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HomeMy WebLinkAboutBuilding Permit #775-2017 - 28 PHILLIPS COMMON 2/15/2017441 W4 -� L'�- BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: '71!�' _1-0i% Date Received 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 D Well ' 0 Floodplain ❑ Wetlantls - D Watershed District y0 <� �w s*iRy�SY. s FwF DESCRIPTION OF WORK TO BE PERFORMED: --PIease Type or Print Clearly OWNER: Name: Phone: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. - .Total Project Cost: $ FEE: $� �— Check No.: l y ?,c/ Receipt No.: NOTE: Persons contracting with unregistered contractors do not have: access to the guaranty fund S_igratiare_of_Age nt/Owner Signature of contractor; Plans Submitted ❑ Plans Waived Ell Certified Plot Plan ❑ Stamped Plans ❑ •TYP13- F 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 Signature CONSERVATION Reviewed on Sianature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: t Comments Conservation Decision: Comments Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT -.Temp Dumpster on site yes Located at 124. Main Street - Fire Department signature/date COMMENT Locatea M4 Usgood Street no F limension- Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: _ G i ELECTRICAL: Movement of Meter location, mast or service drop.requires approval of Electrical Inspector Yes No - DANGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A —F and G min.$10041000 fine Doc.Building Permit Revised 2014 /I 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 o 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 40TE: 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 t Doc: Building Permit Revised 2014 Location 1 , /1, e :I . Cr, YY'0f � 1� v y No. / i-7.7 F✓ l Date Check #-/q t7 C, 7..1 28 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ l Building Inspector lj p r H 0 8 0 FMO ti d rim I R1 0 R O cu o .2 W �I �'.Qd cn d V L � W OI t d '^ c°a� Q' 'W" �N O � fn Z CL J E Cfl Q U)cn CD 0 Lu o = o 0 CL F- O WO W .r '� 3 C W J cow CL a CD m • U .r c 0 Q L L M .O CD F'O N1 0_ CD V m d r W _ '0— O O µ.. LL 2 c N = O no f- n 0 �, Z w E M. 0-0 n Q 4- =cc J F=— t 4- CL0U > EF w .w ti lw c cr- O H O � z W W. J U yUj O W _ CWC pW, 2 Z a Z Z LL Q O C7 J H a Q Z W Z Z 0 m Ln LU CO W LL C J J m W Y Z cn UN \ U -6 L C t t t +-' to bb > _ O LL N CC U LL \ K LL K In LL �' LL m N N I R1 0 R O cu o .2 W �I �'.Qd cn d V L � W OI t d '^ c°a� Q' 'W" �N O � fn Z CL J E Cfl Q U)cn CD 0 Lu o = o 0 CL F- O WO W .r '� 3 C W J cow CL a CD m • U .r c 0 Q L L M .O CD F'O N1 0_ CD V m d r W _ '0— O O µ.. LL 2 c N = O no f- n 0 �, Z w E M. 0-0 n Q 4- =cc J F=— t 4- CL0U > EF w .w ti lw BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION' -- Permit No#: Date Received Date Issued: I t a-0 TYPE OF IMPROVEMENT J.PROPOSED USE '' Residential Non- Residential 0 New Building tF-One family AC 0 Addition 0 Two or more family 11 Industrial Iteration No. of units: 0 Commercial 11 Repair, replacement Ei Assessory Bldg 0 Others: 0 Demolition 0 Other uHome,lmprov_ement Septra EWNIF ❑FloodplainM Wetlands`Wa fHsNidBiWiG DESCRIPTION OF WORK TO BE P�RFORIVIED: - Please Type or Print Clearly' OWNER: Name: JLA� Address: '' .Contractor N fth Pfio 7 AC S b0ervisensi, onstrUetioni License 'ni —, WT, license 17 uHome,lmprov_ement FYI Phone:`"(- /6 -Co V6 -bi t4 L, D a t b,! io�r`rl ! 1,x z - P. Datbn �Oxd.Ah1, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. MOO PER $1000-00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. _ ,Total Project Cost: $_ --FEE: $ Check No.: 1 q ?,I Receipt No','. If 5- P__T NOTE: Persons contracting witli unregistered contractors do not have: access to the guaranty fund ig c hfr�bt67r _9�atu[re' d M., The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 w www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Analicant Information Please Print Leeibly Name (Business/Organization/individual): Builder Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03060 Are you an employer? Check the appropriate box: 1.® I am a employer with 100 employees (full and/or part-time).* Phone #: 603-324-1984 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.M I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I 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 proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance? 6. n we are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. [] Remodeling 9. ❑ Demolition 10E] Building addition 11.Electrical repairs or additions 12. Q Plumbing repairs or additions 13. ❑ Roof repairs 14. ®Other Weatherization *Any applicant that checks box 41 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ACE American Insurance Company Policy # or Self -ins. Lic. #: WLRC 48151553 Expiration Date: 6/30/2017 Job Site Address:City/State/Zip CA)t Attach a copy of the workers' compe sation 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 form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerhfy_ynder the Phone #: 603-324-1984 of perjuryJat the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: A �® CERTIFICATE OF LIABILITY INSURANCEF DATE(MM/DD/YYYY) 10/25/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Aon Risk Services Central, Inc. Southfield MI Office CONTACT NAME: (A1C. No. Ext): (866) 283-7122 (A No.): (800) 363-0105 3000 Town Center Suite 3000 E-MAIL ADDRESS: Southfield Mi 48075 USA MWZY 1$ INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Old Republic Insurance Company 24147 TrUTeam Builder Services Grout), Inc. d/b/a Quality Insulation A TopBuild Company INSURER B: ACE American Insurance Company 22667 INSURER C: 110 Perimeter Rd Nashua NH 03063 USA INSURER D: INSURER E: DAMAGE TO RENTED $2,000,000 PREMISES Ea occurrence INSURER F: COVERAGES CERTIFICATE NUMBER: 570064230317 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 1$ EACH OCCURRENCE $2,000,000 CLAIMS -MADE OCCUR X DAMAGE TO RENTED $2,000,000 PREMISES Ea occurrence MED EXP (Any one person) $2S,000 PERSONAL B ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 X POLICY [:]PRO- PRO- LOC PRODUCTS - COMP/OP AGG $4,000,000 OTHER: A AUTOMOBILE LIABILITY MWTB 307519 