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Home My WebLink AboutBuilding Permit #78-11 - 121 GREAT POND ROAD 7/21/2010 BUILDING PERMIT o� No oTH q TOWN OF NORTH ANDOVER 2 APPLICATION FOR PLAN EXAMINATION r Permit NO: Date Received Date Issued: Z( SSACHUs��y IMPORTANT:Applicant must complete all items on this page 'LOCATION /�I_ r=(�-� }Pb Tod' Pnnf. PROPERTY OWNER-, C I/1rlT F _ ( r �, tT—&� 'z 5(41 17 Print _ MAP 21 Q--A PARCEL; _ZONING'DISTRICT _ Historic`District yes ria 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, replacemen Assessory Bldg Others: Demolition Other 5epfic Well Floodplain Wetlands Watersher! District Water/Sewer - DESCRIPTION OF WORK TO BE PREFORMED: r-n ZbTz 'FbzQ4 A -rej rY� Identification Please Type or Print Clearly) OWNER: Name: PIT- Cl yh)IFS A – r~v.,, ,D Phone 9 y Address: 88 f — z CONTRACTOR Name: -r�- iz,,u,g � '��,�, r XPhone: 7) Q_37 790 L) - _ is Address:_ Su.pervis&s.-Construction License /&0 6 Exp. Date: Home Improvement License:_ . /(�l9 9 3 : Exp. Date _. ARCHITECT/ENGIN �R �" Phone: *bO3 �I $ Z 14L Iir vo TN / Address:�64JMW , ��m� y9 � SSS q S 7_ Reg. No. 32- FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. ` Total Project Cost: $ ZY'_on8 --r FEE: $ Check No.: - Receipt Receipt No.: 3 I � , NOTE: Persons contractin with nre istered contractors do not have access to the guaranty fund Signature of Rgen Signature.ofcontractor 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 i n Board of Appeals: Variance Petition No: Zoning Decision/receipt submitted yes Zoning pp , r 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 ite, yes no _ Located at 124-Main Street Fire Depirtment.:'signature/date COMMENTS L— Dimension p 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 2010 J 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 d Workers Comp Affidavit wl Photo Copy Of H.I.C. And/Or C.S.L. Licenses �opy of Contract .a/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:Building Permit Revised 2008 Location 4�: T Dn No. Date 11 �� TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ �'��'•n�';,<� Building/Frame Permit Fee $ 4CMUs Foundation Permit Fee v.$ Other Permit Fee $ ' TOTAL $ Check # / � � 23 : Building Inspector ORTH T0VM of 1,0z 4 0 71, oli 4 0 4t- = -LAKE o dover, Mass., �- o It' COCHICMEWICK 1 7�ADRATE D P0LC, SS BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System ' ® ' BUILDING INSPECTOR THIS CERTIFIES THAT............: ..�......... ........U .. ............ ....... ................. Foundation has permission to erect` ............. ........................ buildings on ... ,�..... W....... Rough : .. &!.raAa................................ to be occupied as........ !� ��j(1 , Chimney provided that the person accepting this permit shall in every re pest nform 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 b MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS 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 Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner ' Street No. SEE REVERSE SIDE Smoke Det. Proposal PERFORMANCE Building Company, Inc. 50 Tanner Street Lowell,MA 01852 Tel.(978)937-7900 Fax(978)937-7500 To: CMTF Limited Partnership 881 East Street Date: 7-21-10 Tewksbury,MA Job Name/Location:Enclose Three Porches Proposal#:2010-644-2 We hereby submit an estimate for ALL NECESSARY LABOR,MATERIALS AND EQUIPMENT as required to: Enclose three porches at the following address: 121 Great Pond Road North Andover,MA Construction to be performed per drawing A.100 Bennett Sullivan Associates,Inc. Dated June,21 s`,2010 We propose hereby to furnish material and labor-complete in accordance with the above specifications,for the sum of: ($74,950.00) Seventy-Four Thousand,Nine Hundred and Fifty dollars and no/100 Any change orders to this contract will be performed at a rate of cost,plus 18%.TERMS: 15 days from invoice date unless otherwise indicated. 1.5%interest (18%annum)added per month on all past due accounts. The purchaser agrees to pay all costs of collection including attorney fees. All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements are contingent upon strikes,accidents or delays beyond our control. Owner to cavy fire,tornado and other necessary insurance. Our workers are fully covered by Worker's Compensation Insurance. Authorized Signatu�- Perforffa6ce Bui mg Company Inc. NOTE:Performance Building Company Inc.may withdraw this proposal if not accepted within 30 days. ACCEPTANCE OF PROPOSAL:The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date The Commonwealth of Ajtfssachusetts Department of Industrial Accidents Office of ftzvestigations 600 Washi eaMn Street Boston, MA 02111 Workers' Compensation Insurance Affidavit: gud rs/Co wDlicant Information niraetors/Electriclans/Plumbers Please Print L.eaibly Name (Business/organization/Individual): an Address: City/State/Zip: L.s�L+�e.�1fnAJ Phone#: 9 `] 7 9��J A�re.you an employer?Check the appropriate boa: �la a employer with 4. ❑ I am a a� Type of project(required): b"neral contractor and I oyees(full andlorpart-time).* have hired the sub-contractors 6. ❑Neur construction 2.❑ sole proprietor or partner- listed on the attached sheet t 7. -( J Remodeling ship and have no employees These mob-contractors have working for me in any capacity. workers Com 8. ❑Demolition [No workers'camp. ' P insurance. p insurance 5. ❑ We are a corporation and its 9. Building addition 3. required.] officers have exercised their 10.0 Electrical repairs or additions ❑ I am a homeowner doing all work right of ex myself. [No workers'co emption P MGL 11.❑Plumbing repairs or additions MP• c' Ic2,§1(4);and we have no in.c„r:,nce required.] t employees. [No workers' 12.F7 Roof repairs COMP.msurance required.] 13.0 Other `•=-LS'. •?ic:�t that,ch—Ifs bo:-1 must also tui ca!;zcr•secriot, . I'toIDEOWnetS W im`..., OY.'-ha W�r .; 0..0{„ hO submit '...•S'coSL" ---;...,....i;..., affldaytt indicating tliCS'a.=dour^ati-;v--i r--... r.....l wn ate name of t O su _c Mr—Ect�.�i submit a new affidavit Lldlcating'such. +Contsactots that Chu,,; ,��_bo,;�•;o�attached all rioLai sheet showing o the name of the sub-contractors and thea work•co I am an employer that is providing workers'compensation insurance or�n employ Pow} Ltformahon information. �I f Y ees: Below,is the policy and,job site Insurance Company Name: e Policy#or Self-ins.Li-c. O 7/ ?D'Fxpuation Date: Crty/State/Zrp. !3 Sob Site Address: Ic� ejrco ,., � n��,�� - Attach a copy,of the workers' compensation policy declaration sae P b (showing the policy numberand expiration date). Failure to secure coverage as required under Section 25A OfMCiL 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 WO of up to$250.00 a day against the violator. Be advised that a copy of this and a fine aa Investigations of the DIA for insurance coverage verification statement may forwarded to the,Office of RK ORDER I do hereby certify under the pains and penalties of p Siffiature: erjure that the information provided above is true and come cL Phone#: Official use only. Do not write in this area, to be completed by city or torn ofjiciaL City or Town: PermitUcense# Issuing Authority(circle one): 1. Board of Healtb Z.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing 6. Other a Inspector I� Contact Person: Phone r: Information an- d 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 ed in a joint enterprise,and including the legal representatives of a deceased foregoing enragsed emplov- , or the receiver or trustee o`an individual.partnership, association og other legal entity,employing employers. However the owner of a dwelling house having not more than three apartnients and who resides therein,or the occupant of the dwelling house of another who employs persons to do aiaintemance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be cavae of such.employmeiit 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 c onstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of ca3Mpfi=ce 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 theperformance of public work un-bl.acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Y Please fiIl 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 Lzabilitypartnerships(LLP)with no employees other than the members or partners,.are not required to carry workms'comp easation 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-onfirmation of insurance coverage. Also be clure to sig and date the affidavit. The affidavit should be mt'ulued to the city or',own that the ampli-cation forthe^ being.e .•ert7ait or l: ense us . arrested,not ilhe.Department.of Industrial Accidents. Should you have.any quest ionns mgardr�b thi e law-O!.you ai e:.:t^uired to obtain a workers' compensation policy,please call the Department at the numbesr 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 Depai to ent has provided a space at the bottom of the affidavit for you to fill out in the event-the Offi 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 appllications-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. Anew 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 Bice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call- The allThe Department's address,telephone and:fax-.number__.. The Commonwealth Of Massachusetts, ` Department of Industrial Accidents Office of lw est�af oar 640 W ashinp-tm Street Bacton,M-A 02111, Tel. J 617-72.7-4900 C),-t406 or 1-8 77-MASSA.FE Revised 5-26-05 Fax rr 617-72.7-7749 VMrW-mass.-aov/dia Client#:33693 PERFBUI ACORD,. CERTIFICATE OF LIABILITY INSURANCE 3DATE(MM/D /10/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins. Plymouth ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 341 Court Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 3700 Plymouth,MA 02361-3700 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA Peerless Insurance Performance Building Company,Inc. INSURER B: ACE Property&Casualty Ins.Co. 50 Tanner Street INSURER C: Lowell,MA 01852-4419 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR RDD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MM/DD DATE MM/DD LIMITS A GENERAL LIABILITY CBP8051843 07/03/09 07/03/10 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES(E. $1;0,0;0 CLAIMS MADE 51OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 OOO 000 X POLICY jE O X LOC A AUTOMOBILE LIABILITY BA8059234 07/03/09 07/03/10 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIREDAUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY CU8056854 07/03/09 07/03/10 EACH OCCURRENCE $10,000,000 X1 OCCUR FI CLAIMS MADE AGGREGATE $10,000,000 DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WC2930838 07/06/09 07/06/10 X WC STAru-I oTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 X OFFICERIMEMBEREXCLUDED? No exclusions E.L.DISEASE-EA EMPLOYEE $1,000,000 Des describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Workers Comp Information: Included Officers or Proprietors. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Evidence of Insurance DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL A0_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S49739/M44918 DEC 0 ACORD CORPORATION 1988 T1. ��a�� Board of Building Regulations and Standards License or registration valid for individul use only HOME IM OV ENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registialio : 161993 One Ashburton Place Rm 1301 2/2010 Tr# 279132 Boston,Ma.02108 f? --rltj to Corporation PERFORMANC., I C. JAMES MCCLU 1� 50 TANNER ST _ 4y PJM'/ ...... . LOWELL,MA 01852 Administratorvalid _ ... .. ........ .. ... _ ovalid wit out signature alit r Restricted to: 00 ly�t �sachtsetts- Department of PublicSa1'eh Board:of Building Re;►ulations and Standards 00- Unrestricted "! .onstruction Su 1G-1 2 Family Homes pervisor License j License:.,Cs 16060 I� 4. -.Restricted to: 00 ,Failure to possess a current edition of the JAMES W MCCLUTCHY , Massachusetts State Building Code i 50 TANNER ST is cause for revocation of this license. LOWELL, MA 01852 Refer to: WWW.Mass.Gov/DPS . Expiration: 4/19/2012 0)"I.Missioner Tr#: 23482 r