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HomeMy WebLinkAboutBuilding Permit #255-12 - 1 FAULKNER ROAD 9/26/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: vl�, /2-- Date Received Date Issued: I ORTANT:Applicant must co m lete all items on this page LOCATION ��"��y/ e e Print PROPERTY OWNER Unit# Print MAP NO:�VARCEL:_�ONING DISTRICT: Historic District yes Q/ 5-37r Machine Shop Village yes 100 year-old structure yes 6 TYPE OF IMPROVEMENT PROPOSED USE Resiogptial Non- Residential ❑ New Building he family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ISeptic. Well UFloodphain, ©Wetlands; M• Watershed►District 'Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: (Identiocation Please Type or Print Clearly) OWNER: Name: one: Address: to1 CONTRACTOR Name: �e / � _ � tzlez lPkone: 9 Address: Supervisor's Construction License: Exp. Date: C Home Improvement License: /P A�O e7l Exp. Dater ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING P :$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: 49, g��� oo FEE: $ /C1 Check No.: / elpig Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund fQ.irr rY.�+ ire:;f Anion+/(l%einor� - - Rinriati ira rif r'_ni 7 . Location Gy No. ';2`r'- 1Z Datee 4X' MORTq TOWN OF NORTH ANDOVER 3 F w A } Certificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 24618 461Q uilding 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 HEALTH Reviewed on Signature COMMENTS I Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning tanning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no 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 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 ❑ 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 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 nust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi AORTH Town of No. - _ - - M dover, Mass.,- 0 COC MIC EWICK Ids RATED C.) 1 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System /J BUILDING INSPECTOR THISCERTIFIES THAT...../d�•'•'�...........................................................................�.............. ........,....................... Foundarion has permission to erect........................................ buildings on ../../ �C'// '�� ..................................................................................... Rough to be occupied as.... �,'r.,�J.... ......�"i.�?.. �pC�' Chimney provided that the person accepting this perrill shall in every respect conform to the terms of the application on file in Final 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 CONSTRUCTION STARTS Rough ......................... ................. .....�. ............................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. 'onfa t�� Tom Quinn ,,,�t" v Employer ID # (978) 265.2390 QUINN'S CONSTRUCTION 868 Mammoth Road - Dracut, Massachusetts 01826 Name Date Street Address(NoZft�sst�lfi7 Boxx) -4 Job Name City/Town, State&Zipcode �, Nv / Job Location �� J �; ,4,-IVCk) Da me Phone: Evening Phone: / Job Phone Mailing address(if different from above) Salesperson(s): Contractor Registration#: Exp. Date: We hereby submit specifications and estimates for: /v ii �� % •� �'` �' C r) c/ � % fr �✓S i i � i/r r�G� �./'r C,�" f-�,��i"'y,-�t-i.�-' iz�.�t.' �>>^9Ci a/i''�J ')�_.� i -�'�11,7 C C-../ G.i a'7 /•� ��/'G.J /��i�... .-7f"�( � ��`..� p"""� a, /-�%/i i✓ G /��/—J>>ic✓%�/!ir'ai�' '� C t'i/�/�N G�r_'.. 1r H-t.. J �i/`�, '' r c_.//✓ ( .' /✓ t/ f"`/��/iH" /. ? �, .rrii/ �/� �'� / c.� '�.�-moi/ G/' � � r e-, �r✓Sig .� /�' The following scheduled will be adhered to unless circumstan s beyond the contractor's control arise: Work scheduled to begin: /J��'r'' �> ''�✓ pected Date of Completion / // /i/ (Date Contractor Will Be Contracted Work) (Date hen Contracted Work Will Be Sustantially Completed) TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE THE CONTRACTOR A R ES TO PERFORM THE WORK, FURNISH THE MATERIALAND LABOR SPECIFIED ABOVE FOR THE SUM OF: $ *includes all finance charges in this amount* N_ents will be made accordin to the following SCHEDULE: upon signing contract (*Not to exceed 1/3 of the total contract price OR the cost of special order items, whichever is greater*). $ By_/ /_or upon completion of $ By or upon completion of _---------------------------------------------------------------------- ---------------------------------------------------------------------- $ �i/���icJCr' upon completion of the contract(*Law forbids demanding full payment until contract is completed to both parties'satisfaction zz- in order to meet the completion schedule,the following material/equipment must be special ordered before the contracted work begins.(*Law requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contractor price or(b) the actual cost of any special equipment or custom made material which must be ordered in advance to meet the completion schedule*): $ to be paid for DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies f thec c sh u�1go to�the �omeowner and the contractor Home Owners Signatur ( elatop0-yDate: Contractors Signature: "j '--- Date: You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of the agreement. 'rom:Bonnie Welch FaxID:9784549343 Page 1 of 1 Date:5f26f2011 12:16 PM Page:1 of 1 OP ID: BW CERTIFICATE OF LIABILITY INSURANCE r DATE0(,MIDDIY '"Y' 0511261126111 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 CONTACT PRODUCER 978459-8681 NAME: Francis Provencher Insurance 978454-9343 PHOFAX Agency, Inc. E-MAILNE Ext: A1C,No): 530 Rogers Street PRODUCER Lowell,MA 01852 CUSTOMERIDr.QUINNA INSURER(S)AFFORDING COVERAGE NAIC# INSURED Quinn's Construction INSURERA:Endurance American Specialty 868 Mammoth Rd. INSURERS:Commerce Insurance Company 34754 Dracut,MA 01826 INSURER C INSURER 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUB POLICY EFF r01113/12 LTR INSR WVD POLICY NUMBER MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY C.BC10000052400 01/13/11 AE o 50 000 PREMISES Ea occurrence $ , CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY 1E El LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea acadent) B ANY AUTO SBGS68 05/07111 05107/12 BODILY INJURY(Per person) $ 2550,000 ALL OWNED AUTOS BODILY INJURY(Per accident) $ 500,000 X SCHEDULEDAUTOS PROPERTY DAMAGE $ 250,000 X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) "CERTIFICATE FOR WORKERS'COMP COVERAGE WILL BE ISSUED DIRECTLY FROM THE COMPANY WITHIN 2 BUSINESS DAYS— CERTIFICATE HOLDER CANCELLATION LOWE001 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD t The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,ALL 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):—o _� z Address: City/State/Zip -6=hone Anpu an employer?Check thaiTpropriate box: _ 1.8!!! I am a emOPith-1 4. g F roject(required): ❑ I am a general contractor]dI employeed/or part-time).* have hired the sub-contraw construction 2.❑ I am a sole proprietor or partner- listed on the attached shemodelingship and have no employees These sub-contractors haolitionworking for me in any capacity. workers'comp.insurance[No workers com .insurance 5. ding addition' p ❑ We are a corporation and required.] officers have exercised thtrical repairs or additions 3.❑ I 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 insurance required.]t employees.[No workers' 12, 00frepairs comp,insurance required.] 