HomeMy WebLinkAboutBuilding Permit #494-11 - 614 CHICKERING ROAD 12/21/2010TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
ZDate Issued: /,0
IMPORTANT: Applicant must complete all items on this paize
rJ..UIL
MAP NO: kPARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
NKOne family k
El Addition
0 Two or more family
El Industrial
{Alteration
No. of units:
El Commercial
U Repair, replacement
11 Assessory Bldg
El Others:
0 Demolition
0 Other
si� �
- i T T
�MIFI 'MIW
51 W1,
F-11 M- 9 1 W I 1161 R EN 0 NOW IN N 1 UJ -0 1119 11 IN 1 UGJ 114 05 1 Y
7-�D5L- V2,
OWNER: Name:
Address:
CONTRACTOR Name:
Addre..R.q- /C-)2 9
)n Please Type or Print Clearly)
W
Supervisor's Construction License: Exp. Date:
Home Improvement License: _ I �(O 3 Exp. Date:
U4
ARCHITECT/ENGINEER Phone:
q -25 - 7,Xb - IF21
Phone: ?F/ — KOO -1Z d%
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
N
Total Project dost: /Of 76 FEE: $ 2
Check No.: / � / Receipt No.: 9,10— 0 67,4
NOTE: Persons contracting with unregistered contractors do not have acce s to t gu ra tv fund
S -f
c n rac of
6fAd6fit/OW'ner. Signature idnatbre. ture o
Location
No. Date G
MORTiq
TOWN OF NORTH ANDOVER
f �ti
• OL
A
• :
Certificate of Occupancy
$ _
s�cHus
Building/Frame Permit Fee
$
Foundation Permit Fee
$ J
Other Permit Fee
$
TOTAL
$
Check #
23LL6
Building Inspector
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
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
yes no
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
LI 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)
o 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
:hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
oust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: Ic')2
I
City/State/Zip: �c� S Co l i Phone #:
Are you an employer? Check the appropriate box:
I. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. J14 am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are 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 acid their workers' comp. 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
Policy # or Self -ins. Lie.
Job Site Address:
Expiration Date:
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 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 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby �
r the pains and penalties ofperj�urythat the information provided above is true nd correct.
Signature: Date:
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. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #•
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
e :
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: Ic')2
I
City/State/Zip: �c� S Co l i Phone #:
Are you an employer? Check the appropriate box:
I. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. J14 am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are 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 acid their workers' comp. 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
Policy # or Self -ins. Lie.
Job Site Address:
Expiration Date:
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 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 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby �
r the pains and penalties ofperj�urythat the information provided above is true nd correct.
Signature: Date:
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. Electrical 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 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 ani
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 -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 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 inany 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 pen -nits 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 burn 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 Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFB
Fax # 617-727-7749
Revised 5-26-05
www.mass.govldia
a) closet doors
b) electrical baseboard heat
c) all electrical switches
d) all electrical outlets
6. Electrical Work
➢ Contractor shall perform the following:
a) install wall outlet for cable
b) new electrical baseboard heat
c) install all new electrical outlets
d) install all new switches
7. Door ftlacement
➢ Contractor shall replace closet doors to closely resemble existing 6 panel
doors. There is 2 sliding closet doors in master bedroom room.
8. Paint
➢ This proposal allows for no painting
PROJECT DESCRIPTION — KITCHEN — COMPLETE DEMOLITION
Contractor shall demolition kitchen completely. This includes removing all tile
work, all cabinetry, all wall board to the studs, all ceilings to the ceiling joist.
Remove all electrical work and all plumbing as needed. This proposal includes the
cost of all disposal.
DEMOLITION INCLUDES ALL ELECTRICAL WORK DISMANTLING, ALL
PLUMBING WORK DISMANTLING AND DISPOSAL. ALL KITCHEN
MATERIALS WILL BE TAKEN DOWN TO THE STUDS.
PERMITS
Permit fee shall be reimbursed by home owner to contractor.
Ted Grab - Interior Renovations
1029 Humphrey Street
Swampscott, Massachusetts 01907
781-430-0415 office
781-454-5609 cell
MA Home Improvement Contractors Registration # 140838 — Exp 11/28/11
Construction Supervisor License # 89566 — Exp 11/24/11
December 16, 2010
Interior Renovation Project
HOME OWNER: Earline Mango
614 Chickering Road
North Andover, Ma
PROJECT DESCRIPTION - HALF BATHROOM
Demolition
Contractor shall demolish entire existing bathroom down to the framing
structure. Specifically contractor shall:
a. remove toilet existing toilet.
b. remove and dispose of sink and vanity cabinet.
c. remove all doors casings
d. remove all electrical fixtures
e. remove all electrical outlets and switches
f. remove electric baseboard heat
g. remove thermostat and hold for reuse
h. remove existing exhaust fan.
i. remove all wall tile
j. remove all floor tile.
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k. remove ceiling wallboard
1. remove all wallboard to studs
in. remove wiring (non-essential)
n. Properly dispose of all debris
1. Ceiling Preparation
❑ 1" x 3" spruce strapping shall be installed (as needed) on ceiling joist 16" on
center to support weight of new drywall ceiling. (AS NEEDED)
2. Wall Structure
➢ Contractor shall make wall alterations as (as needed). All wall structure shall
be built according to state & local building requirements.
3. Electrical Work
➢ A Massachusetts Licensed Master Electrician shall perform all electrical
work. This project shall include the following.
❑ Ground Fault Outlet as required by code. Ground Fault Outlet can be
created either by Outlet Fixture or by Electrical Panel Circuit
Breaker. This will be determined by the electrician.
❑ Due to the size of the bathroom, the contractor suggests using a Single
Unit Exhaust Fan / Light, vented to existing duct for proper
ventilation. This fixture shall have a switch to control fan and a switch
to control light.
❑ Install wall sconce as directed by homeowner. Because this item is
"personal preference" the homeowner shall choose and supply this
fixture. This fixture will be switched separately.
❑ Electrician will re -install existing thermostat.
❑ Electrician will install new baseboard heat, consistent and proper for
the size of the room.
❑ Electrician will replace and / or supply all wiring that is required and
/ or needed.
4. Plumbing
➢ Plumber shall inspect all plumbing relating to this bathroom that may be
visible or may reasonably be inspected.
➢ Plumber will replace or repair any plumbing necessary for the proper
operation of this bathroom.
❑ Bathroom Ceramic Floor Tile, Grout and Marble Threshold
❑ Medicine Cabinet
❑ Wall Sconces
10. Painting
➢ This proposal allows for no painting.
PROJECT DESCRIPTION — FULL UPSTAIRS BATHROOM
Demolition
Contractor shall demolish entire existing bathroom down to the framing
structure. Specifically contractor shall:
a. remove toilet existing toilet.
b. remove and dispose of sink and vanity cabinet
c. remove and dispose bath tub
d. remove all doors casings
e. remove all electrical fixtures
L remove all electrical outlets and switches
g. remove electric baseboard heat
h. remove thermostat and hold for reuse
i. remove existing exhaust fan.
j. remove all wall tile
k. remove all floor tile.
1. remove ceiling wallboard
m. remove all wallboard to studs
n. remove wiring (non-essential)
o. Properly dispose of all debris
8. Ceiling Preparation
❑ 1" x 3" spruce strapping shall be installed (as needed) on ceiling joist 16" on
center to support weight of new drywall ceiling. (AS NEEDED)
9. Wall Structure
PROJECT DESCRIPTION — GUEST BEDROOM (smaller room)
1. Demolition
➢ Contractor shall remove and dispose of the following:
a) electrical ceiling fan
b) closet doors
c) electrical baseboard heat
d) all electrical switches
e) all electrical outlets
2. Electrical Work
➢ Contractor shall perform the following:
a) install wall outlet for cable
b) new electrical baseboard heat
c) install all new electrical outlets
d) install all new switches
e) new switch for fans to control speed
f) install new fan/ light as chosen and supplied by Homeowner
3. Door Replacement
➢ Contractor shall replace closet doors to closely resemble existing 6 panel
doors. There are 2 closet doors in guest room.
4. Paint
➢ This proposal allows for no painting
PROJECT DESCRIPTION — MASTER BEDROOM (larger room)
S. Demolition
➢ Contractor shall remove and dispose of the following:
➢ Contractor will supply and install new blueboard and veneer plaster on all
walls and ceiling areas.
14. Flooring — Subfloor and Wall Tile — Substrate (tub surround,
➢ Contractor will supply and install new water resistant sub -floor.
➢ Contractor shall install ceramic or porcelain tiles over new sub floor. There
is an additional cost for marble or granite tile. All tiles are supplied by
homeowner.
➢ Contractor shall install moisture resistant wall substrate to accept ceramic
tile wall surround and shall install tiles for wall surround supplied by
homeowner.
8. Medicine Cabinet
➢ Contractor will install medicine cabinet as directed by homeowner.
Homeowner shall supply medicine cabinet.
9. Baseboard and Door Casing
Contractor shall install baseboard and door casing as is consistent with the
rest of the residence.
