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HomeMy WebLinkAboutBuilding Permit #583-12 - 136 RALEIGH TAVERN LANE 5/1/2018 TOWN OF NORTH ANDOVER i - APPLICATION FOR PLAN EXAMINATION r Permit N0: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this age tt LOCATION f ave i p Print PROPERTY OWNER f(frr(4 UJ , SIN rco u./ Unit# Print MAP NO: /07AARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family j 13 Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ' ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other ®��SticWelly M"ONPr� �;.. _ -pood lam srshe'' te= ��Wate�[-^-;= ♦bs__�=�r1�c.: '.»r...._�.t....n .ku4.�''_��.9.a.e. ._•% a.�d..`.. - =- /f DESCRIPTION OF WORK TO BE PERFORMED: /7P/Y1 d(6r sw •�G�y �s�0(,/oc✓ /J °� Q ld n Grid �'XHP/:u ah� .f1 1 17f— Z (/.`s! / Cf//G/ (Identification Please Type or Print Clearly) OWNER: Name: PPI c a Phone: 78/' Address: CONTRACTOR Name: E✓"snve 1 A, S', Phone: q7g- G Pj g -SY6 Address: y E.i Adee, Aur Supervisor's Construction License: ExP. Date: //' Z`d' -Z,0(Z Home Improvement License: Q,0 33 Y Exp. Date: W U. - 0013 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F. 2 D.oc� Total Project Cost: $ o G�S�.du FEE: $ Check No.: Receipt No.: 6 NOTE: Persons contracting with unregistered contractors do not have access tot guaran f d i nafure of�Agent/Ownerr�*;,-�:z�, ,.��� � �� ,��Signature'of contrac. _.. �" � •��` �. Plans Submitted❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑' Tanning/Massage/Body Art ❑ Swimming Pools ❑ 1 Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ .I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING &DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature f COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes a ; :Planning Board Decision: Comments . ti 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 • f'(lTd1�QR1�TTC I I� 4. Dimension Number of Stories:________Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I �I ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No II DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use i LJ I Notified for pickup Date Doc:.Building Permit Revised 2011 June/mi i 'j 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 o 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) u 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 !I Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit i ❑ 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 MOTE: 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 Ilk" No. �� � Z Date • ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ � Other Permit Fee TOTAL $ Check# f 25005 uildi g Inspector V4QRTH Town . ® 0 No. Set 191 0 , dover, Mass., T O LAKE 1 �j COCHIC NEW'CK �B ORATED v V BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIES THAT.......... .. ..............................................:..................................... Foundation has permission to erect............ ........................... buildings on ./S.4....&Ao�. ........!t°.`:........................ Rough 9 to be occupied as /J ��� �iKl�C®c�ad�� .................................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final' 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 TS Rough � � .................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS,INSPECT OR 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 SLIDE Smoke Det. OP ID:CF ACRO' DATE{MMtDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 01127/12 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 617-389-9400 CONTACT O E Philbin insurance Agency Inc 617-389-6948 NCNB ExtI: ac No PHILBIN INSURANCE GROUP EMAIL 629 Broadway ADDRESS:PRODUCER Everett,MA 02149 C S OMER ID p:SILVA-1 P-hilbin r0Up INSURERS AFFORDING COVERAGE NAICp INSURED Silva Lightning Builders INSURERA:Northland Insurance Co Emanual Silva INSURER B:Associated Industries of Mass. 48 Linden Avenue INSURERC: North Andover,MA 01845 INSURER D 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 TYPE OF INSURANCE A DDLIMPOLICY NUMBER POLICY EFF MM/DDN NY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTED A X COMMERCIAL GENERALLIABILITY WS098714 01/17/12 01117113 PREMISES Ea occurrence S 100,00 CLAIMS-MADE FKOCCUR MED EXP(Any one person) S 5,00 PERSONALBADV INJURY $ 1,000,00 GENERAL AGGREGATE S 2,000,00 GEN'LAGGREGATE LIMIT APPLIESPER: PRODUCTS-COMPIOPAGG S 1,000,00 POLICY 'FjPRO n LOC $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ !I (Ea accident) ANY AUTO BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE S HIRED AUTOS (Por accident) NON-0WNED AUTOS. S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MDE AGGREGATE $ DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION WC STATU- OTH- ANDEMPLOYERS'LIABILITY ER B ANY PROPRIETORIPARTNERIEXECUTIVE YEN WCC5010510012011 12/09/11 12/09/12 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? ❑ NIA — (Mandatory in NH) E.L DISEASE-EA EMPLOYEE S 100,00 Udescribe under SRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 300,000 11 l DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) CERTIFICATE HOLDER CANCELLATION PERRYSP SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Per $ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Perry P arOW ACCORDANCE WITH THE POLICY PROVISIONS. 136 Ralley Tavern Lane North Andover,MA 01845 AUTHORIZED REPRESENTATIVE Philbin Insurance GrouPf ' j //J�Jjny/ I I L ti,l:( -ek I JV I f� ©1988-2009 ACORD`�ICORPORAT16W.. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD V �j 1 fie �o�rvnzanureczlCl o�✓l�Cc�aaae�ivaelZa Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration:;6420334 Type: 4,. Expiration: -'711/26/2013. DBA SIL A LIGHTNING BUI_LDE, S EMANUEL SILVA=`� ,_ 48 LINDEN AVE. N.ANDOVER, MA 04845`; Undersecretary I Massachusetts- Department Of public Safety Board Of Building Regulations and Standard!" Construction Supervisor License License: CS 65791 EMANUEL A SILVA ' 48 LINDEN AVE N ANDOVER, MA 01845 Expiration: 11/28/2012 ('unmiissioner Tr#: 5427 `i i a The Commonwealth ofMassachusetts Department oflndustrialAccidents Office of-Invesfigations 600 Washington Street Boston,MA 02111 yV www.massgov/d'ia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le ibl Name(Businessiorganizationllndividual): Sill/ 1 p r 99 t EU cl del s CLnc,"tyr'( St•lt,G \) Address: / Ci P� J J City/State/Zip t Y S' Phone#: y' 7 [hia an employer?Check the appropriate box: _ LTi a emplo ith f _ 4. ❑I am a general contractor and I T'pe of project(required): loyees oul d/or part-time).* have hired the sub-contractors 6. ❑New construction a sole proprietor or partner- listed on the attached sheet.t 7 emodeling and have no employees These sub-contractors have ing for me is any capacity. workers'comp,insurance, 8' Demolition workers'comp.insurance 5. ❑ We are a coipoxation and its 9' ❑Building addition ired.) .officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.[]Plumbin re airslf o workers'c g p or additions [N omp. c.152, §1(4),andwehavenoance required.]t employees. [No workers' 12•❑Roofrepairs comp,insurance required.] 13.0 Other *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 a ou ' fors that outside t check this contractors s box must attached an additional sheet ing such. showing the name of the sub-contractors and utheir workers,comp.policyinfotimation. lam an employer that isproviding workers'compensation insuranceforpyees Below is tlaepolic and'obs in ff my emloy Jite Insurance Company Name: SSe< GiCed �/yl PlpycfE Policy#or Self-ins.Lic.A 501 ds, p U I Z _ Expiration Date: / 2 oj.- /'Z Job Site Address: IX r�q'(f`0 I-C,n e Ci /State/Zi : / Attach a copy of the workers'compensation policy declaration page(showingp NOr�w An/. M� 0 Failure to secure coverage as required under Section.25A ofMGL G. 52 can ad t theimpositi nbofcriminer and aIlrenaolti date). fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties m the form of a STOP'WORK ORDER and a of 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 D9 for insurance cover e verification. t do hereby cert' nder the s a Haloes o er'u tliat the information provided above is true and carred .fP J ry >i nature: • Date: z-3-/Z . Official rrse only. Do not write an 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 Ins 6 Other g pector Contact Person: Phone#: Information and Instructions struct�.ons 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 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'w,ithhold 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 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 app 1 to your situation and,if necessary,supply sub-contractors)name(s),address(es)andphone 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 oz 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 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.' PIease 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 beprovided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out ea year.Where a home owner or citizen is obtaining a license or permit not related for any business or commercial venturche (i.e.a dog license or permit to bum leaves etc)said person is NOT required to complete this affiddvit. 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: T1 e COnl_uorwe-ai� of S�assaG" Lisel is Department of hadustriall Accidents Office of Investigations 600 Washington Street Boston;M—A,0211 X Tel.#617-7274900 ext 4406 or 1-877-MASSAFE Revised 5-26-05 Fax#.617-727-7749 WWW.mass.l;ouldia - G SILVA LIGHTNING BUILDERS 48 LINDEN AVENUE NORTH ANDOVER,MA 01845 (978)688-5464 O/F (617)799-4585 C CONTRACT AGREEMENT I,Emanuel A. Silva of Silva Lightning Builders will perform work on 136 Raleigh Tavern Lane, North Andover,Massachusetts 01845 for the sum of Two Thousand Nighty-Five Dollars and 00/100 cents($2,095.00). WORK TO BE COMPLETED: Exterior& _Interior Berk Window Installation (2) • Remove existing exterior trim. (Head and side casings) • Loosen up siding around perimeter of window. (In order to apply self-adheringflashing) • Remove existing interior trim. (Head and side casings/stool and apron) • Remove existing window unit. • Prep opening for window unit. (Self-adhesive flashings with pitched sill) • Install new window unit. (Homeowner supplies two window units) • Apply self-adhesive flashings to exterior of window flange. (helps keep out water and moisture) • Spray insulation around window unit. (low foam expansion) • Cut and assemble exterior window trim package. (Versatex stock/glue and pocket screw together) • Install window trim package to window. • Re-attach existing siding. • Cut and assemble interior window trim package. (same as existing stock/glue and pocket screw together) • Install window trim package to window. • Caulk interior and exterior weather tight. Contractor will supply permit. Contractor will supply all materials as listed. Homeowner will supply window units as listed. Contractor will dispose of debris. Contractor will not paint or stain. Construction Supervisor License No. 65791 Northland Insurance Company Home Improvement Contractor No. 120334 (Liability Insurance)Policy#WS098714 FULLY INSURED Associated Employers Insurance Company (Workers Comp)Policy#5010510012011 Any other work that needs to be done that is not explained on this Contract Agreement will be executed only upon written order from the Contractor and signed by both parties becoming an extra charge over the agreed amount. CARPENTRY WORK Labor: $1,625.00 Stock: $ 370.00 Debris $ 100.00 Total: $2,095.00 PAYMENTS Deposit on signing. (01/27/12) $ 200.00 On start of job. (02/09/12) $ 840.00 When job is completed $ 1,055.00 (Job will take about 3 days,subject to change depending on weather or additional work) (Approximate start date of February 9,2012,subject to change) I,Perry Sparrow, have had the opportunity to read the above and understand the terms contained therein and by signing this Contract Agreement I agree on paying Emanuel A. Silva of Silva Lightning Builders for the work itemized above on this Contract Agreement. - V SILVA LIGHTNING BUIL6ERS By: z IA19�1 Emanuel A. Silva,Contractor Per4 Sparrov ; I meowner PAGE 3 OF 3 DATED: JANUARY 27,2012