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HomeMy WebLinkAboutBuilding Permit #034-12 - 196 MAIN STREET 7/14/2011 TOWN OF NORTH ANDOVER j APPLICATION FOR PLAN EXAMINATION Permit NO: 1 Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION /f'�C{ I°A/ .6 j�p p' Print PROPERTY OWNER SG)ice`` M1 (Lap�1 g PIS.r;S 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 0 M family ❑Addition ❑Two or more family ❑ Industrial ❑ eration No. of units: El Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic 0 Well 0 Floodplain ❑ Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Roo (Identification Please TyPrint Clearly) OWNER: Name: ' EMS� SPhone: yip Address: fcf(oo YY)aiAl SThd7kr MA CONTRACTOR Name: E Mn cq Phone: 41 ?f7 .k Address: �(O �Q� ( .� �M/f 411$rtJ2 Supervisor's Construction License: yS 9Y Exp. Date: Home Improvement License: 1371113 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: $ ��, $(�a n® FEE: $ i ----� Check No.: Receipt No.: ' �{ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature o nf A ent/Owner __-- _ _. 9 _ _. Si nature of contractor 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 e 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 Osgoo Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS_ L 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 I ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi J 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 V--'Building Permit Application Zorkers Comp Affidavit hoto Copy of H.I.C. And/Or C.S.L. Licenses 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 Li 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) o 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 o Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calcul y atlonspp If Applicable) ( Li Copy of Contract Li Mass check Energy Compliance Report Li 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 Location ke "w Sr- No. Date ,.ORTk TOWN OF NORTH ANDOVER O f R 9 Certificate of Occupancy $ - - Building/Frame/Frame Permit Fee $ JIVE s•►cMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 4z) / 1 Building Inspector NORTH Town of 0 No. 004ft _ z yy 0 o , dover, Mam p Y O '- LAKE COCMICMEWICK V 0RAT E D PPS BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT �< L .......�. .................... ..................................... ...........g. ..................:....................................♦ � t Foundation has permission to erect..........::. ..................... buildings on 1.4 Rough to be occupied as......�� ......!*'........... ... .. ............................................................:................... Chimney C e provided that the person accepting this permit shall in every res conform to the terms of the application on file in 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 6THS ELECTRICAL INSPECTOR UNLESS CONSTRUC Ole, S TS Rough ............... ............................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required t0 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. P Xt -IPO* IDO t""'AL L.E, Morgan Construction Company 36 Billerica Avenuc,Unit#l. id,VIS4i, N. Billericv.,'VA 01862 3 Offit-(t. (97 S)670-47.4", /Fax-. (97 )670-6477 57C An ZIP Como LLCAM o TH Otic I Strip down tx) the wo1A deck, layers of -,hlngles, d1.,.z-pose of dears to a licensed recycling FOCITY. feet of ice and water shield in valleys. Install ice and water shield at the gutters --a` Tustall s" aluminutn drip edge on al] permeters, color 11 White, G NMI, J Brown, a Copper. Install isphadt saturated 1b, felt paper on the re minder of the wood decking. I 111.3tall year a a lauri -architectural s9b. It shingles, and I -icane nail.. -nstall ri4ge veut manufactured b —_—_ _ _�"-- to ah ridges and raing lois wanufaftured, by , ispa.0 11c,W Skylight fiac,'L I Flash -,I) cheep wall~.. Pipes- skylights, and penetrat."ons to J) ctures specificad 1 51-iing or. Cr Ilemove existing, lead fla, J.Pa%gAtf I n. chiynneys and Insta.11 new lead flashin lijstall marching .-Ila.p shingles to all ridges, hips and dormers. VVER )PROPOSE-.h(neby to furnish n;,aterial an,dlat-t.-)r -(!omplete in amordar-,-(,Witt a'-jvi�sv,'rlfketion.-,for aha sum of: 4-A.Y 14ajjm'.E -E 6".4, - 5.kx` dollars I means,-xc.,ndinq to F.itar,,jarj p.-dcCces.An,,,alterstor.or daviiAjor abve Autho-razed Signature: e9tTz' bA axsout4c orliv upan wr)'t,ter,orders,and will Notw This propusal may be vit--tidrawn bo-*,�,o�e io,4ytrg chaige uver.-iid above the swimau.Ni Aoriiars Bra�uily covtiro.l hy Lis if not 3o d oy Worlimen's campenraitcr;muanze ana Ljal�Wty AC',ElIfANU CF PROPOSAL-The above nric"C"P, Da-,e of accovti:nr- e-pacifications and(w)udAi-,-,ms are sq.i;-ksfactcr'Y;1Rd are siputurti: VV—1A YouPwar�k 's are auth.,T,)r'zed to do the zirecifi ed. Pay m.ent-w-III be mads as outlhmd above. yut3..