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HomeMy WebLinkAboutBuilding Permit #29-15 - 27 DEWEY STREET 7/9/2014 BUILDING PERMIT O NORTH*STEED q�O TOWN OF NORTH ANDOVER 0? y, - °� APPLICATION FOR PLAN EXAMINATION � 4 Permit No#: Date Received gDgwTED "SSq�H�s�� Date Issued: C IMPORTANT:Applicant must complete all items on this page t - LOCATION Pfint PROPERTY OWNER An 4U)(.- _ Ll. , D4 Print MAP �a_ PARCEL: _ZONING DISTRICT TYPE OF IMPROVEMENT PROPOSED USE !�k Residential ❑ New Building $One family ❑Addition ❑ Two or more family ❑Alteration No. of units- ❑ Repair, replacement ❑Assessory Bldg_� CJl►Z — ❑ Demolition ❑ Other ❑ Septic ❑Well, ❑ Floodplain ❑V\ ❑Water/Sewer G��r DESCRIPTION OF WORK TO BE PERFORM c� ED: WI D err A i i 1 \q t4 m- wvl Ce`a t clL a S 54. � r v ke ',roat e)(i5-'rin t2,0 � . (=o, oye-C. SG Identification- Please Type or Print Clearly OWNER: Name: ArALy� I- L L Phone: 614- Address: PC 'Stn qq5 teLo VL5bor ru• Contractor Name: ti s + - Phone: _���s- �1�'- � ��.. Address: Supervisor's Construction License: C r—A,_- O N 3 _ -Exp. Date:_ ,I ) Zt,1 - ' Home Improvement License -L.D744� Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULD/NG PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ � FEE: $ Check No.: _ � (4P 6(1�0 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r Signature of Agent/Owner Signature of contract o BUILDING PERMIT of No DT bgtio TOWN OF NORTH ANDOVER ham''`- ` ' '° ° APPLICATION FOR PLAN EXAMINATIONso Permit No#: Date Received ��gwreo�Pp`,�5 / 9SSACHUS�� Date Issued: ® l IMPORTANT: Applicant must complete all items on this page LOCATION` _ _ " _ 41 Pant PROPERTY OWNER_M l<l~t '._ L t, - LLPnnt s 100 Year Structure yes no MAP _PAR CEL:_ z_T ZONING DISTRICT: Historic District yes no Machine Shop Village 2 ,yes no 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 Septic ❑Well ❑ Flood AginY [I Wetlands Vllater`sned District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 53W%J) e—K uA-041 V V N A L C-Ysr—i Ce-,'kl , o15 -,A ex�SN� fZ,o Identification- Please Type or Print Clearly OWNER: Name: AMLy Ic t- L L Phone: (614- 8(O ( 'q-19 Address: PC Sox q45 Feu' K-5)0 )r r1G. 6(14(c Contractor Names t - - Phone: - Address: 4 n4et Supervisor's Construction License 'k �* Exp. Date:..J JW 4 HQme)mprovement License ARCHITECT/ENGINEER Phone: Address: Reg. No. s FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 2 = FEE: $ I • I Check No.: (4p No.:- � �- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I Signature of Agent/Owner Signature of contracto =_ _ _ Location tt No. —1 Date • - TOWN OF NORTH ANDOVER s " Certificate of Occupancy $ Building/Frame Permit Fee r7 Foundation Permit Fee $ � Other Permit Fee $ TOTAL $ P Check# D ' 50 f 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 Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature A COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments s 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.$100-$1000 fine NOTES and DATA— (For department use) ❑ 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 Li 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 Li Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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) o 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 ❑ 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:Building Permit Revised 2014 NORTH Town of A No. * ;T.., - y h ver, Mass,JA 2 oLAK6 1. COCKICN/WICK V R^TED U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ................ !! ........IIAM............ .................................................. BUILDING INSPECTOR . ............... ..... has permission to erect .......... buildings on ...� �1.!J Foundation ........Xing .... ......... ..... ...�.......................... Rough - C ;a to be occupied as .. ... ...��lL7.. .. ..�.. ....... ... .........� .. ...... ... . .... ....... Chimney provided that the person accethis erf it shallineve r s ct conform tot a terms of the lic ionp p p rY p Final on file in 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 CONSTRI STARTS Rough Service ro................................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Smoke Det. ne Commonwealik oflMlassachuse#s - Deparim nt of lndifstriglAccid,e its . Office of.Investigations 600 Washingion Street .Boston,MA 02111 vmmass govldia W0 rkexs'Compewationbsuran.ce Affidavit:Buffdere/Cont°acFoxsfElectrxczans/PIumberp A.pplxeant ormation Please Prim;Le�xbly Name(Business/OrganizationlXndividual): a(I G au i\Ae1ss Address: tel w 1 A� .ey '�?► lG C�l Ci /State/Zip: Phone#: �Y . .Are you an employer?Check the appropriate box: Type of project(regm1red): 1. 1 am a employer with -3 -. 4• ❑ 1 am a general contractor and 1 6. ❑New construction F employees(RM and/or pmxt✓time)* have hiredthesub-contractors 2.