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HomeMy WebLinkAboutBuilding Permit #486-16 - 283 MIDDLESEX STREET 10/19/2015S?,V Al wFd l67VW 115_ TOWN OF NORTH ANDOVER T ° _ APPLICATION FOR PLAN EXAMINATION = Permit N0: Date Received Date Issued: caug t IMPORTANT: Applicant must complete all items on this page 9 f 'LOCATION J/ , tiF Print y} s PRO!PERTY''OWN a Print ..: ';MAP NO, . `PARCEL ZONINGDI.STRICT. Historic District yes' no r , achine Shop. Village . Ves no. M TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family 0 Addition 3,'fwo or more family 0 Industrial n Alteration No. of units: O Commercial L4epair, replacement 0 Assessory Bldg 0 Others: 0 Demolition 0 Other epfiic ©Well - 01=1oodplan Q Wetlands 0 Watershed District '. WaterjSewer hn� a"`� ver x S xrStin� roc,/��,� sv�hwn s, K4-t/,r7� Roan:'- Identification Please Type or Print Clearly) ,� ZZI' OWNER: Name: JUh ��� Phone: 9`7P R34 3/3 A idress: AJ Miaolbt)c Sr //U (XI14UYel', r74(x. UKy,) ARCHITECT/ENGINEER Phone: Address: Reg. No. t FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Totat,epject Cost: $ / L9 $� FEE: $ •f%(9 Check No.: Receipt No.: Q 9 �� NOTE: Persons cotttractihA tq 444egistered contractors do not have access to the Fuaranty fund Permit No#: Date Issued: BUILDING PERMIT O �q� �D TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Z. � Dqq <ocew Date Received ��DRATED Iv IMPORTANT: Applicant must complete all items on taus LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: -Historic istrict yes no achine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Industrial ❑ Addition ❑ Two or more family ❑ Alteration No. of units: ❑ Commercial ❑ Others: ❑ Repair, replacement ❑ Assessory Bldg ❑ Demolition ❑ Other {© FI©odpla n �`f®1IV_et nds .- tersh 'd ®isM trot ,' ®,Wa l ® Septic 01Nell� , t LirOLOKIr- I RJIV yr VV rk % ......— . _. -- - 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: ARCHI F-CT/ENGINEER Phon 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Building Department The following is a list of the required foams 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 d Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products 10TE: 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) 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 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 Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEmRA.GE DISPOSAL Public Sewer ❑ we` �' ❑ Priv e (septic tank, etc. El Tanning/Massage/BodyArt ❑ SwfimniagPools ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLAMNIN G & DEVELOPMENT Reviewed On Signature_ COMMENT'S CONSERVATION COMMENTS ON HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning poard of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes F Plar,nin }Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection's nature � ®ate Driveway Permit DPW Town Engineer: Signature: . _ a 384 Osgood Street F,4IRE 0EP�4�31ii�i8N,Y.�T,Ternp Dumpster�an Loca 4; Yes- Located ono,'rxE�S+",�>#, 51te o e �� .. ted at £241 aWf Street Fine+Dep a m g4� ature!"te `, , . -,, *. �,. » ._ •;rt., : t + k-�}r` tt . .�.6 •°F 4S .F � •+n - r'p hr r.� V . •a ki lv -•. s A r. s � � I- Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ff.: ELEC` TICAL: Movement of Meter location, masts or service drop requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE- Yes No MGL Chapter 966 Section 21A—F and G min.$1oo-$1000 fine Doc.Building Permit Revised 2014 Location No. � ` f� Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ E J 2 LL D 0 m u O LL N v N cc p V Vaf Z Z m c O O L.L O d' t U LL O W a V) Z Z O. O d' O LL c O W N Z u U W O LL' N O LL oC p F- W Z : d' C LL Z W F - W L m aj LJ N N O N n • O � � O 'Q O CL d =\ : ® -: = `6- O U) V CD " O L O N' E a cn �• a) v, � L O `�: •_> .a c 0-0 > _ �•=UQ c V N 0 0 • �: CL� c as - y c as S o= tm CL t •� J a) 00 •� _ `- o cq cn 1cm O c _ L LJU x m Q�•� N N W = -a— O O LL 2 N c O 'cLo E ���� 0 W L V 4, ._ U Q d� m y Q .0 c4- c O x ca L c o F—o CLU > O F- LU cn C9 O Cl) I.f. Z Z cc 0 Z V W F- CL Z W 0 0 CO W W _1 Mzl Its :Z2 Qq `Iv 5 L 0 U) c 0 :2 PlEni .. .. O O ca � co O Q CL ai Q Cc J � O Z 41)CLN c BRUSSARD GENERAL CONTRACTORS, INC. 27 PRISCILLAWAY PELHAM, NR 03076 TEL. 603.635.7008 FAX. 603.386.6009 1.0/8/15 John Camozzi 285 Middlesex Street North Andover, Ma 01845 Following price covers labor and material to replace 2nd floor 6x8 existing rail system with 3 composite railing sections. Job Complete: $1,950 Stephen Brussard John Camozzi 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 & DEVELOPMENT ❑ ❑ COMENTS CONSERVATION ■ ■ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Com Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street 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) ❑ Notified for pickup - Date Doc.Building Permit Revised 2012 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: C� J City/State/Zip: Of 1V 6 307(P Phone #: &03 lw ' Are you an employer? Check the appropriate box: 1.FI am a employer with / 6 employees 0611 and/or part-time).* 2.[] I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] In 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.Q 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.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §l(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. EdRemodeling 9. ❑ Demolition 10 ❑ Building addition I LE] Electrical repairs or additions 12.E] Plumbing repairs or additions 13.E] Roof repairs 14.E] Other *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. tContractors 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. Ian 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. #: l� �i�% 1,�V Expiration Date: Job Site Address:691K/ `l e0les" OY City/State/Zip: / sa_�_k 411%', Attach a copy of the workers' compensation 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 certify ut�je, the,pains gjfMna1fiespWijuty that the information provided above is true and correct. S Phone #' Official use only. Do not ivrite 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 M BRUSS-1 OP ID: WC CERTIFICATE OF LIABILITY INSURANCE DATE(MIYYYY, 12/0044D/14 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 pol(cy(les) 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 978-975-1300 Segreve & Hall Insur.Assoc.Inc 305 North Main St 978-975-7596 Andover, MA 01810 CONTACT NAME: PHONE MIN—LaEft ADDRESS- INSURER(S) AFFORDING COVERAGE Contractors INSURED ontraactt ors Inc General C ! INSURERA:Arbella Protection Ills. Co. 141360 INSUGuard Insurance t �--RERB:---- INSURERC: I 27 Priscilla Way Pelham, NH 03076 INSURER D : _ INSURER E : INSURER F, 1 _I rnv�o w rice• – - - –• -• ---�� .+tam t trta,ra I c Twiner=f". 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 D ! t POLICY EFF POLICY EXP LTR POLICY NUMBER MIDDtYYYY ! M/DDIYYYY ' LIMITS I GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X' COMMERCIAL GENERAL LIABILITY TBI i 11/04/14 11104/15 I PREMISES (EaToccurrence) Is 300,000 CLAIMS MADE OCCUR MED EXP (Any one person) is 5,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY { J jE o I I LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED ' SCHEDULED AUTOS II1I AUTOS HIRED AUTOS ! ii1 NON -OWNED � I AUTOS UMBRELLA UAB OCCUR L t EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N OFFICER/MEMBER EXCLUDED? LA (Mandatory in NH) i If yes, describe under 1 PERSONAL & ADV INJURY J$$ 1 GENERAL AGGREGATE ;$ 2 PRO_ DUCTS - COMP/OP AGG 1 S 2 1S BODILY INJURY (Per person) IS BODILY INJURY (Per accident) i S PROPERTY DAMAGE (Per accident) 1 1$ EACH OCCURRENCE AGGREGATE Is IS 12101/14 12101/15 J EL EACHACCIDENT A $ i E.L.DISEASE - EA EMPLOYEE1 S I 1 EL DISEASE - POLICY LIMIT 1 S DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) ACORD 25 (2010105) 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. The ACORD name and logo are registered marks of ACORD 0 Cil/ze (U00J7/?UwllIJef7ab o C�/�ccto�xc�u�eCCs Office of Consumer Affairs & Business Regulation POME IMPROVEMENT CONTRACTOR egistration 137349 Type: Expiration 10/30/2016 Private Corporatip BRUSSARD STEPHEN BRUSSARD =. 27 PRISCILLA WAY PELHAM, NH 03076 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation ;n 10 Park Plaza - Suite 5170 Boston, MA 02116 i j Not va ' without signature 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. Expiration: Commissioner 08118/2017