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HomeMy WebLinkAboutBuilding Permit #538 - 225 MAIN STREET 4/14/2009BUILDING PERMIT `tty20 hay �O TOWN OF NORTH ANDOVER F?4=''. _ '..° o� APPLICATION FOR PLAN EXAMINATIONWI Permit NO: 3 Date Receivedoq SSACHUS Date Issued: IMP RTANT: Applicant must complete all items on this naize LOCATION c -T rV - A _ ©/s -/o Print PROPERTYOWNER L c�, Print MAP NO:PARCEL; ZONING DISTRICT: Historic District yes no Machine Shop Villaqe vl6s' i no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more famil Industrial Alt ration No. of units: Commercial e air, replacements Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: .- F �2r.�s' S i� )r r i ti s �� M r u Identification Please Type -dr Print Clearly) OWNER: Name: Phone: AririrPCG- CONTRACTOR Name: ?.J,. -I j Gaal%,z�.r!'���, Phone: 5' ; dj ,, Address: 9 » c l'iy 2.,.- C iiz e /�� &A, 41 �. s• � n d � �'7 � Supervisor's Construction License: .232--,/ Exp. Date: 7 A; Home Improvement License: 7 -S3 e` Exp. Date: ARCHITECT/ENGINEER Address: Phone: 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: $ 40*' i FEE: $ r Check No.: 2a 3 -"r— Receipt No. NOTE: Persons contracting with unregistered contractors do not have Signature_ of Agent/Owner Signature of contras 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 -- _ ;OMMENTS 1. Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date COMMENTS uocatea J64 Usgooa ,street yes no 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 o 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location No. �-� Date f NORTH TOWN OF NORTH ANDOVER O�� ,00 ,�.1.0 3: OL ` Certificate of Occupancy $ Building/Frame Permit Fee $''� a.►c Must Foundation Permit Fee $ Other Permit Fee $ `TONT—AL $ Check # �� J 21 Building Inspector m m m m YI m CA mm �I� CO) 10 CD a Z CD O ar d CL .p CD o p CL Q CD O °D CO) 10 CD O CD d O COD C9� C O C CO) n CD O .7 CD a CO). CD CO) O CCD O dc CD lw cn cn 2 o� O z cn G O N N NOC2 ^' d O O n m ^r1 ?�. Cn CD O N •rl Q= ,�rl O r tTj � "r1 N' m 5.0 .- = O �. N M tz ov M � cn � y a?� x 9 m C o m N y O O --1 2 gr Z C C <N9J O N. m : y n �.m CL 0 ,..... : O it mc N : �0CD+ CD C. 01 N CL. m Q _ c .cc c 3E CD y :c N O m fu ao moi N � CD o C° d c`� C, C am Im CL Com: O � W � O . C!J 70 0 Crt n 0 M'1y EllC =i ^' 'Jd O OGV Hco ^r1 ?�. Cn CD ,�v O OGQ Cii n O •rl Q= ,�rl O r tTj � "r1 N' n _� O r 00 O T � a o, tz ov M � cn � y '17 O O - x x 9 H 0 9 0 c ,� �,j�L p.. ✓<7,QdN[Cli�lJ�� Board or Building Regulate ns and Standards _- HOME IMPROVEMENT CONTRACTOR Regs"tson: 107538 TO 272916 _ Expiration; 814/2010 Type: DBA D 8, J CONSTRUCTION Daniel inger-011 g McKenzie Circle Adudristrstor Tewksbury, MA 01876 .�..:.--. �l:ss�:sihu`�tts - DcRs u1 tt�tns :ePiedjSt �,d:trcis ? Bouro-d Buiklin., (eruisor License Construction Sup License= CS 23711 Restricted to: 00 DANIEL N INGERSOLL 9 Mr, KEN21E CIR TEWKSBURY, C 01876 E xpirat ion: 1211712009 Tr»: 2328 1 i r i• FROM : SCHPFFNER INSURANCE PHOW NO. : 9786409375 Feb. 24 2009 03:09PM Pi DATE (NWDWM CERTIFICATE OF LIABILITY INSURANCE 0=40 THIS CERTIFICATE IS ISSUED AS A MATTER OF WORMATION ?RODUM Sdufflw insAlmnm Agency ONLY AND CODERS NO RIGHTS UPON THE CERTIFICATE 1147 Muhl St HOLDER. THM CERTIFICATE DOES NOT AIMM. EXTEND OR TewkshlNy MA 01876 ALTER THE COYMPE AFFORom �1 _lM POLIO Sew.. Phone (978)851-2727 Fax (978)540•937S uL tIRdS AFiORONG COVERAGE 1 MAIC a3t— • _ A: HERMITAGE INS CO.. .. ' INSURED M CONSTRUCTION INSURER e: LIBERTY MUTUAL 9 MdamWe Ckde R!SURER C:.. _ ... - TeMksbtffy. Me 01876- ; msul+ R D: r l INSURER E: COVERAGES INSURER F: -TME,kxIdkS- OF BWAWRANCE LISTED HAVE BEEN ISSUEDTO THE DSD IWWED ABOVE FOR TM POLICY PERIOD IpOICJ►TEO. NOTWII HSTANDDI6 ANY REDUIRE114E17 TERN OR CONDITION OF ANY CONTRACT OR OTHER OOfANMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE i$SUEO OR III WAY PERTAIN. TME INSURANCEAFFORM BYTHE POLjM DESCRIBED HEREIN IS SUBJECT TO ALL THE TERAS EXCLVSIOM AND CONDITIONS OF SUCH POLICIES. AGGREOATFLLMARS SHOWN MT HAVE am REDUCED BY PAID CLAIMS- iSRI wvt i TYPE OF M RANM POLICY NUMBER - a&-m pwmodv '.. m 7eppro " EACH OCCORRENCE WEWW Ij � GEI-RaL t ;HI;L / 54 r-0S 1113tk06 I lrj 9 bojaAm tEa) i00 000 �_ MED EXP QW ore pels0n) 61000 ;_ I U CLAIMSMIADE •__; OCCUR ; ' !PERSOML&ADVINJURV 1.0001000 s � TE �OOOfo00; ❑ I ! PRODUCTS -COMPIOPAGO 1.COO.J.OM I ( GM AGeRe• _mTE LOW APPLIES r '^� POLICYPROTECT LOC 1I COIVIBUIEO SP46LE LWT - I 4 RUTO�bIL.ELMBN.ITY C ANYAUTO Pi ALLOWNEDAUTOS : BODLYMJURY ! 1 $ _- SCNEDULEDAUTOS 1-1 MMDAUTOS Y INJURY i I i 'r! Nm041Vtmmwos eo6de�0 - - (� _._ ... PROPERTY DAIIWGE I 1 AUTO ONLY -EAAOCW2NT : ~� Qd'R"GEU"B"'T" _ OTHER THAN i _.- 1 AW AUTO : AUTO OILY: PGG,• __ s ..............-- LlaB6iTY EACNOCCURREIOCE . —�-- li. 1 OCCiRI I.1 OMWSMADE j . aGOREOATE RETENTION : -- –T- — _41MOAKERB PIIANO Mci-M-326174-03 ' 0212lM 02121/10 7 I EMPLOYERS' LIABILITY__ ' 100.000! : E.L EACWA 0 I ANY PROPRIETOR I PARTNER I EXECUTIVE ! I OFFICER /MIM EXCLUDED? i ` E L OFSEASE - EA EMPLOYEE - 100.0001 ayes, deerribe Inlets► i 'L DISEASE - POLICY LWT ! .� 500,0001 OTHER �._....._ .._.._. ....--;sPEeJALPRDIiIsloers DSSCFi1PTiOm1 of ppERATiOWS I tOCA71ppS I VEHICLES r eX ERSIONS aDOm BY t .. J CERTIFICATE HOLDER C1INCELLATION ----- SHOULD ANY OF THE ABOVE OES�ED POLICIES 69CANCELLED THE CATION DATE THI EOF. THE 9MMS INSURSI MILL ENDEAVOR TO ISAIL DAYS YMRITTER NOTM TO tME CERTIRG►1E HOLM FOTO i THE LEFT.OUT FAD.URE TO DO 80 SHALL I REVR7 TA7NE8 = OF ANY KIND UPON THE wSURER. ITB AUTHOWED -- , i i _ ! _mini .ACORQ 25 (4BD1AM QF CONSTRUCTION PROPOSAL SUBMITTED TO: Dave Lu 09 STREET :40 Sunset Rock Road PHONE: 978-475-2404 cell 978-257-3268 DATE: 3-24- CITY, STATE, and ZIP CODE: Andover, MA 01810 Street, N. Andover, MA ARCHITECT DATE OF PLANS JOB NAME JOB LOCATION: 225-227 Main JOB PHONE We propose hereby to furnish material and labor — complete in accordance with specifications below, for the sum of: $7,800.00 Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practiced Any alterations or deviation from specifications below involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workman's Compensation insurance. 1 Authorized Signature Office Manager Note: We may withdraw this proposal if not accepted within 60 days. We hereby submit specifications and estimates for: Remove existing roof shingles and install new 30 year archetectual roof shingles, to include ice and water shield on 1 st 3' of roof. Acceptance of proposal — The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of acceptance: Signature: Signature: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston, MA 02111 y s• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/Individual): D ,r- 7 Co,.,s nu;7, -,, , Address: 9 Mr- Ir;= n, z. - c,, R g, & City/State/Zip: j 4s61;L j,,,, �,9.7L Phone #:� 2� V Z o,S 3 Are you an employer? Check the appropriate box: 1. P1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part -tithe).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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. Lic. #: t vc / 3 /S- 3.2 G 1 .7 y - 0_2 Expiration Date: Job Site Address: o2o2S `2 City/State/Zip: ,V An,c>✓u�— ,,,,� ®r87,0 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 cer"nder the pis and penjl#ies of perjury that the information provided above is true and correct. Os 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 M