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HomeMy WebLinkAboutBuilding Permit #448-15 - 1407 GREAT POND ROAD 11/6/2014 BUILDING PERMITo*No DT b TOWN OF NORTH ANDOVER y ' Z. APPLICATION FOR PLAN EXAMINATION Permit No#: -y 1 Date Received 44` """ �gSSACHu`.+���� Date Issued: V,4 IMPORTANT:Applicant must complete all items on this page LOCATION 1 4 y`j G r e_a - Po,�,o P-A. Print PROPERTY OWNER Cid 6 P,t f ry ci4,0 , y1 c Print 100 Year Structure yes no MAP �'t 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 ❑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 DESCRIPTION OF WORK TO BE PERFORMED: e4!a--e- C1 as cte pUce-_ sn� iqyar Ju.-,b Fr&-n.T -2 rd r, C6Cfr V Lu' 1 Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Ct?k~ (vh-1 � 3 Address: /,5 4 (�IP atsea „ { ti- 6y,d a v-t�r M Its n (h u Supervisor's Construction License: C)3 6 Com 1 Exp. Date: L -7 - 16 Home Improvement License: I 0 : 77- 2 Exp. Date: _7 — ctt_.I9_ 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. Total Project Cost: $ C1, 0,G— FEE: $ Check No.: \2494 Receipt No.: a2-41 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 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 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 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 Plans Submitted ❑ Plans WaivedEl 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 Signature COMMENTS t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments oWater & 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 COMMENTS Location 14-7 Qe442,nc � No.AR— Date • TOWN OF NORTH ANDOVER • S.�'�T�En r6ya Certificate of Occupancy $ Building/Frame Permit Fee $ - Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 4 Check# oclL ^} �' U `" ` Building Inspector � NORTf{ Town ofndover O No. ie (6 * _ - �`y h ver, Mass, T ;NL*K. COC KICKl WICK 7,9 A0 ArEE) PP,��(5 S U BOARD OF,HEALTH Food/Kitchen PERMIT T Septic System -b L.D THIS CERTIFIESTHAT 4.4t.". ��I BUILDING INSPECTOR ......... #.................... ............ ................. ............................... _ f �, rin Foundation has permission to erect .......................... buildings on ...� ..1........ .... ..............�.... ......-..... Amp ... .. ��. .. .. .. . ... . .......... .. Rough y t0 be occupied as � .+.. . Chimney provided that the pe In accepting this permit shall in every respect conform to the terms of the applicatbn 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 CONSTRUCTION ST T 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. LEVIS-1 OP ID:KM AC� + DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 11/as/14 THIS CERTIFICATE 1S 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 endorsements). CONTArT -RODUCER Phone: 978 688 8829 NAME: Aichaud,Rowe And Ruscak Ins, Fax:978 557 2130 PHONE Ext): arC Nol! �.0.BOX 188 IAICE-MAIL Jorth Andover, MA 01845 ADDRESS: .awrence R.Michaud,CIC INSURERS AFFORDING COVERAGE NAIC N INSURERA:SafetY Insurance Company 12808 INSURED Levis Companies Inc. INSURER s:NorGuard Joseph Levis INSURER C:Preferred Mutual Insurance Co. 15024 154 Pleasant Street 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. NSR B POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDONYYY MM1DOfYYYY GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 C X1 COMMERCIAL GENERAL LIABILITY CPP0170589059 10/26/14 10/26115 PREMISES En occurrence) $ 100,00 CLAIMS-MADE ®OCCUR MED EXP(Any one person) S Excluded PERSONAL S ADV INJURY r 1,000,000 GENERAL AGGREGATE —j S - _ 2,000,000 .........J _.-----------... .. ; i r------ -- --- GEITL AGGREGATE LIMIT APPLIES PER: I l�l ! � PRODUCTS-COMP(OP A�GG 5 _-_1,000,000 F POLICY M PRO I LOC I I AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT 1,000,00 Ea accidentl 5 A ANY AUTO I 1821254 01101114 01/01115 BODILY INJURY(Per person) S ALL OWNED w SCHEDULED { i I BODILY INJURY(Per accident) 5 AUTOS I_�`I AUTOS -- ��� v NON-OWNED ( PROPERTY DAMAGE (Peraccidenll is I r< HIRED AUTOS AUTOS I UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION WC STATU• 0TH- AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNERIEXECUTIVE Y] NIA A LEWC53B379 02127/14 02127/15 E.L.EACH ACCIDENT $ 100,00 OFFICERIMEMBER EXCLUDED? E (Mandatory In NH) L DISEASE-F11 EMPLOYEE S 100,00 If yes,descrlhe under DESCRIPTION OF OPERATIONS helow E.L.DISEASE-POLICY LIMIT $ 500,0 DESCRIPTION OF OPERATIONS f LOCATIONS/VEHICLES (Attach ACORD 101,Additional Ramarks Schedule,If mora space Is required) CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS- 384 Osgood Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE /J I 2�/J i!���/fD►�� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts - -' Department oflndustriglAccid7e is Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationllndividual): �-.C� v Vs r M Jho W ( o S YL Address: _/S/4 (�te6LSa >ifi City/State/Zip: y►ck a Phone#: Z� _ro k 7c�I & -_'X . . Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with._ 4. F1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have Hired the sub-contractors 2.F1 am a sole proprietor or partner- listed on the attached sheet.X' 7• remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.[]Roofrepairs insurance required.] employees.[No workers' 13.[i Other comp.insurance required.] 'Any applicant that checks box4l must also fill outthe section below showing their workers'compensation policy information. iHomeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy anal job site information. Insurance Company Name: 6 u u r64 T V1 Lq04 k J Policy#or S elf-ins.Lic.#: Le w C 5 3 � '�� ( Expiration Date: e) Job Site Address: I �'� G`tP-1 f Po 110 !'�'l City/State/Zip: ti - Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. X do Hereby certify under the pains and p nalties o Of . that the information provided above is true and correct. Signature: Date: l 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#: 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 ofhire,- 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 Heensing 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 flie boxes that apply to your situation and,if necessary,supply sub-contractors)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 au LLC or LLP does have employees,a policy is required. De advised that this affidavit maybe submitted to the Department of Industrial Accidents fox 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. 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 as proof that 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 CoMMORWealth ofMassa.,chusPtt� 'Depattm,ut of WwWal Accideuta Qfce ofIavestigations 600 Wash r&,a Street Boston,MA 02111 Tel,#617-7-27-4900 lat 406 ox 1-877-MASSAFF, Revised 5-26-05 Fax 9 617-727-7749 WW-Ma.agov0'a LEVIS COMPANIES, INC. 1041.046 General Contracting . Residential & Commercial 160 Pleasant Street North Andover, MA 01845 978-687-2783, FAX 978-687-3042 -= PHONE DATE TO: Robert Bernardin 978-835-6921 10/10/2014 1407 Great Pond Rd JOB NAME/LOCATION North Andover MA 61845 1407 Great Pond.Rd North Andover MA JOB NUMBER JOB PHONE 1046 We hereby submit specifications and estimates for: Removalofexisting gas fireplace. Install new gas fireplace from Advantage Fireplace Inc. (Owner's choice) Remove existing front door unit. Install new door unit (Owner's choice) . We Propose hereby to furnish material and labor—complete in accordance with the above specifications,for the sum of: Nine Thousand Five Hundred and 00/100 Dollars dollars($ 9,500.00 ) Payment to be made as follows: Deposit of $5,000. Balance due upon completion. All material is guaranteed to be as specified.All work to be completed in a professional manner according to standard practices.Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders,and will become an extra Signature charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado,and other necessary insurance.Our N te:This proposal may be workers are fully covered by Worker's Compensation insurance. withdrawn by us if not accepted within s.da 10 y Acceptance of Proposal—The above prices,specifications and con- ditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment will be made as outlined above. Signature ? Date of Acceptance: Signature 0 10 t f PRODUCT 137286 USE WITH 771C ENVELOPE Deluxe For Business 1-800-225-6380 or www.nebs.com PRINTED IN U.S.A. A h'i:socchuaetto-Department of Public Safety Board of Building Regulations and Standorft License: CS-030651 - JOSEPH GIEVIS:` 154 Pleasant St. North Andover NfA 01845 J,,G,. �.6ce . ,� "'•� Expirctlon Commissioner 01/07/2016 %�, 1`r inirrr nay rr�/f r j rin..rad I(. - Office of Consumer Affairs&Business Regulation i HOME IMPROVEMENT CONTRACTOR Registration: 103772 Type: _ Expiration: 7!9!2016 Individual JOSEPH G.LEVIS JOSEPH LEVIS 154 PLEASANT STREET NORTH ANDOVER,MA 01845 lindersecreta,