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HomeMy WebLinkAboutBuilding Permit #1325-2016 - 280 SALEM STREET 6/22/2016 BUILDING PERMIT o`"°oT"gtio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION � �o ea Permit No#: ,6 Date Received Rp0 ..�Pay�S �gSSACHUs�� Date Issued: " IM ORTANT:Applicant must complete all items on this page LOCATION .Print PROPERTY OWNER i Pnnt s„ 100 Year Structure yes no MAP, D37. PARGEL:66Z' = ZONING DISTRICT: Hist6fl6lDittfidt yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building �family I' ❑Addition ❑ Two or more family ❑ Industrial 1 teration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other OSept7c t0 Welly k ❑ FoodpJan £x ` 1Wn -tlNate ed1 Di tri'c,t �1Nater%SewerF P DESCRIPTION OF WORK TO BE PERFORMED: Pgov� D,6�_ PW�?A5!-e f-Q6M fic, ptt-Iliv ok Identification- Please Type or Print Clearly OWNER: Name: 1 � ~J ,/►1V(Z -4' Phone: lee'? Address: p Contractor Name: KaL.97 Phone: Address: X9,5. .171 1- ., 5-� X"loxy) 4 7Dc�� Y2 Supervisor s Construction Licenser 6.,� Exp; 'Date:...,. S Home.lmprovement License: / l D Exp. Date: 2/.,.!� h.��.. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS ON$125.00 PER S.F. Total Project Cost: $ Ll ' FEE: $ j Check No.: Receipt No.: S� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �.+K._" :w.y+i F, s' rf. �� .h.. `....--... ..... . .. , Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL f Public Sewer ❑ Tag/Massage/Body Art ❑ Swumning Pools _ ,❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales '❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ " THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i i (PLANNING & DEVELOPMENT Reviewed On Signature_ I COMMENTS } I 1 CONSERVATION Reviewed on Signature COMMENTS r HEALTH Reviewed on Signature COMMENTS t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board.Decision: Comments Conservation Decision: Comments Water& Sewer Connection/sDriveway Permit _ DPW Town.Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT. - Temp Dumpster on sites yes Located at 1x24.Main Street v�'` � rt: ►lo v �� Fire Dep men • g atur '''' � :�����.� ;�, ;,Y .. �F�S,: y,� z't,� •'` .� �. il �, , �.} artyk, ,�yvam. �i a/date • '� �...- } t �E .�� r:�,ty ;�, , �,. ' ,$ 7 �� COMMEN111 `w..v..e. `' I 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 I� DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine I I it NOTES and DATA— (For department use) ® Notified for pickup Call Email Date Time Contact Name DocHailding 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 � Building Permit Application 4., Workers Comp Affidavit a. 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 46 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) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of BuildingPlans One To Be Returned to Include Sprinkler Plan And ( ) p Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit j 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 Doe:Building Permit Revised 2014 _ I Location No.._ Z ~" � � Datea I . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ - a, Building/Frame Permit Fee. ' $ ~ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ t Check# i� 30536 0536 Building I Spector J NORTH Town 0 Andover No. - h , ver, Mass, g Z A_ COCMICNl WIC" 1' .Q 7d RATED lS U. BOARD OF HEALTH M T T %j LD Food/Kitchen PER Septic System THISCERTIFIES THAT BUILDING INSPECTOR .CERTIFIES .. M,,,�.... ...... . 1. .0v... :.......e� .;�.................. � has permission to erect .......................... buildings on .... ....... /.' ................ FoundationRough to be occupied as .. .� ... �f. .... .................... Chimney provided that the person acc pting this permit shall in every respect conform to the terms of t e 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. AMP* / Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST C ONM6 Rough Service .. ........ . ..... . Final BUILDIN PEC R 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. i i i The Commonwealth of Massachusetts f , I Department of Industrial Accidents �a� t. . t ,,, ; t. Office of Investigations 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):'�O Bf,)'�l— L t-t NCS V, 1J 6�-N: 4- PC-Mb _Qf-L) ►vG- Address: _7 9`4�_ -r- City/State/Zip: K)O'P,"1A Phone 7 G 76 -3 �©7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).` have hired the sub-contractors 2.1am a sole proprietor or partner- listed on the attached sheet.1 7. OVemodeling sfiip and have no employees These sub-contractors have 8:-❑ Demolition working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees.[No workers' 13.❑ 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 acid their workers'comp.pol icy information. 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.#: Expiration Date: Job Site Address: oZ d S S-f City/State/Zip: PSI 7�N D DVF-P\ _ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date 1�y5 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 inay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certunder he pains and penalties of peijury that the information provided above is true and correct Signature: Date: Phone#: C1 6 e� -360-7 ' 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#: ROBERT LANGEVIN Building& Remodeling Homeowner Infformation Contractor Information Name Company Name SPI j mu �r �� REJM t X) Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name c]B 3*-cry 5r' S- S City/Town State Zip Code Business Address(must include a street address) AA_ Ll 0eRTH Acs A- U1�5 Daytime Phone fivening"Plione" City/Town"" State Zip Code Mailing Address(It different from ab Business Phone Federal Employer ID or S.S.Number Home Improvement Contractor Reg Number Expiration date Law requires that most home improvement contractors have -a valid registration number 11 ) 970 �V J4t /).7 The Contractor agrees to do the following work for the Homeowner: t (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessga 4�O 14 D -� Cu 7W -rO CRS tM4L&j A- e5K 1466. 1 Ki D S �1,t Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contracto?s control arise (hers who secure their own permits will be /excluded ffrom tae Guaranty Fund provisions off v )J/&/Date when contractor will begin contracted work. MGL chapter 142Ao) ` 1 (� L /C Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor"specified above for the total sum of: O Payments will be made according to the following schedule: de' . j 2i $ t/ .up . � exceed 1/3 of the total-contract price or the cost of special order items,whichever is greater) I $� by /_/ or upon completion of $ by /_/ or upon completion of $ 5 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ ­10-5e paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of (a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordere0in advance to meet the completion schedule. Express Warranty-Is an express warranty being oro]jded by the contractor? KNo❑Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices 4 carefully before signing this contract. 0 Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. © Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. 0 Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. 0 Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. D®NOT SIGN THIS CONTRACT IF THERE ARE ANYMANK S1PAlC]ESM Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. Homeowner's ignature C tractor' Signatur Date Date c go "u �Arlp I ROPERT LANCE IN V 795 Dale Street North Andover, MA 01845 ( � D (rM�IDD A O CERTIFICATE OF LIABILITY INSURANCE an THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDE ,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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ios)must be endorsed M 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 certtficate holder in Ileu of such endorsemerd(), CONTACT—Edward W Hays PRODUCER NAME: Hays Insurance Agency Inc. UVcPHONE . (978)686.3162 PyAc N , (978)689-4425 36 Hawthorne Ave. EA-MAIL haysinsurance®comcast.nal INSURERS AFFORDING COVERAGE NAICS Methuen Ma 01844 INSURERA. Norfolk&Dedham Mutual Fire Insurance Company INSURED INSURER B: Robert D Langevin INSURERC: 795 Dale St INSURER D: INSURER E: North Andover Ma 01845 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 WITM 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. EXCLUSIONSAND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MSR POu F POuCY EXP LIMITS LTR. TYPE OP INSURANCE B POLICY NUMBER M orrrr+I X COMMERCIALGENERALLIABILITY EACH OCCURRENCE S 1.000,000, DANIA CLAIMS-MADE Q OCCUR MISES Ea oualr n S 100,000. MED EXP(Any one Defeo^ S 5,000_ A R0514357A 10/25/2015 10125/2016 PERSONAL aADV INJURY $ 2.000,000. GENIAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S 2,000,000. PRO- PRODUCTS-COMPIOPAGG S 2,000.000• PCLIOY Q JECT 0 LOC $ OYHFR: COMBINED ISINOLS LIMIT S AUTOMOBILE LIABILITY (Em accide t BODILY INJURY(Par Person) S ANY AUTO ALL OWNEOSC SULEO BODILY INJURY(Paroomenq S AUTOS PROPERTYOAM g No"WNED Por acoide HIRED AUTOS P AUTOS b UMBROLLA WAS OCCUR EACHOCCURRENCE S EXCESS LIAR CLAIMS-MAOE AGGREGATE S OEORETENTION S S PER OTH- WORXEReCOMPENSATION STATUTE R AND EMPLOYERS•LIABILITY Y I N ANYPnOPRIETORIPARTNERIEx2CUTIVE a NIA EL.EACH ACCIDENT S (Mandatory in E1.015EASE-EAEMPLOYEE S EL DISEASEPOLICY L It yyes,daefxlbe under : IMtT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES(ACORD 101,Addlllonai Romarks Sehodula,may be etreehad Irmom ePaao It,radulred) Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY Of THE ABOVE DESCRIBED POLICIES aE CANCELLED BEFORE TME EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORnP REPRESEN '91%8-2014 ACORD CORPOFUMN. All rights reserved. ACORD Z 4/01 ACORD name and logo are registered marks of ACORD I k Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-002685 Construction Supervisor _ ROBERT M LANGEVIN 795 DALE STREET- �'• NORTH ANDOVER MA 01845 expiration: Commissioner 02/24/2018 i I I Office of Consumer Affairs&Business Regulation 'OME IMPROVEMENT CONTRACTOR egistration 111990 Type: s`Expiration 2/11/201.7. _ �.—_ _ LLC ROBERT LANGEVIN BLDG&,REMOLDING LLC. ROBERT LANGEVIN —' 795 DALE ST - t N ANDOVER,MA 01845 V Undersecretary I