HomeMy WebLinkAboutBuilding Permit #528-11 - 79 OLD VILLAGE LANE 1/7/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO- Date Received
Date Issued " �
IMPORTANT: Applicant must complete all items on this page
rrulL ,
MAP NO: I:n_pAR.CEL: b ZONING DISTRICT: Machine hop Village yes n
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
❑ Alteration
-V�Repair, replacement
❑ Demolition
lew. `'
PROPOSED USE
Residential Non- Residential
.One family
❑ Two or more family ❑ Industrial
No. of units: ❑ Commercial
❑ Assessory Bldg ❑ Others:
❑ Other
Fl_oodpla n ®Wetlandst^ 1® Waw &shed D
OWNER: N
Address:
CONTRACTOR Name:
Address:
Please Type orfPrint Clearly)
0
Supervisor's Construction License:
l- f`S
Exp. Date:
Home Improvement License:
L/
Exp. Date:
19
X03 �� S`zJOv
Phone:
\ -U L'
ARCHITECT/ENGINEER Phone:
Address: Reg. N
FEE SCHEDULE. BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $q FEE: $
Check No.:
Receipt No.:•J6 1�
NOTE: Persons contracting with unregistered contractors do not have access to ffie guaranty fund
2 � fK4nPnt%Owner? =-
Is
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
• r.
TYPE OF SEWERAGE DISPOSAL, - _
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swunming P°ols ; " , •'
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'�ORM
DATE REJECTED
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
i
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Commen
Conservation Decision:
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
x'
DPW Town Engineer: Signature:
I1 a ^• Located 384 Osgood Street
FIRE DEPARTMENT ' ,TempiDumpster on site yes nod
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
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 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
40TE: 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
lust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
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The Commonwealth of Massachusetts
Department oflndustrial,Accidents
Office oflnvestigations
600 Washington Street
t Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/JElect:ricians) Plumbers
Applicant Information Please Print Legibiy
Naive (B.usiness/Organization/Individual):
Address: ►t�i� .
City/State/Zip:
Phone #: 6o 3 - &-9? ,�'— S - O
Are you an employer? Check the appropriate box:
1. ❑ 1 am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2111 am a sole proprietor or partner-
listed on the attached sheet. s
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.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. [q Remodeling .
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. F1 Roofrepairs
13.❑ Other
7Any applicant that checks box4l 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.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance foY my employees Below is the policy and job site
information. -
Insurance Company
Policy # or Self=ins. Lic. #: `C� l " 1 Z_ �(j f�% �r i �-(? Expiration Date: l
lob Site Address: -71 l V l6� L e -n c City/State/Zip: w/c 1 r
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirations 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 i a 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 ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do Izereby cert der• the pains and Penalties ofperjury that the information provided above is true and correct.
Signature: Date: 1/7///
Phonek 60-1 — ,�l6f—T-(/Uc)
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: PermitMeense
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
ContactPerson: Phone
CERTIFICATE OF LIABILITY INSURANCE
ATE (MM/DD/YYYY)ACORD
D12/23/2010
PkODUCER 603. 224.2562 FAX 603.224.8012
The Rowley Agency, Inc..
139 Loudon Road
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.... .
P.O. Box 'S11
POLICY NUMBER
..............................:...INSURERS.
AFFORDING COVERAGE_. ° : ,:::...' ,..:; _NAIC.# ....,.._.....
INSURED C yr tum er,. Co... .... ,.._..,.. f
INSURER A: A.-I.M. Mutual ;Irfsu0ai ce.,Company:;
I
I P.0...3Box 837
Wirdh'am;'` NH''03087-0837
t
INSURERB: ..... ......:;-... ..... ...W._—_.._...,....,..
INSURER C:
INSURER D: _ ._.. _._...,....... _._t........_...., __.
:.,
INSURER E:
PREMISES Ea occurrence $
r1nV8=RAr:1=C
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRDD
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE M M/DDNYYYL
POLEXPIRATION
DATE MMIDD/YYYY
LIMITS
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
GENERAL LIABILITY
Rhonda Noble/RLN
.J
EACH OCCURRENCE $
PREMISES Ea occurrence $
COMMERCIAL GENERAL LIABILITY
MED EXP (Any one person) $
CLAIMS MADE 17 OCCUR
PERSONAL & ADV INJURY $
IGENERAL
AGGREGATE $
f
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
Ij
POLICY PRO LOC
JECT
�
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea accident) $
BODILY INJURY $
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY ...
(Per. accident) $..? .
HIRED AUTOS
NON OWNED AUTOS ; .: .., n
' :.: ... ... . . .....
