HomeMy WebLinkAboutBuilding Permit # 6/28/2016 OORTH
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
�
o A0.
Permit NoM H Date Received $ 01?Are CS
H
o
6
Date Issued: /b
�
J1V is
EVORTANT: Applicant must complete all items On this page
LOCATION
Print
PROPERTY OWNER Ok PrirA 100 Year Structure _ye no
MAP 0,W1 PARCEL. ZONING DISTRICT:—Historic District yes no
Machine Shop Village no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
Ei New Building Rr70_ne family 11 Industrial
ri(Addition El Two or more family
[I Alteration No. of units: Ei Commercial
Ei Repair, replacement El Assessory Bldg El Others:
o Demolition ❑Li Other
2 Or ILI
71iIYI),Ai!e ((1, 1 i
re UN RINI
HIT
err ,c IN
DESCRIPTION OF WOR TO BE PERFORMED:
(Z & K Zjr hl,"
ht- rezvic-, zl�,4,z ti-
Identi cation - Please Type or Print Clearly Phone:
OWNER: Name: 6 C(7)6�k,�(_)
Address: VJ 1F I to'I I C,1_
Contractpr Name: 'c e cC U JQ Phone:
Email: 15
Address:
o
Supervisor's Construction License 's
Exp. Date:
93
..............
Home Improvement License: 16 ?6$615— Exp. Date: a.
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Pr I ojeGt Cost: $ FEE: $ IM-r-
9,
Check No.: P 6) 6 9 Receipt No.: 7
NOTE: Persons contracting with unregistered cantNactoasto the,guaranty fand
W
R iu
Plans Submitted ❑ Plans Waived El' Ceilified Plot Plan ❑ Stamped Plans ❑
FTYPE OF SEWERAGE DISPOSAL
Sew,
_r
Public Sewer Tanning/Massage/Body Art 0 Swimming Pools 11
11
wen ❑ Tobacco Sales ❑ Food Packaging/Sales El
Private(septic tank, etc. El Permanent Durupster on Site F1
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING DEVELOPMENT Reviewed On6''JJIASignature—��(
COMMENTS J)A "k
CONSERVATION Reviewed on-
Signature"'
COMM ENTSAL..
HEALTH Reviewed on, Signature,
COMMENTS �-- �:)")JA
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection
DPW Town Engineer: Signature:
Located 384 Osgood Street
'DE
0,T -E--' t
I R
,,,Jr a
oddteQat&1,,
U
I�Ilel
9
C, 01
tkORTPI
Town of
ndover
0
No. "M
J!AL�!���2_61
e � ver, 3
ATFD
BOARD OF HEALTH
Food/Kitchen
PERIT T LD Septic System
THIS CERTIFIES THAT ........... BUILDING INSPECTOR
has permission to erect .......................... buildingson . . ... � . .............
.. Foundation
. . . ... ....... : . .......................
g Rough
tobe occupied as ........ .. ......... ....7 ............... ............................................................. chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final
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 06 MONTHS ELECTRICAL INSPECTOR
UNLESS
Rough
Service
5W4BUI
. .......INSPE ®R Final y
CCAS INSPECTOR
Rough
PremisesDisplay in a Conspicuous Place on the Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building H Burner
Street No.
Smoke Det.
NORTry 9
6.6 p(j
Town ®f North Andoverx
Machine 51rap Village Neighborhood Conservation District Commission
C AxHUSE 1600 Osgood Street Nord Andover, MA 01845
SA
Certificate to Alter
Date: ".
Contact Name&Address:
,11=lt
Protect Address:
Project Description (attach additional pages,if needed):
t' IJ QJ�� �� �' �,� t.." � �• , �°,t �rw".� u;� - ' �rf' yrs
Jstti (C
w,
"AA
. ��. �� � �.:�:� � �.rc .
Commission Vote:
f" i
Vated __
_ _to to rcrrrt/denY Cer-tr rcate, to Alter on
Comments (attach additional pages,if needed):
mgr
Signed:
Machne Shop Village Neighborhood Conservation District Cor?missioll
MSV NCDC Page _
Page No. of Pages
of : <: s
�< <
-
itO
a
PROPOSALSUBMITTEDTO PHONE DATE
f .SOB NAME
STREET -
kZ 41 42
Y,STATE and`ZIP CODE r JOB LOCATION
A CHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
...---�.�.�• �.?E�;<�-y.......tr::... �p_�. F..�t:=��.._: f .t,...;:br..�f .......,,f.�` �`�.�.}.L'�_..�-....._.�.�.�! .l...I./-C.i�`.�t°,:_ rI_/..,:�....:.F.c.:�,f��_ ....�...���..dk��1.���'1..-:�.
4c.,_..s�_-t...] �� ��i VA- f'{ -' 1- � C.f C.G.-1- :.........1°.1�i.� �..1'...1_..�.""`�.G-.- �' ,. �. �,.......
71
........_ �I :�f ... a:. � -6.._......... --f � - ��+''3`F '�.L.�'..._� / tv ..J.?.?� � L.r:....f..��Y�.! i.''.E..t� -... f.e 59.
-.--
#L'`Cf-`• :...<?.,,:.,. (�:`.f�iEti=.............
.......
j------ R ry as 1 r. t� '?n:.lt;1 a '� k � T t .ry /1 {f -- f =-{; 1.-.-......................
.._t...��t,<..,.�....1,..1x.L.=�./�rC�-•......_.�i�r...,�,�....y......[��'�,��°`��u�,._:.�__�-L..,t' <;�.��:... d. �:�..�'�_ �r.`:.:,..,:���-.._....fG—,r`.1....... .1..
_.�:C�l�l_!:: ...`3�✓.F�1�- �=��:��f_,`� .��:�-r�,-•� ,.....r�1x12...�;�Jr�.�.:,f���`t fes'... ,;:.�...<��'1_r.';)..-.�_1...._� ..h'�L_ <::s�t...:.. :r.: :�I.."�d...,�
tr-7..e1:. ._. ......._...r�F�.'.'-/: .-.. .:..JE..:fz...._F<.'._ff':i,... .::T:... .L..s..... .c, ... .._..._L....glZ. :.;,r.,.:.,._[....... ..-„ •�F_c..: d' =.._.l*:;F.,fr5 -✓:���..._..._......
t.. !.. _. �zF
} y
f
Zif;
Hit Propa gg hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
dollars($ y�
17—
Payment to be made as follows: ✓ �• �d _
""i •! �-f !.r � '1 �'"� .�! .J l L! :..A "" >'r � � Gr_. -tri_" 7�-
6,7
All material is guaranteed to be as specified.All work to be completed in a workmanlike j
manner according to standard practices Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders,and will become an extra Signature ; f f t. f.
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. Note:This proposal may be
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
rreptaure ®f proposal —The above prices,specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature
yA
KI
(AROA
- : .
�►
A.
sc
10
To P,
► �,, t4y
TH AN40 V��: ? N09 7 it-
oh!I N� �,i.�.M;/,IArJ��� A'l��`�►� J`,l')fR 12 � 1.`l I�1
i 'A� �� �,�s�y ���_�,7 w��..�-Y cry
w ey A�'! D
` y�dtd_t,Anh 4 P/ �Z
JAMES
BA Y 67 A TA
ti �o Rat3E}2Y `4
Encs4. •�
�o s ,
T,:
0
lzcc7c Cie Inspecctol,
w4 : NA e e c locatfom of-ProPertn N. Aw over
NOTE- Rightof Waf
not shower.
Wilte
46.0 , , _
g% 94.5s-deed
`' Pore
PW_P ' tZ
� m
Zot 13 2 sto rt��welhny dot 11
LO
4s.7s _
Lot configuration is
lOt /7 10C 18 based on assessor's
information and may
not be ex
re 3049.103 900d pamf, 25o0g8 00o3 G �ood orrrw; 11A OF
°F a,,ss9
e o
�7 PAUL! yN
.�Jj�heY'eEy C�`r�l�y estrus mortgage ifnspeenon was_pm ra -f or� GROVER
RX0r4 d Jahtos c�AmeY1can (Resihntla/' No 3131
Tv, dwel rtq shower, herein,does not <faU im cL ca F - Ooh
hazar& at�ac wtit am e{�'ective date of 6 -z 93 and the locahbnl o
the dwellit4�yOeS rcon{cfrm rro rte loea.lgonirtg 6y-l.aws
atthei`tnw 0Fcomtmction writ respeato horiioatcd, dimnr (Ona . r
setback1'eG�Lt�lt'('.t11Z is or is ever"l�r-g-orm vtblahOm en-ForCer un't ' Scale: =30
Date: 5-9,94
oz on, under )Aass. General Ccws ChaptW4-02.•5ect't"oyv'7. File No. 11 6594
PLEASE NOTE: The structures as shown on this plot plan are approximate only. An actual survey is necessary for a precise
determination of the building location and encroachments, if any exist, either Way across property lines. This plan must not be
used for recording purposes or for use in preparing deed descriptions and must not be used for variance or building plan
purposes. This plan must not be used to locate property lines. Verification of building locations, property line dimensions, fences
or lot configuration can only be accomplished by an accurate instrument survey which may reflect different information than what
is shown hereon. Please note that this is "NOT A BOUNDARY SURVEY" and is "FOR MORTGAGE PURPOSES ONLY".
LQNIA� LAND SURVEYI G COMPANY, II`�C.
269 Hanover Street Hanover, Mass. 02339 - Phone: 617-826-7186 • Fax: 617-826-4823
SPILLER'S 566207
The Commonwealth ofmassachusetts
Department of Industr"ialAccidents
X Congress Street,Suite 100
Boston,HA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Cont:tactors/Electricians/Plumbers.
TO BE FILED WITH THG PERMITTING AUTHORITY.
AA,Pplicant Information /� Please Print Legibly
NaMO(Business/Organization&dividu (�
al): —/ i �✓y
Address: 44,!�- C (c )4-�,o
City/State/Zip: �`�c' C /�'� 1-1,A Phone#1`: y�C� 0 D� 6 c/ f� U
r!reyou an employer?Clreckfi e appropriate box: 'Type of project()Vequired):
L[a<n a employer with •C... t employees(full and/orpart-time).* 7. [l New consh action
2.0 I am a sole proprietor or partnership and have no employees wonting forme in 8. [I Remo delhig
any capacity.[No workers'comp.insurance required]
3.0 I am a homeowner doing all work myself[No workers'comp..insuranco required.]t 9. 0 Demolition
4.❑lam a homeowner and will be hiring contractors to conduct all work on my property. 1-will 10 [A-Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the#ached sheet. 13.�Roof repairs
These sub-contractors have employees and have workers'cow.insruance.
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14••0 Other
152,§1(4),and we have na-etnployees.[No workers'comp.insurance required.]
i£:- _ ..
'Any applicant that checks B6x#1 must also fill out the section below showing their workers'compensation policy information.
.Homeowners who submit#his 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. Ifthe sub-con`tracfors have employees,they must provide their wor'fers'eomp.poli number.
X am an employer that ispfovidlhg ivorkc rs'compensation Insurance for my employees.•.below is'the policy andjob site
information.
Insurance Company Name:
Policy#or Self ins,Lic.#: Expiration Date:
rob Site Address: City/State/Zip:
Attach a coley of the worlrers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL o. 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.
X do hereby cert' unde, ze a_ndpenalties ofperjary that the information provided above is true and correct.
Si nature Date: o�
Phone#: rO c2-6 X— ,2(5—q
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 4:
CLASS-1 OP ID: MI
CERTIFICATE OF LIA ILI'TY INSU NCE PATE(MM/DDIYYYY)
11111[ 06/02/2016
% 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
`RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
h.-PORTANT. 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 Ileo of such endorsement(s).
PRODUCER CONT
NAME: Chas.F. Hartshorne&Son Inc
Chas.F.Hartshorne PHONE
PAX
3 Chestnut St. IA10.No,Ertl:781-245-4300
Wakefield,MA 01880 E-MAIL (ALC,Ne:T81-246-5810
Chas.F.Hartshorne&Son,Inc ADDRESS:
INSURERIS)AFFORDING COVERAGE MAIC II
INSURERA:NGIVI lnsuranco Compan 14788
wsUREO Classic Construction Co Inc INSURER e:Associated Industries of MA
Michael Robidoux
456 Glendal Rd INSURER C-
Boxford, MA 01921 INSURPR D;
INSURER E:
INSURER F.,
COVERAGES CERTIFICATE NUMBER: 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 AUULISUHN
LTR TYPE OF INSURANCE FF POLI
IND POLICY NUMBER MMIDD/YYYY MMIDD Y Y LIMITS
A X GOMMERGIALOUNERALLIABILITY EACH OCCURRENCE $ 110001001
CLAIMS MADE P�] OCCUR MPJ41041 06/25/2015 06/25/2016 pA dISES Ea occurrence $ 500100(
X Business Owners MPJ41041 06/26/2016 08/25/2017 MED EXP(ft one person) $ 10,001
PERSONAL&ADV INJURY S 1,000,001
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,001
JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,OOI
POLICY E]
ROTHER: £
AUTOMOBILE LIABILITY OMBI ED BINGLE LIMIT $
e accident
ANY AUTO BODILY INJURY(Per perso n) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident)AUTOS AUTOS ) $
HIRED AUTOS NOWOWNED 'ROPE RTY $
AUTOS P rsccldent
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS DAD CLAIMS-MADE AGGREGATE 3
DED RETENTION 3 $
WORKERS COfAPI3NSATIONPER
AND EMPLOYERS'LIABILITY t3TATUTE ER
B ANY PROPRIETORIPARTNERIEYECUTIVE YIN AW0700705001202 09/17/2015 09/17/2016 E,L,EACH ACCIDENT $ 100,00(
OFFICERIMEMBER EXCLUDED? F N/A
(Mandatory In N)4) E.L.DISEASE-EA EMPLOYEE $ 100,00(
If YYes dcscriba under 500 00(
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ ,
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEfIICLR8 (ACORD 101,Additional Remarka$chadufe,may be attached if more spaco Is rvqulre4)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Andover ACCORDANCE WITH THE POLICY PROVISIONS.
AUTItORIZM REPRESENTATIVE
Chas.F. Hartshorne&Son,Inc
®1988-2014 ACORD CORPORATION. All rights reserved.
i
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
&Xe vas l'),no uuealtX a�,'P/h�a scce�r%teCf'.
Office of Consumer Affairs&Busibess Regulation
OME IMPROVEMENT CONTRACTOR
registration: 107835 Type:
g expiration:--8/7/2016 DBA
CLASSIC CONSTRUCTION CO.
i
Michael Robidoux
27A BAYNS HILL RD
BOXFORD, MA 01921 Undersecretary
LWIV040 iauolsslwwoo
uoi}ealdx-
IZ610 VW Ps03gO*1 �
3 "OR 318PU319 fist
� OQ�g02I2I'I�'H�IIAI i
E%090-VJS:) .asu901-1
�rrmc+s ni snc: t�rinc nnrpn r1qui-
a �p,npuL;S Pue suo:+LlnEad Bauippng jo pima
A1ajeS ollgnd.lo juaw1jecla0- s}}asngoesselN