
Type of project (requirecI)
7, ❑ I�e-�'constrir'ciaon
g. emoda g
9. ❑ DemolitiOn
10 [] Building addMon-
11.❑ Electrical repairs or additions
12.G]-glumbing repairs oar additions
13%[]Rbofrepairs
14.r] other
152, §1(4), . tive ,� —
*A,ayap 52, §I chat chgolvs box#1 mirst also fll ouiihe sectionbelow showi Lgtheirworkers, compensationpoficymforrnatiam
i Homeowners who submit this a?fidavit indicating they are doing all work andthenhire outside contractors must submit anew affidavit indicating such
tContractors that checkthis bo�must attaclied'en. additio�sb = y idetheir workers' come.�ofic numb y� staiewhether ornotthose, entities page -
--,_...�..•rf+v,A�„7,-r-n7rtractorshaveemployees,they p P P Y -
arae an employer'tliatzsp�'oviding•t-vor7ceNs' compensation inszaxancefor my errcployee�
information.
Insurance Company
Policy # or Self ins. Lia. #:
,8elo�v is tFiepolzcy mzdiob site
ExpirationDate,
City/State/Zip:
Job Site Address:
Attach. a copy of the Woxkers' compensation policy declaration page (shownzg the policy member and e�piraiiozi dale.
5A is
Failure to secure coverage as required.under M nalties2xnthe form mSmTOp WORK.ORDER Iand fine oifupto $250.00 a
and/or one-yeax imprisonment; as well as p
day against the violator. A copy ofthis statement may be forwarded to the Ofl"tce of Investigations of the DIA for insurance
coverage ver f ration.
l do Iaexeby certify under' tbepains andpenalties ofperjury haat tlae infonnoiion provided ai ove is true and correct
official US-, only. Do not•rvrite in ti is area, to he cornpleted by city or• town official
Permit/License #
City or Town'
IssuingAutho-city (circle one):ector �. Plumbing Inspector
1. Board of Health 2- Building Department 3. CiiylTov�a Clerk 4. l+lectxiealXnsp
6. Other
Phone 9;
Contact PerSon'
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 kite,
express or implied, oral or written:'
An employer is d'efiued as "an inilividuA partnership, also ciation, corporation or other legal entity, or any two or more
ofthe foregoing engaged in ajoint enfdrprise, and including the legal representatives of a deceased employer, or the
receive='or trastee cjf an individual, partnership, association or other legal entYty, employing emplbyees:.However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant ofthe
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 shallnot because of such employment b6 deemed to bean employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a ilcense or permit to operate a business or to construct buildings in the commonwealth for any
appRexatwlid has not produced -acceptable evidence of compTzance with the insurance coverage reqs &ed ,'
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 wiihthe 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 stzb=contractor(s)name(s), address(es) andphonenumber(s) along with theircertmcate(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. B e 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'
compensatiorzpolicy,pleas(-,caJ1theDepartmentatthenumberlistedbelow. Self-insured companies should enter their
self insurance license number on the appropriate lino.
City or Town Officials
Please be sure thatthe 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 ofluvestigations 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 peimit/Rcense applications in any given year, need only submit one affidavit indicating current
PORGY information (if necessary) and under "lob Site Address" the applicant should write fall locations in (city or
town)" A copy of the affidavit that has been officially stamped or marked by the city or towa may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new afFtdavit 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 burn leaves etc) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial.Accidents
1 Congress Street, Suite 100
B oston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877 MASSAFE
Fax # 617"-727-7749
Revised 02-23-I5 WWW.mass.govfdia
4
-9
a
Malcolm Beal herein called the CONTRACTOR agrees to manage the renovation of the North
Andover ProEx office area. We will provide all labour, materials, permits and insurance certificates as
required.
Date: 1/19/2017
CLIENT: ProEx Physical Therapy
Michael J. Mulrenan
CEO & President
Portsmouth, NH 03801
P: 603-427-8066 ext. 153
F: 603-501-0495
C: 239-272-3616
Site Details: 595 Chickerning Rd (125) North Andover, MA Approximated Area: 800 sq. ft.
Payment details: Client agrees to make payments upon request as outlined below.
Total amount: $8,000
Payment terms: $5,000 is due upon signing - permit submittal. Remainder $3,000 to be paid on
completion of work listed below. Materials are to be paid on delivery to the Job site.
Scope as discussed:
Remove partitions currently used for manager's office and exam room in back right hand corner.
Remove old ceiling, raise sprinklers and lights to match existing ceiling height. Patch walls, replace
ceiling tiles as needed and touch up paint to ProEx standard colors. This does not include any fire
alarms or flooring. The work shall begin on receipt of payment and the permit. The estimated time
for completion will be 2 weeks (weather permitting). This is dependent upon payments, inspections
and availability of materials.
Terms and conditions to be obliged by:
■ The client hereby employs the contractor to do all the work and arrange all materials,
labour, tools and machinery.
■ The construction shall be carried out in accordance with the drawings and sketches
submitted after normal business hours.
■ The contractor shall carry liability insurance for the duration of the construction work.
• The contractor shall protect and defend the client in case of complaints of unpaid work from
any labourers.
■ The contractor and client agree not to change schedule, design or other specifications of
work without prior written consent.
Signatures:
Michael J. M�u�lreennan, P
(ProEx Physical Therapy)
Malcolm G. Beal CPM
(Contractor)
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