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HomeMy WebLinkAboutBuilding Permit #480 - 174 BRADFORD STREET 12/14/2011L TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: i1"v Date Received Date Issued IMPORTANT• Applicant must complete all items on this page LOCATION 74 -r!q JCoc J ST _ Print PROPERTY OWNER ; In? of 0 �e `�Unit # Print MAP NO:PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village ye no 100 year-old structure ye TYPE OF IMPROVEMENT PROPOSED USE �t a� Residential Non- Residential ❑ New Building El Addition ❑ One family ❑ Two or more family 11 Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ISeptic 0 Well®loodp ❑ Other "7 lain ®Wetlands Wat hed.Di _ �. [M O Wa 0/Sewer, DESCRIPTIONOF WORK TOBE PERFORMED. I )� ,..ol Sr'eJ:0 a ;,,l (,/ At(iwri hvw Type or Print Clearly) OWNER: Name: Address: 5+ CONTRACTOR Name 7 /� on 4S S'om 146p,?& .�C v r� Phone: Address: Supervisor's Construction License: �(� -2 o-;2 Exp. Date: Home Improvement License: /1-23 Y6 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No 1�—• 17- ( 3 FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED O 925.00 PER S.F. Total Project Cost: $ < 0 o FEE: $ L Check No.: r3 Receipt No.: ° b -' NOTE: Persons contracting with unregistered contractors do not haccess to� e guaranyund Location ��� rq �+�d S� No.qL�2Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ tt Building/Frame Permit Fee $ td Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0 2 4 8 L 7 Building inspector J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ ' Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dempster 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 p - HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comm Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located384Osgood Street Located at 124 Main Street Fire Department signature/date 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.$10o-$1000 fine Doc:.Building Permit Revised 2011 June/mi 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: Doc.Building Permit Revised 2008mi O Z • • W rA R;", � C O d C c� O N C O t C.3 C.2 •d � CL Cc m c • = p 1 O+D W H Ea c TCDts o c. N �' �m O �� C.2 � O q tu os CD E �m O m 3 _ (/) c � O � y c C o V!z N W c o O W cmCDU = vJ ^^ CD tmCf) .CDoc �. �i.�Ha • W m3 m a� COa h 22 O +-% `c c c Q 2 `mc 'o = m O w�.. C N . H 0H O O COD cv = m y=„ W C w 'O ,_ .ryiJ cm a L C Z W �C . c c .y O CJ cm COD O_ O 'O O -S _ a20 oy•� O c m S rs Lai u O O CD 0 C L, c 5 .. Z O D CD as u o w° a Cf)w° 5 or. V G rs° U w A. n�' ca w W �°D " w bo w1= v ,�. cn i CO � C O d C c� O N C O t C.3 C.2 •d � CL Cc m c • = p 1 O+D W H Ea c TCDts o c. N �' �m O �� C.2 � O q tu os CD E �m O m 3 _ (/) c � O � y c C o V!z N W c o O W cmCDU = vJ ^^ CD tmCf) .CDoc �. �i.�Ha • W m3 m a� COa h 22 O +-% `c c c Q 2 `mc 'o = m O w�.. C N . H 0H O O COD cv = m y=„ W C w 'O ,_ .ryiJ cm a L C Z W �C . c c .y O CJ cm COD O_ O 'O O -S _ a20 oy•� O c m S rs Lai u O O CD 0 C L, c 5 .. Z y D CD c CO3 p 'C 'E Co m 0 CD CL as 0 0 a a �a c CO3 ccc C.3 J .� �G. O D ♦ c Z m Q CL �..± y � C W O H' W N 19W W W W H c W O H' W N 19W W W W H The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Vis' www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): / 0 b l`t QS T Se Address: -3-2 W r -C-6 t' r -S+ S4 City/State/Zip: 4 y u., e 8- Phone #: Are you an employer? Check the appropriate box: 1. tA- I am a employer with �/— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp.. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other -Any appiicanc rnaL cnecKs DOXY t must also nu 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: r %4 r �% f Policy # or Self -ins. Lic. #: oC O O (o s�6,q Expiration Date: ! Job Site Address: l 4/f o -d 5, City/State/Zip:V + 4 of o () e. C, -qq. 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 penalties that the information provided above its true and correct. r Date: %62 `/ 1 ` // Phone #: J �� " 7 a – -off 3 1 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 #: r w C- ;u OVD m mr n rm-mtn 0 o Co i = r --j2. y y gym= o 2c4 = Dcn0 n�� .. p 00 Cl) � o r . -+ m r 0 c m (o D �' ' ° (3) m 075 N X (n _ • CC3 K n � • e•R _ Uo r-1 n. �, o ccn o 0 ^' w `. (n v� O i — - ---- --- --- - - -'�jL ° •� NUl "w C aoo 0 ° rr--0 U W V m n 0 0 N �r M T O O (0 N T C m N O M o T o X W m o UJ~ E � CN (n C L _ cljWLO c mwoo COQ cn U) M w >W F—�MJO C I� O bd o � H w d O bid � y C. m C •�' 7 P'a L � rfl w C w U H c) Ce) ai W M N r > No d ^E j Y=e c m N JL c b 0. R O Lu m '=doted L d U Er- x o O m � d w 0 20: W o CF L C U R w w e; y o 41C) ,W e U W r 0CL O h U O o Z 401- U H c) Ce) 1 W M N No ;a W ^E j Y=e c m N JL c Lu m (n Er- x o O m � w LO 0 00 o 0 20: W � E O O (n o LL e; e U W a E u) 75 U E 3 sFasM J a 0 OP ID: BW 144C<:WRE)11 CERTIFICATE OF LIABILITY INSURANCE DAT12114D/YYYY) 12/14/11 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 978-459-8681 Francis Provencher Insurance g7$454-9343 Agency, Inc. - 530 Rogers Street Lowell, MA 01852 CONTACT NAME: PHONE FAX A/C No): IL E-MAADDRESS: PRODUCERCUSTOMER THOMS01 INSURER(S) AFFORDING COVERAGE NAIC S INSURED James M. Thomas Jr. dba INSURERA:American International Group Thomas & Son Home Improvement INSURER B: Preferred Mutual Insurance Co. 15024 Inc. 37 W. Forest St. INSURER c: Com m erce I n s u rance Com pany 34754 X COMMERCIAL GENERAL LIABILITY Lowell, MA 01851 INSURER D: CPP0160579267 03/06/11 INSURER E: 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR pOLICYNUMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence $ 50,00 B X COMMERCIAL GENERAL LIABILITY CPP0160579267 03/06/11 03/06/12 CLAIMS -MADE a OCCUR MED EXP (Anyone person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 POLICY J`lR,0j 71 LOC $ C AUTOMOBILE LIABILITY ANY AUTO BBGS42 07/28/11 07/28/12 COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ 250,00 ALL OWNED AUTOS BODILY INJURY (Per accident) $ 500,00 X SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE $ 250,0010 (Per accident) $ NON -OWNED AUTOS $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DEDUCTIBLE $ $ RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN- WC006518604 03/06/11 03/06/12 X I WC STATU- I OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED. (Mandatory in NH) A NIA E.L. DISEASE - EA EMPLOYE $ 100,00 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT I $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101 Additional Remarks Schedule, If more space is required) RE: James & Janet Foley, 174 Bradford St. N. Andover, MA NANDOVE Town of North Andover 120 Main Street N. Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r-1 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Proposal Vinyl Siding vny! Vinyl Windows Proposal No. 7* -13 ? Gd t <F`af-C'S `I s� Sheet No. THOMAS & SON v w,- U /?,S-/ Cell (508) 726-5231 HOME IMPROVEMENT Date Tel: (978) 934-9872 HIC #123640 Lowell, MA CS SL 99672 JIM THOMAS Proposal Submitted To Work To Be Performed At 9 Telephone We hereby propose to furnish %t s4 -c I IC , �4i City State I Date of Plans the materials and perform all the labor necessary for the/ completion ofCG eit%v:-. colo All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike manner for the sum of Dollars ($ g©©Q `f 1. with( payments to be made` as follows: 6`1' ncuk"�ri`f nN-- � `i /fN^ —n A1 r .. -- - �..f �1_ f .,n.� L _4 e)!—.iil�- L' `�cs2 CC, 44 :� ,. �G/ '4, � 3,!)bn ` , J :/Jct,1 (i n is i°.,:,, Any alteration or deviation from above specifications involving extra costs, will be executed only upon written orders, and will become an extra charge over and above the estimate. All agr menta contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necesso ' surance upon bove work. Workmen's Compensation and Public Liability Insurance on above work to be taken out b %)Glf GS 6Y) Respectfully Per Note — This proposal may be withdrawn by us if not accepted within days ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date 1