HomeMy WebLinkAboutBuilding Permit #734-15 - 247 FARNUM STREET 3/24/2015BUILDING PERMIT 3ro�ti ;c
TOWN OF NORTH ANDOVER
'']jfl"J APPLICATION FOR PLAN EXAMINATION °
Permit NO: II Date Received
_ Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION- ft rhu w�-
Print , A i r
PROPERTY OWNER e K
Pri t
MAP NO: �� PARCELO ZONING DISTRICT: Historic District yes if Machine Shop Village Yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
K One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
9 Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
D Septic ❑ Well
❑ Floodplain 0 Wetlands
❑ Watershed District
❑ Water/Sewer
r1
_ice. day, S
Identification Please Type or Print Clearly)
OWNER: Name: JOY -'bu iacain Phone: C179-697-2(
Address: -Z 4-nt^nu
CONTRACTOR Name:
one: 9'79-y79- 0g10
Address:
Supervisor's Construction License: Exp.: Date:
Home Improvement License: Exp.. Date:
1.1.2 3 s o 31/t117
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ g6'QQ- FEE: $
Check No.: t tA2 Receipt No.: 2$w5 glg
NOTE: Persons contracting with unregistered contractors do not have access to the guq q#ty fund
nature of Agent/Own
nature
N
Location c�4 !
No. -�3l-!
Check # V �+
28 58 06
Date31k) I",,
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ 1
Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
f
c. . *--%
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑
Stamped Plans ❑
TYPT-:5F SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/MassageMody 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
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature_
CONSERVATION Reviewed on Sianature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
v
Planning Board Decision:
Conservation Decision:
Comments
Comments
A, Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
_ t_ocatea Jd4 usgooa Street
tFl_RE'iDEPARtTMEff Tern"p fDumpster�on �slte yeses ______ ._ ^,r oe
�Located�af�y12'4alVlainv,Sf�eet` �
�F re3 a Aift- f3s" gnatur-e/date
__
t
t.
Dimension
Number of Stories: Total square feet of floor area, based on -Exterior. Omens ions.
Total land area, sq. ft.:
.a
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
`i
_ 4
NOTES and DATA — (For department use)
f
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
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
❑ 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/Cross Section/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
VOTE: 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
Doe: Building Permit Revised 2014
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BB Carpentry Service, Inc.
122 Gorham Street
Chelmsford, MA 01824
978.454.1819 / 978.479.0970
Bruce J. Baker, Pres.
i Customer
Joy Duncan
247A Farnum Rd.
No. Andover, Ma. 01845
978-701-2039
carpentry work
DATE ESTIMATE #
3/8/2015 640
ITEM
DESCRIPTION
AMOUNT
i carp 7
Remove damaged drywall materials on the walls and ceiling and
4,500.00
replace with new blueboard and plaster veneer coat, prime and paint
to match existing. Remove and replace wall and ceiling insulation in
the affected areas and remove and replace the roof gutter system
across the front of the master bedroom.
Areas affected include the 1 st floor kitchen back side wall, the 2nd
floor laundry room wall as well as the 2nd floor game room wall and
the master bedroom front wall and ceiling.
Thank You for usingBB Carpentry Service Inc.!
rP ry
Total 4,500.00
The Comirronivealth of Afassaclrttsetts
tVDepartment of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Name
;vww.mars gov/dia
Workers' Compensation Insurance Affidavit: Builders/Coantracters/Electricions/Piumbers.
TO BE FILED W1TD THE PERMITTING AUTHORITY,
Address: /2—Z b2chaitt=57—
C i ty/State/Z ip -
%
City/State%Zip: Ch.___gV.Cid MA
Are you an employer? Check the appropriate box!
Phone#: 92p•yfY l�l4
1.01 am a employer with employees (full and/or part-time).;
2.01 am a solo proprietor or partnership and have no employees working forme in
any capacity. [No workers' comp. insuranoe required.)
3.01 am a homeowner doing all work myself. [No workers' comp. 'insurance required.) t
4.01 am a homeowner and will be hiring contractors to conduct all w oik.on my property. 1 will
ensure that all contractors either have'%wrorh-ers' compensation insurance or are sole
proprietors with no employees.
5.01 am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurarimt
G.'W We are a corporation and its officers have exercised their right of exemption per MGIC c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7, 0 New construction
R.�Remodeling
9. ❑ Demolition
10 rj Building addition
1.1,❑ Electrical repairs or additions
12.0 Plumbing repairs or additions
13. ® Roof repairs
14.0 Other
*Any applicant that checks box 01 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 shoiving 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 entptoyer 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, M Expiration Date:
Job Site Address: City/State/zip:
Attach a copy of the workers' compensation policy declaration page (shonving the policy number and expiration date).
Failure to secure coverage as required under MGL c. 1.52, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the foram of a STOP WORK ORDER and a fine of up to $250.00 a
day against the vio[ator..A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
provided above is tare and correct.
Phone #:
Official use only. Do not write in this area, to be completed by city or Imon offciat
City or Town:
Permit/License #
Issuing Authority (circle one): i
1.. Board of health 2, Building Department 3. City/Town Clerlt 4. Electrical Inspector 5. Plumbing Inspector
G. Other
Contact Person: Phone M
From:Mara Lage FaxID: Page 2 of Z uate:t9rzuu14 uL:Lts em rage:[ oT z
BBCAR-2 OP ID: L1
,4�OR0" CERTIFICATE OF LIABILITY INSURANCE
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 AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
DATE YY}
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(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the poilcy(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 Phone: 508-422-9277
Murphy Hickey Insurance Agency Fax: 508422-9914
133 Milford Street
Medway, MA 02053
ONTACT
NAME:
PHONE FA
AIC No E AIC No):
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC
INSURER A:
INSURED BB Carpentry Services Inc.
Bruce Baker
122 Gorham St
Chelmsford, MA 01824
INSURER 8:
INSURER C
INTRO:
INSURER E:
INSURER F :
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 AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
WOR
POLICY NUMBER
POLICY EFF
MMIDD
POLICY EXP
MMIDDIYYYY
LIMITS
X
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE DOCCUR
CPS28386
05/10/14
05/10/15
EACH OCCURRENCE $ 1,000,00
PREMISES Ea occurrence $ 50,00
MEDEXP (Anyone person) $ 5,00
PERSONAL & ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
GENTA G LIMIT APPLIES PER:
POUCY PR0LOC
PRODUCTS- COMPIOP AGG S 2,000,00
S
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNEDSCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
COMBINED SINGLE LIMIT
Ea accident $
BODILY INJURY (Per person) S
BODILY INJURY (Per accident) S
PROPERTY DAMAGE S
Per accident
UMBRELLA LIAR
EXCESS LIABCLAIMS
OCCUR
MADE
EACH OCCURRENCE S
AGGREGATE S
DED RETENTION S
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
PROPRIETORIPARTNERIE)ECUTIVE ❑
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
It yes, describe under
DESCRIPTION OF OPERATIONS below
N! A
I WCSTATLI OTH-
IT RY LIMITSANY
E.L. EACH ACCIDENT $
E. DISEASE - EA EMPLOYEE $
E.L. DISEASE- POLICY LIMIT I S
ommercial Appilca
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
Sample Certificate
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE �/y},A%�(�
,`6.,fjwwt/1' v'• / , u� � o
W 1998-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 112380
Type: Private Corporation
Expiration: 3/11/2017 Tr# 236971
B B CARPENTRY SERVICE
BRUCE BAKER
122 GORHAM ST. `
CHELMSFORD, MA 01824
Update Address and return card. Mark reason for change.
SCA 1 0 20M-05111 Address E] Renewal E] Employment 0 Lost Card
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supen•isor
License: CS -042055
BRUCE J BAKER
122 GORHAM ST
Chelmsford MA 01824.
Expiration
Commissioner 03/06/2016