HomeMy WebLinkAboutBuilding Permit #203-13 - 890 DALE STREET 9/13/2012 BUILDING PERMIT of No DT bgti
TOWN OF NORTH ANDOVER 3� y�``'•- `��='•'° ��
APPLICATION FOR PLAN EXAMINATION
by '�
Permit N0:,9 0J Z3 Date Received �Rq�R4TSC�pp'`,�5
• �SSACHUS��
Date Issued: l ?�
IMPORTANT:Applicant must complete all items on this page
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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
` ?S pticWellj =xf= ' Floodplain ;}_ , Wetlands= ,; rY�' VI/atershetl Districts �F;
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•p' � +`` A ,/.',s ,,,''L' }#a� ei{ A,.s� R4. r ofC�;•(y !'4.. r',:
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DESCRIPTION OF WORK TO BE PREFORMED:
Co"veX-r- EX t$Tik9 Tfj-tee Se-45&V f�c�cc4 `fid aN� F.� ply �csc�trv�
Identification Please Type or Print Clearly)
OWNER: Name: ✓ ,,S Dul &-n -t f VrtlaO Phone:
Address: O �G I cS'� > 0�( C10vCv-
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CONTRACTORstName
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�S_upervisor's�CoristructionfLicen_se� .�_15�,73��.����.".,�' `'Exp ®ateEf� � ,l ' Z_a,13,� �� ���e�
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- A
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $��J;', ?co FEE: $ S'S3`
Check No.: (a�d Receipt No.: ��6�
T
NOTE: Persons contractin ith unregistered contractors do not have access to the guaranty fund
_9 9 a-"- Com-
Signature of,A ent/Qwn Si nature of contractor:
Location
No.� !l Date �/In �Z
• = TOWN OF NORTH ANDOVER
Certificate of Occupancy $
. ., Building/Frame Permit Fee
..: f Foundation Permit Fee $
Other Permit Fee $
:r rr:n AQP
TOTAL $
Check# ��
25703 wilding 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 Reviewed on Signature
COMMENTS
rN
HEALTH Reviewed on �-6P) .jj'!�/'j7,6;&/Aiqnature
c
COMMENTS .S
0
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
fIRE-D.E.-PARTMENT Temp Dumpster on site yes vno
tocatedAt 124;Mam'Street
,Fite Department'sgnature/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
N OTE: 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
V®TE: 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
Doe:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Enter construction cost for flee cal- North Andover Fee Calculation
Construction Cost
$ 37,900.0:0' m
$ - $ 454.80
Plumbing Fee $ 56.85
Gas Fee 100 comm. $1 100.00
Electrical Fee $ 56.85
Total fees collected $ 668.50
890 Dale Street
203-13 on 9/13/2012
Convert 3 season porch to living room
NORTF•j
Town of t : ndover
No. -
o h ver, Mass /� z
3
COC NICHEWIC.1 V
�•9 A°R�rEo �P�,��C`�
S U
BOARD OF HEALTH
Food/Kitchen
PERM :IT T LD Septic System
ti
THIS CERTIFIES THAT �� �`t/...:.............................................................................. BUILDING INSPECTOR
...... ......................
C Foundation
has permission to erect .......................... buildings on ...�7.. �..... .r... :... `f..................................
/ Rough
tery
. .. . tC•L9•to be occupied as ....... .............................. ............ .. ::�...... Chimney
provided that the person accepting this permit shall in erespect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI TARTS Rough
Service
.......... .... ..R/ .: :...:................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
11 L�Satusetts- 13e���trtment a#'Public Ssr#'eta
Board fii'Batildit�� R:��ulations acrd Standards
V
Co►istrueton`Supervisor License
License:°CS . 15730
DANIEL A DINEEN ¢'
113 WEST ST
GEORGETOWN, MA 01833
Expiration: 8/1/2013
(':nunissiuncr Tr#: 21384
Office`o/f"�on-m a�is`�c"Bi'i';ines�uu onit License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 120753 Type:- i, Office of Consumer Affairs and Business Regulation
Expiration 2!28!2014 Ltd Liability Corpo 10 Park Plaza-Suite 5170
Boston,NIA 02116
D. '. B.CONSTRUCTAOR-LLC
4
DANIEL DINEEN <,
109 SCHOOL ST SU#TE
GROVELAND,NIA 01834 Undersecretary Not valid without signature
c�
0000
o�000
CUSTOM HOMES - REMODELING Date May 18, 2012
109 School St. Suite 3
Groveland, MA 01834
Ph.978 521-7678 Fax.978 521-7670
To: For:
Sheri Ben Porch Conversion
890 Dale St.
North Andover, MA
DESCRIPTION OF WORK AMOUNT
Scope of Work:
1. Prep porch crawl space allowing for stone veneer
2. Porch floor will be same level as dining room floor, and everything
will be brought to code
3. Exterior walls will have one 6'French wood slider,,one 56x53 casement
window, two stationary windows over cabinets. (all Anderson brand)All
exterior siding and trim will match existing house
4. Interior walls and window trim will match existing house. Cabinets
provided by owner will be installed by DBDB
Interior framing will include necessary structural changes.
5. New prefinished wood floor will be installed
6. Electrical will include plugs and switches to code, allowance for 6
recessed lights
7. Heating and air conditioning will be run from main.house, no increase
to units
8. Insulation will be installed and decision on if to use spray or traditional
will be made during process of work
9. Kitchen floor will be replaced with new tile.Tile provided by owner
10. Interior painting by owner
11. All permits are included in price
12. Engenering of Frame work for porch will be done(allowance of$750)
13. All waste will be removed from site
Ar
14. Any changes to pricing will be writen on a change order form between
the owner and builder
We Propose herby to furnish material and labor—complete in accordance with above specifications,for the sum of:
$37,900
Payment to be made as follows:
Start work: $13,300
1/3 ready to sheetrock: $13,300
cabinets installed: $8,000
Finish: $3,300
This proposal may be withdrawn if not accepted within 30 days.
All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard
practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon_
written orders,and will become an extra charge over and above the estimate.All agreements,contingent upon strikes,
accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance.
Our workers are fully covered by Workman's Compensation Insurance.
Signature of builder ^ � T
� 0 $37,900
Signature of owner ` T
A
Please sign and return to accept L
// f(
Int(ktuo
bULLIVMN INbUKMNUt rax lyrH:ibbium JUI L4 LU1L IU:USam FUU1/1.11,11
THIS CERTIFICATE iS ISStlED AS A MA•1TER OF !XFO(RMAT'ON ')Eti1LY AND CONFERS NC RIG1475 11YOw THE ,^,FR'i?FiCATF iiDLD:=`:_
CERTIFICATE DOSS NOT A; FIRMATIVELY OR !VEDATNIZLY AMEND, CR Ai_T.ER y"t*r COVF.RAG-;: AFr03FJED BY THE
BELOW. TH15 CERT!NCATE OF WSU8-ANCE DOTS ;SOT -0i4ZT'1TU•'.c A •,:NTRACT INSURFR(-i),
REPRESENTATIVE OR PRODUCER,AND THF CERT;FICAT£HOLDER. _
WPORTANT: If the certificate holder is an ADDrTIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION iS WANED, sutX... to
i(he terms and condilions of the policy,cartain policies may require an erdorsernent. A sta'mmorit on ttiis certificate dces not confer rights: ti:S
certific=ate holder in lieu of svc?,endorsement(s).
PRODUCER NAME CT Pam Shepard
Bernard M. �ulllilJZ3 Tn$uranCe Agency PHONE _ (gY8?3SS-551 aC No:(9?a)355-01.4
12 Market St. E-MAIL pahepard@rulliva '.AuuranGe-cOT
P.O. Box 568 IN5URER 3 AFFOROIN;;COVERAGE NAiC/t
Ipswich MA 01938 _ INSURER A:Natianal Gra a Mutual IRS Co- 4788
INSURED w,. INSURERB:Safet =uaurance Company "9454
DBDB Corstructiou, LLC INSURERC:S H Smith Insurance Asiencz
109 School St INSURER D:
INyUREq E: I ,
Groveland MA 018341 INSURERF:
COVERAGES CERTIFICATE NUMBER'CL117 1101476 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE iNSUREO NAMED ABOVE FOR THE POLICY P--R60-3
INDICATED. NOTWIT,,4STANDING AtgY REQUIREMENT. 7ERM OR C.ONDIT;ON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO wr{I^ti T H13
CERTIFICATE MAY BE ISSUE_ OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCR!BEG HEREIN IS SI}EJECT TO ALL THE TERMS: i
EXCLUSIONS AND CONDITIONS OF SUCH,POLICIES"L W17S SHOWN MAY HAVE BEEN REDUCED aY PA!O CL AIMS. J
INSR L SUBRPOLICY EFF POLICY EXP
L-.R TYPE OF INSURANCE POLICY NUMBER /D1!1Y LIMITS
GENERAL LIAWLITY I I - I EACH OCCURRENCE $ 11 O 00,0001
l ,
DAMAGE TO RFIT
X.I GOMMERCALGENER�AAL-'LIS,EI:,;'.Y I I ; 1 t S 500,300
AI t! ( °
CLAIMS-MADE6/19/201a 18/19/2013 (X PMED EXPA.lyoiq erson) S 1 ,:C. ;
SONAL9ADV
IN,;URY 5 1,000,0001
I GENERALACGRL--GATE S 2,000,0001
GEN'L AGGREGATE LIMIT APPLIES PER: I I i PR07UC S-GCN.P,OP AGG S 2,0 00,C C O
X POLICY 1 PRO LOC
AJTOM061LE UABI1J'Y I I I COMBINED SLNG"LIMIT 1
e r. I$
ANY AUTO I I i I BODILY INJURY(PW D4:sor'; I S
lO I I JI
i IIi 1�
aoolLYlv':u ,=o;e
cc
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ALL OWNED X SCHEOJ ) 2Cs393 9/30 2011 /30/2012
AL�0.5 AUTOSNON-OtiEO PROWTOAMAG=
HIREDAVTOS 'AUTC)S 100 00
0
SC,Do mot mist ai 3!h;i,rat
UMBRELLALEACHOCCURH_NCE IS
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EXCESS LIAR ( !CLAWS-iADE! I I I AGGREGAY£ S -?
DED RET=\TION S S �M
C WORlC5RS COMPENSATIONWC STATU• X 0T H- ;
AND EMPLOYERS'LIABILITY I 'T IM _
ANY 7ROFRIETOR/FARTNr i N I EFVExt;W;;T!vt. I I E.L.EACR ACC;OEW S .500 a i:C'
OFFICERIMEMBER EXCLUDc7? I N'A 0110/20111:.3/le/a01a
(Mandatory in NH) I I 000538.227
4 c.L t71SEASe.EA EMPLOYE & DG,0 001
I'ye8.aeswoe UnOB" ' 1
DESCRIPTION OF OPERATIONS nalaw I I i I EPOLICY LIMIT S Soo,0 0 0)
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DESCRIPTION OF OPERATIONS f LOCATIONS i VEHICLES(Attr`t ACORD tot.Addi6on8l Remafita 9eheU:ita,If more space 4,equired) ;
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t
1
CERTIFICATE HOLDER CANCELLATION 1
(979)521-7670 SHOULD ANY OF THE ABOVE DESCRIBED PO:,ICIF5 BE CANCELLED BEF;;RF-.
THE EXP(RAT(ON PATE THEREOF, NOTICE WILL BE DFLIVEf%l) IN
ACCORDANCE WITH THE POLICY PROVISIONS. '•
Town of North Andover !
120 Main Street _.�..
North Andover. ri-A 01845 AUTHORgED REPRESENTATIVE ;
I
I
I l ;
17 Lexis: Acct- Exec
r
ACORD 25(2010105) 0 1988.2010 ACORD CORPORATION. All rights rv,,st:rvtc.
INS025(209005).01 The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le0bly
Name (Business/Organization/Individual): i7 Co N .c r-i w L LC
Address: t o � S-, lti,_a I S�
City/State/Zip: G,,_a,re 1-4Nv�, 04a- 6I83/ Phone#: 9 ?8- rz I- 74,7 �?
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
91nployees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet.$ E]Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.F1 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work 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 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 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 Name: _✓A_n v.✓w-L- C��-►�e ty►H r-HpgG
Policy#or Self-ins.Lic.#: W c- 6 Ci:3 8 z z 7 Expiration Date: 10•- 10- 1 Z
Job Site Address: PFO D A1C 5'/- City/State/Zip: Wow v4-.-zYo v« kO-f
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Sienature• c,�--S�Z G-� �v-��-- Date: 1 3- 1 Z-
Phone# 78- 6-Z) - 7 7
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 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-contractor(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 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 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. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www,mass.gov/dia