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Home My WebLink AboutBuilding Permit #Exception - 202 LACY STREET 5/1/2018 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 PrinC,4, 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: .Historic District yes no r 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 ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ ` TYPE-OF-.SEWERAGE Sewer ❑ Swimming Pools El Well ❑ 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 � III HEALTH Reviewed on Siqnature 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'Tows Engineer: Signature: Located 384 Osgood Street 'EIRE=DEPARTME`-N -Temp Dump'ster on site yes.. . no Located"at 124 Mair; Street Fire Departinerat_signatu'r`e/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 ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department .—The following is a list of the required forms to be filled out for the appropriate.permit to.be obtained. Roofivg, 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/Crossection/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 (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ 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 apw al 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.Bufiding Permit Revised 2012 r , NORTH - ve' . No. _ * VOWPIyy . - I T Z y h , ver, Mass, 2 COCHICHIWICK y1. +,A AERATED Pkfp y S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ................ ..... �!!�,. ....... .�. ��!'`................................ BUILDING INSPECTOR has permission to erect . buildings on a c Foundation Rough dEmomfto to be occupied as ..................... %4WT.......... ................... ..... ..................................... Chimney provided that the person acceptin 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 CONSTRUCT S RTS Rough 3 ' 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 Massachusetts-Jeoar;ment of°ubtic vafety Board of Building Regulations and Standards License:CSSL-099217: Se WARREN N w OOERBEEK 4 I.AM50N[.ANTI: NAMPTOIV NH 53842 cx_pirati.on C�snsnissioner 09/03/2015 - ✓fie TG i74�d401G/QAtiLlL o�c/z CX 6Oifice ofConsumer Affairs gcBosiaess ttegnlaRon }4 }IOMEIMPROVEMENT CONTRACTOR N. i Re9 >rat�on X30052 : Type Exp7ration X1,2121/20 3 ` Supplement Ci HOME&HEARTY i WARREN WOLTERBEEiC . 102-LAFAYETTE RD /1 HAMPTONFALLS,NHfl3844 — ._ Undersecreta , ry ,` l�°� CERTIFICATE OF LIABILITY INSURANCE D/19/M'DD13 9�1�9�2013 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(les)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 kNAJERCTRobert BeanBean Insurance Agency LLC NE (603}926-3830FAx (6os)vxs-ozea 151 Winnacunnet Road AIL s bob@beaninsurance.com P.O. BOX 66O INSURERISI AFFORDING COVERAGE NAIC e Hampton NH 03843-0660 INSURERA:OhiO Security Ins Co 4082 INSURED NISURERB:The Ohio Casualty Ins Co X24074 Home & Hearth Conservation Inc. INSURERC:WeSC0 Insurance Company 102 Lafaytte Rd INSURER D: INSURER E Hampton Falls NH 03844 INSURER F: COVERAGES CERTIFICATE NUMBER-2013-2014 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, EXCLUSIONSAND CONDITIONS OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIILDICCLAIpMS. LTR I R I TYPE OF INSURANCE vivp POLICY NUMBER kRailp: Alri,ppYyyyy LIMITS GENERAL LIABILITY ( - X COMMERCIAL GENERALLIABIDTY t DACMAGE HOC oRRENC ENTE $ 1,000,000 c $ 300,000 A CLAIMS-MADE 7 OCCUR OKS55508551 /23/2013 /23/2014 MED EXP(Anyone person) $ 15,000 PERSONAL&ADV INJURY $ 1,000:000 IGENERAL AGO REOATE $. 2.000,000 GEN'LAOOREGATELIMITAPPUESPER: PRODUCTS-COMPlOPA00 $ '2,000.000 POLICY PRO- F LOC 1 $ AUTC940611-E LIABILITY _j ( 1 COMBINED SINGLE LIMIT 1,000,000 ANY AUTO A � BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AS55508551 /23/2013 /23/2014 — AUTOS AUrOs BODILY $ Ix HIREDAUTOS '+� NON-OWNED PROPERTY it)DAMAGE AUTOS $ Pergccida Medicalpa ments $ 5.000 EXCES X LLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 XCESS LIAB CLAIMS-MADE AOOREOATE $ 1,000,000 D D '..{ ETE .ION$ .. 10,00 5055508551 /23/2013 /23/2014 $ C WORNERScomPENSATiON } ( WC STATU• TH 0 - AND EMPLOYERS'LIABILITY Y:N I j ANY PROPRIETORIPARTNERIDGE0UTIVE OFFICERAMEMBER EXCLUDED? N:A i E.L EACHACCIDENT $ 1.000.000 Irrt:LldltolyIll r01) -3058474 /23/2013 4/23/2014 E.L.DISEASE-EA EMPLOYE $ 1.000.000 If es,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICYLIMIT $- 1.000,000 DESCRIPTk:rN OF OPERATIONS;LOCATIONS r VEHICLES(Attidi ACORD 101.AtI tiatiN Remvks Sclrednie.U more space is re(puired) RE: Robert Dickinson 202 'Lacy Street, North Andover, 14A 01845 4;Y 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, IIA 01845 AUTHORIZED REPRESENTATIVE I -- Robert Bean OR ACD 25(2010!05) 1988-2010 ACORD CORPORATION. All rights reserved. IRLSD25 nm nm m Tho 6(l1 p15 nom.enrl Innn erc rn nic4nr A roer4c of Af r1p11 i i o13 Store: 1 Sales Order#949 Store: Ordered: 8/24/2013 Associate: Bob Home& Hearth, Inc Page 1 102 Lafayette Road Hampton Falls, NH 03844 (603)926-2084 homehearth@comcast.net Bill To: robert dickinson 202 lacy st north andover, ma 01845 978-973-4109 Order Status: Open Item Name Attribute Size Qty Sold Due Price Ext Price Tax 1-70-774235-1 P351 IN BLK/23.5"I- 1 0 1 $2,899.00 $2,899.00 N Serial# 008655055 STOVE INSTALL 1 0 1 $450.00 $450.00 N DISCOUNT #P96b814a913G823 1 0 1 ($100.00) ($100.00) N DISCOUNT 10% 1 0 1 ($289.90) ($289.90) N v wood pellets 1 TON 0_ 1 $279.00 $279.00 N Total Qty Ordered: 5 0 5 Percent Unfilled: 100 --....-_......................_ — Deposit History Subtotal: $3,238.10 Cashier: Date Receipt#_ Amount Payment NH 0%Tax: +$0.00 8/24/2013 5238 $500.00 Credit Card TOTAL: $3,238.10 Deposit Balance: $500.00 Balance Due: $2,738.10 Thank you for your order! I i i i l _ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 4 T, 600 Washington Street ^=' ` Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aualicant Information (� Please Print LeMy Name(Business organizationandividual):_ bne 14442 t7 _Zjl�(j� Address: City/State/Zip: MAUi 0 01YY Phone#: (P03" 996 -Ag N Are ou an employer?Check the appropriate box: Type of project(required): 1. I am a employer with r7 _ 4• ❑ I am a general contractor and I employees(full and/or parttime).* 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' [No workers'comp.insurance comp.insurance# 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.E3 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑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 �j employees. [No workers' 13.❑Other f AL551�ft comp.insurance required.] 11/ *Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information. I 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 subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the pglicy and job site information. Insurance Company Name: ___V eSC D Policy#or Self-ins.Lie.#:_ W 1N C 3�'g�j(7 y Expiration Date '" 23 Sob Site Address: 2e>2 �,1-Gy 5-r City/State/Zip: AaA, Aie w 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 ascivil 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. Ido herebycern under tliepains andpenaMes ofpedury that the information provided above is true and correct Si afore: Datr; q,lf.- .24), 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#: