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HomeMy WebLinkAboutBuilding Permit #638-2017 - 161 MAIN STREET 12/13/2016 V BUILDING PERMIT4W ? �!::. • '':� o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION / * - Permit NO:63?'- 9-al-7 Date Receivedl.3 6 n ��SSACHUS t� Date Issued: btrr IMPORTANT: Applicant must complete all items on this qge 15 n LC7CATION ., •. Print PROPERTY` rint z MAP NO /k -L: ZOI IG DIS Historic Distne yNINE es n� c . Machine Shop yes no u TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Buildingne family ❑ Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial g-f�epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other (I Septic l ,. - GI Floodplain ds 0 strict s Water/5emr > , 9, Q) Me J ?0C Identification Please Type or Print Clearly) OWNER: Name: e i- Phone: Address: CONTRACTCs FF a , PhoneME ` `" Address. + Fye r Supervisor's Con bi L►cense: if Exp Date Home IMP rovemnt ee & Exp Date" X . <<, 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: $ �� FEE: $ 160 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agentl3wrtr_ , " w. '� t nature of contrc car m, q • 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 ❑ ILJ' Z ;� X COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ -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 Located at 384 Osgood Street FIRE DEPARTMENT p Qtamps onx o �. ., Log4ted at 12411ain Fire Dep ent signature to s �p /� o' P;_ COMMEN a. % . qV M 1imension Number of Stories: Total square feet of floor area, based op Exterior dimensions. Total land area, sq. ft.: ;- ELECTRICAL: Movement of Meter location, mast or service drop,requires approval of Electrical Inspector lyes No ®ANGER 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 ate 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 o Building Permit Application o Workers Comp Affidavit o 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 o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract act o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products DOTE: 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 Location dol No. (4939G �aU1 7 Date J }// 3/90��s • - TOWN OF NORTH ANDOVER SM y Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# q6(s / ' (Building Inspector NO R T1-� Town of ndover 631 i2 !1-- �o h ver, Mass, / a / s d 6 �!- COCHICMIWICM y�. 7,�5 R�rEo ►�PP��(5 U BOARD OF HEALTH Food/Kitchen PERMIT 4 T & D Septic System I THIS CERTIFIES THATVABUILDING INSPECTOR has permission to erect buildings on .1 .s Foundation , � � Rough to be occupied as ..... .............. ... ............... ! .r...................lam... ...................... Chimney provided that the person accepting 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 6 AJONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC I TARTARI 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. Machine Shop viQage Neighborhood Conservation District Map Maddva Shop Villa=s Nfighi)athaad COOUVatios DiatFkt.\taN �13 Jul .../. Nf••«i � «IN«I N/ilif «INNI N,r1f� l dll,.l t YINMI 1h1 �f•/IN WNIM �1 j � N1tlll t «I•/YI Mf 11111 «7•iM1 WYMiI _ «1iM11 1 5 ? CA'cl a P ,au5. MA Lic.#016201 VALLEY SIDING WHOLESALE, LLC �•)SINE.'t Toll Free 1-877-302-2923vilm W Newton, NH 603-819-5158 • Saco, ME 207-284-6600 • Haverhill, MA 978-241-7343 ® C MEMBER Date: Consultant: h 9sc S"(2, Job Name: MI&I t&&-Cre qejr Telephone: qQA- $S2-6&S— Job Address:16264;j Sr Town&."4 cll� 14 VALLEY agrees to start described work on/or about -crweeks after final measure and complete described work in about _5�F3 working days. VALLEY shall not be held liable for delays due to causes beyond it's control. The following work Includes all labor and materials needed to complete your Job in a workmanship like manner. "�:Y::%::::�:3a:#;:�:5:::$::';.':::�`r: ':`YFY:A:�.%;';:�:;:?:•4:'..:�:'{. .';'::'+,`.::�*is:':'.Y':::is1'::::2:::::'.*:`;:';`•;��t%':,.'F':j:::�:'s�::::�:: ... .. ....:......:..................................:.........:........................................................... .... .. .....::.�.�::.rrY�rn................:....:::.wr:r:.r:{.x4:trr:4rr:,:•:cr:r+:.::::�::.:aC:.it+^:v*::r.arrr Removing Debris In A Legal Manner-Dumpster At Site Or Shop: Center Vent ❑ Fully Vented ❑ Non-Vented Dumpster And Location: Location: Remove Existing Siding Preparation Package Accessory Package Color: F Fuil Gustom Formed J-Less ❑ Full Custom Formed Full Custom Fascia&Rake Trim Cover Calor: �Z, ❑ Blind Stop Capping ❑ None Full Custom Soffit Trim Cover Color: Location: �M Full Custom Window Trim Cover Color: &'A Shutters Color: ❑ Gutters&Downspouts Color: [],,Shutter Amount Location: � 'I Vapor Barrier House Wrap P Lopa n rl m nt Leveling B r Insulation 3/8"U de ay e /Backer ❑ Other Location: Lia-Complete House ❑ Garage ❑ Other Brand:a d: _ Profile: Soy', Q,,,...< ❑ Check Or Cash ❑ Credit Card ❑ Owner to Arrange ►<:>>>>>`:zi>'ii`<i>ii`iia>ii>;;_>'€�<>:�:>::>:>:>:>:>:>:<>;>^ :<':a:>::: Wide Insulated ❑ Wide Non-Insulated Total investment: 3 ❑ Regular Non-insulated ❑ Custom 1/3 Deposit: 5" asc Corner Post Color: 1/3 Payment At Halfway Point: S �O (Jh, 1/3 Balance Day Of Completion: *�RV.C.Coated Alum. ❑ Aluminum NOTE: ❑ If A Building Permit Or Electrical Permit With Updates Are Required B Your Enforcement,rcement The Are Extra And Paid � U, Full Custom ❑ None For At The End Of Job, At Invoice Charge Only Location: ❑ Any Wood Replacement That Is Required After Start Of Job Will Be Extra And Paid For At End Of Job,As Listed On Proposal You may cancel this agreement if it has been signed by a party thereto at a place other than the address of the seller,which may be his main office or branch thereto,provided you notify the seller in writing at his main office or branch by ordinary mail posted,by telegram sent,or by delivery,not later than midnight of the third business day following the signing of this agree- ment.See the attached notice of cancellation form for an explanation of this right. An interest charge of 1-1/2%per month(18%per year)will be added to any amount unpaid after 30 days from invoice date.In the event of default in payment Date of Acceptance of this order or any part thereof and the account is referred to an attorney for Signature A collection,the purchaser agrees to pay reasonable attorney fees. (Homeowner) R-TG,.-��G,.- tib I/We give Valley permission to obtain all necessary permits. Signature Signature (valley) Zg./'11" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvt)p 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): Address:1 ,� n s� City/State/Zip: "p A. I r{�t-) . IV dB5borle#: LO03 Are you an employer?Check the appropriate box: Type of project(required): I I am a employer with /—,/6 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• [remodeling 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. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.El 1 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.❑ Roof repairs insurance required.]t employees. fNo workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also rill out the section below showing thea 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 ofthe sub-contractors and their worker;'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /LB Policy#or Self-ins. Lic.#:!o zzu& "7 /—s3(o%�� -9-/� Expiration Date: Job Site Address:� f/,*,;u SA „City/State/Zip: l d✓ �k_ q�cxJ�i R r 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 he forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under t in's and penalties erjury that the information provided above is true and correct. Signature: V� Date: / � / CP Phone#: L a-3 - s---l 9 5--1.-Y 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): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ,4��oma® CERTIFICATE OF LIABILITY INSURANCE °7/21/20 6' 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 Emil Costello NAME: y Costello Insurance Agency, Inc. PHCN o Ext (978)374-6352 p,AX No:(976)521-5127 2 S. Kimball St. E-MAILADDRES..ecostello@costelloinsurance.com PO BOX 5248 INSURERS AFFORDING COVERAGE NAIC# Bradford MA 01835 INSURER A X.S. BROKERS INSURED INSURER B Arbella Protection Ins CompanV 41360 Valley Siding Wholesale LLC INSURERC:Zurich Insurance 185 South Main Street INSURER D: Unit B INSURER E: Newton NH 03858 INSURER F: COVERAGES CERTIFICATE NUMBER:2016 MA WC Certificate 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 LTR TYPE OF INSURANCE IVSD WVD SUER POLICY NUMBER MMIDDY EFF IPS DY EXP LIMITS X COMMERCIAL GENERAL LIABILITY1,000,000 EACH OCCURRENCE $ A CLAIMS-MADE IX OCCUR DAMAGE TO RENTED 50,000 PREMISES Ea occurrence $ 8078000861 4/7/2016 4/7/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY F-] PRO [::] LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS X AUTOS 1020015829 04 3/11/2016 3/11/2017 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ Medical payments $ 5,000 UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 100,000 OFFICER/MEM BER EXCLUDED? � N/A C (Mandatory in NH) 6ZZUB-9F36642-9-15 11/26/2015 11/26/2016 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood st ACCORDANCE WITH THE POLICY PROVISIONS. Suite 2043 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Emily Costello/COSN21 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 nmann . , gypp r` _ �-5� Y t �K'. '�;/ St �`� �' �. M.. 'l.i� 5':1 n is i2���' � � , {�� p k S !f � '��"��� fi`. I _ t y,} � ,fie t#2�4� �i �4� i p � ��Il i�7(t_it�r�" ,�aF� ���.���. �. � �'�;; �. ty. �' lF a t Y �Y,.. ( t y ys. & � pf � c a k _� � ��� t �. � '� � f P" 5 ��� t#� � y�Wx � _�IE � �_. 1 �( is ' c �� 4 � '� �` ,��� � ��r: �R� j. AaSaCt1Sa##St #tf Pt,rtC S.ae#jr 80ard Of Building Regulations and StVards Licenf.: CS-016201 Construction Supervisor VWWAM P GASB 13 KINGSBURY HAVERHii.l.IIIA 01b K .s` CA—Co .,fes inmissianer L� 11t1sa2n�la