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HomeMy WebLinkAboutBuilding Permit #894-15 - 100 OLD VILLAGE LANE 5/8/2015 BUILDING PERMIT TOWN OF NORTH ANDOVER ►- APPLICATION FOR PLAN EXAMINATION Z —� o 4L^ Permit NO: Date Received S ved 9 <�„<...�. A O Date Issued: IMPORTANT:Applicant must complete all items on this page SSA`""S� LOCATION Print PROPERTYOWNER } f '� Print MAP NO:&PARCEL '7 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New BuildingOne family Y ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other n Septic []Well ❑ Floodplain ❑Wetlands C] Watershed District ❑Water/Sewer fiIdentification Please Type or Print Clearly) OWNER: Name: Phone: - Address: 1o CA I CONTRACTOR Name: v x Cf- . Phone: 55 3 Address: 1 I-)b _ yynCf Supervisor's Construction License: "- -, Exp. Date: 1 io Home Improvement License: ' .-� �6�� Exp. Date: ( , y. 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: $ 4G 51D FEE: $ ,4to0`da Check No.: fa/(_ Receipt No.: 87� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - SSignature of Agent/Owner Signature of contractor . C �. 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 o U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature i 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 FIRE DEP �TtM NT - p�bump�on L0 ated at Fire Departmenttsi-gn tune/dat�_� ° 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 �r Doc.Buildin;Permit 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. And/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 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/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 p 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 I 6/v" rig/,q_, � Location No. '7�l Date l j . - TOWN OF NORTH ANDOVER • S � D 7 A6 I Certificate of Occupancy $ j Building/Frame Permit Fee $ Foundation Permit Fee ` $ Other Permit Fee ge ( $ TOTAL Check qI a yo `�-?30 7� O Building Inspector NORT#1 Town of t hover O - sO �h ver, Mass, CL A— COC KicNlWI[K"1' J�A�R�t7E� S u BOARD OF HEALTH Food/Kitchen PER LD Septic System THIS CERTIFIES THATBUILDING INSPECTOR . .f(b., . .. .. i .has ermission to erect ......... ,, , ,,, AFoundation p ................. building on ... .......!. .. ........ Rough tobe occupied as .............a .o. . ....k.;. . . ... .�................................................. Chimney pre-4Med 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 Coristruction 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 .............. ..... .................................... 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. e tyu NORT#1 Town of � -. ? E ..,,, _ Andover 0 C, ver, Mass, �— Tw I.9S�R�TED nP�`�,�5 V PERMIT T BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT fes, /��'e-,Ite-` BUILDING INSPECTOR .................. has permission to erect.......................... buildings on /Oo D/ „ /�`�/G�E •�cvF Foundation Rough to be occupied as ...................... provided that the person accepting this permit shall in every respect conform to the terms of theapplication Chimney on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Final 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 GAS INSPECTOR 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. J Murray and Sons Construction, LLC Estimate 114 Broadway Somerville, MA 02145 Date Estimate# 05/05/201.5 18154 (781)414-0605 john@jmurrayandsons.com Address Jeff French 100 Old Village Ln North Andover Description Amount • Contractor to demo and remove the cabinets in the kitchen. Contractor will remove 950.00 island. Contractor will leave the walls behind the cabinets. Removal of appliances included. • Contractor has included repair and patching of the walls in the kitchen. Skimming and 1,500.00 plaster included. • Contractor has included purchase and install of kitchen cabinets with allowance of 6,800.00 $2000 on cabinets. Contractor has included an allowance of$2,500 on appliances. All install included. • Contractor has included template and granite with allowance of$1500 2,000.00 •Plumbing to code by state licensed plumber.Fixtures allowance $400. Permit by 2,000.00 contractor. •Electrical by licensed electrician to code. Contractor has included new outlets and 1,800.00 switches in the kitchen. •Paint by owner. Contractor has included new trim and molding.New baseboard 1,600.00 included. ACCEPTANCE OF PROPOSAL-The above specifications and conditions are Total $16,650.00 hereby agreed upon and accepted. J Murray and Sons Construction,LLC is authorized to complete the projects as described. Accepted By _ �/�l ti Accepted Date The Commonwealth of Massachusetts Department of Industrial Accidents d 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia SV' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Pljes e Print Le gibl Applicant Information L Name (Business/Organization/Individual): Address: �� �1 �� ��' � t City/State/Zip: ��^� © �y S Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition In I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.h 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.t 14.❑Other, 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 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 workerscompensation 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. $Contractors 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 am an employer that is pro iding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �rr�����P� �S�� � Policy#or Self-ins.Lic.#: b Expiration Date: 110 r/ Job Site Address:_ y ' y City/State/Zip: Attach a copy of the workers' compensation p icy 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. I do hereby tify under the pains and penalties of perjury that the information provided bov is true and correct. Date: Si nature: Phone#: 1 ^ � Official use only. o 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 Instructions 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 of public 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. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-NlASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia Rightfax I42-1 5/7/2015 6:39:30 AM PAGE 21002 Fax Server DATE(MM)DD/YYYY) IQ CERTIFICATE OF LIABILITY INSURANCE T 'I IFICATE IS ISSUED ASA 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 ACONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:H the certificate holder is an ADDITIONAL INSURED,the policy0es)must be endorsed. It SUBROGATION 1S WAIVED,subject to the terms and conditions of the policy,certain pal icier.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: QUINN GROUP INS AGCY INC PHONE FAX 223 MASSACHUSETTS AVE (AIC,No,Ext): (A1C,No): E-MAIL ARLINGTON,MA 02474 ADDRESS: 77 HB P INSURE R(S)AFFORDING COVERAGE NAIC ti INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA J MURRAY AND SONS CONSTRUCTION LLC INSURER B: INSURER C: INSURER D: 114 BROADWAY INSURER E: 50MERVILLE,MA 02145 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUM BER: 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 ANYCONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATEMAY BEISSUEDOR MAYPERTAK THENSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALLTHE TERMS,EXCLUSIONS AND CONDITIONS OFSUCH POLICIES. LIM17SSHOWN MAY HAVE BEENAEOUCEDBY PAD CLAIMS- NSR ADD SUB POLICY EFF DATE POLICY EXP DATE OR TYPE OF INSURANCE L R POLICYNUMBER IMODIYYYY) ;MMDD\YYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY AAIAGE TO RENTED $ CLAIMS MADE F-1 OCCUR. RVAISES(Ea occurrence) P� L IED EXP(Anyone person) $ ERSONAI_&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY 0 PROJECT Q LOC ROOUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIIJIfr(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OVVNEDAUTDS PROPERTY DAMAGE $ ;Per accident) UMBRELLA LIA9OCCUR EACH OCCURRENCE $ EXCESS LI0.B CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ A WORKER'S COMPENSATION AND xWC5TATU'ORY OTHER EMPLOYER'S LIABILITY YIP) UB-5BE03936-15 03130!2015 05/30/2015 uMrrs ANY PROPERITORrPARTN ER/EXECUTIVE NSA E.L_EACH ACCIDENT $ 100,000 OFFiCERRdENI ER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 "yes,dewboe under E.L.DISEASE-POLICY UM1T $ 500.000 DESCRIP71ON OF OPERATIONS below DESCRIPTION OF OPERATIONS'LOCATIONS/VEHICLESIRESTRICTIONS!SPECIAL ITEMS i HIS REPLACES ANYYRIOR CERT MCATE ISSUED TO TFIB CER'ITFICATE HOLDER AFFECTING WDRKBRS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF WAKEFIELD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE-THEREOF,NOTICE WILL BE DELIVERED 1 LAFAYET M ST IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT VE WAKEFIELD,MA 01880 ACORD 25(2010/05) The ACORD name and logo are reg istered marks of ACORD 1989-2010 ACORD CORPORATION. All rights reserved. 6'd 9££6-9Z9(L 69) ;OnJlsuoo suog�R AE3JJnW (e8Z:80 9 6 20 Regulation `.._ Office of Consumer Affairs&Business ME IMPROVEMENT CONTRA Type. egistration: 179050 Individual Xpiration: 611712016- _ � • i• �I JAMES MURRAY JAMES MURRAY gJ 114 BROADWAMA 02145 Undersecretary SOMERVILLE, Q7�r nnacsachusetts -Department of Public Safety Board of Building Regulations and Sia-,u r juper�i.,,s _icense: CS-107633 4 � JAMES NNB�Y� r. II :rr e 114 I$Kviw w;�••- - Somerville MA 0,1145 ':754, 03!08!2018 rommiss+oner Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# C 4 5Building Inspector