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HomeMy WebLinkAboutBuilding Permit #721-14 - 291 MASSACHUSETTS AVENUE 4/16/2014BUILDING PERMIT TOWN OF NORTH ANDOVER -& APPLICATION FOR PLAN EXAMINATION Permit N0. J , Date Received Date Issued: TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 7One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Others: repair, replacement ❑ Assessory Bldg ❑ Demolition ❑ Other ❑ Septic 0 Well" � 0 Floodplain 1 Wetl4nds C1 Watershed Distfiict" S ❑ Water/$ewer ` lit/itI C�ov✓�' (/�i�I �/4lru.s v� r'G. � p ✓✓ - � Ar �h T i �/ d C�/l�/' S%.!` %G,�OfALG�IG/I /J OWNER: Name: Address: ,)--71 Identification Please Type or Print Clearly) VSs t ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 5zlO©. Op FEE: $ 3D Check No.: �) I'Z-I Receipt No.: NOTE: Persons contr cti g with unregistered contractors do not have a ess to tl uaranty fund ignature of.Agent/0wneSignature of contractor �� L Permit NO: TOWN OF NORTH ANDOVER P APPLICATION FOR PLAN EXAMINATION Date Received .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑Demolition El Other Ei Septic 0 Well; _° ❑ Water/Sewer ❑Floodplain ❑ Wetlands ❑ Watershed District DESGKIPI IUN UI- V11UKK I U of rtmrvnmcu. Identification Please Type or Print Clearly) OWNER: Name: Phone: 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: $, FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of$Agent/Qwnerf `', �i atu>`e>of contractor_ Plans Submitted Li Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ J _. _ Building Department -:The fol;-3wing iva=list of the req'- uired.forms to be -filled outforAhe appropriate:permit to -be obtained. Roofirg, Siding, Interior Rehabilitation Permits o Ruilding Permit Application a Workers Comp Affidavit o Photo Copy Of H.I.C. And7Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster,permits require sign off from Fire'Department prior to issuance of Bldg Permit Addition Or Decks Li Building Permit Application L3 Certified Surveyed Plot Plan o Workers Comp Affidavit a Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) L3 Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses a Workers Comp Affidavit a 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 o 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 apw• al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-tted with the building application Doc: Doc.Bui!ding Permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ ;.:Certified Plot Plan ❑ Stamped Plans ❑ :TYPE OF: SEWERAGE Public Sewer Well Private (septic tank, etc _ Tanning/Massage/Body Art ❑ Tobacco Sales ❑ Permanent Dmpster. on Site ❑ Swimming Pools ❑ 0 Food Packaging/Sales ❑ ❑ f THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY IN SIGN OFF - U FORM DATE REJECTED PLANNING& DEVELOPMENT ❑ COMMENTS DATE:APPR-OVED ,CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow; Engineer: Signature: Located 384 Osgood Street FIRE -DEPART -M -L -"NT -.=-`Temp "Dumpster on site yes no Located at 124 Mair, Street �,.. Fire Department signature/date co MM ` Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. .Total land area; sq. ft.: :ELECTRICAL: Movement .:of, Meter, location, niast-or service drop requires approval of Electrical Inspector Yes No DANGERZONE LITERATURE: Yes No MGL --.Chapter 166. Section 21A -F and.G min.$100-$1000.fine NOTES and DATA — (For department use ZLIlf 0 EJ Notified for pickup - Date Doe.Building Permit Revised 2010 Locati4yi�J�-- No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL ' $ Check 4,19: f 9"1--- 274562 Building Inspector v C � 10 n Z N (D CL o Li � N ..a O vCD CL cr _ cD CD o ou CIDCD 9W 'vU'' CO CD � v U) O CD n 0 O 70 i CD a C CD `V 0 O e� 36 z o. S CD N O O (O O W Q CD to O N 2. cn CD C)=� p --I t:3/� ~' < CD �+ ID =O 0m O o 3 m =r in °t CD o. O O rt CL m CD N p CD CD CD = Q a) % nicn D --1 Q rt O Pr D� C= C COD rt �D D CD rr O < � rt S .