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HomeMy WebLinkAboutBuilding Permit #77 - 30 VEST WAY 7/24/2009BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 2-7 Date Issued: ' 7/) Y/zq Date Received q 1• TYPE OF IMPROVEMENT PROPOSED USE Res id Non- Residential New Building ne famiI Addition Two or more family Industrial Alteration No. of units: Commercial <:-5e—pair, r aceme Assessory Bldg, Others: Demo i ion Other Septic Well Floodplain Wetlands s Watershed `District Water/Sewer. UtS(;KIPTION OF WPRK TO BE PREFORMEDZ M Identification Please Type or Print Clearly) OWNER: Name: Er-atjv Phone: Q W --nil- ji y`7 Address: 3v Vk-s-t L,j4 S'upervisor's Construction License: () a &S Home Improvement License: �,;!M-)77Y ARCHITECT/ENGINEER k �,. �.�.c�ie�Phor7 Z4 75 .: 'Exp. Date: 1Mp 2-4;=-z tV FYn ata• 4zl —a.i - 89 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: e-2-0. 00 8 FEE: Check No.:Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owr�er-- Signature of contractors^, fl� 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 SECTIONS FOR OFFICE.USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nection/sig nature & Date Driveway Permit DPW Town Engineer: Signature: .t 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 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 ❑ 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 2.2008 R Location 30 VFS No. Date r i MORT" TOWN OF NORTH ANDOVER b Certificate of Occupancy $ '� s',^° • t<� Building/Frame Permit Fee $ 9y0 �cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Llf 22249 b Building Inspector 0 N E 4 O z •mc W A o G w° C2 G ii U —cd ii W a W a a�' m pG a � aa E� U w + .+. U G w O C w w w m o 2 .4tY>.l1 U)C/) v Q tu d -C v W \ 'ti w cn 4 O z O a 9 O O O C Z O G L O V COO) Q CM 0 co) O .O m m -E O co = O.a O O i m o a CL CMQ c o Cc .yC3 CL Z V CD v y C C CL. CIO 0 LLI 0 LLI U) W W W •mc c w o � C � O co c Cc O C.3 C.3 •dam ev i r CcC O L N �• L CD_ ..� N E c CD CO v $ �mc v � IA C L N o ;m3 s C� O �V N -o mCIO � N O O N W : CLCJ i m V' N m CD = t O Q! cocoQ O: o c� m Ci N Ocm �- +� n F— = m o : N m c p `mCD •c N w CD W G �••. C rL-. +� o Me •E w 4 •� OQ y CLm g O . m • O N Cl N O a 9 O O O C Z O G L O V COO) Q CM 0 co) O .O m m -E O co = O.a O O i m o a CL CMQ c o Cc .yC3 CL Z V CD v y C C CL. CIO 0 LLI 0 LLI U) W W W D The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 VAEW www.mass gov/dia Workers' Compensation Insurance Affidavit: Budders/Contractors/Electricians/Plumbers jgplicant Information Please Print IJegibly Name (Business/Organization/Individual): pe l lCt Us AA -O w S CL✓L4 D60dS 11\C-. Address: q Sm ppv%44, City/State/Zip:4AVerkill MA 01931°'p�n>$�t#:,,: �'���2�6�•i25� Are you an employer? Check the appropriate box: 1. I am a employer with 2. �' 4. ❑ I 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. t ship and have no employees These sub-contractors'have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I 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.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing theyWor`Wis' 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 as 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: Policy # or Self -ins. Lie. #: ® $ W 1364- 57&12. Expiration D. ­ T_eq— .4.� d C) Job Site Address: 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. 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..6f 'flu's -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 corrector Signature: _.J_ Date: "%-- Y` c's Phone #• ?79.2.65-77_S!5 Official use only. Do not write in this area, to be conlpleted by city or town offkiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. ]Building (Department 3. City/Town Clerk 4. Electrical Inspector S. ]Plumbing Inspector 6. Other -, Contact ]Person: . ' Phone #: ACORD . CERTIFICATE ®F LIABILITY INSURANCE DAT20091D/YYY1) 06/30/2009 16:20 PRODUCER (800) 225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Fred C. Church, Inc. 41 Wellman Street Lowell, MA 01851 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TYPE OF INSURANCE 800-225-1865 POLICYEFFECTIVE DATE (MMIDDNY) POLICY EXPIRATION DATE (MM[DD1YY1 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: Citizens Insurance Company of America New England Window & Door LLC 45 Fondi Road Haverhill, MA 01832-1302 INSURER B: Hanover Insurance Company INSURER C: Massachusetts Bay Insurance INSURER D: Wausau Underwriters Insurance Company EACH OCCURRENCE $ 1,000,000 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. INSR ADO'L TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE (MMIDDNY) POLICY EXPIRATION DATE (MM[DD1YY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR DAMAG ( ENTEa occurence $ PREMISESS 100,000 re MED EXP (An oneperson) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 A ZBN8161407 7/1/2009 7/1/2010 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY M PRO LOC AUTOMOBILE X LIABILITY ANYAUTO COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ C ALL OWNED AUTOS SCHEDULED AUTOS ADN8162169 7/1/2009 7/1/2010 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 $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ 9,000,000 X OCCUR FICLAIMS MADE AGGREGATE $ 9,000,000 $ B UHN8167305 7/1/2009 7/1/2010 $ DEDUCTIBLE RX $ RETENTION $ WORKERS COMPENSATION AND j( WC STATU- OTH- IMITS D EMPLOYERS' LABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE BINDWC 7/1/2009 7/1/2010 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS New England Window & Door LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 45 Fondi Road DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Haverhill, MA 01830 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 REPRESENTATIVES. 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X SZ 0 ~ d m y 2o C a 3 o L O 1-- ui z H G a 'm E z d 0 a U rn 6 rn CD rn m CL rr K DISPUTES Job Name ke r,,.,,,P—a Date U i THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT PELLA HAS A DISPUTE CONCERNING THIS CONTRACT, PELLA MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBIT"RATP�KN AS PROVIDED IN M.G.L.c. 1.42A H meowner NOTICE: THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. NOTICE OF CANCELLATION Customer Name:14 (Please Print) o a Date of transaction: ` , r o F You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so, then you remain liable for performance of all obligations under the contract. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice, or send a telegram to Pella Windows and Doors, at 45 Fondi Rd. Haverhill, MA 0.1.832 not later than midnight of �� (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature)