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HomeMy WebLinkAboutBuilding Permit #640-16 - 14 ANNIS STREET 11/23/2015 %2S BUILDING PERMIT O NORTH �S. �eo ib.9�0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �gSSACHU`��� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Qn13f<, Print PROPERTY OWNER Prin 100 Year Structure yes MAP t' PARCEL:ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building >4�9ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 21:Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic - ❑Well ❑`Floodplain []Wetlands ❑ ;Watershed<District ❑W_ater/Sewer ESCRIPTIONF WO1 K TO B ORMED: " 4 IdentificaY Please Type or Print Clearly OWNER: Name: Phone: Address: 1 &rn Contractor Name: Phone: _od� Email: Address: r Supervisor's Construction License: lot 28Exp. Date: 86 Home Improvement License: 16 63a7 Exp. Date: w < ARCHITECT/ENGINEER r� jl& Phone: — Address: Reg. No. MIT: 12.00 PER 1000.0 OF THE TOTAL ESTIMATED*T BASED ON 125.00 PER S.F. FEE SCHEDULE:BOLDING PER $ $ $ Total Project Cost: $ q�� -� FEE: $ _ Check No.: � ,�D 5-7 q 6 a T1 72 Receipt No.: ' NOTE: Persons contracting with unregist ed contractors do not have acces r d Mnatize ofAgentLo-,,vner---�---IMhMS17--Si- nature of cont G Location I's J No. Date . '= TOWN OF NORTH ANDOVER . Certificate of Occupancy $ i Building/Frame Permit Fee $ Foundation Permit Fee $' Other Permit Fee $ TOTAL $ CheckOUq n ,�." 7 2 1 Building Inspector P y f 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 I E USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature r I COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street 'IFIRE DEPARTMENT,° c ieburn -sterori�srte= �. tF,._reDepartmen' grature/dated I`C __ i 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 Pennit 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ,�6 Building Permit Application 4 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) ;aF 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 NORTft own of �_� ., ndover o .� No. h ver, Mass, �.QcoICK S RATED U BOARD OF HEALTH Food/Kitchen PER. T LD Septic System THIS CERTIFIES THAT ......... ....... ........... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .............1.1........ .... . . r�..... .... �O �.... Rough to be occupied as .0.1: . ..SLt&1�. ....G*4..�.e� ...... Chimney provided that the person accepting this permit shall in every respect 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 UNLESS CONSTRUCTI Rough 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. 16 1A 6740 6740 1 [CONTRACT# 4.274t9 5 ITEMIZED INSTALLED SALES CONTRACT INSTALLED SALES SPECIALIST f/j NUMBER` CUSTOMER STORE NO. STREET ADDRESS STREET ADDRESS 11, 141,11 5 ZIP ZIP r P 0 t l CI! ,4 tlli✓�1 STATE TELEPHONE TELEPHON�,,rF �_ DAT LOWE'S CONTRACTOR LICENSE NUMBER" cASH CARD Lc CHARGE MA,MD—State License Number,All Other States—Lowe's Employee Number. " AL,CT,FL,MA7MD,NV#45450 unlimited,TN#16066,only. This is a contract between Lowe's(as defined in the Terms and Conditions)("Lowe's"),and the above-named Customer for the installation of goods at the Customer's residential premises(the"Premises")at the following installation address: STREET ADDRESS �� � CITY � (f � STATE ZIP Additional Specifications: The Environmental Protection Agency (EPA) has requested that Mat'Is Lowe's notify installation customers that a lead based paint hazard may exist in dwellings built 'Tax prior to 1978. See pamphlet EPA 747-K-99-001 for details. Labor I I•�.�,�� 3�Ut �lisr +,n 4✓ n �EyIur fr, 4,/6rrpr'r,rg)_;1, `Tax r- irC-,r4brr�rSS =t.� i��r� p � t.�/� Total �f _ 4 'W ere applicable labor is taxable; S [ Ph '� a Al��SS c�GG J fo fU 5 S � f t CJS t c aca#tax restrictions L / -/iA�✓t J u�� l.✓ r`�U L.� 3 ✓�-,) !'� v s' dc,G cr 5 f) vr�• I I �+��aI t�f-t� - Work is to commence upon reasonable availability of Contractor which is anticipated to be °--s - � [fill in date]. Estimated completion date is [fill in date]. 0 NOTICE TO CUSTOMER All items listed in this contract and specification sheet(s)are to be installed under conditions agreed upon at time of purchase and at the price appearing on this contract form. This assumes sound existing substructures,superstructure and points of attachments. Extra labor or material incident to installation necessitated by defective substructures,superstructure,points of attachment,or the moving of fixtures or appliances to be billed at extra cost to customer. DO NOT SIGN THIS CONTRACT UNTIL COMPLETE AND YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS CONTRACT. BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDER- STAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. 'f r WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS DAY.OF (Seal) Owner ---{Seal) �. (Seal) Specialist'or Above Spouse . Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof. If credit is extended to you,you the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the attached notice of cancellation form for an explanation of this right. The Commonwealth of Massachusetts Print Farm Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information j� Please Print Legibly Name (Business/Organizationlfiidividuat); Levin Address: J7 7" &mLR L JLky City/State/Zip: 'lltrj /1A J)1'121 Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am ageneral contractor and I employees(full and/or part-time).* have hired the sit b-con tractors 6 El New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. []Demolition working for me in any capacity. employees and have workers' insurance.x 9. ❑Building addition comp.[No workers' comp.insurance P• required.] 5. [] We are a corporation and its 10.Q Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I. plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.❑Roof repairs insurance required] t c. 152,§1(4),and we have no employees.[No workers' 11. //Ether tutu o�., comp.insurance required.] as W '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. tContractors that check this box must attached an additional sheet showing the name of the suh-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'romp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site infornnation. Insurance Company Name: Policy#or Self-ins.Lic.#: 1!� y J Expiration Date: Job Site Address: / L {�J��S Y_ City/State/Zip: /y, 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. l do hereby cern tide tl aiets anus etialties o e u that thein ormatioit provided above is true and correct. S i o nature: Date Phone#: �-7 ��_---� Oficial 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): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: DATE(MMIDDIYYY ACCORV CERTIFICATE OF LIABILITY INSURANCE 6/5/2015 Y' 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 Scott Leavitt, CIC, LIA NAME: MTMBrainerd Inc PHONE ()]g)f6]_9031 AX N (978)667-1018 - lA Andover Road AEDDMAILRE ;scottl@brainerdinsure.com INSURERS AFFORDING COVERAGE NAIC# Billerica MA 01821 INSURERA:Travelers Casualty Ins Company 19046 INSURED INSURERB:Safety Indemnity Insurance Cc 33618 Kevin O'Brien DBA K C O'brien Construction INSURERC: 15 Shanpauly Drive INSURER D: INSURER E Billerica MA 01821 INSURER F: COVERAGES CERTIFICATE NUMBER:Master 2015 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDDIYYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE T RENTED PREMISES Ea occurrence $ 300,000 A CLAIMS-MADE OCCUR 6806424N45A1542 6/3/2015 6/3/2016 MED EXP(Any one person) $ 5,000 X Blanket Additional PERSONAL&ADV INJURY $ 1,000,000 Insured by Contract GENERAL AGGREGATE $ 2,000,000 GEN'I_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 _X1 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 500,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED X SCHEDULED 6214435 8/19/2019 /19/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Uninsured motorist BI split limit $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Lowe's Companies, Inc. and any and all subsidiaries are named as an additional insured as respect to the above referenced General Liability Insurance Policy and Commercial Automobile Insurance Policy, as required by written contract or agreement. This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION vendorinsurance@lowes.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lowe's Companies, Inc ACCORDANCE WITH THE POLICY PROVISIONS. and any and all subsidiaries Attn: Vendor Insurance AUTHORIZED REPRESENTATIVE PO BOX 1111 North Wilkesboro, NC 28656 S Leavitt, CIC, LIA/S ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS075 rgmnnsi nl Tho Armon nnmo-4 Innn nro roniefororl m—lea of Arr11117r1 C�''r.,cir� Hd IJSllCC U1 I.UII,U[I1Ci' MIMES dllU Dttbllless AVgU1QL1U11 ' 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 168327 Type: DEIA Expiration: 2/3/2017 Tr# 261049 K.C. O'BRIEN CONSTRUCTION KEVIN O'BRIEN 15 SHANPAULY DR. BILLERICA, MA 01821 ------ ---_— Update Addrwss a,►d return lard,Mark reason for change. &CA 1 0 20M-Oti11 Address r,7 Renewal ❑ Employment Lost Card ' ���f `!'tUlI IIIOIt t!'!'Rt'�l[r/n•!'(t(J1CtP�uJcl�i of Consumer Affairs&Business Resmiasivn License or registration valid for individul use only fir'' OME IMPROVEMENT CONTRACTOR octore the expiration nate. it iouna return to: it egistration: 168327 Type: Office or Consumer Affairs and Business Regulation .� *Expiration: 2/3/2017 OSA 10 Park Plaza-Suite 5170 -�:r^L' Boston,MA 02116 K.C.O'BRIEN CONSTRUCTION KEVIN O'BRIEN 15 S»ANPAULY DR. r..; .r BILLERICA,MA 01821 Undersecretary Not valid without signature , a r` 0 Ir, co 0 CU G Feb 2413 07:18p p•2 i e ci Yf[c�antirrcrrrrkvr�l�plr^�-r��/a,;��r�Jrl/1 Office of Con3amer Affairs&Busiatss Rtgoiation E IMPROVEMENT CONTRACTOR t68321 - ration: .2rSW I5 . K.C.O' ION' '" KEVIN O'BRIEN 17 TOM GRAC AY BILLERI A01821 Undersecretary M6 ssachusetts -Department of Public Safety Scard of Building Regulations and Standards —s.mtruciix,n Supcn'svur License: CS-090128 tet.I , KE VII`f C OBRIBI F ' 15:HAMAUT Y DRM Bill LERICA KA=01821 r Expirazion Commissioner 08131/2016