HomeMy WebLinkAboutBuilding Permit #526-14 - 74 STONECLEAVE ROAD 1/8/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:. " _ 1 Date Received
Date Issued: 1 i Tr
I IMPORTANT: Applicant must complete all items on this page
LOCATIONS
Print
PROPERTY OWNERL�
v /� Print .. 100 Year Old Structure yes no
P NO: V____. ,PARCELO�Z ._ ZONING DISTRICT Histone District es no
MA - - W y
,Machine Shop Village yes no
TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non= Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
ElSeptic ❑Well
E Floodplain El Wetlands
❑Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
01wo V+-ro 01 '�� Imo, ✓M ✓-}-� V �-�6�
Identification Please Type or Print Clearly)
OWNER: Name: t✓ L \71i9— 144 -LL Phone:
Address: % S�yr2�"GL�✓
CONTRACTOR` 'Name: 2t G �__ T'�-✓1� Phone -97F.. 4.1_
u_h
Address: 1 n ,— _ 13✓l `r/� Ltr` 1�;"� w
Supervisor's Construction License:Exp. Date: _ Li Q
Home .Improvement License:
ARCHITECT/ENGINEER
Address:
Date: _ `7 / Xowl )
Phone:
Reg. No
FEE SCHEDULE: BOLDING PE IT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: c� 0 �� FEE: $
Check No.: 7 4( Receipt No.: �Za
NOTE: Persons contracting with unregistered contractors do not have access to tl ranty�
Sidnaturetof�Agent/Owner,' id ature oftontracf_..
Plans Submitted Li Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
r
-- Plans Submitted ❑
Plans Waived ❑ '-Certified Plot Plan ❑ Stamped Plans ❑
7YPE_.OF'SEWERAGE DISPOSAL '
-
Public Sewer ❑
Tanning/Massage/Body Art ❑ _.
Swimming Pools ❑
Well ❑
,Tobacco.Sales E]
: Food Packaging/Sales ❑
Private (septic tank, :etc.: ❑ -- _ .
=Permanent Dempster on Site ❑
THE_ FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
- -DATE REJECTED: DATE_APPR-OVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
a COMMENTS
Reviewed on_ Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submifted yes .
Planning Board Decision: Com
%, Conservation Decision: - .:C
t Water & Sewer ConnectionPermit
DPW ToivL Engineer: Signature:
Located M4 USgood Street
FIRE DfEPAR.TML.;'VT,. �TErhip Dumpster on site yes_.. no
Located at <124�Mair, Street r`` _.. ._.._ „' 7-
Fire'Departm'�`r
e►�tasignature/date
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area; sq. ft.:
ELECTRICAL: Movement of Motor location, mast or service drop requires approval of
..Electrical Inspector Yes No
DANGER.Z®NE LITERATURE: Yes No
MGL -Chapter -166 Section 21A -F and G min.$10041000..fine
NOTES and DATA — (For department use
® Notified for pickup - Date
Doe.Building Permit Revised 2010
' Building Department
rhe fol owing is"a=list oUthe required -forms to be filled ouffor:the appropriate -permit to be obtained.
;J
Roofivg, Siding, Interior Rehabilitation Permits
u�. 1370i Idi ng.Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/0'r-C.S.L. Licenses
u Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
a Building Permit Application
a Certified Surveyed Plot Plan
o Workers Comp Affidavit
a Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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)
u Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
a Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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 aptral period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.rted with the building application
Doc: Doc.Building permit Revised 2012
Location " � x ' ,, �P� `� A"'
No. 7(0 —I Li
Check # A--7-
2 7 2 0
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ Z ( 00
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
r
u
/� Building Inspector
Enter construction cost for fee cal -
North Andover Fee Cad ulat%on
Construction Cost
20,081.00
m
$ -
$
240.97
Plumbing Fee
$
30.12
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
30.12
Total fees collected
$
401.22
74 Sonecleave Road
526-14 on 1/8/14
Remodel Secon Floor Bath
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y The Commonwealth of Massachusetts
07 Department of Indushigl Accidents
Office of Invesfigations
quo 600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information PIease Print Le;3ibly
Name (Business/Organizaiion/tndividual): L ✓i �/ 7'n 1(7 7`�(/ L7,:% C D t
Address: iD lti I
-City/State/Zip: NZ Lit -74f YI-4, Phone #: 7 g �� 7 y f a
Are you an employer? Check the appropriate box:
Type of project (required):
1. Qum a employer with 3_
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
�• E] Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for mein any capacity.
workers' comp. insurance.
9. F1 Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.❑Electrical repairs or additions
required.]
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. ❑ Roof repairs
insurance required.] t
employees. [No workers'
13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they ace 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 their workers' comp. policy information.
Yam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. ,� Ia
Insurance Company Name:. / I' C / — L
Policy # or Self -ins. Lie. #: 1-9t ) 0 13 L% Expiration Date: �l %
Job Site Address: —7 City/State/Zip: iV i
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 of MGL o.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 tine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DTA for insurance coverage verification.
I -do hereby certify un Ins and sof erjury that the information provided above is true and correct
Phone #• �� �o 0 j V
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
PermitfUcense #
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 employeiis 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 shallnot because of such employment be deemed to be an employes."
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 tfie boxes that apply to your situation and, if
necessary, supply sub -contractors) 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 maybe 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 lice 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 Goammollwealth of M-assachusPtts
Depaxtme,ut of Industrial Accidents
Office of Investigatious
600 Washington Sireet
Boston} MA 02111
Tel, # 617-727-4900 ext 406 ox 1-877:MASSAFE
Revised 5-26-05 Fay # 617"727-7749
vwwwaass,gov/dia.
RICHARD FLUET CONTRACTING, INC
102 BRIDLE PATH LANE
METHUEN, MA 01 844
Name / Address
CLYDE HALL
74 STONECLEAVE RD.
N. ANDOVER MA. 01845
Description
PROPOSAL
Date
Estimate #
11/25/2013
382
SECOND FLOOR BATHROOM. AVILA PLUMBING WILL REPLACE TUB UNIT, SHOWER VALVE TOILET, TWO VANITY
FAUCETS,TWO UNDERMOUNT SINKS (ALL FROM PEABODY SUPPLY), VANITY (TANDSDESIGN),GRANITE TOP
REMNANT(STONEONE), FLOOR AND WALL TILE (MESSINA), AMORE ELECTRIC ONE RECESSED LIGHT IN SHOWER -2ND.
VANITY OUTLET,NEW EXHAUST FAN LIGHT WITH ONE SWITCH OUTSIDE ROOM,REPLACE EXISTING OUTLET SWITCH
AND PLATES.FLUET CONTRACTING WILL DEMO FLOOR AND WALLS,INSTALL NEW BLUEBOARD AND FINISH AS
NEEDED, NEW HARVEY WHITE DOUBLE HUNG REPLACEMENT WINDOW WITH HIGH EFFIECENCY GLASS AND 1/2
SCREEN -PAINT WALLS AND TRIKTWO COATS BEN MOORE). INSTALL TOILET PAPER AND TOWEL HOLDERS. CLOSET
INTERIOR TO REMAIN AS IS.SUPPLY PERMIT AND TRASH REMOVAL.
INCLUDED; TOILET TOPPER OR CABINET ABOVE TOILET, MIRRORS OR LABOR TO INSTALL EACH ONE.
PROPOSAL IS VALID FOR 30 DAYS.
EXTRAS OR CHANGES TO BE COMPLETED AT A RATE OF $75.00/HRJMAN
Finance Charges on Overdue Balance 1 1/2 %/ MONTH
1/3 WITH ACCEPTANCE, 1/3 DAY WORK BEGINS, BALANCE UPON COMPLETION.
Total $20,081.00
Signature
Phone #
Fax #
E-mail
978-685-7010
978-685-7010
RFC102@vcnzon.NET
Al �
Office o ousumer airs mess egu ahon.
HOME IMPROVEMENT CONTRACTOR `u
Registration: 106620• Type:
Expiration: 5124%2014 Private Corporation
R RD FLUETfCQ_NTRACTING'INC.
Richard Fluet �:\
102 Bridle Path Lane' - £
Methuen, MA 01844'
Undersecretary
Massachusetts - Department of,Public Safefy
Board of Building Regulations and Standards
zi Construction Supervisor
License: CS -050710
RICHARD A FLUu'T
102 BRIDLE PATH°
'METHUENMA '01134
w1 XExpiration
Commissioner 04/22/2015
I
OP ID: N
CERTIFICATE OF LIABILITY INSURANCE DAT 01/0DDIYYYY)
01107114
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 holier Is an ADDITIONAL INSURED, the Policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the po Icy, certain policies may require an endorsement A statement on this Certificate does not confer rights to the
certificate holder in Ileu of SUCh endorsement(s).
PRODUCER 978-975-1300 CeNTACT
Berevs A Hall Insur.Assac.lnc NAMEt
306 North Main St 978-975-7596 PNONE
Andover MA 01810 --
Michael C Segreve ADDRE ;
c a OM ms.FLUBT-1
INSURED Richard Fluet Contracting Inc.
102 Bridle (Path Lane
Methuen, MA 01844
A
B
Co.
Co.
360
s
r •- V�KtZVI*IVN NUmt3tK:
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 MANY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SU';H POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
R TYPE OF INSURANCE POLICY NUMBER MM1L01 D MOLIUT EXP LIMITS
GENERAL UABILITY
EACH OCCURRENCE S 1.000.0
A COMMERCIAL GENERAL LIABILITY
'
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
UAMAGE TO R
PREMI U(]:B - S
CLAIMS MAGE ❑X OCCUR
Building Deparment
Main Street
AUTHORIZED REPRESENTATIVE
North Andover, MA 01846
II .—
MED EXP (Any one person) Is
8500034727
08/12/13
06112/14
PERSONAL B ADV INJURY S
GENERAL AGGREGATE S
—
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
1 POLICY F1 M El LOC
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
ANY AUTO
(Ea acddenq S
BODILY INJURY (Per peraen)
ALL OWNED AUTO$
BODILY INJURY (Per aeoidont) $
X SCHEDULED AUTOS
PROPERTY DAMAGE
(Parexldsn1) $
X HIRED AUTOS
XV1460
12/01/13
12101!14
�il NON-OWNEDAUTOS
Is
I
I
I
i
UMBRELLA LIAO
OCCUR
—HX
EACH OCCURRENCE S
EXCESS LIA6
CLAIMS -MASE
AGGREGATE is
DEDUCTIBLE I I i I I Is
WORKERS COMPENSATION
ANDEMPLOYERS- LIABILITY Y114
A ANY PROPRIETORIPARTNEREXECUTIVE,
OFFICEPAAEMAER EXCLUDED? CJI N I A
(Mando(ory In NH)
03131/13 1 03/31/14
DEWRIPnON OF OPERATIONS / LOCATIONS / VEY ICLES (ARaeh ACORO 101, Addhlonal Remarka Schedule, If more spaeo In r%qulrad)
cFRTIFICAT'F unr nos nw►.n�......,..
E.L. DISEASE - EA EMPLOYEE1 S
E. L. D18EASE - POLICY LIMIT I $
1
1
NORTHAN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORt)ANCE WITH THE POLICY PROVISIONS.
Building Deparment
Main Street
AUTHORIZED REPRESENTATIVE
North Andover, MA 01846
®1938-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD