Loading...
HomeMy WebLinkAboutBuilding Permit #688 - 1160 GREAT POND ROAD 5/22/2008 BUILDING PERMITo* tIORoTH qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 70 Permit NO Date Received �l p�RwTto�P°' •(y Date Issued: 22 .0 1l IMPORTANT: Applicant must complete all items on this page LOCATION IQC.t�TyNp Print PROPERTY OWNER BRacm<3 �C-hooL- Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Res' Non- Residential New Building ne family Addition Two ore family Industrial Alteration No. of units: Commercial epair, replaceme t Assessory Bldg Others: Other Septic Well floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: �(� k31se-S S CGd t— Phone: L5 7S 371 O Address: 11 /,0 tj Z 6A) ,D CONTRACTOR Name: yrs,,t,., Phone. `, Address: .0 . -r Supervisor's Construction License: V �3 Exp. Date: l Home Improvement License: 1 1,3 7L/Ll LExp. Date: Ljf - 00 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: $ FEE: $_ 3ff I--- Check No.: �1Receipt No.: cw t ,�—K NOTE: Persons contracting with unregistered contractors do not have access to t g a f n igneture of Agent/Owner Signature of contractor 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 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 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 ration No. Date NORTH TOWN OF NORTH ANDOVER O'�•�ao ,a'�y0 f w � s s ; ; Certificate of Occupancy $ Building/Frame Permit Fee swCHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �� 2 , i 74 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 o � , 5Y V www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): }?Q�d Gy Address:— City/State/Zip: ddress: d City/State/Zip: ,A Phone.#:Areyou an employer? Check the appropriate boa: Type of project(required):. 1. ]/ram a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working,for me in any capacity. employees and have workers' comp.insurance.$ 9. ❑Building addition [No workers' comp:insurance p• ' require&] 5• ❑ We are a corporation and its 10..❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised.their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 131-1 Other comp.insurance required.] *Any applicant that checks box#1 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. f'ontractors that check this box must attached an additional sheet showing the narrie 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. , ` Insurance Company Name:_ /\/,#OTI 4,af 4W E Policy#or Self-ins.Lic.#:' 1A) ��mon 602 a CJ� /A-IOR� Expiration Date: 3Z 332--{gyp Job Site Address: /16?0 C�, I _V730 Pb 9 fj>� -/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 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 Investigations of the DJA fAinsufZce coverage verification. I do hereby certify u er p in an en ie of perjury that the information provided above is tr and correct Si ature: 00 -,/- Date: _ Phone#: 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 S.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 local licensing agency shall withhold the issuance or renewal of a license or permit to,opera'te-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, §25CO)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 situdUon 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 maybe 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 permittlicense 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 1J0T required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth.of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 6.17-727-4900 ext.406 or 1-877-MASSAFE Revised 11,22-06Fax# 617-727-7749 www.mass.gov/dia DATSIMMIOOIYYYY) ACORDCERTIFICATE OF LIABILITY INSURANCE 0311912008 �, PHIS CI=RTAZATE IS ISSUED AS A MATTER HI INFORMATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE COWan Insurance Agency,Inc. HOLDEEND OR ALTERTHEO COVERAGE WORDED D BYTHE POLICIES LLTEREBELOW. 359 Main Street Haverhill MA 01830 INSURERS AFFORDING COVERAGE NAIC# INSURED Rondeau Construction Inc. INSURER A Mautilus Insurance Com a p0 Box 522 INSURER s: pmocioted Employers Insurance Com an INSURER Ct �. Dracut MA 01626 INSURER D: INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INOICF,TED. NOTMIITIISTANOIN ANY REDUIREMENT. 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICIES. POLICY EXPIRATION UMIT6 MSR D POLK:Y NUMBER EACH DCCURRENCE 91000,000 GENERAL LIABILITY 06109107 OIi109106 OAMAOE TO REN ED 150000 A x COMMERCIAL GENERAL^-LI1ABILITY NC682280 I "1°0L CLAIMS MADE a OCCUR MED EXP one 6011 x 5 00� PERSONAL&AOV INJURY x 1 000 000 GENERAL AGGREGATE S 2 000 000 PRODUCTS-COMPrOP AGG x 1 000 000 GENT.AGGREGATE LIMIT APPLIES PER: X Policy PRO- LOG AUTOMOBILE LIABILITY COMBINED dewde SINGLE LIMIT S (CA eEldent) ANY AUTO ALL OWNED AUTOS BODILY INJURY x (P-person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY S (Per acgdant) NON-CAIN ED AUTOS PROPERTY DAMAGE f (PerKcidenU AUTO ONLY•EA ACCIDENT S GARAGE LIABILITY EA ACC S ANY AUTO OTHER THAN AUTO ONLY. AGG f i EACH OCCURRENCE S EXCESSNMBRELLA LIABILITY AGGREGATE OCCUR �CLAIMS MAGE S 13COUCTIOLE x RETENTION -4C: TMAT1 8 - WORKeRS COMPENSATION AND 6 EMPLOYERS'LIABILITY WCC5006885012008 0310312008 0310312009 E.L.EACH ACCIDENT —31-001.0-0-0 AFPICERPRJETOR ExCTNERIE Na E E.L.DISEASE•EA EMPLOYE $100,000 It se.ER/Mee under E.L.DISEASE-POLICY LIMIT S 500000 be OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS (603)635.8080 Commercial carpentry contractor. CERTIFICATE HOLDER CANCELLATION 6OA NT OFTHE AW4P-CESCRIBED POLIMESNtCANCXLLED BEFORE THE EXPIRATION Brooke School REOF,THE ISSUING INSURER WILL ENDEAVOR Tp MAIL 10 DAYS WRITTEN 1160 Great Pond Road OTHE CERTIFICATE HOLDER NAMED TOTNELEFT,eUTFAILURETO00 SO SHALL O OBLMATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR North Andover,MA 01645 m Tam*0"5000va ACORD 26(2001/06) 0 ACORD CORPORATION 1996 OORTH Town of Andover No. L A odover, Massof,5 COC HICHEWICK% OfOATED I"? BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.... ............ azomi��.................. Foundation Of has permission to erect........................................ buildings ol(lwla.... ...... Rough ..................... ......................1. to be occupied as ..................... ..........:..................... Chimney C­c­e­p"t*1 V Final provided that the person a iiiii permit shall in tMery respect confor*m**"t'o'...the an 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. I Rough-, Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS PCONSTRUCTIO S t. S Rough qService ................................................................................................................ 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. QUOTATION Phone (978)459-2684 Fax(6 03)635-3810 Rondeaulnc@aol.com Rondeau Construction, Inc. P. O. Box 522 Dracut, MA 01826 . . Thompson House(Garage only) A -. Brooks School 1160 Great Pond Road N. Andover, MA 01845 Quote Number. 482 Quote Date: Apr 21, 2008 Page: 1 ... - . Brooks 5/21/08 C.O.D. ® - . • • -Existing shingles will be removed to decking. -Roof decking will be re-secured as needed. Aluminum drip edge will be installed on all perimeter edges. -6'of ice and water barrier shield will be installed at eaves. -3'barrier shield will be installed in all valleys. -18"of barrier shield will be installed against all walls and around penetrations. A self-sealing asphalt 3-tab shingle with a 30 year warranty will be applied over under-layments. -All walls and chimney will be re-flashed as required. AII pipes will receive new collar flashings. Valleys will be shingle woven. -Cap-over vents will be installed at all ridges. AII roof related debris will be removed daily. -Roof will carry a 30 year material and 5 year labor warranty. 3,150.00 00 `n Otank#ou fot allow&,#as to ptovk&ru wide"quote. Subtotal 3,150.00 Sales Tax If you would like us to proceed with this quote, please sign and fax back to • v 603-635-3810 Boa d of Builditc�onstru atonsction ng Regulsupervisord Standards Lice' LicenSe nse Al. e C S 35313 Expira6on Res t+ction .00 2090 Tr* 24468 DONALDs PO BOX 522 DRONDEAU R ACUT,MA 01826 C'o►nmissionei /he UarnndoYe a ac�ivaelu% Board of�iuildmg Regulations and Standards HOME IMPROVEMENT CONTRACTOR 1 Reglstra ion:,131434 Expiration: f/12/2008. Tr# 924494 t t TgpeF ptivate.Corporatiori 'f RONDEAU CON$TRLtCTION INC`; DAVID RONDEAU i 182 ARLINGTON ST 1y " Administrator RACUT;MA 01826 "