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Home My WebLink AboutBuilding Permit #319-11 - 145 JOHNSON STREET 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION r J J��/�s C.� Print PROPERTY OWNER tl < ) ,l Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yesOno Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other. Septic ❑Well ❑ Floodplain 0 Wetlands 0 Watershed District Water/Sewer SCRIPTION OF WORK TO BE PERFORM D: Id ntification Please Type or Print Clearly) �� OWNER: Name: ! Phone: Address:�� CONTRACTOR Name: AA Phone: Address: ` C5 7t,�� ` �`3�i Supervisor's Construction License: Exp. Date: Home Improvement Improvement License: a /-7- Exp. Date: G/ a— ARCH ITECT/ENGINEER Phone: . No. Address: Reg. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �/ FEE: $ l Check No.: 19&0 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor _ . x'10 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature 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 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 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 I NOTES and DATA — For department use i i ❑ Notified for pickup - Date i Doc:.Building Permit Revised 2008 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/Crossection/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 thea appeal period is over. PP P Thea applicant must then e PP get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe: Do al3uillmg Permit Revised 200Emi I Location /77 aiojo n ST No. — Date V -4 - TOWN 4 .TOWN OF NORTH ANDOVER 3? •. p F w a Certificate of Occupancy $ Building/Frame Permit Fee $ 32- s,K MusE r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #6('aD 23567 Building Inspector 1 _ _ NORTH 0'" 0T f _ 6Andover No. 3/q CN A K dover, Mass., � d COC MIC MEWICK ^• 7 ADRATED qS U BOARD OF HEALTH Food/Kitchen Septic System .PERMIT T D BUILDING INSPECTOR THIS CERTIFIES THAT GJAI 'C 12 U G.�-- .............. ........... Foundation has permission to erect........................................ buildings on ...... ... ... ........ ... .. n.... ..4.................... 'Rough �. ® Chimney to be occupied as....... ....... .. . . .. . .......................... 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 MONTHSELECTRICAL INSPECTOR ARTS UNLESS CONSTRUCTI Rough - Service ......................................................................................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE 'Niassacltusetts - II ial-tment of Pubiic Siifet} ! Board of Buildinv, Re�-ulations and°5tandards j Construction Supervisor Specialty License License: CS SL :100188 Restricted to: RF,WS,DM GEORGE PENNIMAN 27 PICKENS AVE . SEABROOK, NH 03874 K Expiration: 1/8/2012 1 ('unmeis�iuncr Tr#: 100188 Office ot��o�um A airs �iness egu�--, HOME IMPROVEMENT CONTRACTOR Registration: y 16012.1 Type: r ' Expiration: ;_6/25/2012 DBA 2' GEORGE PENN]MAN_= f 27 PICKENS AVE SEABROOK, NH 03874y`_= Undersecretary RightFax N1-1 10/18/2010 1 : 08 : 46 PM PAGE 2/002 Fax Server I AC" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/VVVY) 0/18/2010 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 CONTNAME:ACT PAYCHEX INSURANCE AGENCY INC (A/CNNo Ext):(877)362.6785 FAX No):•(877)677-0447 150 SAWGRASS DRIVE E-MAIL ROCHESTER, NY 14620 ADDRESS:paychex@travL4ors.com (877) 362-6785 CUSDTO ER D : 2129/36144 SV996 70A INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 2 PENN LLC INSURERB: 81 STARD RD. INSURER C: SEABROOK, NH 03874 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 85451 0544031 1 92 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 MAYBE 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR wyn POLICY NUMBER MM/DD/YYYY) (MMIDD/YYYYI LIMITS GENERAL LIABIITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY IIA MACE TO RENTED CLAIMS-MADE El OCCUR PREMISES E o currents $ MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GENERALAG REGATE $ GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ - POLICY JPRO CT LOC $ AUTOMOBILE LIABILITY CO MBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS HIRED AUTOS (Perr accidenDAMAGE $ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ RRDEDUCTIBLE $ ETENTION $ $ WC STATU- OTH A WORKERS COMPENSATION N/A UB-584OP522-10 01/20/2010 01/20/2011 'X TORYLMITS FR AND EMPLOYERS'LIABILITY YM ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 I1 yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it morespace is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1600 OSGOOD ST EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE BLDG 20 STE 2-36 WITH THE POLICY PROVISIONS. NORTH ANDOVER,MA 01845 AUTHORIZED REPRESENTATIVE ®1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts � A S Department of Industrial Accidents 1 ;_ Office of Investigations 600 Washington Street t,lit� Boston,MA 02.1X1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf Legibly Name (Business/Organization/Individual): �L Address: City/State/Zip: G'� / � A Phone#: '?//7V(;' Z�7 re y an employer?Check the appropriate box: Type of project(required): 1. employer with 4. ❑ I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition [No workers' comp.insurance 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work g p p myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.] 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 7/ Policy#or Self-ins.Lic.#: (,� o� y �a a Expiration Date: Job Site Address: City/State/Zip: /4- a/G�Je/� 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 fonn 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. 1 I do hereby certify er the pains and enaldes of perjury that the information provided above is true and correct Si ature: / Date: Phone#• Official use only. Do not write in this area,to be completed by city or town offciaL 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#• www.twopenn.com � 322 , 2NAME CUSTOMEI DATE AGREEMEN ry k e, 9/'7- Ab 81 Stard Road ADDRESS fel 1.1194 # vx)0iz."t::7 AGREEMENT N Seabrook,NN 038 6`!�✓Su►.� °j - 93°7 -1' 9Z 978-729-4617 A(A/4 �y Dc'V&- m/l 97s-rt9as,s._� I7S- 60(l -32'7 '�- - ROOFING WORKMEN'S COMPENSATION AND FULL LIABILITY INSURANCE COVERAGE- AREA Lu z z a W '� } EXISTING NEW Q ?N o g g =z W COLOR COLOR MFR PRODUc _ 0 az u a � m � "' g= o 4i 4 ADDITIONAL NOTES AND COMMENTS 3 DESCRIPTION OF WORK ,4 40 is Ft lal alz- Eli No I N F- O� PAYMENT TERMS t (r-r- /lam ty 9" M —�t �. JOB PRICE INCLUDING ALL LABOR,MATERIALS AND 17YEAR GUARANTEE FOR: AMOUNTS: $----_TAX:$ AL.$ 0 . CARD TYPE (CIRCLE ONE):_M/C VISA OPTION#1 $ mss, OPTIO $ ITEM/AREA t Ot�� ITEM/AREA CARD# EXP. DATE ICE >v W,j PRICE OPTION $ TOTAL COST OF MATERIALS A . LABOR: $ PENN 10-YEAR GUARANTEE OF QUALITY y ITEM/AREA 2 PENN PROVIDES A TEN YEAR WRITTEN z0 o SCHEDULING DEPOSIT$ oZ ( GUARANTEE OF QUALITY TO COVER ALL NEW OR THIS JOB. REMAINING BALA E DUE ON APPLIED TO THE PURCHASE OF MATERIALS ROOFING LABOR AND MATERIALS. T #*F JOB COMPLETION. AG 0 HA TH AB V KL— I FOR THE PR POSA .PRICE THE ABOV ORK S BEEN COMPLETED TO MY SATISFACTION 026�Vtd CLIENT DA ^_T