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HomeMy WebLinkAboutBuilding Permit #675 - 31 SPRUCE STREET 7/25/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: � �4 Date Received Date Issued: r IMPORTANT: Applicant must complete all items on this page ,-1.07 1 Print 4 � MAP NO: PARCEL: ZONING DISTRICT: WO, - Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family 11 Addition 0 Two or more family El Industrial 11 Alteration No. of units: El Commercial KRepair, replacement El Assessory Bldg El Others: 11 Demolition 0 Other ckll 0 Septic 0 Well 0 Floodplain El Wetlands n Watershed District 11 Water/Sewer I)] OF WO t� TO BE PERFORMED - /rj';50TJ'OtJ 4A Cot N42_4 -s, OWNER: N Adclress:.:�( CONTRACTOR Name: Address: Type or Print Clearly) oe a Supervisor's Construction Licenser —Exp. Date Home Improvement License: 42/42- Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No Phone-17F_,W_0�� /(All 1:2 FEE SCHEDULE: BULDING P RMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F 11 -71 -,5,5r C 0 Total Project Cost: P FEE:$ Check No.: �0 -2 _<�- Receipt No.: NOTE: Perso�n_s contracting with unregistered contractors do not have access to the guars fund Signature L f1ASignature , 4,,contradto 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS 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: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 blain Street Fire Department signature/date COMMENTS 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 NU I t5 and UA 1 A — (1 -or awartment use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 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 Perm 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) a 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 a 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 .fermi, 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: Doc.Building Permit Revised 2008mi Location 31 S ;1 No. Date �— Check # 2�rJJJ TOWN OF NORTH ANDOVER 1 Certificate of Occupancy $ Building/Frame Permit Fee $ .0 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector van kJobeft 140me Improvement LI. C 16 Cafrlida Road Glraveland, Iiia 01834 (50 06322, 0451-0493_ - rills ornA tiatiafta� 4Il buafc rctlufit�mants a¢d10 I;tateaa Home llrtpnivamayimorltruatar f hv! ilYt�i� chapt�ar~ 1g2�), htst� , �t�;q� not include akbttd�r i 1ilu0i� v to protect horaeownbrv. Beak legal nilvlaa ltneausar f, ,la I+ZtraeaQtiitaatta r,QnatAmar guide to ltutnO lxaprravtsrttant" bazars afrntaiit 1 paraatl P1ata.'tiIIU 110lus Improvements ahOulti, drat ablain a Oopy Qi"'a Offini, OfCaaauusar,4trthlrs ani Flu{ ainess gulationss CQuaurmorJnPi�iara�ti n F9Qtlina sa X51 A73-87 7 arWark an Your realamap. �1+8H8 obtain a i ;opy Uy Cnililiy ri'sa , ___ '• �tsrfl�`Itc4tY�• �rlf'I�rrat$�(oII M� (G (� • 4)c rtagatraq,�'artults � Tisa followinl{�bullusfiig' parXttit� gra rogsalraal Pr updnil] ba acoutod by the ozu-notor as the haiusow,+na's want, bo (OWn6re w6 secure their own p' ;nWU will he Iexellided iraltt•ttl arururit)r Fesfld nroviaiDug, of MOL chapter 147A.j ' �'' `t�� u � � 5 tom, l h start and Camplgtlait -echadnlo W T110 fgllawlag schadulu Will— i to tt111088 afrOumatano sa oyatad the Qou"QtoNrr QonirOl ansa LDAtQwhen oautrumurwill bglnQ'CUMctodwort:, L „Y?ata where anntraotad wane will bW aubatautially aQmplatad. Total Contract--�- S ha Cauwantor ugroos'ta per'f'orm the work„ tilwlvh the =41dand laborspoeitled sleeve for Ilia Intal sum n'f;4ji a, 6' Y S a Quls will be ` )'- ---�- ---- - ( ) ri trtuda agaordIna to the fallawlitg schodulc; upas ulgaiue,contract (Atat,to oseearl W at tha`tOtal aautraQt . rlaa r p fora ;fisc Qr'spcaial ard°ir i Ph's, whir' ver is grouter) by i'_1 nraapan aomptatlau ;OP (! `µ, by .arupon aatnplotlanof itpan completion of the GPittYAM% (LUW forbide'doniandlog full payut®ttturttil ;ori asst is completed tobothparty's autla taatian Yho fOlisbw€ug tiaaatarlel/aquipma at must be spacial S ) Ordered before the contracted waid4 1 agiaa lu order �� to ba paid far , w _ .✓ J( a.! to moot the rnctplartiou aabadula•(**) --*- » to bu pad for Y4Q I 3. 