HomeMy WebLinkAboutBuilding Permit #755-16 - 200 WAVERLY ROAD 12/22/2015� BUILDING PERMIT
Flr GIcX�d( TOWN OF NORTH ANDOVER
/�e APPLICATION FOR PLAN EXAMINATION
Permit NO: /` Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this paize
LOCATION
t0(f.-Lt6
PROPERTY OWNER,, R iL f Print
Print
MAP NO: 0/5' PARCEL:6b34rZONING DISTRICT: Historic District
Machine Shop
yes no
ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
I I New Building
One family
❑ Addition
❑ Two or more family
I I Industrial
Alteration
No. of units:
❑ Commercial
I I Repair, replacement
I I Assessory Bldg
I I Others:
❑ Demolition
❑ Other
I I Septic I I Well
I I Floodplain I I Wetlands
I I Watershed District
dWater/Sewer
Identification Please Type or Print Clearly) q'7 (3- 6 (o -,:2 -93'1 W c--
OWNER: Name: \1-1474G
Address: GCa t—J A%J f -r-1
ZMAM
oy O-V"-4ggo (::i --t I
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
f Or�'7o5 0 43 J26/
Home Improvement License: Exp. Date: %
-- n1J11lZ�f%
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLD/NG PERMIT: $1200 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.0 PER S.F.
ry
1 Total Project Cost: $0 0® FEE: $
1 Check No.:-- C-0 Receipt No.: 145
NOTE: Persons co frac 'ng with r gistered contractors do not have access to the g anty nd
Signature of Agen Ow _ _ ignature of contract
1 "
C
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage%Sody Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT Reviewed On Signature,
COMMENTS
t
t
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
A
WAter & Sewer Connection/Sicinature Date Driveway Permit
DPW Town Engineer: Signature:
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.$1oo-$1000 fine
Doc.Building Permit Revised 2014
FM-
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
OTE: 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
4, 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
TE: 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: Building Permit Revised 2014
Location
6Q9r
No. Date !�
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $.
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
29852 Building Inspector
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"Quality craftsmanship with a personal approach"'
J'APS17 J 8-judiddeurs's LLC
Muilders.craftsman@gmail.com
Jamie 978-857-4598
40 Pillsbury Rd.
Sandown, NH. 03873
DATE: 11/2/15
Job Name/Address: Jane Rici "i,-te-kIei
09 0 Waverly Rd.
North Andover
1-508-265-6440
Description: First Floor Bathroom
Price:
Enlarge first floor closet to allow for half bath. Connecting sink
and toilet to existing drain. Vanity supplied by owner (21").
Sink, toilet, and faucet supplied by owner
All rough plumbing, waste and supply included, to code.
Electrical to code, one outlet, ceiling light and heat combo.
Wall finish sheet rock take finished and primed, ready for paint
by others.
Floor vinyl
Start job
$3,000.00
Demo and framed
$2,000.00
Rough plumbing and electric
$2,000.00
Complete
$2,000.00
Total Cost
$9,000.00
We purpose to furnish materials and labor -complete in accordance with the above
specifications for the sum of: $9,000.00
Respectfully submitted by: J&j Builders
Any alteration or deviation from above specifications will become an extra charge
over and above the estimate. Extras will be executed only upon written order and
payment of 50-100% within 24 hrs. of agreement. Any unforeseen issues will be dealt
with accordingly between J&j Builders and client and will be performed to meet all
building code regulations. Any extras or delays from anyone outside contractor and/or
subcontractors will result in immediate change to timeline if given.
Note- this proposal may be withdrawn by us if not accepted within 30 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. Payments will be made as
outlined above.
/-q/A?'//S
Date
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name: martin provost
Location: 40 Pillsbury rd.
City Sandown NH Phone 978-857-4598
❑1 am a homeowner performing all work myself.
x= I am a sole proprietor and have no one working in any capacity
0 I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address City:
Phone #-
Insurance Co. Policy #
Company name: J&J Builders LLC
Address 40 Pillsbury Rd.
City: Sandown NH Phone #: 978-857-4598
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature martin
Date 12/22/15
Print name martin provost Phone # 978-857-4598
Official use only do not write in this area to be completed by city or town official'
❑ Check if immediate response is required Building Dept
❑Building Dept
❑ Licensing Board
Fl
FE]
Insurance Solutions Corporation - Page 1 of 1
✓ CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDNYYY)
12/23/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(los) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement- A statement on this certificate does not confer rights to the
certificate holder In Ileu of such endorsement(s).
PRODUCER
Insurance Solutions Corporation
60 Westville Rd
Plaistow NH 03865
Cynthia S t . Amand
PHONE (603) 382-4600 FAx . (do3)ae2-2oa4
ADORE , ,cstamand0isc-insurance.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER Merchants 23329
INSURED
Martin J Provost
dba J & J Builders Sandown NH LLC
40 Pillsbury Road
Sandown NH 03873-2703
INSURERBMM Insurance Company 15997
INSURER C Miberty Mutual AR — WC
INSURER DI
INSURERE:
INSURER F:
GUVtKAUl Ll I IFIGAI t NUMF3ER:1.;L7.7yLddJU tt$ REVISION NLII
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 MAYHAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCEAawk
AL)L)L
OU15R
POLICY NUMBER
POLICY EFF
MM/DOIYYYY
POLICY EXP
MM/DD/YYYY
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ® OCCUR
ODI0710S6
/20/2015
/20/2016
EACH OCCURRENCE $ 1,000,000
_
aoc$ 500,000
MED EXP (Any onePerson) 15 000
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $ 2,000,000
EN'L AGGREGATE LIMIT APPLIES PER:
7POLICY PRO LOC
PRODUCTS - COMP/OP AGG $ 2,000,000
$
H
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED X SCHEDULED
AUTOS AUTOS
X HIRED AUTOS X NON-OVVNED
AUTOS
KA, 0111319
2/5/2014
2/5/2017
COMBINED SINGLE LIMIT 500,000
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
PeracGdent
Uninsured motorist combined $ 500,000
UMBRELLALIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
AGGREGATE $
DED I I RETENTION III$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PRO FIR Y/N
R
OFFICER/MEMBER EXCLUDED? FY7N/A
(Mandatory In NH)
If�e e, describe under
DESCRIPTIONOFOPERATIONS below
5-319-610522-015
/7/2018
/7/2016
H-
E.L. EACH ACCIDENT 100,000
E.L. DISEASE- EA EMPLOYE $ 100,000
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If mere apace Is required)
The WC Policy does not provide coverage for Martin J_ Provost. 3A State! NH
(978)688-9542
North Andover Building Department
120 Main Street
N Andover, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DC CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL Bra DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
th Maglia/CLS -T �,._�- _.l✓ - I�= u��;.r ..J-
®1988-2010 ACORD CORPORATION. All rlsthts reeerved,
INS025 i n1f wol Tho arnR11 name and Innn aro ranl mark¢ of arnien
E3card of Building -Re u�
Copetrucri„Su 5 ations`and Standards
License_ Per'isor
CS -106705
MARTIN PROVOST
40 PILLS&may ROAD
Sandoycn 1Vg 03873
Commissioner Expiration
04/03/2016
'may' arrrueci /'r n n ,a,lcrr rcn clt
Office of Consumer Affairs & t3usiiiess Regulation
OME IMPROVEMENT CONTRACTOR
egistratlon: 174685
�r Expi anon 3/11/2017 Type:
Individual
.,MARTIN PROVOST
# . MARTIN PROVOST
40 PILLSBURY RD
SANDOWN; NH 03873 F� r
Undersecretary.