HomeMy WebLinkAboutBuilding Permit #300-14 - 275 RALEIGH TAVERN LANE 10/1/2013 i
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO 'I Date Received
Date Issued:AL
IMPORTANT: Applicant must complete all items on this page
LOCATION
-. rint
PROPERTY OWNER N D TYA&L e,
�. Print 100 Year 01d Structure yes
MAP NO:/ PARCEL: ZONING DISTRICT: Historic District yesno
Machine Shop Village yes no-
TYPE OF IMPROVEMENT PROPOSED USE
Resid ntial Non- Residential
❑ New Building P5ne family
11 Addition F1 Two or more family 11 Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
El Septic ❑Well ❑ Floodplain 0 Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: 620AVW\ &A& ( c;7Phone:
Address: gY7 L-,-(, w -mut--nO )WocF IJA
CONTRACTOR Name: (J �/ � '`�� G� Phone:
Address: -�'"'�` � �2 f't t`�l'I �-eo1 w4sj (U Pk
Supervisor's Construction License: G Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Q r_
Total Project Cost: $ � 0 ` FEE: $
Check No.: �f Receipt No.:
NOTE: Persons contracting wit unre istered contractors do not have access to the g aranty fund
,Signature of Agerit/Owner Sigature of contractor 1
Plans Submitted ❑ ans aived ❑ Certified Plot Plan Eltamped Plans El
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
DATE REJECTED: DATE APPROVED
PLANNING & DEVELOPMENTS ❑ ❑
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'To-tw Engineer: Signature:
Located 384 Osgood Street
FIRE-DEPARTMENT - Temp Dumpster on`site yes no .
Located at 124 Mair Street
Fire Depa'ftent signature/date`
F
A.
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.fiine
NOTES and DATA— (For department use
El Notified for pickup - Date
F
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f
Doc.Building Permit Revised 2010
i
Building Department
The fol@owing is'a list of the required forms to be filled out for the appropriate.permit to be obtained.
Roofivg, 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
NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
o 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
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o 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 apw-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 .
f
NORTH
Town of t E �, Andover
No.
h , ver, Mass, o)bO- Z�
o L6.904
a.
COC NIC c"RNl WICK
�d A�4A"rED 014�,`'�5
S V
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
1 BUILDING INSPECTOR
THISCERTIFIES THAT ........................................... .�.. ..........................................................
has permission to erect buildings on 2.1.5 O ' � Foundation
.......................... ..............A..' � ................� .......o�.
Rough
to be occupied as .............SiAlp......A 10 ................................................................... 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 NTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT STA Rough
Service
............. .. .... .................................................. 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.
SEE REVERSE SIDE
i
The Commonwealth of.tiMassachusetts
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA.02111
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Naffie(Business/Organization/Individual): Al vol,✓L'n
Address: V t 0,Z -
City/State/Zip: -,C" ✓ n,/3- Phone
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ lam a sole proprietor orpartner-
listed on the attached sheet. �• F1 Remodeling
These sub-contractors have 8. ❑Demolition
ship and have no employees -,
working for me in any capacity. workers'comp.insurance. g. ElBuilding addition
[No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers' comp. c.152,§1(4),and we have no
) 12.Q Roofrepairs
insurance required.) employees.[No workers' r
q ] � 13.[JOther csa
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information.
7 Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new afftdavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lam 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.Lie.#: ExpirationDate:
CJ � .1
Job Site Address:��v.� �C � � ty tate/Zip: _
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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.
Ido hereby certiounder tlz ins and enalties ofperjury that the information provided above is true and correct. -
Si ature: /o/, /S;,
Date:
Phone#: "� / / f
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - -
Vnnfarf'Percnn.- _._ Phone 4:
Information and Instructs ons '
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,-
express or implied,oral or.written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of au individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or buildingappurtenant thereto shall Pp ll not because of such employment »
meat be deemed
p y to be an employer.
MGL chapter 152,§25C(6)also states that"every state or local licensing 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 of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been 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
necessary,supply sub-contractors)name(s),address(es)and phonenumber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LL C or LLP floes have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department 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 requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only-'submit one affidavit indicating current
Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or.permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations 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 and fax number:
The ComlAoumalth of J\4_ass0,chv.,sPtts
Depaftevt of faduMat.Accidents
Office oflayestigatiow
60G Washington Street
Boston,MA 021 1 Z
617-727-4900 ext 406 ox 1.-877_MASSAFF
Revised 5-26-05 Fax#617-727-7749
Rightfax N1-1 8/29/2013 5 : 59: 22 AM PAUh ZI uuc raze LjuL YVl
I
CERTIFICATE OF LIABILITY INSURANCE DATE t 129/ DNYYY)
C
TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDE HIS
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 15 WANED,subject to
e terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to
he certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
DAVID E ZELLER INS AGCY PHONE FAC
(AIC.No,Ext): (AIC,No): �
370 LYNNWAY
I
E-MAIL
LYNN,MA 01901 ADDRESS:
25D6D INSURERS)AFFORDING COVERAGE NAIC#I
INSURER A: ACE AMERICAN INSURANCE COMPANY
INSURED
BERRY,FRANK&BERRY,JAMES DBA FRANK&SONS INSURER B:
I
INSURER C:
INSUF.ER D: j
45 WINDBROOK DR INSURER E.
EPPING,NH 03042 INSURER F: �.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
HISS O CERTIFYTHAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ED TO THE INSURED NAM®ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY
PERTAIN_THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS ANO CONDITIONS OF SUCH POLICES_LIMITS SHOWN MAY
HAVE BEEN REDUCED BY PAID CLAMS_
INSR ADD SUBPOLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MNIDDIYYYY) (MMIDMYYYY) LIMITS
GENERAL LIABILITY _ACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ -
I
CLAIMS MADE
OCCUR. EMISES(Ea occurrence)
ED EXP(Arty one person) $
RSONAL&ADV INJURY $ -
GENL AGGREGATE LIMIT APPLIES PER: 3ENERAL AGGREGATE $
POLICY Q PRO.:ECT a LOC =RODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $ i
A14Y AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
(Per person)
SCHEDULE AUTOS ...�__
BODILY INJURY $ �
HIRED AUTOS (Per accident)
NON-OWNED AUTOS PROPERTY DAMAGE $
(Per accident)
f
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
S
DEDUCTIBLE
RETENTION $ $ i
I
A WORKER'S COMPENSATION AND =STATUTORY' OTHER
EMPLOYER'S LIABILITY YM UB-4889P893-13 07!222013 07/222014 X
ANY PROPER rrORIPARTNEP-EXECUTIVE NIA E.L.EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED?
E.L.DISEASE-EA EMPLOYEE $ 100,000
(Mandatory in NH)
r yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONSlLOCATIONSIVE4ICLES/RESTRICT10NS1SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. i
NO PARTNERS ARE COVERED BY THE WORKERS'COMPENSATION POLICY.
(
I II
CERTIFICATE HOLDER CANCELLATION
ALL UNDER ONE ROOF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL U DEL
ATTN:NORMAN JOHN IN ACCORDANCE WITH THE POLICY PRO
30 TEMPLE DRIVE AUTHORIZED REPRESENTATIVE
METHUEN,MA 01844
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORAnghts eserved.
� x
vO
Rene ential & Cmtfflev i3l R z ng All Types Of
1
xpert Masonry Work
x nnsec & ins:.re
�ir.
Mass =O,I License#034200
...,lf� fT•vtrt c3 a rcc: 5r 1 u
1-800- VAI US Jsr osrk year Hotand
(924-8487),
Proposal To: Norm Bagley Date 9/11/2013
Street: 275 Raleigh Tavern Lane 781-245-5017
N.Andover, MA
Roof proposal Z nbagley@lextel.com
4 IKO Cambridge/Certainteed Landmark
1. Extra caution will be taken to protect house 12. Removal of all work related debris. Planks will be
exterior and landscaping as best as possible. placed under dumpster to prevent any damage to
(tarps etc.) Magnets run at final clean up. driveway.
2. Remove all layers of shingles from entire house. 13. Building permit included. Q
3. Inspect and re-nail any loose or lifted plywood. 14.Contractor workmanship warranty: 10 years under
! Any compromised plywood will be replaced at an: normal wind and rain conditions,
additional cost of$55.00 per sheet of 1'2"CDX
fir. Total cost: $ 10,400.00
` 4. Install heavy gauge 8" white aluminum drip edge Both IKO and Certainteed direct extended non
to all eaves and rakes. pro rated 20 year warranties are included in
5. Install 6' of IKO Armourguard ice and water this proposal at no additional cost to our
shield along all eaves and top to bottom in all Angie's List homeowners. Please refer to info
valleys. Full coverage on rear low slope porch. pamphlets in the estimate package.
6. Install IKO roof guard synthetic underlayment to
remaining sheathing up to ridge. If Certainteed MFG. is chosen then all
7. Install all new pipe boots. accessory material will be Certainteed.
8. Install IKO Leading Edge starter shingles to all
eaves. *Note*: Please be advised if applicable,valuables in
9. Install TKO Cambridge AR(algae resistant) the attic should be moved or covered due to minor
Limited Lifetime architectural shingles to entire debris, dust and asphalt particles that will accumulate
house. 15 year non pro-rated warranty by mfg. 10 during the stripping process. All Under One Roof not
year if Certainteed is chosen. All shingles will be responsible for any damage or clean up that may
installed and fastened according to mfg.specs. occur in attic.
10. Counter-flash existing chimney lead flashing, Balance due upon completion
wall connections and skylight with ice and water
shield,tie into new shingles and seal. References available upon request
11. Install a n GAF Cobra ridge vent capped with
color mat d hip and ridge shingles. Highly rated member of the accredited BBB and
Anp_ie's List
Thank you!
A ance of Proposal—The above prices, specificptions and conditions are satisfactory and are herby
accepted. You are authorized to do the work as speci ed. Payment will be made as outlined above.
Location,: ��
Date 0
• • TOWN OF NORTH ANDOVER
. Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
'' TOTAL $
Check#4
2693zt
Building Inspector