HomeMy WebLinkAboutBuilding Permit #728 - 100 BELMONT STREET 4/12/2012 "Un Iy
BUILDING PERMIT °Ett`E°:6Atio �I
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received 74A°RAre°rParty�y
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Date Issued:
IMPORTANT:Applicant must complete all items on this page
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PRPI=RT'�l OWNER,
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family . ❑ Industrial
No. of units: Q Commercial
❑ Iteration li
' Repair, replacement ❑Assessory Bldg ElOthers:
❑ Other
❑ Demolitiony
bSelat�o` �i`Well ,s ❑sFlo rl 1a�n'�j� t>❑�Ut/etlancls� Watershetl DistrictM-1
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DESCRI TION OF WO TO BE PREFORMjD:
/�SSL SIL
Tar_/ 1��'SC�',7'TIG✓ ®r/ /�7/ G`,L a7 SLS
Identification Please Type or Print Clearly)
OWNER: Name: LiO 1* PK80RAZ 1q.no���t�-�b Phone:�17� ���'���3
Address
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;CONTRACTOR Nahie, .V w 4 Phone
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SupervisoC'1.
s Go11StrLIGtIOn L�cepse• i E�tp 'Date '� '
t ' t �.r � ; f$ ii x • ) � a � £ r � �� ii ".'�i�r�,�1i ie1^��� ) + I
Home t4' -cense:° � Exp,
bate
ARCHITECT/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 Project Cost: $ ZY FEE: $ �
Check No.: erolf 67, Receipt No.:
NOTE: Persons contractin w' unregist ed contractors do not have access to garan ty
- SiVinature ofontracto `
Signature �fAgent/Owne
I !
1:
Location/00- Ir
No. Date �----
e - TOWN OF NORTH ANDOVER
e Certificate of Occupancy $
Building/Frame Permit Fee lJ
Foundation Permit Fee $
Other Permit Fee $�
TOTAL
Check
0
25180 Building Inspector
i
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 ❑ ❑
4
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑ _
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
y
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
i
Conservation Decision: Comments
J
Water& Sewer Connection/Signature&Date Driveway Permit 4
Located at 384 Osgood Street
FIRS DEPARTMENT Temp Durrtpstet on site
Located at 124 Main Stree# �- - -
F�re Depairfinent signature/state - -
r
' 1
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
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NOTES and DATA— (For department use)
I
I
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
Building Department
The following is a list of the required forms to be filled out for the appropriat,e 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)
I
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Iu 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:INSPECTIONAL SERVICES DEPARTMENTMITORM07
i '
Revised 2.2007
JAORTH
own of - Over
.. . '
No.
o lover, 1Vlass.,
6, O t- LAKE �•
COCMICKE WICK
Of? TE
RATED APS\
BOARD OF HEALTH
Food/Kitchen
Septic System
.PERM IT T D
BUILDING INSPECTOR
T....... .. ......!4
.....................................................
THIS CERTIFIES THAT Foundation
has permission to erect........................................ buildings on......lQ. .......... .. ... ........ftrr........4.y Rough
.... ...............
to be occupied as..........C#.* .'V.%.0M.^..N� .............. ... ..... �r.�..��.�..�.._:...... Chimney
C e
provided that the person accepting this permit 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 CONSTRUC Y? S Rough -
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required t® 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 FIREDEPARTMENT.
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE smoke Det.
Construction Contract
This agreement is made by Kinsella Construction LLC (Contractor) and Leo Deborah Lamontagne
(Owner)on the date written beside our signatures.
Contractor
Kinsella Construction LLC
26 Wintergreen Circle
Methuen,Massachusetts 01844
-Work Phone Number: 978-857-7320
Fax Number. 978-557-5490
Email Address: dan.kinsella@comcast.net
Kinsella.Construction LLC is operating as a limited liability company in the state of Massachusetts.
Kinsella Construction LLC will be referred to as Kinsella Construction t hroughout this agreement.
Owner
Leo Deborah Lamontagne
100 Belmont St
North Andover,Massachusetts 01845
Day Phone Number: 978-688-6683
Fax Number:978-688-6636 ,
Email Address:deb@nasdg.com
Leo Deborah Lamontagnewill be referred to as NASD throughout this agreement.
The Construction Site
100 Belmont St
North Andover ,Massachusetts 01845
I. Project Description
A. For a price identified below, Kinsella Construction agrees to complete for NASD the Work
identified in this agreement as the Install Handrail on existing guardrail.
B. The Install Handrail on existing guardrail is described as follows:
Install 2x6 on flat on support posts of existing guardrail.
Install new handrail on both sides of stairway guardrail.
Rail shall be continuous without obstruction set at a hieght not lower than 30" nor moor than 38"
measured from the leading edge of the treads.
Renail existing ballisters. Replace broken ballisters.
Install backbraces for guardrail using 2x4's as supports
U. Contract Price
A. In addition to any other charges specified in this agreement, NASD, agrees to pay Kinsella
Construction$1,850.00 for completing the Work described as the Install Handrail on existing guardrail.
III. Scheduled Start of Construction
A. After permit is issued '
IV. Scheduled Completion of Construction
A. 30 Days after permit is issued
Page 1
r,
V. Payment Plan
A. NASD will pay to Kinsella.Construction the Contract Price at completion of the Work.
VI. Final Payment
A. Kinsella Construction will submit an application for final payment to NASD when the Work has
been completed in compliance with the Contract Documents. If NASD agrees that Work has been
completed,payment is due Kinsella Construction for the entire unpaid balance of the contract amount.
B. Except as provided otherwise in this agreement, NASD shall pay the amount due within 7 calendar
days after approval of any application for payment.
VII. Insurance
A. General Requirements
1. Kinsella Construction shall carry workers' compensation insurance and public liability insurance as
required by Law and regulation for the protection of Kinsella Construction and NASD during progress
of the Work.
Signatures
The signatures that follow constitute confirmation by those signing that they have examined and
understand the Contract Documents and agree to be bound by the terms of these documents.
This agreement is entered into as of the date written below.
Leo De rahLamo rere,O
(Si e) ate)
�-�
(Priv Name and Title)
tKl-nlla CojWructtion LLC, Co for
✓rte a-d1�--
(Signature) (Date)
(Printed Name and Title)
A�Rr'o CERTIFICATE OF LIABILITY
THIS CERTIFICATE LR ISSUED AS.A MATTER OF INFORMAtiON ONLY AND CONFERS NSUN�Tg���� �TE(MIYYDprypyy�
CERTIFICATE DOES NOT AFFIRMATiilELY OR NEGAT�LY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY�11I2012
BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN VE ISSUING F D� . AUTHORIZED
R11 111111 CERTIFFI HOLDER. THIS
EPRESENYATII/E OR 11 PRODUCER,AND THE CERTI THE POLICIES
IMPORTANT: If the certificate holder is art ADDRI HOLDER
the terms and Conditions of the Polley,certain oltc;esA1NSURED,the,pollLy(ias)must be endorsed. E SUBROGATION IS WANED,Subject to
certificate holder In lieu of such endorsement(sp y n3qulre an snd°r9emgnt• A sfaternent on this IMrt;ficate does not confer
PRODUCER
lights to the
D�ge138 iUSurance ME T><acy Loeschen
283 DQerrimaek Street PHONE (978)682-3397
Fpl(
` L -r9�sp6B1-0773
Methuen
en MA 01844 IN9uR AFFOMNGCovERAGe
INeuRED INsr/RerAA;Nat:ional A1C e
e Mutual ins Co 2
Ri>nBella Construction LLC INSL►RFRa:Zu3•ich Insurance Co.
26 miutergreen Circle asuRERc:
INURER D:
Methuen MA OI84II ursuRERg;
COVERAGES CERTIFICATE NttMI3ER: INSU ERF;
THIS fS r0 CERTIFY THAT THE POt(CIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED a
INDICATED. NOTWITHSTANDING ANY REOUIREMENT. TERM OR REvlSION NUMBER:
111! 1:DR THE POLICY PERIOD
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE 1NSURAN AFFORDED 8Y THCONTR C T R OTHER
HEREIN 1S ATHSLfRESPECT
ALL HE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH CONTRACT DESCRIBED OTHER OO EI WITH RESPECT LL YHE TE THIS
ws POLICIES.uMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
� TYPE OF M9URANCE
GENERAAL UAgH jyy P UCY Are EFF T
UMRS
X COMMERCIAL"NER�AL LIABILITY FACHOCCURRENCE S 11000,000
A CLAIMS•MADE a)OCCURag
- - LITE n oae 1l26/20i; 1/2s/2o12 S 50,000
MED EXP An ane Breen S 10,000
PERSONAL AAMINJURY S 1,000,000
G"nAGGREGATE UMMAPPUESpER GENERAIAGGF(EGATE S 2.000,000
X POLICY PRO. LOC PRODUCTS-COMP/0 AGG $ 2,000,00
AUTORMILE LiAgwy S
A ANYAUrO INE UM
AurOs IED g sCHEOULED gornlr u�4U1iY tPer aNsa+) S
AUTOS 911124469 /z6/4011 a50 000
X HrREDA rro. R A�l/TO � /261ZO12 BODILY IKIURY(Pa 41dgq) S
PR PER OE 500 000
S
LA
R
EXCESSOCCUR �dmotomius Nt S 250 000
XCESS LIAR CLAIMS-MADE EACH OCCURRENCE S
DE RETENTION S - AGGREGATE A
$
WORKERS COMpENSAnON
AND EMPLOYERS LIABILITY S
ANY PROPRIBTORJPARTNERiMcU W YIN VicSTATU• OTK- -
OFFICCRIMIEMBER EXCLUDED? a NIA
�WsraaarylnNM) tZDBO5gOp816 /a9/a0>1 /29/2012 E.L.EACH ACCIDENT S 100,000
IfESCRI u aPERATiOf�pele�v E.l OISEASE•EA EUPLOYE S 100 000
E.L DISEASE•POLIC`fUWT 8 Sao 000
DESCRIPTION OF OPERATLON9!LOCATKNI9/vEpICll:g(+Ulagl ACORD V01.Addruei1v11lttnlarfn Sc
certificate is i9sued in the interest of the named ins K der 1 atad below, Subject to company
conditions and exclusions. Y
'ERTIFICATE HOLD R
" CANCELLATION
978)557-5490
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLM BEFORE
TownTHE EXPIRATION DATE THEREOF. NOTICE WILL BE DELI
1600 VERED IN
600 Osgood Street; tAflO>: North Andover ACCORDANCE7uTHEPOLICYPRomioNS..
1
North Andover, NA 01845 AUTMOWWREPRE CWATWE
David Segal/19M b• �l��
CORD 25(2010105) X11988-2010 ACORD CORPORATION_ A8 rights reserved.
VS025(1p10MI.O1 The ACORD name and logo are registered marks of ACORD
��ie i�n�nmzamueai dj-•/ za3cuua
Office of Consumer Affairs&Bdsmess Regulation
HOME IMPROVEMENT CONTRACTOR
Registration:. .,124016 Type:
Expiration 5!5/2013 Individual
Danie T.Kinsella
s baniel Kinsella _
26 Wintergreen Cir Q 6
�' ;, Methuen,MA 01844 Undersecretary
f
t '
-* �f issaehuoett. lDcpmrtrnent of uiilo� 4;tteY�
Board of Buildin=g Rectwulations and Standards _
C_onstralction Supervisor License
License: CS 66686
DANIEL T KINSELLA
26 WINTERGREEN CIRCLE
i
METHUEN, MA 01844 = _
Expiration: 7/1812013
Tr#: 17500
Commissiwier
The Commonwealth of Massachusetts -
Department of IndustriqlAccidints
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/Zia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: �, ��,�16�G!2 ✓`' i rem f
City/State/Zip: v r 8yy Phone#:
Are ou an employer?Check the appropriate box: Type of project(required):
1.91 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction l
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet. �• ❑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 10.0 Electrical 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 12.E]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.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 the policy and job site
information.
Insurance Company Name:. ZG X/C,� /,,.IS u R ft-N<sL
Policy#or Self-ins.Lic.#: G 2- Z 06 .0 A -z v C,� 9,-,& Expiration Date:
Job Site Address: City/State/Zip: t9'.v pp i/t R
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL 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 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 cert . n er the pa' andpenalties ofper' that the information provided'above is true and correct. -
Signature:
/ Date:
Phone 9:
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.CitylTown CIerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other - -
Contact Person: Phone#:
Information and Instruction's
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 ofpublic 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. B e advised that this affidavit may be submitted to the Department of Industrial
Accidents fox 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 forou to fill out in the event the Office ffice of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense 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 bum 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 Comrgonwealth ofMoSsachvsPtts -
Department ofIndustdat Accidents
Office ofInvestfgations
600 Washington Street
Boston,SIA.021 It
Tel,,#6X7-727-4900 ext406 ox l-877,MA.SSAF '
Revised 5-26-05 Fax#617-727-774.9
_ _www.xnass,gov1ciaia