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HomeMy WebLinkAboutBuilding Permit #484-13 - 122 LANCASTER ROAD 12/21/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: -1 I Date Received l Date Issued: I PORTANT: Applicant must complete all items on this page _ _ r LOCATION! �j Pn t PROPERTY OWNERVt --- Print 100'Year Old Structure, yes; MAP NO: PARCEL: ZONI_NG DISTRICT: Historic District yes n Machine Shop Village, yes. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building i6ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial )<Repair, replacement ❑Assessory Bldg ❑ Others: E,1_Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplbina ❑Wetland's El Watershed Districts. NWater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: X eS 2e v'-,Lk�� ►� �� CN' ovot_ new b��c k, i' �t oA&t5+ Identification PI e a Type or Print Clearly) OWNER: Name: 14,e,, ne Phone: (03 PO �S Address: �';( Lct l6 qs� l21 _ e 10 CONTRACTOR Name: Phone:, 603 U 25o6 r _ - Address: �lt �►G 12 S cul _._ _ 3� Supervisor's Construction Licenser 0 [7 s Exp. Date: X2 �6 I / 3 Home Improvement'License7. Exp: Date: // d,0 ARCHITECT/ENGINEER Phone: e 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: $ I��V . FEE: $ '/o7, n Check No.: � G/ Receipt No.: "4-&✓ NOTE: Persons contracting)w*th unre is red contractors do not have access to the guarantyfund !Signafure.of i-el Own: - Signature of contractor Plans Submitted [IP ans W ' ed ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ElSwimming Pools ❑ Tanning/Massage/Body Art ❑ 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 i i 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 T'ovvn Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT _ Temp Dumpster on site yes no Located at'124 Mair Street I Fire Department.signature/date ` E COMMENTS x. 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 foto DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— For department use I ® Notified for pickup - Date f Doc.Building Permit Revised 2010 Building Department The foliowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 o Building Permit Application on o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) o Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Re Report o 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 subm'Ated with the building application Doc: Doc.Building permit Revised 2012 Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 25,150.00 m $ - $ 301.80 Plumbing Fee $ 37.73 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 37.73 Total fees collected $ 477.25 122 Lancaster Road 484-13 on 12/21/12 Master and Main Bath Remodel NORT#1 own o a.. =:n over r 4�4 -�.K. h ver, Mass, x,9coc HICHEWICK 5 RATED U BOARD OF HEALTH Food/Kitchen PERMI-T T LD Septic System THIS CERTIFIES THAT .....1...1' '�: .:7!..: ..�r`:R/F'� BUILDING INSPECTOR .................................................. ..................... �(, ,� �� Foundation has permission to erect .............:.. buildings �o on ../.......... !./!�.:�............... C /GrfG r ��G�/7• v�' .�� ��.. �. Rough to be occupied as............. E.'. "✓.b.. .. .......... .................. . ........ ....... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S S Rough �� Service ........................... .........:`.��....................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. SEE REVERSE SIDE ® DATE(MMIDD/YYYY) AC� �. CERTIFICATE OF LIABILITY INSURANCE F12/20/2012 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 MATT SERODIO NAME: CORE BENEFITS GROUP AHCNN, Ext:603-329-6197 FAIL No):603-329-4924 2 VILLAGE GREEN RD.SUITE Al ADDRESS:MATT.SERODIO@COREBENEFITSGROUP.COM HAMPSTEAD,NH 03841 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:PATRIOT INSURANCE COMPANY INSURED INSURER 8: DREAMSCAPE DEVELOPMENT LLC INSURER C: AND OTHER NAMED INSUREDS INSURER D: 2 VILLAGE GREEN RD.BLDG A-1B INSURER E: HAMPSTEAD,NH 03841 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. INSRTYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDD/YYY MMIDDIYYY A GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CPP6207612 12/10/12 12/10/13 DAMAGE TO RENTED ✓❑ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $500,000 ❑ CLAIMS-MADE ❑✓ OCCUR MED EXP(Any one person) $ 5,000 El PERSONAL&ADV INJURY $ 1,000.000 ❑ GENERAL AGGREGATE $2,000.000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000.000 ❑✓ POLICY ❑ j�T ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000.000 CPP6207612 12/10/12 12/10/13 (Ea accident $ ✓❑ ANY AUTO BODILY INJURY(Per person) $ ❑ ALLOWNED ❑ SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY $ ❑ HIRED AUTOS AUTOS Per accidentDAMAGE ❑ UMBRELLA LIABUM OCCUR EACH OCCURRENCE $ 1,000,000 ❑ ExcEss LIAB 12/10/12 12/10/13 ❑ CLAIMS-MADE CPP6207612 AGGREGATE $ 1,000,000 DED ❑ RETENTION$ $ WORKERS COMPENSATION TORWCSTATU- 0TH- AND EMPLOYERS'LIABILITY, Y/N Y LIMITS ER ANY PROPRIETOR/PARTNEREXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION 122 LANCASTER RD. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE N.ANDOVER,MA 01810 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I AMSC "a DS�' � D DEVELOPMENT December 20,2012 Job Name/Location: Karen Barnett 122 Lancaster St North Andover, MA Dreamscape Development will remodel the master bath and the 2nd floor main bath. Main bath: • All cabinets,fixtures and flooring will be demoed and replaced • The bathroom will be repainted • Light fixtures will be reused • Fan will be replaced Master bath: • All cabinets,fixtures and flooring will be demoed and replaced • The ceiling will be replaced • A new light will be added • Vanity lights will be replaced • Fan will be replaced • The bathroom will be repainted The total cost of this project is$25,150.00 Ken Berardinangelo laren Massachusetts - Department of Public SafeSty Board of Building Re( arlations and Standards Construction Supervisor License - cLicense: CS 86865 KENNETH J.-BERARDINANGEL 4 KACIE LN E HAMPSTEAD, NH 03826 �" - Expiration: 9/29/2013 Commissioner Tr#: 6625 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 'Y www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual): t 41C Ue Address: V l 6,fCeV\ tkv5iOl `tN City/State/Zip: Phone#:_03 .� o - / j Are you an employer?Check the appropriate b : Type of project(required): 1.❑ I am a employer with 4. P9 I am a general contractor and I 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.t ?• [nRemodeling ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I ama 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.❑Roof repairs insurance required.]1 employees. [No workers' 13.0 Other comp.insurance required.] kny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. tsurance Company Name: :)licy#or Self-ins.Lic.#: Expiration Date: ►b Site Address: City/State/Zip: ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required tmder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a le 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. 3o hereby cerci under the pains andpenalties ofperjwy that the information provided above is trate and correct.r nature: Date: I� tone#: 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 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 he application for the permit or license is being requested,not the Department of be returned to the city or town that t pp p g q P 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 burn 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. #617-727-4900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax# 617-727-7749 www.m a SR.a0v/d i a DREAMSCAPE DEVELOPMENT JOB SITE; 122 Lancaster Road., No. Andover, MA (LIST OF SUB CONTRACTORS) Sub-Contractor Employees Wkrs Comp Policy# PALLARIA ELECTRIC & SONS INC YES WCA9082861 WILLIAM ASHFORD NO N/A Location C ft4e 2 " No.A454� Date 17, Z x ® - TOWN OF NORTH ANDOVER e ���')'I;IxJ�lilg6e e Certificate of Occupancy $ Building/Frame Permit Fee $ 2 < Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# n4 26054 Auking Inspector