HomeMy WebLinkAboutBuilding Permit #715-13 - 23 OLD FARM ROAD 4/30/2013, a
BUILDING PERMIT
TOWN OF NORTH ANDOVER °
—7)51—J 3 APPLICATION FOR PLAN EXAMINATION ; ~
Permit NO. T Date Received
Date Issued: 91 13. 0
IMPORTANT: Applicant
must complete
all items on this page
LOCATION ,�
Z,
� �..�..� One family
Address: ;Z� o-z.����i,�.�1,:��
0 Addition
`
PR£3PERTY t3 W�JEl u..
Print
.o s
No. of units:
.
-�
MAP NCS` 'ARCEL � ZONING DISTRICT,
Histanc Distri f
,y yep`
5
..: ..�
r
Machin Shop Villa a <�, yes, no
TYPE OF IMPROVEMENT
PROPOSED USE
Please Type or Print Clearly)
Residential
Non- Residential
0 New Building
� �..�..� One family
Address: ;Z� o-z.����i,�.�1,:��
0 Addition
1i Two or more family
Industrial
D Alteration
No. of units:
Commercial
E.1-Kepair, replacement
] Assessory Bldg
D Others:
;y Demolition
€ i Other
-
Septic Well
Floodplain r" Wetland's
Watershed District
"Water/Sevier,-
F
yr_
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: $
Check No.: !2) (pt) Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to th juaranty fund
Signature of Agent/Owner— ignature of contractor,
y
Identification
Please Type or Print Clearly)
OWNER: Name: f�l ( (
,J �_
Phone:
�' / �5 2KF
Address: ;Z� o-z.����i,�.�1,:��
c r -r1
ib'OIITRACTOR. Name:-11
phone.
Address: � <
-
1 Supervisor's.to�hst'ruction 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: $
Check No.: !2) (pt) Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to th juaranty fund
Signature of Agent/Owner— ignature of contractor,
y
TOWN OF V40RTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
IMPORTANT• Applicant must complete all items on this page
`D
•>.� •x%
y.
;
100YearsQld`Struct_ure .yes'tS no
-MA 0; -PARCEL: ' _
P,rrnt'
ZONIN,01DIST;RICT:.
Histonc�Distnct�
yes;
no
I-
,�Macfime Sfiop7Village�
.yes•
.. no;:.
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
❑ Alteration
❑ Repair, replacement
❑ Demolition
11.`SeII, fic;; ,pWeII
�,Wate�/Sewer
PROPOSED USE
Residential
❑ One family
❑ Two or more family
No. of units:
❑ Assessory Bldg
❑ Other
.b'Eloodplain, ❑_ •Wetlands
Non- Residential
❑ Industrial
❑ Commercial
❑ Others:
n .Watershed District,:
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
<CbNTRAic Name: _Rhone:
- } .
ell
Supervisor s Gonstrdction LicenseExp: -
t,. ��•
! • • t • [ .. .•'Y is � t � - - _ ., r a , _
Home Improvement License; Exp: Dater
ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $
EE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
:Signature of Agent/Owrier
Si nature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plai.s
r ---
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
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_._
Planning Board Decision:
Comm
Conservation Decision: Comments
Water & Severer Connection/Signature & Date Drivewav Permit
y DPW Town Engineer: Signature:
Located 384 Osgood Street
��IRE ®EPARTitlli NT -Temp Dumpster on site yes no
Located at'124 MainStreet
Fire DepaKmert 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
)oc.Building Permit Revised 2010
Building Department
The folawing 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
gOTE: 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
COTE: 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
e OTE: 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 app; al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm ated with the building application
Doc: Doc.Building Permit Revised 2012
Location 23 v'
No. 3 Date
Check # 9(0-0
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
26337 Building Inspector
CA
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The Commonwealth of Massachusetts Print i orm
Department of Industrial Accidents
i� Office of Investigations
1 Congress Street, Suite 100
Boston, MSA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Legibly
Name(BusinessrOrganizationrhtdividual):
WinWin Properties, LLC.
Address: 165 Hancock St.
/State/'Lip: Braintree, MA 02184
Phone #: 781-843-7253
Are you an employer? Check the appropriate box:
1.0 I am a employer with 5
4. ❑ I am a general contractor and I
employees (full and/or part-time).'
have hired the sub -contractors
2. ❑ 1 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.
employees and have workers'
[No workers' comp. insurance
comp. insurance.+
required.]
5. ❑ We are a corporation and its
3. ❑ I atn a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.]`
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
4. ❑ Building addition
10.0 Electrical repairs or additions
1 I .❑ zoof
bing repairs or additions
1.2. repairs
13.❑ Other
*Any applicant that checks box #1 must also till out the section bolow showing their workers' compensation policy information.
` 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Wells Fargo Inc.
Policy # or Self -ins. Lic. #: 20 WEC RT8776
Expiration Date: 3112/14
3t J
Job Site Address:_ _.....__________..........�_
---------- City/State/"Lip: /�1
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 viola r. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurancroverage verification.
Ido hereby certif under the pains /t d enalties of )er'u that thein ormation provided above is true and correct.
7 Sit nature: Date l� 6'
r,t,,,„„ 4. 508-245-0460
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 Ilealth 2. Building .Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
Jeremy Gavin
MA CSL # 100388
4 Kestrel Way
Carver, MA 02330
508-245-0460
Contract for Repairs
23 Old Farm Rd. North Andover, MA
After inspection of the roof it is determined that there are 2 layers of roofing material that
needs to be removed.
Work to be performed;
O Strip 2 layers of existing shingles, existing underlayment and drip edge
o Install new white drip edge, ice and water shield, felt paper, reflash chimney, new vent
boots and Certainteed 30 year Architectural shingles. (color is determined by you)
Our pricetfor performing this work is $7,500. As soon as we have your approval, &
deposit Or .1/3 of total cost, we can begin work on the project for you.
Gavin
sor
Mike Katz
T.he'CO m6nwealth ofMas's'achusetts
Department of Fire Services
Office' of the Stale. Fire Marshal. '
=� P: 0. Box.I025 SLiteRcad, Stow -M -A 0I775 .
APPLICATION FOR PERMIT
e Date:
A n:d o v e r�' ermitNo
( Cibj ar Town) (4Applicable) =afeIn accordanccwith the provisions ofNLG_L. Chapter 10 as
provided in Section 5.:2 % CMR 3!+ applicatioa is hereby made
'(FuII,namc.ofpersoo, Fimi or Corporation)
'State clearly Address
purpose for -
which peonit (Street oc P.O. Bax Cityor Towa)
•
isrequcsted
For pcanissioato, locate .dumpster' for construe t nn.r-+• /rjPmnI t;n
of buildine•.
Comments: dumpster' must be .25'' from structure or 'covere when Ent'
in ns,e
at
( Give location by street and no., or dace cin suchmanncr as. to provied adequate identification oflocation)
Name of competentoperator Cert Na,
(If AppLicablc )
Datelssucd-rejected ey
(Signature of -Applicant)
Date of e:,psation V -/ xev $ 50 .00 Paid Due
The C®.mmon Baa -dt.h Of NlaSSachusetts
Department of Fire S6rvice-s
Office of the State Fire Varsha.l '
P. 0. Box 1025 S4ite Road, Stow,ltiL4 01775
PERMIT Date:
North Andover TermitNo
(Citrj of Tovm) Di Safe Number
(If Applicable.) g
In accord -c": with the provisions of L G L.l 4$ Chapter* _L Iasprovided in sectiaa 577 (MR
3 4
Startt Date
This Permit is granted to: I'Yl1dn 1 9.-FC�njr1L 1�� � t -I L
Full name ofpersoa, Firm'or Corporation
Pcrrnissionto locate dumpster for construction/renovation/demolition of building.
