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HomeMy WebLinkAboutBuilding Permit #050-14 - 22 MAIN STREET 7/15/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: OS-10— Date Received Date Issued: 715 /3 IMPORTANT:Applicant must complete all items on this page � ,LQCATIONt '�o'� o� ip�`t� Print; t' PROPERTY QWNER ¢U� nR' t` /` ! �(,L�¢F12� � -> ' . y� P,nnt; 100,Year,Old'Structure e MAP,NO: PARCEL:yU�yZONINGIDISTRIC,T .. HistonclDistrict ,yest no {_ ;;Machine;.ShopVillage►., yes. ,no* �.. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family Two or more famil ❑ Industrial 11 Addition ;9y . Alteration No. of units: 3 !-Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other "Septic ,D Well ❑'F,loodplain p Wetlands :' 0 .Watershed District-., �. Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: _fJ _ �- - i2or� LgeA V> u�wl�p Identification Please Type or PrintClearly) OWNER: Name: Phone: Address: L cj -a7 �([o7 - FCONtRACTOR- Name.:CJ�'d- ,� ` ' -Phone' ( 3 3t Address ! fl(� �.. ' i'Exp' Date: Supervisors Cons License. g . Exp. Date: Home.lmproycment License; ARCHITECT/ENGINEER It 10 Phone: C(--7b qy_—0r7( Address: PoI�jp�c 160-1(; �w2jzn ` '�W Reg. No. 3 FEE SCHEDULE:BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $_ Ws,� FEE: $ 3 0a Check No.: -3 y' Receipt No.: 62 NOTE: Persons contracting with unregistered contractors do not have acce4plans my fun Signature of Agent/Owne I nature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ ❑ 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 0 Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWINGS SECTIONS TIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ :�> COMMENTS , C,o n v-4--T t . ems; C���P>rtI ccs �s dZaaedor �� -on CtAb� k /oorf CONSERVATION Reviewed on Signature COMMENTS HEALTH 'Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ._ Planning Board Decision: Comments Conservation Decision: Comments Water & Sevver Connection/ Driveway Permit ]DPW Towp- Engineer: Signature: Located 384 Osgood Street rFire E DEPARTi�IIT - Temp Dumpster on site yes no ated at-124 MainStreet I ®epa'Kmer t 8ignatiure/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 I®cation, 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.$1o0-$1000 fine NOTES and DATA—(For department use Q Notified for pickup - Date I �oc.Building Permit Revised 2010 Building Department The folowing is a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work Li Engineering Affidavits for Engineered products �OTE: 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 o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products ?OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products MTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 1[n 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 appal 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 2012 Location �2 r 2 z1 11 No. Q.7 0 Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $1G� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# A, � y Building Inspector 2 ' Zdk,-�Location4 t� I No. O Date ( 2 . - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Feej TOTAL veG $ z fl Check# 2 v �, Building Inspector i otNOp7MI # o i s �a 3,s/fCNUS<49 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 050-14 on 7/15/2013 Date: January 15, 2014 THIS CERTIFIES THAT THE BUILDING LOCATED ON 22 Main Street—First Floor MAY BE OCCUPIED AS Single Dwelling Unit IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Amalia McCaffrey 22-24 Main Street North Andover,MA 01845 Buil ng Inspector Fee: PrePaid Receipt: 27064 Check : 1435 o t d 00014;/ ��M SJev Deval L.Patrick' Governor �f Thomas G.Gatzunis,P.E. J4me, /-/�/-l/r/rCommissioner Andrea J.Cabral y g Secretary /,g/- Thomas P.Hopkins Director LfJLflf.(�.917.2.a14L�O?��� TO: Local Building Inspector Docket Number V 13 309 Local Disability Commission Independent Living Center FROM: ARCHITECTURAL ACCESS BOARD RE:, Mixed Use Building 22-24 Main Street North Andover Date: 12/19/2013 Enclosed please find the following material regarding he above location: Application for Variance Decision of the Board Notice of Hearing Correspondence Letter of Meeting The purpose of this memo is to advise you of action taken or to be taken by this Board. If you have any information which may assist the Board in reaching a decision in this case, you may call this office or you may submit comments in writing. e/� �C�%77/l7l.Gl9 i mi i d =90 cq� .sc���M sJev`�c V7GP/tX1'•Gl,�^G�EE?