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HomeMy WebLinkAboutBuilding Permit #755-15 - 123 MASSACHUSETTS AVENUE 4/3/2015 NORTF� BUILDING PERMIT 010 "tio TOWN OF NORTH ANDOVER �2 � 't'- - C. ,6 APPLICATION FOR PLAN EXAMINATION 4 = y �,.� "0 10 Permit No#: Date Received Q�.ATBU�ra`g5 gSSACHU`��� Date Issued: I ORTANT:Applicant must complete all items on this page LOCq�IONi A IPROPERATY0011VNR_ P _- tP'nfiY1®D Yeas r c urea ayes, IMpAP ,dP'AR.CE�LZ®NING ®1pSTRICtT Hist©; Icl®istict m ess achine`Sh®r Villa ety TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition J0 Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial A Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other C7 =Septic ❑51Nell - ❑F odp�lain D=EWetlan`se �Tatersh�e Distract gWater/Sewer — DESCRIPTION OF WORK TO BE PERFORMED: [-� n C/1/�lC T!jC Asn T 4 /21 Identification- Please T e or Print Clearly OWNER: Name: .9/1/AtJ .1ivn � is7eD Al aVP5, S Rhone: i. Address: -7 ontrKetor,flame 4 / j � { �� -,.., —��, �...�--•--t -- � �� i16,000t— ,00-0 tcucf�ovn�License 5 p �- , iHoFmelmprove - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED cosrBASED ON$125.00 PER S.F. Total Project Cost: $ w-- FEE: $._Z ry Recei t No; Check No.: p. . --NOTE:----Persons--co tracting-with-unregistered contractors do-not-havewc-cess-to- -g-raYanty7f'�nd._ 11141, A11-1011 Sgnatu��eof A°gent/ wn Signature,of contract® ___f _ 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 ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ 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 ❑ 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/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 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 2014 tirf� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ ,r TYPe F 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS F. 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: Osgood IFIRf IDEP�►RTMENT Temp IDump ra -a� Street stier�o Located 84 Osg ILocatedhat�t124JMain Stre'ei 4 nom iFire�De s art snat 9 � a .,.� `MME% ti Dimension Number of Stories: Total square feet of floor area, based on Exter oT dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires:4pproval 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 Call Email Date Time Contact Name Doc.Building Pen-nit Revised 2014 •9 Location, , �. i No. Date • - TOWN OF NORTH ANDOVER . _ Certificate of Occupancy $ t Building/Frame Permit Fee $ Foundation Permit Fee $ ► Other PermitFee $ TOTAL $ Check# 0. Building Inspector NORTH own of E Andover d over o ; t\A "t- 55 C,o h ver, Mass, A- COCKICKOWICK �.1 7�A�RATEO S BOARD OF HEALTH Food/Kitchen PER ..M IT L D Septic System THIS CERTIFIES THAT .. .. �. BUILDING INSPECTOR ....... ....... .......�.. ..... ,5... .. ..... . ...�......... has permission to erect .......................... buildings on .. �..�.TWOFoundation Rough tobe occupied as ...... .. ... ................!�....:.. .. ........ .... ............................................. Chimney ey provided that the person accept) this permit shall In every respect confTto 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 —- Rough is Permit. VIOLATION of the Zoning or Building Regulations Voids th Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. (p • UNLESS CONSTRUCT ARTS Rough Service ........ .... .......................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildink 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. WAYNE ROOFING SYSTEMS, LLQ' i 65 E Belcher Road TELEPHONE (774)215-5338 Foxboro,MA 02035 FAX (774)215-0421 i This proposal is contingent upon strikes,fires, accidents,or other causes beyond our con`rol, and is not a contract until signed by an officer of this company, and is subject to acceptance within 30 days from the date of this proposal. Our workers are fully covered by Workmen's Compensation Insurance. f Payment Terms: 1/3 due upon commencement of work 2/3 due upon completion u I Interest of I Ul%per month will be charged on all accounts over 30 days ACCEPTED BY �• TIT LE2 12(a 1 w !e- DATE By: c canter Edward Coyle,Managing Member I ' r; s' 2 F, i f WAYNNE I oOFING SYSTEMS, LLC. I b>1:Belcher kwd ItLCPHONE � (774)2 I5-9338 i1:—t'—).MA 0203`' FAX (774)215-0421 .PROPOSAL To: Mr_Brian Rittershaus Date: April 2,21)15 123 Mass Avenue North Andover,MA i RE: Roofing(x,)123 Mass Ave.,North Andover,MA 4's%c propose to furnish all necessary labor, material and equipment (except as noted b:dow) to j pedo nn the following work.in a first class workman like manner: I i SC0l'r,or wt)HK: - Go over existing shingles with new shingles + Clean jobsite of all work related debris i For the sum of: '1;$,000.00(Eight Thousand and 00/100 Dollars) I I 1 i I The Commonwealth of4fassaehusetis Department of IndustrialAccidents ' Office of investigations I Congress Street,Suite 100 ` Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Cont>ractors/Electrieians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Wayne Roofing Systems LLC Address:65 E Belcher Road i City/State/Zip:Foxboro, MA 02035 Phone#:774-215-5338 Are you an employer? Check the appropriate box: Type of project(required): 1.9 1 am a employer with 20 4. ❑ 1 am a general contractor and 1. employees(full and/or part-time).