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HomeMy WebLinkAboutBuilding Permit #319-12 - 171 BRENTWOOD CIRCLE 10/12/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: /2- Date Received Date Issued: �01__ IMPORTANT:Applicant must complete all items on this page LOCATION �cenVvJ®ot� C rC�e_ -print PROPERTY OWNER �20Se S�064CL� Unit# Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial KRepair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑Other '��❑Se is ��'�ell` ���-� ,.d,...;�� a�� � � �-_ ,gip ,��,� , �� � a�❑Floodplain �;i(]�Wetlands - � ks��pMWatershed�Distnst-� - - ❑�Tr water�SeWeI - �- F' + i i t r r �`` ;:e.� �� e � � .,F _..`.�-+--�rte.+ -=,r3# 'sa__ a:;:a'E n ->°..,;a. ...`...'. _.::t"..a.."a'F! F .�c .• Tom;^} - 4- DESCRIPTION OF WORK TO BE PERFORMED: �ecro� 2oC�5 nto(7 wi� rl�t� (Identification Please Type or Print Clearly) OWNER: Name:_ RCde mai opal Phone: qIe QQF 0 V3 9' Address: 1 1 6 ent �vp d C i rGl �J v,/ (�1 �y � CONTRACTOR Name: �2vC1oAS 1 S0-d i CeS Phone: -7?1 -760 2_0S1 Address: eo ean4• A ®em Supervisor's Construction License: -7,39 Exp. Date: 41-71 1Z Home Improvement License: Exp. Date: `l 13 ARCHITECT/ENGINEER P4� Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. 0 Total Project Cost: $ I`1 $50 FEE: $ Check No.: 7 7 Receipt No.: ;2�/ 7 0 2 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si 'nature of A ent/Qvvner: g— — g —_ Signature of contractor ; ' Location,/7z x!'rci�1 No. Date N...T TOWN OF NORTH ANDOVER � w A yes ; : Certificate of Occupancy $ �SsCSE<t' Building/Frame Permit Fee $ fir Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check a W 7� 24702 4702 Building Inspector 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 v FIRE NT T-emp,D.umpste:r on site yes no x E , E-ocatedat 121-MainStreet rt :Eire De:partments`Ignature/date n h 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 NOTES and DATA— For department use) ❑ Notified for pickup Call Email i Date Time Contact Name Doc.Building Pen-nit 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 ❑ 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 a 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 o 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 NORTH o Of oAndover . k1. _n �. o dover, Mass., Q t�- LAKE COC MIC MEWICK RATED C:l BOARD OF HEALTH Food/Kitchen Septic System PERMIT T BUILDING INSPECTOR THIS CERTIFIES THAT Foundation ................�C—G........... i�/' jj .�` . ............................................................................................. ........ buildings /7/ /�r� �rc�ooc�C,al has permission to erect...........:.:.................. gs on ...................................... . . ................................................ Rough tobe occupied as.................................. ���P...,�. E. 4. ?. .................................................................................... Chimney provided that the person accepting this permit shall in eve ryrespect conform to the terms of the application on file in Final- this inalthis 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 CONSTRUCTION ,ARTS Rough Service ........... :.:.-........................................... BUILDING INSPECTOR Fina] Occupancy Permit Required t0 OCaipyy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIR_E.DEPARTMENT Until Inspected and Approved by the Building Inspector., . Burner Street No. IFSEE- REVERSE SIDE Smoke Det. i Schedule of work It is agreed by both parties that this work will be coordinated with the"Client"and "Nexus"to be undertaken in various stages to avoid complete disruption of the home or Office environment and also to allow coordination with existing projects. "Nexus"will give"Client"no less than 2 days notice prior to arriving on site for commencement of any of the agreed stages of work to allow"Client"to prepare. "Client"commits to have sites identified for construction work available for start at the beginning of the scheduled day so as to avoid any unnecessary delays. Contract Cost and Payment Schedule: Total cost of work description and materials included in the proposal(except materials/work stated)-$17,850.00 (Seventeen thousand eight hundred and fifty dollars and zero cents) PAYMENT SCHEDULE Payment due upon signing this contract Q 000 � TOTAL P0k O)c 103 Payment due upon completion of roof TOTAL nn � F► �®� 0007 Total due upon acceptance of this agreement $ I I have read and understand,and I agree to,all the terms and conditions contained in the proposal above. Date..1-441� ••••••......... "Nexus"Authorization................... . Date..... °� �(............ "Client"Authorization....... .. Date... 0h-I "Client"Authorization..... SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT CS Nexus II Carpentry and I? 9 ,-T-7 Construction Design P.O.Box 2823 Woburn,MA 01888 P4© \-V, N-\&,ver 781 760 2031 or 978 688 7929 Fax 978 9751263 nexuscarpentry@aol.com Contract This is a contract between Lee Kinberg of 171 Brentwood Circle,North Andover,MA 01845(Hereafter referred to as the"Client")and Nexus H Services (hereafter referred to as"Nexus")to carry out work irra dated October 6th,2011. GENERAL SCOPE OF WORK DESCRIPTION WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: Roof work as listed below Scope of work: Work to include: 4 Roof work Scope of work will include; 4 Remove and trash existing roof shingles into dumpster supplied by Nexus Furnish and install new vent pipe flanges where needed Furnish and install ice and water shield to all valleys and hips,in addition to the 1St 3' up each main roof section 4- Furnish and install flashing to existing chimney connections 4- Install new 30-yr Architectural shingles-oax&the existing roof shingle COLOR: To be confirmed 04� t`tt-vo-end 6 Furnish and install aluminum drip edge 4 Furnish and install circular soffit vents to areas in rear where required r�k We will remove all of the job related debris 4- All work will be done in a professional manner, and timely basis Exception: weather SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT �,, �I:fti\;dillfstil'YI�— ��I);1F'Yi331'F3Y!)