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HomeMy WebLinkAboutBuilding Permit #253 - 22 WILD ROSE DRIVE 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ;-5-3 Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page f LOCATION ltJ l t Ue Print PROPERTY OWNER rt/ /` i risAJ4,x1sex'I j Print MAP NO:q PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid Non- Residential New Building One family Addition vino or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: �]leR— �s�-� ltJt�a?<1 Identification Please Type or P ' t Clearly) OWNER: Name: Ce -.SS A ; isA 6#JPhone: '7JC 919— /J Address: CONTRACT R N m 0 a e.� LPhone. 3 C Address: "I&e &CZ PZZIA,. &W- 63 d 74 Supervisor's Construction License: 4 3.7� " 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: $ �J0/00eq Aqa-r- FEE: $ 1p Check No.: Receipt No.: 9d 7Y NOTE: Persons contracting with unregistered contractors do not have access to the gu ranty fu signature of Agent/Owner Signature of contractor ■ 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 i . r r• !i I e •! 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 & 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 foricku - Date p p ----............------..............----.............._....._...._..._.........------............._.__...---............._. Doc:.Building Permit Revised 2008 r 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) ❑ 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 Locationdr,a Aa/ Zel 1,&,ve,— No. �S� Date NORTH TOWN OF NORTH ANDOVER 3? • O F S y y �, ,• . Certificate of Occupancy $ .•~ �sJ„cMus Et�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # r . L Oi Building Inspector CIX The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): / Address: City/State/Zip: 11 d1i'1 Phone #: Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2AlI am a sole proprietor or partner- listed on the attached sheet. t r_1 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. 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.❑ Roof 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 are 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. c- c Insurance Company Name: Policy#or Self-ins.Lic. #: /n Expiration Date: Job Site Address: City/State/Zip: S- Attach a copy of the workers' 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 th ' s penal 'e erjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: 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 ret iTied to file City or town that the application jvr the permit or ilCeilse is being request d, not the 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 burn 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 021.11 Tel # 617-7274900 ext 4.06 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia NORTH own of : gAndover No. c; .3 aa. LA _ dover, Mass., 2 ' -1 a� 11 COC HI C HE WICK �d ORATED P`P�\ �y S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ ....4.f 19�.�.... .t'L-�...........C�;�..�i.�..N...I.�.G.��.............................................. Foundation r has permission to erect........................................ buildings on Z (.I�. C....... ................... Rough to be occupied as..... ......... ...... '?'�.!�. .. k✓ +-............................ Chimney 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final (Zs�� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS C0NSTRUqT1qN TARTS Rough .................................. ................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RouFinagh 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. Salem Vinyl Siding & Windows Co. LLC 46 Herrick Circle, Pelham, NH 03076 603-893-8043...... Glenn C. Cote ........................................................... Name of Purchaser: Janis Melanson/Cassandra Czarniecki Date: 08-14-08 Address: 22 Wild Rose Drive Phone#: 978-689-7919 Ci :North Andover State: Mass Zi Code: 01845 �� ` --- Revised 9-17-09 b Glenn 3a Harvey Model Furnish and install one Therma-Tru Smooth-Star fiberglass French door unit. • Model 5-118 Clear glass...20-year limited warranty, 2x that of steel. Looking at door from outside primary working door to be left side. • Includes Low-E Glass treatment to inside of outside glass pane. • One piece aluminum threshold.....Nickel hinges • 31/2"PCV exterior casing. • Installation of door will be preformed using fiberglass insulation installed on all sides. • Interior casing ...no painting included. • Furnish and install 1/4" Styrofoam ridge insulation under floor,if accessible. • Replace existing salvaged exterior vinyl siding. • Construction necessary to cut thru wall and frame for installation, block in existing openings from existing removed windows, sheet rock and finish tape. • Plymouth entrance door long handles are included.....Satin Nickel • Installation of Owner supplied"Phantom" screen @ $50.00/hour/man. additional Subtotal................................................................................$2,793.00 Anderson Wind ow: Furnish and install one Anderson Series 400...CW7-15... Narrow-line unit. • Includes Low-E and Argon glass treatment. • Vinyl exterior and clear wood interior wood. • Casement left exterior hinge. • Bronze handle cranks. • Re-use existing window screen. • Construction necessary to frame up existing wall opening and prepare for installation,block in existing openings from removed existing door,insulate with fiberglass insulation the stud openings, sheet rock and finish tape. Painting not included • Install double 4" vin lig on exterior wall............................. Sub total .............................................. ............................. , .... .