Loading...
HomeMy WebLinkAboutBuilding Permit #709 - 161 RALEIGH TAVERN LANE 6/19/2009 BUILDING PERMIT cf Noer I ".0—F.0 " TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / Date Received �SSACHUS�� Date Issued: - IMPORTANT:Applicant must complete all items on this page LOCATION ..LL , pnnt �' y = PROPERTY OWNqf I21 r , Pent MAP Nfl3P�4FtCEL ZONI'NG.DISTRICT�H�stoiic District kes LLo _ rt � Machine-Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial e air, rei5lacemDt eAssessory Bldg Others: Demolition Other Septic= Well Y s=. Floodplain. xU�/etlands . _ Wat4m,ip#�Distrtct= Vllater/Sewer DESCRIPTION OF WORK TO BE PREFORMED: /� e Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: r'77; /-,k , zi e d v CON-TRACTOR` Name ,Ica rr t d Phone: "M y� a .Address: � a W _ : s a; Supervisor's Cc3nstructron license: - Exp. Date _ e Y home Im rovem nt bacense z�` a Ex Qate. ��' . �r p ..,� . P� 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. r- = Total Project Cost: $ 4!Va0. - FEE: $ G' Check No.: cc>' Receipt No.: 4;? ' ` I NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 5 gnature=ofarAgent/( wraer = ,S gh6 ureof contracto 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 Zor�ng Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Plar`tning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street 1 IRE DEPARTMENT Temp Dumpster on site yes v no i-ocated°at 124 Main, Fire Department-signature/date r - COMMENTS �; , e Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I 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 2008 Ili 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 �1 i ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ? o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract L3 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 { A Location Of No. Z70 j Date 'o 4 MaR,h TOWN OF NORTH ANDOVER # Certificate of Occupancy $ _ . i , cNustt Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building Inspector NORTH o"� of 0 t .r 4Andover No. 7a ? = AKE dover, Mass.,, /S• O COC NIC KE WICK y�. A0aATEO S BOARD OF HEALTH PER IT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ......... .a1i �......... ..........�.�.�N.�A911110400-ap....................:.......................................... Foundation • has permission to e?��o ................................�. buildings on -tv........10A.A. � 71.00.60%.W.... Rough to be occupied as.... . A.��'.......1.46#4........N...... �M► .... ..,���.I../�1. �►,�.��.�I!!� Chimney ,� rovided that the aEce tin thisermit shall in eve res ect conform to�he termsof a application on file inP PP 9 P rY P 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 CONSTRLJ STARTS 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. SEE REVERSE SIDE Smoke Det. m The Common wealth a MassII c hos .f etas j i De/nartmerrt of Industrial Accidents Office of Inas.ation s 600 1frashington Street Boston, MA 02111 www.huws gov/dia . Workers' Compensation 1witrance A davit: Builders/Contractors/Eiectricians/Pinmbers A Iicant Infortaatian Please Print Lm-' Name(Business/orgeniratiorA,dividual): Address: {� CitylState/Zig:_ ,� 4 L Phone F re you an employer?Cheek.the appropriate box: �rim a employer with _ 4. ❑ I am a general contractor and IF7. 0 f (repair . employees(foil and/or * caastrvctionpart-time). have hired the sut>-ctintzactors�] I am.a.sole proprietor or partner- listed on the attached sheet = deling ship and have no employees These stab-contractors have working forme in any capacity. workers' comp.insurance. lition [No workers.'comp. insurance.. 5. ❑ We are a corporation and its ng addition required] officers have exercised their ical repairs or additionsI am a homeowner doing ail work right of exam. an per MGL ing repairs or additions myseIf [No•w.arkers'comp. t~ 152, §1(4),and we have no insurance required. t l 12.❑Roof repairs ]. em a p Pees. o workem comp. h murance required_] 13.7Other * who submit this af Atry appiicam th8t checks boz't t must utiso frti out the sectim boiow showing their workers'oornpensetiari policy infomtafion t Homeowners fidavit iruijcating they are ttoing ail work u3nd then his outside contractors must submit anew affidavit indica* 4cmmtctors that check this box nrust.UwJ*d=additiow)sheet showing.the name of dm sub- S such contactors and their workers'corp• r:•-•• ! err ewigi,er that is proviacng work=,co ensatuin r pc..-,r„tnmmion. irtformadorr. mp insurance for may.emplayr= Below is the policy aad job site Insurance Company Name: Policy#or Self-ins.Lie.#: W C 2. Expiration Date: Job Site Address: 1G,( City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showiizg the policy number and expiration dated . Failure to secure coverage as g required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,5oQ00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine OfUp to$250.00 a day against the viola#rn 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 c under the p and penalties o e ' . 1 P r!t'r7'that the information provided above is&ae and carred Si to e: J Date: �'( / • � � Phone#: Of j`Ictai use only. Do net write is this area,to be cn 1 mp eled by city or town o�rxa[ City or Town: Permit/License# Issuing Authority(circle one): 1. Board of health Z Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Pinnibing Inspector 6.Other Contact PePerson- Phone#: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp 3oyers 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,assooiation,corporation or other Iegai entity,or any two or more of the%regoing engaged in a joint enterprise,and includir-tg the legal representatives of a deceased employer,or the receiver ortrustee of an individual,partnership,association or other legal attity,employing employees.'Roweverthe 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 shaU 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 opamte a business or to construct buildings in tine commonwealth for any applicant who has not produced acceptable evidence ak'compliance with the insurance coverage required." Additionally, MOL chapter 152,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public wort- until acceptable evidence of compliance with the insurance requirements of this chapter have been presenttd to the coritracting 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):axed phone n►mrber(s)along with their certificrate(s)of insurance. Limited,Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orpartners,are not requiredito carr workers'co-Trtpmmition insurance. Ifan.LLC or LLP does.have empioycm,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial .Accidents for confrrma6cm 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'tite Department of Industrial Accidents. Should,you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please-can the Department at the number.listed below. Self-insured eor*rpanies should enter their self insuraztcelicamt number on the•approoiate.line. City or Town OfEudais Please be sure that the affidavit is complete and printed legibly. The Dq=trnent has provided a space at the bottom of the affidavit for you to fill out in true event the.Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permitllicense 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 writer"all locations in (city or town). A copy of. the affidavit that has be=.officially stamped or marked by the city or gown 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 frUed out each year.Where a home owner or citizen is obtaining a license or perinitnot related to any business or commercial venture (i-e. a dog license or permit to bum leaves etc.)said parson is NOT required to compiete this affidavit The Office of Investigations would bice 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 Commonwealth of Massachusetts Department of Industrial Aacidaats Office of Lnv. ea ' ftQatEeons 600 Washington Street 13osfon, 1vIA 02111 TeL#617-727-4900 ex't 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mem.gov/dia AcpCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 6 PRODUCER GEORGE GATH INSURANCE AGENCY, INC. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 703 CHELMSFORD ST ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE LOWELL, MA 01851 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (978)454-7728 :1' INSURERS AFFORDING4OVERAGE NAIC# INSURED DOMINIQUE CONSTRUCTION LLC INSURER A: Liberty—Mutual Group 25 GLENNON AVE INSURER B: DRACUT MA 01826 INSURER C: 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 SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER DA YYY D / Y LIMITS GENERAL LIABILITYEACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS MADE FlOCCUR MED EXP(Any one person $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- MJECT F-1 LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED E acccl idea)accident) LIMIT $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Peracddent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS 1 UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 0 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION WC2-315-359739-018 7/4/2008 7/4/2009WCSTATU- I ER OTH- AND EMPLOYERS'LIABILITY Y/N ANY -• OFFICER/MEMBER EXCLUDED ECUTIVE Q E.L.EACH ACCIDENT $ 500000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 5500000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 S OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS The workers' compensation policy provides coverage only for the state of MA as noted in section 3A of the policy, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION TOWN OF NORTH ANDOVER DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 7 DAYS WRITTEN 1600 O SGOOD STREET NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL NORTH ANDOVER MA 01845 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE (� Jeff Eldridge ' ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. Dominique's Construction, LLC 25 Glennon Avenue Dracut, MA 01826 978-957-6308 Propedy Owners: David&Maria Mesinger 161 Raleigh Tavern Lane North Andover,MA 01845 CONTRACT AGREEMENT Entered into this 1 st day of June, 2009 between Dominique's Construction, LLC ,hereinafter"Contractor") and David &Maria hereinafter"Property Mesinger 9 t p rtY Owners") of 161 Raleigh Tavern lane,North Andover,MA. The Owners and the Contractor, for the consideration hereinafter stated, agree to the following: 1. Scope of work to strip &re-shingle family room and sun room roofs at the above noted address of Property Owners. 2. Remove 18" of siding against house over family room &repair. 3. The Contractor will provide all materials per estimate. 4. The Contractor to supply all labor for the work to be done per the estimate. PAYMENT SCHEDULE • Dominique's Construction, LLC to provide material and labor for the above noted for the total amount of$4,400.00. • $1,000.00 deposit with $3,400.00 at completion of work. Dominique's Construction, LLC 5pkm,d A. Dominique Mr.David M . er Ms.Maria Mesinger Property Owners �/1 Date '. 136ifi�8 fA n§8 an a"r7s i Construction Supervisor License` j LlpeftsiN CS 44201 E piration 4/20/2010 Ti# 21480 E l estri 2iors=_0 ROLAND A D NII 100& f �' 250, DRACUT,MA 01'826ry Commissioner 4 w. fie-�omiino�zurra� � � ,,. { Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registrat n: 151738 Ek0IMtion 6326/2010 _ Tr# 267918 R r 1 .----LtdrLiability Corpor 4 e i /i.js DOMINIQUE S COSTR NUCTION-LLC. l } 1 ROLAND.DOMIM.QUE 25 GLENON DRACUT,MA 01826 yr. Administru#or i I AC40R"® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/11/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION GEORGE GATE INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 703 Chelmsford St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lowell, NA 01851 (978)454-7728 INSURERS AFFORDING COVERAGE NAIC# INSURED DOMINIQUE CONSTRUCTION LLC INSURER A: Lloyd'S ROLAND DOMINIQUE INSURER B: 25 GLENNON AVE INSURER C: DRACUT, NA 01826 INSURER D: 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. !NSR OD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRO TYPE OF INSURANCE POLICY NUMBER DATE MWDD/YYYY DATE MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 ]( COMMERCIAL GENERAL LIABILITY PREMISES Ea occtlrence $ 50 000 CLAIMSMADE D OCCUR MED EXP(Any one person) $ 5,000 A LGL0816083 10/12/08 10/12/09 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 1j,000F000 POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANYAUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 71CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NN) E.L.DISEASE-EA EMPLOYEE. $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CARPENTRY/PAINTING/TILE WORK/DRYWALL/SIDING CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THEEXPIRATION 1600 OSGOOD ST• DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NO ANDOVER, NA 01845 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHO I ACORD25(2009/01) ©1 2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered mars of ACORD