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HomeMy WebLinkAboutBuilding Permit #798 - 100 CROSSBOW LANE 5/31/2011 i li TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: f- Date Received Date Issued: r IMPORTANT:Applicant must complete all items on this page LOCATION 0 G C C7SS 6 () L/i CZ e ' Print / PROPERTY OWNER I l L V Print MAP NOPARCEL,)O —ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential 0 New Building ne family ❑Addition 0 Two or more family ❑ Industrial ❑ eration No. of units: ❑ Commercial epair, replacement 0 Assessory Bldg ❑ Others: 0 Demolition ❑ Other i ❑ Septic D Well 4 0`Floodplain ❑Wetlandsi ' Watershed District i _El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: C- © 4 (Identification Please Type or Print Clearly) OWNER: Name: Y1 A L 0 Phone Address: /o C cuss b cCJ ISO e CONTRACTOR Name: ()e-n 0 Phone: Address: I Supervisor's Construction License: / � �j=Exp. Date: // 0 j Home Improvement License: �/ 7S` Exp. Date: T ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COSTBASED ON$925.00 P ER S.F. Total Project Cost: $ I 0 C? © 0 FEE: / S Check No.: l�Ob Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the aranty fund S gnature�of Agent/.Ownerr _ Signatu_r.e flft*actor Location '&a;,rddP No. Date NpR,� TOWN OF NORTH ANDOVER � s .. A Certificate of Occupancy $ CHU <� Building/Frame Permit Fee $ Foundation Permit Fee $ i Other Permit Fee $ TOTAL $ Check # � f �R < 24 , 67 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well I ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED j PLANNING & DEVELOPMENT ❑ ❑ COMMENTS f j 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: 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 2008mi i Building Department a The following is a list of the required forms to be filled out for the appropriate permit to be obtained. i Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses j ❑ 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 ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o 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) ❑ 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 ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers' Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report u Engineering Affidavits for Engineered products NOTE: 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: Doc.Building Permit Revised 2008mi ORT►- Town of And No: 7 = LAK o over, 1Vlass., S �� COCMICKEWICK ADRATED PPy `s U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .......W............. .................... Foundation has permission to erect.................:...................... buildings on .1 ...........C..1 ......40.......................................... Rough V*6g e. to be occupiedas..... ... ......fi......... ............:/ 1 ., ...........,...................:::::................................................ Chimney provided that the persothis permit shall in eve respect conform to the terms of theapplication on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration nConstruction of Final 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 CONSTRUCTIO S ARTS 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 Until Inspected and Approved by thBuilding Inspector. Burner'. DEPARTMENT i Street No. SEE ;REVERSE S6DE Smoke Det. I Ate Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 '�� Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 116175 J Type: DBA 6 z � Expiration: 5/25/2012 Tr# 297492 DENNIS SHURTLEFF ROOFING IM DENNIS SHURTLEFF t 9 HADLEY RD WESTFORD, MA 01886 , Update Address and return card.Mark reason for change. ❑ Address ❑ Renewal F.� Employment ❑ Lost Card DPS-GA1 ao 50M-04/04-G101216 �r*• Massatdws*,•tts- Departnient ►f Pulilic Safety 'Bold of Building tte ulatio'ns and Stsfllfiird Construction Supe visbr Specialty License Licenser CS SL 102129 Restricted to: RF DENNIS SHURTLEFF 9 HADLEY RD WESTFORD, MA 01886 Expiration: 1/13/2013 • (;ntsuru;i�t�cT. ► .t'Tti: 102129'., i. I I .. ____ _.............. _. ... . PRt I� 3 . ALL 11.111111111 DENSIS SHURTLEFF ROOFING. 9 Hadley ROW Residential l ioommercial Westford,MA 01886 speeartzing in SHEET KO.. Rubber * Shingles*Tar and Or vel Dentis Shurtlef Chimneys Strips aATE Fully Insuted PROPOSAL F AL, ttBJl l " I:3 TO: WORK TO E PERFORMED AT: _. 0r�AO C U). I)iE PHONiw.fr� � AnI Wt hereby propose-to furnish a terns and arm the iii neoess {sir th.0 tompimion f . . s ,: OFT i r7 . ' zo r .. s .. w .. 1 ' t4 1 0. ALL I _ LdAkn.: j212 j2 L+ i Iu. 0. 'ablaih,.: Ahad AQ material is quaranteo3#o be as specified, and the above mark to be pe6ormed in accordance with:the Irawings and specifications $ubma a .fora o e andccs : feted in asuhst�. al uvtatkm��tlitie ariner°fa�rthast��+of � mA : till d 0 4 y4th paymeft to made as follows., 10,V 04 � +rlss w ,ar> w► asran� a Per _.. #�Y�t�E.:�UI��d�%'1f ► ��c�itl�dlYd,ttF96Si�'&b��t4�l�Jf - � -. .. . f °` ` .� Note�`Ihis proposal may be withdrawn . 100, fir us if not acceptedwithin dsye ACCEPTANCE OF PROPOSAL The above prices,speMicatons a-nd comft are sufftfectory aid-are€webs accepted. Yoe€are the Work as specif€ed. Payments will be made as Outlined above. ��.... .4C SHUR-D2 OP ID: ES .. �....: CERTIFICATE OF LIABILITY INSURANCE °ATArt 71""YY' "f 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 978-692-3073 CONTACT Westford Insurance Agency NAME: 224 Littleton Rd P.O.Box 308 978-692-0429 ACNNo Ext: FAX Westford,MA 01886- E-MAIL A/c Nol: Eric Semple ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURED DINSURERA:Central Insurance Company ennis Shurtleff 9 Hadley Road INSURER B: Westford, MA 01886 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADL UB LTR TYPE OF INSURANCE POLICY NUMBER MM DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY 7867502 DAM Ep 03/15/11 03/15/12 PREMISES Ea occurrence $ 100,00 CLAIMS MADE OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ 3,000,00 AUTOMOBILE LIABILITY COMBINED $SINGLE LIMIT � ANY AUTO Ea accident $ ALL OWNEDBODILY INJURY(Per person) $ AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ HIRED AUTOSNON-OWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EXCESS LIAR EACH OCCURRENCE $ CLAIMS-MADE DED AGGREGATE $ RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N TORY LIMI ER OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.EACH ACCIDENT $ If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ � DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 27 Charles Street ACCORDANCE WITH THE POLICY PROVISIONS. N Andover, MA 01845 AUTHORIZED REPRESENTA/ATIV E ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD RightFax N1-1 5/27/2011 6: 35: 39 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF LIABILITY INSURANCE 05/27/2011 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:lithe certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. 11 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 WESTFORD INS AGCY INC (A/C,No,Ext): FAX P 0 BOX 308E-MAIL (A/C,No): ADDRESS: PRODUCER WESTFORD,MA 01886 CUSTOMER ID#: 28W5B INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: CONTINENTAL CASUALTY CONIPANY INSURER B: SHURTLEFF DENNIS DBA SHURTLEFF ROOFING INSURER C: INSURER D: 9 HADLEY ROAD INSURER E: WESTFORD,MA 01886 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 TYPEOFINSURANCE INSR WVD POLICY NUMBER (MIMDDIYYYY) (MIMDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMPIOP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO ' LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WC STATUTORY LIMITS OTHER WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY Y/N UB-0286M502-10 07/23/2010 07/23/2011 E.L.EACH ACCIDENT $ 100,000 ANY PROPERITOR/PARTNER/EXECUTIVE Y E.L.DISEASE-EA EMPLOYEE $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-POLICY LIMIT $ 500,000 11 yes,describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIRCATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SHURTLEFF DENNIS. CERTIFICATE HOLDERCANCELLATION TOWN OF ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE 36 BARTLET ST WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ANDOVER,MA 01810 Dennis Chookaszis ACORD 25(2009109) 1988-2009 ACORD CORPORATION. All rights reserved.