=r g a 0 S Q $ � N < � O �0,CD< CL bow �C y .O•r � O O O CD CD a aim =rC� �CD N � O � rt O �, DCD �D 'a O :3 = O O Q N 3 (D O VI h '-� O co N -n my Z T 3 x S m T :3O N (nD :;O S m m M Z m 0 T .Z7T O, S Vm r C Z Z V 0 n S M Z7 O S T O pQj O C D z tzi+ m O M N O NEs O rD W M v m 2 = CERTIFICATE OF LIABILITY INSURANCE Fl/10/2014D/vYYY) 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. FULIL;y E" (MM/DD/YYY`O 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). X COMMERCIAL GENERAL LIABILITY I CLAIMS -MADE OCCUR PRODUCER M P ROBERTS INS AGCY INC 1060 Osgood Street North Andover, MA 01845 NAME: (A/C,, No, Ext: 978 683-8073 PHOPAICC, No): (978) 683-3147 AODREss:sandi@mprobertsinsurance.com INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: NORFOLK & DEDHAM MED EXP (Any oneperson) $ 5 000 INSURED MICHAEL GOODWIN INSURER B: AIM MUTUAL 7 HOLT ROAD INSURER C: EPPING, NH 03042 PERSONAL&ADV INJURY $ 11000,000 INSURER D: INSURER E: R0714141 INSURER F: 04/27/14 POLICY ❑ PRO ❑ riGEN'L AGGREGATE LIMIT APPLIES PER: JECT LOC 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 LTR TYPE OF INSURANCE ADDL INSD SUBR SUB POLICY NUMBER FULIL;y E" (MM/DD/YYY`O PUUUY EXP (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY I CLAIMS -MADE OCCUR EACH OCCURRENCE $ 1,000,000 UAIVIA -EIKEN I LU PREMISES (Ea occurrence) $ 50 000 MED EXP (Any oneperson) $ 5 000 PERSONAL&ADV INJURY $ 11000,000 A R0714141 04/27/13 04/27/14 POLICY ❑ PRO ❑ riGEN'L AGGREGATE LIMIT APPLIES PER: JECT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITYGumbl$ Ea accident BODILY INJURY (Per person) $ ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ ( ) NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ BOFFICER/MEMBER WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE❑ (M nd ory inNH)EXCLUDED? If yes, describe under DESCRIPTION OF OPERATIONS below NIA VWC10060151752013 02/15/13 0,2/15/14 I PER X STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE- POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attachedifmore space isrequired) AIM MUTUAL WILL SEND YOU THE WORKERS COMPENSATION CERTIFICATE DIRECTLY CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER BUILDING DEPT 1600 OSGOOD STREET NORTH ANDOVER MA 01845 FAX: 978-688-9542 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 © 1988-2013 ACORD CORPORATION. All rights reserved. ACORD25 (2013/04) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 Print,Form '" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): MF Goodwin Co. Address:7 Holt Rd. City/State/Zip:Epping MH 03042 Phone #:978-423-8463 Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 6. New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.: 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 1.3. ❑ 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. $Contractors 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. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: AIM Mutual Ins Policy # or Self -ins. Lic. #:VWC 601517501 Expiraf Job Site Address: o;Z /i / ss' /%!/e City/State/Zip: 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. 1.52 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 certify under the pains and penalties of perjury that the information provided above is true and correct` Phone #:978-423-8463 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 #: x> t Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor 1 icense: CS -081670 MICHAEL F GOOD ' WIN 7 HOLT RD Epping NH 03042 _ /�• =Xpiration Commissioner 08/08/2015 t �%/e �arrr�rra�cnlcalt/ o�:'P/%lGdrIIC/rrselt ; Office of Consumer Affairs & Busi6ess Regulation HOME IMPROVEMENT CONTRACTOR 7 -'�egistration: 105029 Type: 'r expiration 7/16/2014 Individual MICHAEL F. GOODWIN:JR:' ? Michael Goodwin Jr 7 HOLT.RD. EPPING, NH 03042 'a— Undersecretary j License or registration valid for individul use only before the expiration date. If found return to: . Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature