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HomeMy WebLinkAboutBuilding Permit #1109-2016 - 100 MAIN STREET 4/25/2016 BUILDING PERMIT 3? 4O.,r ,..•rr, ., oL TOWN OF NORTH ANDOVER ° �' APPLICATION FOR PLAN EXAMINATION 111 Permit NO: Date Received '� °9q,� Date Issued: �� IMPORTANT:Applicant must comp lete all items on this page LOCATION �C(J �, n S) 'CA-V C N TU 1 c •J . Prin PROPERTY OWNER . Print 166 7/'. MAP NO: PARCEL: MD ZONING DISTRICT: Historic District no Machine Shop Villagefyesno TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial VAlteration No. of units: Commercial P'Nepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District f3' ter/Sewer Wit; ALN Nkw c 4_— Identification Please Type or Print Clearly) OWNER: Name: AcG Phone: a113� X63 L Address: CONTRACTOR Name: � -X77=13�� Phone: Co Address: Supervisor's Construction License: Exp. Date: CS- b�a���Q 1 `Zot-? Home Improvement License: `.�.� Exp. Date: Z 1 Zfc I Ic' 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: $ 3 a FEE: $ 3 o " Check No.: 7- oa1 t Receipt No.: o NOTE: Persons contracting withegistered contractors do not have access to t e aranty fund Signature of Agent/Owner _ gnature of contractor i r - t10RTy w- BUILDING PERMIT of.It + �eo I6� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION L 7D Permit No#: Date Received qss ArEDUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ---- tic— ❑Well .. ❑ Floodplain .,❑Wetlands ❑ Watershed Distract ❑Water/Sewer ": _< p ] rf DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Sianat ur . of Agent/Owner Signature of contractor 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 e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS 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 Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: _ Located 384 Osgood Street AR ED 'RTi�MEN tTemp, D'ump�;sterons�i e°TY�eSA--v p.. no_ _ -- rye, "r- it 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 Call Email Date Time Contact Name E Doc.Building Pennit Revised 2014 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. An d/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks :4 Building Permit Application 4 Certified Surveyed Plot Plan �6 Workers Comp Affidavit 4 Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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:Building Permit Revised 2014 Location (00 No. I1�f�� �.t��l,� Date �I(" j . - TOWN OF NORTH ANDOVER -P° Certificate of Occupancy $ Building/Frame Permit Fee $ 'bo Foundation Permit Fee $ Other Permit Fee $ TOTAL $ „ Check#0i,Al r Building Inspector NORTH own of 0 ti. 0 No. +� h ver, Mass, n 261 o LAKI cocN�cHew�cw y1. �ds RATED U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT . ....... .. ................... BUILDING INSPECTOR ... .. ........ A... ..:!t�....... P�...... ..�. has permission to erect ............ buildings on ItoQl, ...... Foundation .............. .... ... . 1k a Rough to be occupied as . �. ... .. .. ... ...... ... .�i .. p............ Chimney provided that the person accepting this permit shall in every respect co orm t e terms of the a�lplication Final p p g 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT-EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT STARTS Rough Service ......... .. .. ... ........................ 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. I Proposal Shingles EF Fogarty Roofing Co. Ed Fogarty Rubber P.0 Box 177 (978) 777-7337 Siding (978) 815-6758 c Billerica, MA 01821 Proposal submitted to Phone Date 100 Main street Realty Trust 978-835-6630 4-17-16 Street Job name 100 Main Street D. Mermelstein City, State Zip Job location N.Andover, Ma N Andover Architect Date of plans Job Phone We hereby submit specifications and estimates for: Roofing Work 1. Remove shingles from two sides of apron areas of building. 2. Install ice and water shield to roof deck surface. 3. Supply and install 8" dripedge,step flashings and roll flashings as needed. 4. Supply and Install GAF (IKO) Timberline P per as shingles manufacturers specifications. 9 p 5. Install new metal trim to two areas on left side of building. Clean and remove debris fromp remises. Workmanship carries a 5 year warranty. Shingles carry manufacturers warranty. Mass Home Improvement Contractors Member Lic.