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HomeMy WebLinkAboutBuilding Permit #71-15 - 250 BLUE RIDGE ROAD 7/22/2014Permit Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION J��I Date Received__ ANT: Applicant must complete all items on this LOCATIONul�rc K� PK't PROPERTY OWNER IVA/I yes Print 100 Year Structure nn MAP J PARCEL :1'-- ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF VVUKK i U tat rtKrUKivitu: OWNER: Name: Address: d 5-0 Contractor Name. - Please Type or Print Clearly hone: Phone: Address: Supervisor's Construction 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. r Total Project Cost: $q©Q - FEE: $ �3 Check No.: 0)0 Ii 8 Receipt No.: 'T NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 12-Z Location � ����. No.:7) /—/ Date t% Check # a U Gl1��i TOWN OF NORTH ANDOVER Certificate of Occupancy $_ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Signature Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decisio Comments Comments Zoning Decision/receipt submitted yes 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 IVU i is and UA I A — (For department use ❑ Notified for pickup Call Ema 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 ❑ 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 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 2014 The Comonveurih of -n assachuseits Depa.��rnen�of�nc��c��rcclAcczc�en�� Office of l'nvestigations 660 Washington Street .Boston, .MA 02111 vmmussgovIdliz Workers' Compensation insurance Affidavit: BuRderce/Conti°actorslEfectriciansl ?!*PerP Name (Susinesslorgedzationli'nldividud): 2e Address: A0 City/Stade/asp: Phone Are you an employer? Cheek the appropriate boy: Type of project (required): 1. ❑ S am a employer with 4. L91 am a general contractor and I 6. New Onstmetion f employees (10zllandlorparitime)* have like d the mb-contractors 2. Q S am a sole proprietor or partner listed on the attached sheet T 7• � Remodeling ship and`Javena employees These sub -contractors have 8. []Demolition working forme in any capacity. workers' comp. insurance. 9. ❑ Building addition [No Work -Ors, comp. insurance S. ❑ We are a corporation and its 101] Electricalrepairs or additions required.] officers have exercised.their 3. [] i am a homeowner doing all work right of exemption per MGL I1..[] plumbingxepah or additions myself:: Lb workers' comp. c.152, §I(4), and wehave�a 12.P Roofxepairs insurancerequixsd.� Ti employees. [No workers' 13.0 Other comp. insurance required.] Any wlicantthat checks boxgl mustalso fill ouithesergon bel6w showingtheirworkers' compensationpolicy information. i Horneowners who sdmittWg affidavit indi(;atingthey kdoing allworlt and then hire outside contractors must submit a new affidavit indicating sizoh. xCostractors that cheekttus box mast attached an additional sheet showI the name ofthe sub-eontracfors andthekworkers' comp. policy Holmation. I aln are ernproyet'that isp oviding orkers' compensation insurance forxny ernproyees 3eroty isihe olicy ancij0B site information. , Insurance Company LA),as, , policy # or Selz ins. LIG. #' �i O ,f tt) � 1° �l' i Expiraizon Date: lob Site Address D �v tyateLZip: Al, 47-14 Lp— -A.tiach, a copy of tete woxkers' compensatiowpoliey tleclaration. page (show9ng.the policy number and expiration date). Failure to secure coverage.as requirecl.under Section 25A ofMOL 0.152 can lead to the imposition of erinikalpenalties of a true up to $1,500.00 andlox one-year imprisonment, as well.as civil penalties in the form of a STOP WORSE ORDER and a n e of-ap to $250.00 a day against the violator: Be advised that a copy of this statementmay be forwarded to the Office of investigations ofthe DSA. for 1BUranGO coverage veriRcation. ,t do Ilereby cer.1gy,e Ali tns�ancl en ties ofpe.-py Mat i1ie informrr ion pYoviriedabove is true and correct n�fP• -7 Phone # Ofit-ciai use only. Do not write in this area, to be eorrtylefed by city or town official City or Town: I'ermit/Lzcense Issuing Authority (circle Oise): 1. Board ofkrealth % Building 1)epartment 3. Citylfo" Clerk 4. Electrical Inspector 5. Plumbing Inspector f. Other KW a14"" _r a ,ice ssl�. :.■rte +■ M11 c°a- gm M; �rlRr[a� dr lawzw ■ 1 aaam. ■ �ltt:�. ■ ■ L A. •moi T rw r rr . saH � A—Wa-K—t- rlaad. . B111111111..+1f- _ t :t ;!•� yt:� f f w- Oq . C O H C, 0 C Cc O CO CL d cca y d E a L y °' c a� CD L +•' y " 3 Q J i m • � c • > R L C O y C1 O =d O y — � 070 �"a y N =mb.om 00 d yz *moo` CL =o a • � •y C y-• • 3 = o Fo L _ Q Q. y.J ff � •a �% Q i L Cc _ Q O � t 2 uuO O CL 0 V V W c� V QO O N O •> ;�_ U) -0 O I- t 0 . a00 O W :a Z z m za G coo Lu li ) . a Z w0 � U W LLI —i a Z M 1 dWIAMV on dasop rM7 o� r >1 i o CL CL a� Q 's = J -0 O '(1) Z CL �.r 0 O 0 z a w Wa a W ui 2 a Z H N Z u a. LL Z a Z Z u W J m F• N Q W m C E • W LL N N m C d J W T cn O " T O Z \ U 'a t CC = C L :' t U O L ++ Y O O O Q O1 O O L C O O C =$7 O N C O C i N 7 E LL N LL 4' U LL Q' LL OC N LL K LL m In N 0 C Cc O CO CL d cca y d E a L y °' c a� CD L +•' y " 3 Q J i m • � c • > R L C O y C1 O =d O y — � 070 �"a y N =mb.om 00 d yz *moo` CL =o a • � •y C y-• • 3 = o Fo L _ Q Q. y.J ff � •a �% Q i L Cc _ Q O � t 2 uuO O CL 0 V V W c� V QO O N O •> ;�_ U) -0 O I- t 0 . a00 O W :a Z z m za G coo Lu li ) . a Z w0 � U W LLI —i a Z M 1 dWIAMV on dasop rM7 o� r >1 i o CL CL a� Q 's = J -0 O '(1) Z CL �.r 3 Hodgson St. Residential/Commercial Tewksbury, MA 01876, Masonry Ph: (978) 656-8497 Vincent Colangelo Free Estimates Lic. #170575 ROOFING Fully Insured Proposal Submitted to Homeowner Work To Be Performed At Name Street 5o Blue R da e d Street <A AI F — ' of City %U,, A n aoutr State City State Date Telephone q-79-G8'7-01.S/ Telephone_A"r'r: [)!3n !E%fns Complete Description of Work to be Performed: Af e r qP o F; C e ckAd -Z' 4- A 1 e L� C f2r `eI Q t'no , P '/1' �r 4 e- 5 t' e l :,1 Q -5 e r .� ' 1r r e� /'fp , e+ �r f S r f"r' rS _ wood Date work will start Date work will be completed All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from the above specifications must be made in writing on an Add-on/Modification of Contract form and may become an extra charge over and above the amount stated herein. This agreement is contingent upon delays beyond our control. Owners to carry fire, tornado and other necessary insurance. Our workers are fully covered by Worker's Compensation Insurance. Homeowner agrees to pay for all work as set forth below. If the homeowner defaults, homeowner agrees to pay all costs of collection, including reasonable attorneys fees, in addition to other damages incurred by contractor. Full Payment is due upon completion of work. We propose hereby to furnish material and labor - complete in accordance with the above specifications, for the sum of: dollars ($ / 0 / RQQ - �. Said amount shall be paid as follows: As 54 c-�;m,, s 00- (TV Note: This proposal may be withdrawn by us if not accepted within days. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT. THIS SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT AND THE HOME IMPROVEMENT ACT THIS INSTRUMENT IS NOT NEGOTIABLE. Work will not begin until your right to cancel has expired and you have paid a it dollars ($ ), unless this agreement provides o Signature of Contractor or authorized representative: *(VWe) have read the terms stated rein, the hav een plained to (me/us), and (VWe) find them to be satisfactory and hereby accept them. Signature of Homeowner(s): v✓`-'— ACORV CERTIFICATE OF LIABILITY INSURANCE DATE(MINIDDIYYYY, 4/2/14 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 Angela Westen Insurance Agency 557 Central Street Lowell, MA 01852 CONTACT NAME:PHONE FAX (978) 735-4094 A/C. Nd: (978) 735-4095 E-MAIL ADDRESS: ancjela@awesten. com L021008696 3/18/14 INSUREPAS) AFFORDING COVERAGE NAIC ti INSURER A: ATLANTIC CASUALTY INSURANCE CO DAMAGETO RENTED occurrence)$ 100000 INSURED INSURERB:HARTFORD UNDERWRITERS INS COMP FO CONSTRUCTION CORP. 40 READ ST. INSURER C: INSURER D LOWELL, MA 01850 INSURER E: INSURER F: AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS _ AUTOS 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POUCY NUMBER POLICY EFF MIDDIY POLICY EXP hM/DDIYYYY LIMITS A GENERALLIABILITY �(PCO—MMERCIALGENERALLIABILITY CLAIMS -MADE DOCCUR L021008696 3/18/14 3/18/15 EACH OCCURRENCE $ 1,000,000 DAMAGETO RENTED occurrence)$ 100000 MED EXP (Anyone person) $ rj000 PERSONAL BADV INJURY $ 1,000, 000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER POLICY PRO LOC PRODUCTS - COMPIOPAGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS _ AUTOS COMBINED ISINGLELIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ eraccident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTNE OFFICERIMEMBEREXCLUDED? (Mandalory in NH) K yes, describe under DESCRIPTIONOFOPERATIONS below NIA 2E112068 3/30/14 3/30/15 tNC STATU- OTH- IZY I InFR E.L. EACH ACCIDENT 100,000 EL. DISEASE -EA EMPLOYEE 500,000 E.L. DISEASE -POLICY LIMIT $ 100,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: VINCENTCOLANGELO@ SBCGLOBAL . NET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CD ROOFING ACCORDANCE WITH THE POLICY PROVISIONS. VINCENT COLANGELO AUTHORIZED REPRESENTATIVE 3 HODGSON ST. TEWKSBURY, MA 01876 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: VINCENTCOLANGELO@ SBCGLOBAL . NET \ G (0) f 2 ® °& \ oz ? e ..�.. LLJ § / I / / \ \ � Q / / / � • > z \ m £ # m ^ ) r© mLk E�2 • �. .,\/\■a� �37U - , . \ \ \ $ j \ . ,\..d a�/ o @ z I�® / 2 { ! .) $0� � �..V) G (0) f 2 ® °& \ LLJ § -0 U) /§c « § I / j 4h w g gra, { k 0` �37U - J :) ƒ \ .) $0� 2 >m� .� Information an Instructions Massachusetts General Laws chapter l52 xequires all employers to provide workers' comp ensation for their employees. .Pursuant to this statute, au erg,, ployee is defined es "...every person in the service of an under any contract o�kxire; express or haplied, oral or wxittem." An eraT%yei is defined as "an individual, partnership, association, corporation or other legal entity, or any two oxmOre ofibe oregoingengagedinajoiutenterpxise,andincludingthelegalxepxesentativesofa•deceasedemplo e�.ortbe receiver ortt 6tee of an. individual, partxtership, association or other legal entity, employing employees. � lv aver the owner of a dwellinghottsehavingxiotmoxe thanthree apartments and who resides therein, orthe occupant ofihe dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or onthe grounds or building appintanaut thereto shall not b0caus0 of such employmentb0 doamedto be an employer." MUL chapter 152, §25C(6) also states that "every state ox local JZc-easing agency shall witTihold the xssuaUce ox renewal of a license or permft to operate a business or to construct buildings M the commonwealth fox any applicant who has not produced•acceptable evidence of compliancewith the insurance coverage required;' Additionally, Ma chaptex 152, §25C(7) states "Neitherthe commonwealthn0 any ofits political subdivisions shall enter into any contract for the performance ofpubiic woxkuniil acceptable evidence of compliance wzikz the insurance requirements of this chapter haveb0onpros ante dto. tbeconiractingauthority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your sitaation and, if iiecess*' supply sub-contractox(s) name(s), address(es) andphonenumber(s) along with their certificates) of insurance. f-MtedLiab!Ui rCompanies (LLC) or LimitedLiabilityPartierships (LLP)withn0 employees other thin the, members oxpa mars, arenotrequiredto can7workers' compensationinsuxance. Si anLLC orLLP doeshave employees, apolicylsrequired. Be advised thattbisaffidavit may be, submiiiedtothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the aft�Zdavit the affidavit should b e xetu mdd to the city or town that the application for the permit or license is being requested, )tot the Da�artmeni of industrial Accidents. Should you have any questions regarding the law or if you are xegabd to obtain a *orkers' compensatfonpollcy, please call the Department at the lumber listed below. Solf insured companies should enter their self insurance license number on the appropriate line. City or Town Mcials Pleasebesurethattheafftdavitiscomplete audprintedlegibly. The Depart enthasprovidedaspaceatthebottom oftRe aiftdavitfoxyouta fill outinthe event the Office of Investigations has to contactyouregar&g&a applicant. Please be -sure to fill iuthe permit/Iicense number w7uchwill be used as a reference number. 7n• addition, an, applicant thatxnust submitmultiple permit/Rcense applications in any givemyear, need only submit one affidavit indicating current PORGY information (ifnecessary) and under "Job Site Address" the applicant shouldwxite "all locations im (city or town.)" .A copy of the affidavit thathas been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid aifidavit•is on file dor future p ermits or licenses. Anew affidavit must be filled out each year. 'Where a home owner or citizen is obtaining a license ox p ermit not related to any business or commercial venture U.e. a dog license orpermit to burn leaves eta.) said p erson is NOT required to complete this affidavit. The Office of Investigationi 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 a-nd fax number; Tho CQmMonwt alth ofMa5sar"Aw DOPaidmOtt Qfkdu�ftW Accldort Ofoo QUnVQWpAmm 6b0 W4*11 gran ��xe�i< T01 # 617.7-2,`•-49,00 W406 Qr- 1-877�K Revised 526-05 Fax # 617427-7749