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HomeMy WebLinkAboutBuilding Permit #059-2017 - 283 MIDDLESEX STREET 7/20/2016 O`NOaoT e,9tip BUILDING PERMIT 44 3� �.. _ '• .6 0� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 0 �� �� Date Received SAC MUS�tA� Date Issued: IM ORTANT:Applicant must complete all items on this page LOCATION Y l k 0 y!-S �U�� Print PROPERTY OWNER �Gtin'1 U "ZZt Print J MAP NO: _PARCEL-Dk ZONING DISTRICT: f` Historic District yes io Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition [rwo or more family ❑ Industrial ❑ Alteration No. of units: 02 0 Commercial P,Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District L Water/Sewer /I►dentification Please Type or Print Clearly) OWNER: Name: Phone: 911 3 Address.. C�9 YYII Gil lrSe-S� SY f ''f� �v'�/ tllnGt od VS, CONTRACTOR Name: Phone: v3(03S-766J Address: 30-7 Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. . FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 5 FEE: $ 1 �� Check No.: 2546 Receipt No.: 34 NOTE: Persons contracting gistered contractors do not have access to the guaranty K19—nature of Agent/Owner Signature of contractor -_ �, OF NORTF( '9 BUILDING PERMIT t , = hE(TyED.4�16�( TOWN OF NORTH ANDOVER o =- APPLICATION FOR PLAN EXAMINATION '- � 1 . Permit No#: Date Received �RA�R9„TE13 gSSacHUSE� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print lob Year Structure yes no CT: Historic District es no MAP PARCEL. ZONING DISTRICT: Y Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement- ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ® Septic" !0.We ..: .:®.Fto©d_p ain -, Wa,etlands pW�, she F ®istri.ctz DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access-to the guaranty fund ian�tirrPx® �:aPrit/®�n�ner� Siamat�refoftc©ntr�actor� ---�--t - 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 Copy of Contract Floor Plan Or � F Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dum stet permits require sign off from Fire Department prior to issuance of Bldg Permit p p q Addition Or Decks 4, Building Permit Application Certified Surveyed Plot Plan 4� Workers Comp Affidavit 4, Photo Copy of H.I.C. And C.S.L. Licenses 4, Copy Of Contract :r Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering prior to is Affidavits for Engineered products issuance of Bid Permit from Fire Department g OTE: All dumpster permits require sign off p New Construction (Single and Two Family) Building Permit Application 4� 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 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 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 Plans Subrnittea'2 -` Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ r E OF SEWERAGE DISPOSAL c 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 a DEVELOPMENT Reviewed On l V I I�' Signature_ Af OMMENTS ! Loll CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments r I Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street >F„IRE DEPAWTM!E ernp DuUmpster on•sife¢,byes � Fipre Depy�artment ur}e/dated .- +" il'i�,'K ��1, ��k?f �t `Y '4 `�t.•{i'r`.���f�'�� .� .�r+�3�fi3 c'�Y'�M1KFR'7 'g"- ..9�='�---.�-'�-_.,._".�'h:, CQIVIMEIVTS 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 N® DANGER ZONE LITERATURE.- Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Location No. cd�7 Date 7 � ' • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee '$ Foundation Permit Fee $ "Other Permit Fee $� TOTAL $ _ Check# LV 3 0 0 3 it Building Inspe o O�<t�tD '°��'O BUILDING PERMIT TOWN OF NORTH ANDOVER h - . p APPLICATION FOR PLAN EXAMINATION Permit NO: 1 Date Received °4, VArgo �- ��SSACHUS Date Issued: IM ORTANT: Applicant must complete all items on this page L`(JCATION P( OPERTY OWNER4 3t�G�iiYl v 2Z.z MAP N( ,� PARCEL Z NINE DISTRICT � 'nHistoric Distn�t yes n' - . no Ma tae h , illa es y TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition VTwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial VRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well a� }f�' Y ,© Flozodplamw :�W�IAnds ❑ 1Nate"r 161 District }` a xrd 7r ,Nr r - �C? Identification Please Type or Print Clearly) OWNER: Name: chi � m� �� Phone: Address: �CO ' OR NSRACTi�am'e Phorae' Adf#6s.S NI: �x Date �, u eSuper�isor's Construction License p Fo�rie Improvement License.. Exp: Date i , ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ / r 5 FEE: $ Check No.: Receipt No.: � P NOTE: Persons contracting gistered contractors do not have access to the guaranty If J-1 t Si nature of contractor � s S:i�.rlatureoAgenl'Qwn" r 3 9_. — F Plans Subrnittea l� 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 j PLANNING & DEVELOPMENT Reviewed On ( � Signature_ kLIM OMMENTS l �'��/�✓�l CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori 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 Town Engineer: Signature: Located 384 Osgood Street FIREiDEPAR+TM -NT���TemprDumpster onsite: .yes m, _; �;'noW' A -31 =�tr�,"7'" :e. .iY `F4 7 5�,. a Lob atedlat 124 Mam Streetn " Y � E$� kffi' i 3,t 1 m c� :7 ,,- t ro` r�,'a'('at•� h'Yai'f' r Fire" Lueparmen��ur�e/date, � v<f y ryr s .',�A ' S1�' fir,1 ^3.": '�4 "-3 ti "."izX"Y . t.. ,i"•� `"f t`,sT`.4 ?^v�""'a•W ¢'gij'n�r'TM^—'<?, T, ��Tdy,". �.d^:.�. rnnnnARVKI R ooRT#i Town of : ndover 0 No. _T Wml h ver Mass,JI& !j 26 , Zat (v T 0 LANE ' COC NIC Nl WICK U BOARD OF HEALTH Food/Kitchen PERMIT D Septic System THIS CERTIFIES THAT ..1�I rj...... ,,,,, BUILDING INSPECTOR .I Foundation has permission to erect ....... .................. b ings on . ...... ...........� ..... ...................... �� Rough to be occupied as ........... ................ Chimney y . ..Qr.........._......5.! ... ........... v provided that the person accepting thi ermit 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 CONSTRUCTIO T, Rough Service .... . ........ .. Final BUIL INSP TOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. BRUSSARD GENERAL CONTRACTORS, .INC. 27 PRISCILLAWAY PELH.AM, NH 03076 TEL. 603.635.70418 FAX. 603.386.6009 5/31/16 JOHN CAMOZZI JOB**** FRONT ENTRANCE 2 DECKS UPPER AND LOWER THESE TWO DECKS ARE VERY SIMILAR IN SIZE TO THE SIDE DECKS THE FOLLOWING PRICE COVERS LABOR AND MATERIAL TO SUPPLY AND INSTALL TWO NEW DECKS AND STAIR ALL SUPPORTS AND FRAMING PRESSURE TREATED ALL TRIM AND FINISH AZEKS (PLASTIC) ALL RAILINGS AND BALLISTERS (COMPOSITE PLASTIC) 1 30 YARD DUMPSTER PERMIT FEE (BY OWNER) MY DRAWINGS (IF TOWN REQUIRES YOUR COST) MATERIALS (SAME AS PROVIDED FOR SIDE DECKING) $6655.00 LABOR (3 MEN ONE WEEK (120 MAN HOURS) $8200.00 130 YARD CONTAINER $720.00 TOTAL CONTRACT PRICE $15575.00 THANK YOU STEPHEN J. USSARD J04k C MOZZI App—rS 141 t-4 t �6 r-p Sit e a,a 1 - �c - r . t x + — -- m Ago The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgadons 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgmizationandividu y &Ltssard OUVA07J (, �hvM1 3 k C Address: 0 is cittci- City/State/Zip:_ & ()ff O3()76 Phone#: 603 (9S S ICO? Are you an employer?Check the appropriate box: Type of project(required): I.[�I am a employer with 11 4. ❑ I am a general contractor and I 6. ❑New construction full and/or part-time).* have hired the employees( p time). sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ 7. C]Remodeling ship 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 10.0 Electrical repairs or additions 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.[]Roof repairs insurance required.]t employees. [No workers' 13. Other comp. re iced. mP �N ] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy reformation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box most attached an additional sheet showing the name of the subcontractors and their worker,'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site informapon. Insurance Company Name: V Policy#or Self-ins.Lic.#: Expiration Date: �� t /f to Job Site Address: 02 audleit e Sk1--C-y City/State/Zip: ea oa Yf 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 DTA for insurance coverage verification. Ido hereby cortift under the ams andpenal ' ofperjuryth the information provided above is true and correct Si ature: Date: Phone#: 66 3&3 S�'?UU 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: BRUSS-1 CIP 1D:WC FDATE(MM/DD/YYM CERTIFICATE OF LIABILITY INSURANCE 1 04/19/2016 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 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 Segreve 8r Hall InSUr.ASSOC.Inc PHONE FAx 305 North Main St. A/c No Ext): AIC No): Andover,MA 01810 E-MAIL Eric Page ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Ins.Co. 41360 INSURED Brussard General INSURERS:Guard Insurance Contractors Inc 27 Priscilla Way INSURER C:Utica National Ins.Co. Pelham, NH 03076 INSURER D: 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. INSR TYPE OF INSURANCE ADDL B POLICY EFF POLICY EXP LIMITS LTR I R WVD POLICY NUMBER MM/DD/YYYY MM/DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 300,00 CLAIMS-MADE F—I OCCUR MED EXP(Any one person) $ 5,00 8500063422 11/04/2015 11/04/2016 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY 7 PEO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00 Ea accident $ C ANY AUTO 4920734 01/12/2016 01/12/2017 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDEN $ UMf3RELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- TH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDED? D N/A (Mandatory in NH) BRWC674983 12/01/2015 12/01/2016 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 107,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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-058086 Construction Supervisor ROBERT N DUMONT 60 PELHAM RD HUDSON NH 03051 o� (--jZZK CA— Expiration: Commissioner 08/18/4017 �i �e �Oa��ro�za�rcaealf�.a���.ae�crc�ccae(� olpExpiration: Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration: .137349 10/30/2016 Tope= Private Corporatic BRUSSARD GENERAL CONT.INC: STEPHEN BRUSSARD ~ 27 PRISCILLA WAY PELHAM,NH 03076 g "=z Undersecretary t