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HomeMy WebLinkAboutBuilding Permit #353-12 - 209 BRIDGES LANE 10/21/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: 1 IMPORTANT: Applicant must complete all items on this page LOCATION �S��l GkN�G=ds� d- Pri t PROPERTY OWNER �b Unit# ` ,�� 6) Print MAP NO:/*,D PARCEL:��7 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure 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] (]F1'oodplauit Di Wetlandsi Di WatershedlDstrictf { D'Water`/Sewer ( DESCRIPTION OF W RK TO BE PERF D: -E- *QL 1 hevQ ►h�o ;�.tQ,son i (IdentifiCa 'on Please Type or Print Clearly) OWNER: Name: cV Phone 0 3� Address: �,--- ----------- --- CONTRACTOR Name: r7/v_JA;&,,1_ Phone: 903 S37 - Address: Supervisor's Construction License: Exp. Date: pZ57a., Home Improvement License: SM3 Exp. Date: ?b- -`W 4 3 ARCHITECT/ENGINEER . Phone: Address: Reg. No. i FEE SCHEDULE:BOLDING PERMIT.$12,00$/12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. FEE. $- (O Total Project Cost: $ T �� Check No.: Id2 3 Receipt No.: NOTE: Persons c retracting with unregistered contractors do not have access to th g ar my f red ,Signature of Agent/Ovvner v.v Signature_of contracto ,. Location 0 4 � No. Date 0�� TOWN OF NORTH ANDOVER M Certificate of Occupancy $ sACHUStt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ��✓ 24743 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools 0 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 I COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes F I 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 I COMMENTS i Dimension Stories: Total square feet of floor area, based on Exterior dimensions.__ Number of .----- Total land area, sq. ft.: Movement of Meter location, mast or service drop requires approval of ELECTRICAL: Yes No Electrical Inspector Yes No DANGER ZONE LITERATURE: MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use A i i t ❑ Notified for pickup - Date -------------- Doc:.Building Permit Revised 2011 June/mi ntracto . 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 NOTE: All dumpster permits require sign off from Fire Department p nt prror 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 a ❑ Floor/Crossection/Elevation Plan Of Proposed Work With S ' prinkler 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 Departmentrior to issuance nce 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 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 g Doc: Doc.Building permit Revised 2008mi i �liPJ1V11ViLr ,jw - __ ' I NORTIy Town oAndover ., 0 No. �s'3 _ . ci I 0 $�1e If o , over, Mass., Y 0 a LAKE k, COC HI CHEWICK V �d ORATED 7 S ♦ BOARD OF HEALTH Food/Kitchen PERM . IT T D Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT,........Iva►. .�,. ......... �.. t.Q. .. ...............•.................................................. Foundation has permission to erect...........:::.......................... buildings on ...ca ......... 1,!..1. . .. ........lMw�!......... Rough t0 b8.000ul1eaS......... .............. ....................................... ...... .... ...�.�.......... �.�. ..11114W.......................... himn Y C e provided that the person accepting this permit shall in every res ct con orm to the terms of the application on file in Final 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI S Rough .......................... ...... ..... ........................... ................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIREE_DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - Street No. Smoke Det. SEE REVERSE SIDE The Commons _ I L15 25 Indian Rock R-oad SALES ORDER _ Windham, NH 0.3087 SO-15890 ; 10/17/2011 Tel: 603-537-0555 Fa: 603-537-0556 (VIII IIII VIII VIII III I IIII IIII _customer Contact j f Ship To Nancy DiBlasio Nancy DiBlasio ! 209 Bridges Lane p N ANDOVER—MA-01845 UNITED STATES Tel: (617)504-8931 J ? �, ��c: S E �LEAN FAcC Account Terms Due Date Account Rep Schedule Schedule Date 6175048931 Cash 10/17/2011 Casey Bergin'li;'i i `, 10/17/2011 Quotation PO # Reference Ship VIA Page Printed SQ-17744 Company Delive. . . 1 10/17/2011 11:39:12 AM LlItem _TDescription Order' Ship Price! UM Discount Amount 1 JOT351310 C550 FIREBOX w/Surr, Wood - Mat e 1 $3,019.00! EA $3,019.00 IBlk 2 LAB25Note Install Wood Insert w/Full Line1'. $0.00EA j so.m 3!ZFXZFLKIT625NT !Liner Kit, SS No T - 6x251! $724.73'. EA $724.73 j !(20ILKTX I) 4IBKPB690 'Pipe, 6x90 Adj Elbow - Blk 24GA $11.50 !BM0014 j 51ROC61)P Damper Plate 6" 1 $44.95 EA 549.95 6LAB02 Labor - Install 1! $650.00! EA s650.00 71i These parts represent a typical iinstallition, however other parts ! may be required or substituted at i***thei time of installation /� ^. � i**'`*IT IS THE CUSTOMER'S ',//1 W RESPONSIBILITY TO CHECK WITH THEIR !TOWN ON THE REQUIREMENTS FOR A ��� - :PERMIT. ANY FEES FOR PERMITS AND 'PROCESSING WILL BE ADDED TO THE $ BALANCE DUE.**** Bldbriote ********NOTE********** 1 \M I $0.00 EA -_ $O.Oo�'l/ 9i ;These parts represent a typical }, installation; however other parts :may be required or substituted at the time of installation. 10 PermitFee Permit & Processing Feel $125.00, EA $125.00. 