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HomeMy WebLinkAboutBuilding Permit #812-2016 - 25 IRONWOOD ROAD 1/19/2016LIKr10RT, BUILDING PERMIT TOWN OF NORTH ANDOVER �2 5 "-_ �.,, APPLICATION FOR PLAN EXAMINATION _ H Date Received�RA' Permit No#. S Z — % 1 S° ACCoe Ob Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION(�c9rVC.c)L?�% F- 'Print �. PROPERTY OWNER 1 A =5 1Mv Pnnt '' 100 Year Structure fsn MAP PAROEL:$�1 ZONING'DISTRICT: Historic District Machine Shop Village TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building gyne family ❑ Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other `Septic D Wel`I� -�f ❑ F oodoplai`.Wetl s l ❑ ',WateredfD sLnctx f t OWNER: Name: DESCRIPTION OF VVUKK I U t9t rtKrUruvicu: - Please Type or Print Clearly 'AAP :5[Mert--)5 Address: 'S y 1Q©vJ W-z"D R -D Nc9- � 7Fe!W?-15 14/ Contractor Name: e4IFE--1 (-a4 36C f V f N Phone: Email: /meq N V1 N, J3 cel A�D r c -®yr\ Address::.-� Gf'5- f \42kT_ 2) 0-71 Supervisor's: Construction License: -fid Exp: Date..a Home Improvement License: f l mid Exp. Date: 1:;0( _J7 ARCHITECT/ENGINEER' Address: "Reg. No. FEE SCHEDULE. BULDING PERMMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ��/ �� FEE: $ Check No.: Receipt No.: NOTE: Arsons contracting wf unregistered contractors do not have access to the guaranty fund 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 4, Copy of Contract 4� Floor Plan Or Proposed Interior Work 4. Engineering Affidavits for Engineered products OTE: 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 . TE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products TE: 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 J Plans Subrnitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swmmnmg 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature E„ COMMENTS. Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments r Conservation Decision: Comments Wafter & Sewer Connection/s mature Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street HOCaieCt rail 1%14 M_aln Stf2et� Fire Departmen signet e/date, °T ` . �. �.. „•.�,v,.�I it • xf, . 4 r ,C:,>!"X? iY1'ar fii� >s .' ctiaa ENT ; =' n ?, *t COMMS - z t. - - i Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector yes No ®ANGER ZONE LITERATURE: yes No MGL Chapter 166 Section 21A —F and G min.$10o-$1000 fine Doc.Building Permit Revised 2014 Location �l No. z>(2 —Z.c�� Date Check # 2991 TOWN OF NORTH ANDOVER Certificate of Occupancy $� Building/Frame Permit Fee $ i... Foundation Permit Fee $ Other Permit Fee $�_ TOTAL $i�,—_ Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 14,700.00 m $ - $ 176.40 Plumbing Fee $ 22.05 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 22.05 Total fees collected $ 320.50 25 Ironwood Road 812-2016 on 1/19/2016 Bathroom in basement v C � CD CL C.L �• N �0�, vCD CL — CD CDD 0 W W C CD C 0 C• C � v 0 z CD 0 � 0 70 (D B 0 `D c� �� z r m m Cl) Cl) �. 0O.m z iC cn � rn ic cn 0 Cl) C Cl) Z Z 0 -r - O D O z h S CD N O O cm O Q. c N 0 :i cn U) CD3 o�. � OCA y = <CS 7 Mo CD, � 0 CD n 0 �_nC� � m o ? -Sr- ON rt-- O T O O � m W D � N p _i CD CD_ O O cD Cl) co 0- O rt y- Cv :w O =r C9 SCD S CD CD 'p A p0 O CO O0N O 0, a %� •�+ ;moi �- 0= C o CC 0 Cn N o CD D ( CL °° CD � `° 07 l�D 0 O rt o CQ � 0 C �� O � . ��.• r CD CD 3 CD :as CDo N O -h — _O rt CD � � w C'1 a1 O O � C O K N 1 In N O rr Z O W O flD T ,Z7 O Q T 7 In n• O Oq Z, T x 0 Qq T n (DS x OU T 3 (n to T Q rtN T m m z H M q O n � Z M m C W Z Z M m C G C Z m M 0 NW W p O m m = s Homeowner Information ;b roti► ;T Street Address (do not use a Post Office Box address) Contractor Information Contractor/ Salesperson/ Owner Name Ar, my City/Town State Zip Code Business Address (must include a street address) NSA Gil F `f 4S i cr -5— —1)&/-c-- 5'-i'— to �°r ✓ ;P� �fl i i� Daytime Phone . Evening Phone City/Town State Zip Code Mailing Address (It different from above) r-- Business Phone I Federal Employer lu or J.J. Numner +Home Improvement Contractor Reg Number Expiration date Low requires that most home ' improvement contractors have / ^7 a valid registration number / ) I ct C( 0 2,I / I ) / The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.) Required Permits - The following building permits are required and will be secured by the contractor as the homeowner's agent: (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A.) Proposed Start and Completion Schedule - The following schedule will be adhered to unless circumstances beyond the contractor's control arise Date when contractor will begin contracted work. /(i G? oa ROBERT LANGEVIN MEN Building & Remodeling, LLC 795 Dale Street North Andover, MA 01845 (978) 686-3607 HIC # 111990 FID # 26-0816298 www.LangevinBuilding.com Job Description Mr & Mrs John Simons 35 Ironwood Road North Andover, MA< 01845 Bathroom in the Basement 1. All necessary permits 2. Concrete cutting to access drains in floor and refill concrete 3. Plumbing rough -in and finish installation 4. Framing of partitions and strapping on ceiling 5. Blueboard and skim coat plaster on walls and ceiling 6. One passage door for closet, wooden baseboards, closet shelves, custom built vanity 7. Vent the ceiling fan to the outside 8. Install floor tile 9. Paint all surfaces 10. All cleanup and trash removal Note: The following items are excluded from the job and not included in the cost: All electrical work and supplies, finish plumbing fixtures ( shower base and walls, shower valve, sink, countertop, and faucet, toilet, light fixtures and ceiling fan Signed'�7/ Date V(15-// / The Commonwealth of Massachusetts ! Department of Industrial Accidents Office of Investigations 91 �•` / ' 600 Washington Street a ; N 02111 �31 ;15 Boston, MA i www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APPHcant Information PleasePrintLegibly 1r Name (Business/Organization/Individual): NC`s 1 i�G RE-W) Address: —7 9 D A�Lf 5 -r- City/State/Zip: 0 o f,-rA N� V -E -f?, Phone #: J 7 9 G ?'6 -3 !(© 7 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).' have hired the sub -contractors 2.'E2Q am a sole proprietor or partner- listed on the attached sheet. $ s ip and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. OReEffi odeling 8. ❑ Demolition 9. [—]Building addition 10.2"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. #:, Expiration Date: Job Site Address: City/State/Zip: 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 fonn of a STOP WORK ORDER and a tine 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 certXy undet4he pains and penalties of perjury that the information provided above is truf and correct U F 4�9-6 36°7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # )1 / /9' 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 #: o® CERTIFICATE 4F LIABILITY INSURANCE I > f'HOL. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND OR ALTER THE COVERAGE AFFORDCONFERS NO RIGHTS UPON THE ED ATO . ,BY THE POLIC EIc5 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, 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(ias) must be endorsed K 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 canter rights to the certificate holder in lieu of such andorsemerd(s Via+_ Edward W Hays PRODUCER Hays Insurance Agency Inc. 38 Hawthorne Ave. Methuen Ma 01844 INSURED Robert D Langevin 795 Dale St haysinsu rance®comcast.net & Dedham Mutual Fire Insurance Company North Andover Ma 018x5 INSURER F: COVERAGES CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURI INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ( PO LIG F FOUCY EXP NSR L TYPIC OF INSURANCE a POLICY NUMBER MM D M Dmrvr X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR A R051435TA 10/25/2015 10/25/2016 EGEN-L AGGREGATE LIMIT APPLIES PER: POLICY E]j� LOC AUTOMOBILELULBIUTY ANY AUTO AALSWNEO AUTOS NON-OWNEO HIRED AUTOSRsCIIEOULFO AUTOS UMBRELLALIABI OCCUR EXCESS LIAR IH CLAIMS WORKERS COMPENSATION AND EMPLOYERS' UABIUTY NIA In OESCRPTION OF OPERATIONS I LOCATIONS I VENICL.ES (ACORD 101, AddlOonal Romarke 4chodule, may be etteCFed IF MOM &Paco le M46 Carpentry .0 Iuevn, !D NAMED ABOVE FOR THE POLICY PERIOD )OCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS. LIMITS EACHOCCURRENCE S 1,000,000• TO RENTEC egrMISES Ea occur n S 100,000. MED EXP (Any one peleon S 5,000. PERSONAL A ADV INJURY S 2,000,000. GENERALAGOREGATE S 2,000,000. PRODUCTS - COMPIOPAGG S 2,000,000. S COMBINED SIN IT S Ea 1 1i BODILY INJURY (Par peBon) S BODILY INJURY (Per eccldent) S PROPERTY DAM g Por aeries S EACH OCCURRENCE S AGGREGATE S S PER DTH• STATUTE R E.L. EACM ACCIDENT S E.L. DI8EA6E • EA EMPLOYEE 5 FL, DISEASE: POLICY LIMIT S red) c ne- d 3 ®. R 1 (T. ,�pJ ]� _ f SHOULD ANY OF THE ABOVE 0E3CPJBED POLICIES 6E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 0 5 C- « 0 r� s^T AUTHORD ED REPRESEN VE rnA .T�� 139-2014 ACORD CORPOFDMON. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ��r. �,t�z»trrrtoe/z�i�t�C'i�lt / 11 Office of Consumer Affairs & Business Regulation ' OME IMPROVEMENT CONTRACTOR #tegistration 111990 Type: ?Expiration. _-?11.1#2017_ LLC ROBERT LANGEVIN BLDG & REMOLDING LLC. ROBERT LANGEVIN 795 DALE ST g �� N ANDOVER, MA 01845 Undersecretary 9 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor ee License: CS -002685 ROBERT M LANG)EVIN 795 DALE ST N ANDOVER Mk 01845' =- Expiration Commissione.- 02/2412016