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Building Permit #722-2016 - 123 FRENCH FARM ROAD 12/14/2015
Tl� BUILDING PERMIT OF r10R%OR TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received RATED �SSACHU`��� Date Issued: IMPORTANT:Applicant must complete all items on this page 2 � _ LOCATION u33 1'`h rm Ri (j 1,"f' M I `I P PROPERTY OWNER E t)t &V)) ��t'n jOM >t Print MAP 210 b�6 PARCEL:bbb(0 ZONING DISTRICT: Historic District yesno 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, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Re Identification Please Type or Print Clearly) OWNER: Name: n,nne T)i �n�e�> Phone: Address: G3 nC -�U, rm Rd• N. c3 o I�`t S CONTRACTOR Name: Rilr I, ` Cff\St uCSJy) C . Phone: L-Q3- 1 1yL{V g Address: y)r _ Y11(�i . , Rtled V,0 (J Supervisor's Construction License: � Exp. Date: l Home Improvement License: ) U)LIVA Exp. Date: zg� c0 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. otal Project Cost: $_ Uy 0`" 01- FEE: $ Check No.: l Receipt No.: 2:n 3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location P --5 M P, Y No. �� ? — ��o Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ F Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# �7 Building Inspector 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 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 ❑ Notified for pickup - Date .................................._................................................................................__._...............---...........__.._.__.—. _........._._..__.......__.......----.........................._._-....................................._.._..._._.......- - - ---...-----............_. ............ Doc.Building Permit Revised 2010 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 ❑ 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 NORTH Town of : Andover p Y~' �► No. 4;L;L4; * ��.oh ver, Mass o COC MIC Mt WICK ��' �s.9s R^rE J Q'rt S U BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT ............. ...�.A h��.►... .�.. ......4... ......................................... BUILDING INSPECTOR . �... has permission to erect .......................... buildings on .. �. .. .. ....... . Foundation Rough s p to be occupied as ....�...... .�Ii .... ........ ..2.... ��lt ,. .. `. Chimney provided that the persona epting this permit shall in every respect conform to the terms of tap�lication 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 RT Rough y 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. Smoke Det. J�' I Owner's Name:_ .� L' SIDING - ✓,fftlDOCAIS - DOORS Address: —/ �- _ria 1c, It_14,tzi .. `mak' 'L � - - — _ i� Phone: — Family Owned And Operated w.e Me c:re's of the prerrses 7,w cued De'wi.heretf contrad wr.th a^d a;ra':ze;3a tJ f,.rr Sh a.nL-_essa,)matc:a Taber and h kt::nsh'p, tD Wal construct and Place the!mprovements acatrd.ng to me fo1owmg spec':aftns term ano Geri^_.'cnsoq;em ses be x:descr;oed Brand: jq r�, -r; ! GGV (WINDOW)SPECIFICATIONS Quantity: l Bui'd Tie Into Low-E Metal PVC New Inside TOTAL$ `) 7- Roof Overhang Argon Screens Grids Trim Trim Flmsh C Color. olor: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes I No Double Hung Picture 1!3 Deposit$ _2-2 6C CII, Slider Bow/Bzy 1/3 Startof Job$ 1101 C L Garden 1/3 Balance Upon CWAwn Completions ytee Cc NOTES: l qr y �� fry .^c �3o, i�r 13t,,,i`-j A,,(I- f rf P Ute. T(-,0 C rI S 1 Y e 4-t,' a +- S f„ - Trwi 'dC,-�: (SIDING)SPECIFICATIONS APplY — ._ _. over body area of house.Type of insulation Items not covered or installed: Yes No Yes No Yes No Strip off Existing Siding Vinyl Shutters Roof Provide Container and remove all Window Mantels New Gutters debris Cover Fascia&Soffit Door Surrounds Gutter off&on Door Window Casing Ceiling Fluted Post 51h Vinyl Fixture Accessories if needed PVC Trim Traditional Post 51h 4"Corners ON START OF ALL JOBS-HOMEOWNERS MUST REMOVE ALL ITEMS FROM WALLS&SHELVES Construction related permits:if the homeowner obtains his oven construction-relatad permits for the work doscribed tinder this agreement,the homeowner is here by advised that in the event of dispute,judgment and nonpayment of the contrac the hommmer will not be entWzd to make a claim to or colt from the guaranty fund estaWsM-d by Chapter 142A,M.G.L. WARRANTY rs ar r¢ n s L; AYk r ric, y hae_ry•St- N ha^c r V: h a a�: ;e ,s p rw 1,Year st71 ..y e.•^':r e ^y az.J Ix•rw�.- *�a .--4xar a'�'^.:uL a _. ra..,x,.a: ...:.^r... a>rm.•_u r_: '-r1�9;'Y•A� ". ryw,,C. x91, er z e. r.,x....,!`m 't essay.'¢:.;cvm.3•..S"t,ora Mto oc 1 .:.'.ti) J xt Tr..r ._'r r :'> :a••rc:a-cr.^^Pc-r x.'^.,,z;:::a-�c�,rr�k"•a ..,�mw r•I g.'r^r Lca W�'acl ra S- °m:x c^•.r.... _ r a r:.r, - "'OicS'x:'••n.^a -g ^.... :'1. it� S - ..,trm_s.K.....ac•cpm::Icsx.,x9Sccr'•c'rc^."�g 5anaauaLpu-�:��g cena'dnS Bl�:<5:-9^..:� _.,. ... �:w3 ...'-q•.rx 1rC^_0:•7oa .:,.x:,:r,;A•or4<��� r r.. c.�r .^'.,__w.. :. ,_9r,..✓ ....:.:",»En,IOkS:,not IG41y;c.'x•^a7aA•nw tc.�v,_. :es•c:...'n.� .x`t., t.- ic,n.• -�e.a:ce encs•^pprd Lr•.N:a•„e., ,m-r1m 1,. as net '. •Nu:,.mzl:.yet.;' . ..':r. ._ '„C: .�-rx. ..t. .. '••� ...r,r"'c r,. l° ^t 7e..: �y:7m1: ^9 ba9'iC9:n r... x: : .-�.. _3+'.A,^.'FF .. .... ._?;lj'._ ..S 5..0 4 i a.x se•�„'. ^r XrW ba,V !,J03.,.:ce r-.C:1tOX•dMSofcv-4::tc:2x'.>'a,c.r� :r^,'•rk+G .. •:r^'. ,�rrup• .A,.rvy...2,';a•r.ese r •.g,. ,,,;y 4c::'u!'r rh;'r,^sv 2x^i r��-,�€'E 2'3:>D'l..•.f'.,^7 C_rJs'^• TOTAL$-__ _ Brooks Vinyl Siding-Windows•Doors N_—of Contr2LtW a:.:.;r�1:d RYS-I-,t Payment t¢Dr:made as f¢Pows. V3 3 254 N.Broadway-Breckenridge Mail _.. .__J Upon signing Contract: Street Adlr 1,3 g, J Start of Job Salem,NH 03079 (803)894-4488 www.brooksswd.com ----- c',y State c,L..y Mb•fe 11 '� .. _ )Ba'arce upon comp:etion 101682 99730 3 N,c N Rep:W.,11 CS' v fwn-n 1.' //"f�/���/�C.�J.L.• f"'t P 9 rin' N.:lr.9 Ut SY 1:.• _ AcoeptimaoltRcpoaal- ( -•^.x: ' '.'sz-,4Cus. . ,:'•.� :'••.rr'ratLDc'-> i.y,. ,._...n, ^-a nc,You,the Buyer mey cartel thEs trafm:ctbn at eny t;w prior to midnight of the th'rd business day aftr Ca d--t3 of L s trariseceen must be stone m wrPJ g.Y.^e re erve ft richt to check your credit \ DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. IN WI E�S/S WHEREOF O�t partliss Cereunto ha_ve/]sin to their names this.___ _ _ -day of _v l L_ 20 Signetl_ 1.-L1"_ ..� 4�is�-- -- --- — f. t_: c. r eac : Y.yam the 6w1 — — .. Z 7 r.'Jb.A IG. Signed..— — - -- eia«p, r 4 ., r es•>,r a Yes.:am the owner ry The Commonwealth of Massachusetts , - 1 02 Department oflndustrial Accidents Office of Invesfigations 600 Washington Street Boston,MA 02111 www.massgov/clia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information t-S Y Please Print Legb ly Name(Business/Organization/Individual): pa coV16. C, Address: a;5 d viaU City/State/Zip:_ S t �iH 0 3 Un Phone#: (o'D 3-�q y --,44�,E Are ypu an employer?Check the appropriate box: Type of project(required): I. I am a employer with q 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/orpart-time).* have hired the sub-contractors g 2.El am a sole proprietor or partner- listed on the attached sheet.i 7• emodelin ship andEl no employees These sub-contractors have 8, Demolition working forme in any capacity. workers'comp.insurance. y. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑I am a homeowner doing all work right of exemption per MGL I ]Plumbing.repairs or additions myself.[No workers'comp, c.152,§1(4),and we have no 12,❑Roofrepairs insurance required.] employees.[No workers' comp.insurance required.] 