HomeMy WebLinkAboutBuilding Permit #050-13 - 122 OLYMPIC LANE 7/23/2012 TOWN OF NORTH ANDOVER
O CO APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: 7�
IMPORTANT: Applicant must complete all items on this page
LOCATION a O 0 H PIC- LAtJ 6
Print
PROPERTY OWNER a 61 F_ I� A(zz I ht-, Unit#
Print
MAP NO: PARCEL: 12,1 ZONING DISTRICT: Historic District yesOno
Machine Shop Village yes100 year-old structure yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building , One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
5eRepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic Well ' ❑; loodplWtlands �„ Dj Watershedstre"t"t -
Water/S,;ewer �.�,,,. _.�_. ` •
DESCRIPTION OF WORK TO BE PERFORMED:
(Identiication Please Type or Print Clearly
)
OWNER: Name: 1 e-o�,1 e «0.r 1) i &-h Phone• 6 9 9 .,6 74/
Address:
CONTRACTOR Name: h co e eo4; � Phone:
Address: o`3 N R S'( ) ,Oz11 Sh eek 1, Uv\s\ 3,t� 14o• Anbo�ifx, W d 1W
Supervisor's Construction License: Ct?),20 Exp. Date:
Home Improvement License: 1 bq 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.
Total Project Cost: $ 19 00 FEE: $ ��
Check No.: I ") 0-2�, Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signatureoflcontracto
�II
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ I
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
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 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
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❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
I
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
o Workers Comp Affidavit
❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses
a Copy of Contract
D Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for EngineeredN roducts
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition or Decks
o Building Permit Application
L3 Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o 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 pp Permit Application
❑ Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance 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 submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Location 127,
No. Date
e • " TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
�.irt °` Other Permit Fee $
TOTAL $
Check# / �O 2-
25530 25530
Building Inspector
tAORTH
own of
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No. IV
-
h ver, Mass, al u
L 04coc"Ic"IWIc« '►
�d CRATED
S U
BOARD OF HEALTH
Food/Kitchen
'PERW T L D Septic System
•
THIS CERTIFIES THAT BUILDING INSPECTOR
p g ..�. 1 Foundation
has permission to erect .......................... buildings ....... .. ��.�...... ..
4 6
IM 1( Rough
to be occupied as .............. .!!► .. ...... .................................c6 .. ............ Chimney
provided that the person accepting this permit shall In every respect conform to the terms of thea cation 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 ONTHS ELECTRICAL INSPECTOR
• UNLESS CONSTRU10fl TS 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.
SEE REVERSE SIDE Smoke Det.
ACORN CERTIFICATE OF LIABILITY INSURANCE DAyt"'Y"
9/9/2011
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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If d»csrdflcate holder Is an ADDITIONAL INSURED, the pollcy(Iss)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and condlNons of the policy,cartaln policies may require an endorsement. A statement on this certificate doss not confer rights to the
certificate holder in lieu of such andorsemen s .
PRODUCER CONTACT
NAME'
willows Insurance Agcy MME 75V.EilI 979 4 3414 _
( ,No)_•_
EMAIL —--
51 Cochichewik Dr ADDRE'¢a;__ _
vR uceR _ ......._. I
1.
North Andover MA 01045 INsuRER(S)AFFORDING COVERAGE NAIL r
INSURED INauRm A Miden Special ty Ins CO -- -..
DAVID CASTRICONE ROOFING & SIDING INC IRERe_
INsuRERD:
200 Sutton St Suite 226 INSMR 0: - .-
—
NINSURER E;ORTH ANDOVER MA 01845 _..._._ . .
INSURER F:
COVERAGES CERTIFICATE NUMBER-CL119906255 REVISION NUMBER,-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS_ SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
i�TSRRbT blfep
' TOF INSURANCE -- _
PE POLICY NUleeEqucY EFF P�T ---AM WVD
LIMfTs
GENERAL LIA9ILITY EACH OCCURRENCE S 1000000
X COMMERCIAL GENER('A�L LIABILITY ..__•.._.... ._..�._ ...
A I, CLASA3•MADE I X I OCCUR 00031600 9/06/2011 /6/2012 PREM�ISFJ$lE�6gq"nm� S 50000
MED EXP(Amy one en 1 1000
Ftk%ONAL&AOV INJURY b 1000000
GENERAL AGGREGATE S 200000_0
GENL AGGREGATE LIMB APPLIES PER PRODUCTS-COMP/OP AGG 5 S OOOOOO
PO� PRO LOC s
AUTOMOBILE LIABILITY
COMBtNEO SINGLE LIMIT S
I ANY AUTO (�acoldenl)
ALL OWNED AUTOS BODILY INJURY(Por person) S
SCHEDULED AUTOS BODILY INJURY(Per ax dent) g
HIRED AUTOS PROPERTY DAMAGE s
(Per ecTJdeni)
1
NON-OWNED AUTOS
b
UMBRELLA LIAR :CL
UR - .. ..... ... f .
�CEb3 LlAa EACI4 OCCURRENCE _
1Mg.M_A_DE
DEDUCTIBLE AGGREGATE i
RETENTION b S — —
WORKM COMPENSATION S
AND EMPLOYERS'UABIUTY WC STATU• f OOTK_
ANY FRO PRJETOWPARTNER/FXECU rVE Y 1 N T'DRX.LIMITS .._LAR_
OFFICER/MEMBER EXCLUDED? a NIA E.L.t"H ACCIDENT s
(MaMetay In NH) ....._
d}�n delcntm Leder E.L.DISEASE•EA EMPLOYE f
DESCRIPTION OF OPERATIONS boles. ......
E.L.nISEASE.POLICY uMrr
OESCRamo N OF OPERAT164 I LOCI; /VENnLES (Allaefl AOORD 107,Addktonal Remarks Seheeule,M Ines
epees M rogWrod)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
David Cas tricone Roofing 6 Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS.
Castricone Roofing
200 Sutton street suite 226 AIITHORIaOK""XaNTATIW
N Andover, MA 01845 n
ACORD 25(2009109)
INS025(20MM) The ACORD name and logo are registered marks ofACORD KL)CORPORATION. All rights reserved.
.---� CERTIFICATE OF LIABILITY INSURANCE DA TE(MM/DD/YYYY)
ACORD
9 23 X011
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(Sy, AUTHORIZED
nr•nn tilt\IT•TI\Ir An n n11/�f'n •\111 TI Ir ArnTlr'1/'.11TP��nnr•n
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)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:
Eastern Insurance Group LLC — Main PHONE F� No:
—653-8089
233 West Central Street &MAIL
Natick MA 01760 AD RESS:
INSURERS AFFORDING COVERAGE NAIC p
NSLIRERA:Commerce Insurance Company 34754
INSURED 31969 INSURER B:CHART IS
David Castricone Roofing & Siding Inc INSURER C;
200 Sutton Street #226 INSURER D:
North Andover MA 01845
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2141633407 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.
INSR 9
98
rYili�11 I hWLIWI
I �
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY PREMIS S Ea occurrence $
CLAIMS-MADE 0 OCCUR MED EXP(Any ore arson) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $
POLICY F1 PRO LOC $
A I AUTOMOBILE LIABILITY BCNGCV /1/2011 /1/2012 Eaaockiara 1000000
ANY AUTO BODILY INJURY(Per person) $20000
ALL OWNED SCHEDULED BODILY INJURY(Par accident) $40000
AUTOSX AUTOS _
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS Peraocidenl $
1UMBRELLA UABOCCUR
EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
g WORKS RS COMPENSATION C003989723 9/23/2011 9/23/2012 X I WCSTATU- O -
AND EMPLOYERS'LIABILITY YIN Y LIMIT, _
ANY PROPRIETOR/PARTNEMXECUTIVE E.L.EACH ACCIDENT $100000
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $100000
n Tres,descilbe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT- $500000
I
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD tot,Additional Remarks Schedule,it more space Is required)
CERTIFICATE HOLDER CANCELLATION
Castricone Roofing & Siding SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
g g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Suite 226 ACCORDANCE WITH THE POLICY PROVISIONS.
200 Sutton Street AUTHORIZED REPRESENTATIVE
North Andover, MA 01845 �.��,{
01988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
'- '�I:ts.�:lrhu�i't[� - Uclr;tr•itttrnr ul Pulllii 1;tfcn
Bu;lrtl ut Builrlin', Ki,ul;ttiun. incl .5t;tn1lurtl
Construction Supervisor Specialty License
License: CS SL 99358
Restricted to: RF,WS
DAVID CASTRICONE
31 COURT STREET
•1'rs
NORTH ANDOVER, MA 01845
Expiration. 12/16/2013
( nnuii.<i,nirr
T rt~: 7924
SCA 1 ci 20M-05/11
s ,
Office of Consumer Affairs& Busidess Regulation (/
IOMEIMPROVEMENT CONTRACTOR
la06 '
1egistration: 104569Type:
xpiration: 7/14/2014•r Private Corporation
DAVID CASTRICONE ROOFING, SIDING&
David Castricone
200 SUTTON ST SUITE 226
NORTH ANDOVER, MA 01845=
Undersecretary
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations .
600 Washington Street
Boston, MA 02111
°,� 5�•v� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ePlease Print LelZibly
Name (Business/Or ganization/lndividual): CA 3181 CME IS�p O 0 F JA Er
Address: 2 3 Ju T rb ST(Z&—T- 3 A
City/State/Zip: KD. Anooyck HA 6 i M Phone #: 911 - W '3 Q
Are you an employer? Check the appropriate box: Type of project (required):
1.® I am a employer with 7 4. ❑ 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. F-1 Remodeling
ship and have no employees These sub-contractors have 8. ❑ 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.F1 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other_S 11J I til Cs"
comp. insurance required.]
'Any applicant that checks box#I 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
Contractors 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 isproviding workers'compensation insurance for my employees. Below is the.policy and job site
'nformation_
Insurance Company Name: ki A(Z rl S
? SIV olicy#or Self-ins. Lic. #: C 0 0 3 18 9 113 Expiration Date: _!p
. 0l3
fob Site Address: ` `G: e_ City/State/Zip:_& _. l A U
Uttach a copy of the workers' comp nsation policy declaration page(showing the policy number and expiration date).
'ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine 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
A up to $250.00 a day againsf the violator:•-Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coveragq.verification.
!do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct
3ifMature: -�-� C - Date:
Phone#: 9 7 E
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
1 6. Other
Contact Person: Phone#:
Town of North Andover N�k7H
0�{1,�0
Building Department o -
27 Charles Street
Nort1i Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
�R�reo rPµ`y(h
S,SHCHU5e
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL c.l 1, s150a.
The debris will be disposed of in/at:
Facility location
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project tluough the Office of the Building Inspector.
Jul 17 12 09:09p 978-9749256 p.2
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