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HomeMy WebLinkAboutBuilding Permit #1030 - 101 BRUIN HILL ROAD 6/9/2015 BUILDING PERMIT ?aero Q7°s'byo 3 - t TOWN OF NORTH ANDOVER 10 APPLICATION FOR PLAN EXAMINATION AW Permit NO: 1, /9 jjDate Received 4 i Date Issued: ACHU IWNRTANT:Applicant must complete all items on this page LOCATION Print =: PROPERTY 0WNER- �4Ir✓tl_ Print MAP NO/� ARCEL ZONING DISTRICT.- Histonc'District y o: '77 __ Machine Shop Village ye n` TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne family U Addition U Two or more family n Industrial U Alteration No. of units: F]Commercial epair, replacement n Assessory Bldg n Others: U Demolition rl Other Septic 'n Well 11.Floodplain r i Wetlands � Watershed_District n Water/Sewer I: Identification Please Type or Print Clearly) OWNER: Name: 'bA fJ d E(,i Phone: Sok n-7 Address: 2W I A.JJILL . I�I�hO�(ajZ Mh- 17x/s CONTRACTOR Name. Phone:_ 2 - rY_/ ' ' , Address. - , Supervisor's Construction.License. Exp. Date Home Improvement License _Exp. Date Y ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.-BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ , Check No.: 1 ' Receipt No.: Tl NOTE: Persons contra in ith un gister d contractors do not have access to the guaranty fund`. _ r Signature of Agent/Owne_r - `'Signature of contractor -.1 I NORYH. BUILDING PERMIT ���t�E° rb;'��o IN TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION _ 4 Permit No#: Date Received ATEG�pat�g SSACHUS� 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 0 One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg. ❑ Others: ❑ Demolition ❑ Other D FI`ootl lai ' i®We4.tlands - . :#® Ullatershed ®istrict w Water Sewer 3 =y � 21 , �} DESCRIPTION OF WORK TO BE PERFORMED: t. 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:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ Crieck No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund anature©f Aaeritl®vvne ra g am «"�Siariat r of nt' "t6rd' t`� n I -- — - I Location 10 I � U , i No. Date • • TOWN OF NORTH ANDOVER ti • Certificate of Occupancy $ Building/Frame Permit Fee $ -- Foundation Permit Fee $ P Other Permit Fee $ TOTAL $ f Check# 5 ` ' -� Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Ins ❑ z' 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 m 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 Water FA Sewer Connection/signature&Date Driveway Permit ]DPW Town]Engineer: Signature: Located 384 Osgood Street FIREIDEPARTIVIERIT �Temp,kpumpster0n:site Locatetlyat124 Main Street ' f"' y � FireDepartmentsignatureldate az. * � � itwd � L'� CQMIVIENTS ,„ ',° � iJ' � ���� Dimensioln Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, wast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1oo-$l000 fine NOTES and DATA— (For department use) ® Notified for pickup Call Email _. Date Time Contact Name - 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 4. Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses aCopy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products ISIOTIE: 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 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 NORTH own of s EAndover 0 46� h 0 No. /03d — /5 h " ver, Mass, COC NIC 4.1WIC.f y1• S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System '[:THIS CERTIFIES THAT ........ W. .........�.�ir..� !l .w��.... .......... BUILDING INSPECTOR .�.0.'........ . Foundation has permission to erect .......................... buildings on ... .A�►.... .l Rough to be occupied as ....... ... . I��* .� Chimney �. .... ...... ......... ........... .......................................................... ey provided that the person accepti this permit shall In every respe onform 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 f Final PERMIT EXPIRES IN6 ONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT TS 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. UIEMENS&S NS � &R $� INC OWNER INFORMATION CONTRACTOR INFORMATION Owner: Daniel Zehner Company: CLEMENS&SONS CONSTRUCTION&ROOFING Address: 101 Bruin Hill Rd website: clemensroofing.com North Andover Ma Address 67 9th Ave Phone: 508-287-4827 Haverhill, MA 01830 Email: Dzehner4@verizon,net Phone: (781)547 9292 Email: Shane.clemensroofing@gmail.com PROPOSK Clemens & Sons Construction will perform the following: Roof Replacement Strip entire roof to boards Replace up to 150 lineal feet of boards if needed Apply ice&water shield to first 3' of roof Apply ice &water shield to all flashings and protrusions Apply 151b felt paper to entire roof install 8" drip edge to perimeters Install GAF lifetime architectural roof shingles Cut open & install ridge vent Remove gutter guards Clean getters Re-install existing gutter guards Clean & remove all debris Pull all necessary permits with the town Shed Roof included Clemens & Sons Construction & Roofing Inc. is a licensed and insured General Home Improvement Contractor in the Commonwealth of Massachusetts. All workmanship is guaranteed for 5 years (state min. 1 Year). ALL WORK TO BE COMPLETED FOR THE SUM OF : $7,000.00 �.J The Commonwealth of Massachusetts Department of Industria'Accidents . Offlce of Invesdg4dons 600 Washington,Street Roston,lt3A 02.11-1 wwwmass gov14 a Workers'CbmtpenMtlb j6"0g0,Affi4At:Vers/Contraatonfflleettriciait kdts- tleant Informiatioa Please krintLewbly. N&Ine(Business!Organization4ntiividual):: 6�� �'�'✓ � ' .Address: ty ? . CjV1State/Zjp 4 /IJJIOAc 0 Phmp e ou an employer?Chic e<approgriate boz: Type og project(=uquic�d); II am a.e l erwitli 4. Q I:aura general contractor and I ti mp r►Y Q Alewtonsttuction employees.(full atuilot ):' have hired the sub-contractor$ propriet4 PaBaer- listed, the attached sheet:_ 7. ❑Itemodeting 2.[} I am a sol®. r•or ship and have:no employees: These sub-contractors,have $. [ ;Demolition working weany„ ity, workers'cQ� insurance. g. .for aa#tac 0 Buildingaddition. (No workers'comp:insurance 5. ❑ We are a corporatiomind its. required.] right have exercised their I4.{]Hlectrical repairs or additions 3. I am a homeowner doing altwork rigi►i of exemption per.NIGL: 27,❑Plurnbiag iegsic&oc 8t tions myself.(No woikers'comp. c.152,§1(4),and we have no insurance requirefl t en iployees..(No.wo*ers' co”. I'3D oat�r •Any applicant thatkheeka box Ot tnostalto fill oi#:tha`seCtiori bdow showing tharworfcas'compcumboq'pidiry i 6iftilm t Homeowners who submit this att.. icQis/Rit .t) y�ar0 og ail v¢bttc cad thsa ttitsotagide ppnatsubuiita A�t d vit i ch ;Goettac m that c*k thio ilex muata O¢+a3t addidC eeistaawirlg tttcpame+of..tttti sub cotaractorsattct tdcir warttera' k4ma"em er that 1s pmvhrh g ttior#ets"cdnip00dt insufance for mY empWeesw Bev is thepoheq and r aTte P�3' i'nfa!rntaYiote. L*ttittrincc Company Name: Policy t#or Self-ins.Lid.#:: U Y�10 I.l .� Etgthatiori-Bate: fie...J Job Site Address: t W� _0 City/Swizip: A rtof�e warkets"�onYpeii4"atio�,policq ileelars�tttm �(s1.to�vin�Ute ptaltey aatreber.and eaiifiatt�ii:d�e). . Failure to secure coverage as requi A uncle;Sedion:23A.oEM6L c. I5 can iead to d. ui}pasition cfcrirntttg ictteti#ies of a rM up to S 1,500.00 and/or.one year itnpkisomncnt;as-well as civil penalties in.the form-pf a-STDP 11VOH#C I iibD ,. a fine of up to$250.00 a day ag�izsst the o)sZ4air: Be-Advised thata*copy of this staternent:�be forwarded to the Office of Investigations of.the DL .fw inWraaec:coverage•verification. I do hereby certify l it ofpedury Millhe-information.proald/e,Fd chows tmeeJandG ¢et Sijmature: Date: 4 Phone€t: I J Official use only. Do not write in tA*area,to be completed1y ci{K.or town 0joew City or.Town: Permit/License# Issuing,Authority(circle one):, i 1.Board of Health 2.Building Department 3.CityfPown Clerk 4.Electrical Inspector 5:Plumbing Inspector 4.Other Contact Person: Phone#: Rightfax C3-2 6/10/2015 5 : 16: 32 AM PAGE 2/002 Fax Server DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE ICERTIFICATE �'IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. IS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE R 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: FARQUHAR&BLACK INS AGE PHONE FAX 85 EXCHANGE STREET (A/C,No,Ext): (A/C,No): E-MAIL LYNN,MA 01901 ADDRESS: 22PTJ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY CLEMENS&SONS CONSTRUCTION&ROOFING INC INSURER B: INSURER C: INSURER D: 67-69 9TH AVENUE INSURER E: HAVERHILL,MA 01830 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MMIDD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE 0 OCCUR. PREMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY [::]PROJECT [—]LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY ;OTHER EMPLOYER'S LIABILITY YM UB-479OP159-14 09/23/2014 09/23/2015 LIMITS ANY PROPERITORlEXCLUDED? OFFICER/MEMBER EXCLUDEE D?EXECUTIVE N/A E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OP ERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NOTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 120 MAIN ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELIV D IN ACCORDANCE WITH THE POLICY PROV AUTHORIZED REPRESENTATIVE NORTH ANDOVER,MA 01845 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP RA Iv. All rights reserved. From:Marian Cruz Fax:(781)780-2453 To: 19786889542@rcfax.cc Fax: +19786889542 Page 2 of 2 06/09/2015 1:08 PM A�0® CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD 6/9/20155YYY) 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(les) 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 CONTACT Christopher Kennedy NAME Farquhar & Black Insurance Agency, Inc. PHONE (]$1)599-2200 AX (781)581-3940 No Ext), Arc No 85 Exchange Street - Suite 101 E�dAILADDRESS:Chris@FandBInsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Lynn MA 01901-1475 INSURERA:ESsex Insurance INSURED INSURER Charter Oak Fire Insurance Co. 25615 Clemens & Sons Construction & Roofing Inc INSURER C: 67-69 9th Avenue INSURER D: INSURER E Haverhill MA 01830 INSURER F: COVERAGES CERTIFICATE NUMBER:City of North Andover 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSIR LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYYY POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 $ COMMERCIAL GENERAL LIABILITY DAMAGE O RENTED PREMISES a occurrence $ 50,000 A CLAIMS-MADE ❑X OCCUR 3DU5700 6/17/2014 6/17/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JE PRCT O LOC $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT a accident $ 300,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED x SCHEDULED -6307RS74-14-AUF /22/2019 /22/2015 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident $ Uninsured motorist BI split limit $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATIONWC STATLL OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-FJ1 QNPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Compensation Insurance Coverage is written with ACE Group Insurance Coverage effective 9/23/2014-9/23/2015. ACE Group Insurance Company will issue the Workers Compensation Insurance Certificate directly to you shortly. CERTIFICATE HOLDER CANCELLATION (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Marian Cruz ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INAf175 toninnsi m Tk-Ar r10t'1 Homo-4 1^-- -16—^f Af`r1Dll Massachusetts -Department of Public-Safety d Standards Board of Building Regulations an Construction Supervisor Specialty'O12 License: CSSL-1.,I.s / DANIEL F CLENIPS e 67 9th Avenue.0130 Haverhill MA Expiration 11/06/2015 Commissioner 10 ' Office of Consumer Affairs&Business Reg 'anon ME IMPROVEMENT`OONTRACTOR ' egistration. klIj69611 Types xpiration.�.--s7/8/2015Individual •DANIEL CLEMENS '{ � k ( DANIEL CLE EN i, = b?9TH AVE -r n .HAVt?.RHILL MA'01830 Undersecretary, { { k