$ 1 180 00 Vinyl siding repair requested: • Custom metal fabricated and install on garage door casings • Soffit repair, second floor rear of house soffit. • Front garage dentil molding, re-secure with screws if necessary. • Remove and re-mount downspout with correct screws and re-attach trim board. Subtotal.................................................................................$ 500.00 Optional: 1. Front door adjustable thresholds....replace with new piece with screws........$ 50.00 2. Rear wall vinyl corner post is damaged needs replacing...........................$ 25.00 3. PVC board installation under rear door thresholds...6'+3'...x $ 8.00/ft.........$ 72.00 4. Additional siding repairs........requested.............................................$ ...... 5. Any rotted areas, requested to be repaired, will be done at an additional cost...$......... We agree to pay for the aforementioned materials and labor the sum of $_4,573.00 Dollars, in the following manner: • Door is to be special ordered with a deposit here with of 1 573.00 Dollars: • Check received # 1036...9/14/09...$ 1,573.00 • The balance of$—3,000.00—Dollars to be paid in_One_payments of$_3,000.00_: • This order is subject to acceptance by seller. The seller shall not be liable for delays caused by strikes, shortage of material or any other causes beyond,-his control. S.V.S.W. warrants it's professional workmanship for a full years. The seller warrants that it will perform the terms of this contract in a good and workmanlike manner and makes no other warranties expressed or implied other than those written warranties of the manufacturer and furnished to the buyer by the seller of any goods or materials supplied by seller. Purchaser has the right to inspect the job and create a punch list to be discussed with S.V.S.W. and said list will be addressed before final payment. You may cancel this agreement by a written notice directed to the seller at hie main office by ordinary mail or telegram not later than midnight of the third business day following the signing of this agreement. This constitutes the entire agreement, no other agreement, oral or written expressed or implied shall qualify the term herein. Any amount overdue will be subject to 2 %/month Interest and any reasonable legal fees necessary to collect thereof. Mass Lie;#CS 035152 Mass H.T.C..# 114 f34� Vk Lie; Ins.Nationwide&'Travel rs `` s Accepted Date ...09-18-09............ Glenn C. Cote .. . .. ... .............. l Accepted D / p ate 9-18-09......Accepting Purchase ' .... .t..�..... 3 .s Melanson/Cassandra Czarnecki r•romNatashaNaoum FaxID:Santo Insurance Page 1 of 1 Date:9/29/200912:22 PM Page:1 of 1 CSR CERTIFICATE OF LIABILITY INSURANCEOPID NN DATE(MlMlp &wv) PRODUCER SALEM-2 09/28/09 Santo insurance - Salem ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 224 Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Salem NH 03079 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOY F. Phone:603-890-6439 Fax:603-890-0315 INSURERS AFFORDING COVERAGE INSURED NAIC# INSURER A: Nationwide Companies 23787 Salem vinyl Siding LLC INSURER B: St Paul Travelers Glenn Cote INSURER Pr Progressive Insurance Co en 46 Herrick Circle Pelham NH 03076 INSURER D: 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 OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS WHICH THIS CERTIFICATE MAY BE ISSUED D SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR S TYPE OF MISURANCE POLICY NUMBER DATE(MMMDDIYYYY) DATE(MM/DD/YYYY) LIMITS GENERAL UABLRY EACH OCCURRENCE $1,000,000 A X COMMERCIAL GENERAxL OCUBILITY ACP5403886208 05/20/09 05/20/10 PREMISES(Es occurence) $100,000 CLAIMS MADE OCCUR MED EXP(Any one person) $5,000 51ACID66793002 05/20/08 05/20/09 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2-o00'000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- PRODUCTS-COMP/OP AGG s2,000,000 POLICY JECi LOC AUTOMOBILE LIABILITY C ANY AUTOCOMBINED SINGLE LIMIT 08421148-9 01/19/09 01/19/10 (Eaeccident) $500000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS X NON OWNED AUTOS BODILY INJURY (Per eccidert) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILnY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE 8$ RETENTION $ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY XTORY LIMITS ER B o�FFICEwrnER�MeEREXauoEORIPARTNEEXECUTIVE 0 7403899805 03/24/09 03/24/10 E.L.EACH ACCIDENT $100,000 (Mandatory in NH) 7403899805 03/24/08 03/24/09 E.L.DISEASE-EA EMPLOYEE $SOO,000 It describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Janice Melanson 6 Calandra Czarniecki 22 Wild Rose Dr North Andover NH 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBE)POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWNNAN DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of North Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Bldg Dept I REPRESENTATNES. 400 Osgood $t ALITHORIZED REPRESENTATIVE Porth Andover MA 01845 James A Santo ACORD 25(2009101) ©1988 2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Board of:Building Regulations and Standards �. HOME,IMPROVEMENT CONTRACTOR Registrat16n'' 114134 Expirapon IS/6/2009 Tr# 132915,E i Type-•-PBA Salerm Vinyl r Sicf�ng tAli+; uus i b GLENIJ CEJTE- .,"- C \ 46HbtRICKCtR'CEs,_ _� '; v PELHAM,NH 03E376 Admiriistra$or .r. BOARD OF BUILDING REGULATIONS CONSTRUCTION SUPERVISOR NumIJ4�"C� 035152 i expire b$!3-/2Q09 Tr. no: 2819.0 q j GLENN C 46 HERRICK CIRCA ,> PELHAM, NH Commissioner