11,Delivery jDelivery _ 1: $1 , EA $175.00; 12 !Our Store Policies are located on th ck of tvhi 7 Tax Details T e $3,9_5.1e idocument In order for us to improve as a company, SUPT $0.000 p p y, your feedback MAss s1�A - 2 $295.324 !is critical. Please take a few moments to fill out lour survey on line @ www.stoveshoppe.com jTotal Tax $295.32' Thank You for your business! ! (Exempt $825.00 Payment Details Total $4,995.50 10/17/11 M XXXXXXXXXXXX5197 .$2,500.00 ! ! Paid $2,500.00 Balance $2,495.50 X Dep.Avail $2,500.00! I The Commonwealth ofMassachusetts Department oflndustrial.4ccidents Office oflnvestigations 600 Washington Street Boston,MA 02111 yY _ www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A licant Information Please Print Legib] Name(Business/Organization/Individual): r— f Address: -� City/State/Zip: (�Q , T ,(�1,� one 0 �j [EII (onn employer?Check the appropriate box: a em to er with 4. Type of project(required): P y ❑ Iam a general contractor and Iloyees(full and/or part-time).* have hired the sub-contractors6 ❑New construction a sole proprietor or partner- listed on the attached shget. # 7• ❑Remodeling and have no employees These sub-contractors haveing for me in any capacity. workers'comp.insurance. 8' ❑Demolition orkers com .insurance 5. 9. ❑Building addition p ❑ We are a corporation and itsred.] officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.(]Plumbing repairs or additions lf. [No workers' comp. c. 152, §1(4),and we have no ance required.]fi employees. 12.[]Roof repairs [No workers wo r� wp,�N comp,insurance required.] 13.�Other bkQ4 '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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie. ,, Expiration Date: (U;r_o7(D_ Job Site Address:_ow r,9&14�r lane City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expir tion 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 ed that a copy of this statement may be forwarded to the Office of Cnvestigations of the DIA for insurance c erage ve file r do hereb ce v fy nd the / a d pen es perjury that the information provided above is true and correct. li nature: ,iyv✓ Date: Q/ A hone 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: __ i A` oAipM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) j 01/03/2011 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. 'ORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to 'arms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the c�rtiticate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Lakeside Insurance Agency, Inc. ac°NoEXt, 603.432.3666 aAXx:603.432.6076 Three Wall Street E-MAIL ss: Windham, NH 03087 PRODUCER CUSTOMER to INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Acadia Insurance 31325 Fences Unlimited, Inc. , Mis-Bec of NH INSURER B: DBA The Stove Shoppe INSURER C: The Commons INSURER D: 25 Indian Rock Road, Route 111 INSURER E: Windham, NH 03087 INSURER F; COVERAGES CERTIFICATE NUMBER: 2011 Fences/Stove Shoppe 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 ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DDNYYY MM/DD/YYYY LIMITS GENERAL LIABILITY CPA0311123 01/01/2011 01/01/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED j PREMISE Ea occurrence $ 250,000 CLAIMS-MADE a OCCUR MED EXP(Anyone person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRa LOC $ AUTOMOBILE LIABILITY CAA031112 01/0112011 01/01/2012 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ '—J SCHEDULED AUTOS _- PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OW NED AUTOS $ $ UMBRELLA LIAB X OCCUR CUA031112510 01/01/2011 01/01/2012 EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DEDUCTIBLE $ X RETENTION $ $ WORKERS COMPENSATION WCA031112610 01/01/2011 61/01/2012 X I TORY L MIU O R AND EMPLOYERS'LIABILITY Y/N ANY A OFFICER/MEMBER/PARTNEREXC UDED?/EXECUTIVE N/A E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 UMyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 7i DESCRIPTION 0 OPERATIOP(S/LOCq�(QNS/VEHICLES jAtfac ACORD 101,A41tional Remarks Schedule,jj nar spate�is required) overing ence, insta Iation an ogler retai operations or tie trle named insured. WC statutory overage is provided for New Hampshire and Massachusetts. No Executive Officers are excluded from overage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (I FOR INFORMATION ONLY Edwin Duvall/PAULI UD ©1988-2009 ACORD CORPORATION. All rights reserved. 25(2009/09) The ACORD name and logo are registered marks of ACORD ACORP,, AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Lakeside Insurance Agency, Inc. Fences Unlimited, Inc. , Mis-Bec of NH P ^:NUMBER The Commons ( j 1 25 Indian Rock Road, Route 111 CARRIER NAIC CODE Windham, NH 03087 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: ACORD Certificate of Liability Insurance Garage Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS AUTO ONLY•EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ Automobile Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) A Excess/Umbrella Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS A $ 0 Other Liability INSR POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY)EXPIRATION LIMITS ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. 0 The ACORD name and logo are registered marks of ACORD