HomeMy WebLinkAboutBuilding Permit #364-2017 - 20 FULLER MEADOW ROAD 10/5/2016 V I q BUILDING PERMIT o NORTH `StLeo X67 tiO TOWN OF NORTH ANDOVER '. .° APPLICATION FOR PLAN EXAMINATION ° , Permit N0: Date Received �SSACHUS�� Date Issued: I J IMPORTANT: Applicant must complete all items on this page LOCATION 0 ���t 5IL l7)` Dow KC) PROPERTY OWNER ar,,-,d't;.0kee- Pr ~A Print MAP NO: PARCEL: /25-ZONING DISTRICT: Historic District yeno Machine Shop Village ye(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 Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Ple a Type or Print Clearly) OWNER: Name: r.' '►,rt Phone: Address: 4?0 P/lerJz Ax ve4,, CONTRACTOR Name: APS (lPhone: V7 61-Itl //f0 ,1�4Address: - �-� � u �� Supervisor's Construction License: 0� 19/t-1 Exp. Date: -713 1117 Home improvement License: ` � � Exp. Date: zzo 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: $ d i �00 FEE: $ Check No.: \k'lo Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access tote u r nd Signature of Agent/Owner Signature of contractor o . 4,?-, `An �Location r� t c c.�--.• No. 3 CoL. _2 G 0 Date U • • TOWN OF NORTH ANDOVER 6 � Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# i 1 V y 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 4 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 FIRE DEPARTMENT - Temp Dumpster on site yes no 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.$100-$1000 fine NOTES and DATA— For department use I ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 Li Building Permit Application o 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ 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) ❑ 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 Li 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 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 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:INSPECTIONAL SERVICES DEPARTMENTMIZORM07 Revised 2.2008 r 1 - - i NORTH .q - ve" 'o 0 hver Mass 0 26 use, Coc"Ic"aw.c" y�. ��s R�TEO PPp��S U BOARD OF HEALTH Food/Kitchen PER I T� _T L D Septic System THIS CERTIFIES THAT6 BUILDING INSPECTOR ............ .... ........ ....... ...... 1!!�S. .... ..... ......... . .. .... . .... .... .......... �% has permission to erect .............. W dings on �... Foundation ......... ..... .. ..!!!1..........-........ Rough to be occupied as .............. . ..... �........ ...mm ................................................................... Chimney . .. provided that the person accepting this permit shall 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU STAR Rough Service ....... .. .......�.. ... ......... ........................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinm 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. Ir , NORTH - _ . w: .. . . _ _ _ O No. - h ver, Mass 0-o6e- 15, �� o > C0 C"1C"2WKK y1. ^Teo U BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THATBUILDING INSPECTOR .....Mho....- .... ........ ....... ...... i!�!S. ...... ..... ......... . .. .... . .... .... ........... has permission to erect .............. bu' dings on O... Foundation ........ ..... .. ..!!!1.........-........ p /� M� Rough t0be occupied as .............. ..... �.+.......... ................. .. ..................................................................... Chimney provided that the person accepting this permit shall 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRSTAR Rough ..... .7. .. ... ........ ........................... Service ' Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinje 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. Date: �G 3 /( M C�,��' ,(�-- a ; sus RALPH J. BURKE A Family Business Since 1941 Roormg Gutters Rubber Roofmg DANIEL M.BURKE 781-249-7110C 617-640-111-OC RALPH J.BURKE,JR. TELEPHONE 781-245-1110 office FULLY INSURED-LICENSED 27 BYRON STREET,WAKEFIELD,MA 01880 Estimated price for labor and material to: Remove all roof shingles Replace rotted/broken roof boards up to 100,square feet Re-nail loose boards Install aluminum drip edge 6 feet of ice and water barrier CERTAINTEED Synthetic roof underlayment CERTAINTEED LANDMARK ARCHITECTURAL shingles, hand nailed Reflash all vent pipes and chimney Remoye.all roofing