131:1 Other 'Any applicant that checks box#f must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ` Insurance Company Name:._ j((�151 or Policy#or S elf-ins.Lic.#:\1\1c Ste,�3(0a,`1 J (� } Expiration Date: 511 1`b Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. f do hereby certo under ae ins and penalties ofperjury that the information provided above is true and correct. - Signature. Date: 2 8K Phone#: O_ficial use only. Do not write in this area,to be completed by city or town official. City or Town:. PermitUcense# Issuing Authority(circle ane): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and iustructi®�� . 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 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 ofits political subdivisions shall enter into any contract for the performance ofpublic 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-contractors)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 cavy workers'compensation insurance. man LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 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' 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. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or p emrit 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: Tho GQMMO.Uwoalt�ofM-smachv e"Us Dop.az°tment ofJndustdal,Accidonts pi ne ofWestigatim. 600 Washington Street Boston,MA 02-111 Tel,#617-727_4900 eYt 406 or 1-87TMASSAFE Revised 5-26-05 Fax#617"727'7749 www.Mass,gov/dia i A� CERTIFICATE OF LIABILITY INSURANCE 6ATE (MMIDDIYYYY) /ly/1U15 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 Linda SOgdanON]C2 Insurance Solutions Corporation PHONEMo. (603)382-4600 FAIAJX .(603)382-2034 DOME 60 Westville Rd E-MAIL INSURERS AFFORDING COVERAGE NAIC Plaistow NA 03865 INSURERA:PeerleSs Indemnity Insurance 18333 INSURED INSURERS: Brooks Construction Co. of Lawrence Inc, DBA: INSURERCEXCOlSiOr Insurance 11045 254 N. Broadway INSURER D: INSURER E: Salem NR 03079 INSURER r: COVERAGES CERTIFICATE NUMBER-CLIS52621745 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 VMICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THF INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SL16.IFCT TO AIJ_THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR A0DL5UBR POLICPOLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DDY EFF MM/DD UL9TS GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 X COMMERGAL GENERAL LIABILITYAG o PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE a OCCUR CBP8945793 /16/2015 /16/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PJR; COT" LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Fa arNdanll _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE FIRED AUTOS AUTOS Peracc ent $ Medical a nts $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ C; WORKERS COMPENSATION WC STATIC I 011+ AND EMPLOYERS'UABILF Y Y 1 N FR ANY PROPRIETOR/PARTNER/EXECUTNEEL.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? FN N 1 A (Mandatory in NH) 8836275 /16/2015 /16/2016 F I IN.SFARF-FA FNPI DY F $ 500,000 If yes,desc ibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Diane and Philip DiBenedetto ACCORDANCE WITH THE POLICY PROVISIONS. 123 French Farm Rd N. Andover, MA 01845 AUTHORIZED REPRESENTATIVE Keith Maglia/CLS _- -T f `� =— — ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION, All rights reserved. IN9n25 r2mnm)n1 Tho afnpn normo and Innn aro rorrielorad marine of Annon I Office of Consumer Affairs&Business Regulation .� HOME IMPROVEMENT CONTRACTOR �t Registration: 101682 Type• Expiration: 6/29/2016 Supplement BROOKS CONST CO.,INC.OF LAW MARK DI PRIMA 254C N. BROADWAY STE 110 SALEM,NH 03079 Undersecretar, Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor Specialty License: CSSL-099730 MARK DIPRIMA 18 HAWK DRIVE SALEM NH 03079 �1 „ Expiration Commissioner 02/20/2016