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HomeMy WebLinkAboutBuilding Permit #006-12 - 111 PETERS STREET 7/1/2011 APPL OWN OF NORTH ANDOVER Robcr refs. ax- -od1., ICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: / !/ I ORTANT:Applicant must complete all items t`"a '. e VI LOCATION Print f PROPERTY OWNER ,/ Print MAP NO.(19 � PARCEL: n0/�ZONING DISTRICT: Historic District 1es y no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ' ❑Addition ❑Two or more family ❑ Industrial f Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ® Sept` ®Well` ®Floodpla�n .y; ja7,',xW_IaerhedDsistret . ' I DESCRIPTION OF WORD TO BE PERrrORMED: ScreenrU00tr C00 h (Identification Please Type or Print Clearly) OWNER: Name: ��e-t m,a rhone Address: ttt 1z�cRs S4. No, Qndcutr CONTRACTOR Name: (`��,ee� �_®taa�c���,on core Phone: Address: a s Supervisor's Construction License: 31�%I Exp. Date: Home Improvement License: 1 b 5't%I Exp. Date: 9l►4 I a 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. p _ J: Total Project Cost: Aith so w FEE: $ Check No.: Receipt No.: 2 y 3 NOTE: Persons contracting with unregistered contractors do not have access tot uara g ty fu -`r7Y',A ac* c t { �.�� s �SignatureofAgent/Owner _.mom �_ .a- -a gnatureof.contractor ` = - - - Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well • 0 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 i Planning Board-Decision: Comments � Conservation Decision: Comments i I 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 kCOMMENTS ` I Dimension i Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. i.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No it DANGER ZONE LITERATURE: Yes No j MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use i I i I ® Notified for pickup - Date Doc:.Building Permit Revised 2008mi Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. E Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o 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 o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o 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) o 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 o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report o 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: Doc.Building Permit Revised 2008mi Locationl�' No. �� Date I I a TOWN OF NORTH ANDOVER _ o 10. A } ° j Certificate of Occupancy $ NUS Eta' Building/Frame Permit Fee $ AC Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Cl ` r 24 69 C/ Building Inspector NORTH To of . Andover .. 0 ... ......... 0 , '� dover, Mass., 7// O -- LAKE COCHICHE".CK 7�SD'QATE D P'PCl BOARD OF HEALTH Food/Kitchen PEn IT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..... ....... ............................gee-........�............................................................ Foundation //"/has permission to erect........................................ buildings on ... .. ...�s:.... .............................................. Rough to be occupied as........................................,�...................... .. �.:...:............................................................................. Ch 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, Alteratiowand 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 TARTSRough ................... .... '""' "m'............... ........................... Service BUILDING INSPECTOR Final t Occupancy Permit Required t0 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. i I<hk. June 28, 2011 %0 Austin House Marceau 111 Peters Street Construction Corp. North Andover, MA 01845 Contract ATTN: Fr. Bill Garland, OSA Austin House Screen Porch This proposal is for all labor and materials supplied to the pp above mentioned facility for the following items: Screened Porch Draw&submit plan to City for permit, frame and roof new screened porch on existing concrete deck, install screen door at top of stair area. Total $ 10,507.00 5, Acceptedyf -�.�7`- /� I 644ntract With: Date: / Date: y/ / Marceau Construction Corporation —Telephone 978-685-4706— Fax 978-685-3852 28 Osgood Street— PO Box 66— Methuen, MA 01844 rdesiardins anmarceauconstruction com North Andover MIMAP June 29, 2011 NLI iF AfW B r a 'a a 7r # k ,r + =r s f 1V 4.a' Andover z Interstates Interstate - I Major Roads Horizontal Datum:MA Slaleplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack Ci r Easements f.NORTH Valley Planning Commission(MVPC)using data provided by the Town of C �t a q� North Andover.Additional data provided by the Executive Office of [3 MVPC Boundary .�. ®4� �°•°GQ Environmental Affairs/MassGIS.The information depicted on this map is 0 Parcels 3' L for planning purposes only.It may not be adequate for legal boundary O ,—• 9 definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING 41 - % THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY { i' ,^ y OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT 4 oqq< < { ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF .y o�,r�o w•p`�; THIS INFORMATION 9SSACHUSe� 1"=89ft The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 4 r C @a u 00 n a k t U c,1 a n Car p Address: a4 N'60A gi- City/State/Zip: 0i It 4 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. 1 I am an employer with 11 — 4. ❑ I am a general contractor andI 6. ❑New construction - employees(full and/or part time).* have hired the sub-contractors 2: ❑ I am a sole proprietor or partner= listed on the attached sheet. 7. O(Remodeling ship andhave no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. $ 9.❑Building addition required] 5.❑ We are a corporation and its 10.0 Electrical repairs or additions 3..0 1 am a homeowner doingall work: officers cers have exercised their myself 11.'❑Plumbing repairs or additions y [No workers' comp. right of exemption perm MGL insurance required]t c. 152,§ 1(4),and we have.no 12. ❑Roof repairs employees.[no workers' 11.0 Other comp:insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. *Contactors that check this box must attach 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 providing workers'compensation insurance for my employees:Below is the policy and job site information. Insurance Company Name: Pe e c _%Z, Policy#or Self--ins.Lic.#: Expiration Date: 3li V`ta, Job Site Address: It j 9e#e2.15S�A. PA r City/State/Zip: 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 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 $250.00 a da against viol y g violator.Be advised that a co of this statement � copy maybe forwarded to the Office of Investigations of the DIA for coverage verification. i I do herby certify under the pains and penalties of perjury.that the information provided above is true and correct. Si nature:. ( ( Date: (, a Print Name: C e,t al •(�c�u rrC�„� Phone# q l i-6;t 6-416 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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#. ►°rke Compensation And Employers Peerless P p vers LIabllrty Insurance Insurance. _ DICmhu of IAbcr(y Mutual Group EW BUSINESS Transaction Effective: 03/19/2011 INFORMATION PAGE DIRECT BILL Policy Number:WC 8838979 Prior Policy: Date Issued: 03/17/2011 Coverage Is Provided n PEERLESS INSURANCE COMPANY-A SMOCK COMPANY NCCI Number: 11355 1.Named Insured,and Mailing r Address: Agent: MARCEAU CONSTRUCTION CORP, ROBLIN INSURANCE AGENCY, INC. R B DESJARDINS LLC 144 GOULD STREET C/O SMR ROGER A DESJARDINS NEEDHAM MA 02494 28 OSGOOD ST METHUEN MA 01844 Agent Code: 6201056 Agent Phone: (781)-455-0700 Federal Employer.ID Number: 042584531 FilingNumber: 000056638 . SIC Code: 1751 Other Workplaces not shown above: REFER TO ADDITIONAL WORKPLACES SCHEDULE Entity of,Insured- CORPORATION 2 Policy:Period: The Policy Period is from 03/19/2011 to 03/19/2012 , 12:01 AM Standard Time at the insured's mailing address. 3. A. ,Worker's Compensation Insurance: Part One of the policy applies to Worker's Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in 3.A.The limits of liability under Part Two are: Bodily Injury by Accident $ 1 , 000, 000 each accident Bodily Injury by Disease $ 1 , 000, 000 policy limit Bodily Injury by Disease $ 1 , 000, 000 each employee C. Other States Insurance: Part Three of the policy applies to states,if any, listed here: All states except North Dakota,Ohio,Washington, Wyoming and states designated in item 3.A.on the Information Page; D. Endorsements and Schedules: This policy includes these endorsements and schedules: See Extension of Information Page 4. Premium: The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans.All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Code Total Estimated $100 of Annual Number Classifications Annual Remuneration Remuneration Premium See Extension of Information Page POLICY PREMIUM TOTALS Total Estimated Standard Premium $ 9, 597. 00 0900 Expense Constant $ 338. 00 Total Estimated Premium $ 9, 935. 00 Total Assessments/Funds/Surcharges $ 629. 00 Total Estimated Cost $ 10, 564. 00 Minimum Premium $ 342. 00 Deposit Premium $ 10, 564. 00 Adjustment Period: ANNUAL i Date: Countersigned by: Authorized Signature Copyright 1987 National Council on Compensation Insurance. 1)9-4 an in7ma%nmrr,nn nn na AI Inlet torn e1nc v PGDMO60D J08W PCAFPPN 00014719 Paae 17 AC R OP ID:JL `.,.� CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DD/YYYY) 06/21/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHOCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. RIZED 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 an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 781-455-0700 CONTACT Roblin Insurance Agency,Inc. NAME: 144 Gould Street,Suite 100 781-449-8976 AJC,N Ext): FAX Needham,MA 024942321 E-MAIL aIc No Roblin Insurance Agency,Inc ADDRESS: PRODUCER CUSTOMER ID#:MARCE-2 INSURERS AFFORDING COVERAGE NAIC# INSURED Marceau Construction Corp. INSURER A:Peerless Insurance Company 24171 R.B.Desjardins LLC INSURER B Mr.Roger A.Desjardins 28 Osgood Street INSURER C: Methuen,MA 01844 INSURER D: 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 THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE OPOL CIES DESCRIBED CT OR OTHER O HEREIN S SSUBJECTNT WITH PTO ALLECTO HEI TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER LTR TYPE OF INSURANCEIN POLICY NUMBER MMIDD MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CBP 3699023 08/08/10 08/08/11 PREMISES Ea occurrence $ 50,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,00 X PER LOC AGGREGATE PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY Emp Ben. $ 1,000,000 COMBINED SINGLE LIMIT A X ANY AUTO BA 3699018 08/08/10 08/08/11 (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY(Per person) $ X SCHEDULED AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS PROPERTY DAMAGE (Per accident) $ X NON-OWNED AUTOS Coll ded $ 50 X UMBRELLA LIABX occuR Comp ded $ 50 EXCESS LIAB EACH OCCURRENCE $ 5,000,000 A CLAIMS-MADE AGGREGATE DEDUCTIBLE CLI 8792631 08/08/10 08/08/11 $ 5,000,000 X I RETENTION $ 10 000 $ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY =EMPLOYEE - OTH- A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC8838979 S ER OFFICER/MEMBER EXCLUDED? ❑ N/A 03/19/11 03/19/12 DENT $ 1,000,000 � (Mandatoryln NH) If yes,describe under EA EMPLOYEE $ 1,000,000ESCRIPTION OF OPERATIONS below q Equip Floater CBP 3699023 POLICY LIMIT $ 1,000,000 E.L.08/08/10 08/08/11 Leased/ 100,000 Rented DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Project:Austin House,111 Peters St.,North Andover,MA. The Town of North Andover is named as additional insured. CERTIFICATE HOLDER CANCELLATION TOWNNAN ANY OF THESHOUEXPIRATION H DATE VTHE HEREOF, NOTICE POLICIESDESCRIBED WILL BE CBE CDELIVERED BEFORE Town of orth Andover ACCORDANCE WITH THE POLICY PROVISIONS. N North Andover,MA AUTHORIZED REPRESENTATIVE 16aC l�� ACORD 26(2009/09) The ACORD name and logo are registered masks 1988-2009ACORD CORPORATION. All rights reserved. �\ VIte -Comq, Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Reqistration: 109481 Type: Private Corporation Zi �; _ �-Xlr; Expiration: 9/16/2012 Tr# 203491 MARCEAU CONSTRUCTION CORP ' ROGER DESJARDINS m PO BOX 66 -a METHUEN, MA 01844 ,jF� `�6 � `� Update Address and return card.Mark reason for change. } [:] Address [j Renewal ❑ Employment Lost Card PS-CA1 is 50M-04I04•G101216 Office ofo ' fa rs&Bines e u i� License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 009481 Type: Office of Consumer Affairs and Business Regulation ` Expiration: x9/16%2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAU CONSTRU0-1-10MC©RP, ROGER DESJAR'DINS 28 OSGOOD METHUEN, MA 018 w Undersecretary Not va wi ou tg iffure Massachusetts Department of Public SatetN Board of Building Regulations and Standards, Construction Supervisor License License: CS 21191 Restricted:to: 00' A ROGER A';DESJARD1NS 4.COTTAGE RD ,ANDOV.ER, MA"0181`0' ; Expiration: 5/2/2012 C-4-1.IklI.Ii'` T.r##: 24282 i i - �t i"31 f 1 i i d�f— r.S'►s' �� s��s.w�, L� '7.... " I g r , ,• ��i �'� ice,: � 1 �4. ^ o a ' : •r y �1 r a K y i ,1, 7 ' IA 4 N. _gyp t �