HomeMy WebLinkAboutBuilding Permit #619-12 - 796 CHICKERING ROAD 2/27/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: ` Date Received
IMPORTANT: Applicant must complete all items on this page
LOCATION �7 CIC'i CX/CeF:�gl" -9.D
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PROPERTY OWNER Uhl 77— Unit #
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MAP NO:.PARCEL: ZONING DISTRICT: Historic District yesno
Machine Shop Village yes
100 year-old structure yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
�wo or more family
11 Industrial
Iteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
IS�ptic k0
oeier
oodplain® �Jands�
Watershed
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DESCRIPTION OF WORK TO BE PERFORMED:
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01 1,)f11J6Z0ab4qU
(Identification Please Type or Print Clearly)
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CONTRACTOR Name: �'( ne: � 2,?
Address:-
Supervisor's Construction License: _ 9_S�(a Exp. Date:
Home Improvement License: �j" cj Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: I r — Receipt No.: S
NOTE: Persons contracting lw th unregistered contractors do not have access to the ggpranty f#nd
Location eirg 1 1 '12 ap( r
Date
Check
25050
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 OF SEWERAGE DISPOSAL
Public Sewer ❑ �
Tanning/Massage/Body Art ❑
SwimmingPools ❑
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
COMME
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
El
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comme
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dempster 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
® Notified for pickup - Date
Doc:.Building permit Revised 2011 June/mi
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
a 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
o 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
DOTE: 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
roust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
The Commonwealth ofMassachusetts
Department oflnd'ustria[Accidents
Office of Investigationg
600 Washington Street
Boston, MA 02111
s+
www.massgov/tdia
Workers' Compensation Insurance Affidavit: ,Builders/Contractors/Electricians/Plumbers
�plicant Information
Name (B,
Address:
04 / Phone #:_
Are you an employer? Check the appropriate box:
1. El am a employer with
4. ElI am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheget.
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp, insurance
workers' comp, insurance.
5. El We are a corporation and its
required.]
3. ❑ I am a homeowner doing
.officers have exercised their
all work
right of exemption per MGL
myself. [No workers' comp.
c.152, § 1(4), and we have no
insurance required.] T
employees. [No workers'
comp, insurance re iced )
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demblition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbingzepairs or additions
12.0 Roofrepairs
qu 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 and their workers' comp, policy information.
lam an employer that isproviding workers' compensation insurance foYmy employees Below is tlaepolicy and job site
information.
Insurance Company
Policy # or Self -ins. Lie. #:-
ExpiratlonDate:
9 /_� _!�'
Job Site Address:j�sx�!,y All F
City/State/Zip: J�fL
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration ate).
Failure to secure coverage as required Wider 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.
Ido Itereby ti %rdlep sand enaltie er'u that the information provided abgye is trjce and correct.
p J
Official use only. Do not write in this area,
he completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing 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
ofthe 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 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 ofpublic 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 i umber(s) along with their certificate(s) of
insurance. Limited Liatility 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 pennit/license applications in any given year, need only submit one affidavit indicating current
Policy information (ifnecessary) 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 NOTrequired to complete this affidavit.
The Office of Investigations would like to thank you iu 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 Cou"' monwealfla o Ifassae isetts
Department of kdustxlal Accidents
Office of Iuvestigaf qus
600 Washington Street
BQstQ.n; MA, 02111
-- Tel. # 617,-727•-4900 ext 4406 or 1,877 MASS,AFE
Revised 5-26-'05 Fax # 617,72M74.9
t w.rnass.gQvjd!a
TRAVELERS J�
ONE TOWER SQUARE
HARTFORD, CT 06183
T1 -11S IS
WORKERS CILL
AND
EMPLOYERS LIABILITY POLICY
TYPE v INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (XAUB-3624T72-8-12)
RENEWAL OF (XHUB-3624T72-8-11)
INSURER: TRAVELERS CASUALTY AND SURETY COMPANY
1 • - NCCI CO CODE: 11223
INSURED: PRODUCER:
MARK A HOGAN & SON INC PREFERRED INS AGENCY INC
7 FORRESTER STREET 10 NEW ENGLAND BUS CTR DR
NEWBURYPORT MA 01950 STE 303
ANDOVER MA 01810
Insured is A CORPORATION
Other work places and Identification numbers are shown in the schedule(s) attached.
2. The policy period is from 01-13-12 to 01-13-13 12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 12-14-11 TP
OFFICE: NAT' L PRGM' S-ORL 715
PRODUCER: PREFERRED INS AGENCY INC
019453
00715
DIRECT BILL
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MARK A. HOGAN & SON, INC.
7 FORRESTER STREET
NEWBURYPORT, MA 01950
(978) 462-2013
NAME/ADDRESS, t
Stacey Burritt
796 Chickering Avenue
North Andover, MA 01845
❑ ADDITIONAL SHEETS ATTACHED
Proposal
DATE I PROPOSAL#
2/16/2012 181
Contractor submits this proposal for work on the property herein
described. Upon acceptance, Contractor agrees to furnish labor and
materials necessary to improve the above premises in a good,
work"manlike and substantial manner according to the terms,
specifications, provisions, prices and plans (if any).
Start and Completion: The approximate start date of
and approximate completion date of are subject. to
permissible delays as per provision (5) on the reverse side.
Owner and Contractor agreepat a deffjni b completion d7te:
❑ is of the essence Q isnot of °the essen� . r
Submitted by
'Apo%ved and Accepted (Contract r) 1' Date
Remodel existing Kitchen/Diningroom and 1/2 Bath as follows:Remove existing
cabinetry and countertops. Remove existing lino floor(not in 1/2 bath or closet).
Remove existing ceiling. Install new lighting, electrical, plumbing, heat alterations
and ventwork per attached. Remove non-bearing wall between diningroom and
Kitchen. Install new ceiling and skimcoat plaster smooth. Patch walls as needed.
Supply and install new cabinetry per plan. Install knobs if desired.(not
supplied)Install flat strip in between cabinets and ceiling. NO countertops included.
Install microwave/venthood and vent to exterior. Install stove and level. Install
dishwasher and level. Install refrigerator and level, No appliances supplied. Install 2
1/4 prefinished oak flooring and thresholds in Diningroom, Kitchen and back
hall(not.in closet). Tile 1/2 Bath floor(tile and grout not supplied). Replace wood
baseboard as needed. Dispose of debris.
Includes Permit fee allowance of $500 for carpentry, plumbing, gas work and
electrical.
No painting or staining included.
--- Materials, Labor, Plastering, Cabinetry,Plumbing, Electrical,Gas work and heating 26,725.00
per attached.
Payments to be made as follows; 1/3 upon start, 1/3 when 1/2 complete and balance
upon completion.
01
Z
5
I? This estimate may be withdrawn if not accepted within 10 days.
N Total $26,725.00
ACCEPTANCE OF PROPOSAL- Z
This proposal is approved and accepted. There are no oral agreements. The written terms, specifications, X
/14
provisions, prices and plans (if any) are the entire agreement. Changes shall be made by written change order only.pproved and Ac epte (Owner) Date
You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of
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