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HomeMy WebLinkAboutBuilding Permit #712 - 16 MARBLERIDGE ROAD 5/14/2010 BUILDING PERMIT "°pT" qti TOWN OF NORTH ANDOVER 32 ,11 ~6'° oL APPLICATION FOR PLAN EXAMINATION r Permit NO:—T�� Date Received 044reo•�'y(y Date Issued: a �SSgC►+us�� IMPORTANT: Applicant must complete all items on this page 1-0CATI01 4 "¢ Print s , PRP PERTYbWNEI Pram, ZOMNG�DISTRtCT ye o . , .. Machine_5{hop`Vllage yep o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial R^epair, replacement Assessory Bldg Others: Demolition Other Septic .= Wel] Flootlplain 47m,%etlands `reg U1i'aershed District 1/1/aterJ. ewer £x DESCRIPTION OF WORK TO BE PREFORMED: G�t�Gr-h/til lel r�-i.v��G� dtri�rD�w T�rut S � Identification Please Type or Print Clearly) OWNER: Name: 12oc,g�c Phone: I?� 7951Ao-,S` Address:_I X1, 3 Lip O I RCT R Name � � Cc, �. � T' Ph6b, 7 "4- ,-e :Address 09d tSupervisor's Construe#nor License `C� -71, ARCHITECT /EN GI NEER 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: $ Z S7'-,V FEE: $ �� Check No.: 20��o Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranfund -, e 9 . natureYof contractor Signature of A nt/Owner � 1 g ;, 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 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 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools �I 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 k 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 SIRE DEPi4►RTMfNT TempDur�ipster on site dies no "Located at 1.24 MainStreet kq FlreDepartmertti�rrat>��re�dete CO.MMENT.S . 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 - Date Doc.Building Permit Revised 2010 Location �0,No. Date Date NORTH TOWN OF NORTH ANDOVER f � 163? •. + OR Certificate of Occupancy $ ;�ss•►�MusEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ — TOTAL $ Check # 23 i bU Building Inspector WORTH Tovm * of 4Andover . o No. == A dover, Mass., S' � �• � � COC KICMEWICK ADRATED p' �� `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System r ` BUILDING INSPECTOR THISCERTIFIES THAT......................... .. ...............C. .......6! .. .. i�................................................................................ • Foundation has permission to erect........................................ buildings on ..I.�.....� b ........... Rough • tobe occupied as.............�jA.%.40wo........!......................................................................................................... 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 CONSTR STARTS Rough .. ........................ ................ ... Service . ..... ... ..... .............................. .... ........ BUILDING INSPECTOR Final Occupancy Permit Required to Ocmpy 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. SEE REVERSE SIDE Smoke Det. lfktaamswumerzuivn� a�� il�.aae�ueel�a Office oAffairs&Eusiness Regulation HOME IMPROVEMENT CONTRACTOR Registration: 113863 Expiration: 71.19/2011 Tr# 286934 Type: Individual W MICHAEL SCOTT W MICHAEL SCOTT 2 DUNDAS AVE ANDOVER,MA 01810.,. Undersecretary Massachusetts- Depa i-tment of Public SafMc Board of Building Regulations and Standards Construction Supervisor License License: CS 44723 Restricted to: 00 dam. W MICHAEL SCOTT 2 DUNDAS AVE ANDOVER, MA 01810 Expiration: 1/11/2012 ("nnunissi„ncr Tr#: 14570 5/14/2010 8:59 AM FROM: Risman Byette Insurance Agency, Inc TO: +1 (978) 688-9542 PAGE: 002 OF 003 DATE ACORD,. CERTIFICATE OF LIABILITY INSURANCE 05/14//201Q PRODUCER (978)851-6678 FAX (978)851-0106 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Byette Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 8S3 Main St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Tewksbury, MA 01876 Shawna Lamarche INSURERS AFFORDING COVERAGE NAIC# INSURED Michael Scott INLstJRERA: National Grange Mutual Ins Co 14788 DBA: Andover Renovations INSURER 8: 2 Dundas Ave INSURER C: Andover, MA 01810 INSURER 0: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IPM TYPE OF INSURANCE POLICY NUMBER POA E I EFFECTIVE POMMITIONn LICY EXPIRATION LIMITS GENERAL LIABILITY MP10418M 03/06/2010 03/06/2011 EACHOCCLRRENCE $ 1 000 00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,001 CLAIMS MADE a OCCUR MEO EXP IAnY one person} $ 5 00 A PERSONAL&ADV INJURY $ 1.000.00j2000,00 GENERAL AGGREGATE $GENILAGGREGATELIMITAPPLIESPER: PRODUCTS-COMPIOPAGG $ 000 POLICY JEST LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LNIBILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSAJMSRE1IALLABILITY EACH OCCURRENCE S OCCUR CLAIMSMADE AGGREGATE $ S DEDUCTIBLE $ RETENTION $ $ WC STATU- 0TH• WORKERS COMPENSATION ANDUMITS EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETORJPARTNERJEXECUTNE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS I V841CLES I EXCLUSIONS ADDED BY ENDORSEMENT M SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER YPLL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, North Andover Building Dept BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 1600 Osgood Road OF ANY KIND UPON THE INS IRER,ITS AGENTS OR REPRESENTATIVES. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Shawna Lamarche HANNA ACORD 25(2001!06) FAX: (978)688-9542 SACORD CORPORATION 1988 'T� ' .(STM.++ ... '+' i e�^.t. .. -+n•i'i - � ._ � ,'L- -_- •_- ' _^- ....... .__'.� .gyp Q^ � (t'fd.. _.7' 1 ,J�J��.:Ii :•j1- , ' { 1 _ i 1 I 1 aNSTRUC-T(.0AJ S iPGA\JrSoo ._oPoNE -_�HPRCVE►EWT CC)AMRACToR Licap►5E -0" 0 4.4123 9-1—K__6,f5 3 e'63 2 UUNDAS AVENUE ANDOVER, • Michael Scott ANDOVER, MA 01810 Andover Renovations Page / of � 470.2640 Additions a Carpentry a Remodeling PROPOSAL SUBMITTED TO PHONE DATE A4 d M� L4e-! 9-71 sTRE FI � JOB NAPE CITYZ��TE AND ZIP CODE JOB LOCATION itl.oa /�nc�or��-ff oI�'Vt= 3032 ARCHITECT DATE OF PLANS JOB PHONE we nereoy propose to tornun materUts and labor noces"ry lot it*comptetton ol. K�2 0�! Z.�fl �rro� W i n�f�au�S � has s iBl�ct S�t7iiil� x.422 _- ©�c/ - rc-1� gg�r S?DG� yGL ,ice o�/fGGtfr��1 /d�t� f�/�i'S'rr�Z.e., f1TiST���LS w� A> Co s T ole .?r� WE PROPOSE hereby to furnish material and labor—complete in M=rdance with above specifications,for the sum of, 000ars is ayment to De mace as follows: �L /� t,� it��I� �i�z�n'Crs �5 �t�S�'.�/�'✓I All material is guaranteed to De as specified. All work to be completed in a suct- stantial workmanlike manner according to speciticationt submitted, oar standard Authorind practices. Any alteration or deviation from above specifications involving extra Signature 114Z costs will be executed only upon written orders,and will become an extra Charge over and above the estimate.All agreements contingent upon strikes,accidents or Non: this of000sal may to �— detays Deyond our control. owner to carry fire. tornado and other necessary in. withdrawn by u:of not accented.ttntn ' days. SYranCe.Our workers are fully covered by workmen's COTDertsatl6n Insurance. - ACCEPTANCE OF PROPOSAL The above prices. specifications and condi- tions are satisfactory and are ne►eDy accepted. You are authorized to do the work as specified.Payment will be moos as outline above. Si�natert The Comm, onwealth of Mastxchusetts Department of Irndustrial Accidents Office of.Investigations 600.Washington.Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectrieianslPlutribers Applicant Information P,Iease prmtLegiblv:, Name(Business/Organization/Individual): t if Address: 2:Q v)v 094 nn �0 City/State/Zip: ll,( Qv-vl-�t O Phone M 7 t ft:>F_r Are you an employer? Check the appropriate box: Type of project.(required): 1.❑ I am a employer with 4. F] I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.Ej I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. n Demolition working for me in any capacity. employees and have workers' g 0 Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. Ej We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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 S employees. [No workers' 13.®-Other_(`�.c��1 c� 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: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 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. I do hereby certify under the pai ndpe allies ofperjury that the information provided above is true and correct Sip-nature: �WLXIZ Date: Phone#• 9 7 t? 7 ( ra 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 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,associationor 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-contractor(s)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 maybe provided.to the..; applicant as woof: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.doglieense-or-permit to bum 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 youhave any:.guestion please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts L?ep . artrllent of Industrial Accidents Office of Investigations 600 Washington Street Boston;MA 02111 Tel. #'617-727-4-900 ext 406 or 1-877-MASSAFE, Fax#617-727-7749 Revised 4-24-07 WW.Mass.gov/dia =