HomeMy WebLinkAboutBuilding Permit #525 - 25 LINCOLN STREET 1/9/2012Permit NO: r
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ On amity
❑ Addition
wo or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair., replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
0 Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
or Print Clearly)
OWNER: Nam
AdfirP-,s-
CONTRACTOR -Name: _ Phone:
Address:
Supervisor's Construction, License Exp. Date.
Home Improvement License:_
ARCHITECT/ENGINEER
Address:
Phone:
Reg. No
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125..000 PER S.F.
Total Project Cost: $ A 3 __�C) FEE:
J
Check No.:� Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the uaranty d
Signature of Agent/Owner_ z Signature of contract'
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
A .�
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑�
Well ❑
Tobacco Sales ❑
4 t.�
Food Packaging/Sales "k ❑t
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM -
DATE REJECTED
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
Reviewed on Signature
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:
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.$100-$1000 fine
NUTE5 and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2009
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
-
Public Sewer ❑Swimming
Tanning/Massage/Body Art ❑
Pools} ��'
Well ❑
Tobacco Sales ❑
b'r4.. • p p p
Food Packagmg�Sales' ti • Olt
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U P,',ORM
DATE REJECTED
PLANNING & DEVELOPMENT ❑
DATE APPROVED
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: 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 _r _
COMMENTS
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
La . Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
i) Coov of Contract
❑ Floor a
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: Building Permit Revised 2008
Locatio l 6&"� 4
No. Date
AORTR TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
s�CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee �'t�L $�
TOTAL $
Check # gol ^�
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1/9/2012 Time: 12:18 PM To: @ 19786889542
Page: 001
EastPointe Plaza'Y
130 Main St. Suite 103 Aw-F.-O
Salem, NH 03079:
Tel (603)898-6320;
Fax (603)898-8269
The documents accompanying this telecopy transmission contain information which is confidential or privileged. This
information is intended to be for the use of the addressed individual or entity only. if you are not the intended recepient,
be aware that any disclosure, copying, distribution or use of the contents of this telecopied information is prohibited. if
you received this transmission in error, please notify us by telephone immediately so that we can
arrange for the retrieval of the documents at no cost to you.
To: 19786889542 From: Terri Truhn
Fax Number: 19786889542
Subject:
Date: January 09, 2012 Pages: 2
Time: 12:15:46 PM
v
Note:
AID: 1/9/2012
Time: 12:18 PM To: @ 19786889542
Page: 002
ACORN CERTIFICATE OF LIABILITY INSURANCE
DIDDIYYYY)
DD
INSR
1//9/29/2012
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 policy(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
NAMEACT Terri Truhn, CISR ACSR
Foy Insurance - Salem
130 Main St -Suite 103
HNE
o Ell: (603) 898-6320 qIC No : (603) 898-8269
AIC No,
E-MAIL Y
ADDRESS: terri.truhn@fo insurance.com
PRODUCER 00051794
CUSTOMER ID N:
Salem NH 03079
INSURER(S) AFFORDING COVERAGE NAIC#
INSURED
Patrick Connolly DBA
ABSOLUTE HOME IMPROVEMENT
2 BAILEY DR
INSURERA Main Street America Assurance 9939
INSURER B -Ace American Ins CO
INSURER C :
543772
INSURERD:
INSURER E
PLAISTOW NH 03865-2623
INSURER F:
COVERAGES CERTIFICATE NUMBER:2011-2012 Master 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS
TYPE OF INSURANCE
DD
INSR
SBR
WVD
POLICY NUMBER
POLICY EFF
MMIDDIYYY
POLICY EXP
MMIDDIYYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 500,000
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE OCCUR
543772
0/10/2011
0/10/2012
Al R N 500 000
PREMISES (Ea occurrence $
MED FRCP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 500,000
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY P Cj F7] LOC
PRODUCTS-COMP/OPAGG $ 1,000,000
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY (Per person) $
ALL OWNED AUTOS
BODILY INJURY (Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE
(Per accident) $
HIRED AUTOS
NON-OANED AUTOS
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
EXCESS LIABH
CLAIMS-MADE
AGGREGATE $
DEDUCTIBLE
B
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
OFFICER/MEMBER EXCLUDED? r---1
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS bel2t_____t
NIA
STATE : NH
ATRICK CONNOLLY EXCLUDED
6S62UB4778P54011
ONALD CONNOLLY EXCLUDED
/2/2011
/2/2012
$
WC STATU- OTH-
X 0 ITS
E.L EACH ACCIDENT $ 100,000
E.L. DISEASE- EA EMPLOYE $ 100,000
E.L. DISEASE - POLICY LIMIT 1 $ 500,000
ICHOLAS CONNOLLY EXCL
DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CERTIFICATE HOLDER CANCELLATION
(978)688-9542
Town of N. Andover
N. Andover, MA
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
Truhn, CISR ACSR/ST
ACORD 25 (2009/09) O 1988-2009 ACORD CORPORATION. Ail rights reserved.
INS025 (200909) The ACORD name and logo are registered marks of ACORD
massachilnsetts Home Improvement Sample Contract
11
This form satisfies all basic requirements of -die state's Home Improvement Contractor Law (MGL chapter 142A), but does not in standard
language to protect homeowners[ ISeck legal advice if necessary. Any person planning home improvements should first obtain a copy of "A
Massachusetts Consumer Guide to' Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. .
Homeowner Iiformation Contractor Information
Uwe G/
Address (do not use a post 0
(-- f,6 L/4C
State ' Zip Code
Phone
Contractor/ Salesperson/ Owner Name
C' _'.a
Business Address (must inc ude a street
741- 44 S;
- %,rryiiown State Zip Code
Mailing Address (It different from above)
dellel- '1-66 eveyl5,-
Business Phone 7 jG 0 I 3 Federal Employer ID or S.S. Number
Lmv inquires tont most hoHome Improvement Contractor R-.% Number Ex
me
improvement contractors Ilavc
a valid registration number// % % 7
The Contractor agrees to do the foyIowing 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 necessatm,)
Required Permits - The followinglbuilding permits are required Proposed Start and Completion Schedule - The following schedule will
and will be secured by the contractor; as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their 6ivn permits will be
excluded from the Guaranty Fund provisions of
Date when contractor will begin contracted work
MGL chapter 142A.)
�i
L Date when contracted work will be substantially completed.
001
Total Contract Price and Payment! Schedule /
The Contractor agrees to perform the work, famish the material and labor specified above for ell
the total sum of: (�
/ (*)
Payments will be made according to ;the following schedule:
$
ctpon sifining conra(not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater)
$---- __ by /_; or upon completion of
by / /____ or upon completion of
t,om)
i
$ UO upon completion of the contract. (Law forbids demanding fullpyenuntil contract is completed to both
j I amt P party's satisfaction)
The following material/equipment must be special $ to be paid for
ordered before the contracted v61c begins in order
to meet the completion schedule'(**) $
i to be paid for
NOTES: M Including all finance charges (*°k) Law requires that any deposit or down -payment required by the contractor before work begins may
not exceed the greater of ((a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
Expresswarran -Is an resswarran beinsprovidedbytheeontractor.
Subcontractors -The contractor agrees to be solely responsiblhe e for Completionf workdescribed regardless of actions of st be any d to t hd
ctor utilized bthe coontrnc
party/subcontray ntractor. The contractor fin�ther agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this a eement
Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the follo
carefully before signing this contrawing cautions and notices
ct!
• Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear.
• Make sure the contractor has ajvalid Home Itrr rovement Contractor Re istration. The law requires most home improvement contractors and
subcontractors to be registeredliwith the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza, Room 5170 Boston MA 02116 or by calling 617-973-8787 or 888-283-3757.
o Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy of a "proof of insurance" document .
• I{now your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
contractor in writing at his/her mainjoffiice or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the
third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right.
DO NOT SI0GN THIS CONTRACT IF THERE ARE ANY BLSPACES!!!
Two identical copies ofthe contract must be completed and signed. One copy should go ;Oi4itorac
er. The other copy l d bo j op ontractor.
c
Homeowner's Signature
s Signature
2vt l 9 i2
Date
Dae
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
pplicant Information "11-- „ . — ...
Name (Business/Organization/Individual):
Address:
0
City/State/Zip: 1, Phone #:�_a 3 - 3"- /5: _
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. U am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5• ❑ 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.] 1
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10 Electrical repairs or additions ,
11. ❑lum ing repairs or additions
12. Poof repairs
13.❑ Other
rely ap]JM au" u,at c,1ccKs oox ff i musr also tni out the section below showing their workers' compensation policy information.
i 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. #:
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 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 certify under the pains and penalties of perjury that the information provided above is true and correct
Signature:
nate-
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Phone #: