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Home My WebLink AboutBuilding Permit #677 - 101 QUAIL RUN LANE 6/9/2009 BUILDING PERMIT of "O RTH A 6 TOWN OF NORTH ANDOVER :tytti, + !6 o p APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 7q pDRArlD SSACHUS� Date Issued: r d IMPORTANT: Applicant must complete all items on this page LOCATION J C( VA!C (?69Q( PROPERTY OWNER lc iM/ AC44Af Print MAP NO:&�_PARCEL: 12-5 ZONING DISTRICT: Historic District yes 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 ?C Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: 47ur25;,yAwirc< cw G73�qeX Identification Please Type or Print Clearly) OWNER: Name: - oi4w Phone: 9 7�� 3-7- Address: ( 0 l a(-,� CONTRACTOR Name: U� / �`j'z c,7r Phone:q 7 I / o e Address: : Du Al �Kpavt-vqfJtA-- 0 /�'l u Supervisor's Construction License: 0 4/c/?25 Exp. Date: /41 4 1 0 Home Improvement License: j 3 P&3 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$1253PO .00 PER S.F. Total Project Cost: $ I S 6 , vv FEE: $1n )(4-- Check No.: 0& 0 U Receipt No.: NOTE: Persons contracting with)unre ' tered contractors do not have access to the arafund signature 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 - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT 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 & 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 2008 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 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) ❑ 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 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location No. Date ' J NORTH TOWN OF NORTH ANDOVER ` Certificate of Occupancy s i # y $ Building/Frame Permit Fee $lkk ^ �� sACMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �Q 2LVi 'r Building Inspector 1301144) ,q1 an ar lf \ HOME IMPROVEMENT CONTRACTOR Registration: 113863 Expiration: 7/19/2009 Tr# 130331 Type: Individual W MICHAEL SCOTT W MICHAEL SCOTT 2 DUNDAS AVE ANDOVER, MA 01810 Administrator 8��ro w Cg Asa��ar s Construction Supervisor License License: CS 44723 Expiration: 1/11/2010 Tr# 12250 Restrildflon 00 W MICHAEL SCOTT 2 DUNDAS AVE ANDOVER,MA 01810 Commissioner ISI I NORTH Town of Andover . No. - �`y dover, Mass., T O - LAKE I� COCMIC.EWIC. 7�50'QATED 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... ....... ' ........./o.l.l..l .............................................................................................. Foundation has permission to erect........................................ buildings on . :. .... ... .r../ ....., .............................. Rough j _ � to be occupied as �"�.. �`'.'? Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 -z" PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC S 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 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. NORTH Town of O No. - G = _ C� dover, Mass., T Q LAKE COCMICKEWICK ADRATED C7 `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT............ ....... a '-'`?..t'.l.. .............................................................................................. Foundation has permission to erect........................................ buildings on . 1 .C......( 1. .r.. -...../ ?.t;?.:.............................. Rough to be occupied as .2' ss �7' Chimney ...........�........./................ .e.�................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 -z" Final PERMIT EXPIRES IN 6 MONTHS - ELECTRICAL INSPECTOR UNLESS CONSTRUC S Rough .......... ..... ........................................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required w 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 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. oN5T1ZUC-1'(0AJ 5-UpC-ANJ1Sori Wor,�E akApgov&m "-f LOAITRActoR L1CBytit 5 E O 4-4113 R. 3 e63 We Michael Scott DUNDAS AVENUE ANDOVER, MA 01810 Andover Renovations Page Of J 470.2640 Additions e Carpentry Remodeling PROPOSAL SUBMITTED TO PHONE a GATE t M1 cC C e4 C.1 nl 0 3/z&� STREET JOB NAME /a/ a,.,, ti CITY. ST TE AND P CODE- JOB IOCATIOR ARCHITECT DATE OF PUNS J01 PHONE we nem"propose to iurmsn materials ano labor necessary tar ir*completion of CG�i✓IC �'c ��-i,�'S �zJ 7Az�/ �� f�U i z' 15� WG, VkI-Ml/ ��'�57�.ci� S'/f�rni C,4 44 WE PROPOSE hereby to furnish material and Tabor—complote in oecordanco with aowo specifications.for tho sum of: dollars Payment to Be mace as follows. „v n shy All material Is guaranteed to Do as specltled. All work to be completed to a sub- stantial workmanlike manner according to specifications submitted, Der stanoaro Authorued practices. Any alteration or deviation from above soaelfications involving extra Signature L costs will be executed only upon written orders.and will become an extra charge over and above the estlmate.,A11 agreements contingent upon strikes.accidents or Note: This pmpani MY tie oetays beyond our control. Owner to carry tire. tornado and other necessary in- wmorawn by Ys if not aec ted elinin days. It surance.Our workers are fully covered by workmen's ComDenzat16n Insurance. ACCEPTANCE OF PROPOSAL.The adore prices. specifications and cone►- Itons are satisfactory ano are hereby accepted. YOU are 1utn Oriz6d to d0 the work as specttlea.Payment will be mace as outline above. SipnatYlf Date of Atcaounce: U Signature SAVERS Workers Compensation and PROPERTY Employers Liability Insurance Policy C& ASUALT'Y INSURANCE 11880 College Bvld, Suite 500 COMPANY Information Page Overland Park, Kansas 66210-1224 n,.,.ar d.f..a.