06/30/2016 06/30/2017 COMBINED SINGLE LIMIT Ea accident $5,000,000 BODILY INJURY ( Per person) X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident) ONLY AUTOS ONLY 11 HIREDAUTOS LX NON -OWNED UMBRELLA LIAB EACH OCCURRENCE EXCESS LIAB HOCCUR CLAIMS -MADE AGGREGATE DED RETENTION B B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/ PARTNERI EXECUTIVE OFFICERIMEMBEREXCLUDED? NIA WLRC47860180 All other States SCFC47860209 06/30/2016 06/30/2016 06/30/2017 06/30/2017 X PER OTH- S TATUTE I ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under WI Only E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) r— M 0 N Co 0 0 LOLO O Z d Iti O w 1= 4) O CERTIFICATE HOLDER CANCELLATION &i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Of North Andover AUTHORIZED REPRESENTATIVE Building Department Attn: Donald Belanger 1600 Osgood Street, Suite 2035 North Andover MA 01845 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL405992 Construction Supervisor Specialty RicHARlD sr>wPxTz 2160 JtlMY ANN D DAYTONA SEAt H T", (NA CA_ Expiration: Cohnmissioner 49!2612018 Construction Supen(isor Specialty Restricted to: CSSL-IC - Insulation Contractor Failure to possess a current edition of fl -to Massachusetts -State Building Code is cause for revocation of fts license. DPS Ucensing information visit: "AV.MASS.GOVIDPS PT tfoW=sougmfaer airs (dVumes �� u 10 Park Plaza - Suite 5170 Boston, MPQsachusetts 02116 Home Improvem7. ontractor Registration BUILDER SERVICES GROUP, RICHARD SCHWARTZ 260 JIMMY ANN DRIVE DAYTONA BEACH, EL 32114 SCA'. G MU -05111 BUILDER fou �rrnn-ncrrrftuerz%� a�'C/�ytxc�i/.G[�� orConsumer Affairs & Business Regulation RICHARD SCHWAS 110 PERIMETER RD NASHUA, NH 03063 CONTRACTOR Type: Supplement Carta Registration: 179141 Type: Supplement Card Expiration: 6/25/2016 to Address and return card. Mark reason for change. address Renewal ❑ Employment Lost Card License or registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 syi-}/4 r Undersecretary Not valid without signature Fob" 10 d [USE Enginter;pg RI camtdar pe� tic Sim UACOW-.tt*.WitRQlSrOtPrNo t: Rist v, 60 sh2wMat iiaad. Vantan.1% 01621 CONTRACT 339-�T-433d FAX330-X13-6445 'ago i FPOGRAM BeliCpefAAt:'lCli6tYt9%tgCiwt.`t1�Rsa$ OBC'liAMj�i3t9'�`.A#r�tiltXCKl3 t�tBC�C O.ltt :tiC#fe �tROgt+ts Ro.brftCunint {slit 7 ()aii?J.2017 31R3®f, 2.!VA)4 CEAYL"'! ta'tet4'! 7aMA�ta II'ta7 otty t 17M,ataatL ZF cum aw.SS ILVP Nodh 11 uttvss,,ira i33i4� .3rtietiXi 211a*+4i a JOB B DESi�,.l' U f OIN P14AStt; Ohl • Prate far this vake u yc;ts: JIRW.AIJWPf`D i& L*o=dv3 $Bili to %at ffiC of ,.,oa bma'tViw vaddA tA:i"SA jit kskar- Tbis%,s k,*D,bc rafftmej is cancel $fish the tm or vecw 1000 md ds is tc;? s to that rrost>r limas alit tya kat ,�It � Pit ttfaa8 st' is of skexrhmig:md'ia5$a titgazlt y.3ta4aria&toivvedtomaFgc:a4saaatc8antttls*C a ra=lkundoahcrrrr"a Prk=y �sma, $`st rr.>ai:A�inc�alSa 5"L" #,rake to �3i�, 4saatx, atttae�n3 � rzsd utta�r aasAxa7cri aresa, (+a�xie� are act �icrs."?' Thta v4 ft*c (I wj wrst s he : A m4r.ion in cuhc €'es€ per cairmir (c%) of zir 'Mlikruim mD v. -m to tb,- 4 d�t tt.4t3i 'tY'.ttq�eo, t3v tC tiyi�6 wtky, a t`Rt3l tep�C: 4�CC' aXYtt"oS ts�t3 h'r.'t _4uc-te�StttiK�}ar� y�,,�t$16 ,�.���,�,j �Y,,wtt;.YtrJt#L+�€_5�4_�yt ,R},G� =jriw%uAlibc wdaz b� 1 t, thl At�i$i%t"�ti'{ tS1 F�#i. v lbzc rzI.Y !3 thv indu f Eli qudiy Jt.=SiL.tW t !!t 3i4s1t4$t;*iii PM.Vt t jAyi.1f at WSaialle 10 aar3a41 a 11' Uyv or R-39 m6cw riklem Mail tn'(t"431 rr W tat d4ramuat, Pte• SJO3.40 ATTIC MAT: PmvidcWw, =d asa ctirah to i-i-Ws3 a T` tzrtt or 9-"2 t?.vis� I odti= sdW m prsa) u r fed of am attic %;�t1F��&,kl:i:.r 1•sca`ss'c ishsr arsderuta tc s� ti�Ss;sts£ � �-i0 er �.��, the rrc'�ac�€ tr:r rzt�*�is', t2.`4) .e).>aztc fact of � sten ATTIC IC'ACi Prn%idar'Uhar andmucriuls to in Ue (1) bm& rrf the t<r.cct% hsich uai:tit r � hwd st R: 3tl rr citta the tcq*- ifirr rdint.. gad rsmt the rocs or the hatch 1w h'zrs4haa4Lvyp�� A 4t«,iC: ', 'i'tavi ht tsl+ur saaf traaatrriats tU 4'n5'tSii t ) L"' l}}r:O i'ali i4:fb'iYrYCC t'i+7 tifL EttsC ;4LiY4L"' tail !(�' Y,L: A r�- �ti��4;trs ATIMCAMM ?rum%tz txzs sstttislrtozss'r7:}tr r?zaaa c^»te zwta yrs i"lri+?- sea» ztcxdsrt I p�rrT'. �.^,"^:t9r t0 ita�. t;�r, �7."s« .� ".rt.'S°�X2.3 7e:..s�s }•2'E:: �'S;.:9. 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MA 01895 JOB DESCRIP 10IN 3237.50 WF.MLATION. isrovsk labor and madaiai. to kwalt vent tidson doses in (105) taller ha.~, to maintain air Ooac 5262-" M'ONICl WAUA thossir tabor =W tmteriab to install riedbostd at W10 or gazers iih the rapitW Litt wingiv (64) agwt feet of common Vcdl arca. $246.40 Rig £ugaoaiaS� cFPL4 all aFF rY irceto iliaoaatrseL t'oaswil Daly be i+itkdtbt 4l t�wot. carrel. for cbgdc mc=Av % Cobssh Chs offem 75% iscaativc. not to es ad Sto00 per V=. and in L%=:iwr or 10019 fa the Rpt SWiagmeaasss up to the tits Sao =d addtiond 5340 if saviaparel"ified h the au5sar. F'orr tba safdy sail heotth of yow IIGMC'! itttloor air qnM)'. %w wait t► amtlaKing a b6WC door diagtostic of the avails k air nowin yVw }wino both kforc tltescotL u isrpts. andaAa /bc aatbetitetion "atk is "UTIde: wt ww alto condo aftdl aaKrrnctS of the weal dion safdy of your hest ingeucat sad weer kg cr. This, has a vahe of 390 and is d no cog to yea Total allavaW VAwbetiwice buntire is 53.1 to. The Pastil mll he tetattedby the insdaion costtaact. at on, acWkc t ova. It is the hon:amses mp=cib&y to dose cut thb pettnit ty can nainthait tatnicipa ky at the cattptetioo ofttew eorL l { 7 a R! S E II -- tiobM Qutk *no 29 Ma* Certs RISE F. &erring 60libs tmul baud. Cattlog. %" 0201 339-302.6336 P.1.C234.3(F2-6313 Noah Andovet.UA 01845 1,41ftwIDNO&COM R! "mot It"W wt"ka am =Cftvmw Rep{atloa mm= COWRACT PRoc;UNI �° s (MANO.,G 01112:417 auuee meter �iP!>,�s Chms KnM Andover. MA 01845 JOS DESCRiMON 419M Ta1�it: Pmoram ln=nove: wssme�twest:rrawAwawse��s. �18t TObI: C°f°0�'o wtn+noo►��p„y � swtwn orr •••Q= TitOuGOW Seven Httttdtod T111ttyTWO & 251100 Dcgim f - 239M $90.00 $4,84225 $3,1MO0 $1.732.25 $1.732x5 MM 9aCWWACAW as30 ws�iNyar oautorcuavaOMa'4a. srtrasocotr� � r�ri[AIr�Vf{t ae t,*p� � ap�� �t�sat:l01K tYORt I 10