Coraments:, dumpster must be, 25' from structure if unablwith rewired
Ratrictioos:ce tolace learance dumpster must be covered with 1 wood or tarp end of -work day
at
( Give locution by street and no., or describe in such manner as to provied adequate identification of location )
FecPaid .S 50.0.0 ` t
j�jire Chief
ire
P Si
This Pcrrait will cx <3 () f ' -�
(gnature of ofucal Vantin rmit) Offical man g perritit ( Tide )
,�tlr•�G'�'
CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DDIYYYY)
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORD -ED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
02-26-2013
THIS CERTIFICATEIS 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(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS 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
WELLS FARGO INS/PHS
CONWT
NAME:
PA/C, Ne Ext): (860467-8730 ( (AIXC No): (877) 538-8526
260482 P:(866)467-8730 F:(877)538-8526
PO BOX 29611
ADDRESS:
INSURER4S) AFFORDING COVERAGE MAIC x
CHARLOTTE SC 28229
INSURER A :'Twin City Fire ins Co
INSURED
INSURER B
INSURER C
WIN WIN PROPERTIES, LLC
CLAIMS -MADE L OCCUR
165 HANCOCK ST
INSURER
INSURER E
E
BRAINTREE MA 02184
INSURER F
I, I
COVERAGES CERTIFICATE NUMBER: 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 AFFORD -ED 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.
NS
LTR
TYPE OF INSURANCE
D
iINSR
SO'BR
WVD
�'POLICY
POLICY NUMBER
EFF
I (MM1DD/YYYY)
ICY EXP
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(MMlDD/YYYYI LIMITS
' GENERAL LIABILITY
_—
€
i
OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
I
_EACH
i PREN� �IS"tSa eeneel $
CLAIMS -MADE L OCCUR
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€ MED _XP (Any one person) $
_
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Ij PERSONAL 8, ADV INJURY S
GENERAL AGGREGATE $
GFN'L AGGREGATE LIMIT APPLIES PER:€
PRODUCTS - COMP/OP AGG S
._.__J POLICY U PECTRO- LJ LOC
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(
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AUTOMOBILE LIABILITY
[
'
!
I
':. COMBINED SINGLE LIMIT
$
j
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BO ILb
Y INJURY (Per
ANY AUTO
person) S
S
BODILY INJURY (Per accident) $
ALL OWNEDSCHEDULED
Ui
I
AUTOS L AUTOS
HIRED AUTOS NON -OWNED
!
l
PROPERTY DAMAGE
S
(Per accident)
dent)
AUTOS
I$
UMBRELLA LIAR OCCUR
EACH OCCURRENCE $
EXCESS LIAR j CLAIMSWADE
i
_
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_AGGREGATE i $
j
OED3IIi RETENTION S
I
? $
I
WORKERS COMPENSATION
l
V WC STATU- OTH-
AND EMPLOYERS' LIABILITY YIN :
_
TORY 11 TORY LIMITS I ER
—
A
ANY PROPRIETOR/PARTNERIEXECUTIVE"'"— 1
OFFICER/MEMBER EXCLUOEDl I I E
(Mandatory
(Mandatory In NHS "'�"
N!A:
�� (
20 WEC RTS776
03/i2/2013
111
03/12/2019
(
E.L. EACH ACCIDENT $ 500,000
'500
!f yes, describe under I
I
�—L
E.L.' $
DISEASE - EA EMPLOYEq' 000
DESCRIPTION OF OPERATIONS below
II
E.L. DISEASE •POLICY LIMIT $ 500 , 000
I
DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is rettuired)
Those usual to the Insured's Operations. Frank Maranelli is an Additional
Insured per the Business Liability Coverage Form SS0008, attached to this
policy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
Frank Maranelli DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
439 WASHINGTON ST FL 1 AUTHORIZE R PRES£NTATiVE -
BRAINTREE, MA, 02184��ad���^�
r' 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
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