� Pt31317C�:fitii ice ; #i:3i()111 SFE}1{jjd)�v Rf'�fFI:fY3tid3�;3d3f1 1i:1f3l1;3('(i� Construction Supervisor License License: CS 73991 Pestricted to: 00 1 GERALD WHITE 23 GLENDALE DR DANVERS, MA 01923 - A— c Expiration: 4R/2012 Tr--: 22470 IS-CAI 0 50.'-A4W04G101215 f>'v_ o�.wno9scrrea �ursi�-� ° License or registration valid for individul use only ; Office of Consumer Affairs ossa ega aston HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return toe Vit' 'PRegistration, 129177 Type: of ice of Consumer Affairs and Business Regulation Expiration: 7/19!2013 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 Ge kt White Gerald White - 23 Glendale Or Danvers,MA01923 Undersecretary t valid without signature 10/04/2011 11:10 FAX 978 532 2217 CROSS INSURANCE 9 002 A�� CERTIFICATE OF LIABILITY INSURANCE 0/0 1 THIS CERTIFICATE 1S 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 roquie an endorsement A statement on this CertifiCdtee does not confer rights to the earrifieafe holder in lieu of such endorsement(s)- PRODUCER NAME:cONTAGT Lauren Goldman Cross Insurance-Peabody PHONE (978)532-5445 F (978)532-2217 139 Lynnfield Street &NUUL .igoidman@crossagfancy.eom INSURER 6 AFFORDING COYERAOE MAIC F Peabody MA 01960 INSURER A:WOStern World TM8. Co. INSURED INSURMa;Safety Indemnitv 33618 Nexus II Services LLC INSURrFkC; P.O. Box 2623 INSURER D: R E S�Toburn MA 01888 I14NS9UUWREAL: COVERAGES CERTIFICATE NUMBER:CL1191251B50 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. ILTR TYPE OF INSURANCEFOLJCT EFF POIDD FSP LIMITSPOLICY NUMBET! 6ENERALLIABILITY EACH OCCURRENCE § 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea o¢arroncc E A CLAIMS MADE OCCUR PP8023678 /12/2011 /12/2012 MED EXP one parson-§ 5,000 PERSONAL S AOV INJURY S 1,000,000 GENERAL AGGREGATE § 2,000,000 GEWL AGGREGATE LIMIT AFPUES PER' PRODUCTS-COMPIOP AGG $ 1,000,000 X POLICY PRO- LOC § AUTOMORILELIABILITY COMBINED SINGLE LIMIT Ea ,doom B ANYAUTO BODILY INJURY(For person) s 250,000 ALL OWNED x SCHEDULED 3116932 1/10/2010 1/10/2011 500 000 AUTOS AUTOS BODILY INJURY(Peraeeidem) S R HIRED AUTOS S AUTOS PROPERTY DAMAGE § 100,000 Medlcel paymenis S 5,000 UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS.MADE AGGREGATE § OED I I RETENTION = WORKERS COMPENSATION WC STATU. I OTH. AND EMPLOYERS'LIABILITY TORY LIMrrs ER ANY PROPRIETORIPARTNERIEXECUTNE YIN OFFICER/MEMBER EXCLUDED? ❑ N I A EL EACH ACCIDENT § (MoAdatoN In NIn If yyes,dr✓uibc under E.L DISEASE-EA EMPLOYE S DESCRIPTION OF OPERATIONSOeIw• E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(AOaeh Aeo"rm,Addldonak Remarks Schedurn,C mora spats b rpuMed) Refer to policy for exclusionary endorsements and special provisions. CERTIFICATE HOLDER CANCELLATION (978)975-1263 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lee ICinberq ACCORDANCE WITH THE POLICY PROVISIONS. 171 Brentwood Circle North Andover, MA 01645 AUTHORIZED REPRESENTATIVE Timothy Tramonte/LG4 �•7'�'� "d. G.LGH►EO�T ACORD 25(2010105) ®1988.2010 ACORD CORPORATION. All rights reserved. IN5025(201 D06).01 The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of lndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02_711 S� www-mass govldia Workers' Compensation Insurance Affidavit:Builders/ContractorsXlectricians/Plumbers _Applicant Information ,��tt Please Print LeglWy Name(Business/Organization/Individual): Iv2001k S 11 SqrV%Ce,$ Address: 1?® �pxRE 22 City/State/Zip: p��cn (�(\A 01r* Phone#: —1g 9 ` LA �9 Are you an employer?Check the appropriate box: L❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6 El construction 2. I am a sole proprietor or partner- listed on the attached sheet.? 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp. in 8' Demolition [No workers'comp.insurance 5. ❑ We are a corporation and its 9. El-Building addition required.] officers have exercised their 10.❑Electrical repairs ,]red 3.❑ I 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 insurance re q uired.]f employees.[No workers, 12•❑Roofrepairs comp,insurance required.] 13-ElOther *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 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 their workers'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: Policy#or Self-ins.Lic.#: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Signature: Date: o 11 d\ P:none#: 0 2031 Official use only. Do not write in this:rea, by city or town official. City or Town: ermitlLicense# Issuing Authority(circleone): 1.Board of Health 2.Building DeparClerk 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,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartinents 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/licease 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 Office of Investigations would like 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: xlze 0G�iaonwealth ofMassacrzosetts Dgadment of Industrial Accidents Office of investigations 600 Washington Street Boston;MA.02111 Tol.4 617-727-4900 ext 4406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617,727-7749 www.mass.gov/dia