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HomeMy WebLinkAboutBuilding Permit #555 - 29 BLUE RIDGE ROAD 3/17/2010 BUILDING PERMIT °f NORTH q `Stereo 1 61 �O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ' �gSSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Pant _ r r PROPERTY OWNER P nt . MAP 2113_ PARCEL ZONING DISTRICT� , Historic District Vires . Machine-Shop Villageyes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, re lacement Assessory Bldg Others: Demolition Other Septic � Well Flo®dplair� r Wetlands 1111atersl�ed Distnct Waterl,Sewer e _ r DESCRIPTION OF WORK TO BE PREFORMED: �Tt�.p a LD l K S-�'14cc.�. N� tin o F S f�K tYc�s W J iu� � G✓�9p�t/1 S�11E1i0 Identification Please Type or Print Clearly) OWNER: Name: _�E-(M -Y HmlliCLAL Phone: 170- �S JL5 7 Address: ?sj VC.v4, F-io&iL ( ,U. A14ao,/E ' CONTRACTOR 'Name., � vt�►rc� `=� ���v13 : 'wrt, �CjPhone�: Address: K tT Grt K ., Supervisor's Construction:-`license- .' Exp: Oate . HomeTlmprovernent License. _ Exp, Date, l ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST B ED N$125.00 PER S.F. Total Project Cost: $ fpw FEE: ! Check No.: Receipt No.: NOTE: Persons con acting with unregistered contractors do not have access to the guaranty fund igntureof Agent/Owne Signature of contract r m V 01 Location L Aft?5= No. 5 Date v ,.ORT1y TOWN OF NORTH ANDOVER f A ` Certificate of Occupancy $ ss'••♦°�cMus•Ett' Building/Frame Permit Fee $ � r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2265 Building Inspector 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 SECTIO,[VS F.OR OFF!,gE U� E�ONLY INTERDEPARTMENTAL SIGN O0F - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS 4 .3 CONSERVATION Reviewed on Signature COMMENTS A --L�t.�•��. 'J•►ids'':�°'_z :ii�a, ,:, ' ta.::�j y'•i 0�•� "L :V.'f " ' •K m „ *'!'4 i�. . � � -... HEA -T•H ..�.�; Reviewed on Si na r ,r to a -�.. (Yl 14 COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision:.' Comments " t L Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: P Located•` 84 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes no Looted at 124 Main Street Fire Department signature/date COMMEN-TS «• . . .:, 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 2010 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 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/Crossection/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit l 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 2008 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 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 o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) j ❑ Engineering Affidavits for Engineered products I 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 Li 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) Li Copy of Contract o Mass check Energy Compliance Report Li Engineering Affidavits for Engineered-products NOTE: 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 2008 l Quinlan & Rand ]BURLDERS 34 Trinity Court North Andover,MA 01845 Phone 508-682-1570 • 508-521-4196 WORK ORDER O CONTRACT CHANGES DATE: OFFICE NO. JOB NO. WORK ORDER NO. ORDERED FOR CUSTOMER BY: ORDER RECEIVED BY. NAME OFJOB: JOB ADDRESS: B L. Rdor- Z7 Lam✓ t L Q IqAjQoul- NAME OF CUSTOMER: BILLING ADDRESS: SCOPE OF WORK �� '1/ i /� '"�'v D 4= U d - O Customer Authorization: S-f -f ej Signature Date NOTE TO CUSTOMER: THE ABOVE WORK IS A CHANGE IN THE SCOPE OF OUR CONTRACT.WITH A COPY OF THIS WORK ORDER WE ARE NOT- IFYING OUR FIELD FORCES TO PROCEED WITH THE WORK WITH THE UNDERSTANDING THAT THE PRICE AND TIME REQUIRED FOR THIS CHANGE ARE: O TO BE SUBMITTED LATER SUBMTTED PENDING 1 APPROVAL APPROVED TIME EXTENSION FIXED PRICE CONTRACT CHANGE $ $ GUARANTEED MAXIMUM CONTRACT CHANGE $ $ FEE CHANGE $ S . OTHER NORTH Town ofAndover 7. ....- _g ...... O �_ ,,. 0 No. SSS" Cc% A K E = dover, Mass., - 11 -Oaf co MIC ME WICK �� �d AORATED P`PKC:) S � BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT.............. .... ..... .. .. ..... ......1..-IkvK� BUILDING INSPECTOR ........................................................................................ Foundation has permission to erect........................................ buildings onnQ �� r ( � . ..................... Rough to be occupied as #.... d Chimney . . . �Ceiva-i�!-s .. ................................................................................................provided that the person apermit shall in eve respect conform to the terms of the application on file in Final 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 PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONi ARTS Rough ............... ............................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Omipy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Finalh No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. DATE ACORD. CERTIFICATE OF LIABILITY INSURANCE page 1 of 2 09/09/2008 PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willis North America, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 26 Century Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED Installed Building Products, LLC INSURER A: Zurich American Insurance Company 16535-005 Builders Installed Products INSURERB: Cincinnati Insurance Company 10677-001 P. O. Box 5111 P Y Manchester, NH 03108 INSURERC: Steadfast Insurance Company 26387-002 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRDD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION T AT M LIMITS A GENERAL LIABILITY GL0913952702 10/1/2008 10/1/2009 EACHOCCURRENCE $ 2.000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Eaoccurence $ 1,000,000 CLAIMS MADE FX1 OCCUR MED EXP(Anyone person) $ 10,000 X $350,000 SIR PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- X LOC B AUTOMOBILE LIABILITY CAA5878127 10/1/2008 10/1/2009 COMBINED SINGLE LIMIT $ 1,000,000 QQQ,0 0 0 B X ANY AUTO CAA5878131(NY) 10/1/2008 10/1/2009 (Ea accident) B ALLOWNEDAUTOS BA6000545 (TX) 10/1/2008 10/1/2009 BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIREDAUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTYDAMAGE $ / (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EAACC $ OTHER THAN AUTOONLY: AGG $ C EXCESS/UMBRELLALIABILITY AUC913958002 10/1/2008 10/1/2009 EACH OCCURRENCE $ 10,000,000 X OCCUR F-1 CLAIMS MADE AGGREGATE $ 10,000,000 DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND WC913952602 10/1/2008 10/1/2009 X WRYTMTS DER EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE WC913952802 (WI) 10/1/2008 10/1/2009 E.L.EACH ACCIDENT $ 1 QQQ QQQ OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 B OTHER XSll54851(AOS,NY,TX) 10/1/2008 10/l/2009 Excess Auto $4,000,000. Limit DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 Q DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Quinland & Rand Builders REPRES TATIVES. 34 Trinity Court AUT115WEDREPRESENTA North Andover, MA 01840 ACORD 25(2001/08) Coll:2469379 Tp1:824960 Cert:h 290298 U ©ACORDCORPORATION 1988 r�Sit clruxett.. Board of Buildinn�p:r►•trn �rrt of Prrhlic Construction' Rc'tiul.►tion ; len ic Supervisor ►►rd .Standar su CS 55283 do Restricteq to, 00 License JEFFREY 205 RAND HAVERH/LL A4ALLAVE 830 01830 ina•r Ezpiratio n: 5/16/2010 T►y#' 27690 Information as d 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 coinpliance 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 a 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 Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be metes-ned to thee cis or town that the application for the permit or license is being requested,not the Denartmeat of Industrial Accidents. Should you have any questions regarding the law or if you 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 proof that a valid affidavit is on file for future permits or licenses. A new affidavit 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone and fax number. The Commonweal& of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,lt2A 021.11 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 vrvrv7.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Office Of lnvesti ations 600 Washington Street Boston, MA 02111 www mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): (/11v °- V/) �3U t C 117 r Address:— ' Y 2 I/V/ 7 7 C 1 City/State/Zip: - /-I^''�6v�� (/� f Phone 72)E�Jam ployer?Check the appropriate box: ployer with * 4. ❑ I am a general contractor and I 6 ype of project(required):s(full and/or part-time), have hired the sub-contractors ❑New construction e proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity, workers' comp.insurance. g• ❑Demolition [No workers' comp. insurance 5. ❑ We are a corporationand its 9• ElBuilding addition 3.❑ required.] officers have exercised their 10.[1 Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions Myself. [No workers'comp. C. 152,§1(4),and we have no ' 12.[]Roof repairsinsurance required.] t employees. [No workers comp.insurance required.] 13.❑Other :Any applicant that cheeks box#1 must also ill out the Becton below shoiving their workers'compers-on Y„;c,::.o_....atiorL 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for information, my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Sob Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 DIA for insurance coverage verification. I do hereby cern nder the sins s p s eriu?y that the information provided abi ve is true and correct Date.:. ) Phone#: c(5-7 r-Of Z Official use only. Do not write in this area, to be completed by city or town EInspector City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Elect5.Plumbing Inspector 6. Other Contact Person: Phone