HomeMy WebLinkAboutBuilding Permit #487-12 - 204 COVENTRY LANE 12/16/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: A°1 1''- 11
nRTANT: Annlicant must comblete all items on this page
LOCATION OLQq CO V LAnlr Ait &i!t� 0f a_k57
Print
PROPERTY OWNER �l2 DE?T - boHe 2 77)�
Print
MAP NO: It) V PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
11 Addition
El Two or more family
❑Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ De_molition❑
® Se :tic {01We11 "
Other
{Floodplain - {�\W..,e-C ifs,
0,`Watershed District
LO
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Typ"r Print Clearly)
OWNER: Name:
Address: �-y� �O1� nl 7 -le LAly - /i/, AA11%VES d /2 VS
CONTRACTOR Name: (go �> 5 (, 641e44,W6 Phone: c��-er11G-7/GO
Address: d_9 ieoMll kib W, 01525
`7100
Supervisor's Construction License: �j a -Q-- Exp. Date: // �I h 1.3
Home Improvement License: (D Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: 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: —FEE: $
Check No.: 2 62 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fl[nd
-
�innati irr�: of=AciPnt/Ovunerz a . —
Location _
No. C 12— Date
MORTh TOWN OF NORTH ANDOVER
9
o ; ; Certificate of Occupancy $
sCMUs <� Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
3
Check # �l
24894 / Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/MassageBody 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
PLANNING & DEVELOPMENT
COMMEN
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
K
DATE APPROVED
0
Reviewed on Signature
Reviewed on Signature
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
® 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
❑ 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 f
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
t1hat 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: Doc.Building Permit Revised 2008mi
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next step, living
frame effloienry, made easy
This agreement Is made and among
HainaAatte Malty
204 Coventry La
North Andover, MA 01845.2132
Customer IDI COOMOD28300
Site IDs 800002018488
Next Step Lwin$, Inc. ('NSL')
26 DrydockAvenue B« floor
Boston, NA 02210
contract ID: 2011110A W01tK
q,• 2g%rIPTKMIOFWORK TO BE PERFORMED
NSL vAl perform orcause lobe pedomhed the Wowir g work on the customers address above. Ina professional manner end In sowdenoe vAth the ierms of
this Contract, including the attached reoommendaknsMorkordor descrlbfog the work in dotal (the'Worit) wgtck are incorporated herein by reference:
Description
Quantity
Location
•_ Propavent 2' or 4',--•--•--•-••---•--•......_....__.,..._-----
----_._...__._........_ 101..._._.
AS41o.....,:_...._........__._..._._._._......_._.____..._..._..
$847.4 ._
Vent bath fan to roof flapper
2
Attla
r�432'2a -
,. __,_
___.„�--
ttloFtoorOen8lawCetiufosa4°___._,.,.
4872
_ ..............._._._._._..._w.- ..____
Lwin ._.._._._._____.._
_ 0 p
2 208.96 ,_
_Q _
tub Totai:
$2,828.77
Energy Efficiency Incentive
$2,000.00
Not Sates Tax After Incentive
$0.00
Total
$626.7?
I. CUSTOMER affirms that they have received no incentives during the peat 42 months. initial here.
2. The Incentive Is dependent upon the package purchased and/or prior Incentive utitizallon• Changs ndivl ual [Ins
tame artdlar
previous incentives may increase or decreses the size of the incentive.
3. CUSTOM&R atArma that their electric provider Is National Grid Electric. initial here,
printed: 111412011 Page 2 of 2
2, PAYMENT: CUSTOMER agreestopay NSL forthewotkeafofldwa:
Payment #I: $— yr
-Credit Card orE•ohsckdeposit Isdue atlhetimethe Work Issoblidtlia¢ Required paymentinformationwAbeadilseledovarthe phone byacustomer seNice
repreaer+tatvsaitkatmeotachadu9rhg, DeposltIsnot toexceed 113ofthe total MWIooab. This contract is not Ineffect unlit Ibis deposit topaid bythe
Customer. (Note; Mastercard, Viae, andD�isscoveraooepted)
Add! iohaiPayments and Flnal.tnvolce:$
-Addltonal payments for Ria Work shall be due upon completion of the Work.
Nov 8, 2011
».....
_ Cus rS n t' ._....».,..__.. ».»_..... Data...... ff
—t. M-1. - kr
NSL 3lgnetura Date Name of NSL Repreaerdet'we
The Terms of this Agreement ere contained on both sides of this page
Next Step Living 25IRydodk Avenue • 6fliW r a Boston, NW 02210 • (666) 867.8729 • bolr @nexistepiivinginacom • www.noxtslopTMn4Inc.odm
Document Integrity Verified EchoSign Transaction Number:
11/16/06: TITU 17:04 FAX 617 393 2915 _;,� -'eT; 16005
The Conamottwealth of Massachusetts•
Department.oflradasiriolAccideats
j Office of Xnnestigations
t r 606 l foshington Street
Boston MA 02!11
.. www.MWSS-gov/dna
Workers' Compensation Insurance Affidavit.- Builders/Contractors/Electricians/Plumbers
Analicant 1nfonnation Please Print kAly
N2Me (BusinmWOrganuation/lndividuW):
City/State%Izip: oma, }-o -r, VY\ c, Phone #: �.45 GG) 1
Are you an employer? Check the ap nate bort:
I . ❑ I am a employer with=
1 am a general ontiam. and D
4. Elc
employees (full and/65"M-0.0
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet =
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
(No workers' oomp. insurance
5. ❑ We are a corporation and its
requir d.)
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. (No. workers' comp;
c. 152, § 1(4), and we have no .
insurancecequired.] t
employees. [No workers'
comp. insurance required.)
Type of project (requhvd):
6. ❑ New oonsbucdon
7. ❑ Remodeling
S. ❑ Demolition
9. [] Building addition
10.❑ Electrical repairs or additions
I l .❑ Plumbing repairs or additions
12.❑ Roof repairs
111 Other Zr\5o �, i w.
'ADY grptieam that cheeks box N1 must also tli out die section bdow showing their workers' contpaaseWon policy information.
Y 1l60100waas who submit this affidavit indicating They are doing all work and thcn biro outside oon=ors must submit a new affidavir indicating such.
�>Mctors that checrr.this bort must a'atchrd an addiliooat sheet Showing rhe narue ofthe sub.emnaotors and their workers' comp, policy MFOMution.
I0m an mVloyer that is providing worke l eongrensa*n inarrrtvrrce for my anlployeec Betow is Ike policy mid job stie
infot"Idwon.
Insurance CompmW Name: r a. Lrn�t�v-a,n.; e
PoDiry # or Self -yrs. D.ic. #. 1 7 3 L -- - —Expiration Date: 11i y I zt 1 Z
.Dob Site Address:
City/Stare/Zp:
A tach a copy of the workers' comopensatdon policy declaration page (showing the policy number and ezniradon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal ptnmldes of a
&0 UP to $1:500.00 and/or one-year i mprisonmcnt, as well as civil penalties in the form of a S710P WORK ORDER and a fate
of up to 5250.00 a day against the violater Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the IIIA for insurance 4veraee :verification.
246 her*r r under the
Phone !i:
o perjerty Sha¢ the iraformadon provMed abode /a tare and come&
®B'l W rase only. Do nol write in this area, to be compldedby ch y or town oa dal
City or Town- 1Per®it/1L,icemse #
I<ssaingAudhorsty(c1nvle_one)•
�. Daaatd of Health Z. RuiMing Department 3. City/Town Cles$c 4. l achical Inspestnar S. Ftumbiog Inspector
G. Odietr
Conbe ]Pensee- _ - o
B®�®TCERTIFICATE INSURANCE
/�o1�f� �� LIABILITY
I N S U RAN C E. DATE (MM/DD"PRODUCER 11/29/2011
William Gallagher Associates THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Insurance Brokers, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
470 Atlantic Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Boston, MA 02210
I >URED
Next Step Living, Inc.
25 Drydock Avenue
5th Floor
Boston, MA 02210-2600
INSURERS AFFORDING COVERAGE NAIC #
INSURER A: One Beacon Insurance Company 21970
INSURER 8: A.I.M. Mutual Insurance Co. 33758
INSURER c: Riverport Insurance Company 36684
INSURER D: Hartford Fire Insurance Co. 19682
COVERAGES
IINSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT
OR OTHER
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE
NOTWITHSTANDING
DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS
BEEN REDUCED BY
N R DD'
PAID CLAIMS. AND CONDITIONS OF SUCH
_TR NSR TYPE OF INSURANCE POLICY NUMBER
A
POLICY EFFECTIVE POLICY EXPIRATION
DATE MM/DD/YYYY DATE
GENERAL LIABILITY
792000560
MM/DD LIMITS
11/11/2011
X COMMERCIAL GENERAL LIABILITY
11/11/2012 EACH OCCURRENCE $1000000
CLAIMS MADE ®OCCUR
PRMAGE II ES ER oecurr nce $1000000
MED EXP (Any one person) $10,000
PERSONAL & ADV INJURY $1 000 000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $2 000 000
POLICY JECOT LOC
PRODUCTS -COMP/OP AGG $10000 0
A AUTOMOBILE LIABILITY 390001209
11/11/2011 11!11/2012
ANY AUTO
COMBINED SINGLE LIMIT
ALL OWNED AUTOS
(Ea accident) $1,000,000
X SCHEDULED AUTOS
BODILY INJURY
X HIRED AUTOS
(Per person) $
X NON -OWNED AUTOS
BODILY INJURY
(Per accident) $
GARAGE LIABILITY
PROPERTY DAMAGE
Per accident) $
(
ANY AUTO
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
EXCESS / UMBRELLA LIABILITY 792000561
AUTO ONLY:
AGG $
11/11/2011
X OCCUR CLAIMS MADE
�
11/11/2012 EACH OCCURRENCE $3,000,000
AGGREGATE $3 000 000
DEDUCTIBLE
$
RETENTION $
$
WORKERS COMPENSATION AND 71733288
EMPLOYERS' LIABILITY
A
$
11/11/2011 11/11/2012 X WC STATU- OTH-
OFFINY PROPRIETOR/PARTNER/EXECUTIVE TBD106787
(ManCER/rMErMIBH) EXCLUDED?
Mandato
11/11/2011 11/11/2012
N
If
El, EACH H ACCIDENT $500,000
yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - EA EMPLOYEE $500,000
OTHER
E.L. DISEASE - POLICY LIMIT $500,000
Property 08UUMHX5485
11/11/2011 11/11/2012 $212,594
5CRIPTION OF OPERATIONS I LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/
SPECIAL PROVISIONS
RTIFICATE HOLDER
CANCELLATION
Evidence of Insurance
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _30_ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES,
AUTHORIZED REPRESENTATIVE
ORD 25 (2009/01) 1 of 2 #5239491/M239489
01§8b--2-00 CORD CORPORATION. All rights reserved.
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