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HomeMy WebLinkAboutBuilding Permit #494 - 1193 GREAT POND ROAD 1/27/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:/ Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION ©n? > i , Print r PROPERTY+OWNER_ 9,00 y s 5 e n 0o Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes h / Q3, : +a Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One famil Addition Two or more family Industrial Alteration No. of units: Commercial epairrre lacemen Assessory Bldg Others: Demolition Other Septic Well Floodplain, Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Q& Mose O Q w00� Identification Please Type or Print Clearly) OWNER: Name: �f2ry) le"S S, i��(� *n c�ma.NA gp-6 e.(Phone:CVT — US-L,28'' Address: J%0 �REA�- CONTRACTOR Name: -AON l Q Phone: '4'" 1 = Address: 01 A }��� C Supervisor's Construction License: f Exp. Date ) /Vzo Home Improvement License: Exp. Date. 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. 006 Total Project Cost: $ 3�, �.� FEE: $ qa 1000- Check No.: 3 Receipt No.: ga-4-4�;,y NOTE: Persons contracting w' unr gistered contractors do not have access-0 the g aran fund Signature of Agent/Owner Signature of contractor k , � 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 Li 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: 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 Siqnature 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/Siqnature & 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 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 Location//9.3 No. f v Date 1v NORTh TOWN OF NORTH ANDOVER F y Certificate of Occupancy $ + o b'••°•'<� Building/Frame/Frame Permit Fee $ "us Foundation 9 . Foundation Permit Fee $ s Other Permit Fee $ TOTAL $ Check # 22760 Building Inspector NORTH T0' VM of _. 4And-over 0 No. Ll - LAKE dover, Mass., COCMICMEV ADRATED S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT •C �� — ..! ....... �lQ� ..........SSC. ........ ........................... .. t.J� �. ............................................ // ��JJ Foundation has permission to erect........................................ buildings on `1..9�........4�'/u .f 40/t� 0�................. Rough ...... .......... .............. to be occupied as.....?'`vl.LCOY*..... P.4ex.�- ,S 1.... ,................................. .-::...� :.... Chimney 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, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough 3 • PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS ,CONSTRU ST TS Rough .:.:...::. .::..-...:...:... :::-:::rte...:.. .... 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 Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE. REVERSE SIDE Smoke Det. Annaldo Construction 12 Sweetbriar lane Estimate Hampton, NH 03842 DATE 'ESTIMATE# 11/21/2009 217 BILL TO Brooks School 1160 Great Pond Road North Andover, MA 01845 Attn Normand Grenier DESCRIPTION AMOUNT_ STEVENES HOUSE 0.00 REMOVE ALL CLAPBOARD SIDING AND WOOD TRIM. 6,000.00 ALL GROUNDS AND PLANTS WILL BE COVERD AROUND HOUSE AT TIME OF DEMO. SITE WILL BE 0.00 CLEANED UP AT END OF EVERY DAY, ANY MINOR ROT DAMAGE WILL BE REMOVED AND REPLACED.ANY MAJOR STRUCTURAL DAMAGE 1,000.00 FOUND WILL BE BROUGHT TO THE ATTENTION OF BUILDING SUPERVISOR. WINDOWS AND DOORS PLUS GARAGE DOOR TRIM WILL BE TRIMED WITH 1X5 PVC AZEK 2,200.00T TRIMBOARDS REMOVE AND INSTALL NEW BULKHEAD 800.00 HOUSE WILL BE RAPED WITHJ TYVEK HOUSERAP AND 1/2 RIGID INSULATING SHEATHING WITH A 2,900.00 3.3 R-VALUE.WINDOWRAP WILL BE UESD AROUND ALL WINDOWS AND DOOR TI INSULATE HOUSE WILL BE SIDED WITH CERTAINTEED MAINSTREET DODUBLE 41N WOODGRAIN CLAPBOARD 18,500.00 .042. COLOR TO BE DETERMINED BY BUILDING SUPERVISOR AT LATER DATE. MOUNTING BLOCKS WILL BE USED WHERE NEEDED. ALL EXTERIOR WOOD TRIM WILL BE COVERED WITH WHITE TRIM COIL METAL. 0.00 VINYL SOFFIT WILL BE USED ON ALL SOFFITS 0.00 0.00 REMOVE AND REPLACE THREE PORCH POSTS WITH 4X4 PT POST WRAPED WITH AZEK TRIM 550.00T LABOR AND MATERIAL DUMPSTER TO BE PUT AT JOB 1,100.00 MIS MATERIALS 500.00 THIS ESTIMATE INCLUDS ALL MATERIAL,LABOR AND ALL PERMITS AND FEES REQUIRED. 0.00 PAYMENT TERMS: 0.00 15% DUE AT START OF WORK. SUBMIT LABOR AND MATERIAL 0.00 INVOICE EVERY TWO WEEKS FOR WORK COMPLEATED. FINEL PAYMENT DUE APON COMPLETION OF WORK. Pagel The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): /Ple Address: 31 lzd)lr 4 � City/State/Zip: Gt//1aj19,0 Ah'r' C)3&e,2 Phone#: Are you an employer?Check the appropriat e °� Type of project(required): 1.El am a employer with 4. 1 am a general contractor and 1 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. ❑Remodeling ship and have no employees These sub=contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp. 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 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ oof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13. Other j CI/ti .tiny applicant that cher'-s box rl must also fill out the section below�shot ing+hems worltcers'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 sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /J '77- L 5 19 G,cf-ter,, C e.5-/- 6 679 Policy#or Self-ins.Lic.#: r4"- .5g908& Expiration Dater Job Site Address: t.&,n 1D, City/State/Zip:,/i�/(,06;Veo^ 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 u to$250.00 a da against p st the violator. Be adv' Y g advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceFkfy under pains a d penalties of rjury that the information provided above is true and correct Signature: 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 CIerk 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 local 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 retuned 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 bum leaves etc.)said person is NOT 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. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Massachusetts- Department of Public Safety 1 Board of Building; Regulations and Standards Construction Supervisor License License: CS 89665 —- Restricted to: 00 DAVID A SIVERHUS . 31 MARBLEHEAD RD WINDHAM, NH 03087 Expiration: 10/1/2010 ('ummissiunrr Tr#: 6291 lf I �,j� ,.,. [7AIiTFORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S60UB-9841 M87-A-09) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: 1521 ------------------------------------------------------------------------------------ STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 815 PREMIUM DISCOUNT NONE 0900-28 EXPENSE CONSTANT 185 TOTAL ESTIMATED PREMIUM 1000 TAXES AND SURCHARGES 10 DEPOSIT AMOUNT DUE 1010MP A/R (WCIP) # Minimum Premium: $ 1000 ST ASSIGN: NH DATE OF ISSUE: 08-04-09 MC OFFICE: ORLANDO DA HTFD 05G PRODUCER: BEAN INS AGENCY 76SBP 1 Ir I�HTFORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S60UB-9841 M87-A-09) NEW-09 INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY 1. NCCI CO CODE: 80411 INSURED: PRODUCER: ANNALDO, FRANK BEAN INS AGENCY 12 SWEETBRIAR LANE PO BOX 660 HAMPTON NH 03842 HAMPTON NH 03843-0660 Insured is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 07-21 -09 to 07-21 -10 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: NH m o� B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit O Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE EXCLUDED - REFER TO RESIDUAL MARKET LIMITED OTHER STATES " INSURANCE ENDORSEMENT WC 00 03 26 N O� D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. _. DATE OF ISSUE: 08-04-09 MC ST ASSIGN: NH OFFICE: ORLANDO DA HTFD 05G PRODUCER: BEAN INS AGENCY 76SBP 007803 Annaldo Construction Estimate Sweetbriar lane Hampton, NH 03842 DATE ESTIMATE#. 11/21/2009 217 BILL TO Brooks School 1160 Great Pond Road North Andover, MA 01845 Attn Normand Grenier DESCRIPTION :. AMOUNT START DATE 02-01-10 COMPLETION DATE 02-28-10 0.00 ALL DATES ARE SUBJECT TO CHANGE DUE TO WHETHER AND OTHER UNFORESEEN DELAYES. 0.00 ANNALDO CONSTRU ON 0.00 BROOKS SCHOOL d 2 7 //O /¢S 4 Bt-q-7- oo-w-e Xe4da1"j -rep/?We Subtotal 33,550.00 0%Tax Page 2 'Qta ' 33,550.00