* have hired the sub=contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. p Remodeling shipand have no employees These sub-contractors have $. ❑Demolition working for me in any capacity. employees and have workers' 9. Buildingaddition [No workers' comp. insurance comp. insurance.1 ❑ required.] S. E] We are a corporatSon and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 1.❑Plumbing repairs or additions myself. [No workers' comp. right of exemptions per MGL 12 ®Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] "Any applicant that checks boa#I must also till out the section below showing their workers'compensation policy inibrmation. t Homeowners who submit this affidavit indicating they are doing all work and then hireloutside 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. I f the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am art employer that is providing workers'compensation insurance for my employees. Below is the policy and job site iia formation. Insurance Company Name:CNA Policy#or Self ins. Lie.11:4024977222 Expiration Date:6/18/2015 i Job Site Address: 123 Mass Ave. North Andover,MA 01845 _CitylState/Gip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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. I do/:erehy certify under the pains andpenalties of perjury that the information provided above is true and correct 4/2/2015 Signature: Date: Phone#: 857-753-546 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#: i I �3 i WAYNROO-01 MMCNAB CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) 4/2/2015 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 hold,, is an ADDITIONAL INSURED,the policy(ies)must be endorsed. It 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 Deland,Gibson Insurance Associates,Inc. PHONE 36 Washington Street (AIC No E R)(781)237-1615 1 jAlc N,);(781)237-1805 E�JIAIL ; ...... _.... .......... _._. Wellesley Hills,MA 02481 AODREss:Info@delandgibson.com INSURER(S),AFFORDING COVERAGE I NAIC p _.._..___.__ ., ._......._. INSURE A:Continental Cas ualty ,20443 INSURED INSURERe Safety Insurance Company 139454 Wayne Roofing Systems,LLC INSURER C Natlonai Union Fire Ins.Co of Pittsburg,PA Belcher Road INSURER D Transportation Insurance Company 20494 Foxboro,MA 02035 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. INSR ... .. ............... ... ....... i LTR I TYPE OF INSURANCEADCKPOLICY YYY) POIICYEXP I- - L IM........ �— jNSD.WVD POLICY NUMBER (p4MIDDIVYYYI (MMIDDIYYI'YII LIMBS COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE I E 1,000,000 X ! 1 'CLAIMS-MADE X i OCCUR X4024977219 -DAMAGE TO RENTED 106/18/2014 06/18/2015 PR $ 100EMISES(Ea occu rence) ,i 000 MED EXP(Any one person) }$ 5,000 E PERSONAL 8 ADV INJURY S i,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: I i i GENERAL AGGREGATE $ 2,000,000 POLICY! X.: ECT I.�._..� LOC I : .OMP/OA PRODUCTS- 2,000,000 OTWER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _ E 1 000,000 SCHEDULED I i I !(Ea _ B 01 _ ANY AUTO ALL OWNED E 5058830 06/18/24,0611812015 I BODILYILY INJURY(Per person) E . i AUTOS AUTOS ; BODILY INJURY(Per accident)1$ X NON-OWNED PROPERTY DAMAGE ` HIRED AUTOS ' I 'AUTOS ((Per.acatlent).-._ $ X i UMBRELLA LIAB X I �— .; OCCUR ! I EACH OCCURRENCE E 9,000,000 C EXCESS LIAR i CLAIMS-MADE, IBE080850833 06118/2014;06/18/2015 AGGREGATE $ 9,000,000 _...._ I LIED 1 X I RETENTION$ 10,000 i I .. ...�.E .... WORKERS COMPENSATION -- ! X I PERH—t-- — AND EMPLOYERS'LIABILITY i I STATUTEYIN ER - _F ANY PROPRIETOR/PARTNERlEXECUTIVE024977222 06/18120141 06/18/201$ E L.EACH ACCIDENT 1$ 1,000,000 OFFICER/MEMBER EXCLUDED? 1 NIA! (Mandatory In NH) I I E.L.DISEASE-EA EMPLOYEE?.$ 1,000,000 II yes,describe under __. ..,. .,. _. . .. .-...__ DESCRIPTION OF OPERATIONS below E.L,DISEASE-POLICY LIMIT 1$ 1,000,000 A ;Equipment Floater 4024977219 i06/18/2014 812015 short term rentals 165,000 A 'Installation Floater 4024977219 !06/18/2014 06M8,2016 Special Form 300,000 e DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be,attached if ont re space is required) Project:123 Mass Ave.,North Andover I i i CERTIFICATE HOLDER J CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover Building Department THE i EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street,Building 20,Suite 2035 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-20114 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I I i i i i Massachusetts -Department of Public,Safety R;;ard of Builthng 6tegulat.ons and Standard:, i License: CS-090495 FDWARU COYLE-` ;• 53 Summer Street= i West Roxbury MA 02132 ✓.�. • " ''`' Expiration Gnrnnussioner 07/3112016 i I i i I