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HomeMy WebLinkAboutBuilding Permit #245-2016 - 278 HILLSIDE ROAD 8/27/2015 r DING PERMIT .�;_ •.' o� TOWN OF NORTH ANDOVER ���� APPLICATION FOR PLAN EXAMINATION k Permit NO Date Received ' -.34 - - Date Issued: fT Z? S �Ss.c,wstt IMPORTANT:AAA lli—icantt must co tete all items on this e P. VJ LOCATION clC�s.�W t 1 Q Print PROPERTY OWNER ��m�ti� t-•'O �� ,1 Print`- MAP NOAM—PARCELQ14 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential Fl New Building tone family ❑Addition ❑Two or more family ❑Industrial ❑Alteration No.of units: ❑Commercial epair,replacement ❑Assessory Bldg ❑ Others: ❑Demolition ❑Other U Septic I,Well a Floodplain i�Wetlands U Watershed District ❑Water/Sewer Identification Please Type or Print Clearly) f OWNER: Name: c�s�nr>t,�+P���Q� Phone:9"T&603'4 ( 2 Address: CONTRACTOR Name:.-yam Phone: —16N�1 Address: Supervisors Construction License: SQ�a E�J�3u Exp. Dater Home Improvement License: , t Exp. Date: L ARCHITECT/ENGINEER Phone: Address: Reg.No. FEE SCHEDULE:BULDING PERMIT.,$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$12S.00 PER S.F. Total Project Cost:S �V' FEE: $ Check No.: Ih --;� Receipt No.: "Z4•I NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Age nt/Ow_ r/ Signature of contractor �f 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 4.. 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 OTE: 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4 Building Permit Application 4. Certified Proposed Plot Plan .4. Photo of H.I.C. And C.S.L. Licenses 4 Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 4 2012 IECC Energy code 4, Engineering Affidavits for Engineered products OTE: 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 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) i I ❑ Notified for pickup Call Email 3 - F Date Time Contact Name Doe-Building Pennit Revised 2014 Plans Subrnitbe&S4 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOS Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed Onoma& /5r Signature COMMENTS CONSERVATION Reviewed on 2-CR 16' Si nature l COMMENTS HEALTH Reviewed on Signature COMMENTS Y-J)P�— Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 11 Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ;FIRE .DEPARTMENT Te pi[9=0ster,Ojjjite; ,yaesY lno i i;L'ocatecilaH11,AM4ihi8tre4 Fire{Departmentsignature/date COMMENTS Location No. Date f . - TOWN OF NORTH ANDOVER L EDED • Certificate of Occupancy $ �, Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check���V[�_ rt r Buildin spector 4ORTH To' 'wn of ndover 0 No. - ,� o h ver, Mass, 1 A- COC NINE WI[1c 1' 7�ADRATED ► 5 S U BOARD OF HEALTH Food/Kitchen PER MIT T L D Septic System THIS CERTIFIES THAT10 BUILDING INSPECTOR ................ .. ...... ...................................................... ....�............................... ., Foundation has permission to erec ......................... buildings on ..a ........�k.l. a"04.0.... .... Wddf - l&to be occupied as ..... ............. ......... ......J''�.�....�....��.�t�',i...!ri� ... gney provided that the person accepting this permit shall in every respect conform to the terms of the applicati n 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 aMONTH ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOS 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. 0 JMF Construction Georgetown, Massachusetts john M. Floyd: 978.833.6191 Mass Construction Supervisor License CS-096834 Estimate for Joanne Mackey August 19,2015 278 Hillside Road N.Andover MA 978-609-4821 Work to be performed: • Remove existing deck and dispose of all debris • Dig 4 sonotubes 48"deep and pour concrete • Pour new concrete pad (size TBD) • Overall dimensions for new deck:6'wide by 21' long;this includes 6'x 10' upper deck,2 sets of stairs 42"wide each, and a landing 42"wide and 36" long • Remove the brick stones as needed • Estimated Labor&Materials Cost o $4,850.00(permit not included) Contractor Signature _ John M. Floyd Date Customer Signature_ Joanne Mackey Date_20 August 2015 t ------ 1 - ems s SaG - QIZ ------------- .5 \ _ 4 v Qt ------ � f .. .... ...... .. . .............. . 5�` s J " s 1 ��-5- d � i r I • -s I N -Ex„T coo 5,� Ta er-c /ZSR s �S f/ERE�Y CECT/fy TO TyE T/TGE/,c/SU•eO.�.�L�/O �G. D T ���`+► Tl� 7.4�EB•4N.f T.VgT Tif�EO�rELG/•cK'/S LDCATEG O.V I Tf/E Go7'.!S SisCA►',t/A.VO TiGG4T/T OG S G0.1/FGtPAf /IV lY/T•�1 T.s/E Tow.✓ OF No.ANoo vs� 2pN/.vG c�E6�/L.4Tib t�S �// OA S F(/.ClyE.t CE.�T/FY T//AT TiY/S�iY'ELL/N6 /S�t/OT ` / GOG4TEo/N T.y� FEOE.PAG FiCGIOO HAZ4.�0 A.PE.4. � O�A�N FO� ,�yawnr civ Ffw.t• t'o.�.�.y�•v�rY P.rv�� '�` 25z�78 ooa6 C �✓/GGS1l.J` -�ALTf �O•e� OF,N J F o .H.v14 L•S. A E MOF,tiIANN .` '� #36381 `{�°'��ssto�P� AlE.P,P/�fl•9Gf�",vG/.�/EE.P/.1/6 SE.PY/G'ES A.vODYE.� /�1AS.S•4l-//!/SETTS O/8/O �� North Andover MIMAP August 24, 2015 k� ' 1 'A � A. u # a r '.125 f 4 yrs ^7 fJ k e r y i ( � �rpr z a MVPC So Interstates _I Hommntal Datum:MA Stateplane Coordinate System,Datum NAD83, SR Meters Data Sources:The data for this map was produced by Merrimack NORTH Valley Planning Commission(MVPC)using data provided by the Town of -- Roads Of North Andover.Additional data provided by the Executive Office of r Easements ? ���« r���OO Environmental Affairs/MassGIS.The information depicted on this map is Parcels 3' _ G for planning purposes only.It may not be adequate for legal boundary f o definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER • MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING 41THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ^ OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT iF�o�+ ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ! THIS INFORMATION CHU 1"=37ft ^�° The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA.02X14-201 7 www mass.goy/dia SJ' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. 19-BE FILED WITH THE PETTIN UTHORITY. _A Iicant Information �_ Please Print Le 'bl Nalrle(Business/Organization/Iudividual): �i .Address: 7(" 1 %5." )P_ City/State/ZipPhone#: Are you an employer?Cbec'IctEe appropriate box: Type of project(xequired)• I �� 1.L_I'•am a employer with • .�. : employees(full and/oz part-time).* 7. []New construction 2.�am a sole proprietor or partnership and have no employees working for me in 8. [1 Remodeling any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3..Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 []Building addition 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. ROOF repairs These sub-contractors have employees and have workers'comp.insurance.t 6.F1 We are a corporation and its offfcers have exercised their right of exemption per MGL c. 1d• Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also filn out the section below showingtheirworkers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit anew 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 rimst provide their workers'comp.policy number. 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.#: C>Gj- l Expiration Date: �� '�44� ►� '�4'. city/St p��� ,� s� 019 4 o rob Site Address: Ci /State/Zi Attach a copy of the workers'compepsation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fiDnu of a STOP WORK ORDER and a fine of up to$250.00 a an Y day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. f do hereby certify under thepains andpenaId ofperjury that the information provided above is Prue and correct. Sign e: d Date: rt __.-- Phone# �l _CZ-� �C-1 J 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 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbingbaspector 6.Other Contact Person: Phone#: Information and Instructions ' 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 of hire, 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 an 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 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 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=contractor(s)name(s),address(es)and-phone number(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 LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Ifzdustrial Accidents foi 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 yo'u'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 proofthat a valid affidavit is on file for future permits or licenses. Anew afTidavit 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA.02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia A6. CERTIFICATE OF LIABILITY INSURANCE �'�' 8�2'15 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 CONTACT NAME: Georgetown Insurance Agcy, Inc PHONE FAX 10 West Main Street E-MAIL 352-8000 / N : (978) 352-7719 ADDRESS: info@ Georgetown Insurance.com Georgetown, MA 01833 INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance INSURED INSURER B:Travelers John Floyd INSURER C dba JMF Construction INSURER D: 26 Parish Road INSURER E: Georgetown, MA 01833 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVID POLICY NUMBER M/DD/Y MM/DD/YYYY LIMITS A GENERALUABILITY BGQBVP 7/2/15 7/2/16 EACH OCCURRENCE $ 1,000,000 AMAGE ENTED TO R X COMMERCIAL GENERAL LIABILITY D occurrence) $ 100,000 CLAIMS-MADE a OCCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 }{ POLICY PRO- JECT RO LOC $ AUTOMOBILE LIABILITY COMBINED iSINGLE LIMIT $ ANYAUTO BODILY INJURY(Per person) $ ALL 0 WNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERLY DAMAGE $ HIREDAUTOS _AUTOS Per accident $ UMBRELLA LIAR F OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION OG135305 7/3/15 7/3/16 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/NI. Pp ANY PROPRIETOR/PARTNER/EXECUTNEE.L.EACH ACCIDENT $ 500,000 OFFICERMIEMBER EXCLUDED? � N/A (Mandalory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes describe under DEStRIPTIONOFOPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Renarks Schedule,if more space is required) Operations usual and customary to the named insured. Sole Propietor, John Floyd, has not made an election for coverage under workers compensation MA Limited Other States Benefit endorsement applies to workers compensation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover, MA ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St Building 20, Suite 2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Stacey Croteau ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: bemery@emeryconstruction.com Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration 182684 Type: $ xpiration: DBA 7f1a201�- JMF CONSTRUCTIOf ` 1 C ^� JOHN FLOYD VA . -- 26 PARISH ROAD GEORGETOWN, MA 01833 Undersecretary 1 i -z I Massachusetts - Department of Public Safety Board of Building Regulations and Standards Constr ,uctlorl SUrve1 Vilsor License: CS-096834 JOHN M FLOYD 26 PARISH ROAD IF 77 GEORGETOWN44A r yy Expiration 04/24/2016 Commissioner