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HomeMy WebLinkAboutBuilding Permit #297 - 19 CARTY CIRCLE 5/1/2018 BUILDING PERMIT 3�u�tt�lD 6tioL TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION " Permit NO: Date Received 9q Date Issued: SS"cHU IMPORTANT: Applicant must complete all items on this page LOCATION A 6Ak-w- C.1N.Ayooye-t AA Q I%L4 S Print PROPERTY OWNER1A1`�7 6 Gegg A e,!jT\1 Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Vbne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑ Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer Identification Please Type or Print Clearly) r J OWNER: Name: x-9/1)ed.Ui5',2i -rE- (E,e1c1, aeH' 4 Phone: I - Zra— LT Address: CONTRACTOR Name` Phone:X0'5 735 34g`i5 Address: -- - l . W G=sri c&� iii p -r-yA, L sso&o AAA- v co �i 3 Z Supervisor's.Construction License: Exp. Date: C5—o�b��s`1 oz 61 Home Improvement License 1357-7(o Exp: Date: cis �t Zr�i� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. G Total Project Cost: $ �7r, 3" FEE: $ 4 Check I No.: 11 ( —4 Receipt No.:NOTE: Per n coy g with unregistered contractors , do not have access to t e guar my fund ignature of Agent/Owii Signature of contractor___. .r �J TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION - ` Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER._. _ Print 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village 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 ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic q Well ❑ Floodplain ❑Wetlands ❑ Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone Address: M Supervisor's Construction License: Exp. Date: _ Home Improvement License: _ __ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r _ Signctare,of AAgent/Ownor r W Sig afuro,of contractor ~ 4 '� Plans Submitted 171 _ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ . d i Location ClC14, r r No. Date i i iI • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ '� TOTAL Check#-�'�-t� v U 260/ 31 Building Inspector Plans Submitted-0 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ C TYPE_OY-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:APPR-OVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Siqnature a COMMENTS a_ 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 Tow;2 Engineer: Signature: Located 384 Osgood Street FIREDEPARTMf_NT> Temp Dumpster on site yes no Located at 124.Mair, Street- 'Fire-DLip6r!mei'it,si-igiiattffe/d6tb treet'Fire-Departmerit,siginature/date COMMENTS i 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 I 1 Doc.Building Permit Revised 2010 Building Department The fohswing is-a list of the required forms to belilled out for the appropriate permit to.be obtained. Roofirg, 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 o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks L3 Building Permit Application Li Certified Surveyed Plot Plan o Workers Comp Affidavit o 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) 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 Li 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) o Copy of Contract o Mass check Energy Compliance Report o 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 apwal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 NORT►i Illi oAndoveT LAN! h ver, MMass ® 1 1 Y O • COC NIC Nl WtCK �� S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT �t� ..,,.,, ,,.,,,, .,, BUILDING INSPECTOR ....... ............. .. .......... ....... .......•..................... has permission to erect Foundation p .......................... buildings on ....�..............�.!!►�'....... .....Jt.��... Rough to be occupied as .........�J.. ........ ....... ........... �a.L ............................................... Chimneyprovided that the personaccepting his permit shall in every respect c 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 6 PERMIT EXPIRES 6 M T S ELECTRICAL INSPECTOR UNLESS CONST ON S TS 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. SEE REVERSE SIDE The Commonwealth of Massachusetts - Department oflndustriglAccidents Office oflnvestigations 600 Washington Street Boston,MA.02111 www.mass govkdia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationftdividual): 9::�o�U a/'ri '� St3 Vn Address: S_70f4 rrt City/State/Zip: v,, /'1 Q/ Phone#: Sp 9,Zr 3 LZ 14 Are you an employer?Check the appropriate box: Typo of project(required): 1 ( I am a employer with 4. ❑ I am a generaco, d I racor an6 � l_ El Now construction employees(full and/or part-time)* have liked the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.I 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 ' insurance 5. ❑ We are a corporation and its eq workers comp.jnsura 10.❑Electrical repairs or additions required.] officers have exercised their 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 1,2\Q.Roof repairs insurance required.] employees.[No workers' 13.[1 Other comp.insurance required.] 'Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they 27re doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis 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. I r Insurance Company Name: d 1/'1 1^'�vfv, T, ar-4 Policy#or Self-ins.Lic.ff: 120a`S o'Z ? 01-7, Expiration Date: Dl Y Job Site Address: c7 �i/�V ��r C'& City/State/Zip:__}vt,cJ oy,&r Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 ofup to$250.00 a da against the violator. Be advised that a copy of this statement may be forwarded to the Office of p Y g . 'Investigations of the DIA for insurance coverage verification. .1 do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. - Sim ature• Date: ZO Phone# 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.PIumbing Inspector 6.Other - - Ph nn r>f#• Information and Instruction's 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 ofhire, 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 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 ofpublic 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 notrequired to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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(ifnecessary)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. Anew affidavit must be filled out each year.Where a homeowner 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: The Commoaawcalth ofMassachv.:sPtts 13epafteut of Zndustdal Accidents Ofte of Intyestigatims. 600 Washlogtau Street Boston?MA.02111 Tei, 617727-4900 ext 406 or 1.-877-MASS.AFE Revised 5-26-05 Faze#617-727-7749 COBUAND-01 LHOLLAND CERTIFICATE OF LIABILITY INSURANCE F DATD/YYYY) 9!119/21912013 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 NAME: Salem Five insurance Services,LLC PHONE FAX 445 Main Street JAIC.No Ext):(781)933-3100 5583 arc No):(781)933-9048 Woburn,MA 01801 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Max Specialty Ins Co INSURED INSURERB:AIM Mutual Insurance Co. 0913 Coburn and Son,LLC INSURER C: 321 Westford St INSURER D: Tyngsboro,MA 01879 INSURER E: INSURER F 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. S INS L7R TYPE OF INSURANCE POLICY NUMBER POLICY EFF MmmD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. AJC COMMERCIAL GENERAL LIABILITY BDG3001808-01 4/22/2013 4/22/2014 pREM Slyl Ea occurrence $ 50,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PROJEC- LOC g AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS PeracGdent $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DEC) I I RETENTION$ $ WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY X RY LIMI _r70TH_ B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N AWC40070292832013A 71312013 71312014 E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? N r A (Mandatory in NH) Ifes, escribe undE.L.DISEASE-EA EMPLOYE $ 500,000 yder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLESAttach ACORD 101 Additional( Remarks Schedule,K more space is required) CERTIFICATE HOLDER CANCELLATION 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD I CONTRACT Property Owner Contractor Marge Gerraughty Coburn & Son LLC. 19 Carty Circle 321 Westford Road N. Andover, MA 01845 Tyngsboro, MA 01879 The Project Address: Business T lephone: 978-649-3488 19 Carty Circle Business Lic# CS 0767'd N Andover, MA 01845 H.I. Lic#V1357765 '� The owner and the contractor for the considerations named herein ago ree as set forth-,below: 1. AGREEMENT made as of the twenty sixth day of eptember `n the year tw6 thousand thirteen. 2. ESTIMATE SUM: $ 7,125.00 Seven thousand one hundred and twenty five dollars no 100 3.PAYMENT SCHEDULE AS FOLLOWS: 1. Down payment upon execution of contrac . $ 2,375.00 2. Due upon completion of first day of work./ $2,375 00 3. Due upon completion of job. r!$ 2,37r .00 otal Job Cost $ 7,125.00 1 I /� 4. WORK SCHEDULE. Start date: 1 /O1/1' Completion date: 10/04/13 Contractor is not respoinsible for any�delays�in completion which are out of their control, such as I its � . ! a fU weather,labor strikes a+tnd maternal shortages or, delays. 5. SCOPE OF WORK TO BE=D� INC DING MATERIALS: Remove one layer of asphalt ash nl es paAd lnderl yment and dispose of all debris. This is for the main house and front part of garage/b�eez�way only. � Inspect roof deck. Any roof deelk that needs to be�r eplaced will be an additional charged. Retast'en all roofsh"eathi1. Install heav�-duty 7"drip g d �at all r ake nda�cia boards. Color white Install Grace Ice&JW:Ite� SZeic on the bottom' of roof and in all valleys then 15#felt to ridge. ln�tall a sta dar�25 year 3-1ab shingle to best match the rest of the garage/breezeway roof. GAF Sovereign color Silver t in . Install new, pipe flange. Customer would fik to stay lith the gable end vents with gable power vent and does not want to install ridge ent an- soffitvent. 6. LICEINSES,PERMITS AND BONDS ARE SUPPLIED AND PAID BY AS FOLLOWS: Contractor will acquire any permits and bonds related to the work to be performed. _ Property owner is required to pay the cost of bonds and permit plus time to retrieve permits. PLEASE NOTE:; 1. Coburn& Son LLC is not responsible for material stored on job site and material defects. 2. If shingles are to be removed from said structure we recommend that anything in the attic is removed or covered. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES f Pro a�Yowner's ig� ontractor's signature Marge Gerraughty John Coburn Date � f /;� Date 0,-, F�„j� Under Federal and State law you have up to(3)business days to cancel this agreement in writing. The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c142A. Owner: Marge Gerraughty of 19 Carty Circle N.Andover,MA 01845 Contractor: Coburn&Son LLC.of 321 Westford Road Tyngsborough,MA 01879 NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor.The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. I II J1ie Massachusetts -Department of Public Safety Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards -- HOME IMPROVEMENT CONTRACTOR Registration: .^.=135776 Type; Construction Supervisor License: CS-076787 Expiration 5/7/2014 DBA CO URN+SON "` ` - JOHN A COBUW 321 WESTFORD ItOAD JOHN COBURN Tyngsboro MA 01879 ; W 321 WESTFORD RD TYNGSBORO,MA 01879 Undersecretary �J '� �'��� Expiration Commissioner 07/04/2015