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HomeMy WebLinkAboutBuilding Permit #207 - 240 MARBLERIDGE ROAD 9/13/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must completer�all items on this age LOCATION c v Print PROPERTY OWNER IC44 r C7 R s @ rte Unit# Print MAP NO: aCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes6no 100 year-old structure yes 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 ®rSepticW11 RIT Qodh WatershedM,istncf _ O,Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: t� viloaF /2 0 LL S (Identification Please Type or Print Clearly) OWNER: Name: l tF Y??v/z-; Q°vs Phone: 14? a rr Address: Yy �? ae tib (° 12-C 9we •o = CONTRACTOR Name: /y on 1J © /L//?1C1 Phone: Address: Supervisor's Construction License: 0 l l 2 Exp. Date: Home Improvement License: J C 12- Exp. Date: 2U / 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: $ C� �� d FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �a __g _ Signature�of contractor Sgnatur_e�of A ent/Ovvnert J 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 o Building Permit Application ❑ 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 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 o Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ 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 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o 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 o 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 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.Buildmg Permit Revised 2008mi 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 HEALTN4, 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.$10041000 fine NOTES and DATA— For department use I ❑ Notified for pickup - Date Doc:.Building Permit Revised.2011 June/mi Location No. U Date / „QRTot TOWN OF NORTH ANDOVER of.•••' ,.Yac , a f i Certificate of Occupancy $ CNUsE<� Building/Frame Permit Fee $ '� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # I/.� 24569 Building Inspector The Commonwealth of Massachusetts Department oflndustrial Accitlents Office of Investigationg 600 Washington Street Boston,MA.021-11 'Y www.massgov/rlia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers _Applicant Information Mase Print Leg ibly Name(Business/Organization/fndividual) Address: City/State/Zip:_ �� �e a, �. (`� Phone#: Are you an employer?Check the appropriate box: _ 1. A am a employer with 4. Type of project(required): .�_ ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.01 am a sole proprietor or partner- listed on the attached sheget. t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demblition working for me in any capacity. workers'comp.insurance. [No workers comp.insurance 5. 9. El Building addition ' p ❑ We are a corporation and its required.] .officers have exercised their 10.0 Electrical repairs or additions 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 insurance required.]t employees. 12�Roof repairs [No workers' comp,insurance required.] 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 thea workers'comp,policy information. I am an employer that is providing workers'compensation insurance for information. my employees. Below is the policy and job site _ Insurance Company Name:_ I _ Policy#or Self-ins.Lic. f! Expiration Date: Z S" . Job Site Address: 2 �/U 1a2 �� (L f aQT� City/State/Zip:or AndUa-� 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 ofMGL 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. do hereby cerigu er thepains and enaldes o p p fperjury that the information provided above is true and correct. ii nature: _ZX� Date 'hone#: k^i ` 3 5 Official use only. Do not write in this area,to he 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 CIerk 4.Electric 6.Other al inspector 5,Plumbing Inspector 1 Contact Person: 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 apartinents 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-contractors)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 returned to the city or town that the application for the permit or license is being requested,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 Wi11 be used as a reference number. In addition,an applicant that must submit multiple peiniit/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 bum 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 Com,,n.omwealth o,i yiassaclInsetts Department of Industrial Accidents O1'ioe of investigations 600 Washington Street Boston;MA 02111 TO. #617-727-4900 ext 406 or 1..877-MASSAFE Re.vicaA 11Z_04 nc Fax#617^727-7749 ACORDM CERTIFICATE OF LIABILITY INSURANCE 05/1133DATE //22011011) -- PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Pelham Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 960 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 122 Bridge Street Pelham NH 03076 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Northfield Insurance Co Thomas Doyle dba Thompsons INSURER B:AIM Construction and Roofing INSURER C. 8 West Street INSURER D: Salem NH 03079 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 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. ; AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'NSR AOD'L TYPE OF INSURANCE POLICY NUMBER DATEYMM/DD(YY) PDATE(MM/DD/YY)N LIMITS LTR INSRD ( A GENERAL LIABILITY WS10659 04/15/2011 04/15/2012 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREM SES(E..' nce S 100,000 CLAIMS MADE NO OCCUR MED EXP(Any one person) $ 5,00-0 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 PRO- POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS _ BODILY INJURY _ $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR F-1 CLAIMS MADE AGGREGATE - $ $ DEDUCTIBLE $ RETENTION S S $ WORKERS COMPENSATION AND AWC 7012214012011 04/21/2011 4/21./2012 TCRYLIMtTSOTR TH EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 100,000 OFFICERIMEMBER EXCLUDED, E.L.DISEASE-EA EMPLOYEE$ 100,000 If yes.describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Roofing jobs CERTIFICATE HOLDER CANCELLATION Fax: 978-623-8320 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LAB LI OF KIND UPON THE Town of Andover Mass INSURER,ITS AGENTS ESENTATIV 36 Bartlet Street AUTHORIZEDREPRE ' Andover Ma 01810 ACORD 25(2001/08) ©ACORD ORPORATION 1981 INS025!0'.081.07 AMS VMP Mortgage Solutions.Inc.(800)327-0545. Page 1 of. NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined-by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section l OA. The debris will be disposed of in: (Location of Facility) 2 W,,,, Signature of Permit pplicant Date e l P his % }5S O C -�, CJUx,0,P s-/,Oe P61,?M 74 --mel N42Y 4 (-ee- ft" Of Free Estimates Thomas Doyle D.B.A. 8 West Street Fully Insured Salem, NH 03079 THOMPSON'S ROOFING (978)691-1355 Shingles - Slate - Rubber Roof Single Ply - Copper Work PROPOSAL suamiTTED TO PHONE ONE Kate Morgan -24-11 STREET JOB N" 240 Marbleridge Road CITY,STATE AND ZIP CODE JOB LOCATION North Andover MA 01845 ARCHITECT DATE OF PLANS JOS PHONE We hereby submit SpeCtkoons and estimates fol': Cover side of house and bushes from falling debris Strip off roof shingles on front 2 center sections and back middle sections Renai_l all loose plywood Instal)_ . 02.4 thickest brown drip edge Apply ice and water shield 6 ft, up all along edge Apply ].51b. felt ppaper on rest of roof area � Reshi..nvle with a 30 year Architect sh.,._ngl._ tr1__rxg to match install neva flange around soil pipe Install new ridge vent Clean out gutter Remove all work related debris i 30 year warranty on mat2ria-1 5 year guarantee on labor construction lic . 71060112 improvement x`128612 Ut PrO"Ot hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: Six thousand three hundred doNans($ 6 - 300 .. 00 ? Payment to be made as fogows: $3 ,000 . 00 start of lob balance upon completion i al material a guaranteed to be n specMied.A9 work to be completed In a worWrinAte..— woordi%itostiudardpractimmAny I Mir or dwkdbn from above E extracvrrll awaited wMtert aiders. viand beoonr an�e1tarps otdp ArNrorixsd 'f above the astinmte.AN i9earin eontklgm upon strikes soeidants or delays bayorrd our cornrot.Owner to carry fire,tornado and other rwessery ksuanoe.Our workers we tiny Note:This proposal may be covered by Mbrionan's Compensation krNsance.Not liable for occuring problems caused by wlithdraw n by us K not accepted withk daya� LCepullme of Vrop"111—The above prices,apecirications and condof are satistactaq and are hereby atxepl, I You abs authorized to do the S 1, work as specified.Payment snip be as outlined above. Date of Acceptance: ` NORTH ONM 0 o over 0 _V jl� V" z • �� • 1� o , dover, Mass.,_,_ T O . LAKE COCHICHE ADRATED S BOARD OF HEALTH Erma D Food/Kitchen rLRMIT T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..........�4r.................... .................................................................................. Foundation llII has permission to erect........................................ buildings on ...... .1. .......... �... . ..... Rough Ch �v imney to be occupied as........... ....... ..............................................lrsk�i Zr....... . . ��.i.............................. provided that the person accepting this permit shall in everyco orm 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 ��♦ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ART Rough .............. ........................................._................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. Date. /�/O;�i. . . .. . .. . Of NO oTM 1ti TOWN OFAORTH ANDOVER PERMIT4OR GAS INSTALLATION s a i 9 SACHUSE�� This certifies that . . �!?f! .f`. . . �.�' . . . . . . . . . . . . has permission for gas installation . . . .`". . . . . . . . . . . in the buildings of . . . . r'./'. .4 Via_ .�" . . . . . . . . . . . . . . . . . . . . . . at . . .2-. .((,). . . . .�� !!�F . . ., North Andover, Mass. Fee: . .�U' Lic. No.. .71.?.) . I. S. INSPECTOR Check# 2-)—,j a 6718 I MASSACHUSETTS UNIFORM APPLICATION F0 PERMIT TO DO GASFITTlNG Mass. Date 3 Per it #r Building Location ner's Name U �=4 Type of Occupzncy /1'17� N e,& Renovation Repacernentv/ P1ans Submitted: Yeses No L" uJ u 1 L) Vi N U C C y c C Z to W u c O q I r- c > C) x co J N. LL 1`- >- _ < c� F 1 u C O O= )IJ �G r jj L� c Li d U W = y Z C G i i o TLL-< 0 0 U w 0 %Q Z O C7 2 L' O 3 G Cr J U C Y t a n- F- O SUB—BSWT. i BASEMENT -1ST FLOOR 2ND FLORA J it 3RD FLOOR _ � � 3 4TY. FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 6TH FLOOR / lnstalt:rg Company name f * Check one: Certfcate Ac 0,-,—Corporation i Clmate Z — One jqps � ❑. Partnership Bt 24 Normae Road 1-3 , El Firm/Co. FS URANCE COVERAGE: ave a current f ury insurance policy or Ps substantial equivaleni which meets the requirements of MGL Ch. 142. Yes IV No O If you have checked}_es, please indicate the type coverage by checking the appropriate box. A liability insurance policy Ofher type of indemnity❑ Bond D OWNER'S INSURANCE WAIVER. 1 am aware that the licensee does not have the insurance coverage rewired by Chaptl?r 142 of the Mass ,enece)Laws, and that my signature on this permit application waives this requirement. _ Check one: Owner[] Agent [ Sfg�afu�e of Umer or O,vner s Agent I hawby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my kne.0edge and that all plumbing wort':and installations performed under the permit issu for his ap lica on b in compliance with all Perl nent provisions of the Wusachusetls State Gas Code and Chapter 142 of the Gener �.La 11s. j By_ 7 of license' Plumber gn rof LicensediF r r bas ftier Title slitter ster license mber alytrTovm Journeyman APPRC,Y,'ED 10 1C US . NL l BELOW FOM OFFICE USE ONLY FINAL INSPECTION SKETCHE9 PROGRESS INSPECTION FEE ---- N0. APPLICATION FOR PERMIT TO DO OnSFITTINCI NAME A TYPE OF OU1LWHO LocnrloN of nu1LnlNn PLUMSER OR OASFITTER LIC.. NO. PEMMIT CIMANTED DATE 0ASINSPECTOR o r -