HomeMy WebLinkAboutBuilding Permit #634 - 73 LANCASTER ROAD 4/30/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:(/J,5 7 Date Received
Date Issued: 1 1, 5v
IMPORTANT: Applicant must complete all items on this page
LOCATION.tsC�¢-. h.
Print
r
PROPERTY OWNER__ rrt A C oi;�-Ac
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED SE
Residential
Non- Residential
New Building
OrJe-f ily
Addition
wo or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
<//72�(04r7c,) o�eF--�
Identific ion Please Type or Print Clearly)
OWNER: Name: .J f rn V e>
Address: 7.3 /,.SGA --5 a'L
CONTRACTOR Name:WtPhone:�"`�""
d
Address;
t.
'
Su ervisors Construction License: GS S r d
P � � Exp,... ;:Date: �/ �,� k
Home Improvement license.` v Exp. Date:,
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
fFEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
k ,_ /
Total Project Cost: $ ` ® FEE: $
Check No.: 13-3 Receipt No.:'
NOTE: Persons contracting with unregistered contractors do not have access to tarantr 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 Famny)- r
❑ 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
Hydradii c'Calculations (If Applicable)
❑ Copy of Contract x '
❑ 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
LOcatea M4 US OOa street
FIRE DEPARTMENT - Ternp,Dumpster on site yes ono
Located at '124 Main Street
Fire Department 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 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)
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
/3
/1 C
Location
No. Date
G D
TOWN OF NORTH ANDOVER
-
.
4 AM��
air Nw.
C ertificate of Occupancy $
Mu
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #d' 13-3
Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
M ,°y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Gv �>� °G� ®®�S%Jp� K✓ sc�� .E� L
Address: !/ .I �S 4d-
City/State/Zip:
dCity/State/Zip:® Phone #:
Are you an employer? Check the appropriate box:
1. ® I am a employer with
4. F-1 I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ 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.
employees and have workers'
[No workers' comp. insurance
comp. insurance.t
required.]
5. We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):,,
6. ❑ New construction
7. [& Remodeling
& F_� Demolition
9. [] Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.[] Roof repairs
13.0 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:' Q i C>� �f ®2 r7 Ze� Expiration Date: �� ��Za
Job Site Address: 173 L °C -*Si 2.Ia— /�O City/State/Zip:/& iyjOt/ `y�
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 certiffutoer the pain nd penalties of perjury that the information provided above is true at.
pnd correct.
Si atuie:_ Date; ffv �a _
Phone #; —4,
not write in this area, to be completed by city or town official
City or Town: Perri/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. 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." !
i
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 cleemed''1'o be aii employer."
MGL chapter 152; §25C(6) also states that "every state or local licensing agency thAll withhold,the issuance or
renewal of a license or permit'to,opera'te!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-contiactor(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 otherthan 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 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 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 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. # 6.17-727-4400 ext.406 or 1-877-MASSAFE
Revised 11822-06
Fax # 617-727-7749
www.mass.gov/dia
04/28/2008 12:12 FAX 978 957 8612 COUGHLIN INSURANCE
16001/001
AW -RD. CERTIFICATE OF LIABILITY INSURANCE OP iD c DATE(MMCDDNYYY)
WILSW02 04/29/06
PRODUCER I THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION
CHARLES J COUGHLIN ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
INSURANCE AGENCY I HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
14 DINLEY ST. P.O.BOX 10 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
DRACUT NA 01826-0010
Phone . 978- 957 -3588 lax : 97 8- 957- 6612 INSURERS AFFORDING COVERAGE NNC p
InsuREn INSURER& National Grange Ina Co 14788
Wilson Woodwo king, Inc. -- - -"--
]ffi0thy J. Wilson INSURER C__
1 JEoqueB Rg add NSURER D.
Tyagaboro, MA 01579
;VVtKAIjtl
THE POLICIES OF INSURANCE LISTED EELOW HAVE SEEN ISSUED TO THE INSURED NAMED ASCVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OA OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE (JAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIOIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS *MOWN MAY HAVE SEEN REDUCED BY PAA CLAIMS,
LTR
NSR
TYPE OF INSURMiCE
POLICY NVIJBBR
DAIS
TE 2MMfDDJYLry
mow
DATE M lYY
-
LIMITS
REPRESENTATIVES.
AUTHORIZED REPRESENTA
GENERAL LIABILITY
EACH OCCURRENCE S1,000,000.
A
X COMMERCIAL GENERAL UAWLITY
CLAIMS MADE C OCCUR
PREMISE$ E• °rruror� 4500,000,
MED EXP fAnYenopldlo") 110,000.
MPH16s2o
i 10/15!07
10/15/08
PERSONAL&AOVINJURY 91,000,000.
GENERAL AGGREGATE e 2 000 ,000.
GEMLAGOREGAr£LIMIT APPLESPSit
POLICY PEL00
PRODUCTS•COMPIOPAOG s2,000,000.
1
AUTOMOBILE
LIABIL:17
ANY AUTO
COMBINED SINGLE LIMIT S
I (Fa aWiiP.II))��
A
FX,
ALLOWNEDAUTOS
SCHEDULED AUTOS
i M9K76042
i 11/17/07
11/17/08
,BODILY !NI JURY
�•�p°`i°") $ 100,000.
X
X
HIREDAUTOS
I NON• "ED AUTOS
I
RT
BODILYINJU39DO,000.
(P•reoGOenD
PROPERTY DAMAGE 5 100,000.
(va acLi6anq
`GARAGE 0AIIUrY
AUTO ONLY-EAACVDENT 6
DTHER TITAN EAACC 3
ANY AUTO
AU T p ONLY: AGO 6
EXCES3fUMBR4LAUADPIITY
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EACH OCCURRENCE S
OCCUR CLAIMS MADE
I A3GREGATE S
_
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DEDUCTIBLE
S
RETENTION $
$
WORNERSOOMPENiArON AND
PRTNERIEXECUi4VE EMPLDYfiRIETCINLITY
ANPROPRIETOli/P
QFFICYERJMEMBER EXCLUDED'+
WIWC902925
01/16/08
01/16/09
X T RYLDARS E
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E.I.EACHACCIDENT• 3100, 000,
9 C162A41 EA EMPLOYE $100,000.
fl M, a6Ac+Wa unCg7
S;ECTAL PROVISIONS baNw
E.L. DISEASE POLICYLIMT 3500 000.
AMER
DESCRVTION OP OPERATIONS I LOCATIONS J VEHICLES I EXCLUSIONS ADDED MY ENDORSEMENT,- SPECIAL PROVISIONS
Carpentry
U_ KTWII:ATE lIaLOPR rAIMVFI I ATInNI
ANDOVER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES IE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Town of Andover
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEPIjVVI FAILURETODO606NAL6
ATTN: $U31dA=g Inspector
1600 Osgood St.
IMPOSE NO OBLIGATION OR LIABILITY OF ANY RIND UPON THE INSURER, ITS AGENTS OR
North Andover MA 01845
REPRESENTATIVES.
AUTHORIZED REPRESENTA
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j BOARD OF BUILDINiG REGULATIONS
License: CONSTRUCTION SUPERVISOR
NumbelfbS 088573
Birtth_tlatee-E f�:6/1969
171Nf rn
Tr. no. 88573
R t d= r 0 jt
TIMOTHY J WILJ014 � = ¢
11 JAQUES RD op
TYNGSBORO,- MAA -41
Commissioner
Wilson Woodworking Inc.
11 Jacques Road
Tyngsboro, MA 01879
(978)649-8598
Fax (978)649-0562
PROPOSAL
Jim Yonchak
Kathleen Yonchak
73 Lancaster Road
No Andover, MA
(978)989-9242
To Jim and Kathleen:
Wilson Woodworking is pleased to submit the following contract for work to be
performed at 73 Lancaster Rd Andover, MA. This letter, which will serve as our
Proposal, when signed by you on the Agreement Acceptance line below. The parties to
this agreement are Jim and Kathleen Yonchak hereinafter called the "Owner" and Wilson
Woodworking herein after call the "Contractor", for the services stipulated below.
KITCHEN AREA
Remove old kitchen and install part of old kitchen in basement.
Install new kitchen with crown molding around entire kitchen.
Countertops granite, done by others.
Decorative tile backsplash. (Labor Only. Homeowner to supply tile, glue and grout.)
VENTING
Remove old stove vent.
Patch siding in.
Install new vent.
WINDOW
Install and frame new window. (Window supplied by homeowner.) Siding will be
patched in when window is installed.
ELECTRICAL
Update electrical. Install new recessed lights, under the counter lights and two new
pendant lights.
(Pendant lights to be supplied by homeowner.)
PLUMBING
New plumbing for two sinks, dishwasher, refrigerator and install gas line for stove.
(Sinks, sink baskets, Faucets and Pot filler to be supplied by homeowner.)
FLOOR
Sanding existing oak floor and applying 3 coats of finish. (Homeowner to supply
stain.)
INSULATE
Insulate to code where needed.
DRYWALL
Hang drywall on ceiling where necessary from new placement of lights and kitchen
window wall.
PAINT
Repaint kitchen ceiling (Sherwin Williams Ceiling White) and kitchen walls two coats
(color to be chosen by homeowner).
Paint repaired siding.
(Homeowner to supply paint for repair of siding.)
PERMIT FEES
Building, Plumbing and EIectrical permit fees included in price.
TRASH REMOVAL
Everyday trash and any construction debris will be removed and house will be cleaned
and vacuumed. No trash will be left in the house or in the yard.
This Agreement shall be governed by the law of the location of the project.
The Owner and Contractor, respectively, bind themselves, their partners, successors,
assigns and legal representatives to this Agreement. Neither party to the Agreement shall
assign the contract as a whole without written consent of the other.
If any changes are requested to the above, a separate change request will be signed at the
time.
We look forward to working with you on this project and if you have any questions
regarding this contract please call.
Estimated start date: May 1, 2008
Estimated finish date: 4 weeks from starting date
l�
Total Contract Price: $37,390.00
Deposit due at signing $7,000.00
Payment $7,000.00
Payment $7,000.00
Payment $ 7,000.00
Payment due at finish $9,390.00
Demo, framing and window installation
All mechanicals
Kitchen Installation and floor finishing
If you have any questions you can E-mail questions directly to
WilsonwoodwrkCd),comcast net.
Tim Win.Contractor
Kathleen Yonch , Owner
,��
Boar o w ln�la�
It S gu ons an tan ar s
One Ashburton Place - Room 1301
Boston, Mass husetts 02108
Dome Improveme ,t;Utractor Registration
Wilson Woodworking
Timothy Wilson
11 Jacques Road
Tyngsboro, ma 01879
d 5(**4Wor-PC&=
Registration: 142324
Type: DBA
Expiration: 3/28/2010 TO 263246
late Address and return card. Mark reason for change.
!__I Address 0 Renewal D Employment j -j Led Card