10. Materials Su�nlied by Contractor
➢ Contractor will supply and install all materials and fixtures. However the
fixture listed below shall be supplied by homeowner and installed by
contractor.
❑ Bathroom Sink / Vanity / Faucet / Drain Mechanism
❑ Bathroom Tub, Faucet, Shower Mixer and drain mechanism
❑ Bathroom Toilet / Toilet Seat
❑ Bathroom Ceramic Floor Tile, Grout and Marble Threshold
❑ Medicine Cabinet
❑ Wall Sconces
10. Painting
);,- This proposal allows for no painting.
➢ Contractor shall make wall alterations as (as needed). All wall structure shall
be built according to state & local building requirements.
IO.Electrical Work
➢ A Massachusetts Licensed Master Electrician shall perform all electrical
work. This project shall include the following.
❑ Ground Fault Outlet as required by code. Ground Fault Outlet can be
created either by Outlet Fixture or by Electrical Panel Circuit
Breaker. This will be determined by the electrician.
❑ Contractor shall install 2 6 inch recessed lights.
❑ The contractor suggests using a Single Unit Exhaust Fan vented to
existing duct for proper ventilation. This fixture shall have a switch to
control fan and a switch to control light.
❑ Install wall sconce as directed by homeowner. Because this item is
"personal preference" the homeowner shall choose and supply this
fixture. This fixture will be switched separately.
❑ Electrician will re -install existing thermostat.
❑ Electrician will install new baseboard heat, consistent and proper for
the size of the room.
❑ Electrician will replace and / or supply all wiring that is required and
/ or needed.
II.Plumbing
➢ Plumber shall inspect all plumbing relating to this bathroom that may be
visible or may reasonably be inspected.
➢ Plumber will replace or repair any plumbing necessary for the proper
operation of this bathroom.
➢ Install new sink / vanity -sink. Supplied by Homeowner
➢ Install new Tub / Faucet / Shower Mixer. Supplied by Homeowner
➢ Install sink faucet and draining mechanism. Supplied by Homeowner
➢ Install toilet. Supplied by Homeowner
12.Insulation
➢ Contractor shall insulated all outside walls to code based upon the needs of
the structural members.
13. Wallboard — Wall Finishing — Ceiling Finishing
➢ Install new sink / vanity -sink. Supplied by Homeowner
➢ Install sink faucet and draining mechanism. Supplied by Homeowner
➢ Install toilet. Supplied by Homeowner
S. Insulation
➢ Contractor shall insulated all outside walls to code based upon the needs of
the structural members.
6. Wallboard — Wall Finishing — Ceiling Finishing
➢ Contractor will supply and install new blueboard and veneer plaster on all
walls and ceiling areas.
7. Flooring — Subf loon
➢ Contractor will supply and install new water resistant sub -floor.
➢ Contractor shall install ceramic or porcelain tiles over new sub floor. There
is an additional cost for marble or granite tile. All tiles are supplied by
homeowner.
8. Medicine Cabinet
➢ Contractor will install medicine cabinet as directed by homeowner.
Homeowner shall supply medicine cabinet.
9. Baseboard and Door Casing
Contractor shall install baseboard and door casing as is consistent with the
rest of the resisdence.
10. Materials Sullied by Contractor
➢ Contractor will supply and install all materials and fixtures. However the
fixture listed below shall be supplied by homeowner and installed by
contractor.
❑ Bathroom Sink / Vanity / Faucet / Drain Mechanism
❑ Bathroom Toilet / Toilet Seat
Project Investment
$10876.00
➢ Payment Due with Agreement $1000.00
➢ Payment Due when Project begins $ 3600.00 (33%)
➢ Payment Due when all rough electrical
is complete $ 3600.00 (33%)
➢ Balance upon completion
Commencement Date
Project shall begin on or about December 20, 2010 and shall be completed
on or about January 21, 2011. These dates are approximate.
Accepted by:
O Date: 12-16-2010
Earline Mango
Accepted by:
Date: 12-16-2010
Ted rab
Massachusetts Depaillne"ons of Pud ,;blit,,Inc Sa(lai dVe *Y S,
AM Board of Buildino, Regulliti
Construction Supervisor License
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License'. CS 89566
Restricted to: 00
THEODORE GRAB
1029 HuMPHREY ST
SWAMpSCOTT, MA 01907
Expiration: 11124120"
Tr#: 10221
office of Consumer Affairs & Business Regull"t"'
HOME IMPROVEMENT CONTRACTOR
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RegistratiO& _140838 -Tr# 290650
Expiration =1;��2Bf2011
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G, INC.
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THEODORE
1029 HU PH
Undersecretary
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