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HomeMy WebLinkAboutBuilding Permit #735 - 30 KITTREDGE ROAD 5/10/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 6 �7 Date Issued:_ ; - (d, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family Li Addition El Two or more family [I Industrial El Alteration No. of units: [I Commercial io?<epair, replacement El Assessory Bldg El Others: D Demolition El Other d,Septic F1,WellFloodp; 6in ff Wet(i js, 7' rshed District 0, YVa ter/Sew'er Z�- , , �� ""-$ -2 1P I DESCRIPTION OF WORK TO BE PREFORMED: Please Type or Print Clearly) OWNER: Name: Address: .2 0 CONTRACTOR Name: 7: Address.., A ... ........ d k, Superviso r's Const ction-License: Supervisor's X0 Home Imorovement 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: $ �)000 FEE: $ I.; Check No.: N Receipt No.: NOTE: Persons contrain ith unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor, Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Qr pste a sits °yeses 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 ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 14 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _ i Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Drivev/av Permit Located at 384 Osgood Street FIRE DEPART, Temp Qr pste a sits °yeses no i_+ cated at 124 Main Street. .,: a Fire ©eiarnent Signa#`eldat ra .tom` Art F r a �.. ., alk y 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine M NOTES and DATA — For department use ❑ Notified for pickup - Date ........................................................................................................................................................................................................................................... ........................................................................................................................................................................................................................................... Doc.Building Permit Revised 2007 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 i ON o ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ,,Copy of Contract el, -1w �v '�- ❑ ropo or Work ❑ I avis or 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location 3d A7� /41 ' ' ` i Date S`Igo -& — TN TOWN TOWN OF NORTH ANDOVER 0 s ` Certificate of Occupancy $ 4 , �•1 S'"'O' Eta •k 5 NU Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ` ( Check # 2o Building Inspector E 0 z • 0 W co ro E N Z ca zoo 0 N CD ac co m O CD JS m Z O Z 0 g O 1 r z 0 U 9 W �91' 1169 W W 19 W U) a a a O A x u o w 48A a U a, a 0 o o x G w 4 04 o w W)Go u W o p U o G A a co V) o cn E N Z ca zoo 0 N CD ac co m O CD JS m Z O Z 0 g O 1 r z 0 U 9 W �91' 1169 W W 19 W U) oypod�r °yo.ey o .» a 1. Q y 0 R y A CL a e and 0 C a 6- M mrnm ZX ZD(njm M z -� 00 z C 0 X m cn O `Z D o (� 'C'^o V, N X Q 010 O R5oR iv a A O O N 06 Z0 <. n O V 0 0 0 rn� CA) Ul O O(,Z� �m O) L. 1 I� m � Ii!I < W O �y `- D (-+ 0 D{gyp a ��ocra ao mcn O m o �, �0�0 -{ Km— d N nn o -� ;0 3 to A Z W 7 3 Q a m O � O •u{J O y N 00 Z C N 0 p 5- j 0 H pp 3 ° -� � C a h 0 ° O N �6 , 0 , G) a 01 oypod�r °yo.ey o .» a 1. Q y 0 R y A CL a e and 0 C a 6- M mrnm ZX ZD(njm M z -� 00 z C 0 X m cn O `Z D o (� 'C'^o V, N X Q 010 O R5oR iv a A O O N 06 Z0 <. n O V 0 0 0 rn� CA) Ul O O) � � O �y a,^ (-+ 0 V/ a ��ocra nn �� � � i O � O •u{J O 74. OC) j a. � a ;��lre fpomvm�-n�«aal./� n�Tl'a,:�ac���,�ella BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 055190 Birthdate: 11/08/1959 Expires: 11/08/2007 Restricted: 00 ERNEST G JERRETT JR 164 MAIN STREET W NEWBURY, MA 01985 Tr. no: 9060.0 Commissioner ACORD,, CERTIFICATE OF LIABILITY INSURANCE (MMIDDIYYYY DATE 05/09/2007 ) PRODUCER (978)352-4990 FAX (978) 352-8991 Fabri & Rourke Insurance Agency, Inc. 65 Central St. Suite #2 Georgetown, MA 01833 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Jerrett & Son LLC DBA: Ernest G. Jerrett P.O. BOX 733 Rowley, MA 01969 INSURERA: American International Group POLICY EFFECTIVE INSURERB: LIMITS INSURER C: INSURER D: INSURER E: f _nVFRARFS 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. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS No Andover, MA 01845 GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE [:] OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO LOC JECT AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC894-34-71 06/27/2006 06/27/2007 X I WCSTATU.OTH- TORY LIMITS ER_ A EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS f'FRTIFIrATF HAI IIFR CANCELLATION ACORD 26 (2001/08) ©ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT: Celeste Damon BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 30 Ki tt r i dge Road OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE No Andover, MA 01845 William Fabri/MJG ACORD 26 (2001/08) ©ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 5on L Address: A� "K, Neal�v ry 7yfy� k.t. City/State/Zip: Phone #: r.?"f- J 4 Sl — (�. G Z„ Z. Are you an employer? Check the appropriate box: ch 1. [✓� I am a employer with % 4. El am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. _ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp, c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *An licantthat k bo #I I fll Type of project (required): 6. ❑ New construction 7. Q Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 I. El Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other y app ec s x must a soi 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: '4N1CIt I Policy # or Self -ins. Lic. #: 4 Expiration Date: (k2 o- Job Site Address: 3b 'Fit•i�ftAC[ �Q' City/State/Zip: 03 L A�y�{J 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 DIA for insurance coverage verification. I do hereby rd y an er t e its allies of perjury that the information provided above is true and correct Si nature Date: 5/1167 '14 'Y -<afa2 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 #: