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Home My WebLink AboutBuilding Permit #424 - 21 CLEVELAND STREET 12/1/2009 TOWN OF NORTH ANDOVER �24 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Al C __JPrint '� PROPERTY OWNER_& (ZPk I J� 1 L L C rint MAP NO: PARCEL: 'ZONiNG DISTRICT: Historic District yes no Machine Shop Village a y es 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 Sephell Floodplain Wetlands Watershed District titer/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ez-cz4 /I AC4"0- Tnn-vn Identification Please Type or Print Clearly) OWNER: Name: �-fi( Rey Phone: Address: r'Q -- -u1✓'L �, Ol��l CONTRACTOR Name: , ( Phone: (713 91_ = � j Address: .G tj0�L ,� i�L?' _ l 01Sp Supervisor's Construction Licenser q Exp. Date: -7 h) /Q.0 Home Improvement License: 1�r S� Exp. Date: 3t?J U 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: $ 1 aS, QOU FEE: $ Check No.: Gl -4 zi Receipt No.: f NOTE: Persons contracting with unregistered contractors do not have access to the gu r ry _ nd Signature of Agent/Owner Signature of contractor Location C�/ No. Date NaRTM TOWN OF NORTH ANDOVER + ; , Certificate of Occupancy $ Building/Frame Permit Fee $ /�yy fncMU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3031 2 2 6 / 1 Building Inspector Plans Submitted Plans Waived Certified Plot Plan 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 DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS r t 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 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) u 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 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 2008 NORTH Town of _: 4 over 0 No. L dower, Mass., l2 � - LAKE T = COCHICHEWICK �d ADRATED Alf S BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT � //,,'' BUILDING INSPECTOR ...............1%�...... ..................... ...... :.,.....G�..................................................................... Foundation has permission to erect........................................ buildings on .010(.....ClGi t-- /A11 .....-................... Rough to be occupied .....1!C�C. ..�� .-......1��Y '!!�✓ .�r.... ....��h- .....a-...! f ......... Chimney e provided that the person accepting this permit shall in every respect conform 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. S'G� Go,��...T PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final SOp PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS U N TS 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 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Timothy A. Giard Plumbing & Heating Inc. Estimate Name/Address Date Estimate# Abel Realty, llc 12/1/2009 1296 281 a Broadway Lawrence, MA 01841 Project Description Total RE: 21 - 23 Cleveland Street North Andover, Ma Timothy Giard Plumbing and Heating shall act as the general contractor to facilitate and over see contractor services for the above address. Rip and strip roof, replace with 35 year ark. shingles Insulate and apply new vinyl siding Replace 24 replacement windows to code replace 2 kitchens and 2 full bathrooms replace 2 furnaces , install 2 water heaters,place and update plumbing to both units to code. supply faucets , sinks, and fixtures. oversee sheet rock, painting and carpentry. Update electrical in both units. update electrical service to both units. All subcontractors shall have workman comp and general liability. As Quoted 125,000.00 Total $125,000.00 Signature P.O. Box 782, North Andover, MA 01845 Telephone (978)689-833 B o ff(1ffW&ijWfo t��tfa HOME IMPROVEMENT CONTRACTOR Registration: 153255 Expiration: 11/13/2010 Tr# 282222 Type: Individual TIMOTHY A GIARD TIMOTHY GIARD 60 SAUNDERS ST. - ,.,,� N ANDOVER,MA 01845 Administrator `lassachusetts- Department of Public Safer. Board of Buiidin- Re±-ul.ations and Standard. Construction Supervisor License License: CS 86299 Restricted to: 00 TIMOTHY A GIARD PO BOX 782 NO.ANDOVER, MA 01845 Expiration: 7/15/2011 (unnni,�iu+rer Tr#: 1722 From:Bonnie Welch FaXID:9784849343 Page 1 of 1 nate:Tuu[uwuur-Yr —,—w— CERTIFICATE R CERTIFICATE OF LIABILITY INSURANCE G I DATE(MMroomw) RT1 12/01/09 P O UCE THIS CERTIFICATE IS ISSUED ASTER O A MATF INFORMATION Francis Provencher Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 530 Rogers Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lowell MA 01852 Phone:978-459-8681 Fax:978-454-9343 INSURERS AFFORDING COVERAGE NAIC>f INSURED INSURERA: Merchants Insurance Group 23329 INSURER B: Timothy Giard Plumbing & INSURER C: Heating Inc. PO Box 782 INSURER D: N. Andover MA 01845 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTUK -P0LXV1TFECTW- R $ TYPE OF INSURANCE POLICY NUMBER DATE tMM>DD�'Y) DATE(MMIDDIYYYY) LIAT� GENERAL LIABILITY EACH OCCURRENCE $1000000 A X COMMERCIAL GENERAL LIABILITY CCP1030489 04/07/09 04/07/10 PREMISES(Eeoceurence) $50000 CLAIMS MADE I—XI OCCUR MED EXP(Any one person) $5000 PERSONAL 8 ADV INJURY $1000000 GENERAL AGGREGATE $2000000 GENLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 POLICY JE0. LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1000000 A ANY AUTO 0277014755 01/09/09 01/09/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ (Per person) X SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY $ (Per accident) X N014-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ALTO ONLY-EAACCIDENT $ ANY AUTO OTHER THAN EA ACC $ I AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR LICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPE SATION TORY LIMITS ER AND EMPLOYERS'LIABILITY Y/N A OFFICEOPRIETERERCLUDERE CLITIVE ® WCA9093654 06/19/09 06/19/10 E.L-EACHACCIDENT $500000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $SOOOOO If yes,describe under E.L.DISEASE-POLICY LIMIT $500000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS PLUMING CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of If. Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Building Dept. REPRESENTATIVES. Building 20, Suite 2-36 AUTHORIZED REPRE TIME 1600 Osgood St. Andover MA 01845 ACORD 25(2009/01) ®1988-2009 ACORD CORPORATION. Ali Tights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organiza6on/Individual): Address: City/State/Zip: (1. Phone#: Are u an employer?Check the appropriate box: Type of project(required): 1. I am a employer with Z') 4. ❑ I am a general contractor and I 6. F-1 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 1 7 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 131-1 Other comp.insurance required.] *Amy 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. lContractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: (�1 -a3 City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to s erage as required under Section 25A of L c. 152 can lead to the imposition of criminal penalties of a fine to$1,500.00 an one-year imprisonment,as a as ci ' penalties in the form of a STOP WORK ORDER and a fine rvestigations to$250.00 a day again the violator. Be ad 'sed that a co y of this statement may be forwarded to the Office of of the DIA fo ins ce co verificati b cerci r -pen s of per t the information provided above is true and correct. Si ture: Date: Phone#: Official use only. D, not write i t s 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'fur the permit or license is being requested,not+—'---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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should.you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-72.7-7749 Revised 5-26-05 www.mass.govfdia