Loading...
HomeMy WebLinkAboutBuilding Permit #096-2017 - 12 WILLIAM STREET 7/29/2016 1o� NoRTy, q BUILDING PERMIT ��4LEo tia TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION � Z � .-- b Permit No#: 0 Date Received "—�- �SSAcHl1b, Date Issued: IMPORTANT: Applicant must complete.all items on this page LOCATION. Print PROPERTY OWNER Lti Print 100 Year Structure yesCno MAP ©10 PARCEL:_ZONING DISTRICT: Historic District yeso Machine Shop Village yes 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 El'Septic ❑Well 0 Floodplain " ' ❑Wetlands _ Ei Watershed_Disfriet_ D Water/Sewers c DESCRIPTION OF WORK TO BE PERFORMED: 1 y 410 Identification- Please Type or Print Clearly OWNER: Name: L-cerc Ld she-v4-& Phone: Address: F ntractor Name:;� , l Phone: D��� 3 5-77 q ail �o�e - Address: 4,9//�ri�roan ���T�,�!1•� 44u: &NW 4,4,41 a Supervisor's Construction License:,:�f411`1. 7-3 Exp. Date: &//S /2®/7 Home Improvement License: Exp Date: 211[, h 19- — _ ARCH IT ECT/ENGINEER Phone: r Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project C St: $ t9 O J, (z ® FEE: $ Check No.: �m - Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund naturP of con Siang ure of Anent/OWnPr J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL I Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On � �p Signature_ LLLLIA�_ COMMENTS—W 1 CONSERVATION Reviewed on_ Signature COMMENTS HEALTH Reviewed ori Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments J - Conservation Decision: Comments Water& Sewer Connection Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIDE DEPARTMENT - Temp Dumpster on,site yes, no Located at 12.4 Main Street - Fire Department signature/date COMMENTS L Dimension I 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.$10o-$1000 fine NOTES and DATA— (For department ease) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. i i 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 OTE: 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 46 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 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 2012 IECC 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 Doe:Building Permit Revised 2014 Location Noo /!� �Q�f_ Date Oz? • - TOWN OF NORTH ANDOVER �4 as� �t d a• Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ ti TOTAL $ Check# {? /1 Building Inspector r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL ±. Public Sewer ❑ Tanuing/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On %Lit.�p Signature_ 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 ®ate Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DVARTMENT - Temp Dumpster onsite yes. no . - Located at 12.4 Main Street Fire Department signatureldate COMMENTS ORT - r � � N H w: : 1c ver ,� oh ver, Mass, 41 41 A-� _OC.4ICN111We y1. 7.es RgTEO V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ., BUILDING INSPECTOR .........�:.. .G.�.. , ..... . . ',P.. .......1�*f I� has permission to erect ....... buildings on .�/.. ...Jfi.�..l�!`/I.af ► f7-77"'........ Foundation ................... .... .... ....... ................................................................ Rough to be occupied as ....���.. . ..... ...&-Aor... ...........:. chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final f 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR ON_ S Rough ervice .. ... .... ......... ....... ......... .......... ..... Final BUILDING INSP IOR 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. I i } Page No. of Pages •Roofing •Siding ,ferry R LeBlanc PROPOSAL AND ACCEPTANCE •Gutter 9 Atkinson Depot Road Construction onsu ionurvisrRse •Painting License: Specialty co•Carpentry Plaistow, NH 03865 Tr#:5177 Expires:10/15/2015 •Windows Home (603)382-0817 Home Improvement Contractor •Snowplowing Cell (978) 835-7740 Registration:149881 Expires:2/16/2014 PROPOSAL SUMMED TO PHONE DATE) SET / JOB NAME ` W ! G Ci1Y,STATE AND ZIPCODE = JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: /Yl �.i 4. ` t r h ( n r' r v f oc", Gr- Cr` n We Propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: tl donors(S t3.4 U 0, 1 ). Payorj 't be mads as fo ows: 11 y' All material is guaranteed to be as specified.All work to be completed in a workman- Authorized like manner according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and Signature will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado Note:This p posai may be and other necessary insurance.Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted within days. pensation Insurance. Acceptance of Proposal -The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work ass Signature n / pacified. ant will be made as outlined above. 9 Date of Acceptance w - Signature I i The Commonwealth of Massqchusetts z. .. Department oflndustrialAccidents I Congress Street,Suite 100 q° Boston,MA 02114--2017 www.mass.gov/dia sY• Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE J�ED W�(TH THE PERMITTING AUTHORITY-A_ Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: 074.fk n Sari 4&/a2 X i City/State/Zip:plg/�6,,/._,&/&d Z t_ Phone#: 7 6 Areyon n employer?Checktlie appropriate box: Type of project(required): 1�a employerwith s employees(full and/or part-time).* 7.. New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodelilig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition IF]I am a homeowner doing all work myself[No workers'comp..insurance required.]f 10 FJ 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.'0 Roof repairs These sub-contractors liade employees and have workers'comp.insurance.: 6.Q We are a corporation and its of�cers have exercised their right of exemption per MGL c. 14.FJ Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] -Any applicant that checks box 4l must alsofill 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 sub-contractors and state whether or not those entities have employees.'If the sub-contractors fiave employees, ey must provide their workers'comp.policy number.' I am an employer tfzat is pi*ovidingworkers'compensation insurance for my employees.'Beloit/is the policy acid job site information. Insurance Company Name: Policy#or Self-ins.Lic.#:/; 06 1)M kT4-11 -N (� Expiration Date: Job Site Address-_(2 a„ `� f � �SCity/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. I do hereby certify under the pains and penal"ties ofperjury tlzat the information provided above is true and correct. Si afore: Date: 21 2- �42 Phone#: Of 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): i 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 ofhire, 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 commonTealth 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. lie advised that this affidavit may be submitted to the Department of•Industrial Accidents for coir m.ation 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' compensatiod 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 areference 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"rob 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 GERALEB-01 JONEILL YY ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE(M 7i2s/2o1 ) �•-� 2016 s 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 CONTACT NAME: Durso&Jankowski Insurance Agency PHONE 978 s88-7000 FAX 11 Saunders Street A/C No Ext):( ) A/c No: (978)s88-7001 North Andover,MA 01845 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Preferred Mutual Insurance Co. 15024 INSURED INSURER B:MSA Group 14788 Gerald LeBlanc INSURER C:Liberty Mutual Ins.Co. 9 Atkinson Depot Road INSURER D: Plaistow,NH 03865 INSURER E 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. INADDLSUBR LTR TYPE OF INSURANCE NSD WVD POLICY NUMBER MM/DDY EFF MO DD EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR BOP0100717134 05/01/2016 05/01/2017 MISES Ea occurrence AG ORENTED $ PRE100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY D PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 500,000 B ANY AUTO B1 B2755S 01/04/2016 01/04/2017 BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB i CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N WC531 S369385025 10/12/2015 10/12/2016 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 384 Osgood Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <rp Office of Consumer Affairs&13 n ss Regulationef�J (SOME IMPROVEMENT CONTRACTOR ` I;egistration: —T 149881 Expiration 2/18/201°8,, Individual_ Individual ` JERRY P LEBLANC-,' JERRY LEBLANC 9 ATKINSON DEPOT RSD` PLAISTOW,NH 03865 Undersecretary + v Massachusetts Department of Public Safety ' Board of Building Regulations and Standards License: CSSL-099633 Construction Supervisor Specialty. JERRY P LEBLANC 9 ATKINSON DEPOT ROAD PLAISTOW NH 03865 Expiration. Commissioner 10115/20.17