�'^i:.FSig-tur-c: Add,tioTial Re n1 a Y.,k s: 7r- t THANK Y01T FOR CHOOSING L.E. MORGAN CONSTRUCTION OSHA.....:..--' Ttns card acknovrkdges that the re apier9 has aucaessh*compleW a 304aur OoWpabonet Safety and mean,Trading Course In Co ns truction Safety and Health I-Arry /Yore -- — �t.�,i,G. ffraaw name-pru't or type) (Course and date) OSHA v - A M_OBa_E_EQUIPMENT O J M hJ} t OPERATOR, CEP,TIFICATE -- - ctV �Kf wk9f +� It LARRY MORGAc�.� ,�t>�JINJI—d _���t.3�d< � : M,—�d."d i,.:aaan 7v<4:s3yudu.ad a qM-A,•,"Wd "w e:Le.�.x dpzl%M4r5 7Pa lu 13 ccs tt. Qr s`::y a tt_::: tears Ror-+Dau � oSAUErGq �T�LwvUNI lIJ U2eiS��4i� . Nlassachuwlls-'P De t trtment of Public Safer- Officc o nneomer. airs �S sine�� e n iUo�n I HOME IMPROVEMENT CONTRACTOR Board of Buildin-,RcLulations and Standards a, r.'Registration: 137913 Type: Construction Supervisor License n Expiration: 127/2013 Individual License: CS 79476 LAWRENCE E.MORGAN JR. LAWRENCE E MORGAN JR LAWRENCE MORGAN JR. 86 BILLERICA AVE UNIT 1 86 BILLERICA AVE UNIT 1 N BILLERICA,MA 01862 N.BILLERICA,MA 01862 Undersecrew v Expiration: 6132013 ___ _- __ ('..mmi.•f.a.•r Trrf: 16354 AC40R0® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD-YYY) 07/13/2011 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: NORTH ANDOVER INSURANCE AGENCY, INC. (AIC,NNo, Ext): (978) 686-2266 -i AX No):(978) 686-6410 M.J. FOSTER INSURANCE SERVICES ADDRESS: cfernandez@naf:ins.com PRODUCER 163 MAIN STREET CUSTOMER ID Aorgan Construction NORTH ANDOVER MA 01845-2508 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A :S.H. SMITH & COMPANY, INC.. Morgan Construction INSURER B :HANOVER INSURANCE PO BOX 75 INSURER C ACE USA INSURER D :SCOTTSDALE INSURANCE INSURER E North Billerica MA 01862- JINSURER 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. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DDIYYYY) (MMIDD/YYYY) A GENERAL LIABILITY CBC10000241200 4/13/2011 4/13/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY / / / / PREMISES Ea occurrence) $ 100,000 CLAIMS-MADE n OCCUR / / / / MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS-COMP/OP AGG $ 21000,000 FX- POLICY PRO LOC / / / / $ B AUTOMOBILE LIABILITY AWN6529181 0/13/2010 0/13/2011 COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS X BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS / / / / (Per accident) X NON-OWNED AUTOS / / / / $ $ D X UMBRELLA LIAB X OCCUR KLS0071751 1/07/2011 4/13/2012 EACH OCCURRENCE $ 5,000,000 EXCESS LIAR CLAIMS-MADE / / / / AGGREGATE $ DEDUCTIBLE / / / / $ RETENTION $ / / / / $ `. WORKERS COMPENSATION C4 63 89 65 7 2/14/2010 2/14/2011 WC STATU- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER ANY PROPRIETORIPARTNEWEXECUTIVE Y/N / / / / E.L.EACH ACCIDENT $ 11000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) / / / / E.L.DISEASE-EA EMPLOYE $ 1 000,000 Kes,describe under DESCRIPTION OF OPERATIONS below / / / / E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION (978) 688-9545 (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 "NA� - ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidems Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): d Address: tS(Q aLeC C.,0_ A!<? . t1�►,w?i'' i N City/State/Zip: & C2;l( c p(8 Phone#:—!7 9S(p 26—1-17JI T Are yo n employer?Check the appropriate box: _ 1. 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. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sh%et.t �• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers' comp.insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.]q ] .officers have exercised their 10.❑Electrical repairs or additions 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 12.E]Roof repairs insurance required.]t employees. [No workers' comp,insurance required.] 13.0 Other Any applicant that checks box#1 must also fill 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:C ���S Policy#or Self-ins.Lie. Expiration Date:_/.211-1 Job Site Address:_1% 1Nr91r�1 5''1' City/State/Zip:&,4r\J, ...MA 011 rAttach 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 certlif under theP P ains and enalties o f perjury that the information provided above is true and correct. Si nature: j?/l Date: Phone#: G]`�9 C„X70�- 1/`7�I� 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): I.Board of Health 2.Building Department 3.City/Town Clerk 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 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 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-contractor(s)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/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 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: The COMr onwealtii,ori Massachusetts Department of Industrial Accidents Office of Investigations 400 Washington Street Boston,MA 02111 Tel 4 617.-727-4900 ext 406 or 1-877-MASSAEE Revised 5-26-05 Fax#617,727-7749 www.mass.gov/dia