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HomeMy WebLinkAboutBuilding Permit #100-15 - 104 FRENCH FARM ROAD 7/29/2014 BUILDING PERMIT o�"��T b;��o TOWN OF NORTH ANDOVER 03� 9: - 6 0 APPLICATION FOR PLAN EXAMINATION _ I � e, t � 04 Permit No#: lv�-1 Date Received � '0"ArEo,Pp c5 �SSAc►+U Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure ye no MAP �1�PARCELW� ZONING DISTRICT: Historic District es no Machine Shop Village es n TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well 0 Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Nam fie- Phone: /9)r Address: . Supervisor's Construction License: Zo Exp. Date: c Home Improvement License: / 7 Exp. Date: - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF TJX TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ I .Jl FEE: $ c/0 Check No.: Receipt No.: �D -�-22-t� NOTE: Persons contractingunr 'stered contractors do not have access to the guaranty fund Signature of Agent/Owne gnature of contractor Location /6 ! ��vw 2-Z No. 10(-) Date T_7 / • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit FeeiC $ ' Foundation Permit Fee $-1 Other Permit Fee $ TOTAL $ Check# 1GJ Building Inspector Plans Submitted ❑ Plans Waived 0 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 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& 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 Call Email ' Date Time Contact Name Doc.Building 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 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/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 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 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 Doe:Building Permit Revised 2014 From:Stephanie Desmarais FaXID: Page 2 of 2 Date:7/29/2014 12:43 PM Page:2 of 2 COVERIT-01 STDE DATE(MMIDDNYYY)CERTIFICATE OF LIABILITY INSURANCE 1 7/29/2014 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). CONTACT (508)252-3312 NAME: J PRODUCER oanne deSousa Viveiros Insurance Agency,Inc. ac°No Ext: 508 676 0309 (AAic No): PO Box 459 ADDRESS,275 Winthrop Street SS:jdesousa viveirosinsurance.com Rehoboth,MA 02769 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:The Travelers Indemnity Insurance Company of Connecticut 25682 INSURED Cover Rite Siding Sr Windows Corp INSURERB: 1015 Broadway INSURERC: Haverhill, MA 01830- INSURERD: 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 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSAIML SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER IMMIDDIYYYYl (MM/DDIYYYYlLIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCALGENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE F-1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY jE LOC $ AUTOMOBILE LIABILITY OMBINED SINGLE LIMIT Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED DAMAGE­-- $ HIRED AUTOS AUTOS PERACCIDEN UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X TORY LIMITS OER TATU- AND EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTNE YIN IE-UB-6624X63-A-14 3/18/2014 3/18/2015 E.LEACH ACCIDENT $ 100,000 OFFICERlMEMBEREXCLUDED? NIA (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/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845- AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD NORTh Town of t EAndover o "t No. 166- 16 oh ver, Mass, al COC MIC MI WICK �1. ��S RATED i`PP�,(5 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ................... .J.&M.....�.,...r V, ,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, BUILDING INSPECTOR has permission to ere .... buildings on 0 ...'r!�` Foundation �....................� ......................�.. ..... ......... _ . ..?....... ........� ® Rough to be occupied as .. .... ... .....�............................................. Chimney provided that the person accepting this ermit shall in every resp 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 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 DID . UNLESS CONSTRUCTIO TA 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. proposal GOND -7 _--� Siding & Window Corp. Siding& Window Specialists - — Haverhill,MA 1015 BROADWAY Atkinson,NH 978-372-3260 �ecl HAVERHILL,MA 01832 603-362-9951 SIDING Esa ,q�b� Home Improvement Contractor Lic#112392 WINDOWS Construction Supervisor Lic#103535 GUTTERS OSHA Certified T ROOFING FREE coverritecorp.com BBB. FULLY coverrite1976@gmail.com ESTIMATES INSURED DATE PROPOOSSAL SUBMITTED TO PHONE G.. � L STREET-' JOB NAME /D L CITY,STATE,AND ZIP JOB LOCATION zeWe hereby submit specifications and estimates for: Colof Style Insul. Window Trim Trim Color JOB OUTLINE COST JOB OUTLINE COST Siding Gutters o Insulation Pipe s /7y Facia Cover Siding Removal Facia Board t—) Replmt. Windows Soffit Cover Windows Windows Full-Sills GJ Doors y Door Casings Ceiling Shutters7" Roof NOTES: ~ ly Vle propOt hereby to furnish material and labor-complete in accordance with above specifications, for the sum of: _/Z dollars ($ -d PAYMENT TO BE MADE ,S OAOWS: All material is guaranteed to be as specified.All work to be completed in a workmanlike manner Authorized according to standard practices.Any alteration or deviation from above specifications involving extra Signature ..�' costs will be executed upon written orders and will become an extra charge over and above estimate. All agreements contingent upon strikes,accidents,or delays beyond our control.Owner to carry fire, Note:Thts proposal may be tornadoand other necessary insurance.Our workers are fully covered by Workman's Compensations withdrawn by us if not accepted within / days. Rcreptance of Vrop05aLThe above prices,specifications Signature, ' and conditions are satisfactory and hereby accepted.You are authorized to do work as ; specified.Payment will b dei as ou$i/n�1 aboyey Date of Acceptance: / �� / Signature I i i Massachusetts -Department of Public Safety. Board of Building Regulations and Standards' Construction Supervisor License: CS-103535 ., JOHN J SERRAT9RE 15 Smythe Street. Haverhill MA 01$30 r .. Expiration Commissioner 11/05/2015 en�xnzaazcueall� V JetLr z a, cr.uac zu Office of Consumer Affairs&Business Regulation IMPROVEMENT CONTRACTOR egistration: 112392 Type: xpiration:., 3/27/2015 Private Corporatic , COVER-RITE SIDING&WINDOW CORP John SERRATORE 52 OLD-COUNTY-RD.- PLAISTOW,NH 03865 �r Undersecretary i The Commonweal&of tYlamehaselts -- Depa��nen�o,�'.tiac��s�icclAccic�ent� • . Office o,flnvestigaflons 600 Washington Mreet Boston,MA 02111 www.rnassgovlcixrx Wgrkexs'Compensation Insurance Af iidav it:BiiRdp-rs/Contractor$)ElectrlciansJPXum PM .A. Zcant Wbrnnatio n Please Print Le 'bX Name(Business(OrganizationJTndz'viduat}: Address: Ol�7— Ar- - My/S tate/Zip: Phone 11: Are yotx plaper?Cb.eck the appropriate box: Type of project(rre jaired): 14aam a employer with 4• d x am a general contractor and I 6• ❑New construction f employees(full an(Yox part-time)* have hire dthe sub-contractors 2.[� T am a sale proprietor or partner listed on the attached sheet 7• �]E emodeling slop and`7iaveno.employees These suis-contractors have 8. [(Demolition working forme in any capacity. workers'comp.insurance. 9• ❑Building addition Wo workers'comp.insurance 5. ❑We are a corporation and its 10.0 Electrical repairs or additions recluixed.� officers have exexeisecl.iheix 3.[] am a homeowner doing alt work right of exemption per MGL 1111 Plumbing repairs or additions myself PTO workers,comp. c.152,§1.(4),andwehaveno UPRoofxepairs insnranceret3uired.1? employees.[No workers' 1311 Other comp.insurance required.] A�applicantthat checks box#I mustaiso alt outtheseeHon beldw showingfheirworkere eompensafion policy infounation. i Homeowners who mbmit this affidavit indlcatingthey ire doing allworXand then hire outside contraotors must submit anew affidavit indicating such. TContractors that checkthis box must attached as additional sheet showing the name ofthe suh.-contractors and their workers'comp.policyinformation, I am an emproyeN tliai s providing wo.-Ifers'compensation insurance forray ctgfoyees Below b ihepoliey an4joh site information. insurance Company Name;. Policy##or Selz los.Lic.#' Expiration Date: lob Site Address: City/State/Zip: Attach a copy od Me Workers,compensationTolicy declaration page(showing-the polleynumber and expiration date). yailure to secure coverage as xequirecdunder Section 25A ofMGL o,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 WORTS ORDER.and a frn.e of-up to$250.00 a clay againstthe violator. D advised that a copy of this statement maybe forwarded to the Office-of Investigations of the DTA.for insurance coverage verification. Xdolierebyor andpenaXtiesofperimythattheir2 orrnationprovidectabovveiis`trueaJndeo reet, - Si ature• Date: Phone#• Oficial use only. Do not wfite in iNs area,to be completel y city or town offZciar City or Town: I'erralflLicense 0 Issuing.Authority(circle one): 1.Board of Health 2.Building XDepartment 3.CityNown Clerk 4.Electrical Inspector 5.plumbing Inspector fi.Other - - - Information and Instructions Massachusetts General Laws chapter 152 xequires all,employers to provide workers'compensation for their employees. Pursuant to ttds statute,an employee is defined as"...evarY person k the service of another under any contract ofh re; express orimplfed,oral orwxitten:' An eVloye is defzued as"an individual,partnership,association,corporation or other legal entity,or anytvro oxrnoxe of the toxegoiug engaged in a joint enterprise,and includingthe legal representatives ofa-deceased emplo�ex,.or the receiver outrustee of"an individual,partnership,association or other legal entity,employing employees. Ilowevex the owner of a dwelling house having notmore than three apartments and who xesides therein,,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction ox repair work oa such dwelling house or onthe grounds or building appurtenant thereto shall not because of such,employment be deemedto be an employer." MUL chapter 152,§25C(6)also states that"every sfate or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings iu 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 ofpublic work until ' ecepfable evidence of coxnpliauce with the insurance requirements of this chapterhave beenpresentedta the coufracting authority" Applicants .'lease ill out the workers'compensailon affidavit completely,by checldng the boxes that apply to your situation and,if necessary,supply sub-confractor(s)name(s),addresses)and phonenumber(s)along with their eer fficate(s)of insurance. Limited Liability Companies(GLC)or Limited Liability Pax tn.erships(LU)with no employees otfier than the members orpartuers,are notrequixedto carry workers'compensationlosurauco. If an LLC orLLP does have employees,apolicy is required. Be advisedthattbis affidavit maybe submittedto the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. i ie affidavit should be returned to the city or town that the application for the permit or license is being requested,Pot the De�axtment or Tndusfrial Accidents. Should you have any questions regarding the law or if you are xequired to obtain a yTorkexs' compensationpolicy,please call the Department at the numbor listed below. Self insured companies should enter their selfinsurance license number on the appropriate line. t City or Town Officials Please be sure thatthe affidavit is complete andprinted legibly: Tib Department has provided a space at the bottom ofthe affidavitfoxyouto fill out in the event the Office of Investigations has to contactyouxegardingilio applicant: .'lease be-sure to fiil inthe pomait/license number whichwill be used as a reference number. In addition,an applicant tlaatanust submitmultiple permit/Rcense applications ia any given year,need only submit one affidavit indicating current policy'information(ifnecessmy)and under"lob Site Address"the applicant should write"all locations in (city or town)."A copy o£the affidavit that has been Officially stamped or marked by the city or townn may be pxovided to the applicant as pr" of that a valid affxdavit•is ou file for future permits or licenses. Anew azddavit must be filled out each year.Where a.home owmerorcitizen is obtaining a license orperitnot related to anybusiness or commercial venture (i.e.a dog license orpermitto bum leaves etc.)said person is NOT require d to complete this aftxdavit. The Office of Investigations would life to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Departm.ent's address,telephone and faxnumber: The CQ: o,u-weal of X1 e1a a Dap-a tment QfUT-m Bial Accident., 6,00 Washington Mon,MA 42111. Revised 5-26-05 FaX 0 617-727-7749 WWW'Maw,go-Waa