[� 1 am a sole proprietor or partner listed on.tha attached sheet� `7• El Remodeling ship and`have no employees These sub-contractors have 8. [(Demolition working forme in.any capacity. workers'comp,insurance. g, El Building addition. [No workers'comp.lnsurauce 5• ❑We are a corporation and its 101]Electrical repairs or additions required.] officers have exerelsed.their right of exemption erMGL 11.❑Plumbingrepairs or additions 3.Cl I am a homeowner doing all work c X52 1 and we have no myself[No workers comp. a§ ( )a 12.0 Roofrepairs insurancerequhed.]i employees.[No Workers' 13.0 Other comp.insurance required.] checks box#1 must also fal outthe section bel6w showingtheir workers'compensagon.poHcy information. xAny applicantthat c Homeowners who checks his affidavit indicatingtfiey bio doing aliworic and then hire outside contractors must submit anew affidavit indicating such. xContractors that cheekthis boxmust attached as gddWonai sheetshowingthe name ofthe sub.-contractors andthokworkers'comp,policy infomlat on. a7n an eX12,1rOyBf thfltiS�IYoYldtllg 1i10Yr{EYs,cDYtZpeiisation insurance formy EYTloyeey- BeloW istheIJOReY anfrJ0.b ite information. InsuxanceCompanyName; I 6G66yS Exp iratioaDate• Policy�Or SCI.L�iT1s.�iC.�; A(T- ��� ��� / . •--�. .. rob Site Address, 2I• Da4z pitylState/Zip_AL. N�i-\V-4 ^ Attach a copy()Me workers'compensationTolley declaration page(showing the policy mmnber and expiration elate). Failure to secure coverage as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a flue up to$1,500,00 andlor one-year impon risment,as wallas civil.penalties in the form of a STOP WORD ORDER and a fine o£up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o£ Investigations of the DIA.for insurance coverage verification. I do hereby cert f wiffor file pains and penalties ofpei,/ury that tree information movided above is true and correct. - S7matare � � � � ,� Date: 71 f llI p 4� :Phone,9: `��" " �15-- S i3 t/3 Official arse only. .Do not write in this area,to be completed by city or town official City or Town: Permit/1Jicense M Issuing Authority(circle one): 1.Board of Health?.BuildingDepartment 3.0ty/Town Clerk 4.Electrical Inspector 5.Numbing Inspector 6.Other - - - Information and Instruction Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an ernployee is defined as 11..every p exson iri the service of another under any contract o fine, express orhuplK oral or•written." An ernplayWis defined as"an individual,partnership,association,corporation ox other entity,or any oxanoxe of the,Foregoing engaged in a joint enterprise,and includingthe legal representatives ofa:deceased employex,.ox tie receiver ox trustee'ofan individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having notmore than three apartments and who xesides thereina or the occupant of6a 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 to cal IZcensing 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have,b eon 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 necegsary,supply sub-contractors)name(s),address(es)andphoxtenumbex(s)along withtheir certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orpartners,axe,notrequiredto carry workers'compensation insurance. IfanLLC orLLP does have employees,apolicyis required. Be advisedthatthis affidavit ay be submittedto theDepartment 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 xequeAed,not the Department of Industrial Accidents. Shouldyou have any questions regarding the law or if you are xequired to obtain a workers' compensationpolicy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance,license number on tho appropriate line. City or Town Of Ucials Please be sure that the afftdavit is complete audpxinted legibly. The Department has provided a space at the bottom of the affidavit fox you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be-sure to fill inthe permit/license number Which-will,be used as a reference number, lh addition,an applicant thatmust submitmultiple permit/Rcense applications in any givenyear,need only submit one affidavit indicating current policy information(if necessary)and under"Jab Site Address"the applicant shouldwxite"all locations in (city or towzr).".A copy dthe,affidavit that has been officially stamped or marked by the city or town may be provided to the applicant aspzoofthat avalidafCdavit•isOnfile-fOxfuturepeimitsorlicenses. Anew affidavitmustbetilled'out each year.Where a home owner or citizen is obtaining a license ox permit riot related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc)said person is NOTxequired to complete this affidavit. The Office of Investigations would Eke to thank you in advance fox your cooperation and should you have any ciuestioxis, please do uothesitate to give us a call. TheDepartment's address,telephone andfaxnumber. T'ho cm-M011- of mlauadhwPtl' Office offAvedigA` ua 6b Wash giionlet Boston,, 02111 TOL RM-2L,4900-22,4900 QA 406 ox 1-87-7-U - Revised 5-26-05 a � YAW-MasmovIdz`a CONTRACT FOR SIMPLE HOME REPAIRS Amlux LLC,desires to contract with,JRC Builders Inc,to perform certain work on property located at: 27 Dewey St.North