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OZZ£9 SO :asuaall asueorl JoslAiadnS uo lonjisuo0 sp rrpu .IS pur. suollrl ;aa �ulplmg 3o p rro8 ila;rS illgnd 30 luaurlardaa - sjIhngarssr.{q tee Lo Vw'aNV13A0F19 avow vaiwvo sl 4t 1131NVa ts1}3_N` Ynl� i uOE) x" ION ISU ssylo a - _ 996 L IC -LO t W -IN C ! .• RODS 1 3SN3�Il"S#i�Al1i� The Commonwealth of Massachusetts FOR Board of Building Regulations and Standards '' MUNICIPALITY Massachusetts State Building Code, 780 CMR, 7"'\edition; USE Building Permit Applicatibn Revised January 1, 2008 This Section For Official Use Only . Building Permit Number: Date Applied: Signature: Building Inspector Date SECTION 1: SITE IlYFORMATION : . Residential ❑ = 'Commercial ❑ Other Description: 1.1 Property Address: 1.2 Assessors �Iap -& Parcel Numbers Ce - Map Number Pdreel Nyunbbr.. _.,. I.la Is this an accepted street? yesL no 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Publicb ✓ Private ❑ Commercial- Service Size Zone: Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP" 2.1 weer' of �ord: / N Tint Ad ress forService: glkntore J Telephone SECTION 3: DESCRIPTION OF PROPOSED WORIe (check all that apply) New Construction ❑ Existing Building ❑ Owner -Occupied ❑ 1 Repairs(s) ❑ Alteration(s} Addition 13 Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Bri f Description of Proposed Worle: 5 -d., 114#9w ` SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only y 1. Building $ 1. Building Permit Fee: $ 2. Indicate how fee is determined: 13 Standard City/Town Application Fee r 2. Electrical $ 3. Plumbing ❑ Total Project Cose temmultiplier_ � (I 6) x x 4. Mechanical (HVAC) $ 3. Other Fees: $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: $ 6. Total Project Cost: $ /�`� Check No. Check Amount: Cash Amount: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) LicenseNumber E+'M66 Dnte Name of CSL_ Helder _ / d ��/� I�Q'�- N-l��i �c7"1 List CSL Type (see below) Add T e Description U Unrestricted (u to 35,0000 Cu.CFt.) R Restricted M2 Family Dwelling Signature M Masonry Only Telephone RC Residential Roofing Covering WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered emenmct C) ��= l�� Registration Number E pirati n Date HIC Com any am or C gistr t Name Addre Signature Telephone SECTION b: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? yes .......... ❑ No ...........17 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize to act on my behalf; in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION ((�� (0eJ ( I, p , as Owner or Authorized Agent hereby declare that the stat eats an ,41in on the foregoing application are true and accurate, to the best of my knowledge and behalf: Print Nnme .` G� Signature of Owner or Authorized Agent Date �— (Signed under the pains and penalties of perjury) NOTES: I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (MC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HRC Program and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.Rb and 110.115, respectively. 2. When substantial work is planned, provide the information below: Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7`s Edition Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Avc- Family Ihvelling I SECTION 8: ADDITIONAL APPROVALS I I. Ballardvale Historic District Commission: Date: Z. Board of Health: Date: 3. Conservation Commission: 4. Design Review Board: 5. Electrical Permit Number: 6. Fire Prevention: 7. Planning Board Lot Release: 8. Preservation Commission: 9. Zoning Board of Appeals: Date: Date: Date: Date: Date: Date: Date: The Commonwealth ofMassacltirsetts tl l Departbnent oflidustrial Accidents Office Of Investigations i 600 Washington Street .f Boston , AL4 02II0211.7•. � �� �' wwwanass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El lectricians/Plumbers Applicant Information ( ( Please Print Legibly Name (Business/Organization/Individual): 11 ( b \ �`�lh� '-n7 _ "L Address:_ l (6 GC7_r S � ed, - - — --- City/State/Zip: Gee" PU 6, Phone #: S��` Ste( 4c Are you an employer? Check the appropriate box: L ❑ I am a employer with 4_ ❑ I am a general contractor and I Type of project (required): employees (full and/or part-time).