# 111772 -617-727-8598 National Roofing Contractors Member Lic. # 136814 Mass Builders Lic#062349 We Pr'opOSe hereby to furnish material and labor-complete in accordance with above specifications, for the sum of: One thousand three hundred fifty dollars ( $1,350.00 ) Payment to be as follows All material is guaranteed to be as specified. All work to be completed in a substantial workmanlike manner according to specifications submitted,per standard Authorized practices. Any alteration or deviation from above specifications;involving extra costs Signature will be executed only upon written orders,and will become an extra 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. Title owner/ODerator Our workers are fully covered by Workmen's Compensation Insurance. 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 hereby a pted. You are authorized to do the rfied. yment work ass c 'I b made as tlined above. Buyer: Signature: Signature: Signature: Date of Acceptance: \ The Commonwealth of Massachusetts kiDepartment of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aipulicant Information I Please Print Legibly Name(Business/Organization/Individual): Address: Z.S ©KA k5L,-Jk �&IL City/State/Zip: A JLAI C,�, Phone#: COO~77 7 -7*3,;7- Ar71.. n employer?Check the appropriate box: Type of project(required): 1. a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 3.E]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10 FJ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ p 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'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 a new affidavit indicating such. tContractors 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I I I am an employer that is providing)porkers'compensation insurance for my employees. Below is the policy and job site information. I Insurance Company Name: S Policy#or Self-ins.Lia#: �U� �`( �'�� Expiration Date: 7 e0 Job Site Address: X00 m4tv\ I I k City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 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. Ido hereby certify t nde the pat s and peva tees of perjury that the information provided above 1 true and correct. Si afore: Date: 2 ; If-, Phone#: Official use only. Do not sprite 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#• I i ,eco CERTIFICATE OF LIABILITY INSURANCE DATE(MMMD/YYYY) 4/19/16 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(es) must be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement. A statemerd on this certificate does not confer rights ID the certificate holder in lieu of such endorsemen PRODUCER NAME: DEBORAH GRIMSHAW Beacon Insurance Agency, Inc. PHONE978 251-2882 FAX N (g78) 251-3185 22 Middlesex Street E-MAIL N. CHELMSFORD, MA 01863 ADDRESS: INSURE S AFFORDING COVERAGE NAICS INSURER A:ATLANTIC CASUALTY INSURANCE INSURED INSURER B:TRAVELERS EF Fogarty Construction Co INSURER C: 28 Old Haswell Park Rd. INSURER D: Middleton, MA 01949 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 ANDCONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPEOFINSURANCE INSR WVD POLICYNUMBER M/DDNYY MLNDDfYYYY LIMTS A GENERAL LIABILITY L261000698 7/10/15 7/10/16 EACH OCCURRENCE $ 1,000,000 $ COMMERCIAL GENERAL LIABILITY DAMAGETO RENTED $ 100,000 oocumoce)CLAIMS-MADE ®OCCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILELIABILITY EMBIINEaccIdaDtSINGLELIMIT $ ANYAUTO BODILY.INJURY(Perpenson) $ ALLOWNED SCHEDULED BODILY INJURY Per accident AUTOS AUTOS ( ) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS eracEnt UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORCOMPENSATION AND EMPLOYFRS'LIABILIT Y 6MM-OG15184-0-15* 7/10/15 7/10/16 OTH- Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACO CENT $ OFRCERMIEMBER EXCLUDED? N/A If(Mes.dLDry In be U EL.DISEASE-EA EMPLOY If yes,describe under DESCRI PTIO N OF OPE RATIONS below E.L.DISEASE-POLICY L IM R *EMPLOYEE ONLY POLICY DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Renarks Schedule,If more space Isregd red) CARPENTRY/ROOFING CONTRACTOR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 100 MAIN STREET REALTY TRUST ACCORDANCE WITH THE POLICY PROVISIONS. 100 MAIN ST ANDOVER MA 01810-3819 AUTHORIZED REPRESENTATIVE DEBORAH GRIMSHAW ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 356-6680 E-Mail: i i i Massachusetts -Department of Public Safety Board of Building Regulations and Standards 1.1111\Lt U1L11/11 JUIIGI Y1s1)i License: GS-062349 j FS EDMUND F FOG ' 28 0LD HASWEL''L aft at � NIIDDLETON MA Ol r Expiration Commissioner 07/24/2017 Q7—_.._ 1 _ -- - -- -- -- - - ,sem lce . -\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only — HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: a Registration: 1,11772 Type: ;• Office of Consumer Affairs and Business Regulation Expiratio n:.=.=2%26/2018 DBA 10 Park Plaza-Suite 5170 t = Boston,MA 02116 C= T A E.F. FOGARTY CONST---CO EDMUND FOGARTY,'`-= = - 28 OLD HASWELL PARK"RD�',•- MIDDLETON, MA 01949 - -- ---"- —"- — --- • Undersecretary Not vali wit out signature I