�n,..t•I......«c...,. Policy Number Renewal Of Policy Period Agency AR0426107 New 10/01/2008 to 10/01/2009 0000750 Item Named Insured and Address Agent 1. Scott,W Michael Byette Insurance Agency, Inc. 2 Dundas Avenue 853 Main Street Andover, MA 01810 Tewksbury MA, 01876-1854 FED ID Number: 042915070 NCCI Carrier Code No.: 31771 Risk ID No.: 0201186 Other workplaces not shown above:None Entity: Individual 2. Policy Period: 10/01/2008 to 10/01/200912:01 am standard time at the insured's mailing address. 3A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation law and any occupational disease law of each of the states listed here: MA 3B. Employers Liability Insurance: Part Two of the policy applies to Employers Liability Insurance for work in each state listed in Item 3A. The Limits of Liability are: Bodily Injury by Accident $100,000 Each Accident Bodily Injury by Disease $500,000 Policy Limit Bodily Injury by Disease $100,000 Each Employee 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WV,WY and states designated in Item 3A of the Information Page. 3D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All Information below is subject to verification and change by audit. Adjustment of premium shall be made at: Policy Expiration Classification of Operations: See attached schedule Minimum Premium: Expense Constant: Deposit Premium: Total Estimated Annual Premium: Countersigned 09/26/2008 By DATE Authorized Agent This Information Page with the Workers Compensation and Employers Liability Insurance Policy and Endorsements, if any, issued to form a part thereof, completes the above number policy. Date of Issue:09/26/2008 Insured Copy RENMB001 WC 00 00 01 SV(12/98) a55 NGINSMANCE COMPANY INSURED V,west Street, Keene, NH 03431 Telephone: 1-888-646-7736 CONTRACTORS POLICY DECLARATIONS Named Insured and Mailing Address ANDOVER RENOVATIONS Policy Number: MPJ0418M 2 DUNDAS AVENUE Account Number: CACP13969 ANDOVER, MA 01810 Agent: BYETTE INS AGENCY INC Producer Code: 200113 AGENT PHONE : 978 851 6678 POLICYHOLDER INFORMATION Named Insureds Business: CARPENTRY RESIDENTIAL Entity: INDIVIDUAL Policy Term: 12 Effective: 03/06/09 (12:01 A.M. Standard Time at the address Expiration: 03/06/10 of the Named Insured stated above) In return for the payment of the premium and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. See the attached schedules for Description of Premises, Property Coverage, Optional Coverages, Forms and Endorsements applying to this policy and Mortgagee Schedule if applicable. BUSINESSOWNERS LIABILITY COVERAGE LIMITS OF INSURANCE Liability & Medical Expenses - each occurrence S 11000 , 000 Personal and Advertising Injury Limit S 11000 ,000 Products-Completed Operations Aggregate Limit S 2, 000 , 000 General Aggregate Limit S 2,000 ,000 Fire Legal Liability - any one fire or explosion S 500 , 000 Medical Expense Limit - per person $ 10 , 000 Business Liability and Medical Expense: Except for Fire Legal Liability, each paid claim for the above cover- ages reduces the amount of insurance we provide during the applicable annual period. Please refer to section DA. of the Businessowners Liability Coverage Form. For policies subject to premium audit: Annual Audit Applies. Commercial Inland Marine Coverage Part $ Estimated Annual Premium: S TOTAL PREMIUM AND CHARGES S Countersigned: t -'1i� J By, 64-5470 (9/00) 03/19/09 NEW BUSINESS DN ' �/ The Commonwealth of Massachusetts r Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (J,t / � l C 6A� Ship j� Address: 2—0 fA[ DAI vAvL City/State/Zip:A Dovr5,�C Al A 0 I E1 u Phone M-9 1 7� Are you an employer? Check the appropriate box: Type of project(required): 1.X I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6. New constriction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. F] Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. E] Building addition required.] 5. We are a corporation and its 10.0 Electrical repairs or additions ❑ � 3.❑ I am a homeowner doing all work officers have exercised their i l.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, S 1(4), and we have no employees. [No workers' 13XOther �JZC�A'l comp. insurance required.] *Any applicant that checks box#I 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. *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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy turd job site information. hlsurance Company Name: //6V,6 P'dLt-d2��) a40 At" /AI-S CV Policy# or Self-ins.Lic. #:A9 0 g 2 (o/ '0-7 Expiration Date: /o// /a7V Job Site Address: t 0 I V*C A/i City/State/Zip: !'t 0: //x00VU<- A-1N qVi Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal 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 hnvestigations of the DIA for insurance coverage verification. I do hereby certify;11del tl pair utd pe es �ofperjury that the information provided above is true and correct. Signature: V (f Date: U el Phone#: 9i of 71 ) f o?l Official use only. Do 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#: