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HomeMy WebLinkAboutBuilding Permit #756-2017 - 202 MARBLERIDGE ROAD 2/1/2017ITOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 7z-- 'Po / 7 Date Received / a�G Date Issued: IMPORTANT: Appli must complete all items on this TYPE OF IMPROVEMENT PROPOSED USE Ca i��/� Phone �_ "� a __ ��1 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 MSORPc � Welly Flootlplain Wetlandsl = J t �� Watersh Distnb �tWater/Sewe[aY�$... DESCRIPTION OF WORK TO BE PERFORMtu: C U7- T)m0 � © CEAlIfV r:r- Fel0M f< 17CI-EtJ `.mac? flIWIrUGr Identification Please OWNER: Name: or Print Clearly) A,4,4roon- IA / go a K I go /=r'.0A Ct:::- dlJ'q—4ei%P MA M i i'.• .r�trr. "z'+Mlb '1 ��r"a �7t"�i4 '� Y�'s" +. GEF ^y4.� � .(�'4i�`t. r � r rL�"f '.:r... - '' �� 4��.rw J � Yi. '.: rt[A-.rw�w� Fi©u:s.- CO HIRACTOR Nam;'e (� S.J Ca i��/� Phone �_ "� a __ ��1 Supervis_ or;s Con_ structionlliti —e e Hor a I`m�menfI Li nse ARCHITECT/ENGINEER Address: Phone: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ ��, Oct FEE: $ Check No.:Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund .signature of �4gent/.Qwner :; .. Sig nature of:.confiracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stam d Plans ❑ Building Department Tine fol[owing is a list of the required forms to be filled out for the appropriate permit to be obtained. woofing, Siding, Interior Rehabilitation Permits ❑ Btailding 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 MOTE: 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 MOTE: 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 ❑ 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 TOTE: 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 apr)-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be- submAted with the building application Doc: Doc.Buiiding permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ FA 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 PLANNING & DEVELOPMENT ❑ DATE APPROVED .❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zo�iring Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments e 1' x- onservation Decisi Comments Water & Sewer Connection/Signature � Date Driveway Permit DPW To-*v;Engineer: Signature: Located 384 Osaood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at -124 Mair., Street Fire Departmerit 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 Ll Notified for pickup - Date Doe.Building Permit Revised 2010 t Location 0 � ym M; 3�� 14 E �4 i � � No 7s6,• 2-017 Date r a�17 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check #� ' 3 1 14 C $ I /Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 15,000.00 m $ - $ 180.00 Plumbing Fee $ 22.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 22.50 Total fees collected $ 325.00 202 Marbleridge Road 756-2017 on 2/2/17 kitchen reno Z CD O C r CL �. n c0 � O 0 O v CDC c� CD O � CDo CL o S' = cc CD CD O Lwk 0 n' y 0 CD CD CD U) CD cn v z r� CD O CD r v z 0 = " v _ r N x N5.lD cn X0'1 CD n C � n � 0 S S.0 N O fA rt CD" C T O O �-� CL m oo0�v 0cn CD CL 0) m - D 0 CD -i caCLv N 0 O v•r 0 CD -0 : A 0 <CO 1 OOSN S :« N D =« D �D F. v 0 0r.C N O — < y �wIDCD CL 03 2 p Z as D U) �o O cc 11 CD C cn `° � Z n N 0 S O 0 t 0 d y 0 Ln c W T Z7 TV7 ::a ic A T n N- T N T 0 M O Z 7 O Cl) S. a O' �m Ei' S O O ncn 0— (D O O o � z cu< = ° °—' cn (D r v z 0 = " v _ r N x N5.lD cn X0'1 CD n C � n � 0 S S.0 N O fA rt CD" C T O O �-� CL m oo0�v 0cn CD CL 0) m - D 0 CD -i caCLv N 0 O v•r 0 CD -0 : A 0 <CO 1 OOSN S :« N D =« D �D F. v 0 0r.C N O — < y �wIDCD CL 03 2 p Z as D U) �o O cc 11 CD C cn `° � Z n N 0 S O 0 t 0 d y 0 Ln N W T Z7 TV7 ::a T A T n A T N T 3 O 7 O S. O0 O' O Ei' S O O (D O O cu< = ° °—' (D we opo a Q (D z S 3 S N \ CD rD V) T. O 'G •"' .0 N re' A m V Cl) N 7° W v v z y z z v m G) Ln r O A LA H m m O m m m > 0 0 2 Grasso Construction Co., Inc. General Contractors -Developers January 30, 2017 Paul Pollano 202 Marbleridge Road No. Andover, MA 01845 PROPOSAL 865 Turnpike Street (Rte. 114) North Andover, MA 01845 Tel (978) 688-8895 Fax (978) 685-0049 We propose to furnish Labor & Material at above address to include the following . 1. Remove existing kitchen cabinets 2. Install new kitchen cabinets (labor only — cabinets by owner) 3. Cut door opening from kitchen to dining room 4. Refinish hardwood floors 5. Paint walls & trim Total Labor & Material $15,000.00 Note: Kitchen plumbing fixtures and appliances by owner GRASSO CONSTRUCTION CO„ INC. //,)J - John ss President JG:sg ed by: Po an Date: 3 ACORO® CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDnrrv) 02/01/2017 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: Diane Kulick PNC.N Extia (781) 792-3238 alC No: HUB INTERNATIONAL NEW ENGLAND LLC hubinternational.com ADDRESS: diane-kulick@hubinternational.com INSURERS AFFORDING COVERAGE NAIC1t 600 LONGWATER DRIVE INSURER A: LM INS CORP 33600 NORWELL MA 02061 INSURED INSURER B : INSURERC: GRASSO CONSTRUCTION CO INC INSURER D: INSURER E 865 TURNPIKE ST INSURERF: NORTH ANDOVER MA 01845 .COVERAGES CERTIFICATE NUMBER: 123564 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 MAYBE 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. ICYEXP LT R LTR TYPE OF INSURANCE ADDL SWVD UBR POLICY NUMBER MMIIDDDY/YYYY MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE F OCCUR DA AGE ToRENTEU PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO - LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ PROPERTYaccident NON-OWNED HIRED AUTOS AUTOS $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A — DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? I NIA1 (Mandatory In NH) NIA NIA WC531S382148016 09/30/2016 09/30/2017 X STATUTE EERH E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 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 St AUTHORIZED REPRESENTATIVE No Andover MA 01845 Daniel M Cr y, CPCU, Vice President — Residual Market — WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massa. chusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeZibly Name (Business/Organization/Individual): Address: /g/L/3&/V7 , t�t�ld City/State/Zip: /) D r ND 0 (a f ,� � Phone #: Q % Are u an employer? Check the appropriate box: Type of project (required): 1.y am.a employer with employees (full and/or part-time).* 7. F1 New construction 2.F] I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 Building addition 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. E] Plumbing repairs or additions 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Roof repairs These sub -contractors have employees and have workers' comp. instuanceJ p 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152, §1(4), and we have no. employees. [No workers' comp. insurance required.] *Any applicant that checks box 41 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. tContractors 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: r i Policy # or Self -ins. Lie. #: iAi G -_3 �J(nExpiration Job Site Address: City/State/Zip: Afi , &A)- (% a� M pJ 0) ` Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify Wer the pains and penalties of perjury that the information provided above is true and correct. 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 #: 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 1 1/31/2017 22:23 FAX 978 685 0049 GRASSO CONST Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -022988 Construction Supervisor JOHN GRASSO 865 TURNPIKE SIR NORTH ANDOVSA zz'7 CA— Expi ration: Commissioner 10131/2017 (-_,7/�' t . , * ( * 0/b Office of Consumer Afralra & Business Regulation �FIOME IMPROVEMENT CONTRACTOR 09IStration: 113130 Type: Expiration: 5/18/2017 Private Corporation GRASSO CONSTRUCTION CO., INC. JOHN GRASSO 865 TURNPIKE ST N. ANDOVER, MA 01845 Undersecretary � 001