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HomeMy WebLinkAboutBuilding Permit #881-14 - 10 PEACH TREE LANE 6/5/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: %I I� Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATICOIV rte.�,, 7 JAS . ' nt. PROPERTY WINNER_ -: _ -.--- _ 1:00°Year Old Structure ' yes no MAP NQ: V,_t PARCEL _ r_.. ZONING DISTRICT: ,Historic District yes no, Machine Shop Village yes no A_ TYPE OF IMPROVEMENT, PROPOSED USE Residential Non- Residential ❑ New Building 14-One family ❑Addition ❑Two or more family ❑ Industrial YAIteration No. of units: ❑ Commercial 0 Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septics 0 Well Ej Floodplain Q Wetlands. 0 Watershed District ❑Water/Sewer p DESCRIPTION OF WORK TO BE PERFOR ED: �Oof � �LJ eI�`� (Y- �� /� � fr!/ ` Q Are 9� 4> &,.? Ident' ica ion lease Type or Print Clearly) OWNER: Name: ,�� f� ��1�1 =. Phone: X2-1 Address: /0 .L CONTRACTOR' NamePhone:._ Add' ess' Supervisors Construction License flfvSRZQ_ -.Exp. Date:­/7-)J /> Home Improvement License: - 1i1s- / ` 7Z.g Exp ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMAT OST BASED ON$125.00 PER S.F. � . Total Project Cost: $ .20 `7�5`�21 FEE: � Check No.: 2—k 9A Receipt No.: 2-1 NOTE: Persons contracting with unregistered contractors do not have access to the u my fund gnature of Agent/Ovvner� c;,� aturerof"contractor 3Y. ' ~' Plans Submitted Li Plans Waived ❑ Certified Plot Plan 0 Stampe Plans ❑ Building Department The foliewing is a-list of the required:forms to be-filled out-for the appropriate.permit to.be obtained. Roofirg, Siding, Interior Rehabilitation Permits Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or G.S.L Licenses o Copy of Contract o 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 o Building Permit Application L3 Certified Surveyed Plot Plan ❑ Workers Comp Affidavit Li 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) 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 ❑ Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And, Hydraulic Calculations (If Applicable) ❑ Copy of Contract a Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-tted with the building application Doc: Doc.Building Permit Revised 2012 - Plans Submitted ❑ Plans Waived'[] .7-Certified Plot Plan ❑ Stamped Plans ❑ :TYPE-Ol{-SEWERt1GEDISP_OSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales -El Tood Packaging/Sales ❑ Private-(septic tank,etc._ . ❑ Permanent Dtinpster on Site ❑ =THE..FO.LLOWING 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 u 9 tl Q Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments. r'later & Sewer Connection/Si nature&Date DrivewayPermit Y � DPW'Tow2 Engineer: Signature: Located 384 Osgood Street FIRE WENT,'.NT . Teriip Dumpster onsite yes no Located at124;Mair; Street , , .. `A` •. ^. 'Fire DepartmeYrt signature/date COMMENTS . , 1 ---Dimension-- Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area; sq. ft.: ELECTRICAL: -Movement of.Meter,I.ocafron 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 B Notified for pickup - Date i 3 Doc.Building Permit Revised 2010 I Location No. t^ Date . - TOWN OF NORTH ANDOVER' • � � ,. Certificate of Occupancy $ Building/Frame Permit Fee �� Foundation Permit Fee $ r � Other Permit Fee $ TOTAL $ Check# 27647 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 20)J750.00 m $ - $ 249.00 Plumbing Fee $ 31.13 Gas Fee 100 comm. Is, 1O.Oi..0.G. Electrical Fee $ 31.13 Total fees collected $ 411.25 10 Peachtree Lane 81-14 on 6/5/2014 Bathroom Remodel F NORTh oven of � � E �, ndover 0 No. * t - I BB %6 over, Mass, � IJP `Q 0 o LAK. A. 2coc Nlc Ml WICK ADR^TED )'4P`,`'�5 S U BOARD OF HEALTH Food/Kitchen P E R� Septic System THIS CERTIFIES LD THAT .... �. ....� d.�. Q BUILDING INSPECTOR ....`.... ..................................... .... ............ ..................... .. . .... ..... .. .. � � �� � Foundation has permission to erect .......................... buildings on .......6................................................................. �� Rough tobe occupied as ..............6A%.. ..............!�!R+.............................................................. chimney provided that the person accepting this permit shall in every respect 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 CONSTRUCTION TARTS Rough ............................ Service ..............:....j. .......... .... ......` 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. Office of Consumer Affairs&Business:Regulatiq/ i O1VIE IMPROVEMENT CONTRACTOR- ' i egistration 124728 lf- ... TIE:' Expiration:°_8/14�2015: e x, DBA G.J.Burgess t 'Charles Burgess `���..3' �; 1 B LATCH ROAD_ # r' CHELMFORD, MA 01824 � Unc�eraecreta�;j% ,1� Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor �� t License: CS-0688.20 i l VS i CHARLES J BUROESU"J"3 LATCH RD CHELMSFORD SIA " ", Expiration Commissioner °91/13/2015 t DATE(MMIDDIY YYY) c� CERTIFICATE OF LIABILITY INSURANCE 07/22/2013 + THIS CERTIFICAT IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFI,ATE HOLDER. THIS DERTIFICATE DO S NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE.COVERAGE AFFORD BY THE POLICIES BELOW. THIS C RTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU ER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEN. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION I WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does n t confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 02916-001 NAMEACT Pantano Vonkahle 16surance (781)881.3100 Na; 220 Broadway#2201A�� E : Lynnfield,MA 01840 U SAFFORD] G C SURER • A.I.M.Mutual Insurance Company 33758 INSURED Charles Burgess INSURER B INSURER 0, 2 Latah Road .INSURER D: Chelmsford,MA 018 4 INSURER : i COVERAGES CERTIFICATE NUMBER: REVISION NUMBS THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW VE BEEN ISSUED TO THE INSURED NAM D ABOVE 00 THE POLICY PERIOD INDICATED. NOTWI'( '. H ,N STANDING ANY REQUIREMENT, TERM OR CONDI-n OF ANY CONTRACT OR OTHER DQCUMENT WITH RES DECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJ801 TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEDCyBEYppPAIDpCL{AIIyMS' /LTR TYPE O�INSURANCE /NSR POLICY NUMBER MM�-&Wy A0&J' YYYY IMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL ENERAL LIABILITY DA G T $ SES lEa iccurr,c CLAIMS-M DE EJOCCUR iNED EXP(Any one pe sol I $ bERSONAL 8 ADV INJU $ I GENERALAGGREGA E $ EN'L AGGREGATE LI IT APPLIES PER: PRODUCTS-COMPlOP)GG $ LICY CDT OC AUTOMOBILE LIABILiITY COMBINED SINGLE MI $ Ea accident 1! ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS ABODILY INJURY(Per!' Cl ent) $ UTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGizzS AUTOSPer accident) $ $ UMBRELLA LIA OCCUR EACH OCCURRENCE $ I EXCESS LIAR CLAIMS MADE AGGREGATE $ yypgKDEEDg pM SRN ENTTIONN$ j g7q l� TH $ AqNNYD pE�MppLOCY�ERpPSR'LpIqR I�QTY X TY LIMITS ER Y A OFFICEWMMBERlEXCI�� CECUTIVENN NIA VWC-100-6 158 - E.L.EACH ACCIDENT $ '100,000.00 0 15 2013A 6/23/2013 6/23/2014 fMandatory in NH) E.L.DISEASE-EA LC]YtEl$ 100,000,00 60CAPTI&N OF OP RATIONS below E.L.DISEASE-POLIC L IT $ 600,000.00 ESORIPTION OF OPERA ONS I LOCATIONS I VEHICLES(Attach ACORD 107,Additional Remarks Schedule,if more space is required)' i I i 1 + i i I j t ERTIFICATE H6LD R CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIE1 B CANCELLED BEFORE. THE EXPIRATION DATE 'THEREOF, (NOTICE WIL BE DELIVERED IN i ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE {{ i ©1988.2010 ACORD CORPORATI(N.All rights reserve . ACIDRD 25(2010105) The ACORD name and logc are registered marks of ACORD F � F Afi l i,I i 919 t tg � . iwk s1Y1Y. 64 tJf GGJ�Cr:��' �i�L.��,��,�.C:7. G`1. �'`� �;.�.�'�, a''j s�,.✓i��` �^sr° �� .r ,��} .�'°� :� A w /'J/ t.Pag# 4J I of pages 0/0 PROPOSAL t _ L �� � /kms o/8Z t Proposal Submitted To: Job Name Job# tel' DC AGC A� Address !� � � � � Job Location Date Date of Plans Phone# _ Fax# Architect l M r We hereby submit specifications and estimates for: 4&4 s/'�& Wait ZWA I A V ---- ra&-,,n604 . aMa,. dh U SII /G'Kil� r a.G� sza aAr We propose hereby to furnish material and labor_complete in accordance with the above specifications for the sum of: Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will Respectfully submitted: be executed only upon written order,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. ti ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are ti g hereby accepted. You are authorized to do the work as.specified. Payments Y<i nature will be made as outlined above. til.. l Date of Acceptance: - Signature A-NC3819/T-3850 ' 4 l"yPROPOSAL Page# of pages tr"'a"6�s-: 41 �4 Proposal Submitted To: ,( ,� Job Name Job'# 3 j Address Job Location Date Date of Plans Phone# Fax# Architect We hereby submitspecifications 4rid estimates for: g© C I - 43/ too t t f r We propose hereby to furnish material and labor—complete in.accordl nce�vith�the above specificationshe sum of: 5t ��� �s©� Rlcit �!7 �7 Dollars 4 1 with payments to be made as follows: /J r Any alteration or deviation from above specifications involving extra costs will Respect f 3 ubmitte be executed only upon written order,and will"become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents,or delays `t beyond our control. , - Note—this proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions:are satisfactory and are - 1�k ! M hereby accepted. You are authorized to do the work as specified. Payments SignatureM�1� (ji� ' 1 will be made as outlined above. Date of Acceptance: Signature A-NC3819/T-3850 t � . - The Commonwealth of Massachusetts - Department of Industrigl Aceld&ts Office o,fluvestigations 600 Washington Street -Boston,MA 02111 _WMMUSs.gov/clia Workers'Compensation Insurance Affidavit:Builders/Cont°actoxs/Electrxczans/�'Xiim 'er. A ppliteant 1n£orznatiton Please Print Legibly 'Name(BusinessiorganizaUonlln(Rviduai): Address: City/Statemp: Phone#• Are your an employer?Check the appropriate box: 'Type of project(required): 1.[] I am a employer with 4. ❑ I am a general contractor and 1 6. n New construction employees(fall and/or part-time).* have hiredthe sub-contractors listed on the attached sheet.T 7. remodeling 2.❑ 1 am a s ale proprietor or partner- . shipand'haveno.employees These sub-contractorshave 8. [[Demolition working forme in.any capacity. workers'comp.insurance. 9. Building addition [No workers'comp.insurance 5. ❑We are a corporation and its 10.[(Electrical repairs or additions required.] officers have exereised.their 3.El X am a homeowner doing all work right of exemption per MGL IL E]Plumbingxepairs or additions myself.EEOworkexs'comp. c.152,§1(4),andwehaveno 12.0 Roofxepairs insurancerequixed.]? employees.- workers' 13.[Other comp.insurance required.] xAny applicaatthat checks box#1 must also fill out the section below showingtheir workers'compensation polloy information. Homeowners who submit this affidavit indicatingthey kdoing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name ofthe sub-contractors andtheir workers'comp,policy information. .I'am an employer that is providing workers'compensation Msurance for fny employees Below is the policy and joh site information. 1 Insurance Company Name% Policy#or S elf ins.LIG.9: Expiration Data:— lob ate:Job Site Address: 6© pity/state/zip: Attach a copy of the workers'compensaVOUTolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requ4 dunder Section 25A ofMGL o.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 STOR WORK ORDER and a fine ofup 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. X do Hereby ce rider d penalties of perjury that the information provided above is ttue and correct. - signature: Data: Phone#: �!! 3 �- 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 Instruction Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an eW,ployee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral orwxitten.,, An empZoyeis defined as"an individual,partnership,association,corporation or otherlegal entity,or anytwo ormoxe ofthe foxegoiug engaged in a joint enterprise,and including the legal representatives of xdeceased employe,.or the receiver or'.trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having notrnore than three apartments and who resides therein,or the occupant of Me dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or onthe grounds orbuilding appurtenant thereto shallnot because of such employmentbe deemedto be an employer.,, UGL 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 fox'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 chapterhave beenpresentedta 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),addresses)andphone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orpariners,arenotrequiredto carryworkers'compensation insurance. If au LLC orLLP doeshave employees,apolicylsxequired. Be advised that this affidavit maybe,submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit: 'phe 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 he. 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 ba-sure to fill.in the pen it/Jicense number which will be.used as a reference number. In addition,an applicant thatunust submitmultiple permitflicense applications in any given year,need only submit one affidavit indicatlug current policy Information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as pxoofthat a valid aflidavit.is on file for future p ermits or licenses. .A new affidavit must be filled out each year.'Where a home owner or citizen is obtaining a license ox p ermit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves eta.)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 aird fax number: Tho CQmMoR.W.ealtl ofyamach_Ueft4 Doparbe-ut dkdu�xzal Accidents Off toe()f)[AVodtigacou., P090n,MA 02111 AFE Revised 5-26-05 Fay1 �¢