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HomeMy WebLinkAboutBuilding Permit #578 - 101 GRANVILLE LANE 2/27/2013 f NORTh q ✓ BUILDING PERMIT TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATI Permit NO: 70 Date Received !i 04 «„«. TED Date Issued: CHUS IMPORTANT: Applicant must complete all items on this page LOCATION-101 C1-y,-r1 V{r(i e. L6 Pri t PROPERTY OWNER L R(,r-,4 + KAti 4 r\o V&,A\ Print MAP NO: W PARCEL:�Z ZONING DISTRICT: Historic District yesnn Machine Shop Village yes 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 ❑ Septic ❑Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer / RE' sJf-- 2 $ec (w, c� i-Uxr 9(K 16' Identification Please Type or Print Clearly) Ilk, OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: I Ky j*'A f A� C+ ill c o/-, NlI�d t eO Supervisor's Construction License: $ 1914q Exp. Date: Home Improvement License: Exp. Date: 1 0SLIN '7 - 1-7- ZGIy 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: $ 10, 1-50 FEE: $ 1 1111� Check No.: Receipt No.: NOTE: Perso tracting with unregistered contractors do not have acc s to the guaranty fund Signature of Agent/Owner 9AA(�– Signature of contractor ,4 Locatio./o/ No. 3 Date • - TOWN OF NORTH ANDOVER e - --y Certificate of Occupancy $ Building/Frame Permit Fee $ '7F Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 26176 Building Inspector v. 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 ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH`S Reviewed on Signature 4 COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sevier Connection/Signature& Date Driveway Permit DPW Tow. Engineer: Signature: Located 384 Osgood Street FIRE bEPARTMENT - Temp Dumpster on site yes no Located at'124 MainStreet Fire Departinenf-signatu"re/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 2010 I! I I 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 In Affidavits for Engineered products roducts g 9 9 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) o 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 ❑ 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 In all cases if a variance orspecial permit was required the Town Clerks of ce 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 subm;tted with the building application Doc: Doc.Bui?ding permit Revised 2012 From: GFI FaxMaker To: 9786889542 Page: 2/2 Date: 2/27/2013 8:42:47 AM ,eco CERTIFICATE OF LIABILITY INSURANCEF2/27/2013 DATE(MMIDDIWlY) tk�' 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 NAME: Joan Street FAX SOUCY INSURANCE AGENCY AICNNO Ext: (978)744-7110 AIC No: (978)791-2059 P. O. Box 4467 ABDRESS:Jsoucy@soucyinsurance.com PRODUCER 83 Lafayette Street _ CUSTOMER ID •00000192 Salem MA 01970 INSURER(S)AFFORDING COVERAGE NAIL# INSURED _ INSURERA:VerMOnt Mutual Insurance Co. 26018 INSURER B Allmerica Financial Ben Ins 41840 MYSTIC BUILDERS JOHN RISSER DBA INSURERCAssociated Employers Ins. Co 3 LAUREL ST INSURER D: INSURER E: WOBURN MA 01801-4421 INSURER F: COVERAGES CERTIFICATE NUMBER:CL132601245 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 ADUL SU13K POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDIYYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREM SES Ea occurrence $ 50,000 A CLAIMS-MADE 7 OCCUR P11019917 /1/2013 /1/2019 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 $ POLICY JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO B ALL OWNED AUTOS WN8845233 9/1/2012 /1/2013 BODILY INJURY(Per person) $ BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS Medical payments $ Broadening Form Applies $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATIONx WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS I 1R ANY PROPRIETOR/PARTNER/EXECUTIVENIA E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? CC5006121012013 /12/2013 /12/2019 (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 OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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. Building Department 1600 Osgood St AUTHORIZED REPRESENTATIVE Suite 2-36 North Andover, MA 01845 Paul Soucy/PAL ACORD 25(2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD This fax was sent with GFI FaxMaker fax server. For more information,visit: hfp://wvvw.gfi.com 02/27/2013 09:08 7819332504 MYSTIC BUILDERS PAGE 02/02 I CERTIFICATE OF LIABILITY INSURANCE OATE(MMlDD/YYYY) 2/6/2013 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)mint 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 certificats holder in lieu of such endoesement(s). PRODUCER CONT Joan Street NAME! SOUCY INSURANCE AGENCY (AIC°NN Ext), (978)744-7110 F� No):(97e)741-2059 P. O. Box 4467 ADDRRFSS: ]soucy@soucyinsurance,com 85 Lafa ette- Street PRODUCER 00000192 X CUSTOMER.ID lo: Salem KA 01970 INSURER(S)AFFORDINfd COVERAGE NAIL� INSURED INSURERa Vermont Mutual Insurance Co, 26018 INSURER B Allmerica Financial Sen Ins -41940 MYSTIC SUIL,DERS JOHN RISSER DBA INsuRERc Associated Etftployers Ins- Co 3 LAUREL ST INSURER D: INSURER E: WOBURN MA 01801-4421 INaURERF: COVERAGES ICERTIFICATE NUMBER:CL132601245 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' ;ADDLISUBR! pOLICYEFF ' POLICY EXP LTR• TYPE OF INSURANCE wVD! POLICY NUMBER MkVDD MMIDD LIMITS cENERAt.L1AQ1uTv EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PRiA CLAIMS-MADE X OCCUR PI1019917 1/1/2013 1/1/2014 MED EXP(Any occurrence)r)) :9 50,000 MED EXP(Any one ptrt�n) ;S 5,000 _ ;PERSONAL&AOVINJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S 2,000,000 X•POLICY Pko- LOC $ AUTOMOBILE uaeluTY COMBINED SINGLE LIMIT S 1,000,000 •ANY AUTO IEe ecadsnl) $ ALL OWNED AUTOS ASM8845233 9/1/2012 .9/1/2013 BODILY INJURY(Pet Dersvn) .S XSCHEDULED AUTOS BODILY INJURY(Per awide,,O;S PROPERTY DAMAGE S X 'HIREO AUTOS (Per 200id¢nt) I X NOWOWNED AUTOS Medical payments $ Broadening Farm Applles S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE; :AGGREGATE 5 DEDUCTIBLE R£TQNTION S S C WORKERSCOMPENSATION WCSTArU- ' :OTH AND EMPLOYERS'LIABILITY `,I N X j TORY LIMITS ER ANY PROMGMSeRrEXCLUDE/EXECUTIVE E.L.EACH ACCIDENT S 100,000 (maFnda1R/MEnNIHpIXCLUOED? ❑:NIA: WCC5006121012013 1/12/2013 1/12/2014 Ir e3,de!;zbe under E.L.DISEASE-EA EMPLOYEE$ 100,000 DESCRIPTION OF OP£RATIONa Wow E.L.DISEASE•POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Atteeh ACORD 101,Additional Rrmerke Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Raul Soucy/PAJL ACORD 25(2009/09) ®1988.2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD 'Town � NORT1�/ o n over 0 No. h ver, Mass, cp •�,—4I COc NIc"IWICK y1. �,9 ASR^TED r.4P�,�5 PE s V BOARD OF HEALTH Food/Kitchen RMIT Septic System THIS CERTIFIES THAT (Gt✓.'.. rDPA al!a.:` ........................................ ............... BUILDING INSPECTOR .............. ... ....... ...... V has permission to erect ....... buildings on gu �!lGd•V�� ............................ Foundation Rough 1-01 to be occupied as ...... ..... /. ..... .....dl-�.�.r:✓!(V.!..�..... .r........'.rl..4l..« ..:........................ Chimney provided that the person accepting this permit shall in every respect form 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 Final �a. • PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI STA 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 I FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE NORTH own. o t E : ., ndover o - to h ver, Mass, C` •r1`4 ! I COC NIC HIWKK y1. A04ArED 0ea�,�5 S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..............�.rt/,.'!:L,....... ...D? a.4!al ............................................................. BUILDING INSPECTOR has permission to erect g , .� �!l.Cd•V.!1. ............................ Foundation .......................... buildings on ....,,, Rough to be occupied as ...... ..... 'an .....CO JJ. ..���.r!....dio.r�.: t.. .j.......................... Chimney provided that the person accepting this permit shall in every respect 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 Final aa. • PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI STA 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. SEE REVERSE SIDE 02/26/2013 16:30 19782582598 DN PAGE 01 MYSTIC BUILDERS 781-933-2504 Estimate John M_ Risser 1 R Vining Ct DATE ESTIMATE NO. Woburn MA 01801 2/26/2013 3278 NAME/ADDRESS Fully Licensed and Insured Larry&Kathy Donovan References furnished upon 101 Grandville Ln request North Andover MA 01845 Visit us at: www.mysticbuilders.net CUSTOMER PHONE DESCRIPTION Total Remove stucco siding, decorative boards, cornerboards&window trim on 10,150.00 two sections approx. 9x16'on front of house, replace with new red cedar shingles. PAYMENTS AS FOLLOWS: $150.00 DEPOSIT $5,000.00 START OF JOB $5,000.00 DUE UP QN CLr� X J 7 � X CUS MER SIGNATURE CONTRACTOR SIGNATURE Phone or e-mail questions to jobs@mysticbuilders.net Total Prices valid for 30 days $10,150.00 www.mysticbuildem.net I The Commonwealth of Massachusetts Department of Industrial Accidents _ ®ffice�of Investigations ' C1600 Mashington Street Boston, MA 02111 www.ut ass.gov/dia `'porkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Informatiall Please Print Ise ilii Name(T usiness/0rganizztiomgiidividual):A_yAtrc- R, J4 Address: {- City/State/Zip: W QJ U` 01 (M Phone #: Are you an employer?Check the appropriate box: 1. am a employer with. _ -_ 4. 0 1 am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors o• ❑New construction 2.[] I am a sole proprietor-or.partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have working for me in.any capacity. employees and have workers' g' 0 Demolition [No workers' comp.insurance comp. insurance,t 9. ❑ Building addition required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised,their 11,[�plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL insurance required.]t c. 152, §1(4),and we have no 12.[l Roof repairs 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. I 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 andstate whether or not those entities have employees. If the sub-contractors have employees,they must provide-their workers'camp.policy number. 1 am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: �� n � Policy#or Self-ins. Lie.#: C -- Soo Z a 1 d xpiration Daten ' J�tl /S 2.p � Job Site Address: (0 1 rwvt% u 111 L,,� City/State/Zip: ?V O 1/I G(ayy-- 144 - number a copy of the workers' compensation policy declaration page(showing the policy nuntber a ration4 f Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal P 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 Investieations of the DIA for insurance..coverage verification. 1 do hereby certify under-the pains-and penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone#: !'— 133— Z5 U`f Offccial use only. Do not write in this are , tb he completed by city or town official L City or Town: Perniit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector G.Other Contact Person: Phone#: �4u,•arhu�ctt� Dep. (II'Ptsislir 4afct� Rdiartl of Builtlin-, Reu(siation• and sland.artf Construction Supervisor License License: CS 51844 i �S= JOHN M RISSER 3 LAUREL ST WOBURN, MA 01801 Expiration: 5/13/2013 (unlinl��Inllcl' 7r#: 14451 �����crn.nro��iar,�i�/�r,�C-��<ra9ac�✓i1n.(�i , Office of Consumer Affairs&Business Regulation SOME IMPROVEMENT CONTRACTOR =� egsstration: 105480 Type: xpiration: 7/17/2014 DBA MYSTIC BUILDERS John Risser 3 Laurel St. Woburn,MA 01801 Undersecretary