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HomeMy WebLinkAboutBuilding Permit #813 - 1160 GREAT POND ROAD 6/7/2007 "ORTH BUILDING PERMIT o� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received U �44TE, c5 �� 9SSgcHuS�� Date Issued: IMPORTANT:Applicant must comp a all items on this page s K �� 'a b , TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Buildingne family ❑ Addition 0 Two or more family ❑ Industrial ❑ Alter tion No. of units: 0 Commercial epair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other s� DESCRIPTION OF W9RK TO BE PREFORMED: dentification Please T3' e or Print Clearly) OWNER: Name: /�ov�c,�' SSC�Gd 1 Phone: l� —2?f Address: `. Iiid " � r' � <��^. _„� S.r{ vii": ,� 3`Y .�•�` '� ' , ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED CTT BASED ON$125.00 PER S.F. Total Project Cost: $ ��� S O FEE: $ Check No.: Receipt No.:-�C�d a NOTE: Eersons t ti yth Ud�o�n actors do not have acces t the n Sagrat� e 02J c 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 o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 L3 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) a 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 2.2007 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ i COMMENTS g Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Si nature & Date Driveway Permit Connection/signature v Located at 384 Osgood.Street � � g �� 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 2007 Location ry W% 6,e No. !f Date _ 2 NORTq TOWN OF NORTH ANDOVER ' ( f Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ Hust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # s 20282 Building Inspector 06/05/2007 21:43 6035949840 APPLETREE PAGE 01 Certificate of Liability Insurance Date Of Issue 0610612007 _-_�- Producer This Certificate Is issued as a rnatter of information A letree Insurance only and confers no rights upon the certificate holder. PP This certificate does not amend, extend or alter the coverage afforded by the polleles below. 1 Campbell Ave _— Hudson,NH 03051 _ Companies Affording Coverage 6038819900 Company CONCORD GROUP Insured SGM CONSTRUCT Company HANOVEW,INSURANCE --- SGM CONSTRUCTION Company _ 2 TATE ST Company: HUDSON,NH 03051 Company - ST PAUL TRAVELERS Company F Coverages 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 certilicate may be issued or may .pertain,the insurance afforded by the policies decribed herein Is subject to all the terms,exclusions and conditions of such policies,limits show may have been reduced by paid claims. - Go Type of Insurance Policy Number Policy Effective Policy Expiration Limits Ltr Date Date _ - _... — , General Liability Gen erril Aggregate A [] Commercial General Liability E8879259 0312112007 03121/2008 Products-ComplOpAgg $2,000,000 ❑ Claims Mad 141 Occurrence Persaral&Adv Injury $1,000,000 ❑ Owners&Contractor's Prot Each occurrence $1,000,000 r Flre Dornage(anyone fir _$500000 - Med E;cp(Anyone pemo $1,600 Automobile Liability - - Combi,ed single Limit $300,000 n Any Auto ABY717319500 0311212007 03!1212006 - B 800 iiy In TY $ Ll All owned Autos (Per Parson) E] Scheduled Autos Bodily injury $. U Hired Autos (ParAxident) Non-Otimed Autos - • Property Damage $ ,Garage Uabillty Auto Cinly t;a Accident C Othar'rhan Auto Only: _ , I Any Auto JEach - ❑ Aggregate Foch tkcurrsnce Excess Liability — D ❑ Umbrella Form Aggrgiy2h3 -� ❑ Other Tuan Umbrella Form _•_.• __._. .—.. .... 1 —_ _ ❑ WcStatu- ❑Other _ I E Workers Compensation 6KU85147CO58 0411412007 0411412008 toYLimita Limits EL Ea:h Accident MARRO The ProprietorlPartnerst G Incl EL Di:Aase-Policy Limit _ $900,000 Executive Oiflcem are: ❑ F_xG 100,000 Othe — _.... Description of Operations/Locatlons/VehlcieS/Specl21 Items FAXED TO:978-725-6295 __Cancellation Certificate Holder -Should any of the above described policies be cancelled before the BROOKS SCHOOL expiration thereof,the issuing company will endeavor to mall 10 1160 GREAT POND RD. days written notice to the certificate holder named to the left,but failure to mall such notice shall Impose no obligation or liability of any kind upon the company,its agents or representatives, _ NORTH ANDOVER, MA 018451298 AuthorizedRepresentative __ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Workers' Compensation Insurance Affidavit: Builders/Contracto A licant Informationrs/Electricians/Plumbers Please Print Le 'bl Name(Business/organization/Individual): j s7r Address: AT S,7- City/State/Zip: 'TCity/State/Zip: fyt;�l,vok) Phone#: 603- Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I Tyg[1 f project(required): 2.❑ employees(full and/or part-ti )me .* have hired the sub-contractors 6• New construction I am a sole proprietor or partner- listed on the attached sheet.t 7.ship and have no employees These sub-contractors have Remodeling working for me in any capacity. workers'com 8 ❑Demolition [No workers'comp. i P.insurance' 9. C]Building addition p insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10•❑Electrical repairs or additions 3•❑ 1 am a homeowner doing all work right of exemption per MGL i .0 Plumbing repairs or additions myself.[No workers'comp, c. 152,¢1(4),and we have no insurance required]t employees.[No workers' 12•❑Roof repairs comp.insurance required.] 13.❑Other *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 subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: 140 le 7peta fy .l- Policy#or Self-ins.Lic.#:_ Q,� 5- Expiration Date:_3 Job Site Address: �' G / City/State/Zip: Attach a copy of the workers'compensation policy declarationa e showing the policy number andel expiration date . Failure to secure coverage as required under Section 25A of MGL . 52 can lead to the imposition of criminal ) 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 Investigations of the DIA for insurance coverage verification. on. S n hereby certify unde ' s ties o er a that the information provided above is due and correct. ./•p J 7' Si na e• Phon #: QJykial use only. Do not write in this area,to be completed by city or town oJ)&ial 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#: r T7- Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registratidri\ 142928 ExpirBfign 6/1/2008 Tr# 130173 ~I` TYPe DBA' R S.G.M.CONSTRUCTION SERGE MICHAUD" tj A . 2'TATE ST HUDON,NH 03051 Administrator proposal SGM CONSTRUCTION 2 TATE ST HUDSON,NH 03051 1-603-595-6923 6/7/07 BROOKS SCHOOL HOLCOMBE HOUSE 1160 GREAT POND RD. NO.ANDOVER,MA 01845 978-725-6284 Scope of work to be performed on Holcombe House: Stripping and disposing of siding Remove windows and install new windows to be supplied by Brooks School Wrap house in Tyvek Install Hardi Plank siding and wrap trim with pre-primed pine Install new bulk head Permit Fees $67,950.00 Signed by Serge Michaud V Owner NORTiy Town of _ over 0 No. dover, Mass., (2 - 2 T O LAKE D� I� COCMICMEWICK V RATED PC5 u BOARD OF HEALTH 7 Food/Kitchen PERMIT T D Septic System &0%. BUILDING INSPECTOR THIS CERTIFIES THAT-46P.d�.....jM#�..1............. ......v..... . . .... �...... ....... ...... ................ Foundation has permission to erect............ .................... buildings on//4..040......... . ASM-0.Poe0� Rough to be occupied as SIS �... � * .. t.................................................................. Chimney . . . . . .. . .. . . ........ . . provided that the person accepting is 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TAR 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 BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Bumer Street No. SEE REVERSE SIDE Smoke Det.