1311 Other Any applicant that checks box#I 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. I am an employer that is providing workers'compensation insurance for my employees. Below is tlae policy and job site information. Insurance Company Name: 00, Policy#or Self-ins.Lie.M l / �in-v .Ql6'(� � Expiration Date: . � /Z � Job Site // G Address / Y-��/�kjc��iQ City/Stateip: y�-,�.� �� 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 Df 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. ado hereby certify under tlzepains andpenalties ofgerjury that the information provided above is rue an 1 correct. 'i nature: ( Date: 1C/� :hone 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector _ 6. Other Contact Person: �. RightFax C2-1 5/27/2011 7 : 55 : 23 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF LIABILITY INSURANCE 05127/2011 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX FT,kNCIS E PROVEN(I IER INS (A/C,No,Ext): FAX 530 ROGERS STRIE'T (A/C,No): E-MAIL ADDRESS: PRODUCER LOWELL MA 01852 CUSTOMER ID 9. 26F9 C. INSURER(S)AFFORDING COVERAGE NAIC It INSURED INSURER A: HARTFORD CROUP NSURER B: QUINN THOMASINSURER C: INSURER D: 868 MAMMOTH RD INSURER E: DRIAW 1',MA 01526 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 ADDLSUBR POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE POLICY NUMBER (MM\DO\YYYY) (MM,OD\YYYY) LIMITS GENERAL LIABILITY INSR WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS MADE OCCUR. DAMAGE TO RENTED $ PREMISES(Ea occurrence) MED EXP(Any one person) $ GENT AGGREGATE LIMIT APPLIES PER: PERSONAL&&ADV INJURY $ GENERAL AGGREGATE S POLICY PROJECT LOC PRODUCTS-COMP/OP AGG S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE S ALL OWNED AUTOS LIMIT(Ea accident) SCHEDULE AUTOS BODILY INJURY $ HIRED AUTOS (Per person) BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE $ DEDUCTIBLE AGGREGATE S RETENTION S $ 5 WORKER'S COMPENSATION AND WC S"IAIUTORYLIMITS OTHER EMPLOYER'S LIABILITY Y/N Ue-4116P701-I1 01/15/2011 01/15/2012 E.L.EACH ACCIDENT ANY PROPERII"ORiPARTNEREXSCUTIVE Y $ 100,000 OFFICER/MFt4AF-RFXCI IIDFD? E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory in NH) 11 yes.des:dt,andel E.L.DISEASE POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERAT[ONS/LO CATIONStVEHICLES/RESTRICTIONSiSPECIAL ITEMS THIS RL•PLACIS A,,IY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDFR AFFTCTING WORKERS COiv1Y Cc iVi RAc I:. TIIE Hrom:RS'CONIPFtiSATION POLICY DOES NOT PROVIDE COVERAGE FOR QLTI\TI TIIONIAS. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2009/09) Raniani Ayer 1988-2009 ACORD CORPORATION_ All rights reserved. Alte _66""NVMV" Office of Consumer Affairs and usiness Regulation 1.0 Park Plaza- Suite 5170 Boston,.1VMassachusetts 02.116 Home Improvement'O tj ctor Registration �— -- Registration: 121.604 Type: Individual m• Expiration: 5/24/2012 Tr# 293905 QUINN'S CONSTRUCTION THOMAS QUINN 868 MAMMOTH RD. DRACUT, MA 01826 Update Address and return card.Mark reason for change. ❑ Address ❑ Renewal Employment Lost Card DPS-CA1 u 50MAW04-G61101216p ,q ✓/xe L7p7sLlYtancaP.CLLUG O�✓I�GGQJC>�ILctQP�6 Officeof Consamer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date: 'If found return to: Re stratloOffice of.Consumer Affairs and Business(Regulation 9 421604 2412012, Tr# 293905 IO Park Plaza Suite 5170: ExpiratLo Boston,MA:02.116 Typet Iodlvldual QUINN'S CONST Th THOMAS QUINN r 868 MAMMOTH Rbc-7� ,�'� , DRACUT MA 01826 -� Undersecretary Not valid without signature j Nlas achusetts Deltarupenf of Public Safety + Restricted to: 00 a Board of Bur(ilin�� Renul�tfi.on, fad St.u►dal Construction Supervisor License 00- Unrestricted License: CS 39732 1G-1 2 Family Homes zi Restt�icted to: 00. ..- THOMAS.I ':QU1NN s: Failure to possess a current edition of the 868 MAMMOtH RD 7 3 f ! Massachusetts State Building.Code DRACl1T,M4,01,826 is cause for revocation of this license. � Refer to: WWW.Mass.Gov/DPS Expiration: 31-2512012 ('omni: i<,acr Tr#: 18330