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HomeMy WebLinkAboutBuilding Permit #124-15 - 13 WALKER ROAD 8/4/2014 BUILDING PERMIT NORTH oFstLED 1O ;yam',' F •6 O� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ Permit No#: Date Received 74�DAATED PPay y Q �SSACHUS��� Date Issued: O K-1PORTANT: Applicant must complete all items on this page . LOCATION G�Gr, Pri � PROPERTY OWNER Print 100 Year Structure yes no : MAP 3 PARCEL: ��i.3 ZONING DISTRICTHistoric District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition 0 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 DESCRIPT ON OF WOR - TO BE PERF MED: crc 1A c�e� �� s �- �J" I a A-9 VVV)4A mveytk dentif4catio - Ple seRpe or int Clearly OWNER: Name: `et0 (ror--Pl Phone: dam' Address: f t A` ULT- � Uo Contractor Name: U lb F'Fhone: Address: C� Jtq� 11m _ Supervisor's Construction License: v d(o-7 ,-), /Exp. Date: 3 `b Home Improvement License: -76 n. Exp. Date: lad ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $� ` - Check No.: 1 -7LP5 Receipt No.: 2,1 e5z W NOTE: Persons contracting itgiste ed contractors do not have access to the guaranty fund Signature of Agent/Ow e Signature of contractor �� Iii 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature 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 Si sneer:DPW Town En nature: E g� g Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on 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 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work Li 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 o Certified Surveyed Plot Plan a Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) o 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) Li Building Permit Application Li Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract a 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 Locationlam- I No. `' Date • - TOWN_ OF NORTH ANDOV�� Certificate of Occupancy $ Building/Frame Permit Fee `$ - Foundation Permit Fee $ Other Permit Fee $ TOTAL $ y Check# c: 1 v :7 ,e- Building Inspector NORTFt Town of . t E : .T ndover No. % ver, Mass, COCMIC..l WICK �01• U BOARD OF HEALTH Food/Kitchen . PERMIT D Septic System THIS CERTIFIES THAT ......�.A.C........ . .� Foundation BUILDING INSPECTOR has permission to erect .......................... buildings on .....f. .......fn.? L&,4 , Rd.........2. Rough tobe occupied as ..................... .�.. ...... ......� .............. ............. 4..................................... Chimney provided that the person accepting this permit shall in every resp 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 U - . UNLESS CONSTRUCTI TA 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. ACORD CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDIYYYY) 08/04/2014 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 WNIAW NAME: Emily Costello COSTELLO INSURANCE AGENCY PHO A/c No Ext: 978.374.6352 ac,No:978.521.5127 2 South Kimball St. ADDRESS: ecostello@costellonh.com PO Box 5248 INSURERS)AFFORDING COVERAGE NAIC# Bradford, MA 01835 INSURERA: Liberty Mutual Fire Ins. -ARWC 16586 INSURED Servpro of Haverhill INSURER B: DBA: 211 Broadway Realty Trust INSURERC: 211 Broadway INSURER D: Haverhill , MA 01832 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 2013-2014 WC 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 LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ EM COMMERCIAL GENERAL LIABILITY PREMISES(Ea ocence $ CLAIMS-MADE F—]OCCURMED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY 7 PROECT LOC $ IN ZANULLUM11J AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED AUTOS AUTOS Per accident UMBRELLA LIAB HOCCUR a EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC531S368163013 08/19/2013 08/19/2014 X TH AND EMPLOYERS'LIABILITY TORY LIMITS ER YIN ANY PROPRIETOR/PARTNER/EXECUTIV� E.L.EACH ACCIDENT $ 500,000 A OFFICERIMEMBER EXCLUDED? i • i N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Mike & Michelle Moore AUTHORIZED REPRESENTATIVE 13 Walker Road, Unit 2 North Andover, MA 01845 Emily Costello ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD r 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 d in a g g en a eg g joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an indivi dualartnershi p p,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 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 P self-insurance license number on theappropriate 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 roof that pp as p at a valid affidavit is on file for future permits or licenses. Anew 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia 4 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction SuperNisor License: CS-067602 DAVID R HART PO BOX 1723 211 BROADWAY '' Haverhill MA 0183,1 v' 4 Expiration Commissioner 05/23/2096 �� �'f/e t(o.rrrrn-arrtoecr��� '�G�lcrJ;ica.+�cc.;eff; Office of Consumer Affairs&Business Regulation ( OME IMPROVEMENT CONTRACTOR 'registration 143708 Type: r Expiration Y/ 2016 DBA SERVPRO OF HAVERH1LE- t DAVID HART 230 ESSEX STREET HAVERHILL,MA 01830 Undersecretary Authorization to Perform Services a Direction of Payment � -- �� Nhv– A-AT CustomerName: � Date ofLoss: �Loss Address: City: State: Zip: Client: Claim Number(if available): The undersigned client, being the building owner, owner's representative, or resident, authorizes the Provider identified below to perform any and all necessary cleaning and/or restoration services on Client's property located at the property address above, and with respect to items that need to be cleaned at a remote location to remove and clean such items as necessary. I Client authorizes Insurance Company, herein referred to as "Insurance Company," to pay Provider solely and directly for that portion of the work covered by Client's insurance policy. If, for any reason, Client receives a check from Insurance Company made payable to Client, Client agrees to pay Provider immediately upon receipt of the check. In order to expedite payment to Provider, Client hereby appoints Provider as attorney-in-fact, authorizing Provider to endorse Client's name on Insurance Company checks or drafts, and to deposit Insurance Company checks or drafts for Provider services. Client agrees to pay Client's deductible in the amount of $ f — that applies to this claim. If any amounts owing to Provider for Provider services are not covered by insurance, Client agrees to pay those amounts to Provider within fifteen (15) days of Client's receipt of invoice. It is fully understood that Client and its agents, successors, assigns and heirs are personally responsible for any and all deductibles and any costs not covered by insurance. Interest and finance charges will be charged at the maximum allowable by law, or at 1.5% per month, whichever is less, on accounts over thirty(30) days past due.Time is of the essence. Client agrees that Provider is working for the Client and not Client's insurance company or any agent/adjuster. Property Owned By: Remarks: I HAVE READ THIS AUTHORIZATION T PERFORM SERVICES AND DIRECTION OF PAYMENT,INCLUDING THE TERMS AND CO O SERV ON THE REVERSE SIDE HEREOF,AND AGREE T SAME. 1 Client's Signature: , Provider's Signature: _ Printed Name: /C /400Y� Franchise Legal Name: 1 Client Reviewed Customer I format n Form: O Y O N d/b/a SERVPRO°of: — Date: V Date: White: SERVPRO® Yellow: Claims Professional Pink: Customer ©SERVPRO®INTELLECTUAL PROPERTY,Inc. ALL RIGHTS RESERVED FE-051707 1.0 28000 06/11 Each SERVPRO®Franchise is Independently Owned and Operated. Main Level 91101, -9'2" 5'8" Office `t 0 T 9'T' 1 9'7" 1' 00 10'2allw 2'—+ 2'" -� y 9'6" T � Bathroom ' 00 Livingroom O° 7 2 1 3' 4' 7'2"� 2 1 �--3 K 14'Y ITT 12'9" 13'5" o Bedroom - G Main Level MOOREMICHAEL 7/31/2014 Page: 6 j? t "at� The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office ofInvestig ations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia id av>t: Builders/Contractors/Electricians/plumbers Compensation Insurance Aff Applicant Information Please Print Legibly Name (Business/Organization/Individual): rb4egsi axio bi -i rr Address:- City/State/Zip- �0 0,�, ) Phone #: g Are you an employer? Check the appropriate box: 1.[t I am a employer with 4. ❑ I am a general contractor and I Type of project(required): 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. ❑ Remodeling ship and have no employees These sub-contractors have g. ®.Demolition --WtT C working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. ❑ Building addition required.] 5. E] We are a corporation and its 10.0 Electrical repairs or additions 3.E] I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] f c. 152, §1(4), and we have no 12.❑ Roof repairs employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 4I t 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: (�v I Policy# or Self-ms.Lic. #: `5 (D(� /6,30 1 Expiration Date: Job Site Address:_ c� !f'ia 14K 0/1 f%7r— City/State/Zip: -A) AV 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 hereby certi under thepains andpenalties_ er'ur that the in ormation provided above is true and correct. Signature: 'Date Phone#: � 7� 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#•