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Home My WebLink AboutBuilding Permit #769-15 - 301 RALEIGH TAVERN LANE 4/8/2015Permit NO: Date Issued LOCATION_ PROPERTY MAP NO: a BUILDING PERMIT hi TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 4/ IMPORTANT: Applicant must complete all items on this Print ZONING DISTRICT: Historic District Machine Shop yes r / TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other CI Septic ' ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ater/Sewer OWNER: Name: Address: CONTRACTOR Name: Address: Identification Please Type or Print Clearly) Ph( Phone: y ldc_bp / IV "I VVI ]I--. is' t+✓' zco" `1/ mei .d/ Supervisor's Construction Licensees Exp. Date: /� r Home Improvement License: Exp: Date: 7t/ 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: $ 90 Check No.: 414 gk 4 Receipt No.: Q PP 2 -7 NOTE: Persb'ns/cdVztr5cdng with unregistered contractors do not have access totthe guaranty fund nature of Plans Submitted ❑ m Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE,.' '! F SEWERAGE DISPOSAL P1z6lic 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 Reviewed On Signature. CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r' Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: - 84 r Located iFIRE (DEPARTMENT Temp.l®umpsterEon site - Osgood Street 1,oeatedkdt 124.±IVIa±n ;Sheet �`� W i 409111, tj-fOent" s gnature/date sCOMME liTS = Z. Dimension Number of Stories: Total square feet of floor area, based on Exterar ;dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requiresapproval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Pennit Revised 2014 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/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 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: Building Permit Revised 2014 E �n� 0 J Q 2 LL O Q m C N O LL N a N CL In 0 W 0. N Z Z O J =n C +T LL C' N U LL Q u lJJ CA Z t7 Z mm C J d bo :3> LL O u lJJ 0. ? Q U F J W OD Of (n c LL oC O V a Z N Q bD =s W r LL Z W °G a LIJ O W LL L Co O z v Ln D l/1 n o l3 m4) � ) a * c N v r m CL f <Y WAW `� + k \: CD V C • _ O — 4=I 0 i Z G Z W w x LLJr G LLI CL O LUa U) z m �H Lf 0 U F— Z O U) LUJ ZE E Z 0 .E a.L O V FL V .CL V ccr— m U) w ca � G O O C' Q C Q J Z v CD CLN AW rroposiu HIC # 174377 Dam housse ■ l Roffing LLP A trusted name since 1938 Roofing - Siding - Windows 87 Belmont Street - North Andover, MA 01845 P: 978-683-45888 - F: 978-685-77446 NAME OF OWNER Z ADRESS OF JOB �� f f �ilL d✓-' TEL. (J" DATE:_'+, We will remove all roof shingles off total roof area, up to two layers. Replace any boards or sheathing at additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. A 8@yr• architectural roof shingle installed. Install new vent pipe boot flashings. Waterproof existing chimney flashing and remove debris. Shingle Color: Ridge Vent Upgrade $8.00 per ft. ' Wood Sheathing Repair +$per ft. 4:5;� evel 40, i We Propose herby to furnish material and labor - complete in accords ce with above specifications, for the sum of. - J? donors ($ Payment o be made as follows - r�40 /Yom ' tS ,va) Authorized Signature L J r NOTE: This proposal may be withdrawn by us if not accept with in.- days Acceptance of Proposes - The above prices, specifications and conditions are satisfactory and are herby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: . / J — l S Signature 1 M The Commonwealth ofMassachusetts - Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Larne (Business/Organization/Individual)- lQ p �'4 Address: City/State/Zip Je00111v" AW, Phone #:- 1,719-1 , 7 Are you an employer? Check the appropriate box: 1. is 1 am a employer with 4. ❑ I am a general contractor and I Type of project (required): 6. ❑ New construction ' employees (full and/or part-time).* 2.'0 1 am a sole proprietor or partner- have hired the sub -contractors . listed on the attached sheet. ? �• Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. El Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. ❑ Electrical repairs or additions required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Pl bing repairs or additions myself. [No workers' comp. c. 152, §1{4), and we have no 12. oofrepairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *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 -67m doing all work and then hire outside contractors must submit anew 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:. Policy # or Self -ins. Lic. MA) ZA Expiration Date: " / ®.5 Job Site Address• A City/State/Zip: Attach a copy of the workers' com nsation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certitu. under the pains andpenalties ofperjury that the information provided abo a is true and correct. Si afore: -- Date: ��/✓ 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 S. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Client#: 14415 DAMPHQUASF ACORD- CERTIFICATE OF LIABILITY INSURANCE o�;,� 14YM PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency, Inc. P.O. Box 1985 21 Elm Street ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. A Andover, MA 01810 INSURERS AFFORDING COVERAGE NAIC A INSURED Damphouase Roofing LLP 87 Belmont St INSURER A: Atain Specialty Insurance Comps INSURER B: INSURER C: North Andover, MA 01845 IMSURER D: 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. TYPEOF INSURANCE GENERAL LIABILITY POLICY NUMBER CIP16938701 POLICY EFFECTIVE- 04/12/14 POLICY nON 04A2hS Lam A EACH OCCURRENCE $1000000 X COMMERCIAL GENERALUABILITY CLAIMS MADE � OCCUR P DAMAGE TO RENTED $100 000 MED EXP (Arty one person) $5000 X PERSONAL 6 ADV INJURY $1,000,000 GENERAL AGGREGATE $2 000 000 GENt AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 Xi POucY PRO M Loc AUTOMOBILE LIABILITY ANYAUTO COMBNED SINGLE LIMIT (EneCCdeM) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per pemm) S HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ IPer oomdem) PROPERTY DAMAGE S (Per a=denl) GARAGE LL UMM AUTO ONLY • EA ACCIDENT S OTHER THAN EA ACC S ANY AUTO AUTO ONLY: AGO $ E(CES&VMBRELLA LIABILITY OCCUR F1 CLAIMS MADE EACH OCCURRENCE 8 AGGREGATE S S S DEDUCTIBLE S RETENTION S WORKERS COMPENSATION AND MIC STATU- OTH EMPLOYERS' LIABILITY E.l. EACH ACCIDENT S ANY PROPRIETOWPARTNEREXECUTIYE E.L. DISEASE • EA EMPLOYEE S OFFICERIMEMBER EXCLUDED9 HyeS desalbe molder SPECIAL PROVISIONS below E.L. DISEASE • POLICY LIMIT S OTHER DESCRIPTION OF OPERATK)NS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT ISPECIAL PROVISIONS Covering operations usual to Damphousse Roofing LLP... Town of North Andover 1600 Osgood Street North Andover, MA 01845 LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL —Jr0_ DAYS WRITTEN :E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SMALL SE NO OBUOATION OR LIABILITY OF ANY ARID UPON THE INSURER, ITS AGENTS OR AUTHORIZED ACORD 26 (2001M)1 of 2 #S30466/M30465 / —DML ,/ ) O ACORD CORPORATION 1988 Acc R CERTIFICATE OF LIABILITY INSURANCE �� °ATE`MM/D°�YYY' 05/07/2014 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(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). PRODUCER 00474 - 001 NAME: Doherty Insurance Agency Inc PO Box 1985 Andover, MA 01810 (P c°NN . Ext): (978)475-0260 (AA/C. No.: EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: A.I.M. Mutual Insurance Company 26158 INSURED Damphousse Roofing LLP INSURER B: COMMERCIAL GENERAL LIABILITY INSURER C: INSURER D: 87 Belmont Street North Andover, MA 01845 DAMAGE TO RENTED $ PREMISES Ea occurrence INSURER E: CLAIMS -MADE F—] OCCUR 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 INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence CLAIMS -MADE F—] OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMPIOP AGG $ OLICY ECOT OC AUTOMOBILE LIABILITY CEa MaOBED INGLE LIMIT $ xidentINS BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY tDAMAGE $ Per acciden HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS MADE $ DDEERDg $ t/ypI pry ERryETpEN�TIIONN AND EMPLOYERS' LSABI % X TORY LIMITS OER A AN PROPRIE��R/PAItLNERIEJCECUTIVE YIN o ICCEERR//MEEM RR EEJJCCCCLUUDDEE�D�� NIA AWC-400-7028774-2014A 4/17/2014 4/17/2015 E.L. EACH ACCIDENT $ 500,000.00 E.L. DISEASE - EA EMPLOYEE $ 500,000.00 (Mandatory in NH) If es describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) No partners are covered by the workers compensation policy. CERTIFICATE HOLDER CANCFLLATION Town of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover, MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE U 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD x. A. Office o onsumer Affairs & s Regul B�inesationw THOLI HOME IMPROVEMENT CONTRACTOR Registration: .4—,174377 Type: Expiration: �2�I_412D17 LLP. SSE ROGMNGJ`P_=2 7 SHAUN TWOMFY' < 87 BELMONT ST N. ANDOVER, MA 01$45 - �$ Undersecretary Massachusetts = Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor i..; License: CS -0675.60 SHAUN M TWOMEY 61 PATROIT ST ' n N ANDOVER M -c 01$45 \ 951.,,, Jy� Expiration Commissioner 10/25/2015 Location No. Date r Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 26 O 42 -3 Buildinghspector