* 2. [ I am a sole proprietor orparhaer- have hired the sub -contractors listed on the attached sheet 6- ❑New construction 7_ �j Remodeling ship and have no employees These sub -contractors have •_'$ E] Demolition working for me in any capacity. employees and have workers,'. [No workers' comp. insurance comp. insurance_t g- ❑ Building addition required.] 3. ❑ I am a homeowner doing all work 5. ❑ We are a corporation and its officers have exercised their 10.0 Electrical repairs or additions myself ys [No workers' comp, right of exemption per MGL 11. Plumbing r � g epairs or additions insurance required_] t c_ 152, §I(4), and we have no 12,0 Roof repairs employees. [No workers' 1311 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 mustprovide their workers'tomp• policy number. I am an employer that is providing tporlrers' compensation insurance for my employees. Below isahe policy avid job site information. Insurance Company Name: i t Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address`��/ �ACi1C� Cjt�� �bt9aF City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure boverage as required under Section 25A of M& c. 152 can leadto the imposition of criminal penalties of a fine up to $1;500.00 and/or one-year imprisonment; As well as c":1 penalties in the farm of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office bf Investigations of the DIA for insurance coverage verification. I do hereby cnify under 1h$ ai s ant7enal es ofperjury that the information provided above is true and correct. 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 G. Other Contact Person - Phone #: v%/11/4v11 2 ; Lo; z)o t%Vl AC"RLY CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 0311,/2911 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 Fred C. Chuch, 'Inc. 41 Wellman Street NAME: C Tracy Hauswidh, CISR FAX aCNNo Ext): 978 3227249 A1C No : (478)454-1855 EMAIL thauswi(thCfmdcchureh.com ADDRESS: Lowell, MA 01851 (800) 225-1805 INSURERS AFFORDING COVERAGE NAIC ff INSURER A : Peerless Irdamnity Insurance Company g 1,090,000 EACH CCCURRENCERENTED INSURED Dan Gobeil Home'mprovemert LLC INSURER B : INSURER C : INSURER D : % Carina Road Groveland MA 01834 MED EXP (Ary one person) S 5,090 PERSCNAL & ADV INJURY , S 1.090:000 INSURER E : INSURER F : v 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. fADDL uLTR TYPE OF INSURANCE INS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN POLICY NUMBER POLIICCY EFF MMIoD POLICY EXP MMlDDM' LIMBS i GENERAL LIABILITY g 1,090,000 EACH CCCURRENCERENTED PREMISES Ea occurtence S 5°'000___ XCCIAMERCIAL GENERAL LIABILITY CLA4JS-MADE M OCCUR MED EXP (Ary one person) S 5,090 PERSCNAL & ADV INJURY , S 1.090:000 A CBP20347 i4 1/124120/0 t 1i2412011 GENERAL AGGREGATE S 2'000'000 GEN L AGGREGATE LIMIT ADPL ES PER. PRODUCTS - CCMP/CP AGG $ 2:000'090 $ POLICY PRO- LCC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY JEa accident 5 BCD1Y INJURY (Per Polson) : S ANY AUTO BCDILY INJURY (Per accident) S ALL OWNED I SCHECULED AUTOS AUTOS TOS NE0 HIRED AUTOS AUTOS N PROPERTY DAMAGE S Per accident 1 S UMBRELLA LIAR OCCUR I EACH OCCURRENCE S AGGREGATE S I EXCESS CLAIMS -MACE DED RETENTION S S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY FROPRiETOPARTNERIEXECUfIVE Y / NE.L. RI WC STATU- O TH- Y ER EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE $ OFFICERtM MBER EXCLUDED? ❑ (Mandatory in NH) NIA E.L. D;SEASE - POLICY LIMIT 1 $ if yyes, describe urder CESCRiPTiON OF OPERATIONS below I i I i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 181, Additional Remarks Schedule, If more space Is required) Evidence of Workers Comp Insurance will be forwarded separately and directly by the carder. Cfier1k "'" Mst0 try I CertHolder# " w Uluats-zUlU ALUKU uukt-uKAI Ivry. All rigr11s reserves. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 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 REPRESENTATIVE Cfier1k "'" Mst0 try I CertHolder# " w Uluats-zUlU ALUKU uukt-uKAI Ivry. All rigr11s reserves. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD