HomeMy WebLinkAboutBuilding Permit #129-16 - 114 MIDDLESEX STREET 7/30/2015 VOK BUILDING PERMIT o�N0 oT 6;�tio
TOWN OF NORTH ANDOVER �� y '- "
APPLICATION FOR PLAN EXAMINATION 00
Permit No#: Date Received o ;
A�RAT[D 'QPy.��J I
gSsvcHus�c
Date Issued:
IMPORTANT: Applicant must complete all items on this page
c
LOCATION e.Se S7
Pri t
PROPERTY OWNER `I o h n ct_ kn U
Print 100 Year Structure yes no
MAP ��� PARCEL: ZONING DISTRICT: Historic District ye no
Machine Shop Village ye no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building )<One family
❑Addition ❑Two or more family ❑ Industrial
Iteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer - -
DESCRIPTION OF WORK TO BE PERFORMED:
-!�-r o n T PorA mik c , c9 r Tt�A7 o p u o t1'C'V ,r L —
�w r w�A �c - �m cL4., sl--ins Remove- 5Px,9� r
add �+ .x G '
Identification- Please Type or Print Clearly
OWNER: Name: Phone: 9-78
Address:
Contractor Name: e�.e r �„ Pef-o a'j— Phone: 7 – IDOq
Email: D
Address: oC r. v Irl
Supervisor's Construction License: – X38/ Exp. Date:
-Home Improvement License: _ _ Exp. Date: 3 Lcq, ds 6
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: $ QJ p0 FEE: $ �
Check No.: I Receipt No.: Z –
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
J
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL ;
Public Sewer ❑ Tanning/Massage/Body Art ❑ Sw"ning 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 e U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature .r;9
COMMENTS
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
r Planning Board Decision: Comments
t
} Conservation Decision: Comments
`Water& Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE3DEPAR IWiENT Temp#Dumpster onsite. ,yes.. I
+ Located�at 124IMain,�Sti:eet•
FireD-epartment;sgnature/d'a"te
COMMENT ,S.
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)
G aww� 1
❑ 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
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
,,,t Engineering Affidavits for Engineered products
OTE: All d pster 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
4 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)
;r< Copy of Contract
2012 I ECC 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
Location
No.` —" Date (�, 1
® - TOWN OF NORTH ANDOVER
•
• Certificate of Occupancy $���
Building/Frame Permit Fee
rr Foundation Permit Fee $
Other Permit Fee $
TOTAL $ *,
Check#3'-q
�• �' 2 Building Inspector
NORTH
Town of S EAndover
No. _ a ,T
a s
h ver Mass �D , aoI6
o 7
,f� COCNIC MI WICM ��
°R^rEo rPa��S
S t]
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT %7- 0b.�... BUILDING INSPECTOR
.... ...... . .. .... ....
has permission to erect .. buildings on ... ,. ,... ...... �e.�e ,,,, Q Foundation
.. . ,
Rough
to be occupied as . ® �........... ..� !..�!:..:..: � �.l�c�. �? ..V. .. . ... .......... Chimney
provided that the person accepting this permit shall in every respect 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
3W ® .UNLESS CONSTRUCTION/ '. Rough
�T Service
................................................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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.
RENE' L. PERONT CUSTOM CARPENTRY
2 Rag Rock Dr.
Woburn, MA 01801
REMODELING CONTRACT
This contract between Mr.John Lahoud 114 Middlesex St.North Andover, MA and Rene'L. Peront(contractor)for
labor and materials described below, is agreed to by the undersigned parties.
Remove the existing front porch and replace it with a canopy over the front door and stairs and a platform. Contractor
agrees to remove all debris and supply all materials and labor to complete the project.
The building permit will be obtained by the contractor and is part of the total cost.
The project will begin on or about Aug. 3rd and is expected to end on or about Aug. 315f
The total cost of the project will be $25,000.00
Payment will be scheduled as follows:
1/3 due upon signing of contract
1/3 due upon 50%completion
remainder upon satisfactory completion
Rene L.Peront
2 Rag Rock Dr.
Woburn,MA 01801
CSL CS-095381
HIC 151906
Contractor or subcontractor inquiries should be directed to:
OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATION
TEN PARK PLAZA,SUITE 5170
BOSTON,MA 02116
PHONE(617)973-8700
I hereby agree to all terms and conditions of this contract and acknowledge the homeowners right to cancel this
contract within three days of the agreement.
HOMEOWNER DATE 0 71a8/A5-
CONTRACTOR
� 0
DATE �� ��
�`; _
r
• y�
�y "•'� I £--'�^-
j � _
_, .. .„ _�... .r�.'' T
Z -y � � t �`
_ — � � �� '�
l. .. f
'� � N�._ is - �_ � _ '� ,�!.— � �
�{ IIE � � _ _ �_ 1�. �'� � �p�S.� � � ._ � _
r � 1 � � � '� � /Y ...�i�
'ac It { i � ii
�,� � � w �� � � `_ �� fit: I ~��_ � 1 # �,. � �_L _�hi � + I � + �
err' i. ij_..._....� � j � f ��� ( i i 1
,.� { ... � _ a��_�.� _ 1.__ 1 !
i� //. *__ � � e
m ? i , . , 1
is ---_—_- :,�! . -�_:=�_�__�, f, „ � 1 +�t � 1
'�I � _
V
,— � i �
1
1 }
� i ,
North Andover r MIMAP Jul 30 2015
o y
v ,
a P »
a
P:
•
M
rN
�t
T. kid 4
B �
17
VX
r. max.
ii
x r'
s
s
a
•�:r O� $,3r r u
a.
na.
G MVPC Be
Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
—I Meters Data Sources:The data for this map was produced by Merrimack
—SR
Roads f NORTH, Valley Planning Commission(MVPC)using data provided by the Town of
"*0 .� North Andover.Additional data provided by the Executive Office of
Easements r��� •6�6 OQ Environmental Affairs/MassGIS.The information depicted on this map is
Parcels 3' _ _ L for planning purposes only.It may not be adequate for legal boundary
F 9 definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
it -40,MFNW } THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
V s } OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
}o� r ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
.j� •b�,rip THIS INFORMATION
'sSACH
1"=45ft °
The Commonwealth of Massa chusetts
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
. � www mass.gov/dia
sJ• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le 'bl
Name(Business/Organization/Individual): R.pccP e,--i
Address: D
City/State/Zip: bo, 4/ O Phone#:,33? c229 Q�
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.M I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
ny capacity.[No workers'comp.insurance required.]
9. ❑Demolition
I❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no,employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 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 and state whether or not those entities have
employees. If the sub-conlraciors have employees,'tlicy must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby certify underthep7an�pen ties ofperiury that the information provided
above is true and correct.
,5—PhSi ature: Date: / ao/.,5—
Phone#:
one#•
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#:
Information and. Instructions •
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in 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 of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub=contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the.law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should•enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
7 ® DATE(MM/DLYYYW)
ACORD CERTIFICATE OF LIABILITY INSURANCE 7/22/15
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) 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 NAME:CONTACT
NAME:
W. Gochis Insurance Agency IncPHONE 781 272-8306 FAX N (7131) 272'1362
113 Cambridge Street ADDREss: ochisl@verizon.net
Burlington, MA 01803 INSURERS)AFFORDING COVERAGE NAIC#
INSURER A:Commerce Ins. Co.
INSURED INSURER B:
Rene's Custom Carpentry INSURER C:
Rene Peront INSURER D:
2 Rag Rock Rd. INSURER E:
Woburn, MA 01801 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 ADDLSUBR POLICY EFF POUCY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MM/DDIY MM/DD✓YYYY
A GENERALLIABILITY BCYQDS 7/6/15 7/6/16 EACH OCCURRENCE $ 500,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTErren co D $ 100,000
CLAIMS-MADE F-1 OCCUR MED EXP(Arty one person) $ 5 000
PERSONAL&ADV INJURY $ 500,000
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 1,000,000
POLICY PRO-ECTLOC $
AUTOMOBILE LIABILITY COMB W�DtSINGLE LIMIT $
ANYAUTO BODILY INJURY(Per person) $
ALL 0 WN=D SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS _AUTOS (Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION —1 TORY WC LIMA OTH-
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE ----1
N/A E.L.EACH ACCIDENT $
OFFICE RMIEMBER EXCLLOED9
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yyes describe under
DESt RIPTION OF OPE RATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is recidred)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TOWN OF NORTH ANDOVER MA ACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING INSPECTOR
1600 OSGOOD ST AUTHORIZED REPRESENTATIVE
BLDG 20 STE 2035
NO ANDOVER MA 01845
@1988-2010A ORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail:
CJ/ e�poowr�aoyuuea�f,o �/�/ �ot�ccc.�eG
Office of Consumer Affairs&Business Regulation
=- OME IMPROVEMENT CONTRACTOR
egistration: ._151,906
Expiration:- .7/13/2016 DBATYPe I
t I
RENE'L PERONT CUSTOM CARPENTRY
i
RENE' PERONT Yt
2 RAG ROCK DR j
WOBURN, MA 01801 � `-- -
Undersecretary '
i
I
Massachusetts -.Dep-rtment of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-095381
Rene L Peront UU
2 Rag Rock DriveWoburn MA 01801
11 s >r•�ti�`` Expiration
04/01/2016
Commissioner
_ I