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HomeMy WebLinkAboutBuilding Permit #265-14 - 211 COVENTRY LANE 9/13/2013 NORTH BUILDING PERMIT 0�t`69o'6 ��°� TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Permit N,&, Date ReceivedToo �9SSACNUS���� Date Issued IMPORTANT:/Applicant must complete all items on this page LOCATION ' E Pnnt PROPERTY OWNER .,Print MAP NO PARCEL ZONING DISTRICT Historic District L yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ane family ❑ Addition ' ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial "epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic D Well ❑ Floodplain, Q Wetlands D.:.Watershed District ❑Water/Sewer , Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: _ CONTRACTOR Name: . Phonel:' IJ Address Supervisors Construction License , Exp date d� Home lm rovement License �" °I �r �' °� ;., Ex Date�li'' p p' x , i 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: $ I 0 FEE: $ 0��3 Check No.: Receipt No.: NOTE:. PersJlt&Wng wi nre ed contractors do not have adGtvrttAth d g aranty fund ignature of Ag t/en Owner a re`of contractor l` TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NUJ: Date Received F Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION - Print PROPERTY OWNER _ Print 100 Year Old Structure yes no MAP NO: _ PARCEL: ZONING DISTRICT: Historic District yes no 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 El 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: $ i Check No.�. Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund a r Signature of Agent/ caner Signature of contractor cal Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location C9 11 ' 6' No.( s DateL)1113 • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $cl523 — Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ Check# � Building Inspector Plans Submitted ❑ Plans Waived-E] Certified Plot Plan ❑ Stamped Plans ❑ -TYPE OF-:SFWERAGE.DiSPOSAL Public Sewer, ❑ Swimmin Pools Ely Tanning/MassageBody Art ❑. . g 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 DATEAPPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS i .CONSERVATION Reviewed on Signature COMMENTS i HEALTH Reviewed on Signature y COMMENTS i 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 Tow;2 Engineer: Signature: Located 384 Osgood Street FIRE DEP�4RTMENT - Temp Dumpster on site yes no Located at 124�Mair, Street.r - Fire Departmen-signature/date' :�< - t • - COM'M.ENTS I '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-$1000fine NOTES and DATA — For department use I ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department I The foliowing 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 u Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work t o 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 oWorkers 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) o Mass check Energy Compliance Report (If Applicable) Li 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) Ll Copy of Contract ❑ Mass check Energy Compliance Report o 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 submJted with the building application Doc: Doc.Building permit Revised 2012 . NORT1y Town Of E ndover 0 No. 'w�cw h q ver, Mass, Qlaos IS cocN�cne �F o �'A � S u BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT .r!!�..... .................. . . �a�r.. !! AS................................ BUILDING INSPECTOR ....... ................... Chas permission to erect buildings on . Foundation Rough to be occupied as '' . ...... ............... ....... ............I. . . . ......Wll�.!!M! ................................. Chimney ting this permit shall in ever provided that the person accepting 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ST S Rough Service ............... ... ................... ........... ................... Final ING 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 Wa-ll-To Be--Done — — -- FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE i The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):JL WHITE WOODWORKING INC. Address:108 KIILLAM HILL RD City/State/Zip:60XFORD MA 01921 Phone #:978-314-2447 Are you an employer?Check the appropriate box: Type of project(required): 1.21 I am a employer with 2 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E] New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [E Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' insurance. 9. ❑ Building addition comp.[No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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 employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must 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 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:Associated Industries of Massachusetts Mutual Insurance Company Policy#or Self-ins.Lic.#:AWC7024045012012 Expiration Date:12/12/13 Job Site Address:211 Coventry Lane City/State/Zip:North Andover MA 01819 Attach a copy of the Iworkers' 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 as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under he pains andpenalties o er'u that thein ormation provided above is true and correct. Si ature: . Date ©�Z3`�3 V11 �7 Phone#: �9—Y*7—9Sg'7 97f1 3/y-any� Official use only. iDo not write in this area,tocompleted by ci ry or town official t City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803 (800)876-2765 NCCI NO 26158 POLICY NO. I AWC 7024045012012 PRIOR NO. AWC 7024045012011 ITEM 1. The insured J L White Woodworking Inc Mail Address: 108 Killam Hill Road Boxford MA 01921 Street No. Town or City County State Zip Code FEIN xxxxx9707 ❑Individual []Partnership ®Corporation ❑Joint Venture ❑Association []Other Other workplaces not shown above: 2. The policy period is from 12/12/2012 to 12/12/2013 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. i The limits of our liability under Part Two are: Bodily Injury by Accident$ 100.000 each accident Bodily Injury by Disease $ 500.000 aolicy limit Bodily Injury by Disease $ 100.000 each employee C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsements and schedules:SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. All information required below is subject to verification.and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 039177 SEE E TENSION OF INFORMATIC N PAGE Minimum premium$ 483.00 Total Estimated Annual Premium $ 1,416.00 As indicated interim adjustments of premium shall be made: Deposit Premium $ 1,461.00 ® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg. $1,072.00 x 4.2000% n n $45.00 This policy,including all endorsements,is hereby countersigned by 11/21/2012 Authorized Signature Date GOV GOV 11 KIND PLACING CLAIM NAME SAFETY Circle Business Ins Agency Inc STATE CLASS AUDIT OFFICE OFFICE CHECK' GROUP 247 Newbury Street MA 5437 1 2 705 Danvers,MA 01923 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-082995 �.t..I i.v ,� b JEFFREY L WHIG C 108 i[QLLAM IiI 'L s Boxford MA 01911 Expiration Commissioner 10/18/2014 I i I J ^�/- KV Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Cor Registration Registration: 118096 Type: DBA Expiration: 1/30/2015 Tr# 235460 J.L. WHITE WOODWORKING INC. W JEFFREY WHITE + o 108 KILLAM RD a W BOXFORD, MA 011921 � w Update Address and return card.Mark reason for change. Address Renewal F] Employment Lost Card ;CA 1 Co 20M-05/11 1 J.L. White Woodworking Inc. 108 Killaxn Hill Rd., Boxford, MA 01921 978-887-9997 MACS #082995 H.I.C. Lic. 4118096 Fed. ID #04-3459707 Sales Agreement Page of � Date 7— J Customer Name PhonegV'�40 -1/5-0 Street Cit 9 nt L(k l �. y nl/y State zipC�f ` S/ Date work is scheduled to begin Date work will be substantially complete I Description of work to be done and materials to be used: I Remodeling estimate for exterior trim repairs and window installation at 211 Coventry Ln. Remove existing pine rake boards from left gable end of main house. Install new-Azek trim to be prepainted by homeowner. I Install 2 double hung windows in garage. Trim with Azek exterior casing. Installjdouble casement windows with quarter round top above garag6, fimt and back. Trim with Azek exterior casing. g Replace 2 corner boards on garage with Azek. i Replace 1 corner board front left main house wjth Azek. Replace water table, right side of garage,with Azek. Disposal of all debris. I i i