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HomeMy WebLinkAboutBuilding Permit #761-14 - 117 MAIN STREET 4/29/2014 00RT11 q r C;4 BUILDING PERMIT ° � ' do TOWN OF NORTH ANDOVER ° L L APPLICATION FOR PLAN EXAMINATION ne" Permit NO: f{ Date Received �9SSACHUS���y Date Issued: MPO &ANT: Applicant must complete all items on this page LOCATION �1kk 6'9 Y1 e - ` (W PROPERTY OWNER L-a� P"' eo l Trtk�&-t c Print MAP NO: 1 PARCEL:0A& ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well. ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer mao d m Identification Please Type or Print Clearly) 760 OWNER: Name: S Phone: -+� G Address: N { )M am CONTRACTOR Name: Phone: - - - && sill 111 ri Ou Address: 10 al L1 li Supervisor's Construction'License: . Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. ' FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON 125.00 PER S.F. — Total Project Cost: $ t _ FEE: $— Check No.: 3 3(pa3 TReceipt No.: U NOTE: Persons contracting with unregistered contractors do not have access to a guaran fund Signature of Agent/Owner Signature of contrac or Plans-Submitted ❑ Plans Waived❑ ;;..Certified Plot Plan ❑ Stamped Plans ❑ :TYPl 01T SEWER.AGEDISP.OSAL" Public Sewer ❑ Tanning/MassageBodyArt ❑. . Swimming Pools ❑ Well ❑ Tobacco.Sales Food Packaging/Sales ❑ -Erivate••(septic tank,ete:_ -"❑ • _- -permanent Dempster on Site THE..FOL`LOaIVING SECTIONS FOROFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM 2._ DATE REJECTED DATE:APPR:OVED 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& Da#e Driveway Permit DPW Todv;, Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMNt =•Temp"Dumpster on site yes no Located-at 124,Mair, Street - Fire Departme►it�pignatu"r_e/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 El Notified foricku - Date P p i t Doc.Building Permit Revised 2010 Building Department ,T'he foL;swing is a list of the req:*uired.forms to be filled outIor:the appropriate:permit to be obtained. Roofh,g, Siding, Interior Rehabilitation Permits o Biuilding 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 apn•,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.+.ted with the building application Doc: Doc.Bui?ding Permit Revised 2012 h2iLocation &117 6 No. f Date 2 l C� . - TOWN OF NORTH ANDOVER • ���"��jam` � Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# / + M " ., i- � 6 �� J Building Inspector NORT#j Town of ? . s ndover I- I "n ?,o h ver, Mass, 1, COC-4-cla WICK y1. �,95 R�reo �PP��S U BOARD OF HEALTH Food/Kitchen PERMIT Septic System THIS CERTIFIES THAT ......... L4T...... ..... S BUILDING INSPECTOR !�, o . . has permission to erect .......................... buildings on 1.01............ .... �.�......... ... . .............. Foundation Rough to be occupied as .....94pou'Orn........Vtktajot.... A Chimney Finalprovided that the person accpin this permit shall in eve respect conform toterms of the on file in this office, and to the provisions of the Codes-and By-Laws relating.to the Inspection, Alteragon and Construction of Buildings in the Town of North Andover. WdOw �`�j PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR lbao UNLESS CONSTRUCTION AR 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. ttORTH Town of z . sAndover O :, :�' 0 No. �oh ver, Mass, l COC LAKO NIC nt WICK �1• Q�RATE0 S U BOARD OF HEALTH Food/Kitchen PERMIT Septic System THIS CERTIFIES THAT 4T...... .....COS. BUILDING INSPECTOR has permission to erect .......................... buildings on 1.0.. ............ .... A......... ... .................... Foundation Rough i to be occupied as ..... ........ ..�.�. V.coktaol. .. .... ..YI'.1 !► � Chimne........... ..... y provided that the person&acc pting this permit shall in every respect conform to terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating.to the Inspection,Alteragon and Construction of Buildings in the Town of North Andover. WdOw �`�j PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR thas UNLESS CONSTRUCTION AR Rough � Service � ..................... ..... r4.e . 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. 7 ® DATE(MM/DDIYYYY) AC40R o CERTIFICATE OF LIABILITY INSURANCE 4/22/2014 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(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). CONPRODUCER NAMEACT Judith George CIC,CPIA,CPIW FIAI/Cross Insurance PHONE . (603)669-3218 FAX No:(603)645-4331 1100 Elm Street AoDRESS:jgeorge@crossagency.corn INSURERS AFFORDING COVERAGE NAIC# Manchester NH 03101 INSURERA:Union Insurance Company INSURED INSURER B-Acadia Ins Co. Thomas A. Dube Construction-Plus, Inc. , DBA: -INSURER C: Plus & Dirt Pro; Watertown Village, LLC INSURER D: 10 Bricketts Mill Rd, Suite C INSURER E: Hampstead NH 03841 INSURER F: COVERAGES CERTIFICATE NUMBER:14-15 All lines 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. ADDL SUBR POLICY EFF POLICY EXP ILTR NSR TYPE OF INSURANCE I POLICY NUMBER MM/DD/YYYY MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A I CLAIMS-MADE ❑X OCCUR CPA5028190 4/26/2014 4/26/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 riPOLICY X PRO LOC I $ AUTOMOBILE LIABILITY Ea acccidentSINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED 028191 4/26/2014 4/26/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Auto Extension Endorsement $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ UA5028192 4/26/2014 4/26/2015 $ B WORKERS COMPENSATION CA5028193 X WORY C SL' ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y N (3a.) IIA & NH E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A Thomas Dube excluded 4/26/2014 4/26/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Covering work performed by the Named Insured during the policy period. *******FOR INFORMATIONAL PURPOSES ONLY******* CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Information Only For Information Only AUTHORIZED REPRESENTATIVE For Information Only J George CIC,CPIA,CPI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 rgninn.m n1 Tha A('r)Rr1 nnma and Innn nro raniefararl mnr4e of Ar-r1Rr1 C 71-1 d Office of Consumer A airsoinB usmess egulation 10 Park Plaza - Suite 5170 ®� Boston, Massachusetts 02116 RECD AUG Home Improveme'rs~t contractor Registration Reqistration: 119623 Type: Supplement Card i f= ;� i:s'` Expiration: 8/6/2013 Dube Construction - Plus, Inc. LORIANN LANGAN i"`; 10 Bricketts Mill Road, Suite"C" Hampstead, NH 03841 nT . Update Address and return card.Mark reason for change. SCA 1 e; 20M-05/11 Address [] Renewal F-] Employment F-] Lost Card � �j ie tpoaaLrnoozcuea�a�C>�av�ac�uaeG%.a- IF.ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: = :- `'• Office of Consumer Affairs and Business Regulation egistration:,.41g623_=:: Type; 10 Park Plaza-Suite 51'70 __ _ Exp iratiiq -816/204`13 y Supplement,.ard Boston,MA 02116 - Dube Construction Plus;Inc° LORIANN LANGAN; 10 Bricketts Mill ��. Hampstead,NH 63841 Undersecretary Not valid witho 6 natu e r sa a Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor• 1 License:-CS-094372 LORIANN J LANGi1N 7 CREST ROAD -;-F if MGSTONNS i384A Expiration Commissioner 07/31/2015 I � t%ULtcaG�cc�tcueG — ffice of Consumer Affairs&Business Regulation ME IMPROV&M'ENT CONTRACTOR y�Registrationr ' 119623°-- • I Expirafio`..' Y`"' Typ it 8/6L015 Supplemeni Dube Consfruction IN d LORIANN .LAN.GAN' - 10 Brfcketts Mill Road,86.j!6"C'•" 4� _ Hampstead,NH 03841 Undersecretary . x I i i The Commonwealth of Massachusetts Print Form Department of IncdustrialAccidents F Office of Investigations X Congress Street,,Suite 10O Boston,MA 02114-2017 '- ��• www mas's.gov/cdia_ Workers' Compensation Insurance Affidavit:Builders/Contractors/7Electriciang/Plumbers Applicant Information Please Print Legibly Name(Business/Orgauization/IndiAdual): — Address: � City/state/Zip: WKW— 0 1L i a ° I Phone#:Lm? Z1 Are you an employer?Check the appropriate box: Type of project(required): 1.��1 1 am a employer with 4• ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/ox part-time). have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling employees These sub-contractors have g, F1 Demolition ship and have pr pr working for me in any capacity. employees and have workers' 9 E]Balding addition [No workers'comp.insurance, comp.insurance.; required.] 5. [] We are a corporation and its 10.n Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ILEI Plumbing repairs or additions myself.[No workers"comp. right of exemption per MGL 12.E]Roof repairs insurance required.] c.152,§1(4),and we have no employees.[No workers' 13.�(Other comp.insurance required.] *.Any applicant that checks box#1 must also'frll out the section below showing their workers'compensation policy information. At Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'con2pensation insurance for my employees Below is thepolicy and job site information. , 6-6 Insurance Company Name: 4 ,f ,3�rA_ o� _ h % PoRoy#or Self-ins.Lic.#: Ii C L•• a Expiration Date: 1 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). GL c. 152 can lead to the imposition of criminal penalties'of a Failure to secure coverage as required under Section 25A of M p 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verificati6n. I do hereby certify under the p gins an dp enadties ofp erjuiy that the in formation provided above is trae and cornett Si afore: Date: `1 2-9 2�I Phone#: Official use only. Do not write in this area,to be completed by city or town offtchd 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#: *ID b�^p 1 u.s:(aar)3—VSDTe Fs(603)33.7016 Authorization to Repair (To Be Signed Prior to Beginning Services/Repairs) INSURED. San Lau Realty Trust 109 Alain St N.Andover AIA 01845-Claim#•HM83900114 I have selected and authorized Dube-Plus Construction to perform repairs as indicated on their estimate due toa.vehicle impact loss on or about i/912014 'I'his agreement is made between Dube Plus Cons true tion&San Lau Realty Trust and supersedes any otber agreements verbal or otherwise.Thus agreement is a binding legal agreement to authorize repairs as outlined in the Dube Plus Zactimate estimate dated 4/2/2014 totaling$13,560.83(FHL ES'InuvrE.). Additional and/or open items currently not outlined in TIIE ESITALATE would be supplements to the original estimate and agreed upon by the San I zu Realty Trust,Dube Plus and Travelers Insurance. Payment terms are as follows: $3,400.00 upon signing $3,400.00 upon start of project $3,400.00 upon substantial completion $3,360.83 upon completion I agree to pay Dube-Plus Construction for any additional improvements made at my direction that are not covered under my policy and outlined as a change order to ESTWATE. Dat San I au Realty Trust Date Dube Pitts Construction