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HomeMy WebLinkAboutBuilding Permit #598-2016 - 1538 TURNPIKE STREET 11/16/2015 BUILDING PERMIT °� p►ORTFi q �StLED 164 �� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 70 n 0 Permit No#: "" Date Received �,q"0 ATED,ep�c5 CHUS� Date Issued: ri 1 15 SSA IMPORTANT. Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print i od.Year Structure yes no MAP '© PARCEL: ZONINGDISTRICT: Historic District yes no. T Machine Shop Village yes no C\Sz TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: i(Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well: ❑ Floodplain El Wetlands. ❑ Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: II Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: AgaL._. Phone: Email: . _ ,n S Address: yN - - Supervisor's Construction,License:l_, [7�, 3_ _Exp. Dater 1 2t ., p _Exp. -Date _ Home Improvement rovement License. .._- I b�{ �-�O____ __..._ 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. ._�e C:- �i Ph Total Project Cost: $ 2Zi �� g O� FEE: $ ZcoA- Check No.: I! Receipt No.: 2- NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund 171-1 1-2 Signature of Agent/Owner ignature of contractor Plans Submitted ❑ Plans Waived,L1 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. ❑ Pennanent Dumpster on Site ❑ I 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 I `— 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: !T�!' -- - '-MEN- T Temd124'Main Street Fire 0eparttmenfis..ignatort /d`ate __ CbMIVIENTS� �: ..d 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 Doe.Building Pennit Revised 2014 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 ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work a 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 i Location Ut ' No. " T C� d�(� Date �1 \l0 1rj T . - TOWN OF NORTH ANROVER ww4e w Certificate of Occupancy R Building/Frame Permit Fee $ ' Foundation Permit Fee $ 4t Other Permit Fee $ �v TOTAL $ Check# 29674 Building Inspector r r 1 NORT#i ve". 'o o No. Z h C, ;�S'499. h ver, Mass W6A— A A- COC NlcmlwICN '1 S V BOARD OF HEALTH Food/Kitchen P E RM LD Septic System THIS CERTIFIES THAT .14lTr� BUILDING INSPECTOR .......... .. ...klkekl....................... .i.. ........ ........... 153? � �•. Foundation has permission to erect .......................... buildings on .. ...... .. .�,......... Rough to be occupied as ...... .� ... . .............................................................................. ` Chimney provided that the person acceptin�this permit shall in every respect 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 NTH ELECTRICAL INSPECTOR UNLESS CONSTRUC 0 AR Rough Service ............ ....... ... ...... ........................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy.Buildin 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. G.L. Clark Construction Tony Delourie 177 Jenkins Rd. 1538 Turnpike St. Andover MA 01810 N.Andover MA 978-375-3425 978-230-1609 CSL#102350 HIC#164510 SCOPE OF SERVICES-Entire Roof. 1) Roof R&R 64 sq.2 Layers of asphalt roof shingles with IKO Architectural shingles. Install 6ft of ice & water shield along entire perimeter of roof. Install Synthetic underlayment over remaining roof deck, and install new 8' white drip edge. Extend fascia and rake up to 18". Wrap in white metal. Replace up to 64sf of plywood at hatch entrance due to rot. 2) Clean up and removal of all debris. Notes* Unless noted above any changes to scope of work or changes due to any unforeseen issues may change the cost of the project such as Rot, Code upgrades or any engineering that may be needed. Or any changes the customer may make that will change the scope of work to be done. All changes to be done will have a change order to be signed prior to start of any new work to be done not included in original scope. a) All work will be done with the required permits and to building code. Owner will pay for cost of all permits needed. b) All extras will be done at time and material Total cost of proposed work. $ 22,400.00 Payment Schedule $7500.00 upon signing of contract $7500.00 upon start of project $7400.00 upon completion of project. 'Tony Delourie 1�a-dtq Gregory L Clark I � .,=� CLARGR1 OP ID: DL � 14417"Rte~ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYWY) 11112/2015 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(les) 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). CONTACT PRODUCER Phone:978-777-9394 NAME: Dan Hurley Dan Hurley Insurance Agency Fax:978 777-3306 PHONE 978-777-9394 Chestnut Green,Suite 24 ruC No Ext: pIC No: 978-777-3306 Seven Federal Street n DRESS:dan@hurleyinsurance.com Danvers,MA 019233620 Daniel J Hurley INSURER(S)AFFORDING COVERAGE NAIC 0 INSURERA:Providence Mutual 15040 INSURED Gregory Clark INSURER B:AIM Mutual Ins.Co. 117 Jenkins Road Andover, MA 01810 INSURER C: 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. IAUULII POLICY EFF POLICY EXP LTSRR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIWY MMIDDIYWY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY BOP0070029 04/23/2015 04123/2016 PREMISES Ea occurrence $ 50,00 CLAIMS-MADE 1XI OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 POLICY PROJECT- LOC $ AUTOMOBILE LIABILITY Ea accident)EDtSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ( ) AUTOS AUTOS accident Per BODILY INJURY $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X WCSTATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY ER B ANY PROPRIETOR/PARTNERIEXECUTIVE VWC-100-6017451-2015A 04/24/2015 04/24/2016 E.L.EACH ACCIDENT Is 100,00 OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) SEE NOTES E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) As per policies: Gregory Clark is exempted from workers compensation. WC Insurance coverage applies only to the workers compensation laws of the state of Massachusetts. CERTIFICATE HOLDER CANCELLATION TOWNNOA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St. Bldg.20,Ste 2035 AUTHORIZED REPRESENTATIVE N.Andover, MA 01845 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ,1- CLARGR1 PAGE 2 NOTEPAD INSUREUSNAME Gregory Clark OP ID: DL DATE 11/12115 As required by Massachusetts Workers Compensation Rating and Inspection Bureau: All requests for (workers compensation) Certificates of Insurance must be submitted to the servicing carrier or voluntary direct asignment carrier. A request has been faxed to Insurer B named on page 1. The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 yv;y�t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): �,� c40� Address: AT? City/State/Zip:=&JA4 99-- Phone#: Q('lg �-7 X^ —3 -Z Are you an employer?Check the appropriate box: Type of project(required): I.F-1 I am a employer with employees(full and/or part-time).* 7. Q New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. • 12.0 Plumbing repairs or additions 5.[I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'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 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: 1 EA t8 Q�J AS C 6 Policy#or Self-ins.Lic.#: 0 e— ^ l DO 61 `745 —Za/57 4 Expiration Date: IZ4 12-01,& Job Site Address: i f? T—OR net t� KrIa City/State/Zip: (N) Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert( under the pains and penalties of perjury that the information provided above is tr a and correct. Si natu e• Date: 2 Phone#: 2, ' 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 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=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 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 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. A new 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-102350 GREGORY L CLA>tiK =' r� 177 JENE INS RIY !� ANDOVER MA 61810 l Expiration Commissioner 10/15/2016 t xe W61MI 0911aeall a/QW1aaaaclratel \ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: ,'f,",164510{ Type: . Expiration = 1.0/,19/`20,17 Individual GREGORY L CLARK JR fY r GREGORY CLARK =e i 177 JENKINS RD. { : � ANDOVER MA 0181 0 Undersecretary 1