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HomeMy WebLinkAboutBuilding Permit #537 - 30 MASSACHUSETTS AVENUE 2/16/2006NORTH TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ,SSACHUSE4 ? Permit NO: �i7• Date Received:" 06 Date Issued:_,�.7�����[� IMPORTANT: Applicant must complete all items on this page `LOCATION_t� % PROPERTY OWNER LVA,senc� _ Print MAP NO.: PARCEL: 'ZONING DISTRICT: TVPIW ANTI IiCF (IF R1TII.n1NGr — — , 0 HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential J New Building D Addition Alteration -i One family Two or more family No. of units: C: Industrial L-JRepair, replacement U Demolition �; Assessory Bldg 01 Commercial Moving (relocation) ❑ Other L Others: _! Foundation only DESCRIPTION OF WORK TO BE PREFORMED t-oc� OWNER: Name: Signature Address: ® P ,,s " y - CONTRACTOR Name: Address:® �✓rr. S?� Phone: ?�,? - 72.r 7x'60 Supervisor's Construction License: 0�5-Y'23 F Exp. Date: Home Improvement License: �C���G y� Exp. Date: 7 2/ 200 T ARCIIITECT+NGINFE,R Name: Phone: o Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $10.110 PER $1000.1111 OF THE TOTAL ESTIMATED CO�PV ASED O $125.00 PER S. F. ,�- 00 Total Project Cost :$ S 000 xI0.00 =FEES � `&6 Check No.: /0130 1 Receipt No.:1-16-1�aoo 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 o Debris Removal Form u Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Form U ❑ Surveyed Plot Plan ❑ Debris Removal Fonn u 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) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Form U ❑ 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 Hydrauli( Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report 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 SF.RN ICES DEPAR"rn,1LNT:BPF0R\1115 i' y, 1 TYPE OF SE\k'ARGE DISPOSAL Tanning/'Massage Body ,ort Swimming Pools Public Sewer _-. Tobacco Sales ,m Food6Packagin- Sales - Well Permanent Dempster on Site Private (septic tank, etc. _. NOTE: Persons contracting with unregistered contractors do not have access to the i;uarantljiond Si(matUre of Agent/Owner Signature of Contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Kans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition Zoning Decision/receipt submitted yes Planninu, Board Decision: Conservation Decision: \dater & Sewer connection signature & date DATE REJECTED DATE APPROVED ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE REJECTED ❑ DATE REJECTED ❑ S Comments Co Temp Dempster on site yes__no__ Fire Department signature.'date Building Permit approved and Issued by: DATE APPROVED DATE APPROVED ❑ Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided UIML+'NSION Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on F..xterior dimensions. No I FS and DATA — (For department use) I — � I u„ i:01 i.(. rtutiA I. si.a': i< i s i;t IV, r.I MI. I ,. o . Mu J."171;0" Location jo SS�1 l�! �t��°� �►'E Vii° No. Date TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ M�sE< Building/Frame Permit Fee $ � Foundation Permit Fee $ w 111 - Other Permit Fee $ TOTAL $ *y . Check # 18980 irPr4d �, &,wo Building Inspector M (r FEB -16-2006 THU 11:31 AM FAX N0. 