Andover MA 01845 1. Job Description The work to be performed under this agreement consists of the following:Rider B 941�— 2. Payment Terms /117 T I In exchange for the specified work,Homeowner agrees to pay Contractor as follows(choose one and check the peva*'T appropriate boxes): 0100 ❑ a. $ t © payable upon completion of the specified work by❑cash check ® b. $4,000,payable after the roofing phase is 100%complete and$8,400 after the final phase of the exterior Cf C) project is 100%completed,by❑cash ®check. ❑ c. $ per hour for each hour of work performed,up to a maximum of$ ,payable at the following times and in the following manner: 3. Time of Performance The work specified in this contract shall(check the boxes and provide dates): ®begin on 7/14/2014 ®be completed on 7/24/2014 Time is of the essence 4. Independent Contract Status It is agreed that Contractor shall perform the specified work as an independent contract. Contractor(check the appropriate boxes and provide description,if necessary): ®Maintains his or her own independent business. ® Shall use his or her own tools and equipment 5. License Status Number Contractor shall comply with all state and local licensing and registration requirements for type of activity involved in the specified work. (Check one box and provide description) ® Contractor's state license or registration is for the following type of work andcarries the following number: ❑Contractor's local license or registration is for the following type of work and carries the following number: ry- ❑ Contractor is not required to have a license or registration for the specified work,for the following reasons: 6. Liability Waiver If contractor is injured in the course of performing the specific work,Homeowner shall be exempt from liability for those injuries to the fullest extent allowed by law. 7. Permits and Approvals (Check the appropriate boxes) ®Contractor ❑Homeowner shall be responsible for determining which permits are necessary and for obtaining the permits. ® Contractor ❑Homeowner shall pay for all state and local permits necessary for performing the specific work. ® Contractor ❑Homeowner shall be responsible for obtaining approval from the local homeowner's association,if required. Additional Agreements and Amendments a. Homeowner and Contractor additionally agree that: b. All agreements between Homeowner and Contractor related to the specified work are incorporated in this contract. Any modification to the contract shall be in writing. Homeowner: Dated: ho ' Contractor: Dated: Offr� arivi�za�zca OMu of Consumer gf/airs&g E IFAPROV asrness t t _ egistra;ion: E27E!YT CoNrRgC7gR�uEat.t�` j. EXPIration 1y3/206Q Type t�q riii 5�1 fgJF�s = Indiyiduai t t` DAVIDC s�li4UFt1s 4 HgZELWOpngVE rEIn,Ksi3URY, MA 01878 secrerarS s has Board Co _ Of itDepartment nsrructi�,n�aPc Re9trlations of Pttbiio Safe, Licens tsor i- anti St ./ DA 4�F�}�il� andards Oy DAVE� 0187, - y .. J, •, commissione Expiratio 01/23/2016 OP ID:MH CERTIFICATE OF LIABILITY INSURANCE OATE(M 07/002112/1YYY) 4 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(ies)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 978-975-1300 Iclo,,.ACT Segreve&Hall Insur.Assoc.inc 978-975-7596 PHFAX 305 North Main St AIC NONE o Ext): AIC No): Andover,MA 01810 E-MAIL Patrick D.Hall ADDRESS: PRODUCER JRCBU-1 CUSTOMER ID# INSURER(S)AFFORDING COVERAGE I NAIC# INSURED JRC Builders,Inc. INSURER A:Commerce Insurance Co. 34754 PO Box 911 INSURER B:AEIC 11104 Tewksbury,MA 01876 INSURER C: INSURER D: INSURER E: INSURER F: I 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. rA DL UBR POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER MMIOD MMIDO I LIMITS GENERAL LIABILITY EACH OCCURRENCE Is 1,000,00( DAMAGE—T-0-REN I ED X COMMERCIAL GENERAL LIABILITY BGCGYS 11106113 11106114 PREMISES Ea occurrence s 100,00( CLAIMS-MADE a OCCUR MED EXP(Any one person) S 5,00( PERSONAL&ADV INJURY S 11000,001 GENERAL AGGREGATE $ 2,000,001 GEN'L AGGREGATE LIMIT PLIES PER: PRODUCTS-COMPIOP AGG S 2,000,001 POLICY PWT F RO LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO 1020020157 04108/14 04/08115 (Ea accident) $ 1,000,001 BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Per accident) S A X SCHEDULED AUTOS � PROPERTY DAMAGE HIRED AUTOS (Per accident) S NON-OWNED AUTOS S S UMBRELLA UAB OCCUR EACH OCCURRENCE 15 EXCESS LIAB HCLAIMS-MADE AGGREGATE S DEDUCTIBLE is RETENTION S 1$ WORKERS COMPENSATION X I WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER B ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT 5 1,000,001 OFFICERIMEMBER EXCLUDED? N I A (Mandatory In NH) 500-5011685 01118/14 01!18115 E.LDISEASE-EAEMPLOYEd$ 1,000,00t If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT I$ 1,000,001 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1134S USA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 21 North Street ACCORDANCE WITH THE POLICY PROVISIONS. Burlington,MA 01803 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD