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HomeMy WebLinkAboutBuilding Permit #542-2017 - 29 COLUMBIA ROAD 11/18/2016BUILDING PERMIT �d P� LF TOWN OF NORTH ANDOVER APPLICATION FOR.PLAN EXAMINATION �% Date Received —-/ �' �' o/ Permit No#: S�io1 ' 8 o Date Issued: l l - O l LVIPORTANT: sL ;PROPERT`(OW ,ERS v 6Z MAP "rip _P L I�✓�-� Z ,pplicant must complete alsll kitems on this pa .�7f- .t�7T �",Pnnt 1DDYear Stnuctu ENING DISTRICT r�Histonc Distnei 4i-hinP shoo �yORTy 79 ORATED APR\ SSACHU TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building . ne family r r " ❑ Two or more family ❑ Industrial 0 No. of units: ❑ Commercial ❑air, replacement ❑ Assessory Bldg ne TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building . ne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑air, replacement ❑ Assessory Bldg ❑Others: ❑ Demolition ` V1/eII c�-S ❑Floodplain Wetlands }Nafershed District El Sepfic . _ - � _ - - - - _•..�.Wate�/._Sewer....:..., nC:crrP1PTtnM nF wnRK TO BE PERFORMED: ter.,(-- `� f� "jo^t' /I✓ Cs-" 1Le� Identification - Please Type or Print Clearly' OWNER: Name: Phone: Address: 9q CoLumc30 ' r Contactor NameR=::Z1v?.. Phone::.- 781�331.2�c l _ Address: � - - - - - - -- Supeivisors Construcfion License .,�f;' 7:? �'� _:. p Date 2 Date :r` �Zy t Home lrnpxovement License:... __ ... ... _ _ Exp, - - - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. B ULDING PERMIT: $12.00 PFR $9000.00 OF THE TOTAL ,ESTIMATED COST BASED ON $125.00 PER S.F. .ems _ .Total Project Cost: $ -7800 FEE: $ Check No.: i `�� 3 eq No.: 3"►alg yPOrson contracting with unregistered cont)of pe: access s to the guaranty fund Si'_ri:; _re_of.A :ent/Ow>1er Signature of coritractar .r Location f ,a G M 4/ No. 5 (f ) - DO 1:7 Date /I- f g" a0/-4 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # , 3121 U �� Building Inspector i �i Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ 1 ]FP 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 v U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature. Reviewed on Signature Reviewed on Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes PlanniC`g Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nection/Sianature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT = Temp Dumpster on site yes Located at 124. Main Street Fire Department signature/date COMMENTS Locatea �b4 usgooa Street no -)imension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: [Movement of (Meter location, roast or service droprequires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine No Doc.Building 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. r 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/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 DOTE: 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 Doe: Building Permit Revised 2014 CD 0, Z O Cr CL �. >co O 0 ,3v C C C a CD O Lwk �G 0 r� C CD CD CD CD U) I v z CD S CD cIt O z mcn m ic O D O z h CD N co 0 C: co O O 0 CLy CD o 0 ° =0 U) Ma 2 N =� < cn 00 C� CL m 0 =r =r 0 C m 0 0 C ° m W CD CO) m 0 CD o = Q. m N n �O o „n* C) 3 r CD c� � :O d �D c :X)Mmmq .-► O NO. Ana,- o A 00 CLco : 1 < y O O O cD � CL N �1 rte: O dMV N WT 0 Om :0 _ T X � Z �• CD CD -� Cn T �Ncn A T �E D CD . m C Cn C o CL y -1 O Z O j O ic >' O O Z O --I D °-' VI''2A °-' 2 °-' °-' Z Z 0 rf c ago 3 m 5 a rp r*rD O D O z h CD N co 0 C: co O O 0 CLy CD o 0 ° =0 U) Ma 2 N =� < cn 00 C� CL m 0 =r =r 0 C m 0 0 C ° m W CD CO) m 0 CD o = Q. m N n �O o „n* C) 3 r CD c� � :O d �D c :X)Mmmq .-► O NO. Ana,- o A 00 CLco : 1 < y O O O cD � CL N �1 rte: O dMV N WT 0 :0 _ T N � �• CD CD -� T �Ncn A T �E D CD . m -••./ O SU - C o CL y -1 O O s (n N WT :0 _ T N ;o T ;v T (� A T (n T 3 1 C 3 O O' O j O >' O O rD O D °-' .� °-' 2 °-' °-' _S 0 rf c ago 3 m 5 a rp r*rD S S r) S =3S Q r) \ z rDrD N rD O r? O ? mr 3 N C C 3 O v°0 ° A z Dr D H O D m z'i 0 0 O 0 x Lemus Home Improvement Commercial & Residential Lic & Ins 186 Breedens Lane, Revere MA 02151; Jose Mario Lemus; 617-438-3653 Homeowner's Information: Roger 29 Columbia Rd North Andover MA, 01845 Date: November 10, 2016 The following contract/estimate are for the alteration. This paragraph describes the work to be performed. With this price it includes labor and materials: - Remove existing roof - Install new shingles (timberline) - Install ice & water (on all flat) - Install liner paper (for the roof) - Install Lead in chimney - We dispose of trash - Install ventilation on the edge of roof Posts Note: Any alteration or deviation from above specifications involving extra coasts will be executed only upon written order, and will become an extra charge over and above the estimate. Note: you may cancel this agreement provided you notify the contractor in writing at the address above by ordinary mail posted, by telegram sent or delivery, not later than midnight of the third business day following the signing of this -agreement. Notes:(*) any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. (**) Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. TOTAL AMOUNT: $7,800.00 Le Home 1 r vemen Client 1) DATE: 1 DATE: It 11q/(O Information and 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 enferprise, 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 ofihe dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelluig 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 compRance with the insurance coverage xequiked" 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 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 d6es 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 returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial•Accidenis. Should you have any questions regarding the law or if you are required to obtain a v�orkers' 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 PORGY 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. Anew 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 burg leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASS.AFE Fax # 617•-727-•7749 Revised 02-23-15 www.mass.gov/dia ., the Commonwealth of Massachusetts Department of IndustrialAccidents M r I Congress Street, Suite 100 Boston, MA 02114-2017 b' www mass.gov/dia `d�M SJ'ti Wovkers' Compensation hsuranc6 Affidavit! Buiidexs/CO ASO s icians/ Xum exs. TOBEFILEDWITHTHEPERNIrI tilo �o1Pr;nt Name (Businessl(jrgabization/Individual): Address- 3 (. City/State/Zip: Are you an employer? Roo, -S 0/302- .e /,90 i ecktlie appropriate box: fie I%-rj� Pvvti�t N i DISI err / Phone #: -7 S' / - 3 lt9- 1.54eam-a employer with.3 employees (full and/or part time)•`` 2.0 1 am a sole proprietor or partnersh'P and have no employees Working for me m any capacity. [No workers' comp. insurance required.] 3.0 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. l will ensure that all contractors either have workers' compensation insurance or are sole proprietorswithno' -... -yetis. hed sheet 5.❑I am a general contractor and 1 have hired the sub -contractors listed onthe attar These sub -contractors have employees and have workers' comp. insurance # 6. ❑ We are a corporaiio;i and its, officers have exercised their right of exemption per MGL c. 1 4 and ive have no empldye; s. [No workers' comp. insurance required.] Type of project (xeq&ed) 7. [] Nevv'donstriidiion 8. [] Remodeling 9. ❑ Demolition 10 C7 Building addition 11.0 Electrical repairs or additions jZC]:Plumbing repairs or additions 110 Ro6f repairs 14.0 Other 152, § O, M such a hcantthat cheoks box#1 must also fill out the sectionbelow showingtheirworkers' compensationpo&cy information: PP all -work andthen hire outside they are I Homeowners who sub b ajEa. attached indi�ato additional sheet showing theame of the sub contrcontractors tors and e whether or, not thus entities, have TContractors that check this must employees. Ifthe sub -contractors have employees, they must provide their workers' comp. policy number. n insurancefor my employees. Below is tlaepoliey andjoh site X am an employer that ispPovidingwoPkers' compensatio information. 8 (� Insurance Company Narae:i2�" is # or Self -ins Lie. #: Expiration Date. Po cy Co1�N�-� Q , A. R -Ca City/State/Zip: N . 9t?o C Job Site Address: �'� 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 a fin and/or one-year' imprisonment, as well as civil Penalties inthe form of a STOP orward d to the Office o fn ORDER ns of the DIA for insurancea of up to 0 a day against the vztor. A copy of this statement maybe f d t epains andpenalties ofperjuPy that the information provide above Ido herehy �&is ue a�. • _ 71o4a• �/ /�� /�-O/y -?kt-3,F-i.zyo/ Official use only. Do not wfite in tliis area, to be completed vy city oP town official Permit/License # City or Town- )[Ssuiug Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. plumbing Inspector 6. Other - Phone #: ContactPerson 'om: Marian Cruz Fax: (781) 581-3940 To: 19786889542@rcfax.cc Fax: +19786889542 Page 2 of 2 11118/2016 9:28 AM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDfYYYY) 11/16/2016 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(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)_ tODUCER arquhar 6 Black Insurance Agency 5 Exchange Street - Suite 101 ynn MA 01901-1475 SURER od's Home Improvement, DBA: Roderick Rivera 6 Haviland Avenue MA 01902 NAME:`' Christopher Kennedy PHONE (AIC, No, Ext); (781)599-2200 FAX (781)581-3940 ADORESS: Chris@FandBInsurance.com ADDRE INSURER(S) AFFORDING COVERAGE MAIC a INSURER A Acceptance Indemnity Insurance INSURER B: INSURER C: INSURER 0: INSURER E : OVERAGES CERTIFICATE NUMBER:Town of North Andover 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 15 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'RTYPE OF INSURANCE ADDL SU BR POLICY EFF POLICY EXP POLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 CL00186638 2/26/2016 2/26/2017 MED EXP (Any one person( $ 51000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X ; POLICY PRO - POLICY LOC PRODUCTS - COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea. accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N STATUTE ER ANY PROPRIETORMARTNER(EXECUTIVE E EACH ACCIDENT $ :OFFICER/MEMBER EXCLUDED? N 1 A -L ' (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Town of North Andover 120 Main Street North Andover, MA 01845 CORD 25 (2014101) S025 (201401) SHOULD ANY OF THE THE EXPIRATION L ACCORDANCE WITH' AUTHORIZED SCRIBED POLICIES BE CANCELLED BEFORE EOF, NOTICE WILL BE DELIVERED IN PROVISIONS. IC Kennedy/MAR1LN �{ ,( ©1988- 4 ACORD The ACORD name and logo are registered marks of ACORD TION. All rights reserved. 0 -r� Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -082273 -Or'-;;tri,,ction Super 'vlsor RODERICK RIVERA 36 HAVILAND AVENUE: LYNN MA 01902 Expiration: Commissioner 06/28/2018 6r1/1 Un W?Mzvneo 'acfr 1w, "'Ice 6f:C0nSUMerAffairs & Busivess OME WRROV,810ENT CONTRACTOR 11stration,174926 Type: �NnsyExpjlraflbm�F.4— -7 Individual ROD Rli RA —T- ROL) RIVERA 36 HAVILAND AVE. LYNN, MA 01902 Un'dersecretary as