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Home My WebLink AboutBuilding Permit #165-2015 - 270 WINTER STREET 8/6/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 1 ��201 Date Received Date Issued: I IMPORTANT:Applicant must complete all items on this page z _ �,PRQPERTYt"OWNERxl �./ C � Pring 100YearsOltl;Structure� yes; not MAP'N® PARCEL► _ ZONIAO ISTRICT_ HistoriC -1stnct Yes-1nog _ _ 1' I MachlneShop'5Village ye_s nq3- TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Buildingne family � Y ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ S_eptic� .❑Welly F E-1, dplaint ❑Wetlar dsa A +❑ V1latersfiedlDi`strict - +: ❑4Water/S:ewer, DESCRIPTION OF WORD TO BE PERFWMED: Identification Please Ze or Print Clearly) OWNER: Name: »►/ � v �2 Phone: 979-3IV-636( Address: '70 1.c11 rc��-ci2 /t o coli r��2 1'y1�9 �? g � ' �� C.®NTRA&TOR Name tJ- _. �S-CwA� - Phone Aes ddrs ie Tom' r� SupervlsorsConstructioniLicense4e Of L Home Im .rovement,License; c _ Ex Date. / .. ARCHITECT/ENGINEER Phone: Address: Reg. No. J FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 301 FEE: Check No.: Receipt No.: Mel . NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fund `Signature ofµAgent/Owner �.- Sig�atureof contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF.SEWERAGEDISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑. . 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT' ❑ ❑ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments f ;QOnservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit i DPW Town Engineer: Signature: Located 384 Osgood Street FIRE ®LPARTMENf -Temp Dumpster on site yes no Located at'124 Mair.,`Street Fire DepartiheF t-signature/date ` COMMENTS 1 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: ELECTRICAL: movement of meter 16 cation, mast or service drop requires approval of i Electrical Inspector Yes ft90 DANGER ZONE LITERATURE: Yes No I MGL Chapter 166 section 21A-7-F and G min.$100-$1000 fine NOTES and DATA— For department use i - I ® Notified for pickup - Date I Doc.Building Permit Revised 2010 Building Department The fob. wing 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 o 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit Li Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation P.Ian'.Of Proposed Work,With Sprinkler Plan And Hydraulic�Calculations (If Applicable) ❑ Mass check Energy'Compliance,Repo'rt (If Applicable) ❑ Engineering Affidavits for Engineered products DOTE: 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 a 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 appy-al period is over. The applicant must then get this.recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building permit Revised 2012 i l Location t �-A e-,z— No. ( Date f (z-, • - TOWN OF NORTH ANDOVER LED Certificate of Occupancy $ Building/Frame Permit Fee $ � •� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �� Check# 1 7 4 291.67 Building Inspector NORTH Town of N E. .....,, Andover O ` .:�.. 0 No. C Q� T Z � o - L^�� h ver, Mass, 11zl � �� coc..M.". y1' S RA7E0 U BOARD OF HEALTH Food/Kitchen PER L D Septic System A � BUILDING INSPECTOR THIS CERTIFIES THAT ....................... .... ............. ..... ........./. ........ ............... ...................... ` Foundation has permission to erect ...... .............. buildings on . �.® L�!........�. .. . ..... ..... ..... .. 0*0 Rough to be occupied as ... ........ . ... .... � ..�...1�!�r!J Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application 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 CONSTRUCTION STARTS Rough Service ................................. u... .. *._..1.......... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. MOYNIHAN-NORTH READING LUMBER, INC. "QUALITY BACKED BYA DESIRE TO PLEASE" 164 Chestnut Street FEIN:04-2261995 North Reading, MA 01861 A&A Contractor Reg No.: 978-864-3310/781-944-8500 Exp.Date: Salesperson(s): HOMEOWNER INFORMATION Name Daytime Phone C� 7o C,tJi&,rl--e ✓z Street Address(Not P.O.Box) Evening Phone Cityfrown State Zip Code Mailing Address(if different from Street Address) WORK TO BE PERFORMED AND MATERIALS TO BE USED Moynihan-North Reading Lumber, Inc. agrees to perform the work set forth in Exhibit A for Homeowner and to use such materials in connection therewith as set forth also in Exhibit A,attached hereto and made a part hereof. The following schedule shall be adhered to unless circumstances arise beyond Moynihan-North Reading Lumber, fnc.'s control:Work scheduled to begin: — Expected date of completion: —T — May be based upon arrival of special order material TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Moynihan- North Reading Lumber, Inc. agres tQWform the work, and furnish the material and labor set forth in Exhibit A for the Total Contract Price of: $ (which amount includes all finance charges). Payments shall berade by Homeowner according to the following payment schedule: $ 1 V9P J Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of one-third (1/3)of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom Orders as set forth below). $ V9,0,Eby—/—L—or upon completion of delivery of materials $ ,G by_/ / or upon completion of install $ upon completion of the Contract In order to meet the completion schedule set forth above,the following materials/equipment must be special ordered before the Contract work begins,for a Total Cost of Special/Custom Orders of$ $ to be paid for b 'ding permit $ Zai to be paid for V sfjAllcs2 __1 $ to be paid for DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES 7 / d 7-0 P Moynihan-North Reading Lumber,Inc._ Homeo' er's Signature Date Contractor Date Nan 'u C i-y4Lty/ By: Dale Fuller Homeowner's hame(Printed) Installed Sales Coordinator You may cancel this Contract if it has been signed by a party thereto at a place other than an address of Contractor,which may be its main office or branch thereof, provided you notify Contractor in writing at its main office or branch by ordinary mail posted, by telegram sent or by delivery, no later than midnight of the third business day following the signing of this Contract. See attached notice of cancellation for an explanation of this right. See reverse side for additional Homeowner Terms and Conditions 1057-NR 1/11 White-Office Yellow-Sales/Service Pink-Customer Page 1 of 5 Y ai _ . MOYNIHAN LUMBER BEVERLY NORTH READING PLAISTOW 164 ChesMut Street 12 Old Road 82 River Street P.O.Box 1160 P.Q.Box 509 P.O.Box 128 Beverly, ox 0915 North Reading,MA 01864-0128 Plaistow,NH 03865 (978)664-3310•(781)944-8500 (603)382-1535 (978)927-0032 FAX:(603)382-1935 FAX(978)927-8201 FAX:(978)664-0872 Subcontractor Workers' Compensation Waiver IShawn Arsenault ,. hereby acknowledge that 1, as an independent contractor; have been asked by Moynihan Lumber Company to provide it with a certificate of Workers Compensation Insurance coverage for myself. Based on the exemption provided by the Worker's Compensation Insurance coverage for myself because I am a sole proprietor without employees. Therefore, I hold Moynihan Lumber Company and its related organizations and the Arcadia, Insurance and or Self Insured Lumber Business Association, Inc. totally harmless for any injuries or cost of injuries incurred by myself because l have voluntarily chosen to exclude myself from coverage by engaging the exemption provided under the Worker's Compensation Laws. I have taken this option of my own free will. Witness Sigrta Date: 2 Y / <� "QUALITY BACKED BY A DESIRE TO PLEASE" .ti The Commonwealth of Massachusetts Department of Industrial Accidents u Office of Investigations ' a 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Shawn Aresnault & Eric Arsenault d/b./a_ Arsenault Brothers Construction Address: 105 Hamilton Street, 1st Floor City/State/Zip: Leominster, MA 01453 Phone.#: 978-514-4848 Are you an employer? Check the appropriate bog: Type of project(required): 1.® I am a employer with 3 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance. $ 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 131-1 Other comp.insurance required.] *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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Travelers Policy#or Self-ins. Lic.#: IHUB6B90875713 Expiration Date: 04/02/1,6 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��e�s%� z Date: Phone#: C17 P Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# 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#: ✓"� ARSEN-2 OP ID:NS CERTIFICATE OF LIABILITY INSURANCE DA08105120151� 08105/2015 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 CONTACT NAME:Anderson,Bagley&Mayo PHONE aInsuranceAgncy,Inc. , Ext): C No): 44 Main Street,P.O.Box 360 ADDRESS: Leominster,MA 01453 Richard M.Bagley INSURER(S)AFFORDING COVERAGE NAIC# INSURERA.Charter Oak Fire Ins Company 25615 INSURED Shawn Arsenault& INSURER 13:Travelers Indemnity of America 25666 Eric Arsenault INSURER C:Travelers Arsenault Brothers Constructio 105 Hamilton St 1st FL INSURER D: Leominster,MA 01453 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRR hDDL TYPE OF INSURANCE R POLICY NUMBER MOMILDD EFF MIDDY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DA AGE ToRENTED B X COMMERCIAL GENERAL LIABILITY 16805583M546ACJ15 0810112015 08/0112016 PREMISES Ea occurrence $ 300,000 CLAIMS-MADE F_y__1 OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY F PRO LOC $ AUTOMOBILE LIABILITY EO aBBINEOD SINGLE LIMIT $ 500,000 A ANY AUTO BA-8672A678-14-SEL 08/26/2014 08/26/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X TORY LIMIT ER AND EMPLOYERS'LIABILITY C ANY PROPRIETORIPARTNERlEXECUTIVE Y/N IHUB6B90875715 04/02/2015 04/02/2016 E.L_EACH ACCIDENT $ 100,00 OFFICERIMEMBER EXCLUDED? F—] NIA ---- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE--POLICY LIMIT $ 500,00 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Moynihan Lumber Co. ACCORDANCE WITH THE POLICY PROVISIONS. 164 Chestnut Street North Reading,MA 01864 AUTHORIZED REPRESENTATIVE Richard M.Bagley ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD �QLL�CllIG/Z 6��(/GLlJdC2Cl7 LLde�i1 Office of Consumer AffaJ72972L192irs&Business Regulation V'ME IMPROVEMENT CONTRACTOR gistration: 171474 Type: piration: „3/21L 016_,; Individual SHAWN ARSENAULT SHAWN ARSENAULT '; 24 GRAHAM ST LEOMINSTER,MA 01453''``= y Undersecretary 11f NI ass acnuseri5 - Depai` j-1 ti � � Board of Building Regulations a.,a u �,St.a:.n ,..ards Construction SuppLicense- CSFA-106031 .`, SHAWN ARSENAi3LT — 105 HANIILTON STREET r:; _ ,, Leominster MA 01153 Expi;atiOn Commissioner 08/24/2016 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston--- 0211 b N' Home Improvement Co or Registration Registration: 136860 Type: Private Corporation Expiration: 9/6/2016 Tr# 255814 MOYNIHAN NORTH READING LUMBER I DALE FULLERS PO BOX 128 - R� R.�� •;,,.�� ;amu_� l�;�f N. READING, MA 01864 \• .Y""-�`..�`.-.rte ' Update Address and return card.Mark reason for change. Address F] Renewal ❑ Employment ❑ Lost Card