HomeMy WebLinkAboutBuilding Permit #544-2016 - 940 JOHNSON STREET 11/2/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
iAPPLICATION FOR PLAN EXAMINATION
Permit No#: `� Date Received
Date Issued:
/ I]1 P011TANT: Applicant must complete all items on this page
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LOCATION gyri JehtiSeJn ef
Print /
PROPERTY OWNER��/Cts
Print 100 Year. Structure yes _ no
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MAP 101 PARCEL: C3aGl1 ZONING DISTRICT: Historic District yes no
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
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
PTION OF WORK TO BE PERFORMED:
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OWNER: Name:
Address:
Contractor Name:
Email:
Address: yrs,
Identification - Please Typq or Print Clearly
Phone:
Supervisor's Construction Licenser C = dj�'djeX,47 Exp
Home Improvement License: --5 C9 Exp
Date:a/��// G�
Date:
ARCHITECT/ENGINEER Ay/t Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $/12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00•PER S.F.
Total Project Cost: $ <, v2 PO. ---- FEE: $ L
Check No.:
1-4-30 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
re of(Aaent7Owner /1/.4., / %51,lid7':a4 Sianature of contractor
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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
Reviewed On
Signature
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
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
DPW Town Engineer: Signature:
Locatea Jb4 usgooa Street
FIRE DEPARTMENT Temp Dumpster on site;
Located at 124'Main Street
Fire 00 -Part' entsignature/date
MME
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 Call Email
Date Time Contact Name 3
Doc.Building Pennit Revised 2014
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
a Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
• 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
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Cross Section/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)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
a Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
VOTE: 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: Building Permit Revised 2014
Location 9 `'Co 1U��JS u
No. ".J -W —7,0 �, Date } 1 1
Check #1 Q6
TOWN OF NORTH ANDOVER
r
Certificate of Occupancy $
Building/Frame Permit Fee $ a
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
NORTH SHORE BUILDING SERVICES LLC
1 Westward Circle
North Reading, MA 01864
1-800-564-4016
Licensed: CS -060149, HIC-165538, RRP Lead Certified
PROPOSAL
September 25, 2015
*Revised October 18, 2015 per Arnica Mutual Insurance Company's Report
Steven Diamond
940 Johnson Street
North Andover, MA 01845
Email: sdiamond89@aoi.com
We hereby submit specifications and estimate for:
Finished Basement
SCOPE OF WORK
• Check exiting framing and interior partitions.
• Frame in opening on stairs.
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• Insulate to Massachusetts code.
• Install fire rated insulation in furnace room.
• Install %" blue board on walls and skim coat plaster; smooth finish.
• Install existing doors, trim and baseboard.
• Install new doors, trim and baseboard where needed.
• Apply two finish coats of paint on ceilings, walls, trim baseboard and doors.
• Install existing toilet, washer and dryer.
• Install existing baseboard heat covers.
• Install laminate flooring on floor ($3.50 per sq. ft. allowance for material).
• Contractor to obtain all necessary permits.
• Contractor to dispose of all debris.
BATHROOM
• Repair water damaged sheetrock.
• Skim coat to match existing finish.
• Apply two coats of paint on ceiling and walls.
We hereby propose all materials and labor—complete in accordance with the above specifications, for
the sum of: $21,290.00 Twenty One Thousand Two Hundred Ninety Dollars
Payment to be made as follows:
1. 1/3 upon acceptance of proposal.
2. 1/3 at midpoint.
3. 1/3 upon job completion.
Acceptance of proposal —The above prices, specifications, and conditions are satisfactory and hereby
accepted. You are authorized to do the work as specified. Payment will be made as outlined above.
Date of acceptance: /0_ 2 -7 /5
,��ak'd
(Custom61
er's Signature)
/,feontractor's Signature)
All work is 100% guaranteed for one year on all craftsmanship. All other warrantees are through the
manufacturer. All warrantees will be null and void if job is not paid in full.
Thank you for letting us serve you!
North Shore Building Services LLC
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The Commonwealth of Massachusetts
z . Department oflndustrialAccidents
- d 1 Congress Street, Suite 100
Boston, AL4 02114--2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAHTTING AUTHORITY.
Name (Business/Organization/Individual):
Address:
City/State/Zip:O. /C�GcI•
Are you an employer? Check the appropriate box:'
Phone #:
LE] I am.a. employer with . employees (full and/or part-time).*
2. Q I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5Z I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.#
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no. employees. [No workers' comp. insurance required.]
Type of project (required):
7. 0 New construction
8. Remodeling
9. Demolition
10 F] Building addition
11. [J Electrical repairs or additions
12. (] Plumbing repairs or additions
13.0 Roof repairs
14. [J Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
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, &y' must provide their workers' comp. policy number.
X 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. Lie. 9:�aJi�%Bv��.4CG�.�%s Expiration Date:
Job Site Address: ✓a!'��.�Ci� �T/L� i City/State/Zip:�
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance
coverage verification.
Z do hereby certify /under the ains/afnd penalties ofperjury that the information provided%abovee is true and correct.
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 #:
v
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. Anew 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
ACORO® CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
10/27/2015
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 holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME: Nicole OrlanZo
BYETTE INSURANCE AGENCY INC.
A/cCNa Ext: (978) 851-6678 FAX
No):
E-MAIL --�—
ADDRESS: nicole@akfowlerins.com
INSURER(S) AFFORDING COVERAGE NAIC #
200 Park St.
INSURER A: ACE AMERICAN INSURANCE CO 22667
North Reading MA 01864
INSURED
INSURER 8:
BARBAGALLO PETER DBA NORTH SHORE BUILDING SERVICES
INSURER C:
INSURER D:
PO BOX 663
INSURER E:
1 INSURER F:
NORTH READING MA 01864
COVERAGES CERTIFICATE NUMBER: 8046 REVISION NUMBER:
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 MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL,SUBR
I D
D
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/Y
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
EACH OCCURRENCE $
DAMAGE TO RENTED
PREMISES Ea occurrence $
MED EXP (Any one person) $
_
PERSONAL & ADV INJURY $
N/A
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY D PRO-
JECT LOC
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
$
OTHER:
AUTOMOBILE
--
LIABILITY
COMBINED SINGLE LIMIT $
Ea accident
_
BODILY INJURY (Per person) $
ANY AUTO
_
ALL OWNED SCHEDULED
AUTOS AUTOS
N/A
BODILY INJURY Per accident $
( )
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE
Per accident $
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
N/A
DED I I RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?NIA
(Mandatory in NH)
If yes, describe under
NIA
NIA
6S62UB2E30048515
07/02/2015
07/02/2016
/� STATUTE EOH
R--
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEE $ 100,000
—
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
N/A
i
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to
employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this
certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at
www.mass.gov/lwd/workers-compensation/investigations/.
Sole proprietor has not elected coverage.
l.filY I.CLLA I IUIY
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
1600 Osgood St.
AUTHORIZED REPRESENTATIVE
�t
North Andover MA 01845 "�' { '
Daniel M. Cro{aey, CPCU, Vice President—Residual Market—WCRIBMA
U 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
lug Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Cdlltra+ctor Registration
...:. .Registration: 165538
r Type: Corporation
Tr# 248873
Expiration: 3!112016
C.J. & B CONSTRUCTION CORP �._..__..,;..::..:.... ;
PETER BARBAGALLO '
1 WESTWARD CIRCLE
NO.READING, MA 01864 �r '
,,
��''�n��K ";'Updste Address and return card. Mark reason for change.
Address Renewal L]Employment ❑ L W Cwd
SCA 1 0 20M-05111
ammroozu�e o�P°acr��`aeCta License or registration valid for individul use only
off, of Consumer Affairs &Business Regotation before the expiration date. If found return to:
ME IMPROVEMENT CONTRACTOR TypeOffice of Consumer Affairs and Business Regulation
istration: ;15538 ' 10 Park Plaza - Suite 5170
xpiration ,3111201 ,; Corporation Boston, MA 02116
C.J. & B CONSTRUCT-
PETER
ONSTRUCTPETER BARBAGALLb `4 '
1 WESTWARD
NO.READING, MA 01864 Undersecretary
Not valid without signature
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Super%ilsor
License: CS -060149
PETER J BARBAgWL ;�'
1 WESTWARD CIR it
N READING MA%018
y'a ,
Expiration
Commissioner 10/31/2016