_.......
:PROPERTY DAMAGE
(Per accident)
_......
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN.. ". EA ACC . $
ANY AUTO
'AUTO ONLY: AGG $
EXCESS I UMBRELLA LIABILITY
EACH OCCURRENCE $
AGGREGATE $
_
OCCUR EICLAIMS MADE
$
DEDUCTIBLE
$
RETENTION $
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVEYFIN
OFFIC.E4JNdEMSER EXCLUDED? I—J
(Mandatory in NH)
WMZ8006166012011
3A STATES: NH
NO EXCLUDED OFFICERS
01/01/2011
01/01/2012
TORY LIMITS ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
E.L. DISEASE -POLICY LIMIT $ 1,000,000
If yes, describe under
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
ttesting to NH workers compensation coverage.
['except 10 days for nonpayment of premium.
GI.- 0 I..IAI r%co C:ANUL-LLA I IUN
ACORD 25 (2009/01) v 1900- VV.7 nvvlw WW1AFW11^ IVI.. fill l lyllw
The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30* DAYS WRITTEN
Town of North Andover
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
1600 Osgood Street
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
B1d.20 Suite 2-36
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
No. Andover, MA 01845
Rhonda Noble/RLN
.J
ACORD 25 (2009/01) v 1900- VV.7 nvvlw WW1AFW11^ IVI.. fill l lyllw
The ACORD name and logo are registered marks of ACORD
• 1 bag grout Total: $90.67
Toilet:
• Kohler
• Cimarron K3497
• Seat k4663-0
• Round front
• Comfort height Total: $312.68
Labor:
• Demo existing vanity cabinets. C -tops, tile, etc.
• Install new tile floor
• Install new vanity
• Install new toilet
• Paint room
• Change out light fixtures
• Reconnect plumbing after granite install Total: $1,800.00
Grand Total: $38,933.24 before tax and delivery
Shipping:
• Delivery of kitchen cabinets
• Plus mass sales tax of 6.25%
Terms & Conditions:
Total: $25.00
Total: $680.62
Grand total: $39,638.86
Due upon ordering $19,819.43
Due upon completion of one work week $9,909.71
Due upon completion of job $9,909.72
The prices listed above are a result of the dimensions provided by Cyr Lumber. 50%
deposit is required at time of purchase the balance is paid at time of delivery. Cyr Lumber can and
will deliver to any homeowner who wishes with a $25.00 delivery fee.
YR LUMBER
39 Rockingham Road, Route 28 • Windham, NH 03087 • Tel 603-898-5000 • Fax 603-898-4154
Lombard:
Updated November 22, 2010
Kitchen Estimate:
Kitchen cabinets:
• Cabico
• 365/k full overlay door
• Maple with painted finish on main kitchen & desk (dove) and stained on island (mahogany)
• Particle board with full extension soft close drawers
Total: $12,916.48
-15% off discount good through Dec. 31St Total: $10,127.92
Additional 3 corbels (cbl-pn3-ma) Total: $ 321.00
Kitchen Countertops:
• Granite (includes kitchen, island, and desk unit)
• Template and install
• Standard edge profile (1/4 round)
• No backsplash
• Kashmir Gold Total: $3,394.30
Window:
• Bonneville
• Bay window
• White vinyl exterior / primed interior
• White grills on exterior of glass
• 72" x 40" Total: $1,042.89
• An additional labor cost Total: $500.00
Sink:
• Wentworth
• Bowl & % sink w/ grid and strainer
• Stainless steel
• CMU32219/7D ii Total: $308.00
c W %kh %af "& C,lS-F SGS- 1
If any amount that you owe becomes overdue, interest will be added to the balance due at
the rate of two percent (2%) per month (twenty-four percent per annum) or the maximum
rate allowed by the law, whichever is less, of the outstanding balance. In the event that it
becomes necessary for Cyr Lumber to engage a professional, such as an attorney, to
collect an overdue balance from you, you shall be responsible for the payment of all
expenses incurred by Cyr Lumber in connection with said collection, including but not
limited to cost and actual attorney's fees.
Once you place your order and Cyr Lumber accepts your deposit, you cannot make any
changes to your order. THERE ARE NO RETURNS ON SPECIAL ORDER ITEMS.
Cyr Lumber has made no express warranties with regard to the ordered goods other than
as set forth in this agreement.
Please allow 5-7 weeks for delivery of cabinets. Any cabinets that may come in
damaged or below quality standards will have to be reordered. This could take up
to 1 — 3 weeks. The lead-time given above is an estimated date. Cyr Lumber will notify
customer in a reasonable matter if the date is to change. Cyr Lumber does not take
responsibility for backorder cabinets, parts of pieces.
Faucets and fixtures must be at job site on the time of granite template. Failure to do so
will result on a $100.00 charge
Please note: Cyr Lumber reserves the right to adjust scheduled date for install due to
unforeseen scheduling conflicts.
Two year warranty on all labor and workmanship as stated on Cyr Lumber website.
All work to be done in a good and workman like manner in accordance with town and state
building codes.
Cyr Lumber does not take responsibility for the quality of work done by another installer.
The customer is now responsible for all parts in hand and also the quality of the work to be
completed by someone other than Cyr Lumber.
The above prices, specifications and conditions are satisfactory and are hereby accepted
by signing below you are authorizing CYR LUMBER CO. to order all above items and complete all
work as specified.
�XDate:
Customer Signature
• Install new under cabinet lighting in kitchen
• Repair and finish kitchen ceiling
• Replace moldings around door ways and window to match existing
• Fill in, sand, and refinish hardwood floor in kitchen finish with three coats of poly
• Install kitchen cabinets, moldings, and hardware'
• Add gas line for stove
• Paint kitchen ceiling, walls, doors, and trim
Vanity cabinets:
• Cabico
• 365/k full overlay door
• Maple with painted finish (dove)
• Particle board with full extension soft close drawers
-15% off discount good through Dec. 31St
Vanity Countertops:
• Granite
• Template and install
• Standard edge profile (1/4 round)
• 4"backsplash
• Includes white under mount sink
• Kashmir Gold
Faucet:
• Kohler
• 8" wide spread faucet
• Brushed nickel
• K-13491-4
Hardware:
• Amerock
• Knobs qty. 2 (1950-g10)
• G10 finish
Bathroom Tile:
• Daltile
• Sale tile
• 12" x 12" tile (bx03 mushroom)
0 3 boxes need
Total: $18,050.00
Total: $518.00
Total: $441.13
Total: $520.00
Total: $265.00
Total: $7.18
Faucet:
• Kohler
• Single hole faucet with pull down sprayer
• Stainless steel
• K690 Total: $505.71
Soap dispenser:
• Kohler
• Single hole soap dispenser
• Stainless steel
• K1894 -c -vs Total: $67.79
Hardware:
• Amerock
• Pulls gty.12 (9365-g10)
• Knobs qty. 24 (1950-g10) 0
• G10 finish Total: $204.60
Kitchen Tile:
• Daltile
• "rittenhouse° semi gloss
• 3" x 6" subway tile (0 135 almond)
• 3 boxes need
• 1 unit epoxy grout (85 almond) Total: $224.32
• Tile backsplash installation Total: $750.00
Labor:
• Demo existing kitchen cabinets. C -tops, tile, appliances etc.
• Dumpster and removal
• Make opening to family room and dinning area larger to design specs (install necessary
beams)
• Remove existing closet for desk area
• Take out existing windows, frame and install new window to customer's specs. Use azek
trim on the exterior to match style/width of current exterior trim on other windows recently
replaced.
• Replace/ fix and paint cedar clap boards on exterior and insulate area
• Move plumbing for sink and DW and refrigerator to new location
• Move electrical for all appliances to new location including wine cooler in island
• Change out baseboard heating to toe kick heating
• Add/move recess lighting qty 12
• Add 3 pendent lighting above island dimmers to be added on all lighting switches
�xxny .. - . ✓_.c. I .. acv...vs.,.,srzx�,�viva:am..���Yiar_bti�n(.c.13➢r:G1lT•ry:^£: ^er.ESL'i�S
w
e�L_
All dimensions -size designations•�
given are subject to verification on
job site and adjustment to fit job
conditions.
�� g
TECHNOLOGIES
This is an original design and must
not be released or copied unless
applicable fee has been paid or job
order placed.
Designed: 11/9/2010
Printed: 11/23/2010
lombard All Drawing #: 1
iNlassachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 80522
Restricted to: 00
EDWARD R ADAMS
PO BOX 743
DERRY, NH 03038
('ummissioner
✓tie Uonvnzoouue o�✓lactruGell
Board of Building Regulations; and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 154581
= Expiration: 3/23/2011 Tr# 282445
Type::" DBA
E.R. A. CONSTRUCTION
EDWARD ADAMS
16 FOLSOM RD.:;,•
DERRY, NH 03038 Administrator
Expiration: 8/8/2011
Tr#: 1625
License or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Boston, Ma. 02108
Not valid without signature
Location I ",4"e—
No.
" ' Date_
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
23644 Building Inspector