debris from the yard q Total cost All workmanship guaranteed twenty years. Please remove or cover all items in attic,as dust and roof particles may settle on attic floor.. Thank you Af NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 115 S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: (3un-Kc koo; Twck, — P tjns);P-- f,7 l 46Pb4�l/ /YID (Location of Facility) /////W/z /Sinatu �of Permit Applicant Date The Commonwealth of Massachusetts Pantourrl 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): ty9 I p� M Address: - pVgojy smr: Er City/State/Zip: Wlv�-tr--1,E/d to 0j FcJ Phone M 7k/ 1////0 Are you an employer?Check the appropriate box: Type of project(required): 1.[3 I am a emplo ith 4. ❑ I am a general contractor and I employees full an rpart-time). * have hired the sub-contractors 6. E]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' insurance.f 9. ❑Building addition comp.[No workers'comp. insurance required.] 5. ❑ We are a corporation and its 10.E]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 12SRoof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *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 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: PM-Q1,,7 2 d Z Ns u ILAWC e 0- 0 Policy#or Self-ins.Lic.#: R J_ Cal C 7%0 /,� Expiration Date: ~Z 0 T Job Site Address: d 0 FY P L q D"t) y2O City/State/Zip: A/ 01Qoovz'-C,Q 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 cern er e d penalties o er'u that the information provided above is true and correct. Si ature: D7— M ate Phone#: - I 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: -rom:Linda J Caruso FaxID:SALEM03 Date:10/3/2016 11:04:13 AM Pace:2 of 2 /•'1 RALPJBU-01 LCARUSO '`��Rte• CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYYY) 10/312016 1 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. i 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 PHONE781 Fax 445 Main Street Arc No au: 1 933.3100 Arc No):(781)933.9048 Woburn,MA 01801 EMAIL i ss: nsurance.services@salemfive.com a-MAI .INSURER(S)AFFORDING COVERAGE MAIC C INSURER A:Penn America Insurance INSURED INSURER B,Amguard Insurance Co Ralph J Burke Roofing Company,Inc. INSURER C: 27 Byron Street INSURER 0: Wakefield,MA 01880 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 POLICY EFF POLICY EXP LTR INSD NNO POLICY NUMBER MMlDDNYY MMrOOIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 500,000 CLAIMS-MADE [�OCCUR PAC7112031 05117/2016 05/1712017 PREMISES Ea=nce S 100,000 MED EXP(Any one person) S 5,000 PERSONAL 8 ADV INJURY S 500,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 1,000,000 X POLICY DECT F�LOC PRODUCTS-COMP/OP AGG S 1,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED 80DILY INJURY(Per accident S AUTOS AUTOS ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTOS Per accident S UMBRELLALiAB [ OCCUR EACH OCCURRENCE 5 EXCESS UAB i CLAIMS-MAOE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATIONP OTH• AND EMPLOYERS'LIABILITY YIN X R E STATUTE i ER B ANY PROPRIETORIPARTNERIEXECUTIVER2WC770313 0FFtCER/MEP.4BER EXCLUDED? rN_]N l A 06/20/2016 06/20/2017 E.L.EACH ACCIDENT S 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 100,000 If pes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB S 500,000 DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration _ . Registration: 107146 x Type: DBA ;;,_; r=• Expiration: 7/29/2018 Tr# 419291 RALPH J. BURKE ROOFING Ralph Burke 27 Byron St '� sub Wakefield, MA 01880 .• moi;,Fes_. ��''�/ Update Address and return card.Mark reason for change. SCA 1 % 2OM-05/11 Address 0 Renewal 0 Employment ❑ Lost Card C��e W01)".nzu-N1roetl.1/11.o�C�/j/l�actear�udel Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration ;; 07146 Type: Office of Consumer Affairs and Business Regulation Expiration!-- 7129/209.8 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 RALPH J.BURKE ROOFING Ralph Burke 27 Byron St -- Wakefield,MA 01880 Undersecretary Not valid without signature Massachusetts-Department of Public Safety —Board of Building Regulations a Standards :_3)1:1!7 Lliil1171 Jt.'11:;I 13.ltil J11t..ii77L: License:CSSL-099814 47 RA-UHJBURU L 54 PADDOCK LAM.-!' DRACUT AIA 01$26}' z J y� pry .�nttt Expiration Commissioner 0710312017