9784750303 P. 02/03 Cllantil: 2231 I;AKT7 &C CERTIFICATE OF LIABILITY INSURANCE Ulm(1111111111000" -0 -Ra. POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, PRODUCER Doherty Insurance Agency, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION AND NO RIGM S CERTIFICATE P.O. Box 1085 21 Elm Street OWER THIS, CERTIFICATE DOENOT AMEND. OR ALTER THE COVERAGE AFFORDED BY THE POI.ICIEti BELOW. Andover, MA 01810 INSURERS AFFORDING COVERAGE NAIL 0 INSUREO Glenn Gary General Contactors LLC 08 Island SUM Lawrence, MA 01840 NeuRERA: St PAUlt►rAVers ls INSUKAD; I RC INsuREa o- INSURER E: MM OMURRENCE st 000 000 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, TYPE OF INSURANCE POLICY NUMBER MM UMrM A GNNeRAL LIABILITY IB808e4NS623TCT05 07/06105 07/06!08 MM OMURRENCE st 000 000 COMMERCIAL GENERAL LIANLI V DAMAGE TO RENTED 1300800 AMPISEME CLAW MADE l...A 1 OCCUR NvtD EXP one s8 000 PNR$ONALaADV INJURY 01000 000 X PD Ded:250 GENERALAGGREOATE $2.000.000 OENL ARxNiP.AATE LIMB APPLIES PER: PRODUCTS . COMPIOP AGG 112,060.440 POLICY M6 41Q1 71 IAC AUTOMOBILE UABILITY ANY AUTO COMPNED BINGM UWT S (EN ealeeeg BOOILY INJURY 4FW W@enl ALLOWNEDAUTOS SCHEDULED AUTOS BODILY NJURY etr1JOM1) : MRSA AUTOS NON -OWNED AUTOS PROPMY DAMAGE _ GAR"sUABILITY AUTO ONLY -EA ACCIDENT S OTHER THAN EAACC S AUTO ONLY: AGG S ANYAlTO E7LCEi61HMBREIIALWBIUTY EACHOOCURRENCE S OCCUR F-1CLIMSMADE AGOREOATE 5 S S DEDUCTIBLE S RETENTION $ WORKERS COMPENDATION AND 61111PLOYBRB' LIABLITY 1-L EACH 1' DENT ANY PROPRIETORMARTNEPJEXECuTrvE E.L DISEASE - EA EMPLOYEE S OFFICEPJMEMJMR EXCLUDED? SPECIAL oe 1 PROVISIONS halawI 9.1- DISEASE - POLICY LWT S OTHER ONSORIPnON OF OPERATIONS I LOCATION$ I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Covering operations usual to the insured... Workers Compensation: AIM,11/24/OM, Policy NAWC7020221012005, Limits 10011001500. COrtlficate of Insurance ordered from AIM and will be sent directly by them. Lawrence Savings Bank 30 Mass Ave North Andover, MA 01848 ACORD 25 (2NI108)1 of 2 620005 LO ANY OF THE ABOVE OESC 45ED POUCIE$ BE CANCNLUM eEFORG THE MLOATION THEREOF, THE U SUING MWRER WILL ENDEAVOR TO SIAL --U- DAYN WRITTEN I TO TNN CIRTIAGATE MOLDER NAMED TO TME LEFT, BUT FARM TO 00 b $HALL IE NO OSUOATIDN OR UASILRV OF ANY KIND UPON TM WSURRR.178 AGENTS OR DML V 0 ACORD CORPORATION ION CA m m x m 4 m m CA m m a) ra, CA Cl) "0 0 CD az CA CLO CO) C-) CD CD rf CL cr =r CD CDo CD caw a 0.CO) — CD CL CO) tC CD 0 COD Cr W M Zto 0 CL C-) C) cop a- coL cL cl F -n -r CD =rd W a COD 0 E =r CD 5", C,,41r C2 CA a - Er 150, 7a r-4 m CL U2 0 C/) CD oc co C/) 4 CC7 OD 7n. nSD 0 ro. *3 = i K z 0 cn -CCO cn CD CD: CA: dw CD: 10 SI: ON 0: OVA% 0 0 -4 : 0 tri. CA Z-4 CD C,: C. pq w: CD sm ,w = =0 � CL cn CN, C CD: dw C/) 0 cn 4:j R z z C Ix ;z 0 tz m z n :7, g, C T C 0 C/) CD C/) 0 I A i �Yil ' orrtrnnazrirea�t�, � , / _t BOARD OF BUILDING R! License: CONSTRUCTIONS r;. Number: CS 058238 '` y Birthdate: 09/15/1964 Expires: 09/15/2007 ---------------_.: _ Restricted: 00 GLENN M GARY 507 W LOWELL AVE HAVERHILL, MA 01832 Commissioner The Commonwealth of �Vassaehtrsetts Department of Industrial Accidents Office of Investigations 600 Washington Street 14 U Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /Please Print Legibly Name (Business/thganirtti On/Individual): C�Ce 4� �C�Ic WH f�.✓v� z Address: (oo Ss A -,o S 5� City/State/Zip: ci ?`b Phone # g -),0-- S3-7 - Are you an employer? Check the appropriate box: I .,� I am a employer with 9- 4. ❑ I am a general contractor and employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- 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.] + have hired the sub -contractors listed on the attached sheet. These sub -contractors 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.] Type of project (required): 6. ❑ New construction 7. gReinodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *,any applicant that checks box # 1 must also till out the section below showing their workers' compensation policy information. + I lomeowners 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 most 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. t Insurance Company Name:_ /t=L Policy # or Self -ins. Lic. #: L) Cicet -- ExpirationDate: I-bo— Job Site Address: P6 &Q City/State/Zip: k /.ku,, {-04 U t SYS` 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 NIGL c. 152 can lead to the imposition ofcriminal 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the painj�and penalties of perjury that the information provided above is trite and correct. [ity v cval use only. Do mot write in this area, to be completed by c•i(y or town o%ftc•ial. or Town: Permit/License # suing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: OFFICE OF-W9,01M INSPECT TOM CW MOM IatN60VI9R C0KWffi&nQ&QQWR0L PROJECT PROJECT PROJECT UOCATil " l--/'��-� NGS l� A NAME OF NATURE OF OF THE MASSACHUSETTS STATE BUILDING ODE, REGI'STRATiON NO. BEING A GRE IS rawm PROFESSIONAL ENGINE'ER%AR��-� C'lMRT1FY THAT I HAVE PREPARED OR WtECTLY SUPERSCGN INC TtUN OF ALL DESIGN PLANS, AND SPEC1 ENTIRE PRt�.JECT Q ARCM) STRUCTURAL MECHANICAL 0 FIRE PROTECTION ELECTRICAL � OTHER (SPECIFY) FOR THE ABOVE NAh" PROJECT AND THAT, TO THE BEST: OF MY KNOV."-GF. SUCH PIANS, COMPUrATItN S AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACMUSETTS STATE BUIUDIIG '.ODE. ALL ACCEPTABLE EMINIEERING PRATICES USE AND OCCUPANCY. AND APPLICABLE LAWS ANO -ORDINANCES FOR THE PROPOSM I FURTHER CERTIFY THAT I WALL PERFORM TM NECESSARY PROFESSIONAL SPRVICSS AND B SON A REC3U M ANS PERIODIC ISIS TQ DETERMINE THAT THEDIN E T THE PROCEENSTRUCTIN M. SITEITE WITH TME DOCUMENTS APPROVED FOR THE BUILDING WORK 16ORDANCE PERMIT AND.SNALi. 8E RESPONSIBLE—FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for'codm"mm to the shop C$ and Gthef s mMa18 which are submitted by the cmtmoWr In accmd@rM with the mWkemerds at the con*ucdW docwnents. 2: Revlaw and gyral of the qu'W ty r>oE*d "M&M for an fn�i W 8ft- 3. Be Wesod St 1"JervalS approplieft W the 0"0 gf MMuc*m to ly f "ller w1t gom progress aul qtuWNY of the wait and to Vie, in genoW, if the work is ting perromlad m a maMW CWW"M wilts r& � - PURSUANT TO 8EPER NENT GLOMI MENTS O THE NORTHHALL SUBMIT YANDOVER BU LDING INSPECTOR. REPORT TOGETHER VIIITH PERT) . UPON COMPLETION OF THE WORK .1 SHALL S o � �JEMPOKr CT AS TO THEc�r- SATISFACTORY COMPLETION AND READ) _ SI(aNf1TURE SLWCMBED AND SWORN TO MORE ME THIS_,. PAY OF 18-- NOTARY PUBLIC MY COMMISSION EXPIRES — LU < U.J z _j < 0 Lie) W z lu z LU 0 C, 0 cz 0 P g U-1 0 zU LU2 z p i� 0 0 M SD �7- mom IL r ---------------- k7/ \z 0 'k oz b (V/ I Ln i 0 ul z t= LL LL u sib 0 (S) �—o . z z t �® h1 L-NO17V - y\ i " W I I � V O L6 LLI iu Cn z E2 CLO E2 u)� z 'on a - U) U - z U - z 02 coz M V- U') co cnl z Uj L C; LLI U Z0 LIJ c"