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HomeMy WebLinkAboutBuilding Permit #163-15 - 197 VEST WAY 8/13/2014 i OORT11 BUILDING PERMIT ®, 3?0� ��eD X6.6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINAT 0 Permit NO: Date Received Q� Zo o Date Issued: U IMPORTANT:Applicant must complete all items on this page LOCATIONyz6t w41 �i Prin PROPERTY OWNER I`Civ l��') LD 'G y Print MAP NO: PARCEL: NZONING DISTRICT: Historic District yesno 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 VRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer TY) ilia 11 J141-1t S I�,f4r/J�c , P1,4hk /L�P_ W wry 0()w 4— /� floor Identification Please Type or Print Clearly) OWNER: Name: KC.Vi~h 60/t y Phone: 61? S�2 8 y� Address: '� L,,,'r CONTRACTOR Name: p Phone: Address: Supervisor's Construction License: Exp. Date: CS ©go?3 2 3 -.917- is Home Improvement License: C�3 Exp. Date: f —ad + 1 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. Total Project Cost: $ L3 FEE: Check No.: Receipt No.: c9 71-93 NOTE: Persons contractin with unre ister d contractors do not have access to the guaranty fund Signature of Agent/O ner A Ignature of contractor i Plans Submitted Plans Waived ❑ Cerl!ified 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 ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate — �y 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 Call Email Date Time Contact Name Doc.Building Permit 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 ❑ 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 ❑ Workers Comp Affidavit Two Sets of Building Plans (OnelTo Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance�Report j ❑ 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 I I Doc:Building Permit Revised 2014 I i I P . 1\1 roagal Page# of pages e1-e2 d,4/,-A# aA ,D rjoccl rn h Gl y3 �oti,(°ur0 /�r��� ntlp Proposal Submitted To: Job even lle Name Job# Iesfi N /k Address `/p � Job L tion PA A- A' t_A Date Date of Plans i�f Phone# r -{ e /Vf'� �'�ry J Fax Architect T 1 i"V We hereby submit specifications and estimates for: Ln L11 JI -_ _86010V6 e-X-i 51-i n . 5 J i nr Do m 11(15�0-11 PVC, �� tri Sta)) 6D C t°t- a-fn fee ar=ch l tt°� f _ n S r. S tick) C/ ovin �A 0 i c ode - We propose hereby to furnish material and labor—complete in accordance with.the-above specifications for the sum of: $ 4<21 7llars wi h payments to be made as follows: k�o 0S) � � 10)000 q�GY1 �Om 2if7.� p)t� ul T0)000 u)he.n hous6 5j( � f:S.i306 -,q p 0 n Icon')iq -r�Gn of jul) Any alteration or deviation from above specifications involving extra costs will be Respectfully �y 1 executed only upon written order, and will become an extra charge over and submitted T �" �"` / JV 6- above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. 21creptance. of Pr oga - _ f The above prices,specifications and conditions are satisfactory and are SignattF a ' hereby accepted.You are authorized to do the work as specified. Pa ments will be made as tlin { y ou ,dab ve. 1 Date of Acceptance ( � Signature —T� 9, NC3819. MADE IN MEXICO` - .. _6:_t�...a NORTH Town of _ s E : ., Andover No. h ver, Mass, A �� 2d A- QA coc"Ic„t-1cw V1 'Jie DRATED U BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT .........r.... .v.!. .`!:../ ....��. ............. ... ..,,,,,......,,........,,,...,,......,,,,. BUILDING INSPECTOR .. . . .... ..... . has permission to erect buildings on Foundation Rough to be occupied as ............ „ .....................sr s tip. .�r....1�..r;�:!. I ::;.. .. ✓.;.�.�`....��Ff.�.'. © ... Chimney Ch' provided that the person accepting-this permit sh I In every respect conform 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ........ .... ....... ... . ':�................................. F BUILDING INSPECTOR �- inal 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. { Massachusetts-Department of Public Safety �f Board of Building Regulations and Standards. Construction Supervisor License: CS-080738 _ = JAMES J GOGIJe 17 JOY TERRACE s METHUENMA 81&W_` i t %ii 0 Expiration Commissioner 03/27/2015 A Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 143178 Type: Private Corporation Expiration: 6/22/2016 Trl/ 254796 M + P SIDING , INC. PETER GAMACHE § 43 CONCORD RDf DRACUT, MA 01826 %Update Address and return card.Mark reason for change. - Address FRenewal Employment Lost Card SCA 1 0 20M-05/11 - - - �1ie�parrurraanrue�/t�a�C�/�crearcc/eurelh ; License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation gistration 143178 Type: xpiration: 6l22/2a16 Private Corporation 10 Park Plaza-Suite 5170 M+P SIDING, INC. i Boston,MA 02116 PETER GAMACHE 43 CONCORD RD DRACUT, MA 01826 Undersecretary Not valid without signature f' _ The Commonwealth of Massachusetts Print Form Department of Industrial Accidents ' Office of Investigations ' I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): P) / Address: L] 3 C-o h ire m to o f y.�4 City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.[] I am a employer with 4. ❑ I am a general contractor and I 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 sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. FJ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. J] We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.[] Other s,,a?,9 t- comp. insurance required.] 1-51"n ten, ti o ,,,f *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: i"� l'�y;41A 11wQ OC)---Xi 5—,r —.Idly 'I !S Policy#or Self-ins.Lic.#: 455'JJ' 'o Nsic Expiration Date: 3— Job Site Address: l [/eR- w14�' AVO iQ/►0--L& City/State/Zip: 01 2L/5— 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 certift under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date s L 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.Plumbing Inspector 6.Other Contact Person: Phone#: r M&PSIA OP ID: BC AC REP' DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/21/2014 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 Lisa Foster Sullivan Insurance NAME: 163 Main St. (PAHicD"N E,tt:978-686-2266 ac No):978-686-6410 North Andover,MA 07845 n D Michael J.Foster RESS:liariviere@fostersuilivangroup.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:SAFETY INDEMNITY INS CO 33618 INSURED M and P Siding,Inc. INSURER B:SAFETY INSURANCE COMPANY 39454 43 Concord Rd Dracut,MA 01826 INSURERC:A.I.M MUTUAL INS CO 33758 INSURER D: 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. INSR TYPE OF INSURANCE D UB POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD MMIDD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 B X COMMERCIAL GENERAL LIABILITY BMA0018997 03/16/2014 03/16/2015 DAMAGE PREMISES Ea occurrence $ 500,00 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 jECT F-1 X POLICY PRO_ RO LOC $ AUTOMOBILE LIABILITY (CEO, OEaMBINED accident SINGLE LIMIT , 1,000 OO $ A ANY AUTO 6222213 03116/2014 03116/2015 BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOSNON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,00 B EXCESS LIAB CLAIMS-MADE CM00001594 03/16/2014 0311612015 AGGREGATE $ 2,000,00 DED I X I RETENTION$ 10000 $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER C ANY PROPRIETOR/PARTNERIEXECUTIVE Y/" C ASSIGNED RISK 03/2012014 03120/2015 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) TO BE ISSUED BY CARRIER E.L.DISEASE-EA EMPLOYEd$ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if 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 Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Location No. A0 3 Date 3 A • • TOWN OF NORTH ANDOVER o - Certificate of Occupancy $ , .d Building/Frame Permit Fee $ rmm T, G Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# �! a Building Inspector