�LG� V i !(%! ala Deval L.Patrick Governoras'q flip- �O��O Thom Coms oner tzunis,P E Andrea J.Cabral �O�IPi r/ ,G Secretary �J- �J Thomas P.Hopkins Director Docket Number V13 309 RE: AMENDED NOTICE OF ACTION Mixed Use Building 22-24 Main Street, North Andover 1. An application for variance was filed with the Board by Amalia McCaffrey (Applicant) on November 13, 2013 The applicant has requested variances from the following sections of the 2006 Rules and Regulations of the Board: Section: Description: 20.1 Petitioner seeks relief from having to provide a ramped entry. The Board has been notified by the Northeast Independent Living Program that a ramp previously served the building and has been removed. On December 13, 2013 the Board received material from the owner of the building that outline the plan to convert the building back to its original use as apartments located on the first and second floors. The ramp was removed after the first floor tenant open to the public vacated the premises and the space is now an apartment. The owner is currently working to remove the second floor tenant and will convert that space to an apartment as soon as that happens. 2. The submittal was reviewed by the Board on Monday, December 16, 2013 3. After'reviewing all materials submitted to the Board, the Board voted as follows: DENY: the variance to Section 20.1 as proposed in the application submitted, for the reason that impracticability (see definitions of impracticability in Section 5 of 521 CMR) has not been proven in this case. (Vote issued December 2, 2013) After careful review of the material submitted on December 13, 2013 by the petitioner, the Board voted that due to the fact that the first floor is now a private residential apartment and that the plan going forward is the same for the second floor apartment no access for persons with disabilities under 521 CMR is required at this time. The Board further voted that the petitioner/owner must provide confirmation of the conversion of the 2nd floor to an apartment as soon as it occurs. Any person aggrieved by the above decision may request an adjudicatory hearing before the Board within 30 days of receipt of'this decision by filing the attached request for an adjudicatory.hearing. If after 30 days, a request for an adjudicatory hearing is not received, the above decision becomes a final decision and the appeal process is througf Superior Court. NOTE: If the work being performed is reconstruction, renovation, addition, or alteration, compliance with this decision must be achieved by completion of the project and prior to final approval by the building department. Otherwise, if the work being performed is new construction, compliance with this decision must be achieved prior to the issuance of an occupany permit. i cc: Local Building Inspector Architectural Access Board Local Disability Commission Chairperson Independent Living Center Date: December 19, 2013 Location — 62 No. — Date . - TOWN OF NORTH ANDOVER Certificate of Occupancj $ Building/Frame Permit Fee $ Foundation Permit Fee $ � m Other Permit Fee $ TOTAL $ Check# 2 'i J ': Building Inspector OMo.TM'N ss�c�s6 TEMPORARY CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 050-14 on 7/15/2013 Date: October 31, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 22-24 Main Street Valid for Sixty Days From Issuance MAY BE OCCUPIED AS _Change of Use from Lawyer's office to a Single Dwellinof Use from Lawyer's office to a Single Dwellin Unit IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. A Letter of Intent will be submitted for a variance to the Massachusetts ABA Board for a waiver for a wheelchair ramp. The variance must be issued in order to issue a CO for the apartment. Q Certificate Issued to: Amalia McCaffrey 22-24 Main Street North Andover, MA 01845 1 Building Inspector Fee: $50.00 Receipt: 27064 Check : 1435 NORT#1 Town of ? E : Andover h ver, Mass TtAlllo almt Fut , *A• S IJ BOARD OF HEALTH Food/Kitchen PERI LD Septic System THIS CERTIFIES THAT ....... . .... . ...,1...... ... ...... qr ,,,,,,,,,,,,, BUILDING INSPECTOR . . �..y...... ................. has permission to erect ............... buildings on ..CR9?-7n io:).'4......lr :.S`�.... Foundation ;10Rough tobe occupied as .............. .... ....Q........... ............................................ Chimney provided that the person accepting this permit shall in every 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. Roo Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough �- �`� Service ...............................(�.......................... ...................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough S/-2 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. 9 -� 3 - NORTH - - .own of 2Andover 4 No. - ih ver Mass 0 LANE CoCHIc"IWIC.( �1' pORATED ►PP�,�S S tl BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ............................... BUILDING INSPECTOR ..................................................................... has permission to erect buildings on ............................................................................. Foundation .......................... Rough tobe occupied as ................................................................................................................................... Chimney provided that the person accepting this permit shall in every 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 Roughr004 ' 0i 7/17 VIOLATION of the Zoning or Building Regulations Voids this Permit. ( ' Final PERMIT EXPIRES IN 6 MONTHS r ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Raug d� - Service f ................................................................................ Finales � - BUILDING 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 Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE x'6-0 PR -392-9537 OPERTIES PO Box 20441 Westford,MA 01886 Gerald Brown Inspector of Buildings Town of North Andover 1600 Osgood St North Andover, MA 01845 October 30, 2013 RE: Wheelchair ramp at 22-24 Main St, North Andover, Massachusetts Dear Mr. Brown: This letter is to inform you of our intent to submit a variance request to the Massachusetts Architectural Access Board, waiving the requirement for a wheelchair ramp to the first floor unit. The first floor unit has been converted to a residential unit. The wheelchair ramp that was requested to be installed would only service a residence, and would not provide access to any commercial space. It is our position that a wheelchair ramp at this location is unnecessary, as the cost of compliance is excessive without any substantial benefit to persons with disabilities. If you have any questions, please call me at 978-392-9537 or 757-814-8204. Sincerely, Amalia McCaffrey SIG-0 Properties, LLC Property Manager for 22-24 Main St, North Andover, Massachusetts NORTy Town of t E , Andover No. — VIX - ^_ h ver,." Mass o I3 L ME 9 'QA CONK Nl wICR V ` d D'R AT /nP�` JSOA 7S E0 • `•+ 4%% .5 IJ BOARD OF HEALTH Food/Kitchen LD Septic System THIS CERTIFIES THAT .....PERNI .. , ..., ,,,,, �,,, BUILDING INSPECTOR . .y... ................................... .. has permission to erect .... .................... buildings on ..C2.12.7n... ,,,,.. ,,,,, �� Foundation ,�,,,, �'} � ` . ... Rough to be occupied as .............. ...... . ........... ..... ...............�1 .................................................. Chimney provided that the person accepting this permit shall In every 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 CONSTRUCTION STARTS Rough Service ...........:..... g ........................................ BUILDING INSPECTOR Final 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 Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. IFSEE REVERSE SIDE Smoke Det. NO RT!-� Town of t EAndover h ver, Mass, `70 44.*V, LA '4AOR c Hoc Ne wl PA`��•y ,9S Oreo ►� ,��( U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ......... �t1. ..ti.1.1k......... ........... .....r. ........................................... BUILDING INSPECTOR y � � � . , Foundation has permission to erect .......................... buildings on _45?2. ...................... ............................................. Rough to be occupied as ........ z.14!. ................................................................ Chimney provided that the person accepting this permit shall in every 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 CONSTRUCTIO STARTS Rough ......................... Service .............. ..�..... Final BUIL 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 Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE � NORTF� Town of t EAndover O - toi- I r� ­;O� h ," ver, Mass, `� L" \ -(/i%��' ' PA coc.Ic"twicw`�1 �,4ATE0 /'PP S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System a THIS CERTIFIES THAT ......... ........�....c.��=:.��cs=:. ........................................... BUILDING INSPECTOR 7 Foundation n has permission to erect .......................... buildings on ..a� ...................... . .......................................... Rough r to be occupied as �.�1.��pc?xrs �6�;.,( �!. ................................................................ Chimney........ .... provided that the person accepting this permit shall in every 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 CONSTRUCTIO STARTS Rough ......................... Service ............... .. ..... Final BUIL 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 Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE NORTH Town of s E , Andover O r 0 No. * - �`y z h ver' Mass T O LAME � ' COC"ICHIMCK y1' ��S RATED PPp��S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT �'N'.1.N. '� � .... � �''� BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on Rf ................... . . r.;Y... ? ........................ Rough to be occupied as ...... f°.?.1G7r1, 6d4s:..1�. : :': l¢�k::s:.................................................... Chimney provided that the person accepting this permit shall in every 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 CONSTRUCTION RTS Rough ..f % ................... Service ...................... Final BUILDING 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 Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE 0,HD22,R92Z Rocket r+. ff, t I."R { The Commonweallh of"MassncltttsOls MUNICIPALITY l Board of Building Rcbttlations and Standards . USH Massachusetts State Building Code,780 cm,7`"cdnittlt h<,trJstYl rtutttfst,Jon Building Permlt Application Phis Section For Official Use.On! Building Permit Number: bats Apltlisd: Signature: Date _ Building Inspector SECTION It SITE INFO1011ATION Other Usscri tion: Residential 13 Commertial a -•-"""" "`"'" 1.1 Property Address: 1.3 Assessors Map&Parcell Numbers µ - Map Nninbor I,I a Is this an accepted street? yes no Parobl Nnmtwr 1.3 .Zoning Information. 1.4 Pr operty Dintrnaionst ---�- Fsuntnito(iI3 Zoning District - Proposoa Use I,ot Aron tsq tl} " 1.5 Bnilding Setbacks{ft} Rear Yard Front Para SideYards Eprovide Required Provided Required Provided Rcgaircd 1.6 WaterSupltly:(M,G,I..c.4tl,§34} 1.? Flood Zone Ittfornt»tion: l.9 Sewage I)icposat Systatau Outside Flood Zona? tvinnicipnl D off site dialxisnt sN=steal A Public.13 Private D Zolfo: 4— Check if Y0813 Comtnorcial Service Sita SECTION 2: PROpgR'1'Y OWNl`%RSllli't t}tSd+ j 2. (}caner of Itecorda .t1) + � Addrnss for Service; Nanfe(Print) clophono B•Masl Adds Signator SEGTIOIV 3:DESCRIPTION OF PROPOSED WORK'{check all that aplsEy} i Alteration003 Addition 0 New Construction 0 Existing But C1 Owner-Occupied D Rc other} D Accessory Bldg. Number of U..nits - _Y Demolition Brie Description of Pro ,sed Work; P SECTION 4:ESTIMATED CONSTRUCTION COSr'1'S � . _ ,.. . Estimated Costs: Official Use(?lily Item Labor and MatsrialsI Btsildsng Permit Hes:$ I:Iittitdln8 $ -3� o'� 2. ' Indicate)JOWL fee is dotermined. $ QS• 0 p Standard Csty/fowit Application Fvs 2.Electrical t ..�. . $ ���a.�® E3 Total Project Cosir(hent tij x tntslti diet x 3.Plumbing 3. Other Fees: 4.IyeGhanteat {HVAC) $ S.Mechapical :. $ Total All Fees:S .Fire Su cession Cash Amount: .,.� Check No. • ------- Chock Antitttiti:--Cash $ ''f 4 6,'Total Project Cost: ��.4 . Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost m $ $ 530.94 Plumbing Fee $ 66.37 Gas Fee 100 comm. $ 1fl0.00 Electrical Fee $ 66.37 Total fees collected $ 763.68 22 and 24 Main Street 050-14 on 7/12/13 Interior Reno adding Kitchen Reno Exisitng bathroom Brown, Gerald From: Jim Lyons Ulyons@NILP.ORG] Sent: Monday, August 19, 2013 10:01 AM To: Brown, Gerald Cc: NATownie@gmail.com; Christensen, Susan (MCB) Subject: Question Regarding: 22 Main Street Hi Gerry: How are you? The Commission has noticed that the owners of 22 Main Street, (where the Academy Auto School is located) seem to have removed a wheelchair ramp at the site. Mr. Manzi nicely built that ramp about 8-9 ? years ago at the request if the Town along with the Commission and folks with disabilities. That ramp was needed there, and the door it once served should have been kept unlocked, as we had advised them. We did not see a building permit posted. Can we work together to see why they removed their accessibility? Looks like a clear AAB issue? Take Care, Jim � Ct James Lyons Northeast Independent Living Program, Inc. ����J� 20 Ballard Road, Lawrence, MA 01843 Tel: (978) 687-4288 v/tty Fax: (978) 689-4488 Notice of Confidentiality: The information contained in this e-mail is privileged and confidential and is intended only for the use of the individual or entity named above. If the reader of this e-mail message is NOT the intended recipient, you are hereby on notice that you are in possession of confidential information. Please immediately notify the sender by telephone (978.687.4288) of your inadvertent receipt and destroy this e-mail. Consumer, Participant privacy policy is claimed. Nota Confidencial La informacion que contiene este correo electronico es confidencial y estrictamente para el use del individual o la identidad nombrada arriba. Si el lector de este correo electronico no es el destinado, por este medio usted esta en posesion de informacion confidencial. Favor de notificarle al remitente por telefono (978)687-4288 el recibo accidental y destrulla este correo. La poliza de privacidad del consumidor participante es reclamada. i Aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDM/YY) `..�� SU CE 5/6/2013 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)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: ROSE MVIIOZ Wilson Insurance Agency PHONE (781)665-1034 FAXLAIC, (791)662-0301 109 West Foster Street E-MAIL INSURE S AFFORDING COVERAGE MAIC 1) Melrose MA 02176 INSURER A:Scottsdale Insurance Co. INSURED INSURER B:Technology Insurance CO. Atlantic Wallboard Construction Services Inc. INSURER C:Ci tat ion Insurance Co. P.O. BOX 68 INSURER D: INSURER E Chelmsford MA 01824 INSURER F: COVERAGES CERTIFICATE NUMBER:CL125800774 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 POLICY NUMBER iMMIDDIYYYYl (MMIDDNYYY1LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY -11AWE TO PREMISES Ea RENTED n $ 50,000 A CLAIMS MADE OCCUR X PS1544113 /7/2013 5/7/2019 MED EXP(Any oneperson) $ 11000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 I— IX POLICY PRO- LOC $ AUTOMOBILE LIABILITY 12MWT7119 2/11/2013 2/11/2014 COMBINED SINGLE LIMIT a ci dent, 11000,000 C ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY per accident) $ AUTOS X AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS accident) $ X UMBRELLA UABOCCUR EACH OCCURRENCE $ 11000,000 A EXCESSLIAB HCLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION XBS0022231 /7/2013 /7/2014 $ B WORKERS COMPENSATIONWC STATU- X 1- AND EMPLOYERS'LUU3ILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) C3276707 /17/2013 /17/2014 E.L.DISEASE-EA EMPLOYE $ 1,000,000 Ues,describe under SCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 109,Additional Remarks Schedule,It more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PROOF OF INSURANCE ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE All Clark Lindley/ROSE - ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All d9fiqreserved. INS025(2o9oos).ot The ACORD name and logo are registered marks of ACORD TIo�I s: Co*i s£CsrRL=CT y s£ev1C£s S.I �.Icen C0411truction Supervisor(CSL) goZ . 9 �aN nj - Laccnat Number Expi»tioa Date Add", List CSL Type(sa beton) d3 08 G TMKI Dcsmptioft -• � ,,�.�+► U t nrestriewd(up to 33 OW Cu.Ft. Sigunt►r .r. .. . _..� R Restricted 1&2 Famih•Dwelling M hiasonn-on K, leltphptl �' - RC Residcatiai Roottn Covering__ -ire,of �"'4 r Aa � � WS Residcnttat 11'indow and Sidln �' A SF Residential Solid FM Buriling Appbajice Installation LrHngri Address t cou"I D IResidential Demolition S•2Itt"icare(daGI"l..o_itnl►c�Im-.p,Lr-o,tv�efmxe?n'?tL..Contra c�tar(Ht(tC1jG} nvynlaorti*ltcgls N' e .• aR�e�gistt1ration Number b. er 50 5 ' Z +dd #?•).rs -18BG Expiration Data Signalu I Telephone 40fe; I:�t11A1)Addmss SECTION 6:WORKERS-COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152.§2SC:(6)) . Workers.Cotttpensation Insurance affidavit must be compJeted and submitted with this application. Failure to provide Allis affidavit will result in the denial of the issuance_PMe building permit. Sigued.Aflidavit Attached? Yes.......,,.11r, No..........,.o SEC"1ON?at OWNER AUTHORIZATION TO BE COMPLETED WHEN OSi'Nk;R'S AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby atttltorize +. fi;y to act on my behalf,in all matters trlative to work authorized by this building permit application. Sr uaiurc of t�+n c SECTION 7b:OWNER'OR AU'T'HORIZED AGENT DECLARATION T, as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf, Signeturo of OiNver or Authorized Agent tate (Signet under alto pains and patalties of perjury) NOTES: 1, :An Owrter who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Homo.Improvement Contractor(RIC)Program),will a—d have access to the arbitration program or guuratrty fund under M.G.I.,c, 142A.Other important information on the HIC Program and Constriction Supervisor"Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 114.85,respectively, 2. When substantial work is planned.provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementlattics,docks or porch) Gross living area(Sq.Ft,) - Habitable room count Number of fireplaces Number of bedrooms . Number of bathrooms Number of half/baths _ Typo of heating system Number of decks(porches Typo Of cooling system Enclosed Open The Commonwealth of Massachusetts - Department of InrlustricclAccitlents Office of-Investigations 600 Washington Street Boston,MA 02111 www.massgov/rlia Workers' Compensation Insurance Affidavit:Builders/Contractor6/Electricians/Plumbers Applicant Information Please Print Ledbly Name(BusinesslOrganization!)•ndividual): ��/IJU�� 1)j3 Address: — .0• City/State/Zip: '-L/1/I t� Phone M `aJ^7, 4—I'D ' D / 7 Are yo}r an employer?Check the appropriate box: Typo of project(required): 1 1 am a employer with Z 4. ❑ lam a general contractor and I 6. [J New construction employees(full and/or part-time).* have ned the sub-contractors 2.El am a sole proprietor or partner- 7. Remodeling listed on the attached sheet. ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, [No workers'comp.insurance 5. ElWe are a corporation and its . EI Bg addition Electrical repairs or additions required.) officers have exercised their 1 3.❑ 1 am a homeowner-doing allwork right of exemption per MGL 1 L Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.QRoof repairs insurance required.]t 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. T Homeowners who submit this affidavit indicating they ice 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 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: `-t4.4-4N 0 L-0 G7 so m�Le (:�D ' Policy#or Self-ins.Lie.#: TW L 2���a� Expiration Date: Job Site Address: 7i -Z,y JA A) S?"" City/state/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of investigations of the DIA for insurance coverage ver' X do hereby cert under the p ' nd ti rjury that the information provided above is true and correct. - Signature: Date: ~ Phone#: ZT 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#: Massachusetts -Department of Public Safety Board of Building Regulations and Standards Office of ss egu a on PW Q ME IMPROVEMENT CONTRACTOR 144401 Type: License: CS-085162 piration: 9/30/2014 DBA Qr CRAIG V TARBOX ATLA WALLBOARD CONST CO. 209 FOREST RD WELTON NH 03086 CRAIG' TARBOUX 137 OLD WESTFORD RD CHELMSFORD,MA 01824 Undersecretary 09/09/2014 UA PM Certified Renovator OSHA 002201302 00 Ti hdW 3Q5/2010 Test 3a5120I0 xse(E RRP Initial Ce nglish) U.S.Dp.,t,—,.,—,t of Labor Craig TarboxOccupational Safety and Health Administration. ii 137 Old Westford Rd. ('41 i.S ChebmW MA 0 IVA has successfully completed a 1C-hour Occupational Safety and Health st Training Course in Expires:312 015 Construction Safety&Health R-I-19692-10-01116 ffrainei) eLead-Edu a 23 Nute Rd a tA (60)749-5775 o (Date.) 7;— Th 1 .tRis M121ral=4 mill -tio—certity that is Craig Tarbox has receWed the prescalbed trailmiling m4luilred and is qualified to operate the Itrw Rankset"Red Head Powder Actuated tools fisted below, Date issued; 6/28/2007 at I. e Date of birth- 9/9/1966 Lic.No.00628070444 1VIPER,D60,D45A,Auto Fast;,SA270,COBRA 72 1,M70,MD380,L1600,HD22,RS22,Rocket Ruud Red Head