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HomeMy WebLinkAboutBuilding Permit #1092-16 - 126 MAIN STREET 4/19/2016 1I � NORTH BUILDING PERMIT �� C.1 F0 6 6 TOWN OF NORTH ANDOVER 10 ' p APPLICATION FOR PLAN EXAMINATION * Date Received � ASgCH�15`4y Permit No#: '1s e� Date Issued: / �y IMPORTANT: Applicant must complete all items on this page LOCATION 30 a 9 MO 1 V) PROPERTY OWNER ROC Prin �C�► tint 100 Year Structure yes no MAP a� PARCEL:_` )�ZONING DISTRICT Historic District yes no Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition */Fwo or more family ElIndustrial [IAlteration No. of units: A ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ C�7„Sepr fl Well ❑ Floodplain D Wetlands ❑ 1Natershed Distrrct DESCRIPTION OF WORK TO BE PER ORMED' � 1 Identification- Please T pe or Print Clearly ,, ff,, OWNER: Name: I" C 14, �f Phone: Q�900t?i'�_� Address: ag( 1' lqW y-"GQ- Contractor Name: L. tUAC6I ='V Phone: � �d Email i >1 m Address: l r(1 DMALI Supervisor's Construction License: 631 Q Exp. Date: Home Improvement License: Itu'a,3g 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. ` �d Total Project Cost: $ I51 OQ� - FEE: $ f Check No.: 9� -6-31 Receipt No.: 3 0,2c 2 NOTE: Persons contracting w'h unr gist r d co ractors do not have access to the g"ftund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanaing/MassageBody 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments r Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street 'FIRE DEPARTMENT + stet o : t Trn4p Dumpnste Y,eeos �. .1no {Located ate2 1 J` rA Fire De artmen �`'`"`-"'�':date 4 a 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 Call Email Date Time Contact Name _ Doc.Building Permit Revised 2014 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 OTE: 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 ISIOTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 Location No. Date 4'1 1?14 r • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �'� Foundation Permit Fee $ Other Permit Fee TOTAL $_ P Check# J r, r r Building Inspector r, , NORTH - vv: E �. c . ver 0 No. eil% 1 ( s / 0 LA , ver, Mass, I� CO[HICHlWIC H %ds RATED 1 U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ..c. BUILDING INSPECTOR .. .. .. ..... .r..... ...: .G......................................... .............. _ ��/� � Foundation has permission to erect.......................... buildings on ...12.:� ....:...1 2.Z.. ..•••••••••••••••......•..•..• Rough tobe occupied as ............... ..R'00.714.................................................................... 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST RT Rough Service ...................... ........ ..t!`j . ......�-,.-�.............. 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. CONTRACT i ROBERT BOHONDONEY CONSTRUCTION CO. 12 HALL STREET METHUEN, MA 01844 978-685-0970(office)/978-685-8262 (fax) Fully Insured Construction Supervisor License#979 Exp 4/21/2018 Home Improvement Contractor#114238 Exp 8/16/2017 bohondoneyconstruction@yahoo.com Customer Name: Rack Realty LLC Property Address: 126-128 Main St, North Andover, MA 01845 Contract Type: Roof Date: April 19, 2016 Scope of Services: Repairs 1. Supply local building permit. 2. Supply workers compensation and liability insurance certificate. 3. Strip existing roof shingles to bare sheathing. 4. Supply and install 6ft of ice and water barrier on all lower roof edges and 3 ft in all valleys. 5. Supply and install synthetic shingle base on remaining roof areas. 6. Supply and install new aluminum drip edge at all roof edges. 7. Supply and install new limited lifetime architectural shingles entire roof—choice of stock color. 8. Supply and install new pipe flanges as necessary. 9. ,Provide job site clean-up and safe work zone. 10. Dispose of debris from site. TOTAL CONTRACT AMOUNT: $15,000.00 Customer Signature: Date: Contractor Signature: Date: Page 2 of 1 i NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with 7�rovision of MGL c 40 S 54, a condition of Building Permit at: /a�l�-Id G/`I is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. - Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: (Location of Facility) Signature of Permit App cant Date e l - hAs CIX The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 Vwww mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information I Please Print LeFdbl Name(Business/Organization/Individua/l):� Address: City/State/Zip: DIRE-I�Phone#: Lq�L6 ICS b �`�—)o Are you an employer?Check the appropriate box: Type of project(required): I.[]301/am a employer with ,t employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. 12.[:]Plumbing repairs or additions 5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] •Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I I am an employer that is providing workers' ompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ''''^^ ,,// &c..e (2- Policy#or Self-ins.Lic.#:� ar YZ^l�70,:;),)t�� �SExpiration // J m f(� Date^:' .fin,f ,�[� Job Site Address: ��t0_ l , ' /Q��y City/State/Zip:/V'/1/ !t/ y"er // iq Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification.;' Ido hereby cerfify1i nde Tie pains an al s of perj that the infotvttation provided above is true and correct. Signature: a Date: Phone#- 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 M YM1 A� CERTIFICATE OF LIABILITY INSURANCE ��` 4119/)16 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(es) 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 endorsemen s. PRODUCER CONTACT NAME: Bates Insurance Agency Inc. PHONE (781) 396-4985 TMNI: (781) 395-9454 92 High Street, Suite B1 ADDRESS: Andrea@BatesIns.com Medford, MA 02155 INSURE S AFFORDING COVERAGE NAIC# INSURER A:RCA—Essex Ins Co INSURED INSURERB:A.I.M. Mutual Ins. Co. Robert Bohondoney INSURERC: Bohondoney Construction INSURER D: 12 Hall St INSURER E: Methuen, MA 01844 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I POLICY NUMBER M/DD/Y MM/DDIYYYY LIMTS A GENERALLIABILITY 2CV1242 2/3/16 2/3/17 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDjrrencej $ 100,000 CLAIMS-MADE Fx_1 OOCUR MED ExP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGA TE L IN T APP UE S PE R PRODUCTS-OOMP/OPAGG $ 1,000,000 POLICY PRO- LOC $ JECT F-]AUTOMOBILE LIABILITY COMBINED S NGLE LIMIT a accident) $ ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS $ NON-OWNED (PeODAMAGE HIREDAUTOS _ AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ B WORKERS COMPENSATION AWC40070243322015 8/9/15 8/9/16 WC STATU- OTH- AND EMPLOYERS'LIABILITY — ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 OFFICERNEMBER EXCLUDED? N/A (Mandabry in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If Yyes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is requi red) 126-126 Main Street North Andover, MA 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Inspectional Services AUTHORIZED RE PRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-000979 it ROBERT A BOHONDONEY =s 12 HALL ST METHUEN MA 01844 . ommissioner 0412112018 Office ofCOnsumcrAf'fairs&liusf ess .-., �tOME"PROVEMENT CONT R g"I tion _:, `Registration; RACTO -'.expiration: 114238 , 1 . 8/16/2017 Type: ROBERTSOHONDONEYDSA CONST CO ROBERT BOHONDONEY 12 HALL ST METHUEN,MA 01844 dersec�,